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Pediatric Outcome Measures
Claudia Senesac, PT, PhD, PCS Associate Clinical Professor
University of Florida
-‐Selec3ng Outcome Measures-‐ Considera3ons in Pediatrics
Clinical, Research, Social Policy,
Educa5onal, Sta5s5cal • Age of client • Reason for documenta3on
– Jus3fica3on for treatment • Insurance or funding agency • Facility driven • Family driven • Clinician Driven
– Measurement or tracking of progress • Assess needs and POC • Evaluate interven3ons
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Consider Criterion Referenced Outcome Measures
CRITERION REFERENCED TEST • Scores are interpreted on basis of absolute criteria; number of items answered/performed correctly
• Interpreted by considering directly whether child has met age appropriate func3onal demands
• Measures a person’s mastery of a set of “behavioral objec5ves”
• Developmental quo3ent is the ra3o between the child’s actual score (developmental) age and the child’s chronological age
Consider Norm Referenced Outcome Measures
NORM REFERENCED
• Use norma3ve values as standard for interpre3ng individual score
• Compares a pa3ent with the norm or average of a group of children (usually “typically developing”)
• Use percen3le scores which indicate the number of children of the same age or grade level who would be expected to score lower than the child tested
• Compare score to scores obtained by large number of comparison children
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Benefits of Outcome Measures
• Objec3ve assessment
• Scaled subjec3ve assessment • Tracking Progress • Comparison
• Guidelines for POC • Research and data collec3on • Established baseline for discussion with other professionals and family
Interna3onal Classifica3on of Func3oning ICF
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Component Parts of the ICF Defined for Pediatrics
• Health Condi3on: Diagnosis • Body Func3on (Systems)/Structure/Impairments:
Motor deficits, sensory, musculoskeletal, strength, balance, coordina3on
• Ac3vity/Limita3ons: skills, unable to sit, unable to stand • Par3cipa3on/Restric3ons: unable to play, family, friends,
sports, ADL’s • Personal Factors: age, gender, educa3on, family, friends,
cogni3on, social/emo3onal • Environmental Factors/Internal/External: stress, anxiety, home, day care, church, school
Barriers To Use of ICF in Children
• Challenges: Children change every 6-‐12 months (some3mes in shorter 3meframe), children are not small adults, environments and par3cipa3on are different in children, matura3on is a factor throughout growth
• Does provide: con3nuity of documenta3on, facilitates transi3on from child to adult and communica3on among professionals and parents, common language
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Barriers to Use of Outcomes in a Therapy Se^ng
• Time
• Equipment • Modifica3ons • Environment
• Lack of resources
Common Pediatric Outcome Measures by ICF Categories
h_ps://pediatricapta.org/includes/fact-‐sheets/pdfs/13%20Assessment&screening%20tools.pdf
Body Structure/Func5on (Impairments)
Anthropometrics
Cardiopulmonary
Coordina3on Endurance/Energy Expenditure
Fitness Measures Mul3
Pain Posture/Balance
Body Structure/Func5on (Impairments)
Posture/Structural Integrity
ROM
Reflexes Sensory Processing
Spas3city Strength/Muscle Power
Visual Motor/Percep3on
*Follow the link above to the Pediatric Section of the APTA for a list of outcome measures
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Common Pediatric Outcome Measures by ICF Categories
Ac5vity (Limita3ons)
Gait/Walking
Gross Motor
Fine Motor Play
Developmental Screening Tools Mul3-‐Domain
Par5cipa5on (Restric3ons)
Mul3-‐domain
Quality of Life
Health Status
Personal/Contextual (Personal/Environmental)
Case Example
• 4 year old with cerebral palsy: spas3c diplegia • Able to creep on all 4’s, pull to stand, cruise at furniture and just beginning to stand independently but falls frequently, not taking independent steps yet
• Walks with a push toy with a crouched gait pa_ern, falls to knees frequently
• She has difficulty maintaining elonga3on through her trunk while cruising and walking with push toy
• Inconsistent balance reac3ons (R/E/PE) • Wears bilateral AFO’s
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Selec3ng an Outcome Measure
• Family would like to know how she compares with typical kids her age and those children that have a similar disability
• Therapist would like to establish a POC • Insurance requires objec3ve measures for approval of POC
• Facility has no requirements or specifica3ons for use of specific outcome measures
Things to Consider in an Outcome Measure Based on the ICF Model
Body Structure/Func5on • ROM • Muscle Tone/Spas3city
• Coordina3on • Reflexes • Posture/Balance (R/E/PE)
Par5cipa5on • Quality of Life • Observa3on and by report
Ac5vity • Gait/Walking • GM
• FM
• Play-‐observa3on and by report
Personal/Contextual • History taking • Observa3on
Based on the history what categories should be documented?
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Appropriate Assessments Body Func3on/ Structure and Ac3vity
• ROM – Goniometric measurements and special tests for hips
• Observa3on – Handling, tes3ng of postural reac3ons, other
• Modified Ashworth Scale www.rehabmeasures.org
– Subjec3ve measure of muscle tone
– Frequently used in research and pre/post surgery – SEM: not established
– MDC: documented in stroke with Botox use
• Gross Motor Func3on Measure www.canchild.ca/en/measures/gmfm.asp
– Developed for children with CP and Down Syndrome
– Assesses 5 categories – Describes current motor level, assist in determining POC
– Confidence Interval of 95% – SEM and MDC published in the manual
Appropriate Assessments Body Structure/ Func3on and Ac3vity
• Peabody Developmental Motor Scales 2nded www.proedinc.com
– Based on a typical popula3on – GM/FM
– Determine level of motor skill acquisi3on
– Detect small changes motor abili3es
– Assist programming/POC
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Appropriate Assessments Par3cipa3on, Environment, Personal
• Pediatric Quality of Life Inventory (PEDS QL) h_p://www.pedsql.org/
– Parent proxy forms
– Disease specific modules for certain condi3ons
– Child report available over age 5
• Environment and Personal – History Taking – Observa3on and Report (child and parent)
Summary Based on Assessment
• Janelle is a 4 year old with spas3c diplegia. She is not walking yet independently however she is able to cruise, beginning to stand alone and walk with a push toy. – ROM:
• Limited hip extension, 3ght hip flexors, 3ght heel cords, 3ght adductors, 3ght hamstrings
– Modified Ashworth Scale: • Scored 3’s in most LE ms groups, indica3ng significant increases
– GMFM • 100% in lying/rolling, 87% in si^ng, 52% in crawling and kneeling, 54% in standing, 15% in walking, running, jumping,
– PDMS-‐2 • Locomo3on = between 12-‐18 months
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Summary Based on Assessment
• Observa3ons…many
• Postural and Balance – Noted on assessment
• Righ5ng reac5ons of the head are present to midline
• Righ5ng reac5ons of the trunk are incomplete right > les with an inability to right the trunk to the midline with FROM and difficulty maintaining elonga3on of the trunk on the WBS
• Equilibrium reac5ons are inconsistent on the ball in si^ng with the same difficulty noted above with elonga3on and poor trunk rota3on to the midline
• Protec5ve reac5ons: present in si^ng side to side, forward, but not consistently backward. Posi3ve downward parachute reac3on. Inconsistent PE in standing
Plan of Care Based on Assessment
• Management of Muscle Tone
• Improve ROM and prevent limita3ons
• Motor skills to target: significant delay compared to other children of his age
– Rolling /Lying NO – Si^ng perhaps look at quality
– Crawling/Kneeling difficulty with reciprocal mvt
– Standing dissociated mvt
– Walking most delayed skills associated with this category
– Postural Reac3ons delayed and inconsistent for age
• Par3cipa3on, Personal, Environmental – Monitor and assist family with resources
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Goals Related to Assessment
Short Term Goals (3-‐6 months) • Hip extension ROM will improve by 10 degrees
• Janelle will creep 10’ reciprocally with LE dissocia3on 2/5 trials • Janelle will be able to a_ain ½ kneel at the furniture with UE support of
furniture 3/5 trials
• Janelle will be able to stand independently and squat for a toy regaining her balance 3/5 trials
• Janelle will be able to take 3-‐5 steps independently 3/5 trials • Janelle will be able to demonstrate PE when challenged in si^ng in all
direc3ons 3/5 trials, 2/5 trials from standing
• Janelle will be able to bring her trunk to the midline when balance is challenged on the ball and in standing when small perturba3ons are given 3/5 trials
Goals Related to Assessment
Long Term Goals (6-‐12 months) • Janelle will be able to walk independently without the use of an assis3ve
device carrying a toy without falling 3/5 trials
• Janelle will begin to use arm swing on the treadmill with moderate assist for 1-‐2 minutes
• Janelle will be able to demonstrate Equilibrium tested on the ball in si^ng all direc3ons 3/5 trials with full elonga3on on the WB side
• Janelle will be able to demonstrate Equilibrium tested in standing with support provided at the pelvis 3/5 trials correc3ng trunk to midline without assistance at the trunk
• Janelle will pull to standing through ½ kneel 2/5 trials
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Current Ongoing Research on Outcome Measures
• Jacqueline Flohr: collec3ng qualita3ve data on Pediatric Assessment Tools.
• The purpose: to inves3gate which standardized outcome tools are most osen used by physical therapist within a pediatric se^ng.
• Ques3ons focused on: use of different standardized assessment tools common in clinical prac3ce and research literature.
• Findings: a be_er understanding what clinical prac3ce measures are most common and what areas need further development.
Pediatric Special Sec3on APTA
• Ongoing research con3nues comparing outcome measures, valida3ng and establishing reliability. Development of psychometric measures in an ongoing process that is con3nuous
Strengthening Pediatric Outcome Measures
1. Recogni3on/Inclusion on Rehab Measures and other sites that offer same type of informa3on i.e. PTNow
2. Research and development of outcome measures 3. Outcome measures that document changes in quality of
movement (GMPM-‐ measure looking at quality)
4. Outcome measures that are more sensi3ve to change 5. Updated list of currently available tools with validity and
reliability with SEM/MDC-‐available through Pediatric Sec5on APTA 6. Resources that allow free access to outcomes that don’t
require special training
7. Con3nued research on the comparison of outcomes for best results
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References
1. Reference Curves for the Gross Motor Func3on Measure: Percen3les for Clinical Descrip3on and Tracking Over Time Among Children With Cerebral Palsy. Steven E Hanna, Doreen J Bartle_, Lisa M Rivard, Dianne J Russell. Phys Ther. 2008 May; 88(5): 596–607.
2. Longitudinal construct validity of the GMFM-‐88 total score and goal total score and the GMFM-‐66 score in a 5-‐year follow-‐up study. Lundkvist Josenby A1, Jarnlo GB, Gummesson C, Nordmark E. Phys Ther. 2009 Apr;89(4):342-‐50.
3. Validity and reliability of two abbreviated versions of the Gross Motor Func3on Measure. Brunton LK1, Bartle_ DJ. Phys Ther. 2011 Apr;91(4):577-‐88.
4. Concurrent validity of the Bayley Scales of Infant Development II (BSID-‐II) Motor Scale and the Peabody Developmental Motor Scale II (PDMS-‐2) in 12-‐month-‐old infants. Connolly BH1, Dalton L, Smith JB, Lamberth NG, McCay B, Murphy W.Pediatr Phys Ther. 2006 Fall;18(3):190-‐6.
5. Concurrent validity of the Bayley-‐III and the Peabody Developmental Motor Scale-‐2. Connolly BH1, McClune NO, Gatlin R. Pediatr Phys Ther. 2012 Winter;24(4):345-‐52.
References
6. Feasibility, test-‐retest reliability, and interrater reliability of the Modified Ashworth Scale and Modified Tardieu Scale in persons with profound intellectual and mul3ple disabili3es. Waninge A1, Rook RA, Dijkhuizen A, Gielen E, van der Schans CP.Res Dev Disabil. 2011 Mar-‐Apr;32(2):613-‐20.
7. Test-‐retest reliability and inter-‐rater reliability of the Modified Tardieu Scale and the Modified Ashworth Scale in hemiplegic pa3ents with stroke. Li F1, Wu Y, Li X. Eur J Phys Rehabil Med. 2014 Feb;50(1):9-‐15
8. Concordance of Child and Parent Reports of Health-‐Related Quality in Children With Mild Trauma3c Brain or Non-‐Brain Injuries and in Uninjured Children: Longitudinal Evalua3on. Pieper P, Garvan C.J Pediatr Health Care. 2015 Mar 3.
9. Validity and responsiveness of the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales in the pediatric inpa3ent se^ng. Desai, A. D., Zhou, C., Stanford, S., Haaland, W., Varni, J.W., & Mangione-‐Smith, R.M. (2014). JAMA Pediatrics, 68, 1114-‐1121.
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Resources
1. Fact Sheets-‐Pediatric Special Sec3on APTAh_ps://pediatricapta.org/includes/fact-‐sheets/pdfs/13%20Assessment&screening%20tools.pdf
2. Rehab Measures: www.rehabmeasures.org 3. Can Child resource for GMFM, GMFP, GMCS:
www.canchild.ca/en/measures/gmfm.asp
4. ProEd resource for PDMS-‐2: www.proedinc.com
5. Pediatric Quality of Life Inventory: h_p://www.pedsql.org/
Questions
