Selected Abstracts from the 2005 AASCIPSW Conference
#30
Measuring Forgiveness of Oneself and Others in Spinal Cord Injury: A Psychometric Evaluation
Jon Webb, PhD; Loren Toussaint, PhD; Claire Kalpakjian, PhD; and Denise Tate, PhD
Objectives
• Understand the construct of forgiveness
• Understand the applicability of forgiveness to spinal cord injury
• Examine the psychometric characteristics of a measure of forgiveness in a spinal cord injury population
Introduction/Problem Statement: There is growing interest in the connection between forgiveness and health. However, the availability of psychometrically sound measures of forgiveness is limited and no instruments have been evaluated in a sample with SCI.
Objectives/Goals: As such, this study was tdesigned to evaluate a brief measure of forgiveness of self (FS) and others (FO). While used in the general population with good success, this measure has not been used in a sample of patients with SCI. Hence, we evaluated the structure, reliability, and validity of the measure in two samples of patients with SCI.
Method: Sample one consisted of 57 inpatients and outpatients with SCI (75% male; 83% high school education or above; 50%/50% tetraplegia/paraplegia; age at injury M=38). Sample two was a community-based sample of 111 adults with SCI (91%/5% Caucasian/African-American; 84% male; 84% high school education or above; 48%/52% tetraplegia/paraplegia; age at injury M=37). FS and FO were measured using 2 and 5 items, respectively. Satisfaction with life and self-rated health were assessed as a means of evaluating construct validity.
Data/Results: Separate factor analyses were conducted in each sample. In both samples, the seven items loaded on two different factors: FS and FO. The two-factor solution accounted for 65% and 61% of the variance in the original items in samples one and two, respectively. Each solution resulted in factors with high item loadings (> .59) and acceptable levels of internal consistency (alphas > .65). Both forgiveness scales showed good construct validity.
Conclusions: The brief seven-item measure of FS and FO evaluated in this study shows good psychometric characteristics. The structure of the measure was as expected with appropriate items loading on the self and others factors. Factors were internally consistent and showed good validity. Given the growing interest in the health benefits of forgiveness, clinicians and researchers interested in measuring this variable in SCI samples can use this brief measure to provide a reliable and valid assessment of two dimensions of forgiveness. As a brief scale, this measure may be especially useful for clinicians wanting to assess therapeutic forgiveness needs with SCI patients.
#25
How Does Source of Funding Impact Attendant Care?
Debra Burdsall, MPH, OTR
Objectives
• To examine the relationship between the source of funding for personal assistant services in the spinal cord injured population, and consumer satisfaction
• To learn more about the level of skill and training of personal care assistants and how it relates to consumer satisfaction
• To learn more about factors that influence consumer satisfaction with personal assistant services
Objective: To assess the relationship between the source of payment for personal assistant services (PAS), level of skill and training of personal care assistants (PCAs) and overall satisfaction with PAS among individuals with spinal cord injury (SCI).
Research Design: Prospective survey.
Setting: Community.
Participants: Twenty-eight individuals with SCI 2 15 years post injury currently utilizing PAS.
Main outcome measures: Skill level of primary caregiver, source of caregiver training, hours per day PAS were provided, consumers satisfaction with quality of care and skill level of PCA.
Statistical analysis: Descriptive statistics and chi-square analysis.
Resuls: Participants were grouped by payment source for PAS. In-Home Support Services (IHSS) was the payment source for 50% of the participants; 21% were not paid by any third party payor; 18% were private pay (PP); and 11% were workers compensation (WC). 100% of caregivers in the unpaid group received training in the hospital, compared to only 7% of the IHSS group in which many of the consumers trained their caregivers. 100% of the unpaid group and 86% of the IHSS group were very or extremely happy with the skill level of their caregiver, as compared to only 66% of the WC group and 60% of the PP group. 100% of the unpaid group and 79% of the IHSS group reported being extremely or very happy with the quality of care they received, in comparison to 66% of the WC and 60% of the PP groups.
Conclusions: Individuals whose PAS were paid for by IHSS or were un-reimbursed were most satisfied overall with the skill level and quality of care provided by their caregiver. Individuals in the IHSS and unpaid groups were more likely receiving care from a spouse/family member versus hired assistant, and reported greater satisfaction even though that caregiver may not have received specialized training.
#24
An Increase in ASIA D Patients over 10 Years
Kathy Miller, BA; Jerry Wright, BA; and Tamara Bushnik, PhD
Objectives
• To learn more about the increase in ASIA D patients
• To learn more about the etiology of ASIA D patients
• To learn more about other demographics related to ASIA D injuries
Objective: To examine factors correlated with the increased number of individuals with spinal cord injury (SCI) who are being admitted to and discharged from the Spinal Cord Injury Model System of Care with ASIA grade D.
Design: Longitudinal National Database.
Setting: SCI Model Systems of Care (SCIMS).
Subjects: 3,306 individuals who met the inclusion criteria for the SCIMS and were admitted within 24 hours to a SCIMS from 1993 to 2002.
Main Outcome Measures: ASIA grade; age and etiology of injury.
Results: The percentage of people with ASIA D SCI admitted within 24 hours to a SCIMS increased from 12% (n = 60/499) in 1993 to 24% (n = 63/263) in 2002 (z = 4.3, p < .001). The percentage of individuals discharged with ASIA D SCI also increased from 26.5% (n = 132/499) in 1993 to 34.6% (n = 91/263) in 2002 (z = 2.34, p < .05). The average age rose from 37.2 years (n = 132) in 1993 to 44.2 years (n = 91) in 2002
(t = 2.9, p < .005). The percentage of ASIA D injuries resulting from a fall increased from 21.2% (n = 22/104) in 1993 to 36.6% (n = 30/82) in 2002 (z = 2.32, p < .05).
Conclusions: As reported in Facts and Figures (www.spinalcord.uab.edu), there has been an increase in the mean age at injury from 1973 to 2003 as well as an increase in the proportion of injuries from falls. This study looked at a restricted time range to avoid potential confounds in medical management, SCIMS contributors and changing rehabilitation lengths of stay. From 1993 to 2002, the percentage of individuals admitted with ASIA D SCI increased significantly. Concomitant with this increase, in 2002, the individuals with ASIA D SCI were significantly older and were more likely to have incurred their injury in a fall. These results suggest a shift in the pattern of SCI impairment which may be the result of an aging population and increased fall risk.
#19
Predictors of Quality of Life One Year After Spinal Cord Injury
Mia A. Bergman, PhD; Rosemarie B. King, PhD, RN; Pat Semik, BA; Michelle Gittler, MD; Mary Ann Pec, MS; and Charles Merbitz, PhD
Objectives
• To learn about possible predictors of quality of life after spinal cord injury
• To draw attention to specific predictor variables that may be targeted during comprehensive rehabilitation in individuals with violent etiologies
• To increase awareness of domains that may affect quality of life in persons from ethnic minority groups living in urban settings
Spinal cord injury (SCI) that results in permanent paralysis implies tremendous changes in many areas of life, such as health, physical functioning, socioeconomic, family, and psychological-spiritual domains. These changes can also have a substantial impact on a person’s quality of life (QOL). Recognizing these effects, an important aim of rehabilitation after SCI is to increase QOL. Surprisingly, little is known about predictors of QOL after SCI.
This project aimed to: (1) assess QOL (both global and domain specific) in an inner city minority sample at discharge (T1) and at one-year post discharge (T2) as reported by persons who recently sustained a SCI (N = 152, mean age = 37 years, range = 18-89 years of age, 60% with paraplegia and 40% with tetraplegia, 77% male and 23 % female) and participated in acute rehabilitation at one of two Midwestern rehabilitation hospitals; (2) identify predictors of quality of life (i.e., social support, Functional Independence Measure [FIM] motor score, age, race, pressure ulcer occurrence, violent etiology) reported by these individuals; and to (3) determine the extent to which each of these variables predict QOL at one year post discharge. The instruments used to measure the variables of interest consisted of: the Quality of Life Index, the Interpersonal Support Evaluation List, and the FIM. In order to improve the utility of the ordinal scales used, rating scale (i.e., Rasch) analysis was conducted. Hierarchical regression revealed that motor function, social support, and violent etiology were predictive of QOL in this sample. Thus, persons who had sustained violent injuries (e.g., gunshot wounds, stab wounds) had lower QOL scores at both T1 and T2 than persons in the general population. There were no significant gender differences in QOL scores. QOL significantly
increased from discharge to one-year post discharge; however, level of injury was not associated with QOL.
It is of interest that a small subsample of the study participants had very low QOL scores. With this information, future research may provide techniques under which enhanced QOL outcomes and financial savings for those with SCIs, rehabilitation programs, and society may be possible.
#15
Measuring Nursing Staff Training Needs in Sexuality Rehabilitation Following Spinal Cord Injury
Jon Rose, PhD; Michael Dunn, PhD; and Linda Love, MS, RN
Objectives
• Understand the relationship between unmet need for sexuality rehabilitation and spinal cord injury nursing staff training needs
• Know four domains of knowledge about sexuality rehabilitation
• Understand the reliability and validity of the KAASS when it is used to monitor training needs of nursing staff in the USA
Rehabilitation of sexual functioning has been identified as an underserved need in spinal cord injury (SCI) rehabilitation. The extent to which this is due to unmet education and training needs of SCI staff is not known. We tested the suitability of an Australian survey––the Knowledge, Comfort, Approach and Attitudes Towards Sexuality Scale (KAASS)––for measuring training needs and educational outcomes of actual and potential SCI rehabilitation staff in the USA. Twenty-four nursing staff (RNs, LVNs and CNAs) were assessed before and after a one-hour lecture on sexuality after SCI. They averaged 6.3 years experience in SCI (range 0–24), and 23 years experience in nursing (range 0–40). The original factors remained valid as judged by replication of subscale–subscale and subscale–total correlations. Questions appeared clear and relevant to our sample as judged by a high internal reliability (Cronbach’s alpha) in three of the four domains and few unanswered questions. Alpha for the Attitude subscale (0.6221) was lower than that reported for the original Australian sample (0.835). Post-test scores indicate that the KAASS is sensitive to change. Following the lecture, significant improvement was found for Knowledge, Comfort and Approach. Nurses remained least comfortable with the Approach domain (being grabbed, asked for sex, and unintentionally intruding on patients’ sexual activity). Post-test scores for Approach indicated that more extensive training in how to deal with sexual advances and behavior of SCI patients might be helpful. Scores for Attitude prior to the lecture indicated little to no discomfort, leaving sparse room for improvement. It appears from this data that rehabilitation of sexual functioning of SCI would be improved by helping staff be more comfortable, thus responding appropriately to various sexual approach behaviors of patients. An abridged version of the KAASS eliminating the 5-item Attitude subscale appears to be a valid and reliable way to measure sexuality training needs of SCI rehabilitation nursing staff.
#12
Characteristics of Young Spinal Cord Injury Consumers of Assistive Technologies
Laura Cushman, PhD; and Marcia Scherer, PhD
Objectives
• To know what areas younger spinal cord injury (SCI) persons did not differ in terms of assistive technology (AT) user characteristics
• To name two areas/concerns which were more important to younger assistive technology users
• To name two characteristics younger consumers more often rated themselves as having
Most psychosocial health care providers are aware that assistive technologies can significantly enhance function, participation, and quality of life. Data relevant to AT use specifically in adolescent/early adult persons with SCI is rare, however. We studied perceptions of self, disability and AT in a group of 14 SCI consumers who were age 17 to 23. In terms of summary scores reflecting emotional status (anger, depression), self-efficacy and readiness for technology use, individuals in the study (i.e. the younger) group did not differ from older individuals with SCI. However, there were significant differences in terms of responses to specific questions. Younger subjects had greater concerns regarding comfort, social acceptability, and self-consciousness related to AT use. They also tended to have more concerns regarding the impact of AT on their usual routines. In terms of personal characteristics, younger consumers more often saw themselves as: encouraged by their therapists, aspiring to go to school or work, having many things to accomplish, finding technology interesting, having little privacy, and assuming therapists know what is best for them. They also saw themselves as more often angry or discouraged. These results suggest that educational approaches to AT, as well as the process by which a specific AT is chosen and prescribed, should be influenced by what is known about younger AT consumers. Further research in this area is a crucial next step.
#09
Chronic Pain in Veterans with Spinal Cord Injury: A Prevalent Problem
Diana H. Rintala, PhD; Sally Ann Holmes, MD; Daisy Courtade, MA; Richard Neil Fiess; and Paul G. Loubser, MD
Objectives
• Be aware of the high prevalence of pain in veterans with spinal cord injuries
• Be able to identify factors that exacerbate pain
• Be able to discuss the need for more pain treatment research
Several studies have found that chronic pain is prevalent among persons with spinal cord injury (SCI). Few studies have focused exclusively on chronic pain in veterans with SCI who receive care from Veterans Affairs facilities. A telephone survey was conducted among 348 (66%) of 530 veterans with SCI who received care from one regional VA SCI Center during a three-year period to assess prevalence and various facets of individual chronic (> 6 months) pain components in the veteran SCI population. The Short-Form McGill Pain Questionnaire (SF-MPQ) assessed qualitative properties of the pain experience. Other questions assessed frequency, duration, intensity, exacerbators, and effects on daily activities. Seventy-six percent of the respondents reported at least one chronic pain component. The majority (83%) of the pains occurred daily (mean = 27.4 days/month), and lasted most of the day (mean = 17.4 hours/day). Pain intensity in the past week averaged 6.7 (0 to 10 scale), while worst pain intensity averaged 8.6. Two-thirds of the pains interfered with daily activities. The most common exacerbating factors were being active (39%) and weather-related issues (18%). The most common SF-MPQ descriptors were aching, sharp, hot-burning and tiring-exhaustion. Nearly half (49%) of the pains were in the lower extremities only or in combination with other areas of the body. Pains extending from the neck or upper trunk down to and including the lower extremities occurred on more days per month and more hours per day, had the worst pain intensity, and had the highest SFMPQ scores. The majority of the pains occurred at and/or below the level of the SCI lesion. Pains that occurred in all three areas relative to the lesion (above, at, and below) were the most frequent, longest lasting, and most intense, while pains that occurred both at and below level fared second worst. Extrapolating from our findings, of the approximately 15,000 veterans with SCI who annually receive health care from VA facilities, 11,400 (75%) have chronic pain and 6,270 have severe pain. More research is needed to identify better ways to prevent, assess, and treat chronic pain in the VA SCI population.
#02
Development of an Index: Restaurant Wheelchair Accessibility
David Tulsky, PhD; Trevor Dyson-Hudson, MD; and Amy Bullman, BA
Objectives
• Attendees will learn about accessibility issues
• Attendees will understand how data collection can be accomplished through the worldwide web
• Attendees will understand the dimensions that make public places accessible
Introduction: Despite the passage of Title III of the Americans with Disabilities Act (ADA) which prohibited discrimination on the basis of disability by public accommodations, many facilities open to the general public are often not accessible to people with disabilities. For individuals with spinal cord injury (SCI), the accessibility of a restaurant is often the most important factor in deciding where to eat. Unfortunately, it is not always easy for them to know beforehand if a restaurant is accessible or not. In fact, unless someone who uses a wheelchair has been to the restaurant already, people must often rely on attempts by non-wheelchair users to assess its accessibility. Anyone who has been told that a restaurant was wheelchair accessible only to find multiple steps leading up to the entrance when they got there, however, knows that accessibility information from non-wheelchair users may not always be reliable. Over the last few years, restaurant review web sites have become increasingly popular. Most of these web sites rate restaurants on factors such as food, decor, service, and cost. However, they do not indicate if a restaurant is wheelchair accessible or to what degree it is accessible. This is partly due to the fact that there is no working definition of restaurant accessibility and no factor available which quantifies accessibility in a meaningful and practical way.
Objectives: To inform consumers of the development of a web-based index (rating survey) for restaurant accessibility.
Methods: Starting with feedback from a focus group of wheelchair-using individuals with SCI, they created a comprehensive list of the various items influencing a restaurants accessibility. The resulting survey, called the Accessibility Index, covers areas such as the accessibility of the restaurants parking, entrance, interior, restroom(s), and service and hospitality. A special web site was also created to make the Accessibility Index available to everyone and to make it convenient for people to use www.demo.accessibilityguide.com.
Results and Discussion: To date, 68 individuals who use wheelchairs have participated in the study and visited over 30 different restaurants. Not only have participants rated the restaurants for their accessibility for individuals who use wheelchairs, but have provided direct feedback of the scale itself. All users have found the reviews easy to complete and the online submission process has provided a streamlined method for participants to provide ratings. All entries are entered into a database for analyses that could easily be converted to become a feedback mechanism for consumers. The ultimate goal of the project is to create a practical and meaningful measure of accessibility that can eventually be adopted and incorporated as a standard by existing mainstream restaurant web sites. This demonstration project was designed to develop and build a website that could drive commerce, allowing people with disabilities to choose restaurants based not only on their location, food, decor, service, and cost, but also based on their accessibility.
#305
A Single Question Screen for Coping with Spinal Cord Injury
Jonathan Sills, MA; and Michael Dunn, PhD
Objectives
• Becoming familiar with brief screening measures for coping processes with spinal cord injury
• Describe how brief screening measures may be useful in needs assessment and treatment planning
• Describe the relationship between age and coping processes
Depending on the coping process employed, people with spinal cord injury (SCI) have a better mood, a higher quality of life, and are able to maintain greater self-care. A comprehensive assessment of coping processes is often facilitated by administration through the sixty-six item “Ways of Coping” questionnaire. One drawback to employing the measure is that administration may take up to 30 minutes to score and interpret the questionnaire, which may be impractical in hospital/clinical environments. In an attempt to identify a patient’s coping processes within a time frame more congruent with clinical encounters, an open-ended, single question screen, on the ways patients cope with their disability, has been used for three years on our in-patient SCI service. This study examines the general utility of employing the single question screen by comparing responses between the two measures. Screening was conducted by one of three team members, including one psychologist and two psychology graduate students in training on the service. Of the patients assessed to date (n = 287), 146 were paraplegics and 141 were quadriplegics. Due to the open-ended nature of the screen, patient responses were coded and grouped according to the eight coping processes identified on the Ways of Coping Questionnaire. The range and distribution of the screen responses were then compared to the range and distribution of responses identified by the “Ways of Coping” questionnaire.
Analysis of the data suggests that: 1) the one item screen achieves a similar range and distribution with responses on the “Ways of Coping” questionnaire and; 2) Age at the time of injury impacts the frequency at which particular coping process are employed. These results support the use of a single question coping screen when working within a clinical environment that renders the administration of the “Ways of Coping” questionnaire unfeasible.
#214
Women with Violently Acquired Spinal Cord Injury:
Examining Psychosocial Issues on the Clinical-Research Continuum
Martin Forchheimer, MPP; Amy Armstrong, PhD; Marcia Redwood, BS; and Michelle Meade, PhD
Objectives
• Participants will increase awareness of the occurrence of violently acquired spinal cord injury (VASCI) in women and how these individuals differ from males with VASCI
• Participants will be able to discuss ways in which violently acquired spinal cord injury may effect womens’ roles as mothers, daughters, lovers, and workers
• Participants will be able to identify risk factors for poor psychological outcomes and possible methods of addressing the issues
Introduction: This study presents the results of a multi-center investigation of gender differences among individuals with the violently acquired spinal cord injury (VASCI).
Problem Statement: Because VASCI predominantly occurs in young, minority males, females injured through violence have received little attention in prior research. The resulting lack of awareness of gender differences may lead to inappropriate generalizations.
Objective: To explore how males and females incurring VASCI differ in terms of pre-injury attributes and to evaluate the interactions of gender and violence and long-term psychosocial outcomes.
Statement of Methods: Participants consisted of 4,460 individuals with SCI who are part of the National Model SCI System Database for whom follow-up data was collected during the period between 2000 and 2003 (mean 9.7 years post-injury). Approximately 79% of the sample was male and 21% female; overall, 13.6% were injured as a result of violence. Descriptive and inferential (Chisquare, ANCOVA) statistics were conducted to examine pre-injury characteristics and assessments of depression, alcohol abuse and pain at long-term follow-up.
Results: VASCI was significantly less prevalent among the females (10.4%) than among males (14.5%; p < .001). However, while violence as an etiology of injury was far more prevalent among minority males (39.4% vs. 28.7%; p < .002), there were no gender differences among non-Hispanic Caucasians (5.3% vs. 5.1%). Similarly, no differences were observed between prevalence of VASCI and gender among either participants who were married or those who had completed at least high school prior to their injuries. With regard to alcohol misuse, VASCI was more prevalent among men who did not have issues of abuse (classified using the CAGE; 21.6% vs. 13.9%; p < .0001), while there were no significant gender differences among those with abuse problems (29.0% vs. 27.5%). Women with VASCI had the highest rates of subsequent depressive disorders (25.8%) and, among men, there was a significant relationship between VASCI and depression among women (p = .02). No differences in pain reports were observed between VASCI males and females.
Conclusions: Global assessments of the relationship between gender and VASCI mask important differences and thus care needs to be taken when drawing conclusions about this group.
#27
Spinal Cord Injury and Divorce: Resolving Some Contradictory Findings
Glenn Curtiss, PhD; and Lisa M. Brown, PhD
Objectives
• Describe the variability of research findings pertaining to spinal cord injury as a risk factor for divorce
• State the empirical relationship between spinal cord injury and divorce in the United States
• Describe possible reasons for differences in divorce risk between the United States and other countries
Introduction: Spinal cord injury (SCI) has a significant impact on the individual’s lifestyle and role functioning. Independence, vocational functioning, spouse/parent functioning, and sexual intimacy may all be affected. Such changes can place a strain on the marital relationship. However, studies of divorce following SCI have produced mixed results (Craig & Hancock, 1998; Kreuter, 2000). Estimates of divorce prevalence vary widely, with some studies showing increased proportions of divorced individuals following SCI while others find no relationship.
Objective: To evaluate the empirical literature on SCI and marital status.
Methods: Medline and Psychlit were searched using the keywords: spinal cord injuries, marital status, and divorce. The search was supplemented by a Social Science Citation Index search and a manual search of cited studies. Inclusion criteria were: studies published between 1985 and 2003, studies published in the English language, empirical data provided on marital status (divorced/separated) of individuals with SCI, and sufficient data provided to calculate an effect size (Cohen’s d). United States and international census marital status data were used for base rate comparisons.
Results: A total of 31 studies were identified. Of these, 24 were excluded because they did not permit calculation of d. Thus, seven studies were available for inclusion in the analysis, which yielded a total sample of 4,331 subjects. Effect sizes were calculated against appropriate country population census data. Effect size values ranged from .002 to .396, with an average d of 0.24. However, the set of d values had a large standard deviation relative to the variance attributable to sampling error, Q(6) = 50.20, p < .001, indicating the presence of moderator variables. Examination by country showed that SCI had a relationship with marital status in the United States only, d = .25. However, approximately 66% of the variance in marital status remained unexplained.
Conclusions: In the United States, SCI is a risk factor for divorce or separation. The lack of relationship between SCI and marital status in European countries and Australia suggests that U.S. societal norms and values may underlie this risk. These findings illustrate the need for access to marital support systems following injury.
#210
International Classification for Functioning Disability and Health: An Orientation with Practical Applications
Nancy H. Merbitz, PhD
Objectives
• Participants will gain information with which to analyze the ICF as a dynamic system
• Participants will gain information on the interaction of environment, people and technology
• Participants will apply this information in their research and clinical practice
The project for the International Classification of Function (ICF) aims to develop a system for measuring human function, including bodily function and functioning in daily activities and participation. Within the ICF, contextual factors describe the environmental and personal contexts which shape (and in turn are shaped by) the individuals functioning in those domains. Using the example of assistive technology (AT), this paper explores the structure of the ICF and the recursive, non-linear relationships between person and environment. AT, and indeed any useful technology, enables users to fashion more effective contact with various environments to fulfill needs and wants. The paper will describe the complex nature of AT at the interface between the person and multiple environments. Access to AT resources, or lack thereof, is a contextual factor related to the users physical environment (e.g., is appropriate technology available and is there money to pay for it?) and social environment (e.g., are knowledgeable professionals available to dialog with the potential AT user regarding options?). Successful use of AT also depends on Personal Contextual factors related, in part, to the users own learning history (e.g., what is the users history of experiences with technology, and what attitudes and skills have been developed so far?). Other personal contextual factors influencing the use of AT include interests and goals (e.g., what does the user wish to do; where does he or she want to go?). On further reflection, an iterative process is revealed; for example: the persons selection of AT is influenced by bodily function, environmental resources, and personal history and preferences, and if the selected AT positively affects his/her quality and frequency of activity and participation, these successes in turn become part of his/her personal history, including more positive attitudes toward technology and more skills. Perhaps even bodily function (e.g., strength, mood, concentration) improves as a result of increased exercise, allowing consideration of additional AT choices and new activities. So, in this way, the ICF system is viewed dynamically, and measurement captures but one point in time.