Computerized Adaptive Tests Detect Change Following Orthopaedic Surgery in Youth with Cerebral Palsy

Research Priorities of the Pediatric Spinal Cord Injury Population: An International Insight for Rehabilitation Care

BACKGROUND

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered for new rehabilitation programs, little is known about the priorities of the pediatric-onset SCI population. This study describes and compares health and life (H&L) domain research priorities of youth with pediatric-onset SCI and their parents/caregivers.

METHODS

A cross-sectional survey, designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) Collaboration, was performed at six European countries. Dyad data from 202 participants, youth with pediatric-onset SCI (n = 101) and their parents/caregivers (n = 101), were analyzed with the PEPSCI H&L domain surveys.

RESULTS

The cohort was composed of 8 to 12-year-olds (30.7%), 13 to 17-year-olds (38.6%), and 18 to 25-year-olds (30.7%). The top three H&L domain research priorities reported by parents/caregivers of 8 to 12-year-olds were "walking/ability to move" (91%), "bladder" function (90%), and "general health/feel" (89%), compared with "physical function" (93%), "general health/feel" (90%), and "walking/ability to move" (89%) rated by parents/caregivers of 13 to 25-year-olds. "Bowel" function (85%), "leg/foot movement" (84%), and "bladder" function (84%) were reported as priorities by 13 to 25-year-olds, whereas "physical function" (84%), "experience at school" (83%), and "general mood" were highlighted by 8 to 12-year-olds. The top 10 priorities preferred by 13 to 25-year-olds when compared with the top 10 priorities reported by their parents/caregivers, included problems related to "bowel" and "pain."

CONCLUSIONS

Health domain research priorities were highlighted by 13 to 25-year-olds, compared with their parents/caregivers who equally identified H&L domains. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive research strategy for the pediatric SCI population.

Pediatric health and life domain priorities: A national survey of people with spinal cord injury and their parents and caregivers

CONTEXT/OBJECTIVE

No information is available regarding priorities for pediatric-onset spinal cord injury (SCI). This study described the Health and Life (H&L) domain priorities of youth with pediatric-onset SCI and their parents/caregivers living in Spain.

DESIGN

A cross-sectional survey.

SETTING

Two SCI rehabilitation centers.

PARTICIPANTS

Sixty participants, youth with pediatric-onset SCI (n = 26) and parents/caregivers (n = 34).

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Median overall priorities calculated on the basis of importance, unhappiness, and research measured with a new survey of pediatric H&L domains and rated using a 5-point Likert Scale.

RESULTS

A total of 60 surveys were received providing information on 35 individuals with SCI: 2-7-year-olds (25.7%), 8-12-year-olds (22.9%), 13-17-year-olds (31.4%), and 18-25-year-olds (20.0%). The top three overall H&L priorities reported by parents/caregivers of 2-12-year-olds were "parenthood expectations" (84%), "leg/foot movement" (83%), and "bladder" function (83%), compared to "dressing/undressing" (78%), "walking/ability to move" (77%) and "bladder" function (77%) rated for 13-25-year-olds. "Sit-to-stand" (79%), "leg/foot movement" (78%) and "arm/hand movement" (77%) were reported as priorities by 13-25-year-olds. The 13-25-year-olds highlighted "sit-to-stand" (100%), "eating/drinking" (54%), and "physical function" (94%) as their top unhappiness, importance, and research priorities, respectively. Significant differences between tetraplegia and paraplegia were found in "mobility in the community" (unhappiness item) for 13-25-years-old.

CONCLUSION

Health domains were considered the top overall H&L priorities by parents/caregivers of 13-25-year-olds, compared to life domains reported for their 2-12-year-olds. This survey will aid rehabilitation professionals to engage stakeholders to implement a comprehensive SCI management program for the pediatric population.

Clinical functional outcome measures for children with cerebral palsy after gait corrective orthopaedic surgery: A scoping review

AIM

To identify the most frequently reported non-instrumented measures of gait, activity, and participation in children with cerebral palsy (CP) after undergoing gait corrective orthopaedic surgery.

METHOD

Four databases were searched from database inception to the 9th December 2021 for studies that evaluated functional outcomes for children with CP under 18 years undergoing gait corrective orthopaedic surgery.

RESULTS

Of 547 citations, 44 publications (n = 3535 participants, n = 1789 males, mean age 10 years 5 months [SD = 3 years 3 months], Gross Motor Function Classification System levels I-III at the time of surgery) were eligible for inclusion. Fourteen different outcome measures were used: one measure of gait, 10 measures of activity, and three measures of participation. Gait was measured with the Edinburgh Visual Gait Scale (EVGS; 4 out of 44). The most common activity and participation measures were the Functional Mobility Scale (FMS; 15 out of 44) and Pediatric Outcomes Data Collection Instrument (11 out of 44) respectively. No studies reported a combination of gait, activity, and participation measures.

INTERPRETATION

The EVGS and FMS should be considered as core outcome measures in gait corrective orthopaedic surgery, while a measure of participation is unclear. Additional considerations for developing a comprehensive suite of outcomes include identifying a combination of clinical measures and performance-reflective questionnaires that are standardized for children with CP undergoing surgery and meaningful to clinicians and families.

Assessment of the relationship between Brachial Plexus Profile activity short form scores and modified Mallet scores

INTRODUCTION

This study aims to assess the relationship between the modified Mallet classification and the Brachial Plexus Profile activity short form (BP-PRO activity SF). The therapist or surgeon classifies upper extremity movement for the modified Mallet classification, while the BP-PRO assesses parents' perceptions of difficulty performing activities.

PURPOSE

To provide a deeper understanding of the relationship of functional and perceived outcome measurements.

STUDY DESIGN

Prospective, correlational design.

METHODS

Eighty children with brachial plexus birth injuries were evaluated using the modified Mallet classification, while parents simultaneously answered the BP-PRO activity SF questions. All patients had undergone one of three surgical interventions to improve shoulder function. The relationship between the two measures, patient injury levels, and surgical histories were assessed.

RESULTS

The average modified Mallet scores and BP-PRO activity SF scores weakly correlated (r = 0.312, P = .005) and both measures differentiated between C5-6 and C5-7 injury levels (P = .03 and P = .02, respectively). Conversely, the modified Mallet scores could differentiate between the three surgical groups (F = 8.2, P < .001), while the BP-PRO activity SF could not (P = .54).

CONCLUSION

The results suggest that these tools measure different aspects of patient outcomes. The Mallet classification may be more focused on shoulder motion than the BP-PRO activity SF. Additional questions that specifically require shoulder function could be incorporated into the BP-PRO activity SF to improve understanding of patient/parent perceptions of shoulder function for children with brachial plexus injuries. Clinicians should be aware of the strengths, weaknesses, and limitations of each outcome assessment tool for appropriate use and interpretation of results.

Health and LifeDomain ResearchPriorities in Children, Adolescents and Young Adults With Pediatric-Onset Spinal Cord Injury: A National Cross-Sectional Survey in England

Background

Although feedback from people with adult-onset spinal cord injury (SCI) has been considered in developing research programs, little is known about pediatric-onset SCI priorities.

Objectives

To describe the health and life (H&L) domain research priorities of youth with pediatric-onset SCI living in England.

Methods

Youth with pediatric-onset SCI (≥6 months) were recruited from five English rehabilitation centers and invited with their parents/caregivers to complete the age-appropriate surveys designed by the Pan-European Paediatric Spinal Cord Injury (PEPSCI) collaboration.

Results

A total of 73 surveys were received (32 from participants with SCI and 41 from their parents/caregivers), providing information on 47 individuals with SCI: 2- to 7-year-olds (29.8%), 8- to 12-year-olds (19.2%), 13- to 17-year-olds (17.0%), and 18 to 25-year-olds (34.0%). The top three research priorities reported by parents/caregivers of 2- to 12-year-old and 13- to 25-year-olds were pain (81%/89%), physical function (91%/83%) and health care access (78%/78%). Eighty-nine percent of 8- to 12-year-olds emphasized schooling, peer relationships, and general mood as their research priorities. The top three research priorities for Health or Life domains reported by 13- to 25-year-olds included spasms (95%), pain (91%), pressure injuries (91%), health care access (83%), physical function (78%), and daily personal needs (74%).

Conclusion

Although there should be an emphasis on addressing important life domain issues for 8- to 12-year-olds with SCI, adolescents and young adults mostly prioritized health domain research priorities in addition to health care access. This survey will aid health care and clinical research organizations to engage stakeholders to implement a comprehensive SCI research strategy in England for the pediatric population.

Scoping Review of Judgment-Based Measures of Ambulation with Assistive Devices for Children and Youth

AIM

To identify available judgment-based measures of ambulation with assistive devices for the purpose of examining item content and responses to aid in the expansion of the Pediatric Evaluation of Disability Inventory Computer Adaptive Test (PEDI-CAT) Mobility Domain.

METHODS

PubMed and CINAHL databases were used to identify measures meeting the following criteria: 1) applicable for children/youth; 2) self-report, proxy-report, or interview administration; and 3) assistive device (walker, cane, crutches, gait trainer) use specified or considered with responses. Population, administration, respondent(s), items, and responses were compiled. Item content was categorized and response scales grouped by type.

RESULTS

Fifteen measures met inclusion criteria. Measures included child and proxy-report. Item categories included Surfaces, Steps/Stairs, Dual Tasks, Negotiation of Environment, Distance, and Time. Only two measures distinguished between device type within items. One measure specified gait trainers. "Difficulty" and "Assistance" were the most frequently used response scales.

CONCLUSIONS

Available measures have content examining device use; however, none of the measures are comprehensive, devices are not consistently specified, and responses are imprecise. Items with well-defined responses for measuring a child's ambulation with an assistive device are needed for clinical practice, research, and program evaluation.

Outcome domains and measures after lower limb orthopaedic surgery for ambulant children with cerebral palsy: an updated scoping review

AIM

To determine the reported outcome domains and measures used to assess lower limb orthopaedic surgery of ambulant children and young people with cerebral palsy (CP) and map these outcomes to the International Classification of Functioning, Disability and Health - Children and Youth (ICF-CY) framework.

METHOD

This updated scoping review included studies published between January 2016 and July 2019 in five databases: MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies were included if participants were ambulant individuals with CP aged between 0 and 20 years who had undergone lower limb orthopaedic surgery. Health outcome domains and measures were identified and classified using the ICF-CY framework.

RESULTS

Forty-four eligible studies were identified with a total of 40 different outcome domains recorded. Among eligible studies, 44 (100%) measured body function and structural impairment and seven (16%) measured activity limitation and participation restriction. The most frequently reported outcome was gait pattern (n=37, 84%). Few studies reported adverse effects of surgery (n=13, 30%). Twenty-nine different outcome measures were identified. Patient-reported outcomes measures were used in 10 studies (23%).

INTERPRETATION

The review highlights a heterogeneity in the reported outcome domains and measures used in CP studies. The majority of the reported outcomes focus on the ICF-CY domain of body function and structure. The review also highlights a notable shift towards patient-reported outcomes in recent years. Development of a core outcome set for lower limb orthopaedic surgery would guide researchers to use more consistent and complete measurement sets.

Outcome Metrics in Pediatric Sports Medicine: Do PROMIS Computer-adaptive Testing Metrics Correlate With Pedi-IKDC?

BACKGROUND

A modified version of the International Knee Documentation Committee (IKDC), the Pedi-IKDC, is a validated patient-reported outcome measure in pediatric patients with knee pain. However, this questionnaire is lengthy and can fatigue patients, leading to inconsistent outcome collection. Thus, we sought to compare more easily attainable Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing patient reported outcomes to the gold standard Pedi-IKDC.

METHODS

We prospectively collected PROMIS scores and Pedi-IKDC scores in 100 new, consecutive patients presenting with knee pain to a pediatric sports medicine practice. Patients were excluded if they provided an incomplete Pedi-IKDC, had prior ipsilateral lower extremity surgery, or significant associated medical comorbidities. PROMIS domains including Mobility, Pain Interference, and Upper Extremity (control) were compared with the Pedi-IKDC with Pearson correlations. The number of questions in each metric was analyzed. Floor and ceiling effects of each test were also assessed.

RESULTS

The average age of the study cohort was 14 years (range, 7 to 18  y) with 53% female and 47% male. 70% of patients completed the Pedi-IKDC questionnaire, compared with 100% with PROMIS tests. The average Pedi-IKDC score was 48.8±22.3 (range, 5.4 to 100). Mean scores for Mobility, Pain Interference, and Upper Extremity domains were 38.4±10.1, 53.5±10.3, and 49.7±8.7, respectively. All tests demonstrated similar and acceptable floor and ceiling effects (<15%). The length of the Pedi-IKDC (22 questions) was roughly double that of combined PROMIS Pain Interference and Mobility tests (11.9±2.3 questions). Pedi-IKDC scores correlated with tested PROMIS measures (Mobility/Pain Interference, r=0.42/-0.49). When 7 highly functional patients with significant pain symptoms were removed for a secondary analysis, Mobility and Pain correlations improved to 0.69 and -0.67, respectively.

CONCLUSIONS

PROMIS Mobility and Pain scores demonstrate moderate correlations with the Pedi-IKDC, highlighting these tests are not capturing the same patient experiences. These correlations are weakened by a small group of painful yet highly functioning patients. The Pedi-IKDC was significantly longer and had a much lower completion rate than PROMIS tests, highlighting a need for a validated computer adaptive testing in evaluating pediatric patients with knee pain.

LEVELS OF EVIDENCE

Level II.

The Cerebral Palsy Profile of Health and Function: Upper-Extremity Domain's Sensitivity to Change Following Musculoskeletal Surgery

PURPOSE

The Cerebral Palsy Profile of Health and Function (CP-PRO) Computerized Adaptive Tests (CAT) are quality of life measures developed specifically for use in children with cerebral palsy. This study examined the ability of the upper-extremity (UE) CP-PRO CAT to detect change in function after UE surgery compared with the Pediatric Outcomes Data Collection Instrument (PODCI), ABILHAND-Kids, and Box and Blocks test.

METHODS

From 2009 to 2013, children with cerebral palsy who had UE musculoskeletal surgery completed the UE CP-PRO CAT, PODCI-UE, ABILHAND-Kids, and Box and Blocks tests before surgery (97 children) and at 3 postoperative intervals: 6 months (80 children), 12 months (73 children), and 24 months (52 children). Mean, SD, effect size (ES), and standardized response mean (SRM) values for each measure at each time interval and each level of the Manual Ability Classification System were calculated and compared. Finally, the minimal detectable change at the 90% confidence level was determined.

RESULTS

Values for the ES (0.40) and SRM (0.53) for the UE CP-PRO CAT at baseline to 6 months were moderate and significantly greater than the PODCI-UE (ES, 0.18; SRM, 0.25). The ES and SRM for the PODCI-UE, ABILHAND-Kids, and Box and Blocks tests were not significantly greater than for the UE CP-PRO CAT at any period. From baseline to 6 months, the UE CP-PRO CAT detected a large and significant improvement for Manual Ability Classification System level II (SRM, 0.70; ES, 0.70). The minimal detectable change for the UE CP-PRO CAT was 5.20.

CONCLUSIONS

The UE CP-PRO CAT is significantly better in detecting change in UE function in the first 6 months after surgery and is comparable to other measures at 12 and 24 months.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

Examination of psychometric properties of PROMIS®: Pediatric upper limb measures in youth with cerebral palsy

Introduction

This study examines the validity and distribution characteristics of the PROMIS® pediatric upper limb measures in a sample of young people with cerebral palsy.

Method

Data are a cross-sectional subset of a larger prospective study of the responsiveness to change of PROMIS® pediatric measures following surgery to improve functioning in young people with cerebral palsy. Ninety-three participants between the ages of eight and 21 years completed the PROMIS® pediatric mobility and upper limb computer adaptive tests and short forms in conjunction with a set of static “legacy” measures of physical functioning, including a parent-report of upper limb function.

Results

The PROMIS® Pediatric upper limb short form demonstrated acceptable internal consistency (Cronbach’s alpha = 0.85). PROMIS® pediatric upper limb computer adaptive tests and short form mean values (42.1(11) and 43(10.4), respectively) were nearly 1 SD below normal, which is appropriate when a generic measure is used in a sample of young persons with cerebral palsy. The PROMIS® pediatric upper limb computer adaptive tests had a higher frequency of ceiling effects (29.50%) compared to the short form (18.30%).

Conclusion

Results of this study suggest that the PROMIS® pediatric upper limb computer adaptive tests and the short form are valid indicators of upper limb function in young people with cerebral palsy. The item bank can be replenished to address ceiling effects.

The Feasibility and Validity of PROMIS: A Novel Measure of Quality of Life among Children with Cleft Lip and Palate

BACKGROUND

Health-related quality of life is inconsistently captured among children with cleft lip and palate. The Patient-Reported Outcomes Measurement Information System (PROMIS) captures health-related quality of life, with the added benefit of comparability across clinical conditions. In this study, the authors define the validity and feasibility of PROMIS among children with clefts.

METHODS

Children with cleft lip and palate who were at least 5 years old and able to complete instruments independently were eligible for inclusion (n = 93). Children completed PROMIS anxiety, depression, and peer relationship item banks as short forms or computerized adaptive tests. Participants also completed the Pediatric Quality of Life Inventory. Construct validity was measured by Spearman correlations between PROMIS and the Pediatric Quality of Life Inventory controlling for race, sex, age, and income. Feasibility was measured using instrument completion time, reading level, and floor/ceiling effects.

RESULTS

PROMIS computerized adaptive tests (peer relationship, r = 0.49; depression, r = -0.56; and anxiety, r = -0.36) and short forms (peer relationship, r = 0.65; depression, r = -0.54; and anxiety, r = -0.56) demonstrated moderate correlation with the Pediatric Quality of Life Inventory. Computerized adaptive tests had fewer floor (0 percent versus 0 percent) and ceiling (8.6 to 19.3 percent versus 21.8 to 41.9 percent) effects than short forms, and demonstrated better readability. Computerized adaptive tests required more time than short forms (peer relationship, 0.84 ± 0.67 versus 1.3 ± 0.92; depression, 0.52 ± 0.38 versus 1.1 ± 0.73; and anxiety, 0.53 ± 0.23 versus 1.1 ± 0.62; p = 0.001), as each computerized adaptive test included on average four more questions.

CONCLUSIONS

PROMIS correlates well with the Pediatric Quality of Life Inventory and demonstrates similar accuracy, with better readability and efficiency. Use of PROMIS will improve our ability to compare children with cleft lip and palate to diverse populations and clinical conditions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Computerized Adaptive Test vs. decision trees: Development of a support decision system to identify suicidal behavior

BACKGROUND

Several Computerized Adaptive Tests (CATs) have been proposed to facilitate assessments in mental health. These tests are built in a standard way, disregarding useful and usually available information not included in the assessment scales that could increase the precision and utility of CATs, such as the history of suicide attempts.

METHODS

Using the items of a previously developed scale for suicidal risk, we compared the performance of a standard CAT and a decision tree in a support decision system to identify suicidal behavior. We included the history of past suicide attempts as a class for the separation of patients in the decision tree.

RESULTS

The decision tree needed an average of four items to achieve a similar accuracy than a standard CAT with nine items. The accuracy of the decision tree, obtained after 25 cross-validations, was 81.4%. A shortened test adapted for the separation of suicidal and non-suicidal patients was developed.

CONCLUSION

CATs can be very useful tools for the assessment of suicidal risk. However, standard CATs do not use all the information that is available. A decision tree can improve the precision of the assessment since they are constructed using a priori information.