Convergent Validity of PODCI and PROMIS Domains in Congenital Upper Limb Anomalies

Concurrent Validity of PROMIS and LD-SRS Scores in Pediatric Patients With Lower Limb Differences

BACKGROUND

We sought to assess the concurrent validity of select Patient Reported Outcomes Measurement Information System (PROMIS) domains and Limb Deformity-Scoliosis Research Society (LD-SRS) scores.

METHODS

We prospectively administered PROMIS - 25 (including anxiety, depression, fatigue, pain interference, peer relationships, and physical function) and LD-SRS questionnaires to 46 consecutive pediatric patients with lower limb differences, presenting to a single surgeon for reconstruction. Concurrent validity between various subdomains of the 2 outcome measures was assessed through Pearson's correlation, with significance defined as P <0.05. The strength of correlation was interpreted by Evans criteria: absolute r value <0.20 indicating very weak correlation; 0.20 to 0.39, weak; 0.40 to 0.59, moderate; 0.60 to 0.79, strong; and 0.8 or greater indicating very strong correlation.

RESULTS

The LD-SRS Pain, Function, and Mental Health domains most strongly correlated with the PROMIS pain interference ( r =-0.79, P <0.001), physical function ( r =0.74, P <0.001), and anxiety ( r =-0.68, P <0.001) domains, respectively. In addition, LD-SRS pain strongly correlated with PROMIS physical function ( r =0.61, P <0.001) and LD-SRS function with PROMIS pain interference ( r =-0.72, P <0.001). All PROMIS domains significantly correlated with total LD-SRS scores. PROMIS pain interference ( r =-0.79, P <0.001), physical function ( r =0.67, P <0.001), and fatigue ( r =-0.60, P <0.001) domains demonstrated the strongest correlations with the total LD-SRS score.

CONCLUSIONS

The significant concurrent validity between LD-SRS and multiple PROMIS domains suggests considerable overlap, and perhaps redundancy, between these 2 outcome measures. Given the high degree of concordance and the advantage of computer adaptive testing (CAT) in mitigating administrative burden and survey fatigue, along with the ability to compare outcomes across a wider group of children with a variety of underlying diagnoses, select PROMIS domains may be a viable alternative to LD-SRS score for assessing patient-reported outcomes when treating pediatric patients with lower limb deformities. A larger, multi-center study including pediatric patients with lower limb differences from a diverse background, including age, etiology, native language, and ethnicity, would be helpful to externally validate our findings.

LEVEL OF EVIDENCE

Level-I.

Pediatric Outcomes Data Collection Instrument Scores Within Gross Motor Function Classification Scale Levels and Functional Mobility Scale Ratings in Individuals With Cerebral Palsy

BACKGROUND AND OBJECTIVE

The Pediatric Outcomes Data Collection Instrument (PODCI) is a patient/parent-reported outcome measure used in children with cerebral palsy (CP). PODCI score variability has not been widely examined in patients of Gross Motor Function Classification System (GMFCS) level IV or using the Functional Mobility Scale (FMS). The purpose of this study is to examine the distribution of PODCI scores within patients with CP GMFCS levels I-IV and FMS levels 1-6.

METHODS

Retrospectively identified patients with CP whose parent/caregiver had completed the PODCI at their visit were grouped based on GMFCS and FMS level. One-way ANOVA with pairwise Bonferroni-adjusted post hoc tests was performed to compare the effect of GMFCS and FMS levels (1, 2-4, 5, or 6) on PODCI scores.

RESULTS

Three hundred sixty-seven patients were included (128 female, 11.7 years, SD 3.6). Global, Sports, Transfer, and Upper Extremity scores differed among all GMFCS levels ( P ≤0.056) and were significantly lower for GMFCS IV compared with all other levels. Happiness, Expectations, and Pain scores did not differ significantly among GMFCS levels including level IV ( P >0.06). Similar trends were seen at all FMS distances (5, 50, and 500âm). At 50âm, Global, Sports, Transfer, and Upper Extremity scores differed significantly among all FMS levels ( P <0.001) except that Upper Extremity Scores were similar between levels 2-4 and level 5 ( P =1.00). Happiness and Pain scores were not different between FMS levels ( P >0.27). Expectations scores differed only between FMS 1 and FMS 6 with FMS 6 being higher at the 50-m distance only ( P =0.03).

CONCLUSIONS

Parent-reported outcome measures are important for providing patient-centered care. Providers can examine these measures alongside functional classification systems to create a more complete clinical picture of the patient. Providers should be aware of the score trends seen in our results when evaluating the PODCI for individuals with CP to improve shared decision-making and better monitor their need for future care.

LEVEL OF EVIDENCE

Level III-retrospective study.

Satisfactory thumb metacarpophalangeal joint stability after ligament reconstruction with flexor digitorum superficialis in children with radial longitudinal deficiency

We investigated thumb joint stability and patient-reported and functional outcomes a minimum of 1 year after flexor digitorum superficialis opponensplasty and ligament reconstruction in 23 thumbs of 20 consecutive children with radial longitudinal deficiency. In total, 15 thumbs had preoperative multidirectional instability in the metacarpophalangeal joint. We reconstructed 22 ulnar and 16 radial collateral ligaments. At follow-up, all the metacarpophalangeal joints were stable ulnarly. Seven metacarpophalangeal joints were unstable radially despite ligament reconstruction but had no related complaints. We recommend the flexor digitorum superficialis opponensplasty as a safe and reliable procedure in hypoplastic thumbs to create stability and augment thumb strength.Level of evidence: IV.

Congenital Upper-Limb Differences: A 6-Year Literature Review

➤ The Oberg-Manske-Tonkin (OMT) classification of congenital hand and upper-limb anomalies continues to be refined as our understanding of the genetic and embryonic etiology of limb anomalies improves.➤ We have conducted an evaluation of graft and graftless techniques for syndactyly reconstruction; strengths and drawbacks exist for each technique.➤ Treatment for radial longitudinal deficiency remains controversial; however, radialization has shown promise in early follow-up for severe deformities.➤ Recent emphasis on psychosocial aspects of care has demonstrated that children with congenital upper-limb differences demonstrate good peer relationships and marked adaptability.

Cross-cultural translation, reliability and validity of the Thai version of the Patient‑Reported Outcomes Measurement Information System (PROMIS) Parent Proxy Upper Extremity Short Form 8a in children with congenital upper extremity anomalies

BACKGROUND

The PROMIS Parent Proxy Upper Extremity Short Form 8a version 2 (PROMIS Parent Proxy UE-SF) is one of the most commonly used self-assessment questionnaires for evaluating function in children with congenital upper extremity anomalies. However, this English questionnaire is difficult for Thai parents to complete. The purpose of this study is to translate the PROMIS Parent Proxy UE-SF into Thai and test its reliability and validity.

METHODS

The PROMIS Parent Proxy UE-SF was translated into Thai using FACIT translation methodology. This version and the Thai version of the Michigan Hand Questionnaire (Thai-MHQ) were used to evaluate 30 Thai children with different types of congenital upper extremity anomalies. The reliability and validity of the Thai-PROMIS Parent Proxy UE-SF were evaluated by test-and-retest with the intraclass correlation coefficient (ICC) and Cronbach's alpha coefficient. Correlations between the Thai-PROMIS Parent Proxy UE-SF and Thai-MHQ were analysed by Pearson's correlation coefficients.

RESULTS

The children's mean age was 4.47 ± 2.08 years (range 1-9 years). The main diagnoses included thumb duplication (11 children), syndactyly (4 children)4, congenital trigger thumb (3 children) and obstetric brachial plexus palsy (3 children). The children's parents completed the questionnaires, taking 164.23 ± 22.58 s for the Thai-PROMIS and 337.8 ± 49.37 s for the Thai-MHQ. The test-retest reliability of Thai-PROMIS evaluated by ICCs, was 0.9909 (good reliability), and the Cronbach's alpha of all items was 0.923. The Pearson's correlation coefficient between the Thai-PROMIS and Thai-MHQ showed a strong correlation with Domain 2 (activities of daily living, r = 0.7432) and a moderate correlation with the overall Thai-MHQ score (r = 0.699).

CONCLUSIONS

The Thai-PROMIS Parent Proxy UE-SF is a valid, reliable and easy-to-use patient-reported outcome measure for assessing function in children with congenital upper extremity anomalies.

Effect of Race and Geography on Patient- and Parent-Reported Quality of Life for Children With Congenital Upper Limb Differences

PURPOSE

Patient beliefs about health and disability are shaped by many social factors and are a key determinant in their ultimate outcome. We hypothesized that pediatric and parent-reported outcome measures regarding a child's congenital upper limb difference will be affected by geographic location, parent education, sex, ethnicity, race, age, and presence of additional medical comorbidities.

METHODS

Patients enrolled in the multicenter Congenital Upper Limb Difference registry were included. Age, sex, race, ethnicity, medical comorbidities, highest level of parental education, area deprivation index, and geographic region were recorded. Patient-Reported Outcomes Measurement Information System (PROMIS) in the pediatric and parent-reported domains of upper extremity, anxiety, pain interference, peer relationships, and depressive symptoms were collected.

RESULTS

The only difference between geographic regions in the United States in pediatric and parent-reported PROMIS was that parents in the Midwest reported higher upper extremity function scores in children with upper limb differences than the West. Black patients demonstrated higher scores in parent and child-reported domains of depression, pain, and anxiety, and lower scores in upper extremity function than White and Asian peers. Additionally, children with medical comorbidities also demonstrated worse outcomes in multiple PROMIS domains. There was no difference in scores based on sex, parent education, and ethnicity.

CONCLUSIONS

In children with congenital upper limb differences, race and additional medical comorbidities have an impact on patient- and parent-reported PROMIS outcome measures in multiple domains, with Black children and those with additional medical comorbidities scoring lower than their peers.

CLINICAL RELEVANCE

As we strive to develop a health care system that provides equitable care to all patients, providers who care for children with upper limb differences should be aware that race and additional medical comorbidities can negatively affect patient- and parent-reported PROMIS outcome measures.

Key considerations to reduce or address respondent burden in patient-reported outcome (PRO) data collection

Patient-reported outcomes (PROs) are used in clinical trials to provide evidence of the benefits and risks of interventions from a patient perspective and to inform regulatory decisions and health policy. The collection of PROs in routine practice can facilitate monitoring of patient symptoms; identification of unmet needs; prioritisation and/or tailoring of treatment to the needs of individual patients and inform value-based healthcare initiatives. However, respondent burden needs to be carefully considered and addressed to avoid high rates of missing data and poor reporting of PRO results, which may lead to poor quality data for regulatory decision making and/or clinical care.

The collection of patient-reported outcomes (PROs) may capture patients’ assessments of their health status. Here authors highlight PRO-specific issues that should be considered to minimise respondent burden in clinical trials and routine care.

PROMIS Utilization in Pediatric Orthopaedics: A Scoping Review

BACKGROUND

The lack of a common patient-reported outcome metric used among the orthopaedic population is a problem that has been previously identified by the American Academy of Orthopaedic Surgeons. The Patient-Reported Outcomes Measurement Information System (PROMIS) was developed by the National Institute of Health with the goal of creating a precise and efficient measurement tool for patient-reported symptoms, functioning, and health-related quality of life to be used in clinical research. A study summarizing its use in the pediatric orthopaedic population has not been previously performed.

METHODS

We performed a literature search of Ovid Medline, Embase, Scopus, and the Cochrane Central Register of Controlled Trials from 2010 to August 2021. There were 1961 unique citations included after the removal of 1756 duplicates. After initial screening, 183 studies were screened under full-text review leaving a final number of 51 studies included in this scoping review.

RESULTS

Pediatric PROMIS studies were grouped by body part or sub-speciality: "Hand and Upper Extremity" (25.5%, n=13), "Sports" (23.5%, n=12), "Spine" (13.7%, n=7), "Trauma" (13.7%, n=7), "General Pediatric Orthopaedics" (11.8%, n=6), "Lower Extremity" (9.8%, n=5), and "Orthopaedic Oncology" (2%, n=1). An increase in studies utilizing PROMIS was seen throughout the study period with only 3 studies published from 2013 to 2016 to 39 in 2020 and 2021 alone. The 3 most frequently used pediatric PROMIS domains were Pain Interference (76.5%, n=39/51), Mobility (60.8%, n=31/51), and Upper Extremity (54.9%, n=28/51). 64.3% (n=9/14) of the included studies which reported on the floor effects of Pain Interference exhibited a significant floor effect. In all, 77.8% (n=7/9) of the included studies which reported on ceiling effects of Upper Extremity exhibited a significant ceiling effect.

CONCLUSION

The use of PROMIS increased significantly since the first publication in 2013 suggesting orthopaedic providers have increasingly utilized PROMIS in their day-to-day practice as an outcome measure. Ceiling and floor effects were prominent in several of the included domains (Pain Interference and Upper Extremity). Overall, PROMIS measures are efficient, reliable, and effective to use.

LEVEL OF EVIDENCE

IV.

Patient-reported Outcomes for Children With Unilateral Congenital Below Elbow Deficiency

BACKGROUND

The Patient Reported Outcomes Measurement Information System (PROMIS ® ) is a validated tool used to evaluate different domains of function in patients with chronic health conditions. This tool has not been validated in children with unilateral congenital below elbow deficiency (UCBED). The purpose of this study was to determine whether PROMIS discerns functional impairment for children with UCBED and whether children with UCBED differ from the general population with respect to PROMIS outcomes. We hypothesized that children with UCBED report mild impairment in upper extremity function but normal mobility, pain interference and peer relations.

METHODS

A retrospective chart review of children aged 5 to 17 years with a diagnosis of UCBED who completed a PROMIS questionnaire at their clinic visit at the [blinded locations] was conducted between April 1, 2017 and March 31, 2020. The mean PROMIS scores of UCBED patients were compared with that of the general reference population. Mann Whitney and ANOVA tests were used to explore the differences across the PROMIS upper extremity function domain by arm length and prosthesis use.

RESULTS

Fifty-five children (28 boys) with a mean age of 11±3.6 years met the inclusion criteria. Children with UCBED had similar PROMIS scores as the reference population in mobility (51.9±6.2), peer relations (53.5±9.4), and pain interference (40.1±7.2), with mild impairment in the upper extremity function (44.3±10.7). Compared with the 8 to 17-year-old cohort, the parent-proxy (5 to 7-year-old group) reported significantly more upper extremity function impairment (31.3±5.9) vs (48.0±8.8) ( P =0.000). The two age groups did not differ with respect to mobility, pain interference and peer relations.

CONCLUSIONS

Our study confirms previous findings that children with UCBED report upper extremity function, peer relationships, pain interference, and mobility, similar to the reference population. In addition, parents of younger children with UCBED report more upper extremity functional impairment than is self-reported by older children with UCBED.

LEVEL OF EVIDENCE

Prognostic Level III (comparison with reference population).

The Impact of Isolated Versus Multiple Osteochondromas: Analysis of the CoULD Registry

PURPOSE

The burden of upper extremity (UE) osteochondromas on function and self-perception among pediatric patients is unclear. The purpose of our study was to study the impact of osteochondromas in comparison to population norms and to evaluate solitary versus multiple osteochondromas on subjective UE function as measured by patient rated outcomes.

METHODS

We utilized the CoULD (Congenital Upper Limb Differences) Registry to review all pediatric patients presenting with osteochondromas between January 2014 and February 2021. Demographic information was collected and patients were classified as having either single or multiple osteochondromas. Patient-Reported Outcome Measurement Information System (PROMIS) and Pediatric Outcomes Data Collection Instrument (PODCI) tools were utilized for assessment. Scores for PODCI subscales of UE function, Pain/comfort, and Happiness and PROMIS domains of UE Function, Pain, Depression, Anxiety, and Peer Relations were reviewed. Differences between groups were analyzed using the Student t test.

RESULTS

Ninety-nine patients met inclusion criteria for the study with an average age of presentation of 9.3 years and 61 patients (62%) were male. Overall, patients demonstrated worse UE Function as well as greater Anxiety and Depression in comparison to the population normals on PROMIS assessment. Patients also demonstrated worse patient and parent reported PODCI UE, Sports and Physical Functioning, Pain/Comfort and Global Functioning scores compared with population norms but demonstrated better than average happiness scores. Patients with multiple osteochondromas demonstrated greater PROMIS pain interference and more disability in PODCI Sports and Physical Functioning, Pain/Comfort and Global Functioning compared with those with solitary osteochondromas.

CONCLUSION

Patients with UE osteochondromas have worse overall function in comparison to population norms, exceeding established minimally clinically important difference values. In addition, patients with multiple osteochondromas reported more pain and poorer physical function than those with solitary osteochondromas. Physicians should be alert to the physical and psychosocial burden of this disease.

LEVEL OF EVIDENCE

Level II-prognostic.

Translation and Cross-Cultural Adaptation of the Pediatric Outcomes Data Collection Instrument into the Italian Language

(1) Background: The Pediatric Outcomes Data Collection Instrument (PODCI) is an English-language questionnaire specifically designed to assess health-related quality of life in children and adolescents with musculoskeletal disorders. This scoring system has been translated into several languages. Given the lack of an Italian version of the PODCI, this study aimed to translate, cross-culturally adapt, and assess the psychometric properties of the PODCI score in the Italian pediatric population. (2) Methods: The PODCI questionnaire was culturally adapted to Italian patients in accordance with the literature guidelines. The study included 59 participants from a single orthopedic institution who underwent orthopedic surgery for various skeletal conditions. The questionnaire was administered to participants at multiple time-points (T0, T1, T2). Internal consistency was evaluated using Cronbach’s alpha. Reproducibility was assessed using the intraclass correlation coefficient (ICC) between T0 and T1 assessment. Criterion validity was assessed using Spearman’s correlation coefficients between PODCI and the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Responsiveness was evaluated by the difference between T0 and T2 using the effect size (ES) and the standardized response mean (SRM) calculation. (3) Results: Cronbach’s alpha was acceptable in both the self- and parent-reported versions with values of 0.78 (0.68–0.90) and 0.84 (0.60–0.92), respectively. The ICC fluctuated between 0.31 and 0.89 for self-reported and 0.49 to 0.87 for pediatrics. The Spearman’s r showed a moderate correlation between HSS Pedi-FABS and the “Sport & Physical Functioning” and “Global Functioning” domains. ES and SRM varied from small to moderate across all the domains. (4) Conclusions: This study demonstrates that the Italian version of the PODCI, translated following the international standardized guidelines, is reliable, valid, and responsive in pediatric patients who underwent orthopedic surgery.

Congenital Upper-Extremity Differences: A Thematic Analysis of On-Line Discussion Boards

PURPOSE

On-line discussion boards (DBs) are used by patients and family members to pose questions and share experiences with a broader community. Systematic analysis of the text posted to DBs about congenital upper-extremity (UE) differences may allow physicians to identify and address patients' questions and concerns better.

METHODS

We used Google and Yahoo! Internet search engines to identify on-line DBs pertaining to congenital UE differences. Posts written between January 1, 2009 and January 1, 2019 were collected and analyzed. Each on-line post was coded by 2 researchers using 3 rounds of grounded theory: open coding, axial coding, and selective coding. This allowed comprehensive, central themes of the DBs to emerge.

RESULTS

We collected 521 posts and analyzed 420 posts from 152 threads. A total of 163 unique users contributed to posts. Parents of a child with a congenital UE difference accounted for the majority of users (65%), most of which were postnatal (91%). Of posts written by patients, 48% expressed negative emotions pertaining to their difference, whereas 17% conveyed a positive experience. Five selective codes were identified from posts written by non-administrators: (1) Connecting With Others, (2) Emotional Aspects, (3) Treatment, (4) Diagnosis, and (5) Function. Connecting With Others was the most frequently assigned selective code; users were looking to establish a connection in 73% of posts. Posts seeking information (n = 106) were more often technical in nature than were posts providing information (54% vs 44%). Posts providing information (n = 206) were more often emotional (18% vs 13%).

CONCLUSIONS

Individuals accessing on-line DBs are commonly searching for technical and emotional support from others. Through analysis and identification of the themes from these posts, we believe physicians should be proactive in addressing technical concerns through education and counseling, but should also validate emotional concerns and assist families and patients via support groups or connections to others.

CLINICAL RELEVANCE

Treating surgeons can improve their care of patients with congenital UE differences by better understanding the needs of patients and their families that may not be elucidated in a traditional patient encounter.