Deductive automated pollen classification in environmental samples via exploratory deep learning and imaging flow cytometry

Pollen and tracheophyte spores are ubiquitous environmental indicators at local and global scales. Palynology is typically performed manually by microscopic analysis; a specialised and time-consuming task limited in taxonomical precision and sampling frequency, therefore restricting data quality used to inform climate change and pollen forecasting models. We build on the growing work using AI (artificial intelligence) for automated pollen classification to design a flexible network that can deal with the uncertainty of broad-scale environmental applications. We combined imaging flow cytometry with Guided Deep Learning to identify and accurately categorise pollen in environmental samples; here, pollen grains captured within c. 5500 Cal yr BP old lake sediments. Our network discriminates not only pollen included in training libraries to the species level but, depending on the sample, can classify previously unseen pollen to the likely phylogenetic order, family and even genus. Our approach offers valuable insights into the development of a widely transferable, rapid and accurate exploratory tool for pollen classification in 'real-world' environmental samples with improved accuracy over pure deep learning techniques. This work has the potential to revolutionise many aspects of palynology, allowing a more detailed spatial and temporal understanding of pollen in the environment with improved taxonomical resolution.

Development and Validation of a Computerized-Adaptive Test for PTSD (P-CAT)

OBJECTIVE

The primary purpose was to develop, field test, and validate a computerized-adaptive test (CAT) for posttraumatic stress disorder (PTSD) to enhance PTSD assessment and decrease the burden of symptom monitoring.

METHODS

Data sources included self-report and interviewer-administered diagnostic interviews. The sample included 1,288 veterans. In phase 1, 89 items from a previously developed PTSD item pool were administered to a national sample of 1,085 veterans. A multidimensional graded-response item response theory model was used to calibrate items for incorporation into a CAT for PTSD (P-CAT). In phase 2, in a separate sample of 203 veterans, the P-CAT was validated against three other self-report measures (PTSD Checklist, Civilian Version; Mississippi Scale for Combat-Related PTSD; and Primary Care PTSD Screen) and the PTSD module of the Structured Clinical Interview for DSM-IV.

RESULTS

A bifactor model with one general PTSD factor and four subfactors consistent with DSM-5 (reexperiencing, avoidance, negative mood-cognitions, and arousal), yielded good fit. The P-CAT discriminated veterans with PTSD from those with other mental health conditions and those with no mental health conditions (Cohen's d effect sizes >.90). The P-CAT also discriminated those with and without a PTSD diagnosis and those who screened positive versus negative for PTSD. Concurrent validity was supported by high correlations (r=.85-.89) with the validation measures.

CONCLUSIONS

The P-CAT appears to be a promising tool for efficient and accurate assessment of PTSD symptomatology. Further testing is needed to evaluate its responsiveness to change. With increasing availability of computers and other technologies, CAT may be a viable and efficient assessment method.

Ability of PROMIS Pediatric Measures to Detect Change in Children With Cerebral Palsy Undergoing Musculoskeletal Surgery

BACKGROUND

The Patient Reported Outcomes Measurement Information System (PROMIS) was developed to provide patient-reported outcome measures that are designed as being universally relevant across health conditions, low burden, and precise. A major problem for research and clinical practice in cerebral palsy (CP) is the void of outcomes instruments that are capable of evaluating the wide range of abilities and broad age spectrum inherent in this clinical population. Given the tremendous potential of PROMIS, the research questions for this study were "How do PROMIS pediatric computer adaptive tests and short forms detect change in children with CP following elective musculoskeletal surgery?" and "How do PROMIS instruments compare to the Pediatric Quality of Life Inventory Cerebral Palsy Module Version 3.0 (PedsQL CP), Pediatric Outcomes Data Collection Instrument (PODCI), the Timed Up and Go (TUG), and the Gross Motor Functional Measure (GMFM)."

METHODS

PROMIS Pediatric computer adaptive tests and short forms and the PedsQL, PODCI, TUG, and GMFM were administered before and after surgery. Effect size (ES) and standardized response mean (SRM) were calculated. Floor and ceiling effects were evaluated and, exposure rates for the PROMIS item banks were examined.

RESULTS

ES and SRM for all PROMIS Pediatric Measures were nonsignificant. PedsQL CP detected significant, positive change in mobility at 6 (ES=0.26; SRM=0.31) and 12 (ES=0.36; SRM=0.36) months; pain at 12 months (ES=0.29; SRM=0.34); and fatigue at 6 (ES=0.24; SRM=0.22) and 12 (ES=0.36; SRM=0.41) months. Significant negative changes were detected by the PODCI (ES=-0.20; SRM=-0.26), GMFM (ES=-0.13; SRM=-0.24), and TUG (ES=-0.29; SRM=-0.25). Ceiling effects were high. Exposure to an appropriate range of the PROMIS Mobility item bank was limited.

CONCLUSIONS

PROMIS measures were less able to detect change than other measures. PROMIS measures may be improved by tailoring start/stop rules or by adding items to include content appropriate for children with mobility impairments.

LEVEL OF EVIDENCE

Level III-diagnostic study.

Measuring activity limitation outcomes in youth with spinal cord injury

STUDY DESIGN

A cross-sectional study.

OBJECTIVES

The Pediatric Spinal Cord Injury Activity Measure (PEDI-SCI AM), which includes calibrated item banks (child and parent versions) for general mobility, daily routines, wheeled mobility and ambulation, can be administered using computerized adaptive tests (CATs) or short forms (SFs). The study objectives are as follows: (1) to examine the psychometric properties of the PEDI-SCI AM item banks and 10-item CATs; and (2) to develop and evaluate the psychometric properties of PEDI-SCI AM SFs.

SETTING

US Shriners Hospitals for Children (California, Illinois and Pennsylvania).

METHODS

Calibration data from a convenience sample of 381 children and adolescents with SCI and 322 parents or caregivers were used to examine PEDI-SCI AM item banks, 10-item CATs and SF scores. We calculated group reliability, internal consistency (Cronbach's alpha) and interclass coefficients (ICCs) to assess agreement between 10-item CATs, SFs and item banks. The percent of the sample with highest (ceiling) and lowest (floor) scores was also determined. An expert panel selected items for 14 SFs.

RESULTS

PEDI-SCI item banks, 10-item CATs and SFs demonstrate acceptable group reliability (0.73-0.96) and internal consistency (0.77-0.98). ICC values show strong agreement with item banks for 10-item CATs (0.72-0.99) and SFs. Floor effects are minimal (<15%). Ceiling effects are minimal for children with tetraplegia but high in children with paraplegia for general mobility (13.41-26.05%) and daily activities (12.99-32.71%).

CONCLUSIONS

The PEDI-SCI AM exhibited strong psychometric properties for children with tetraplegia. Replenishment of the general mobility and daily routine item banks is needed to reduce ceiling effects noted for youth with paraplegia.

Outcome Rating Scales for Pediatric Head Injury

Intensivists, surgeons, neurologists, and others involved in pediatric intensive care units (PICUs) have an important investment in both short-and long-term outcomes of children and adolescents with head injury who are treated under their care. Outcomes are most often documented by either single-or multiple-item rating scales and are implemented both during and after hospital care. For this review, the authors have organized the content of rating scales into 6 general classes: (1) mortality prediction, (2) severity, (3) global recovery, (4) activity restrictions, (5) secondary adverse conditions, and (6) limitations in participation, quality of life, and health status. Rating scales that describe the outcomes of children and adolescents after head injury are used to monitor medical and functional recovery, guide clinical management, drive quality assurance initiatives, and conduct clinical research. The authors restrict their selective review to rating scales that describe child outcomes (vs family) and that have been reported and applied in the outcome literature. Although head injury is a major cause of mortality and short-and long-term morbidity in children and adolescents, there is no consensus on which rating scales are optimal for hospital care or community follow-up. Major considerations for clinical use are feasibility, type of outcome information needed, content breadth across multiple ages and levels of recovery, and utility in determining the short-term impact of PICU care on long-term outcome.

A Hierarchical Model of Functional Performance in Rehabilitation Medicine

This article describes the development of the Tufts Assessment of Motor Performance (TAMP). The TAMP measures fine and gross motor performance status across multiple classifications of functional skills. A Raschmodel item response theory analysis supported the hypothesis that the eight motor domains within the TAMP have a hierarchical structure consistent with clinical expectation. Furthermore, total scores summed across the domains were clinically meaningful and statistically defensible. An example of how the TAMP may be employed in clinical assessment is provided. Advantages of the use of the Rasch model are discussed in reference to issues of instrument construction and the clinical description of motor performance.

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

BACKGROUND

The Cerebral Palsy Computerized Adaptive Test (CP-CAT) is a parent-reported outcomes instrument for measuring lower and upper-extremity function, activity, and global health across impairment levels and a broad age range of children with cerebral palsy (CP). This study was performed to examine whether the Lower Extremity/Mobility (LE) CP-CAT detects change in mobility following orthopaedic surgery in children with CP.

METHODS

This multicenter, longitudinal study involved administration of the LE CP-CAT, the Pediatric Outcomes Data Collection Instrument (PODCI) Transfer/Mobility and Sports/Physical Functioning domains, and the Timed "Up & Go" test (TUG) before and after elective orthopaedic surgery in a convenience sample of 255 children, four to twenty years of age, who had CP and a Gross Motor Function Classification System (GMFCS) level of I, II, or III. Standardized response means (SRMs) and 95% confidence intervals (CIs) were calculated for all measures at six, twelve, and twenty-four months following surgery.

RESULTS

SRM estimates for the LE CP-CAT were significantly greater than the SRM estimates for the PODCI Transfer/Mobility domain at twelve months, the PODCI Sports/Physical Functioning domain at twelve months, and the TUG at twelve and twenty-four months. When the results for the children at GMFCS levels I, II, and III were grouped together, the improvements in function detected by the LE CP-CAT at twelve and twenty-four months were found to be greater than the changes detected by the PODCI Transfer/Mobility and Sports/Physical Functioning scales. The LE CP-CAT outperformed the PODCI scales for GMFCS levels I and III at both of these follow-up intervals; none of the scales performed well for patients with GMFCS level II.

CONCLUSIONS

The results of this study showed that the LE CP-CAT displayed superior sensitivity to change than the PODCI and TUG scales after musculoskeletal surgery in children with CP.

Development of a self-report physical function instrument for disability assessment: item pool construction and factor analysis

OBJECTIVES

To build a comprehensive item pool representing work-relevant physical functioning and to test the factor structure of the item pool. These developmental steps represent initial outcomes of a broader project to develop instruments for the assessment of function within the context of Social Security Administration (SSA) disability programs.

DESIGN

Comprehensive literature review; gap analysis; item generation with expert panel input; stakeholder interviews; cognitive interviews; cross-sectional survey administration; and exploratory and confirmatory factor analyses to assess item pool structure.

SETTING

In-person and semistructured interviews and Internet and telephone surveys.

PARTICIPANTS

Sample of SSA claimants (n=1017) and a normative sample of adults from the U.S. general population (n=999).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Model fit statistics.

RESULTS

The final item pool consisted of 139 items. Within the claimant sample, 58.7% were white; 31.8% were black; 46.6% were women; and the mean age was 49.7 years. Initial factor analyses revealed a 4-factor solution, which included more items and allowed separate characterization of: (1) changing and maintaining body position, (2) whole body mobility, (3) upper body function, and (4) upper extremity fine motor. The final 4-factor model included 91 items. Confirmatory factor analyses for the 4-factor models for the claimant and the normative samples demonstrated very good fit. Fit statistics for claimant and normative samples, respectively, were: Comparative Fit Index=.93 and .98; Tucker-Lewis Index=.92 and .98; and root mean square error approximation=.05 and .04.

CONCLUSIONS

The factor structure of the physical function item pool closely resembled the hypothesized content model. The 4 scales relevant to work activities offer promise for providing reliable information about claimant physical functioning relevant to work disability.

Scale refinement and initial evaluation of a behavioral health function measurement tool for work disability evaluation

OBJECTIVE

To use item response theory (IRT) data simulations to construct and perform initial psychometric testing of a newly developed instrument, the Social Security Administration Behavioral Health Function (SSA-BH) instrument, that aims to assess behavioral health functioning relevant to the context of work.

DESIGN

Cross-sectional survey followed by IRT calibration data simulations.

SETTING

Community.

PARTICIPANTS

Sample of individuals applying for Social Security Administration disability benefits: claimants (n=1015) and a normative comparative sample of U.S. adults (n=1000).

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

SSA-BH measurement instrument.

RESULTS

IRT analyses supported the unidimensionality of 4 SSA-BH scales: mood and emotions (35 items), self-efficacy (23 items), social interactions (6 items), and behavioral control (15 items). All SSA-BH scales demonstrated strong psychometric properties including reliability, accuracy, and breadth of coverage. High correlations of the simulated 5- or 10-item computer adaptive tests with the full item bank indicated robust ability of the computer adaptive testing approach to comprehensively characterize behavioral health function along 4 distinct dimensions.

CONCLUSIONS

Initial testing and evaluation of the SSA-BH instrument demonstrated good accuracy, reliability, and content coverage along all 4 scales. Behavioral function profiles of Social Security Administration claimants were generated and compared with age- and sex-matched norms along 4 scales: mood and emotions, behavioral control, social interactions, and self-efficacy. Using the computer adaptive test-based approach offers the ability to collect standardized, comprehensive functional information about claimants in an efficient way, which may prove useful in the context of the Social Security Administration's work disability programs.

Validity of computer adaptive tests of daily routines for youth with spinal cord injury

OBJECTIVE

To evaluate the accuracy of computer adaptive tests (CATs) of daily routines for child- and parent-reported outcomes following pediatric spinal cord injury (SCI) and to evaluate the validity of the scales.

METHODS

One hundred ninety-six daily routine items were administered to 381 youths and 322 parents. Pearson correlations, intraclass correlation coefficients (ICC), and 95% confidence intervals (CI) were calculated to evaluate the accuracy of simulated 5-item, 10-item, and 15-item CATs against the full-item banks and to evaluate concurrent validity. Independent samples t tests and analysis of variance were used to evaluate the ability of the daily routine scales to discriminate between children with tetraplegia and paraplegia and among 5 motor groups.

RESULTS

ICC and 95% CI demonstrated that simulated 5-, 10-, and 15-item CATs accurately represented the full-item banks for both child- and parent-report scales. The daily routine scales demonstrated discriminative validity, except between 2 motor groups of children with paraplegia. Concurrent validity of the daily routine scales was demonstrated through significant relationships with the FIM scores.

CONCLUSION

Child- and parent-reported outcomes of daily routines can be obtained using CATs with the same relative precision of a full-item bank. Five-item, 10-item, and 15-item CATs have discriminative and concurrent validity.

Conceptual foundation for measures of physical function and behavioral health function for Social Security work disability evaluation

Physical and mental impairments represent the 2 largest health condition categories for which workers receive Social Security disability benefits. Comprehensive assessment of physical and mental impairments should include aspects beyond medical conditions such as a person's underlying capabilities as well as activity demands relevant to the context of work. The objective of this article is to describe the initial conceptual stages of developing new measurement instruments of behavioral health and physical functioning relevant for Social Security work disability evaluation purposes. To outline a clear conceptualization of the constructs to be measured, 2 content models were developed using structured and informal qualitative approaches. We performed a structured literature review focusing on work disability and incorporating aspects of the International Classification of Functioning, Disability and Health as a unifying taxonomy for framework development. Expert interviews provided advice and consultation to enhance face validity of the resulting content models. The content model for work-related behavioral health function identifies 5 major domains: (1) behavior control, (2) basic interactions, (3) temperament and personality, (4) adaptability, and (5) workplace behaviors. The content model describing physical functioning includes 3 domains: (1) changing and maintaining body position, (2) whole-body mobility, and (3) carrying, moving, and handling objects. These content models informed subsequent measurement properties including item development and measurement scale construction, and provided conceptual coherence guiding future empirical inquiry. The proposed measurement approaches show promise to comprehensively and systematically assess physical and behavioral health functioning relevant to work.

A preliminary evaluation of the PEDI-CAT Mobility item bank for children using walking aids and wheelchairs

OBJECTIVE

To examine the discriminant validity and scoring patterns of the PEDI-CAT Mobility item bank for children who use a walking aid or wheelchair.

METHODS

Parents whose children use a walking aid (n=35) or a wheelchair (n=31) completed the full PEDI-CAT Mobility item bank (105 items including 13 walking aid and 14 wheelchair items) on-line. An independent sample t-test was used to examine mean scores between the groups. Point spread and placement of the scores along the overall 20-80 test scale and response patterns for the 27 mobility device items were analyzed descriptively.

RESULTS

Mean scaled scores were significantly different (p < 0.001) for the two groups. Mean score for the Wheelchair Group (38.37, SD=7.09) was lower than the Walking Aid Group (46.97, SD=5.10). The Walking Aid Group started and ended higher on the 20 to 80 scale metric than the Wheelchair Group. No floor or ceiling effects were seen for the scoring of the 27 items specifying use of a mobility device.

CONCLUSION

The %scores of the PEDI-CAT Mobility domain could differentiate the functional mobility status between known groups of children who use a walking aid or wheelchair and provides specific items to measure functional mobility with use of a mobility device.

Sediment source tracing in a lowland agricultural catchment in southern England using a modified procedure combining statistical analysis and numerical modelling

Catchment erosion, soil losses and resulting sediment pressures continue to represent cause for concern with respect to the ecological vitality and amenity value of riverine systems, including those in the agricultural catchments of southern England. Given that the sources of fine-grained sediment are typically diffuse in nature, it is essential to adopt a catchment-wide perspective to corresponding management strategies and sediment source tracing procedures have proved useful in assisting such planning. There remains, however, scope for further refining sediment sourcing procedures and on that basis, a recent study in the upper River Kennet (~214 km(2)) catchment in southern England, provided an opportunity for designing and testing a refined statistical procedure for sediment source discrimination with composite fingerprints using Genetic Algorithm (GA)-driven Discriminant Function Analysis, the Kruskal-Wallis H-test and Principal Components Analysis. The revised statistical verification of composite signatures was combined with numerical mass balance modelling using recent refinements including a range of tracer weightings and both local and GA optimisation. Comparison of the local and global optimisation increased confidence in the outputs of local optimisation and the goodness-of-fit for the predicted source contributions using the optimum composite signatures selected from the revised statistical testing ranged from 0.914 to 0.965. Overall relative frequency-weighted average median source type contributions were estimated to be 4% (agricultural topsoils; predicted deviate median inputs 1-19%), 55% (unmetalled farm track surfaces; predicted deviate median inputs 9-91%), 6% (damaged road verges; predicted deviate median inputs 4-42%), 31% (channel banks/subsurface sources; predicted deviate median inputs 5-41%) and 4% (urban street dust; predicted deviate median inputs 0-20%). The study provides further evidence of the importance of eroding farm tacks as a catchment scale sediment source and confirms the utility of tracing for assembling information on sediment inputs from both the agricultural and urban sectors.

Accuracy and precision of the Pediatric Evaluation of Disability Inventory computer-adaptive tests (PEDI-CAT)

AIM

The aims of the study were to: (1) build new item banks for a revised version of the Pediatric Evaluation of Disability Inventory (PEDI) with four content domains: daily activities, mobility, social/cognitive, and responsibility; and (2) use post-hoc simulations based on the combined normative and disability calibration samples to assess the accuracy and precision of the PEDI computer-adaptive tests (PEDI-CAT) compared with the administration of all items.

METHOD

Parents of typically developing children (n = 2205) and parents of children and adolescents with disabilities (n = 703) between the ages of 0 and 21 years, stratified by age and sex, participated by responding to PEDI-CAT surveys through an existing Internet opt-in survey panel in the USA and by computer tablets in clinical sites.

RESULTS

Confirmatory factor analyses supported four unidimensional content domains. Scores using the real data post hoc demonstrated excellent accuracy (intraclass correlation coefficients ≥ 0.95) with the full item banks. Simulations using item parameter estimates demonstrated relatively small bias in the 10-item and 15-item CAT versions; error was generally higher at the scale extremes.

INTERPRETATION

These results suggest the PEDI-CAT can be an accurate and precise assessment of children's daily performance at all functional levels.

Group swimming and aquatic exercise programme for children with autism spectrum disorders: a pilot study

OBJECTIVE

To evaluate the effectiveness of a 14-week aquatic exercise programme for children with autism spectrum disorders (ASD).

DESIGN

Non-randomized control trial.

METHODS

Twelve children participated in this pilot study with seven participants in the aquatic exercise group and five in the control group. The programme was held twice per week for 40 minutes per session. Swimming skills, cardiorespiratory endurance, muscular endurance, mobility skills and participant and parent satisfaction were measured before and after the intervention.

RESULTS

No significant between-group changes were found. Within-group improvements for swimming skills were found for the intervention group. Programme attendance was high. Parents and children were very satisfied with the programme activities and instructors.

CONCLUSIONS

This pilot programme was feasible and showed potential for improving swimming ability in children with ASD. Exercise intensity was low for some participants, most likely contributing to a lack of significant findings on fitness outcomes.

Computer adaptive test performance in children with and without disabilities: prospective field study of the PEDI-CAT

PURPOSE

To examine the discriminant validity, test-retest reliability, administration time and acceptability of the pediatric evaluation of disability inventory computer adaptive test (PEDI-CAT).

METHODS

A sample of 102 parents of children 3 through 20 years of age with (n = 50) and without (n = 52) disabilities was recruited for this prospective field study. A sub-sample (n = 25) also completed the PEDI-CAT a second time within one month. Parents completed 15 items in each of the four PEDI-CAT domains (daily activities, mobility, social/cognitive, responsibility) using a laptop computer. Following completion, parents answered a four-question user evaluation survey.

RESULTS

PEDI-CAT scores based on parent responses differentiated between groups of children with and without disabilities in all four domains. Test-retest reliability estimates were high (ICC = 0.96-0.99) for all four domains. The mean time to complete 60 items for the full sample (n = 102) was 12.66 minutes (SD = 4.47). Parents reported favorable reactions to the PEDI-CAT.

CONCLUSIONS

The PEDI-CAT offers a valid and reliable assessment acceptable to parents.

Linking the activity measure for post acute care and the quality of life outcomes in neurological disorders

OBJECTIVE

To use item response theory (IRT) methods to link physical functioning items in the Activity Measure for Post Acute Care (AM-PAC) and the Quality of Life Outcomes in Neurological Disorders (Neuro-QOL).

DESIGN

Secondary data analysis of the physical functioning items of AM-PAC and Neuro-QOL. We used a nonequivalent group design with 36 core items common to both instruments and a test characteristic curve transformation method for linking AM-PAC and Neuro-QOL scores. Linking was conducted so that both raw and scaled AM-PAC and Neuro-QOL scores (mean ± SD converted-logit scores, 50 ± 10) could be compared.

SETTING

AM-PAC items were administered to rehabilitation patients in post-acute care (PAC) settings. Neuro-QOL items were administered to a community sample of adults through the Internet.

PARTICIPANTS

PAC patients (N=1041) for the AM-PAC sample and community-dwelling adults (N=549) for the Neuro-QOL sample.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Mobility (N=25) and activity of daily living (ADL) items (N=11) common to both instruments were included in analysis.

RESULTS

Neuro-QOL items were linked to the AM-PAC scale by using the generalized partial credit model. Mobility and ADL subscale scores from the 2 instruments were calibrated to the AM-PAC metric.

CONCLUSIONS

An IRT-based linking method placed AM-PAC and Neuro-QOL mobility and ADL scores on a common metric. This linking allowed estimation of AM-PAC mobility and ADL subscale scores based on Neuro-QOL mobility and ADL subscale scores and vice versa. The accuracy of these results should be validated in a future sample in which participants respond to both instruments.

Measuring physical function in children with airway support: a pilot study using computer adaptive testing

OBJECTIVE

To assess the responsiveness, examine the scoring range and determine the efficiency of a multidimensional computer adaptive testing version of the Pediatric Evaluation of Disability Inventory (PEDI-MCAT) for children admitted to inpatient pulmonary rehabilitation.

METHODS

The PEDI-MCAT was completed by clinician report for 30 infants and children. Mean self-care and mobility admission scores were compared with discharge scores for the total group and two diagnostic sub-groups (prematurity and congenital/neurological conditions). The scoring range of the mobility and self-care scales was examined to determine placement of the scores along the overall PEDI-MCAT scale. Efficiency was determined using an internal clock and average number of items required for score generation.

RESULTS

Mean changes for the total group and both sub-groups were significant for both self-care and mobility, except for the prematurity group's mobility scores. Effect sizes were small-to-moderate. Scores for both groups were at the low end of the scoring ranges. Average time to complete the PEDI-MCAT was 1.57 minutes. Average number of items administered was nine for self-care and 11 for mobility.

CONCLUSION

The PEDI-MCAT was responsive to change in physical function, although only low-ability items were needed. The PEDI-MCAT can potentially minimize clinician burden in inpatient settings.

Children’s and Parents’ Perspectives About Activity Performance and Participation After Spinal Cord Injury: Initial Development of a Patient-Reported Outcome Measure

OBJECTIVE. To report on a cognitive testing study on newly constructed items designed to evaluate client-reported outcomes of activity performance and participation after spinal cord injury (SCI).

METHOD. Thirty-three children with SCI and 13 caregivers participated in cognitive testing interviews. Open-ended questions were used to gain a better understanding of activity performance and participation. The interviews were transcribed verbatim. A thematic analysis was carried out independently by 2 researchers, and key sentences and phrases from both analyses were merged.

RESULTS. Four themes were defined: (1) apprehension related to activity performance and participation, (2) reference point, (3) missing out, and (4) autonomy.

CONCLUSION. Insight into children’s and caregivers’ perspectives provided important information that helped refine the wording of test items and response scales. The theme of autonomy provided a stronger catalyst to solidify items for both child- and parent-reported outcomes. This study further validated the complexity of the construct of participation.

Precision and content range of a parent-reported item bank assessing lower extremity and mobility skills in children with cerebral palsy

AIM

The aim of this study was to determine the psychometric properties, content range, and measurement precision of a lower extremity physical functioning and mobility skills item bank (LE85) in children with cerebral palsy (CP).

METHOD

Lower extremity functioning and mobility skill items were administered to 308 parents of children (169 males, 139 females; mean age 10y 8mo, SD 4y) with spastic CP (145 diplegia, 73 hemiplegia, 89 quadriplegia; [for one person type of CP was unknown]) classified using the Gross Motor Function Classification System (75 level I, 91 level II, 79 level III, 37 level IV, 26 level V). Additional legacy measures were administered to assess concurrent validity. Psychometric characteristics, differential item functioning, content range, and score precision were examined.

RESULTS

The LE85 had acceptable psychometric properties. Content range matched the ability range of the sample population and exceeded legacy measures with minimal differential item functioning. The LE85 had good correlation with the Paediatric Outcomes Data Collection Instrument, Functional Independence Measure for Children, Gillette Functional Assessment Questionnaire, and Paediatric Quality of Life Inventory-CP module (range r=0.63-0.86). Precision of the LE85 and 10-item simulated computer adaptive test scores outperformed legacy measures.

INTERPRETATION

The LE85 appears to be suitable to administer as a computer adaptive test to measure lower extremity physical functioning and mobility in children with CP.

Validity and reliability of physical functioning computer-adaptive tests for children with cerebral palsy

BACKGROUND

The purpose of this study was to assess the concurrent validity and reliability of scores from 4 new parent-report computer-adapted testing (CAT) programs developed to measure the physical functioning of children with cerebral palsy (CP). The Shriners Hospitals for Children CP-CAT battery includes upper-extremity skills, lower-extremity and mobility skills, activity, and global physical health.

METHODS

This was a prospective study of 91 children with CP who were tested cross-sectionally and 27 children with CP who were administered the CP-CAT programs twice within approximately a 1-month interval. We examined the concurrent validity of the 4 Shriners Hospitals for Children CP-CAT programs by Pearson correlations with comparative parent-report instruments. The scale reliability was tested by developing estimates of marginal reliability; test-retest reliability was assessed by intraclass correlations.

RESULTS

Pearson correlations were moderate to high in matching content domains of the CATs with the comparison measures. Marginal reliability estimates were always better for the CAT program than the comparative instruments. Average test-retest reliability using Intraclass correlations across the 4 CATs was ICC3,1=0.91 with a range of 0.88 to 0.94.

CONCLUSIONS

We found the CAT scores to be related to expected domains from external instruments, to have good scale reliability, and to have stable scores as determined by test-retest reliability. These results support the use of parent-report CATs in the assessment of physical functioning in children with CP.

Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy II: upper-extremity skills

The specific aims of this study were to (1) examine the psychometric properties (unidimensionality, differential item functioning, scale coverage) of an item bank of upper-extremity skills for children and adolescents with cerebral palsy (CP); (2) evaluate a simulated computer-adaptive test (CAT) using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) upper-extremity core scale; and (4) determine the discriminant validity of the simulated CAT with Manual Ability Classification System (MACS) levels and CP type (i.e. diplegia, hemiplegia, or quadriplegia). Parents (n=180) of children and adolescents with CP (spastic diplegia 49%, hemiplegia 22%, or quadriplegia 28%) consisting of 102 males and 78 females with a mean age of 10 years 6 months (SD 4y 1mo, range 2-21y), and MACS levels I through V participated in calibration of an item pool and completed the PODCI. Confirmatory factor analyses supported a unidimensional model using 49 of the 53 upper-extremity items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficient [ICCs] >0.93) with the full item bank, had high correlations with the PODCI upper-extremity core scale score (ICC 0.79), and discriminated among MACS levels. The simulated CATs demonstrated excellent overall content coverage over a wide age span and severity of upper-extremity involvement. The future development and refinement of CATs for parent report of physical function in children and adolescents with CP is supported by our work.

Development of a parent-report computer-adaptive test to assess physical functioning in children with cerebral palsy I: lower-extremity and mobility skills

The objective of this project was to develop computer-adaptive tests (CATs) using parent reports of physical function in children and adolescents with cerebral palsy (CP). The specific aims of this study were to (1) examine the psychometric properties of an item bank of lower-extremity and mobility skills for children with CP; (2) evaluate a CAT using this item bank; (3) examine the concurrent validity of the CAT with the Pediatric Outcomes Data Collection Instrument (PODCI) and the Functional Assessment Questionnaire (FAQ); and (4) establish the discriminant validity of simulated CATs with Gross Motor Function Classification System (GMFCS) levels and CP type (diplegia, hemiplegia, or quadriplegia). Parents (n=190) of children and adolescents with spastic diplegic (48%), hemiplegic (22%), or quadriplegic (30%) CP consisting of 108 males and 82 females with a mean age of 10 years 7 months (SD 4y 1mo, range 2-21y) and in GMFCS levels I to V participated in item pool calibration and completed the PODCI and FAQ. Confirmatory factor analyses supported a unidimensional model for the 45 basic lower-extremity and mobility items. Simulated CATs of 5, 10, and 15 items demonstrated excellent accuracy (intraclass correlation coefficients [ICCs] >0.91) with the full item bank and had high correlations with PODCI transfers and mobility (ICC = 0.86) and FAQ scores (ICC = 0.77). All CATs discriminated among GMFCS levels and CP type. The lower-extremity and mobility skills item bank and simulated CATs demonstrated excellent performance over a wide span of ages and severity levels.

Evaluation of an adaptive ice skating programme for children with disabilities

OBJECTIVE

To describe an adaptive ice skating programme designed by paediatric therapists.

METHODS

Twenty-two children, ages 5-12 years, with developmental disabilities participated in this once per week skating programme lasting 6 weeks. Ice skating instructors led the group lessons, while university student coaches provided individualized assistance to the children. The programme was evaluated using a summative evaluation design. Outcomes included participant attendance, incidence of injuries, skating skills and parent and student coach survey data.

RESULTS

On average, participants attended 83% of the sessions and one minor injury was reported. Participants' parents were very satisfied with the programme and reported improvements in their child's skating skills, leg strength, endurance, balance, self-esteem/confidence and ability to participate in a group. Student coaches also reported high levels of satisfaction with this programme and reported similar improvements in the children they coached.

CONCLUSION

The programme appeared promising, but may require minor modifications.

A computer-adaptive disability instrument for lower extremity osteoarthritis research demonstrated promising breadth, precision, and reliability

OBJECTIVE

To develop and evaluate a prototype measure (OA-DISABILITY-CAT) for osteoarthritis research using item response theory (IRT) and computer-adaptive test (CAT) methodologies.

STUDY DESIGN AND SETTING

We constructed an item bank consisting of 33 activities commonly affected by lower extremity (LE) osteoarthritis. A sample of 323 adults with LE osteoarthritis reported their degree of limitation in performing everyday activities, and completed the Health Assessment Questionnaire-II (HAQ-II). We used confirmatory factor analyses to assess scale unidimensionality and IRT methods to calibrate the items and examine the fit of the data. Using CAT simulation analyses, we examined the performance of OA-DISABILITY-CATs of different lengths compared with the full-item bank and the HAQ-II.

RESULTS

One distinct disability domain was identified. The 10-item OA-DISABILITY-CAT demonstrated a high degree of accuracy compared with the full-item bank (r=0.99). The item bank and the HAQ-II scales covered a similar estimated scoring range. In terms of reliability, 95% of OA-DISABILITY reliability estimates were over 0.83 vs. 0.60 for the HAQ-II. Except at the highest scores, the 10-item OA-DISABILITY-CAT demonstrated superior precision to the HAQ-II.

CONCLUSION

The prototype OA-DISABILITY-CAT demonstrated promising measurement properties compared with the HAQ-II, and is recommended for use in LE osteoarthritis research.

Children's reports of activity and participation after sustaining a spinal cord injury: a cognitive interviewing study

OBJECTIVE

To evaluate the readability, comprehension and response processes of test items designed to measure activity performance and participation by children with spinal cord injury (SCI).

METHODS

Eleven parents and 33 children participated. Descriptive statistics were used to calculate frequency of problems based on age, grade, domain and response scale. Agreement was evaluated by weighted kappa coefficient values.

RESULTS

Most (54%) of the problems were due to reading/comprehension, with the majority by children 8 years of age or younger (56%) who had not completed 2nd grade (51%). Agreement between child-parent reports ranged from poor-good, with strongest agreement for mobility items and weak agreement for chores, self-care and participation.

CONCLUSION

Children with SCI 8 years of age and older who have competed 2nd grade are able to read, understand and respond to items associated with activity performance and participation.

Physical performance testing in mucopolysaccharidosis I: a pilot study

OBJECTIVE

To develop and field-test a physical performance measure (MPS-PPM) for individuals with Mucopolysaccharidosis I (MPS I), a rare genetic disorder.

METHODS

Motor performance and endurance items were developed based on literature review, clinician feedback, feasibility, and equipment and training needs. A standardized testing protocol and scoring rules were created. The MPS-PPM includes: Arm Function (7 items), Leg Function (5 items), and Endurance (2 items). Pilot data were collected for 10 subjects (ages 5-29 years). We calculated Spearman's rho correlations between age, severity and summary z-scores on the MPS-PPM.

RESULTS

Subjects had variable presentations, as correlations among the three sub-test scores were not significant. Increasing age was related to greater severity in physical performance (r = 0.72, p<0.05) and lower scores on the Leg Function (r = -0.67, p<0.05) and Endurance (r = -0.65, p<0.05) sub-tests. The MPS-PPM was sensitive to detecting physical performance deficits, as six subjects could not complete the full battery of Arm Function items and eight subjects were unable to complete all Leg Function items. Subjects walked more slowly and expended more energy than typically developing peers.

CONCLUSIONS

Individuals with MPS I have difficulty with arm and leg function and reduced endurance. The MPS-PPM is a clinically feasible measure that detects limitations in physical performance and may have potential to quantify changes in function following intervention.

Weaning children from mechanical ventilation in a post-acute care setting

As medical and technological advances have made it possible to prolong the life of children with chronic respiratory failure, children are being referred to post-acute inpatient rehabilitation programmes. In these settings, children can be weaned from their ventilators and receive medical and rehabilitative care in a developmentally supportive environment at a lower financial cost than in an intensive care unit. There is strong evidence that weaning children from mechanical ventilation has beneficial effects on their functionality, ease of care and quality of life. There is, however, little scientific evidence describing how often successful weaning is achieved or the most effective methods. The purpose of this article is to present a consensus report detailing a structured approach to weaning children from mechanical ventilation in a post-acute care setting. This study proposes a Weaning Severity Index and a Weaning Algorithm for use in the assessment and implementation of the weaning process in post-acute rehabilitation. Future clinical studies are needed to validate the suggested approach to ventilator weaning and to determine whether or not the weaning algorithm results in beneficial patient outcomes.

Evaluation of the nutrition counselling component of a fitness programme for children with disabilities

OBJECTIVE

To describe and evaluate the nutrition counselling component of a fitness programme for children with disabilities.

METHODS

Twenty-eight children with disabilities, ages 6-14 years, participated in a 16-week comprehensive fitness programme consisting of twice weekly exercise sessions, nutrition counselling and physical activity promotion education sessions. Nutrition sessions consisted of three individual and two group sessions. Individual nutrition goals were developed for each child using 3-day food intake diaries and parent interview. Body Mass Index (BMI) and progress towards nutrition goals were documented.

RESULTS

No significant BMI changes were recorded for the entire group (n=28) or a sub-group with a goal to decrease BMI (n=8). Most of the children made improvements in individual goals indicating improvements in healthy eating habits. This included eating the daily recommended amount of servings of each food group, trying new foods and limiting foods containing saturated and trans fats, sodium and sugar.

CONCLUSION

Short-term changes were noted in eating habits and behaviours during the 16-week fitness programme, although the effects did not influence overall BMI during the 16-week programme. Children with disabilities are at nutritional risk, and long-term follow-up is needed to determine if initial changes in parent-reported child eating behaviours will impact long-term nutrition, BMI and overall health.

Development of a disease-specific disability instrument for Pompe disease

PURPOSE

The purpose of this study was to modify the Paediatric Evaluation of Disability Inventory (PEDI) to create a Pompe disease-specific disability instrument for use in clinical trials and natural history studies.

METHODS

PEDI item content was revised to include self-care and mobility items appropriate for children and youth with Pompe disease. Data were collected on 30 individuals with Pompe disease (mean age 7.7+/-5.6 years; range 0.4-22.1 years) by parent proxy through telephone interviews. New items were merged with original PEDI items using Rasch rating scale methods.

RESULTS

The Pompe-PEDI extended the content range and scoring precision of the original PEDI. Construct validity was demonstrated and test-re-test reliability was excellent.

CONCLUSIONS

The Pompe-PEDI is a reliable and valid instrument to assess and monitor the functional changes of children and youth with Pompe disease.

A functional difficulty and functional pain instrument for hip and knee osteoarthritis

INTRODUCTION

The objectives of this study were to develop a functional outcome instrument for hip and knee osteoarthritis research (OA-FUNCTION-CAT) using item response theory (IRT) and computer adaptive test (CAT) methods and to assess its psychometric performance compared to the current standard in the field.

METHODS

We conducted an extensive literature review, focus groups, and cognitive testing to guide the construction of an item bank consisting of 125 functional activities commonly affected by hip and knee osteoarthritis. We recruited a convenience sample of 328 adults with confirmed hip and/or knee osteoarthritis. Subjects reported their degree of functional difficulty and functional pain in performing each activity in the item bank and completed the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Confirmatory factor analyses were conducted to assess scale uni-dimensionality, and IRT methods were used to calibrate the items and examine the fit of the data. We assessed the performance of OA-FUNCTION-CATs of different lengths relative to the full item bank and WOMAC using CAT simulation analyses.

RESULTS

Confirmatory factor analyses revealed distinct functional difficulty and functional pain domains. Descriptive statistics for scores from 5-, 10-, and 15-item CATs were similar to those for the full item bank. The 10-item OA-FUNCTION-CAT scales demonstrated a high degree of accuracy compared with the item bank (r = 0.96 and 0.89, respectively). Compared to the WOMAC, both scales covered a broader score range and demonstrated a higher degree of precision at the ceiling and reliability across the range of scores.

CONCLUSIONS

The OA-FUNCTION-CAT provided superior reliability throughout the score range and improved breadth and precision at the ceiling compared with the WOMAC. Further research is needed to assess whether these improvements carry over into superior ability to measure change.

Blending activity and participation sub-domains of the ICF

OBJECTIVE

The objective of the study was to test the supposition that distinct Activity and Participation sub-domains of the International Classification of Functioning, Disability, and Health (ICF) could be identified using physical function questionnaire items drawn from the Activity and Participation Measures for Post Acute Care.

DESIGN

A cross-sectional survey design was employed. Subjects. The sample consisted of 272 patients who had received post acute care across inpatient and community care settings during the previous year.

METHODS

Exploratory factor analysis with oblique rotation was used to identify interpretable dimensions underlying 83 physical functioning questionnaire items.

RESULTS

Factor analysis findings revealed five distinct ICF conceptual sub-domains that explained 61% of the total variance of the data, with root mean square residual equal to 0.089. These domains were labeled: (i) Daily activity, (ii) Applied cognitive, (iii) Role participation, (iv) Mobility, and (v) Social participation. These five factors were correlated to varying degrees and achieved acceptable levels of internal consistency with coefficient alphas from 0.59-0.93.

CONCLUSION

These analyses suggest that clear distinctions between Activity and Participation sub-domains of the ICF could not be identified in a sample of adults who had recently received post acute care. We believe this is important evidence of the ability to measure blended Activity and Participation sub-domains that cut across distinct and interpretable areas of life functioning.

Central auditory processing and social functioning following brain injury in children

PRIMARY OBJECTIVE

To describe the percentage of children with central auditory processing disorders (CAPD) and examine the recovery patterns of social functional skills in children with and without CAPD admitted to inpatient rehabilitation following an acquired brain injury (ABI).

RESEARCH DESIGN

Retrospective, descriptive.

METHODS AND PROCEDURES

Repeated measures ANOVAs were used to examine overall differences in social functioning between groups, within groups and interaction effects for the Paediatric Evaluation of Disability Inventory (PEDI) Social Functional Skills and Caregiver Assistance scales for 31 children admitted to inpatient rehabilitation following ABI.

MAIN OUTCOMES AND RESULTS

Significant overall effects were found in group differences and test occasions, but no significant interaction for either PEDI scale. Both groups showed significant intra-group changes between admission and discharge on both scales.

CONCLUSIONS

Children with and without CAPD recovered social functional skills during inpatient rehabilitation. Children with CAPD were admitted and discharged with lower Social Function scores but demonstrated greater changes. The identification of CAPD during inpatient rehabilitation allows for appropriate discharge recommendations and realistic recovery expectations.

Development and evaluation of a minimum data set for children with airway support for transfers between acute and post-acute care

OBJECTIVE

To generate consensus on the reasons why children with airway support transfer between acute and post-acute care; develop a minimum data set to transmit between care settings; and examine transfer reports to determine the frequency of data set content.

STUDY DESIGN

Two consensus development meetings were conducted of acute and post-acute care professionals to identify reasons for transfer and develop the minimum data set. A content analysis was used to generate the frequency of inclusion of minimum data set elements in the narrative reports of 15 acute to post-acute and 15 post-acute to acute transfer summaries. The observed frequencies were compared with the expected frequencies (95%), as were frequencies between the two groups.

RESULTS

Advanced diagnostic assessment and unexpected changes in medical, surgical and mental health conditions were the primary reasons for transfer from post-acute to acute care. For transfers in both directions, 20 of the 34 data elements were present in <75% of the cases and were statistically different than the pre-set 95% standard. No statistical difference in the occurrence of data elements between transfer directions existed.

CONCLUSION

A minimum data set has the potential to reduce redundancy, improve safety and optimize care co-ordination between facilities for children with airway support.

Evaluation of an item bank for a computerized adaptive test of activity in children with cerebral palsy

BACKGROUND

Contemporary clinical assessments of activity are needed across the age span for children with cerebral palsy (CP). Computerized adaptive testing (CAT) has the potential to efficiently administer items for children across wide age spans and functional levels.

OBJECTIVE

The objective of this study was to examine the psychometric properties of a new item bank and simulated computerized adaptive test to assess activity level abilities in children with CP.

DESIGN

This was a cross-sectional item calibration study.

METHODS

The convenience sample consisted of 308 children and youth with CP, aged 2 to 20 years (X=10.7, SD=4.0), recruited from 4 pediatric hospitals. We collected parent-report data on an initial set of 45 activity items. Using an Item Response Theory (IRT) approach, we compared estimated scores from the activity item bank with concurrent instruments, examined discriminate validity, and developed computer simulations of a CAT algorithm with multiple stop rules to evaluate scale coverage, score agreement with CAT algorithms, and discriminant and concurrent validity.

RESULTS

Confirmatory factor analysis supported scale unidimensionality, local item dependence, and invariance. Scores from the computer simulations of the prototype CATs with varying stop rules were consistent with scores from the full item bank (r=.93-.98). The activity summary scores discriminated across levels of upper-extremity and gross motor severity and were correlated with the Pediatric

OUTCOMES

Data Collection Instrument (PODCI) physical function and sports subscale (r=.86), the Functional Independence Measure for Children (Wee-FIM) (r=.79), and the Pediatric Quality of Life Inventory-Cerebral Palsy version (r=.74).

LIMITATIONS

The sample size was small for such IRT item banks and CAT development studies. Another limitation was oversampling of children with CP at higher functioning levels.

CONCLUSIONS

The new activity item bank appears to have promise for use in a CAT application for the assessment of activity abilities in children with CP across a wide age range and different levels of motor severity.

Self-report measures of physical function for children with spinal cord injury: a review of current tools and an option for the future

OBJECTIVE

The purpose of this article is to provide paediatric rehabilitation providers with a review of self-report physical function outcome measures that have been used for children with spinal cord injury (SCI).

REVIEW PROCESS

A literature review was conducted to identify self-report physical function measures for children with SCI. Further searching of reference lists and textbooks was also completed.

OUTCOMES

Eight measures were identified, but limitations exist in these current tools. There are few reports of psychometrics, in addition to a lack of accommodation for wheelchair use, limited item content for supported ambulation and minimal variation in content for a wide age-range.

CONCLUSION

A comprehensive yet practical self-report measure applicable for all ages with items suitable for a child with a complete or incomplete injury is needed. The best means to achieve effective and efficient outcome monitoring may be computerized adaptive testing.

Replenishing a computerized adaptive test of patient-reported daily activity functioning

PURPOSE

Computerized adaptive testing (CAT) item banks may need to be updated, but before new items can be added, they must be linked to the previous CAT. The purpose of this study was to evaluate 41 pretest items prior to including them into an operational CAT.

METHODS

We recruited 6,882 patients with spine, lower extremity, upper extremity, and nonorthopedic impairments who received outpatient rehabilitation in one of 147 clinics across 13 states of the USA. Forty-one new Daily Activity (DA) items were administered along with the Activity Measure for Post-Acute Care Daily Activity CAT (DA-CAT-1) in five separate waves. We compared the scoring consistency with the full item bank, test information function (TIF), person standard errors (SEs), and content range of the DA-CAT-1 to the new CAT (DA-CAT-2) with the pretest items by real data simulations.

RESULTS

We retained 29 of the 41 pretest items. Scores from the DA-CAT-2 were more consistent (ICC = 0.90 versus 0.96) than DA-CAT-1 when compared with the full item bank. TIF and person SEs were improved for persons with higher levels of DA functioning, and ceiling effects were reduced from 16.1% to 6.1%.

CONCLUSIONS

Item response theory and online calibration methods were valuable in improving the DA-CAT.

Measuring global physical health in children with cerebral palsy: illustration of a multidimensional bi-factor model and computerized adaptive testing

PURPOSE

The purposes of this study were to apply a bi-factor model for the determination of test dimensionality and a multidimensional CAT using computer simulations of real data for the assessment of a new global physical health measure for children with cerebral palsy (CP).

METHODS

Parent respondents of 306 children with cerebral palsy were recruited from four pediatric rehabilitation hospitals and outpatient clinics. We compared confirmatory factor analysis results across four models: (1) one-factor unidimensional; (2) two-factor multidimensional (MIRT); (3) bi-factor MIRT with fixed slopes; and (4) bi-factor MIRT with varied slopes. We tested whether the general and content (fatigue and pain) person score estimates could discriminate across severity and types of CP, and whether score estimates from a simulated CAT were similar to estimates based on the total item bank, and whether they correlated as expected with external measures.

RESULTS

Confirmatory factor analysis suggested separate pain and fatigue sub-factors; all 37 items were retained in the analyses. From the bi-factor MIRT model with fixed slopes, the full item bank scores discriminated across levels of severity and types of CP, and compared favorably to external instruments. CAT scores based on 10- and 15-item versions accurately captured the global physical health scores.

CONCLUSIONS

The bi-factor MIRT CAT application, especially the 10- and 15-item versions, yielded accurate global physical health scores that discriminated across known severity groups and types of CP, and correlated as expected with concurrent measures. The CATs have potential for collecting complex data on the physical health of children with CP in an efficient manner.

Creating a computer adaptive test version of the late-life function and disability instrument

BACKGROUND

This study applied item response theory (IRT) and computer adaptive testing (CAT) methodologies to develop a prototype function and disability assessment instrument for use in aging research. Herein, we report on the development of the CAT version of the Late-Life Function and Disability Instrument (Late-Life FDI) and evaluate its psychometric properties.

METHODS

We used confirmatory factor analysis, IRT methods, validation, and computer simulation analyses of data collected from 671 older adults residing in residential care facilities. We compared accuracy, precision, and sensitivity to change of scores from CAT versions of two Late-Life FDI scales with scores from the fixed-form instrument. Score estimates from the prototype CAT versus the original instrument were compared in a sample of 40 older adults.

RESULTS

Distinct function and disability domains were identified within the Late-Life FDI item bank and used to construct two prototype CAT scales. Using retrospective data, scores from computer simulations of the prototype CAT scales were highly correlated with scores from the original instrument. The results of computer simulation, accuracy, precision, and sensitivity to change of the CATs closely approximated those of the fixed-form scales, especially for the 10- or 15-item CAT versions. In the prospective study, each CAT was administered in <3 minutes and CAT scores were highly correlated with scores generated from the original instrument.

CONCLUSIONS

CAT scores of the Late-Life FDI were highly comparable to those obtained from the full-length instrument with a small loss in accuracy, precision, and sensitivity to change.

Group aquatic aerobic exercise for children with disabilities

The effectiveness and safety of a group aquatic aerobic exercise program on cardiorespiratory endurance for children with disabilities was examined using an A-B study design. Sixteen children (11 males, five females) age range 6 to 11 years (mean age 9y 7mo [SD 1y 4mo]) participated in this twice-per-week program lasting 14 weeks. The children's diagnoses included autism spectrum disorder, myelomeningocele, cerebral palsy, or other developmental disability. More than half of the children ambulated independently without aids. Children swam laps and participated in relay races and games with a focus of maintaining a defined target heart rate zone. The strengthening component consisted of exercises using bar bells, aquatic noodles, and water resistance. The following outcomes were measured: half-mile walk/run, isometric muscle strength, timed floor to stand 3-meter test, and motor skills. Complaints of pain or injury were systematically collected. Significant improvements in the half-mile walk/run were observed, but not for secondary outcomes of strength or motor skills. The mean program attendance was 80%, and no injury was reported. Children with disabilities may improve their cardiorespiratory endurance after a group aquatic aerobic exercise program with a high adult:child ratio and specific goals to maintain training heart rates.

Motor scores on the functional independence measure after pediatric spinal cord injury

STUDY DESIGN

Retrospective descriptive analysis.

OBJECTIVES

The purpose of this study was to report the functional ability of children with spinal cord injury (SCI) as recorded on motor items of the functional independence measure (FIM) and to examine the factors associated with FIM motor admission and post-discharge gain scores.

METHODS

Scores on FIM motor items were analyzed from 941 children (age range: 0-21 years; mean: 13 years 4 months; s.d.: 4 years 8 months) admitted in acute-to-chronic time periods post-SCI to Shriners Hospitals for Children (USA). FIM motor scores at admission and gains at discharge were examined along with neurological level, completeness of injury, age, etiology of injury, and length of time between injury and admission and admission and discharge.

RESULTS

The FIM motor scores at admission were negatively correlated with age, neurological level and completeness of injury. Gain in FIM motor scores was significant across neurological levels, and was associated with lower admission FIM motor scores, lower neurological level, incomplete injury, traumatic injury and less time between injury and admission.

CONCLUSIONS

The motor function of children after pediatric SCI depends on neurological level and completeness of injury, among other factors. FIM motor scores can improve with intervention even several years after the injury.

Assessing self-care and social function using a computer adaptive testing version of the pediatric evaluation of disability inventory

OBJECTIVE

To examine score agreement, validity, precision, and response burden of a prototype computer adaptive testing (CAT) version of the self-care and social function scales of the Pediatric Evaluation of Disability Inventory compared with the full-length version of these scales.

DESIGN

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

Children with disabilities (n=469) and 412 children with no disabilities (analytic sample); 38 children with disabilities and 35 children without disabilities (cross-validation sample).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Summary scores from prototype CAT applications of each scale using 15-, 10-, and 5-item stopping rules; scores from the full-length self-care and social function scales; time (in seconds) to complete assessments and respondent ratings of burden.

RESULTS

Scores from both computer simulations and field administration of the prototype CATs were highly consistent with scores from full-length administration (r range, .94-.99). Using computer simulation of retrospective data, discriminant validity, and sensitivity to change of the CATs closely approximated that of the full-length scales, especially when the 15- and 10-item stopping rules were applied. In the cross-validation study the time to administer both CATs was 4 minutes, compared with over 16 minutes to complete the full-length scales.

CONCLUSIONS

Self-care and social function score estimates from CAT administration are highly comparable with those obtained from full-length scale administration, with small losses in validity and precision and substantial decreases in administration time.

Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: II. Participation outcomes

OBJECTIVES

To measure participation outcomes with a computerized adaptive test (CAT) and compare CAT and traditional fixed-length surveys in terms of score agreement, respondent burden, discriminant validity, and responsiveness.

DESIGN

Longitudinal, prospective cohort study of patients interviewed approximately 2 weeks after discharge from inpatient rehabilitation and 3 months later.

SETTING

Follow-up interviews conducted in patient's home setting.

PARTICIPANTS

Adults (N=94) with diagnoses of neurologic, orthopedic, or medically complex conditions.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participation domains of mobility, domestic life, and community, social, & civic life, measured using a CAT version of the Participation Measure for Postacute Care (PM-PAC-CAT) and a 53-item fixed-length survey (PM-PAC-53).

RESULTS

The PM-PAC-CAT showed substantial agreement with PM-PAC-53 scores (intraclass correlation coefficient, model 3,1, .71-.81). On average, the PM-PAC-CAT was completed in 42% of the time and with only 48% of the items as compared with the PM-PAC-53. Both formats discriminated across functional severity groups. The PM-PAC-CAT had modest reductions in sensitivity and responsiveness to patient-reported change over a 3-month interval as compared with the PM-PAC-53.

CONCLUSIONS

Although continued evaluation is warranted, accurate estimates of participation status and responsiveness to change for group-level analyses can be obtained from CAT administrations, with a sizeable reduction in respondent burden.

Physical function for children and youth with cerebral palsy: Item bank development for computer adaptive testing

The purposes of this paper are to: 1) present a conceptual framework that supports development of a computer adaptive test (CAT) outcome measure of physical functioning for children with cerebral palsy; 2) illustrate the development and refinement of an item bank for use in the CAT; and 3) describe the intended application of these newly developed items in a CAT platform. Improvement in physical functioning is one of the most important developmental and rehabilitative outcomes for children with cerebral palsy (CP). Computer adaptive testing technology provides means to improve outcome measures. We adopted a conceptual framework appropriate to support a CAT of physical functioning consisting of 4 sub-domains: lower extremity skills, upper extremity skills, physical activity, and global physical health. Review of existing tests and measures of physical function, expert clinician review, and cognitive testing were used to identify, develop and refine sets of items (item banks) that reflect the breadth of each sub-domain. These item banks will be used to develop contemporary parent-report instruments by application of Item Response Theory (IRT) analyses, leading to a CAT outcome measure. Such CAT approaches can efficiently assess broad areas of physical functioning across a wide age-range and levels of severity of children with CP.

Bronchoscopy findings in children and young adults with tracheostomy due to congenital anomalies and neurological impairment

The aim of this study was to examine bronchoscopy findings for children and young adults with long-term tracheostomies due to congenital anomalies and neurological impairment and identify characteristics associated with abnormal bronchoscopic findings. We conducted a retrospective study of 128 bronchoscopy cases (81 children) at a pediatric rehabilitation center. Thirty-eight cases (30%) had normal findings and 14 children (17% of all children) were decannulated following bronchoscopy. Ninety cases (70% of cases) had abnormal findings (e.g. granulomas, airway inflammation, fixed obstruction). An acute indication for bronchoscopy was the strongest predictor of an abnormal finding, while age (younger) and diagnosis (multiple congenital anomalies (MCA)) also were associated with abnormalities. For a subsample of children undergoing bronchoscopy for routine surveillance (n= 90), underlying diagnosis (MCA) was the strongest predictor of an abnormal finding, while younger age contributed slightly. These findings add to the limited literature describing bronchoscopic findings in children and youth with tracheostomies due to congenital anomalies or neurological impairment. These findings may be useful for rehabilitation clinicians in determining care needs for children with long-term tracheostomy.

Predictors of basic and instrumental activities of daily living performance in persons receiving rehabilitation services

OBJECTIVE

To examine the relations among cognitive and emotional function and other patient impairment and demographic variables and the performance of daily activities.

DESIGN

Cohort.

SETTING

Acute inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics.

PARTICIPANTS

Adults (N=534) receiving services for neurologic (32.3%), lower-extremity orthopedic (42.7%), or complex medical (24.9%) conditions. Mean age was 63.8 years; 55% were women; 88.6% were white; and the time since condition onset ranged from 0.2 to 3.9 years.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Activity Measure for Post-Acute Care: applied cognitive, personal care and instrumental, and physical and movement scales; Mental Health Inventory-5 (MHI-5); and patient-identified problems (vision, grasp).

RESULTS

Path analyses resulted in good model fit both for the total sample and 3 patient subgroups (chi(2) test, P>.05; comparative fit index >.95). There was a significant (P<.05) direct relation between the applied cognitive, grasp, and personal care and instrumental variables in all patient groups. There were also significant indirect relations between the MHI-5, visual impairment, and grasp problems with the personal care and instrumental scale through an association with the applied cognitive scale. Strength and significance of associations between age, sex, and physical and movement and personal care and instrumental scales varied more across patient groups. The model R(2) for the personal care and instrumental scale for the total sample was .60, with R(2) values of .10, .72, and .62 for the lower-extremity orthopedic, neurologic, and complex medical groups, respectively.

CONCLUSIONS

Results suggest that variations in cognitive function, along with visual impairment and lower perceived well-being are associated with a patient's ability to complete daily activities. Rehabilitation professionals should consider cognitive and emotional factors as well as physical performance when planning treatment programs to restore daily activity function.

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.