An Assessment of An Assessment of Clinically Relevant Clinically Relevant Pediatric Physical Pediatric Physical

Therapy Outcome ToolsTherapy Outcome ToolsRegis UniversityRegis UniversitySept 29, 2010Sept 29, 2010Cody Butler, SPTCody Butler, SPT

Courtney Haia, SPTCourtney Haia, SPTSydney Stan, SPTSydney Stan, SPT

ObjectivesObjectives

At the end of this presentation, each clinician should be able to:

Accurately identify Sn, Sp, MCID, & MDD when selecting an outcome tool

Compare and contrast the psychometric properties of Pediatric PT outcome tools

Describe the effectiveness of the PEDI as an outcome tool in the pediatric setting

Examine the psychometric properties of the PEDI based on evidence-based literature

Accurately search and critically appraise literature for high quality and clinically relevant research regarding outcome measures

Benefits of Outcome Benefits of Outcome MeasurementMeasurement

Information about developmental progress

Ensure continuation of funding

Improve program planning

Inform decision making

Improve guidance in goal development

ChallengeChallenge

The use of measures that are sensitive to small changes in children with differing developmental and functional disabilities.

StakeholdersStakeholders

The Children’s Hospital

Department of Rehabilitation

Individual Physical Therapists

Patients and Families

Recommendations for Recommendations for Outcome Measure Outcome Measure

SystemsSystems Ask Questions

Purpose If purpose is for comparing performance to same age peer then

you need a scale that can give a normative standard score. (PEDI, Peabody, TIMP, AIMS)

If purpose is to measure progress along a continuum of difficulty then you need a measure that can give you a scaled score.(GMFM, PEDI)

Consider validity, reliability, sensitivity to change and responsiveness of the measure

Consider the group or individual of interest: homogenous, heterogeneous, dx, age, severity of functional challenges, rate of change

Specificity and Specificity and SensitivitySensitivity

A test’s ability to obtain a negative result when the condition actually is absent. A true negative. “SpIN”

When a test is positive, you can rule in the disease/ condition

The ability to obtain a positive test when the target condition is actually present. “SnOUT”

If the test is negative, you can rule the condition out. Overestimates

the amount of people who have it.

Clinically Significant DifferenceClinically Significant Difference

1. Responsiveness

“The power of a test to detect a clinically important difference.”

1. Sensitivity to Change “Accurate detection of change when it has occurred.”

Minimal detectable Minimal detectable difference (MDD)difference (MDD)

Defines the amount of change in a variable that must be achieved in order to reflect a true difference The smallest amount of change that passes the

threshold of error.

Minimal clinically-Minimal clinically-important difference important difference

(MCID)(MCID)Smallest difference in a measured variable

that signifies and important rather than trivial differences in patients’ conditions. Smallest difference a patient or clinician would

perceive as beneficial & would result in a change in the management of the pt.

Psychometric Properties

TIMP GMFM PEDI

Responsive-ness

Discriminates between children

with various conditions

Discriminates between GMFCS

levels I-II and II-III3

Greater responsiveness to change with children > 4yo

Sensitivity to change

Age-related changes in motor

performance (r = .83)1

ES and SRM > 0.54 ES and SRM > 0.84

Reliability ICC: 0.89-0.95 Inter-rater: 0.077 and 0.885

ICC: 0.95-0.996

Inter-respondent reliability: 0.64-0.746

Validity Concurrent validity with

AIMS2

Children with CP and Down’s

Syndrome (66)

Construct: strong correlation between mean scale scores and child’s age for functional skills

and care giver assistance scales7

Patient population

34 weeks – 4 months

5mo – 16 yrs < 7yo

InternationalInternational Classification of Classification of Functioning, Disability and Health (ICF)Functioning, Disability and Health (ICF)

Body Function: physiological function

Activity: execution of an action

Participation: places activities in to life situations

ICF

Level8-10 TIMP

Wee

FIM GMFM PEDI

Health Condition

NO NO NO NO

Body Function

NO NO NO NO

Activity YES YES YES YES

Participation NO NO NO YES

Environment NO NO NO YESEnv mod, caregiver

asst

We started with the We started with the QuestionQuestion

What outcome tool effectively measures change in activity level and participation for children with a wide variety of neurological disorders?

PEDI (CP or children) AND physical PEDI (CP or children) AND physical therapy AND responsiveness to change therapy AND responsiveness to change

AND assessmentAND assessment

Pub-med 1 result (Ketelaar 200811)

Conclusion “Only two evaluative assessment measures, the

Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI), fulfill the criteria of reliability and validity with respect to responsiveness to change.”

What is the PEDI?What is the PEDI?

Pediatric Evaluation of Disability Inventory (1990)

Discriminative device Detects functional limitations and participation

Self-care, mobility, social function, caregiver assistance, modifications

Evaluative Tracks progress in individual children with disabilities;

Sensitive to small increments of change Examples: Cerebral Palsy, hemiplegia, spina bifida,

TBI, Down’s syndrome

PEDIPEDI

Number of items/questions 197

Time to complete 30-60 minutes

Age range <1-7 years

Score range 0-100

Administered by clinician/guardian

Usefulness to everyday Usefulness to everyday practicepractice

Engelen 2007Engelen 20071212

CONCLUSION Individual goals set in a physical therapy

practice for children with cerebral palsy can be linked, to a large extent, to items and activities of 2 standardized measures. GMFM-88 and PEDI

Identifying quality Identifying quality evidence in the evidence in the

literatureliteratureWhen asking a question based on gaps in the

literature, use the PICO format: Person/patient population Intervention Comparison Outcome

Databases: PubMed, CINAHL, Cochrane Library

Future EndeavorsFuture Endeavors

Standardized format for documenting pediatric interventions (PPTIA)13

PEDI Multidimensional PEDI Multidimensional Computer adaptive testing Computer adaptive testing (PEDI-MCAT)(PEDI-MCAT)14

ConclusionConclusion

No one assessment tool is able to capture the impact of pediatric physical therapy and the use of environmental modifications/adaptive equipment on the multiple dimensions of the ICF (body function, activity, participation).

Questions?Questions?

ReferencesReferences1.1. Campbell, S. K., & Hedeker, D. (2001). Validity of the Test of Infant Motor Performance for discriminating Campbell, S. K., & Hedeker, D. (2001). Validity of the Test of Infant Motor Performance for discriminating

among infants with varying risk for poor motor outcome. among infants with varying risk for poor motor outcome. Journal of Pediatrics, 139, 546-551Journal of Pediatrics, 139, 546-5512.2. Barbosa VM, Campbell SK, Barbosa VM, Campbell SK, Jaidep Singh DS, et al. Longitudinal Performance of Infants with Cerebral Palsy on Jaidep Singh DS, et al. Longitudinal Performance of Infants with Cerebral Palsy on

the Test of Infant Motor Performance and on the Alberta Infant Motor Scale. the Test of Infant Motor Performance and on the Alberta Infant Motor Scale. Physical & Occupational Physical & Occupational Therapy in Pediatrics.Therapy in Pediatrics. 2003; 23: 3. 2003; 23: 3.

3.3. Bagley AM, Gorton G, Oeffinger D, Barnes D, et al. Outcome assessments in children with cerebral palsy, Bagley AM, Gorton G, Oeffinger D, Barnes D, et al. Outcome assessments in children with cerebral palsy, Part II: discriminatory ability of outcome tools. Part II: discriminatory ability of outcome tools. Developmental Medicine & Child Neurology. Developmental Medicine & Child Neurology. 2007, 49: 181–2007, 49: 181–186.186.

4.4. Vos-Vromans DCWM, Ketelaar M, and Gorter JW. Responsiveness of evaluative measures for children with Vos-Vromans DCWM, Ketelaar M, and Gorter JW. Responsiveness of evaluative measures for children with cerebral palsy: The Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory. cerebral palsy: The Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory. Disability and Rehabilitation.Disability and Rehabilitation. 2005; 27(20): 1245 – 1252. 2005; 27(20): 1245 – 1252.

5.5. Nordmark E, Hagglund G, Jarnlo GB. Reliability of the gross motor function measure in cerebral palsy. Scand Nordmark E, Hagglund G, Jarnlo GB. Reliability of the gross motor function measure in cerebral palsy. Scand J Rehabil Med 1997;29(1):25-8.J Rehabil Med 1997;29(1):25-8.

6.6. Berg M, Jahnsen R, Frøslie K, Hussain A. Reliability of the pediatric evaluation of disability inventory (PEDI). Berg M, Jahnsen R, Frøslie K, Hussain A. Reliability of the pediatric evaluation of disability inventory (PEDI). Physical & Occupational Therapy in Pediatrics.Physical & Occupational Therapy in Pediatrics. 2004;24:61-77 2004;24:61-77

7.7. Haley S, Coster, W, Ludlow L, Haltiwanger J, Andrellos J. Haley S, Coster, W, Ludlow L, Haltiwanger J, Andrellos J. Pediatric Evaluation of Disability Inventory (PEDI).Pediatric Evaluation of Disability Inventory (PEDI). Boston: Trustees of Boston Univeristy, 1998.Boston: Trustees of Boston Univeristy, 1998.

8.8. McCarthy ML, Silberstein CE, Atkins EA, et al. Comparing reliability and validity of pediatric instruments for McCarthy ML, Silberstein CE, Atkins EA, et al. Comparing reliability and validity of pediatric instruments for measuring health and well-being of children with spastic cerebral palsy. measuring health and well-being of children with spastic cerebral palsy. Developmental Medicine & Child Developmental Medicine & Child Neurology.Neurology. 2002, 44:468–476. 2002, 44:468–476.

9.9. Oeffinger D, Gorton G, Nicholson D, et al. Outcome assessments in children with cerebral palsy, Part I: Oeffinger D, Gorton G, Nicholson D, et al. Outcome assessments in children with cerebral palsy, Part I: descriptive characteristics of GMFCS Levels I to III. descriptive characteristics of GMFCS Levels I to III. Developmental Medicine & Child Neurology.Developmental Medicine & Child Neurology. 2007, 49: 2007, 49: 172–180.172–180.

10.10. Lollar DJ, Simeonsson RJ, and Nanda U. Measures of Outcomes for Children and Youth. Lollar DJ, Simeonsson RJ, and Nanda U. Measures of Outcomes for Children and Youth. Arch Phys Med Arch Phys Med Rehabil.Rehabil. 2000;81. 2000;81.

11.11. Ketelaar M, Vermeer A, Helders PJ. Functional motor abilities of children with cerebral palsy: a systematic Ketelaar M, Vermeer A, Helders PJ. Functional motor abilities of children with cerebral palsy: a systematic literature review of assessment measures. literature review of assessment measures. Clin RehabilClin Rehabil. 1998; 12(5):369-80.. 1998; 12(5):369-80.

12.12. Engelen V, Ketelaar M, Gorter JW. Selecting the appropriate outcome in pediatric physical therapy: how Engelen V, Ketelaar M, Gorter JW. Selecting the appropriate outcome in pediatric physical therapy: how individual treatment goals of children with cerebral palsy are reflected in GMFM-88 and PEDI. individual treatment goals of children with cerebral palsy are reflected in GMFM-88 and PEDI. J Rehabil MedJ Rehabil Med. . 2007; 39(3):225-31. 2007; 39(3):225-31.

13.13. Hashimoto M and Westcott McCoy S.Hashimoto M and Westcott McCoy S. Validation of an Activity-Based Data Form Developed to Reflect Validation of an Activity-Based Data Form Developed to Reflect Interventions Used by Pediatric Physical Therapists. Interventions Used by Pediatric Physical Therapists. Pediatr Phys Ther.Pediatr Phys Ther. 2009;21:53–61. 2009;21:53–61.

14.14. Hayley SM, Coster WI, Kao YC, Dumas HM et al. Lessons from use of the pediatric evaluation of disability Hayley SM, Coster WI, Kao YC, Dumas HM et al. Lessons from use of the pediatric evaluation of disability inventory: where do we go from here? inventory: where do we go from here? Ped. Phys. Ther. Ped. Phys. Ther. 2010.2010.