Outcomes of post-acute hospital episodes for young children requiring airway support

In this descriptive study, we examined changes in invasive and non-invasive airway support; studied the rates of home discharge vs. long-term care or acute hospitalization; and examined the relationship between the level of airway support and discharge to home for 92 children (<3 years of age) with 104 admission-discharge episodes to a consortium of pediatric rehabilitation hospitals over a one-year period. We found a significant reduction (p < 0.001) in the level of airway support between admission and discharge. In 21 of 47 (45%) episodes, children weaned from mechanical ventilation to a less restrictive type of support. Sixty percent of the children had final discharges to home. There was a significant, though fair correlation (Spearman Rho = -0.344, p = 0.001) between home discharge and level of airway support. These outcomes data provide a multi-site baseline for understanding expected changes in airway support and home discharge rates of young children who are admitted to a post-acute inpatient program.

Ventilator weaning outcomes in chronic respiratory failure in children

The purpose of this study was to describe mechanical ventilation weaning outcomes for children with chronic respiratory failure discharged from one of six post-acute rehabilitation facilities. Demographic, clinical and outcome data were collected from the medical record. Forty-four children were included in this prospective series; 20 (45%) were weaned off the ventilator at discharge. Children required significantly lower levels of ventilatory support at discharge than admission. Hourly use on the ventilator decreased from admission to discharge for the full cohort and for the subgroup who required a ventilator at discharge. Seventy-five percent of the children discharged with a ventilator had a portable unit. We conclude that nearly half of the children using mechanical ventilation achieve weaning during a postacute rehabilitation admission, whereas others have positive outcomes in severity, hours off the ventilator or portability of equipment.

Prospective evaluation of the AM-PAC-CAT in outpatient rehabilitation settings

BACKGROUND AND PURPOSE

The purpose of this study was to prospectively evaluate the practical and psychometric adequacy of the Activity Measure for Post-Acute Care (AM-PAC) "item bank" and computerized adaptive testing (CAT) assessment platform (AM-PAC-CAT) when applied within orthopedic outpatient physical therapy settings.

METHOD

This was a prospective study with a convenience sample of 1,815 patients with spine, lower-extremity, or upper-extremity impairments who received outpatient physical therapy in 1 of 20 outpatient clinics across 5 states. The authors conducted an evaluation of the number of items used and amount of time needed to complete the CAT assessment; evaluation of breadth of content coverage, item exposure rate, and test precision; as well as an assessment of the validity and sensitivity to change of the score estimates.

RESULTS

Overall, the AM-PAC-CAT's Basic Mobility scale demonstrated excellent psychometric properties while the Daily Activity scale demonstrated less adequate psychometric properties when applied in this outpatient sample. The mean length of time to complete the Basic Mobility scale was 1.9 minutes, using, on average, 6.6 items per CAT session, and the mean length of time to complete the Daily Activity scale was 1.01 minutes, using on average, 6.8 items. BACKGROUND AND CONCLUSION: Overall, the findings are encouraging, yet they do reveal several areas where the AM-PAC-CAT scales can be improved to best suit the needs of patients who are receiving outpatient orthopedic physical therapy of the type included in this study.

Association of environmental factors with levels of home and community participation in an adult rehabilitation cohort

OBJECTIVE

To examine whether home and community environmental barriers and facilitators are predictors of social and home participation and community participation at 1 and 6 months after discharge from an acute care or inpatient rehabilitation hospital.

DESIGN

Cohort study.

SETTING

Postacute care.

PARTICIPANTS

Adults (N=342) age 18 years or older with a diagnosis of complex medical, orthopedic, or neurologic condition recruited from acute care and inpatient rehabilitation facilities. The mean age +/- standard deviation of participants was 68+/-14 years; 49% were women and 92% were white.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participation in social, home and community affairs as assessed with the Participation Measure for Post-Acute Care.

RESULTS

Adjusting for covariates, 1 month after discharge a greater presence of home mobility barriers (P<.01) was associated with less social and home participation; whereas greater community mobility barriers (P<.01) and more social support (P<.001) were associated with greater participation. At 6 months, social support was the only environmental factor associated with participation after adjusting for covariates.

CONCLUSIONS

This study provides new empirical evidence that environmental barriers and facilitators do influence participation in a general rehabilitation cohort, at least in the short term.

Sensitivity of a computer adaptive assessment for measuring functional mobility changes in children enrolled in a community fitness programme

OBJECTIVE

To examine the relative sensitivity to detect functional mobility changes with a full-length parent questionnaire compared with a computerized adaptive testing version of the questionnaire after a 16-week group fitness programme.

DESIGN

Prospective, pre- and posttest study with a 16-week group fitness intervention.

SETTING

Three community-based fitness centres.

SUBJECTS

Convenience sample of children (n = 28) with physical or developmental disabilities.

INTERVENTIONS

A 16-week group exercise programme held twice a week in a community setting.

MAIN MEASURES

A full-length (161 items) paper version of a mobility parent questionnaire based on the Pediatric Evaluation of Disability Inventory, but expanded to include expected skills of children up to 15 years old was compared with a 15-item computer adaptive testing version. Both measures were administered at pre- and posttest intervals.

RESULTS

Both the full-length Pediatric Evaluation of Disability Inventory and the 15-item computer adaptive testing version detected significant changes between pre- and posttest scores, had large effect sizes, and standardized response means, with a modest decrease in the computer adaptive test as compared with the 161-item paper version. Correlations between the computer adaptive and paper formats across pre- and posttest scores ranged from r = 0.76 to 0.86.

CONCLUSIONS

Both functional mobility test versions were able to detect positive functional changes at the end of the intervention period. Greater variability in score estimates was generated by the computerized adaptive testing version, which led to a relative reduction in sensitivity as defined by the standardized response mean. Extreme scores were generally more difficult for the computer adaptive format to estimate with as much accuracy as scores in the mid-range of the scale. However, the reduction in accuracy and sensitivity, which did not influence the group effect results in this study, is counterbalanced by the large reduction in testing burden.

Measurement precision and efficiency of multidimensional computer adaptive testing of physical functioning using the pediatric evaluation of disability inventory

OBJECTIVE

To compare the measurement efficiency and precision of a multidimensional computer adaptive testing (M-CAT) application to a unidimensional CAT (U-CAT) comparison using item bank data from 2 of the functional skills scales of the Pediatric Evaluation of Disability Inventory (PEDI).

DESIGN

Using existing PEDI mobility and self-care item banks, we compared the stability of item calibrations and model fit between unidimensional and multidimensional Rasch models and compared the efficiency and precision of the U-CAT- and M-CAT-simulated assessments to a random draw of items.

SETTING

Pediatric rehabilitation hospital and clinics.

PARTICIPANTS

Clinical and normative samples.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

The M-CAT had greater levels of precision and efficiency than the separate mobility and self-care U-CAT versions when using a similar number of items for each PEDI subdomain. Equivalent estimation of mobility and self-care scores can be achieved with a 25% to 40% item reduction with the M-CAT compared with the U-CAT.

CONCLUSIONS

M-CAT applications appear to have both precision and efficiency advantages compared with separate U-CAT assessments when content subdomains have a high correlation. Practitioners may also realize interpretive advantages of reporting test score information for each subdomain when separate clinical inferences are desired.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes

OBJECTIVE

To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home.

DESIGN

Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit.

SETTING

Follow-up visits conducted in patients' home setting.

PARTICIPANTS

Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66).

RESULTS

AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval.

CONCLUSIONS

Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.

Depression in orthopaedic trauma patients. Prevalence and severity

BACKGROUND

There is a known connection between physical injury and disability and emotional distress. Several investigators have shown a relationship between trauma, depression, and poor outcomes. The literature on trauma and depression is limited with regard to clarifying the relationship between the degree of injury and depression and the relationship between physical function of patients with less severe injuries and depression.

METHODS

One hundred and sixty-one patients who presented to our orthopaedic trauma services were enrolled in the study and interviewed. We obtained information about patient demographics and administered several self-reported outcome measures: the Beck Depression Inventory (BDI), the Short Musculoskeletal Function Assessment (SMFA), and the Physical Function-10 (PF-10) subset of the Short Form-36 (SF-36). We documented the nature and severity of the injury or injuries and calculated correlations between the outcome measures and the BDI. Injury-specific factors such as the AO Fracture Classification, the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Gustilo and Anderson grade of open fractures were also examined.

RESULTS

Fifty-five percent of the patients had minimal depression, as measured with the BDI; 28% had moderate depression; 13% had moderate-to-severe depression; and 3.7% had severe depression. When the somatic elements of the BDI were removed, the prevalence of moderate, moderate-to-severe, or severe depression was 26%. The SMFA scores had a strong negative correlation with the BDI (-0.75; p < 0.001). Of the injury-specific factors, only open factures were found to have an impact on the presence of depression, with an odds ratio of 4.58 (95% confidence ratio, 1.57 to 12.35).

CONCLUSIONS

The prevalence of clinically relevant depression approached 45% in a diverse cohort of orthopaedic trauma patients. Global disability is strongly correlated with depression. The presence of an open fracture may also increase the risk of depression.

LEVEL OF EVIDENCE

Prognostic Level II.

Agreement in Functional Assessment

OBJECTIVE

The objective of this study was to examine the agreement between respondents of summary scores from items representing three functional content areas (physical and mobility, personal care and instrumental, applied cognition) within the Activity Measure for Postacute Care (AM-PAC). We compare proxy vs. patient report in both hospital and community settings as represented by intraclass correlation coefficients and two graphic approaches.

DESIGN

The authors conducted a prospective, cohort study of a convenience sample of adults (n = 47) receiving rehabilitation services either in hospital (n = 31) or community (n = 16) settings. In addition to using intraclass correlation coefficients (ICC) as indices of agreement, we applied two graphic approaches to serve as complements to help interpret the direction and magnitude of respondent disagreements. We created a "mountain plot" based on a cumulative distribution curve and a "survival-agreement plot" with step functions used in the analysis of survival data.

RESULTS

ICCs on summary scores between patient and proxy report were physical and mobility ICC = 0.92, personal care and instrumental ICC = 0.93, and applied cognition ICC = 0.77. Although combined respondent agreement was acceptable, graphic approaches helped interpret differences in separate analyses of clinician and family agreement.

CONCLUSIONS

Graphic analyses allow for a simple interpretation of agreement data and may be useful in determining the meaningfulness of the amount and direction of interrespondent variation.

Measuring patient-reported outcomes after discharge from inpatient rehabilitation settings

OBJECTIVE

To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital.

DESIGN

Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter.

PATIENTS

Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male.

MAIN OUTCOME MEASURES

AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales.

RESULTS

All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups.

CONCLUSION

The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.

Computer adaptive testing improved accuracy and precision of scores over random item selection in a physical functioning item bank

BACKGROUND AND OBJECTIVE

Measuring physical functioning (PF) within and across postacute settings is critical for monitoring outcomes of rehabilitation; however, most current instruments lack sufficient breadth and feasibility for widespread use. Computer adaptive testing (CAT), in which item selection is tailored to the individual patient, holds promise for reducing response burden, yet maintaining measurement precision. We calibrated a PF item bank via item response theory (IRT), administered items with a post hoc CAT design, and determined whether CAT would improve accuracy and precision of score estimates over random item selection.

METHODS

1,041 adults were interviewed during postacute care rehabilitation episodes in either hospital or community settings. Responses for 124 PF items were calibrated using IRT methods to create a PF item bank. We examined the accuracy and precision of CAT-based scores compared to a random selection of items.

RESULTS

CAT-based scores had higher correlations with the IRT-criterion scores, especially with short tests, and resulted in narrower confidence intervals than scores based on a random selection of items; gains, as expected, were especially large for low and high performing adults.

CONCLUSION

The CAT design may have important precision and efficiency advantages for point-of-care functional assessment in rehabilitation practice settings.

A physical performance measure for individuals with mucopolysaccharidosis type I

The purpose of this article is threefold: (1) to describe the development, reliability, and validity of a revised physical performance measure for individuals with mucopolysaccharidosis type I (MPS I); (2) to standardize the test on a normal sample; and (3) to compare results from a selected sample of individuals with MPS I with age-based centiles. The MPS Physical Performance Measure (MPS-PPM) is composed of eight timed functional tasks (FT-8) and two endurance tasks with a modified Energy Expenditure Index for comfortable walking (CW) and fast walking (FW) speeds. Age norms were derived from a convenience sample of 150 typically developing children and adolescents (75 males, 75 females; mean age 11y 2mo [SD 4y 5mo]; range 5-22y). Using a Rasch model for speed tests and confirmatory factor analysis, we established the unidimensionality of the FT-8. Interrater reliability of the FT-8 (intraclass correlation [ICC]=0.98) and test-retest reliability of the FT-8 (ICC=0.96), CW (ICC=0.91), and FW (ICC=0.83) were good. Results of the age-based profiles in 10 individuals with MPS I (five males, five females; mean age 14y 2mo [SD 7y 6mo]; range 6-29y) indicate that the amount of time needed to perform functional tasks is severely affected by the disease, and most individuals were at or below the fifth centile for their age. The patterns of limitations in endurance were more varied. These results suggest the utility of using this revised MPS-PPM to identify the extent of limitation in age-expected physical performance. Implications for using the MPS-PPM for monitoring physical performance changes during clinical interventions are discussed.

Interpreting change scores of tests and measures used in physical therapy

Over the past decade, the methods and science used to describe changes in outcomes of physical therapy services have become more refined. Recently, emphasis has been placed not only on changes beyond expected measurement error, but also on the identification of changes that make a real difference in the lives of patients and families. This article will highlight a case example of how to determine and interpret "clinically significant change" from both of these perspectives. The authors also examine how to use item maps within an item response theory model to enhance the interpretation of change at a content level. Recommendations are provided for physical therapists who are interpreting changes in the context of clinical practice, case reports, and intervention research. These recommendations include a greater application of indexes that help interpret the meaning of clinically significant change to multiple clinical, research, consumer, and payer communities.

Evaluation of a community-based group fitness program for children with disabilities

PURPOSE

This study examined the feasibility, safety, and effectiveness of a community-based group fitness program for children with disabilities.

METHODS

Twenty-eight children with neuromuscular and developmental disabilities, 6 to 14 years of age, participated. The 16-week community-based program, held twice weekly, consisted of strengthening, aerobic conditioning, and flexibility exercises. A pretest-posttest design was used, and the following outcomes were measured: isometric muscle strength of the knee extensors, hip abductors, and ankle plantarflexors, walking energy expenditure, functional mobility, and fitness. Falls and injury data also were collected.

RESULTS

Mean program attendance was 75.3%, and no injuries were reported. Improvements in all clinical outcomes were observed. The most clinically meaningful improvement was in functional mobility with a large effect size (0.87).

CONCLUSIONS

Physical therapists partnering with community centers may feasibly and safely shift group fitness programs for school-aged children with disabilities from the medical setting to the community.

Measuring physical function in patients with complex medical and postsurgical conditions: a computer adaptive approach

OBJECTIVE

To examine whether the range of disability in the medically complex and postsurgical populations receiving rehabilitation is adequately sampled by the new Activity Measure--Post-Acute Care (AM-PAC), and to assess whether computer adaptive testing (CAT) can derive valid patient scores using fewer questions.

DESIGN

Observational study of 158 subjects (mean age 67.2 yrs) receiving skilled rehabilitation services in inpatient (acute rehabilitation hospitals, skilled nursing facility units) and community (home health services, outpatient departments) settings for recent-onset or worsening disability from medical (excluding neurological) and surgical (excluding orthopedic) conditions. Measures were interviewer-administered activity questions (all patients) and physical functioning portion of the SF-36 (outpatients) and standardized chart items (11 Functional Independence Measure (FIM), 19 Standardized Outcome and Assessment Information Set (OASIS) items, and 22 Minimum Data Set (MDS) items). Rasch modeling analyzed all data and the relationship between person ability estimates and average item difficulty. CAT assessed the ability to derive accurate patient scores using a sample of questions.

RESULTS

The 163-item activity item pool covered the range of physical movement and personal and instrumental activities. CAT analysis showed comparable scores between estimates using 10 items or the total item pool.

CONCLUSION

The AM-PAC can assess a broad range of function in patients with complex medical illness. CAT achieves valid patient scores using fewer questions.

A fitness program for children with disabilities

BACKGROUND AND PURPOSE

This case report describes a fitness program for children with disabilities and provides preliminary information about the safety and feasibility of the program.

CASE DESCRIPTION

Nine children, 5 to 9 years of age with physical or other developmental disabilities, participated in a 14-week group exercise program held 2 times per week followed by a 12-week home exercise program. Energy expenditure index, leg strength (force-generating capacity of muscle), functional skills, fitness, self-perception, and safety were measured before intervention, after the group exercise program, and again after the home exercise program.

OUTCOMES

No injuries occurred, and improvements in many of the outcome measures were observed. More improvements were observed after the group exercise program than after the home program, and adherence was better during the group exercise program.

DISCUSSION

This case report demonstrates that a group exercise program of strength and endurance training may be a safe and feasible option for children with disabilities. Further research is needed to evaluate the effectiveness of a group fitness program and optimal training parameters.

Contemporary measurement techniques for rehabilitation outcomes assessment*

In this article, we review the limitations of traditional rehabilitation functional outcome instruments currently in use within the rehabilitation field to assess Activity and Participation domains as defined by the International Classification of Function, Disability, and Health. These include a narrow scope of functional outcomes, data incompatibility across instruments, and the precision vs feasibility dilemma. Following this, we illustrate how contemporary measurement techniques, such as item response theory methods combined with computer adaptive testing methodology, can be applied in rehabilitation to design functional outcome instruments that are comprehensive in scope, accurate, allow for compatibility across instruments, and are sensitive to clinically important change without sacrificing their feasibility. Finally, we present some of the pressing challenges that need to be overcome to provide effective dissemination and training assistance to ensure that current and future generations of rehabilitation professionals are familiar with and skilled in the application of contemporary outcomes measurement.

Head circumference and chronic positive pressure ventilation in children: a pilot study

METHODS

We reviewed the cases of 11 children <12 years of age with complex medical conditions and respiratory failure requiring chronic positive pressure ventilation (CPPV). We conducted a within-group comparison of average head circumference (HC) percentiles with each child's age-expected 50th percentile value and a between-groups comparison with children with no history of ventilation. We examined the relationship between HC, peak levels of positive inspiratory pressure (PIP), and length of time on CPPV.

RESULTS

We found that children on CPPV had an average HC value at the 71st percentile, significantly greater (p=0.009) than the age-expected 50th percentile; that children on CPPV had a greater (p=0.003) average HC percentile compared with children with complex medical conditions not on CPPV; and that peak levels of PIP had a moderately strong correlation to HC (r=0.689, p=0.019).

CONCLUSION

We conclude that children on CPPV have larger than expected HC and HC appears related to the peak level of PIP. Research to further investigate the relationship between HC and CPPV in children appears to be warranted.

Assessing mobility in children using a computer adaptive testing version of the pediatric evaluation of disability inventory

OBJECTIVE

To assess score agreement, validity, precision, and response burden of a prototype computerized adaptive testing (CAT) version of the Mobility Functional Skills Scale (Mob-CAT) of the Pediatric Evaluation of Disability Inventory (PEDI) as compared with the full 59-item version (Mob-59).

DESIGN

Computer simulation analysis of cross-sectional and longitudinal retrospective data; and cross-sectional prospective study.

SETTING

Pediatric rehabilitation hospital, including inpatient acute rehabilitation, day school program, outpatient clinics, community-based day care, preschool, and children's homes.

PARTICIPANTS

Four hundred sixty-nine children with disabilities and 412 children with no disabilities (analytic sample); 41 children without disabilities and 39 with disabilities (cross-validation sample).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from a prototype Mob-CAT application and versions using 15-, 10-, and 5-item stopping rules; scores from the Mob-59; and number of items and time (in seconds) to administer assessments.

RESULTS

Mob-CAT scores from both computer simulations (intraclass correlation coefficient [ICC] range, .94-.99) and field administrations (ICC=.98) were in high agreement with scores from the Mob-59. Using computer simulations of retrospective data, discriminant validity, and sensitivity to change of the Mob-CAT closely approximated that of the Mob-59, especially when using the 15- and 10-item stopping rule versions of the Mob-CAT. The Mob-CAT used no more than 15% of the items for any single administration, and required 20% of the time needed to administer the Mob-59.

CONCLUSIONS

Comparable score estimates for the PEDI mobility scale can be obtained from CAT administrations, with losses in validity and precision for shorter forms, but with a considerable reduction in administration time.

Parental perceptions of oral health-related quality of life for children with special needs: impact of oral rehabilitation under general anesthesia

PURPOSE

The purposes of this study were to: (1) describe the symptoms, daily life problems and parental concerns related to oral health for children with special health care needs; and (2) examine the effectiveness of oral rehabilitation under general anesthesia at improving quality of life (QOL).

METHODS

A single-group design measuring change over time was used. Family caregivers of 107 children with special needs, for whom oral rehabilitation under general anesthesia was recommended, completed a QOL survey upon dental examination.

RESULTS

Seventy-three children underwent oral rehabilitation, and 50 completed a follow-up survey. The most frequent survey responses before oral rehabilitation were: (1) spontaneous toothache and pain with hot/cold temperatures (oral symptoms); (2) difficulty eating and sleeping (daily life problems); and (3) worrying about eating and nutrition (parental concerns). Severity ratings for oral symptoms, daily life problems, and parental concerns were significantly lower (P<.001), and scores for oral well-being were significantly higher (P<.001) following oral rehabilitation.

CONCLUSIONS

Family caregivers of special health care needs patients report a variety of oral symptoms, daily life problems, and concerns attributable to their child's oral health that impact QOL. Oral rehabilitation under general anesthesia is effective at improving QOL for special health care needs children and their families.

A computer adaptive testing approach for assessing physical functioning in children and adolescents

The purpose of this article is to demonstrate: (1) the accuracy and (2) the reduction in amount of time and effort in assessing physical functioning (self-care and mobility domains) of children and adolescents using computer-adaptive testing (CAT). A CAT algorithm selects questions directly tailored to the child's ability level, based on previous responses. Using a CAT algorithm, a simulation study was used to determine the number of items necessary to approximate the score of a full-length assessment. We built simulated CAT (5-, 10-, 15-, and 20-item versions) for self-care and mobility domains and tested their accuracy in a normative sample (n=373; 190 males, 183 females; mean age 6y 11mo [SD 4y 2m], range 4mo to 14y 11mo) and a sample of children and adolescents with Pompe disease (n=26; 21 males, 5 females; mean age 6y 1mo [SD 3y 10mo], range 5mo to 14y 10mo). Results indicated that comparable score estimates (based on computer simulations) to the full-length tests can be achieved in a 20-item CAT version for all age ranges and for normative and clinical samples. No more than 13 to 16% of the items in the full-length tests were needed for any one administration. These results support further consideration of using CAT programs for accurate and efficient clinical assessments of physical functioning.

The emerging role of the pediatric physical therapist in evaluation and intervention for individuals with lysosomal storage diseases

PURPOSE

The purposes of this article are to describe the pathology, medical implications, and typical impairments of individuals with various lysosomal storage diseases (LSDs), summarize results of recent clinical trials on medical interventions relevant to physical therapy practice, report new advances in functional measurement, and suggest a framework for physical therapy management and intervention.

SUMMARY OF KEY POINTS

Medical and surgical interventions are enabling individuals with LSDs to not only survive but to improve their daily functioning and quality of life. This is likely to become an increasing area of emphasis in pediatric physical therapy, as the intervention emphasis for some individuals will shift from maintenance to restorative programs.

RECOMMENDATIONS

We recommend that pediatric physical therapists become familiar with new LSD therapeutics, play a major role in evaluating impairment and functional limitation changes in individuals with LSDs, and become knowledgeable about the indications and precautions for restorative physical therapy programs.

Development of an applied cognition scale to measure rehabilitation outcomes

OBJECTIVE

To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function.

DESIGN

Prospective study.

SETTING

Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States.

PARTICIPANTS

Convenience sample of 477 patients (mean age, 62.7 y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set-Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates.

RESULTS

The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling.

CONCLUSIONS

The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.

Pediatric physical functioning reference curves

We developed normative profiles of physical functioning (mobility and self-care) in infancy up through 14 years of age with an expanded version of the Pediatric Evaluation of Disability Inventory. Mobility and self-care reference curves were based on the original Pediatric Evaluation of Disability Inventory standardization data (n = 412) and data from an additional cross-sectional, convenience sample (n = 373) via web-based survey, telephone or in-person interviews of parents. This new sample, which included children up through 14 years-of-age, was stratified for race, age, and sex, but was primarily limited geographically to the Northeast region of the United States. Goodness of fit of male, female, and combined sex (male and female) reference curves was examined. The mobility and self-care reference curves produced efficient and well-fitting estimates of conventional percentiles (3rd, 10th, 25th, 50th, 75th, 97th). Differences between males' and females' reference curves were negligible. This study highlights the use of these reference curves for determining the functional impact of Pompe disease, a lysosomal storage disorder that affects skeletal and cardiac muscle, restricting normal expression of mobility and self-care activities. This physical functioning instrument could also be used to evaluate the impact of muscle weakness in other neuromuscular disorders.

Validation of the Late-Life Function and Disability Instrument

OBJECTIVES

To assess the concurrent and predictive validity of the Late-Life Function and Disability Instrument (LLFDI).

DESIGN

Cross-sectional.

SETTING

University-based human physiology laboratory.

PARTICIPANTS

One hundred one men and women aged 80.8 +/- 0.4.

MEASUREMENTS

A short physical performance battery (SPPB) and a self-paced 400-m walk (400-m W) were used as performance tests of lower extremity function. The LLFDI was used to assess self-reported function and physical disability. Partial correlations adjusted for age and body mass index were used to determine the concurrent and predictive validity of the LLFDI. Statistical significance was accepted at P<.004 using a testwise correction.

RESULTS

LLFDI Overall Function scores were moderately associated with the SPPB (r=0.65, P<.001), 400-m W gait speed (r=0.69, P<.001), and measures of lower extremity function. Correlations of the two lower extremity subscores of the LLFDI (correlation coefficient (r)=0.63-0.73, P<.001) were greater than for the LLFDI upper extremity subscores (r=0.19-0.26, P>.004). Performance measures of function predicted disability limitations in the range of r=0.37-0.44 (P<.001) and disability frequency in the range of r=0.16-0.20 (P>.004).

CONCLUSION

These findings support the concurrent and predictive validity of the LLFDI. Results support the use of the LLFDI scales as a substitute for physical performance tests when self-report is a preferred data-collection format.