1. An Assessment of Clinically Relevant Pediatric Physical Therapy Outcome Tools Regis University Sept 29, 2010 Cody Butler, SPT Courtney Haia, SPT Sydney Stan, SPT

2. Objectives At the end of this presentation, each clinician should be able to: Accurately identify Sn, Sp, MCID, & MDD when selecting an outcome tool Compare and contrast the psychometric properties of Pediatric PT outcome tools Describe the effectiveness of the PEDI as an outcome tool in the pediatric setting Examine the psychometric properties of the PEDI based on evidence-based literature Accurately search and critically appraise literature for high quality and clinically relevant research regarding outcome measures

3. Benefits of Outcome Measurement Information about developmental progress Ensure continuation of funding Improve program planning Inform decision making Improve guidance in goal development

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

5. Stakeholders The Children’s Hospital Department of Rehabilitation Individual Physical Therapists Patients and Families

6. Recommendations for Outcome Measure Systems Ask Questions Purpose If purpose is for comparing performance to same age peer then you need a scale that can give a normative standard score. (PEDI, Peabody, TIMP, AIMS) If purpose is to measure progress along a continuum of difficulty then you need a measure that can give you a scaled score.(GMFM, PEDI) Consider validity, reliability, sensitivity to change and responsiveness of the measure Consider the group or individual of interest: homogenous, heterogeneous, dx, age, severity of functional challenges, rate of change

7. Specificity and Sensitivity A test’s ability to obtain a negative result when the condition actually is absent. A true negative. “SpIN” When a test is positive, you can rule in the disease/ condition The ability to obtain a positive test when the target condition is actually present. “SnOUT” If the test is negative, you can rule the condition out. Overestimates the amount of people who have it.

8. Clinically Significant Difference 1. 1.Responsiveness “The power of a test to detect a clinically important difference.” 1. 1.Sensitivity to Change “Accurate detection of change when it has occurred.”

9. Minimal detectable difference (MDD) Defines the amount of change in a variable that must be achieved in order to reflect a true difference The smallest amount of change that passes the threshold of error.

10. Minimal clinically-important difference (MCID) Smallest difference in a measured variable that signifies and important rather than trivial differences in patients’ conditions. Smallest difference a patient or clinician would perceive as beneficial & would result in a change in the management of the pt.

11. Psychometric Properties TIMPGMFMPEDI Responsive -ness Discriminates between children with various conditions Discriminates between GMFCS levels I-II and II-III 3 Greater responsiveness to change with children > 4yo Sensitivity to change Age-related changes in motor performance (r =.83) 1 ES and SRM > 0.5 4 ES and SRM > 0.8 4 Reliability ICC: 0.89-0.95Inter-rater: 0.077 and 0.88 5 ICC: 0.95-0.99 6 Inter-respondent reliability: 0.64-0.74 6 Validity Concurrent validity with AIMS 2 Children with CP and Down’s Syndrome (66) Construct: strong correlation between mean scale scores and child’s age for functional skills and care giver assistance scales 7 Patient population 34 weeks – 4 months 5mo – 16 yrs< 7yo

12. International Classification of Functioning, Disability and Health (ICF) Body Function: physiological function Activity: execution of an action Participation: places activities in to life situations

13. ICF Level 8-10 TIMP Wee FIMGMFMPEDI Health Condition NO Body Function NO ActivityYES ParticipationNO YES EnvironmentNO YES Env mod, caregiver asst

14. We started with the Question What outcome tool effectively measures change in activity level and participation for children with a wide variety of neurological disorders?

15. PEDI (CP or children) AND physical therapy AND responsiveness to change AND assessment Pub-med 1 result (Ketelaar 2008 11 ) Conclusion “Only two evaluative assessment measures, the Gross Motor Function Measure (GMFM) and the Pediatric Evaluation of Disability Inventory (PEDI), fulfill the criteria of reliability and validity with respect to responsiveness to change.”

16. What is the PEDI? Pediatric Evaluation of Disability Inventory (1990) Discriminative device Detects functional limitations and participation Self-care, mobility, social function, caregiver assistance, modifications Evaluative Tracks progress in individual children with disabilities; Sensitive to small increments of change Examples: Cerebral Palsy, hemiplegia, spina bifida, TBI, Down’s syndrome

17. PEDI Number of items/questions 197 Time to complete 30-60 minutes Age range <1-7 years Score range 0-100 Administered by clinician/guardian

18. Usefulness to everyday practice Engelen 2007 12 Engelen 2007 12 CONCLUSION Individual goals set in a physical therapy practice for children with cerebral palsy can be linked, to a large extent, to items and activities of 2 standardized measures. GMFM-88 and PEDI

19. Identifying quality evidence in the literature When asking a question based on gaps in the literature, use the PICO format: Person/patient population Intervention Comparison Outcome Databases: PubMed, CINAHL, Cochrane Library

20. Future Endeavors Standardized format for documenting pediatric interventions (PPTIA) 13 PEDI Multidimensional Computer adaptive testing (PEDI-MCAT) PEDI Multidimensional Computer adaptive testing (PEDI-MCAT) 14

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

22. Questions?

23. References 1.Campbell, S. K., & Hedeker, D. (2001). Validity of the Test of Infant Motor Performance for discriminating among infants with varying risk for poor motor outcome. Journal of Pediatrics, 139, 546-551 2.Barbosa VM, Campbell SK, Jaidep Singh DS, et al. Longitudinal Performance of Infants with Cerebral Palsy on the Test of Infant Motor Performance and on the Alberta Infant Motor Scale. Physical & Occupational Therapy in Pediatrics. 2003; 23: 3. 3.Bagley AM, Gorton G, Oeffinger D, Barnes D, et al. Outcome assessments in children with cerebral palsy, Part II: discriminatory ability of outcome tools. Developmental Medicine & Child Neurology. 2007, 49: 181–186. 4.Vos-Vromans DCWM, Ketelaar M, and Gorter JW. Responsiveness of evaluative measures for children with cerebral palsy: The Gross Motor Function Measure and the Pediatric Evaluation of Disability Inventory. Disability and Rehabilitation. 2005; 27(20): 1245 – 1252. 5.Nordmark E, Hagglund G, Jarnlo GB. Reliability of the gross motor function measure in cerebral palsy. Scand J Rehabil Med 1997;29(1):25-8. 6.Berg M, Jahnsen R, Frøslie K, Hussain A. Reliability of the pediatric evaluation of disability inventory (PEDI). Physical & Occupational Therapy in Pediatrics. 2004;24:61-77 7.Haley S, Coster, W, Ludlow L, Haltiwanger J, Andrellos J. Pediatric Evaluation of Disability Inventory (PEDI). Boston: Trustees of Boston Univeristy, 1998. 8.McCarthy ML, Silberstein CE, Atkins EA, et al. Comparing reliability and validity of pediatric instruments for measuring health and well-being of children with spastic cerebral palsy. Developmental Medicine & Child Neurology. 2002, 44:468–476. 9.Oeffinger D, Gorton G, Nicholson D, et al. Outcome assessments in children with cerebral palsy, Part I: descriptive characteristics of GMFCS Levels I to III. Developmental Medicine & Child Neurology. 2007, 49: 172–180. 10.Lollar DJ, Simeonsson RJ, and Nanda U. Measures of Outcomes for Children and Youth. Arch Phys Med Rehabil. 2000;81. 11.Ketelaar M, Vermeer A, Helders PJ. Functional motor abilities of children with cerebral palsy: a systematic literature review of assessment measures. Clin Rehabil. 1998; 12(5):369-80. Ketelaar MVermeer AHelders PJKetelaar MVermeer AHelders PJ 12.Engelen V, Ketelaar M, Gorter JW. Selecting the appropriate outcome in pediatric physical therapy: how individual treatment goals of children with cerebral palsy are reflected in GMFM-88 and PEDI. J Rehabil Med. 2007; 39(3):225-31. 13.Hashimoto M and Westcott McCoy S. Validation of an Activity-Based Data Form Developed to Reflect Interventions Used by Pediatric Physical Therapists. Pediatr Phys Ther. 2009;21:53–61. 14.Hayley SM, Coster WI, Kao YC, Dumas HM et al. Lessons from use of the pediatric evaluation of disability inventory: where do we go from here? Ped. Phys. Ther. 2010.