Suburban firefighter perceptions of health and wellness using patient-reported outcome measures

Abstract

BACKGROUND:

Firefighting is among the most dangerous professions and requires exceptional physical fitness and focus while working. Patient-reported outcomes are a commonly used method to evaluate subjective health information and may be utilized by fire departments to identify the health status of firefighters and provide insight to promote their health and wellness.

OBJECTIVE:

This study is a novel analysis of firefighters’ self-reported health to potentially identify musculoskeletal dysfunction, assist in therapeutic intervention, and improve overall health and wellness.

METHODS:

Firefighters were evaluated using seven different self-reported health surveys to assess various physical capabilities and quality of life. The questionnaires were delivered via online format and administered once to provide a snapshot of a suburban Oklahoma fire department.

RESULTS:

Using the Disablement in the Physically Active Scale, 14 of the 35 firefighters answered “slight, moderate, or severe” for the pain and motion variables. Only two of the firefighters indicated no stiffness or soreness after activity on the Nirschl Phase Rating Scale. The firefighters mean rating for “energy/fatigue” via the RAND-36 was 54.14 out of 100.

CONCLUSION:

Firefighters frequently report pain, impaired motion, and soreness, indicating areas in which health and wellness interventions may be helpful. The incorporation of periodic health surveys into firefighter health and wellness programming can highlight the presence of concerns, as well as intervention effectiveness by subjective health status reporting. By combining the health surveys with aerobic and core strength exercises, fire departments may be able to monitor and improve firefighter health.

Keywords

Health surveys surveys and questionnaires fire and rescue personnel diagnostic self evaluation

1 Introduction

Firefighting is a high risk occupation with activities that frequently expose individuals to hazardous conditions, increasing the risk for injuries, chronic pain, and subsequently decreased quality of life [1 –3]. Specifically, firefighters in the United States are injured every eight minutes [4]. In 2015, there were 68,085 recorded injuries amongst firefighters with 43% of those occurring on scene from falls, jumps, overexertion, and strains [4]. While these injuries can lead to acute dysfunction, chronically debilitating musculoskeletal injuries are often the cause for early retirement, and a decreased quality of life [5, 6]. A potentially confounding factor to these early retirements is the significantly higher rate of occurrence of musculoskeletal injuries for firefighters over the age of 42 [7]. Therefore, the high rates of musculoskeletal injury –– a subsequent decreased ability to work and a decreased quality of life –– likely relate to the prevalence of early retirement in firefighters. Reducing rates of on-the-job injuries resulting in early retirement due to injury and decreased quality of life can benefit fire departments and their firefighters. An opportunity to mitigate poor health outcomes created by musculoskeletal dysfunctions may be through implementation of patient-reported outcomes (PROs).

Patient-reported outcomes are subjective responses directly from the patient with regards to a health condition and subsequent treatment [8, 9]. Patient-reported outcomes provide an efficient method of obtaining subjective information from the patient perspective. Evaluation of patient characteristics such as social well-being, satisfaction with care, and health related quality of life are examples in which PROs can be used [8, 9]. The use of PROs has been found to aid diagnosis and treatment in a wide variety of medical specialties including hematology, oncology, and orthopedics [9, 10]. However, PROs must be applied appropriately, as recent systematic reviews of PRO studies found variability in whether PROs improve patient care in all instances [11, 12]. For instance, the patient population should also be taken into account when choosing specific PRO measures [10 –15]. For this study, multiple PRO measures were utilized to better understand the physical and mental states of firefighters.

Noting the hazardous occupation of firefighting, patient-reported outcomes can provide valuable information to effectively identify firefighter musculoskeletal dysfunction and assist in early therapeutic intervention. Therapeutic interventions to reduce chronic injury may improve health, wellness, and overall quality of life. Despite the use of PROs such as PRTEE and NIRSCHL for tendinous injuries in athletes and computer professionals, few studies have been done within the occupation of firefighting [16, 17]. Therefore, the purpose of our study was to utilize information gathered from seven PRO measures to demonstrate a need for intervention in a firefighter population.

2 Methods

2.1 Study participants and design

Thirty-five firefighters (30 men, 5 women, years of service 13.64±8.45, height 69.3in.±3.77, weight 91.47 kg±14.39) from a single suburban fire department were asked to complete seven health questionnaires which were distributed through Qualtrics (Qualtrics Inc., Provo, UT, USA), a web-based distribution service. Questionnaires included: Patient-Rated Tennis Elbow Evaluation (PRTEE) [18, 19], Foot and Ankle Ability Measure (FAAM) [20], Oswestry Low Back Disability Index (ODI) [21], Disablement in the Physically Active Scale (DPA) [22, 23], Nirschl Phase Rating Scale [24], QuickDASH outcome measure [25], and the RAND-36 measure of health-related quality of life (SF-36) [26]. The assessments were completed by the firefighters in summer of 2019. Participation was voluntary. An institutional review board approved this research and informed consent was gathered electronically.

2.2 Patient-Rated Tennis Elbow Evaluation (PRTEE)

The Patient-Rated Tennis Elbow Evaluation (PRTEE) is commonly used for assessing associated pain and function with lateral elbow tendinopathy (Cronbach alpha = 0.92) [19]. This questionnaire is divided into two parts, part one consists of pain-related evaluation and part two consists of function-related evaluation [18]. Each of the five items in part one is scored from 0 (no pain) to 10 (worst pain imaginable). Part two is subdivided into Specific Activities (6 items) and Usual Activities (4 items), which use a scale of 0 (no difficulty) to 10 (unable to perform an activity). The pain and functional subscales are added to give a total score out of 100 points (0 = no pain and no functional impairment; 100 = worst pain imaginable and significant functional deficit) [19]. Mean and standard deviation (SD), for both the left and right side of the body, were calculated for the PRTEE in this study.

2.3 Foot and Ankle Ability Measure (FAAM)

Perceived foot and ankle stability was assessed using the Foot and Ankle Ability Measure (FAAM) (activities of daily living subscale Cronbach alpha = 0.97, sports subscale Cronbach alpha = 0.93) [8]. The FAAM is a region-specific outcome instrument used to assess self-reported functional deficits related to ankle instability. The FAAM consists of 19 questions related to severity and frequency of previous ankle sprains and associated injuries [8]. The survey results include a perceived function percentage, an activities of daily living subscale scored out of a possible 84, a sports subscale scored out of a possible 32, and a lower extremity functional scale scored out of a possible 80, with lower scores in each indicating worse foot and ankle ability. Means and SDs were calculated for each subscale for the FAAM.

2.4 Oswestry Disability Index (ODI)

The Oswestry Disability Index (ODI) (Cronbach’s alpha = 0.86) [21] was used to measure the intensity and effect of low back pain on nine different daily activities (lifting, ability to care for oneself, ability to walk, ability to sit, sexual function, ability to stand, social life, sleep quality, and ability to travel). Each question consists of six statements which describe the least amount of disability (0) to severe disability (5) to choose from [27]. The total score varies from 0–50 (0% to 100%), ranging from minimal disability (0–20%) to bed bound or exaggerating symptoms (81–100%). The ODI scores were also converted to a percentage-based measurement. The mean and SD of the total score were calculated, along with frequency and percentage for each statement selected.

2.5 Disablement in the Physically Active Scale (DPA)

The Disablement in the Physically Active scale (DPA) (Cronbach alpha = 0.908) [22] is a 16-item questionnaire that covers four domains related to disability: impairment, functional limitation, disability, and quality of life [22, 23]. Items on the DPA are graded using a 5-point Likert scale, with 1 indicating no problem and 5 indicating a severe problem. The final score is obtained from the sum of the 16 items and subtracting 16 points. Final scores range from 0–64, with a higher score representing a higher level of disablement. Mean and SD was calculated for each variable in the DPA.

2.6 Nirschl Phase Rating Scale

In this study, the Nirschl Phase Rating Scale was used to assess the frequency of general physiologic stiffness, soreness, and pain with activity. This scale is commonly used to assess tendinous dysfunction (i.e., tendinosis) and is scored on a 0–8 scale [24]. The scale is dependent upon severity of associated symptoms, ranging from no stiffness or soreness with activity to persistent pain that intensifies with activity and disrupts sleep. The frequency and percentage was calculated for each item on the scale.

2.7 QuickDASH outcome measure (QuickDASH)

The QuickDASH (Cronbach’s alpha = 0.94) [25] is a shortened DASH (Disability of the Arm, Shoulder, and Hand) Outcome Measure [25]. It is an 11-item survey to assess upper extremity function and musculoskeletal symptoms in occupations requiring a high degree of physical activity [25]. The second optional component (high performance sport/music or work modules) was not utilized in this study. Participants were instructed to respond to the questions based on their conditions in the last week. Items in the QuickDASH present daily activities performed by the upper extremities, such as opening a tight or new jar, carrying a shopping bag or briefcase, and questions related to anatomical pain and dysfunction. Each item response is a numerical value 1–5, with higher values indicating more disability. To calculate a score, the 11 items are summed and averaged, producing a score from 1–5. This value was then transformed to a score out of 100 by subtracting one and multiplying by 25.

2.8 RAND-36 measure of health-related quality of life (SF-36)

The SF-36 (Cronbach alpha = 0.81–0.95) [28] is one of the most widely used health-related quality of life assessments. This SF-36 survey consists of 36 items, scoring within the range of 1–6 for each item, that evaluate eight health concepts and yield two summary scores. The eight health concepts include physical functioning, role limitations caused by physical health problems, role limitations caused by emotional problems, social functioning, emotional well-being, energy/fatigue, pain, and general health perceptions [28]. The two summary scores include physical health and mental health. Physical health is reflected primarily by measures of functioning, pain, and role limitations due to physical health problems. Mental health is reflected primarily by measures of emotional well-being and role limitations caused by emotional problems. The scoring approach in this study was completed by transforming each item (36) linearly to a 0–100 scale (percent of possible score) and averaging all items in the same scale together [28]. Means and SDs were calculated for each of the eight health concepts covered within the questionnaire.

2.9 Statistical analysis

A correlation analysis was performed to identify statistically significant relationships between scores from each of the seven PRO measures. Once that was completed, the authors conducted five linear regression analyses with the following SF-36 scores as the dependent variable: General Health, Social Functioning, Physical Functioning, Pain, and Emotional Well-Being. The authors selected these dependent variables for their global impact on an individual’s health.

3 Results

3.1 Patient-Rated Tennis Elbow Evaluation (PRTEE)

For the PRTEE, the firefighters’ left side pain subscale was 3.54±6.55 (out of a possible 50), with the total score as 6.77±13.91 (out of a possible 100). The pain subscale for the right side was 3.63±5.85(out of a possible 50), with the total score as 6.80±11.70 (out of a possible 100). The highest mean value for responses on the left side was for “pain at its most,” at a value of 1.63±2.74 (out of a possible 10). The highest mean value for responses on the right side was for “pain when doing a task with repeated arm movement,” at 1.63±2.06 (out of a possible 10). Complete results for the PRTEE can be found inTable 1.

Table 1
Patient-Rated Tennis Elbow Evaluation (PRTEE) (N = 35)

Side of body Item Mean Standard deviation

Left Pain when at rest¹ 0.40 1.17

Pain when doing a task with repeated arm movement 1.11 2.08

Pain when carrying a plastic bag of groceries 0.31 0.90

Pain at its least 0.09 0.37

Pain at its most 1.63 2.74

Difficulty turning a doorknob 0.03 0.17

Difficulty carrying a plastic bag of groceries² 0.20 0.58

Difficulty lifting a full coffee cup or glass of milk to your mouth 0.14 0.036

Difficulty opening a jar 0.29 1.07

Difficulty pulling up pants 0.26 0.92

Difficulty washing out a washcloth or wet towel 0.29 1.20

Difficulty with personal tasks (dressing, washing) 0.14 0.43

Difficulty with household work (cleaning, maintenance) 0.51 1.36

Difficulty with work (your job or everyday work) 0.57 1.65

Difficulty with recreational or sporting activities 0.80 1.80

Pain subscale 3.54 6.55

Specific activities subscale 1.20 3.60

Usual activities subscale 2.03 4.93

Functional disability total 3.23 7.85

Total score 6.77 13.91

Right Pain when at rest 0.14 1.11

Pain when doing a task with repeated arm movement 1.63 2.06

Pain when carrying a plastic bag of groceries 0.26 0.80

Pain at its least 0.23 0.55

Pain at its most 0.20 2.43

Difficulty turning a doorknob 0.26 0.92

Difficulty carrying a plastic bag of groceries 0.11 0.65

Difficulty lifting a full coffee cup or glass of milk to your mouth 0.14 1.022

Difficulty opening a jar 0.17 0.74

Difficulty pulling up pants 0.51 0.32

Difficulty washing out a washcloth or wet towel 0.60 0.36

Difficulty with personal tasks (dressing, washing) 0.69 0.57

Difficulty with household work (cleaning, maintenance) 0.51 1.09

Difficulty with work (your job or everyday work) 0.60 1.24

Difficulty with recreational or sporting activities 0.69 1.45

Pain subscale 3.63 5.85

Specific activities subscale 1.20 3.32

Usual activities subscale 1.97 4.01

Functional disability total 3.17 6.02

Total score 6.80 11.70

Side of body	Item	Mean	Standard deviation
Left	Pain when at rest¹	0.40	1.17
	Pain when doing a task with repeated arm movement	1.11	2.08
	Pain when carrying a plastic bag of groceries	0.31	0.90
	Pain at its least	0.09	0.37
	Pain at its most	1.63	2.74
	Difficulty turning a doorknob	0.03	0.17
	Difficulty carrying a plastic bag of groceries²	0.20	0.58
	Difficulty lifting a full coffee cup or glass of milk to your mouth	0.14	0.036
	Difficulty opening a jar	0.29	1.07
	Difficulty pulling up pants	0.26	0.92
	Difficulty washing out a washcloth or wet towel	0.29	1.20
	Difficulty with personal tasks (dressing, washing)	0.14	0.43
	Difficulty with household work (cleaning, maintenance)	0.51	1.36
	Difficulty with work (your job or everyday work)	0.57	1.65
	Difficulty with recreational or sporting activities	0.80	1.80
	Pain subscale	3.54	6.55
	Specific activities subscale	1.20	3.60
	Usual activities subscale	2.03	4.93
	Functional disability total	3.23	7.85
	Total score	6.77	13.91
Right	Pain when at rest	0.14	1.11
	Pain when doing a task with repeated arm movement	1.63	2.06
	Pain when carrying a plastic bag of groceries	0.26	0.80
	Pain at its least	0.23	0.55
	Pain at its most	0.20	2.43
	Difficulty turning a doorknob	0.26	0.92
	Difficulty carrying a plastic bag of groceries	0.11	0.65
	Difficulty lifting a full coffee cup or glass of milk to your mouth	0.14	1.022
	Difficulty opening a jar	0.17	0.74
	Difficulty pulling up pants	0.51	0.32
	Difficulty washing out a washcloth or wet towel	0.60	0.36
	Difficulty with personal tasks (dressing, washing)	0.69	0.57
	Difficulty with household work (cleaning, maintenance)	0.51	1.09
	Difficulty with work (your job or everyday work)	0.60	1.24
	Difficulty with recreational or sporting activities	0.69	1.45
	Pain subscale	3.63	5.85
	Specific activities subscale	1.20	3.32
	Usual activities subscale	1.97	4.01
	Functional disability total	3.17	6.02
	Total score	6.80	11.70

¹Pain rated on a scale of 0–10 with 0 no pain and 10 worst imaginable. ²Difficulty rated on a scale of 0–10 with 0 no difficulty and 10 unable to do.

3.2 Foot and Ankle Ability Measure (FAAM)

Using the FAAM, the firefighters’ mean perceived function percentage was 96.03±14.74, meaning there was limited influence on firefighter perceptions of ankle instability. The mean value for activities of daily living subscale was 82.46±3.69 (out of a possible 84). For the sports subscale, the mean value was 29.69±5.30 (out of a possible 32). Lastly, the lower extremity functional scale found a mean value of 74±13.94 (out of a possible 80). Findings for the FAAM can be found in Table 2.

Table 2
Foot and ankle ability measures (N = 35)

Variable Mean Standard deviation

Foot and Ankle Ability Measure (FAAM) Perceived Function Percentage 96.03 14.74

FAAM Activities of Daily Living Subscale¹ 82.46 3.69

FAAM Sports Subscale² 29.69 5.30

Lower Extremity Functional Scale³ 74 13.94

Variable	Mean	Standard deviation
Foot and Ankle Ability Measure (FAAM) Perceived Function Percentage	96.03	14.74
FAAM Activities of Daily Living Subscale¹	82.46	3.69
FAAM Sports Subscale²	29.69	5.30
Lower Extremity Functional Scale³	74	13.94

¹Out of a possible 84. ²Out of a possible 32. ³Out of a possible 80.

3.3 Oswestry Disability Index (ODI)

Assessment of the firefighters using the ODI found that 91.4% (32/35) of the firefighters answered as having minimal disability (0–20% disability). The other 8.6% (3/35) answered as having moderate disability (21–40% disability). Their mean score was 3.97±3.82 (out of a possible 50). Table 3 contains the results of the ODI.

Table 3
Owestry low back disability questionnaire (N = 35)

Score Frequency Percentage

0–20% : minimal disability 32 91.4

21–40% : moderate disability 3 8.6

41–60% : severe disability 0 0

61–80% : crippled 0 0

81–100% : bed bound or exaggerating symptoms 0 0

Score	Frequency	Percentage
0–20% : minimal disability	32	91.4
21–40% : moderate disability	3	8.6
41–60% : severe disability	0	0
61–80% : crippled	0	0
81–100% : bed bound or exaggerating symptoms	0	0

3.4 Disablement in the Physically Active Scale (DPA)

The overall score for the DPA was 12.63±11.51 (out of a possible 64). For the DPA, it was decided to evaluate the frequency of the answers 2, 3, or 4 (slight, moderate, or severe, respectively) for each variable assessed, excluding the answers 0 and 1 (no problem and does not affect, respectively). The highest frequencies of slight, moderate, or severe answers for a variable were seen with the pain and motion variables at 14 of the 35 responses. Table 4 demonstrates the DPA mean results, and Table 5 demonstrates the DPA frequency of responses.

Table 4
Disability in the physically active means (N = 35)

Variable Mean Standard deviation

Pain 1.31 1.13

Motion 1.23 1.24

Muscle function 0.94 1.06

Impaired stability 0.71 0.96

Difficulty changing direction 0.60 0.85

Difficulties with activities of daily living 0.89 0.99

Difficulties maintaining the same position for extended periods of time 0.71 0.93

Difficulty running, jumping, etc. 0.46 0.78

Difficulty with agility, coordination, balance, etc. 1.14 1.12

Difficulty participating in leisure activities 1.60 0.95

Difficulty participating in the sport/activity of my preference 0.71 0.96

Increased uncertainty, stress, pressure, and/or anxiety 1.20 1.23

Altered relationships with team, friends, and/or colleagues 0.34 0.73

Decreased overall energy 0.89 1.02

Changes in my mood and/or increased frustration 0.89 1.11

Total physical score 9.31 8.99

Total mental score 3.31 3.54

Overall score 12.63 11.51

Variable	Mean	Standard deviation
Pain	1.31	1.13
Motion	1.23	1.24
Muscle function	0.94	1.06
Impaired stability	0.71	0.96
Difficulty changing direction	0.60	0.85
Difficulties with activities of daily living	0.89	0.99
Difficulties maintaining the same position for extended periods of time	0.71	0.93
Difficulty running, jumping, etc.	0.46	0.78
Difficulty with agility, coordination, balance, etc.	1.14	1.12
Difficulty participating in leisure activities	1.60	0.95
Difficulty participating in the sport/activity of my preference	0.71	0.96
Increased uncertainty, stress, pressure, and/or anxiety	1.20	1.23
Altered relationships with team, friends, and/or colleagues	0.34	0.73
Decreased overall energy	0.89	1.02
Changes in my mood and/or increased frustration	0.89	1.11
Total physical score	9.31	8.99
Total mental score	3.31	3.54
Overall score	12.63	11.51

Table 5

Disability of the physically active frequencies (N = 35)

Variable	Score¹	Frequency	Percentage
Pain	0	10	28.6
	1	11	31.4
	2	8	22.9
	3	5	14.3
	4	1	2.9
Motion	0	14	40
	1	7	20
	2	7	20
	3	6	17.1
	4	1	2.9
Muscle function	0	16	45.7
	1	9	25.7
	2	6	17.1
	3	4	11.4
	4	0	0
Impaired stability	0	19	54.3
	1	10	28.6
	2	3	8.6
	3	3	8.6
	4	0	0
Difficulty changing directions	0	21	60
	1	8	22.9
	2	5	14.3
	3	1	2.9
	4	0	0
Difficulty with activities of daily living	0	16	45.7
	1	10	28.6
	2	6	17.1
	3	3	8.3
	4	0	0
Difficulty maintaining the same position for extended periods of time	0	19	54.3
	1	9	25.7
	2	5	14.3
	3	2	5.7
	4	0	0
Difficulty with running, jumping, etc	0	24	68.6
	1	7	20
	2	3	8.3
	3	1	2.9
	4	0	0
Difficulty with agility, coordination, balance	0	13	37.1
	1	10	28.6
	2	6	17.1
	3	6	17.1
	4	0	0
Difficulty participating in leisure activities	0	22	62.9
	1	8	22.9
	2	2	5.7
	3	3	8.6
	4	0	0
Difficulty participating in sport/activity of preference	0	20	57.1
	1	7	20
	2	6	17.1
	3	2	5.7
	4	0	0
Increased uncertainty, stress, pressure and/or anxiety	0	13	37.1
	1	10	28.6
	2	6	17.1
	3	4	11.4
	4	2	5.7
Altered relationships with team, friends, and/or colleagues	0	27	77.1
	1	5	14.3
	2	2	5.7
	3	1	2.9
	4	0	0
Decreased overall energy	0	15	42.9
	1	13	37.1
	2	4	11.4
	3	2	5.7
	4	1	2.9
Changes in mood and/or increased frustration	0	16	45.7
	1	12	34.3
	2	4	11.4
	3	1	2.9
	4	2	5.7

¹0 = No Problem. 1 = I have the problem(s), but it does not affect me. 2 = The problem(s) slightly affects me. 3 = The problem(s) moderately affects me. 4 = The problem(s) severely affects me.

3.5 Nirschl Phase Rating Scale

The Nirschl Phase Rating scale found that only 5.7% (2/35) of the firefighters reported no stiffness or soreness after activity (Phase 0). It was determined that 31.4% (11/35) of firefighters reported stiffness or mild soreness after activity, and that the pain is usually gone within 24 hours (Phase 1). Additionally, 31.4% (11/35) of the firefighters reported stiffness or mild soreness before activity that is relieved by warm-up, and that the symptoms are not present during activity, but return afterward and last up to 48 hours (Phase 2). The Nirschl Phase Rating Scale frequency of responses can be seen inTable 6.

Table 6
NIRSCHL phase rating scale frequency table (N = 35)

Rating Frequency Percentage

No stiffness or soreness after activity 2 5.7

Stiffness or mild soreness after activity. Pain is usually gone within 24 hours 11 31.4

Stiffness or mild soreness before activity that is relieved by warm-up. Symptoms are not present during activity, but return afterward, lasting up to 48 hours 11 31.4

Stiffness or mild soreness before specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity, but does not cause the athlete to alter activity 5 14.3

Pain is partially relieved by warm-up but more intense, causing the athlete to alter performance of the activity. Mild pain occurs with activities of daily living, but does not cause major change in them 3 8.6

Significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living but does not cause a major change in them 2 5.7

Pain that persists even with complete rest. Pain disrupts simple activities of daily living and prohibits doing household chores 0 0

Persistent pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity 1 2.9

Rating	Frequency	Percentage
No stiffness or soreness after activity	2	5.7
Stiffness or mild soreness after activity. Pain is usually gone within 24 hours	11	31.4
Stiffness or mild soreness before activity that is relieved by warm-up. Symptoms are not present during activity, but return afterward, lasting up to 48 hours	11	31.4
Stiffness or mild soreness before specific sport or occupational activity. Pain is partially relieved by warm-up. It is minimally present during activity, but does not cause the athlete to alter activity	5	14.3
Pain is partially relieved by warm-up but more intense, causing the athlete to alter performance of the activity. Mild pain occurs with activities of daily living, but does not cause major change in them	3	8.6
Significant (moderate or greater) pain before, during, and after activity, causing alteration of activity. Pain occurs with activities of daily living but does not cause a major change in them	2	5.7
Pain that persists even with complete rest. Pain disrupts simple activities of daily living and prohibits doing household chores	0	0
Persistent pain that also disrupts sleep consistently. Pain is aching in nature and intensifies with activity	1	2.9

3.6 QuickDASH outcome measure (QuickDASH)

From the QuickDASH, the highest mean value on the scale of 1–5 was 1.73±0.80 for the firefighters’ rating of arm, shoulder, or hand pain. The next highest mean value was 1.52±0.76 (out of a possible 5) for ability to complete recreational activities in which you take some force or impact through your arm, shoulder, or hand. The total score was 15.06±5.04 (out of a possible 55). The disability/symptom score was 9.23±11.46 (out of a possible 100). In each case, higher values relate to worse dysfunction. Complete QuickDASH results can be seen inTable 7.

Table 7
Quick dash results (N = 35)

Variable¹ Mean Standard deviation

Ability to open a tight or new jar 1.33 0.69

Ability to do heavy chores (e.g. wash wall, floors) 1.27 0.52

Ability to carry a shopping bag or briefcase 1.06 0.24

Ability to wash your back 1.45 0.71

Ability to use knife to cut your food 1.03 0.17

Ability to complete recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc) 1.52 0.76

During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors, or groups? 1.45 0.75

During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem? 1.39 0.61

Rate your arm, shoulder or hand pain 1.73 0.80

Rate your tingling (pins and needs) in your arm, shoulder or hand 1.33 0.60

During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand? 1.48 0.76

Total score 15.06 5.04

Disability/symptom score 9.23 11.46

Variable¹	Mean	Standard deviation
Ability to open a tight or new jar	1.33	0.69
Ability to do heavy chores (e.g. wash wall, floors)	1.27	0.52
Ability to carry a shopping bag or briefcase	1.06	0.24
Ability to wash your back	1.45	0.71
Ability to use knife to cut your food	1.03	0.17
Ability to complete recreational activities in which you take some force or impact through your arm, shoulder or hand (e.g. golf, hammering, tennis, etc)	1.52	0.76
During the past week, to what extent has your arm, shoulder, or hand problem interfered with your normal social activities with family, friends, neighbors, or groups?	1.45	0.75
During the past week, were you limited in your work or other regular daily activities as a result of your arm, shoulder, or hand problem?	1.39	0.61
Rate your arm, shoulder or hand pain	1.73	0.80
Rate your tingling (pins and needs) in your arm, shoulder or hand	1.33	0.60
During the past week, how much difficulty have you had sleeping because of the pain in your arm, shoulder or hand?	1.48	0.76
Total score	15.06	5.04
Disability/symptom score	9.23	11.46

¹All scored on a scale of 1–5.

3.7 RAND-36 measure of health-related quality of life (SF-36)

In terms of the firefighters’ health-related quality of life, the SF-36 produced the highest mean value for both the scales “physical functioning” and “social functioning” at 80.00±13.61 and 80.00±21.48, respectively (out of a possible 100 each). The lowest mean value found was 54.14±17.93 (out of a possible 100) for the “energy/fatigue” scale. Table 8 contains results from all eight scales of the RAND-36.

Table 8
RAND-36 (N = 35)

Scale Mean Standard deviation

Physical Functioning 800.00 136.12

Role Limitations Due to Physical Health 291.43 159.73

Role Limitations Due to Emotional Problems 211.43 120.71

Energy/fatigue 216.57 71.70

Social Functioning 160.00 42.96

Pain 155.86 32.75

General Health 377.86 83.09

Scale	Mean	Standard deviation
Physical Functioning	800.00	136.12
Role Limitations Due to Physical Health	291.43	159.73
Role Limitations Due to Emotional Problems	211.43	120.71
Energy/fatigue	216.57	71.70
Social Functioning	160.00	42.96
Pain	155.86	32.75
General Health	377.86	83.09

3.8 Statistical analysis

For the correlation analyses, 23 statistically significant results were found across the seven different PRO measures, which can be viewed in Table 9. For the regression models in the SF-36 subscales, General Health found two predictor variables, Social Functioning determined four predictors, Physical Functioning had three predictors, Pain had 10 predictors, and Emotional Well-Being had nine predictors. The data for the regression models is detailed in Table 10.

Table 9
Correlation table

Variable one Variable two Pearson R value P value

DPA Physical Score PRTEE Left Pain Score 0.38 0.02

PRTEE Left Usual Score 0.40 0.02

PRTEE Left Total Score 0.36 0.04

SF-36 Pain Subscale –0.38 0.03

DPA Mental Score SF-36 Physical Functioning Subscale –0.38 0.04

SF-36 Pain Subscale –0.34 0.04

DPA Overall Score PRTEE Left Pain Score 0.38 0.02

PRTEE Left Usual Score 0.38 0.02

PRTEE Left Total Score 0.36 0.04

SF-36 Pain Subscale –0.40 0.02

FAAM Activities of Daily Living Subscale Percentage Perceived Lower Extremity Function 0.49 <0.001

SF-36 General Health Subscale –0.35 0.04

Percentage Perceived Lower Extremity Function PRTEE Left Pain Score –0.45 0.01

PRTEE Left Total Score –0.38 0.03

Lower Extremity Functional Score PRTEE Right Special Score –0.069 <0.001

ODI Low Back Total Score QuickDASH 0.44 0.01

SF-36 Physical Functioning Subscale –0.46 0.01

SF-36 Pain Subscale –0.58 <0.001

PRTEE Right Pain Score SF-36 Social Functioning Subscale 0.38 0.03

PRTEE Right Usual Score SF-36 Social Functioning Subscale 0.36 0.03

PRTEE Right Function Score SF-36 Social Functioning Subscale 0.37 0.03

PRTEE Right Total Score SF-36 Social Functioning Subscale 0.38 0.03

QuickDASH SF-36 Pain Subscale –0.47 0.01

Variable one	Variable two	Pearson R value	P value
DPA Physical Score	PRTEE Left Pain Score	0.38	0.02
	PRTEE Left Usual Score	0.40	0.02
	PRTEE Left Total Score	0.36	0.04
	SF-36 Pain Subscale	–0.38	0.03
DPA Mental Score	SF-36 Physical Functioning Subscale	–0.38	0.04
	SF-36 Pain Subscale	–0.34	0.04
DPA Overall Score	PRTEE Left Pain Score	0.38	0.02
	PRTEE Left Usual Score	0.38	0.02
	PRTEE Left Total Score	0.36	0.04
	SF-36 Pain Subscale	–0.40	0.02
FAAM Activities of Daily Living Subscale	Percentage Perceived Lower Extremity Function	0.49	<0.001
	SF-36 General Health Subscale	–0.35	0.04
Percentage Perceived Lower Extremity Function	PRTEE Left Pain Score	–0.45	0.01
	PRTEE Left Total Score	–0.38	0.03
Lower Extremity Functional Score	PRTEE Right Special Score	–0.069	<0.001
ODI Low Back Total Score	QuickDASH	0.44	0.01
	SF-36 Physical Functioning Subscale	–0.46	0.01
	SF-36 Pain Subscale	–0.58	<0.001
PRTEE Right Pain Score	SF-36 Social Functioning Subscale	0.38	0.03
PRTEE Right Usual Score	SF-36 Social Functioning Subscale	0.36	0.03
PRTEE Right Function Score	SF-36 Social Functioning Subscale	0.37	0.03
PRTEE Right Total Score	SF-36 Social Functioning Subscale	0.38	0.03
QuickDASH	SF-36 Pain Subscale	–0.47	0.01

Table 10

Regression results

Model	Constant	Independent variable	B coefficient	P value
SF-36 General Health Subscale
	82.28
		SF-36 Physical Functioning Subscale	0.79	0.01
		SF-36 Pain Subscale	0.68	0.03
SF-36 Social Functioning Subscale
	3.32
		Lower Extremity Functional Score	–1.15	0.05
		SF-36 Role Limitations Due to Emotional Problems Subscale	0.65	0.04
		SF-36 Energy/Fatigue Subscale	–0.70	0.03
		SF-36 Emotional Well-Being Subscale	1.07	0.01
SF-36 Physical Functioning Subscale
	52.13
		DPA Mental Score	–1.66	0.02
		QuickDASH	–0.41	0.03
		SF-36 General Health Subscale	0.43	0.01
SF-36 Pain Subscale
	100.78
		DPA Physical Score	–0.66	0.01
		Lower Extremity Functional Score	0.58	0.03
		PRTEE Left Specific Score	–3.06	0.01
		PRTEE Left Usual Score	1.99	0.03
		QuickDASH	–0.44	0.01
		SF-36 Role Limitations Due to Emotional Problems Subscale	0.36	0.02
		SF-36 Energy/Fatigue Subscale	0.31	0.003
		SF-36 Emotional Well-Being Subscale	–0.43	0.02
		SF-36 General Health Subscale	0.32	0.03
		Sex	–33.22	0.01
SF-36 Emotional Well-Being Subscale
	87.18
		DPA Overall Score	–0.62	0.04
		PRTEE Left Specific Score	–3.97	<0.001
		PRTEE Right Specific Score	3.30	00.03
		SF-36 Role Limitations Due to Physical Health Subscale	–0.56	<0.001
		SF-36 Role Limitations Due to Emotional Problems Subscale	0.62	<0.001
		SF-36 Social Functioning Subscale	0.32	0.01
		SF-36 Energy/Fatigue Subscale	0.49	0.01
		SF-36 Pain Subscale	–0.57	0.02
		Sex	–31.45	0.02

4 Discussion

Firefighting is a dangerous profession due to hazardous work environments, difficult body positioning, and decreased quality of life [1 –3]. Patient-reported outcome measures provide insight to the participant’s perceived health state [8 –10], which is beneficial in providing more individualized catering to treatment and prevention of adverse health outcomes. The goal of this study was to obtain a snapshot of the health status of 35 firefighters from a single suburban fire department by administering seven different PRO measures related to functional mobility, pain, and health-related quality of life. Identifying areas of concern among this sample of firefighters may provide insight to health states of firefighters from other fire departments, thereby providing an opportunity for fire departments to manage and maintain firefighter health and wellness.

4.1 Patient-Rated Tennis Elbow Evaluation (PRTEE)

The total score calculated using the PRTEE for the left arm was 6.77±13.91, and the total score for the right arm was 6.80±11.70. Another study looked at patients with lateral epicondylitis, and PRTEE findings for the affected arm prior to treatment were 53.90±13.71 [29]. The current findings for elbow dysfunction in this sample of firefighters are much less severe compared to lateral epicondylitis patients, which is promising due to the frequency of upper extremity dysfunction among firefighters from lifting patients and heavy equipment, ergonomic and postural stress, and overexertion-induced injuries [4 , 30]. The dichotomy of findings across this study and those of the lateral epicondylitis study is unsurprising considering the severity of the dysfunction in the latter study, but also support that the firefighters are not suffering from severe elbow impairment. However, due to the presence of mild elbow dysfunction via the PRTEE findings, and the nature of movements required of firefighters on a daily basis, thorough evaluation of possible firefighter elbow dysfunction may identify areas to improve and reduce their subjective reporting of symptoms on measures such as the PRTEE.

4.2 Foot and Ankle Ability Measure (FAAM)

The mean FAAM scores in this study for the activities of daily living and sports subscales were 82.46±3.69 and 29.69±5.30, respectively. A study evaluating individuals with chronic ankle instability found 70.88±2.57 and 70.33±4.44 for the activities of daily living subscale of the FAAM in both the control and testing group [31]. This same study on individuals with chronic ankle instability found pretest percentage means for their two different testing groups of 24.22±1.85 and 21.00±2.69 for the sports subscale of the FAAM [31]. The findings of impairment in the current sample of firefighters generally do not indicate the same level of impairment as individuals with chronic ankle instability. This is promising in terms of the firefighters lacking severe impairment of the foot and ankle, but the scores obtained may still represent dysfunction. While the current study may lack significant findings of foot and ankle dysfunction via the results of the FAAM, comparison to results of chronic ankle instability exhibits a potential forecast or latency of dysfunction in this firefighter population.

4.3 Oswestry Disability Index (ODI)

The mean value for low back disability found in this population of firefighters was 3.97±3.82 (out of a possible 50). This mean value presented as a percentage is 7.94±7.64. Data from clinical trials evaluating participants with chronic low back pain often report mean baseline ODI percentages of more than 20 [32 –34]. Previous literature has demonstrated that back pain is a common and chronic issue among firefighters [6, 30], yet results from this study indicate absent to minimal back disability among participants. This is promising as it potentially indicates that these specific firefighters have effective preventative measures in place to mitigate incidence of or issues resulting from low back pain. However, as highlighted earlier in terms of the prevalence of low back pain in firefighters, the findings from this study may not be representative of firefighters on a larger scale.

4.4 Disablement in the Physically Active Scale (DPA)

The overall DPA score for this population of firefighters was 12.63±11.51. A study of male and female collegiate soccer players found an overall score of 10.6±10.5 using the DPA [35]. Comparing current results and those of the soccer athlete study demonstrates similar findings, with potentially more disability in the firefighter sample. These findings of disability in firefighters relative to soccer players is significant because of the necessity of firefighter health and wellness in order to perform their life-saving duties optimally. Athletes and firefighters each participate in similarly physically strenuous activities as part of their daily routines. Due to the similarities of firefighters and athletes, they are also referred to as tactical athletes. The relatively elevated scores as shown by the DPA for the firefighters may indicate a deficit in their exercise regimens, injury prevention, or proper ergonomic positioning while working [4 , 30]. Limiting injuries by incorporation of preventative measures is important for acute and chronic firefighter health [5, 6]. Firefighters may be able to reduce disabilities contributing to these DPA scores as well as generally promote their own health by incorporating exercise regimens to improve aerobic fitness, core strength, and functional movement [36 –39]. Each of these three physical characteristics have been associated with reduced risk of injuries from sprains, strains, or awkward positioning [36 –39]. While this study is not able to specify causes of the disablements of the sampled firefighter population as reported according to the DPA, incorporation of these targeted exercise programs is likely to aid injury prevention and promote overall health.

4.5 Nirschl Phase Rating Scale

Only two (5.7%) of the firefighters in this study reported no stiffness or soreness after activity on the Nirschl Phase Rating Scale. With more than 94% of the sample of firefighters implicating stiffness or soreness after activity, the physical requirements of their job may place them in a chronic state of stiffness or soreness. Just over 31% of firefighters reported that stiffness or mild soreness before activity is relieved by warm-up, absent during activity, but return after and last up to 48 hours. This represents an area of concern with nearly one-third of firefighters reporting this issue. These findings from the Nirschl Phase Rating Scale may identify a potential issue with musculoskeletal fitness, or improper recovery time since last activity. While it is normal for stiffness and soreness to be present with physical exertion [40], the physical requirements of firefighting coupled with the high rate of reporting of soreness following activity may warrant intervention at the department level. The incorporation of aerobic fitness, core strength, and functional movement exercises may help reduce the prevalence of stiffness or soreness after activity, as these have been associated with a general reduction in musculoskeletal dysfunctions [36 –39].

4.6 QuickDASH outcome measure (QuickDASH)

Using the QuickDASH, the disability/symptom score for the firefighters was 9.23±11.46. Recent studies investigating limb disability in patients with cervical radiculopathy and carpal tunnel syndrome reported QuickDASH scores of 50±23.1 and 32.7±8.8, respectively [41, 42]. This comparison to upper extremity disorder patients shows this sample of firefighters reporting decreased disability of the arm, shoulder, and hand. The patients with upper extremity disorders likely report more disability due to their identified dysfunction being directly assessed by the questions of the QuickDASH. While the firefighters’ score wasn’t as severe as that of the upper extremity disorder patients, the physical stress and demands of firefighting warrant continued evaluation of disability in the arm, shoulder, and hand. More targeted evaluation of the firefighters in the current population may be beneficial to accurately identify troublesome areas of the upper extremity, as the responses to each of the 11 questions in the QuickDASH resulted in mean scores between 1.03–1.73. In any case, firefighters may benefit from increased attention to arm, shoulder, or hand injuries or disabilities given their subjective reporting of disability.

4.7 RAND-36 measure of health-related quality of life (SF-36)

The current study found the highest subscale score on the SF-36 with “physical functioning” and “social functioning” at 80.00±13.61 and 80.00±21.48, respectively, and the lowest subscale score with “energy/fatigue” at 54.14±17.93. A study using the SF-36 for a general population of middle-aged males reported a score of 97.40 for “physical functioning,” 88.88 for “social functioning,” and 69.57 for “energy/fatigue” among participants that reported moderate muscular fitness [43]. In each of these three subscales, this firefighter population reported lower scores of health-related quality of life compared to the study of middle-aged men. While the scores for “physical functioning” and “social functioning” are both relatively high given the scale is out of 100 possible points, the comparatively lower scores of the firefighters indicate lower subjective health-related quality of life than a general population. Further, the values for “energy/fatigue” (and the alternatively named “vitality”) show similar results in that the firefighters are reporting lower health-related quality of life related to this subscale. The firefighters’ perceived health-related quality of life is important, as the daily demands of the job often contribute to injuries or emotional stress [1 , 5]. Therefore, periodic evaluation of the firefighters using the SF-36 may be beneficial in providing information on their current health, especially as it pertains to quality of life.

4.8 Statistical analysis

Of the 23 statistically significant correlations found across the seven PRO measures, there were three p values demonstrated as <0.001. These correlations were for the FAAM activities of daily living subscale to perceived lower extremity function percentage, lower extremity functional score to PRTEE right special score, and ODI low back total score to SF-36 “pain” subscale. The FAAM activities of daily living subscale correlation to percentage of perceived lower extremity function may imply that the firefighters responses regarding daily activities are due to injuries or issues related to their lower extremities. The reason for the statistically significant correlation found between the lower extremity functional score and the PRTEE right special score is less intuitive, but may be related to specific movements common to the occupation like reaching, lifting, and pulling [4 , 30]. The correlation between the ODI low back total score and SF-36 “pain” subscale likely indicates the pain reported by firefighters is located most often in their lower back, which isn’t unexpected given the findings of other studies and the movements required within the occupation [4 , 30].

The regression models for the SF-36 found many associations within the SF-36, but also some interesting associations across PRO measures. The statistically significant (p = 0.05) SF-36 “social functioning” subscale regression model association with the lower extremity functional score may parallel the correlation findings of daily activities to perceived lower extremity function in that the firefighters report lower extremity health as a major factor of the quality or extent of their social interaction. Additionally, the statistically significant findings between the regression model for SF-36 “physical functioning” subscale to DPA mental score (p = 0.02) and the QuickDASH (p = 0.03) show interesting associations in that the QuickDASH findings may indicate upper extremity issues, as opposed to the low back findings of the correlation analysis, and the DPA mental score could represent a subsequent finding related to the reported scores for overall physical functioning and upper extremity health. The independent variable of sex demonstrated statistically significant findings relative to the regression models for SF-36 “pain” (p = 0.01) and “emotional well-being” (p = 0.02) subscales. These findings relative to sex, while interesting, may be parochial given the disparity in number of males and females within our study.

4.9 Strengths and limitations

The study’s incorporation of a variety of PRO screening tools support the validity of these results, although there are some limitations. The small sample size limits the generalizability of the results. The large amount of time required to complete these surveys may have resulted in some participant inattention or lack of focus due to fatigue. Future research incorporating PROs in firefighter research may benefit by the inclusion of sleep-related measures or more detailed non-job-related activity in order to assess the potentially confounding variable of recovery rates.

5 Conclusion

Across the PRO measures utilized in this study, firefighters exhibit minimal to no disability or dysfunction, especially relative to other study populations incorporating the same PROs. However, the DPA, Nirschl Phase Rating Scale, and QuickDASH results may have shown some areas in which issues are present. Further evaluation and more targeted assessment of these firefighters will be required to more accurately determine if these three measures are consistent with more tangible disability. Based on the results of this study, we recommend fire departments incorporate the DPA, Nirschl Phase Rating Scale, QuickDASH, and SF-36 into routine firefighter health and wellness check-ups. While the PRTEE, FAAM, and ODI provide valuable information into health and wellness, based on our findings, these PRO measures appear to be less insightful for use in routine screening for the firefighter population. Implementation of these recommendations will vary across departments, depending on if there has been an apparent issue among the firefighters that would be more aptly assessed with different screening tools. We hope our findings provide insight for departments considering changes to their health and wellness screening methods.

Conflict of interest

None to report.

Footnotes

Acknowledgments

Not applicable.

Funding

Not applicable.

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Suburban firefighter perceptions of health and wellness using patient-reported outcome measures

Abstract

BACKGROUND:

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSION:

Keywords

1 Introduction

2 Methods

2.1 Study participants and design

2.2 Patient-Rated Tennis Elbow Evaluation (PRTEE)

2.3 Foot and Ankle Ability Measure (FAAM)

2.4 Oswestry Disability Index (ODI)

2.5 Disablement in the Physically Active Scale (DPA)

2.6 Nirschl Phase Rating Scale

2.7 QuickDASH outcome measure (QuickDASH)

2.8 RAND-36 measure of health-related quality of life (SF-36)

2.9 Statistical analysis

3 Results

3.1 Patient-Rated Tennis Elbow Evaluation (PRTEE)

Table 2 Foot and ankle ability measures (N = 35) Variable Mean Standard deviation Foot and Ankle Ability Measure (FAAM) Perceived Function Percentage 96.03 14.74 FAAM Activities of Daily Living Subscale1 82.46 3.69 FAAM Sports Subscale2 29.69 5.30 Lower Extremity Functional Scale3 74 13.94

Table 3 Owestry low back disability questionnaire (N = 35) Score Frequency Percentage 0–20% : minimal disability 32 91.4 21–40% : moderate disability 3 8.6 41–60% : severe disability 0 0 61–80% : crippled 0 0 81–100% : bed bound or exaggerating symptoms 0 0

4.1 Patient-Rated Tennis Elbow Evaluation (PRTEE)

4.2 Foot and Ankle Ability Measure (FAAM)

4.3 Oswestry Disability Index (ODI)

4.4 Disablement in the Physically Active Scale (DPA)

4.5 Nirschl Phase Rating Scale

4.6 QuickDASH outcome measure (QuickDASH)

4.7 RAND-36 measure of health-related quality of life (SF-36)

4.8 Statistical analysis

4.9 Strengths and limitations

5 Conclusion

Conflict of interest

Footnotes

Acknowledgments

Funding

References

Table 2
Foot and ankle ability measures (N = 35)

Variable Mean Standard deviation

Foot and Ankle Ability Measure (FAAM) Perceived Function Percentage 96.03 14.74

FAAM Activities of Daily Living Subscale¹ 82.46 3.69

FAAM Sports Subscale² 29.69 5.30

Lower Extremity Functional Scale³ 74 13.94

Table 3
Owestry low back disability questionnaire (N = 35)

Score Frequency Percentage

0–20% : minimal disability 32 91.4

21–40% : moderate disability 3 8.6

41–60% : severe disability 0 0

61–80% : crippled 0 0

81–100% : bed bound or exaggerating symptoms 0 0