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PURPOSE The purpose of this study was to assess the content, format, and comprehension of test items and responses developed for use in a computer adaptive test (CAT) of physical function for children with cerebral palsy (CP). METHODS After training in cognitive interviewing techniques, investigators defined item intent and developed questions for each item. Parents of children with CP (n = 27) participated in interviews probing item meaning, item wording, and response choice adequacy and appropriateness. RESULTS Qualitative analysis identified 3 themes: item clarity; relevance, context, and attribution; and problems with wording or tone. Parents reported the importance of delineating task components, assistance amount, and environmental context. CONCLUSION Cognitive interviewing provided valuable information about the validity of new items and insight to improve relevance and context. We believe that the development of CATs in pediatric rehabilitation may ultimately reduce the impact of the issues identified.

Our objectives were to examine the proportion of children who achieved a minimally important difference (MID) in physical function during inpatient rehabilitation and to identify factors related to achievement of MID. For a consecutive series of 452 inpatient admissions to a pediatric rehabilitation hospital in the northeastern United States, change scores were calculated by subtracting Pediatric Evaluation of Disability Inventory (PEDI) self-care and mobility functional skills and caregiver assistance admission scores from discharge scores and then evaluated for MID. Logistic regression analyses were used to determine the contributions of demographic and clinical variables as predictors of MID for each PEDI scale. More than 55% of the children achieved MID. The highest proportion of children achieving MID was in mobility functional skills (78%) and caregiver assistance (67%). Children who were older at admission (>10 years) had a greater chance of achieving MID on all scales. In addition, associated with achieving MID were longer length of stay, lower admission PEDI score, and a diagnosis of brain injury. More than half of all children admitted achieved MID in physical function. In this pediatric inpatient rehabilitation center, older children with brain injury who have low functional abilities at admission, and are able to extend their length of stay for a safe, planned discharge are most likely to achieve MID. Identifying children who are most likely to make functional progress can help program administrators and clinicians set realistic functional goals and expectations for an episode of inpatient care.

This paper reviews the strengths and weaknesses of two different approaches to assessing ICF concepts: coding versus quantitative scales. It illustrates the advantages of an alternative, integrative approach, called functional staging.A prospective cohort study. A total of 516 subjects in the Rehabilitation Outcome Study.ICF codes provide a useful approach for classifying easy-to-interpret health-related information on individuals that can be incorporated into administrative records and databases. By minimizing measurement error, quantitative scales are well suited for synthesizing health-related data that can be used to compare the health states of groups of individuals across studies, conditions, and countries as well as to detect clinically meaningful change. A functional staging approach combines the attractive features of ICF coding and quantitative scales to help the user interpret the clinical meaningfulness of summary scores while retaining measurement reliability, validity and precision.A functional staging approach to assessing ICF concepts holds promise as a useful technique for measuring and interpreting the core concepts in the ICF framework.

Background The purpose of this study was to assess the utility of measuring current physical functioning status of children with scoliosis and kyphosis by applying computerized adaptive testing (CAT) methods. Computerized adaptive testing uses a computer interface to administer the most optimal items based on previous responses, reducing the number of items needed to obtain a scoring estimate. Methods This was a prospective study of 77 subjects (0.6-19.8 years) who were seen by a spine surgeon during a routine clinic visit for progress spine deformity. Using a multidimensional version of the Pediatric Evaluation of Disability Inventory CAT program (PEDI-MCAT), we evaluated content range, accuracy and efficiency, known-group validity, concurrent validity with the Pediatric Outcomes Data Collection Instrument, and test-retest reliability in a subsample (n = 16) within a 2-week interval. Results We found the PEDI-MCAT to have sufficient item coverage in both self-care and mobility content for this sample, although most patients tended to score at the higher ends of both scales. Both the accuracy of PEDI-MCAT scores as compared with a fixed format of the PEDI (r = 0.98 for both mobility and self-care) and test-retest reliability were very high [self-care: intraclass correlation (3,1) = 0.98, mobility: intraclass correlation (3,1) = 0.99]. The PEDI-MCAT took an average of 2.9 minutes for the parents to complete. The PEDI-MCAT detected expected differences between patient groups, and scores on the PEDI-MCAT correlated in expected directions with scores from the Pediatric Outcomes Data Collection Instrument domains. Conclusions Use of the PEDI-MCAT to assess the physical functioning status, as perceived by parents of children with complex spinal impairments, seems to be feasible and achieves accurate and efficient estimates of self-care and mobility function. Additional item development will be needed at the higher functioning end of the scale to avoid ceiling effects for older children. Level of evidence This is a level II prospective study designed to establish the utility of computer adaptive testing as an evaluation method in a busy pediatric spine practice.

Haley SM, Siebens H, Coster WJ, Tao W, Black-Schaffer RM, Gandek B, Sinclair SJ, Ni P. Computerized adaptive testing for follow-up after discharge from inpatient rehabilitation: I. Activity outcomes. Objective To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home. Design Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit. Setting Follow-up visits conducted in patients' home setting. Participants Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions. Interventions Not applicable. Main Outcome Measures Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66). Results AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77–.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval. Conclusions Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.

The purpose of this paper is twofold: 1) to identify stroke patients who generated substantial charges during inpatient rehabilitation, but did not seem to benefit from that experience and 2) to identify factors that can predict which patients will fall into this group using only variables known at admission to rehabilitation. High cost stroke patients during inpatient medical rehabilitation are examined to determine how they differ from low cost patients and to identify a subset who did not appear to benefit from rehabilitation. This paper is based on longitudinal charge data involving 73 former stroke rehabilitation patients discharged from three Boston area rehabilitation facilities in 1984. Medical charges are presented on initial acute and rehabilitation inpatient stays and on care received in the 12 months after discharge. Among these 73 stroke patients, charges for inpatient medical rehabilitation amounted to nearly 1.8 million dollars, excluding physician fees and out-of-pocket expenses. Of this total, 57.6% was accured by only 33% of the patients. Fourteen patients, who were both rehabilitation cost outliers and apparent rehabilitation "failures," were identified. Rehabilitation charges for these 14 amounted to $673,232 or 37.5% of the total rehabilitation charges for all 73 patients.

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

Tao W, Haley SM, Coster WJ, Ni P, Jette AM. An exploratory analysis of functional staging using an item response theory approach. Objectives To develop and explore the feasibility of a functional staging system (defined as the process of assigning subjects, according to predetermined standards, into a set of hierarchic levels with regard to their functioning performance in mobility, daily activities, and cognitive skills) based on item response theory (IRT) methods using short forms of the Activity Measure for Post-Acute Care (AM-PAC) and to compare the criterion validity and sensitivity of the IRT-based staging system to a non–IRT-based staging system developed for the FIM instrument. Design Prospective, longitudinal cohort study of patients interviewed at hospital discharge and 1, 6, and 12 months after inpatient rehabilitation. Setting Follow-up interviews conducted in patients' homes. Participants Convenience sample of 516 patients (47% men; sample mean age, 68.3y) at baseline (retention at the final follow-up, 65%) with neurologic, lower-extremity orthopedic, or complex medical conditions. Interventions Not applicable. Main Outcome Measures AM-PAC basic mobility, daily activity, and applied cognitive activity stages; FIM executive control, mobility, activities of daily living, and sphincter stages. Stages refer to the hierarchic levels assigned to patients' functioning performances. Results We were able to define IRT-based staging definitions and create meaningful cut scores based on the 3 AM-PAC short forms. The IRT stages correlated as well or better to the criterion items than the FIM stages. Both the IRT-based stages and the FIM stages were sensitive to changes throughout the 6-month follow-up period. The FIM stages were more sensitive in detecting changes between baseline and 1-month follow-up visits. The AM-PAC stages were more discriminant in the follow-up visits. Conclusions An IRT-based staging approach appeared feasible and effective in classifying patients throughout long-term follow-up. Although these stages were developed from short forms, this staging methodology could also be applied to improve the meaning of scores generated from IRT-based computerized adaptive testing in future work.

To examine the relations among cognitive and emotional function and other patient impairment and demographic variables and the performance of daily activities.Cohort.Acute inpatient rehabilitation, skilled nursing facilities, home care, and outpatient clinics.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.Not applicable.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).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.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.

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 (

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.

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.

Objective: To examine the relative sensitivity to detect functional mobility changes with a full-length parent questionnaire compared with a computerized adaptive testing version of the questionnaire after a 16-week group fitness programme. Design: Prospective, pre- and posttest study with a 16-week group fitness intervention. Setting: Three community-based fitness centres. Subjects: Convenience sample of children ( n = 28) with physical or developmental disabilities. Interventions: A 16-week group exercise programme held twice a week in a community setting. Main measures: A full-length (161 items) paper version of a mobility parent questionnaire based on the Pediatric Evaluation of Disability Inventory, but expanded to include expected skills of children up to 15 years old was compared with a 15-item computer adaptive testing version. Both measures were administered at pre- and posttest intervals. Results: Both the full-length Pediatric Evaluation of Disability Inventory and the 15- item computer adaptive testing version detected significant changes between pre and posttest scores, had large effect sizes, and standardized response means, with a modest decrease in the computer adaptive test as compared with the 161-item paper version. Correlations between the computer adaptive and paper formats across pre and posttest scores ranged from r = 0.76 to 0.86. Conclusions: Both functional mobility test versions were able to detect positive functional changes at the end of the intervention period. Greater variability in score estimates was generated by the computerized adaptive testing version, which led to a relative reduction in sensitivity as defined by the standardized response mean. Extreme scores were generally more difficult for the computer adaptive format to estimate with as much accuracy as scores in the mid-range of the scale. However, the reduction in accuracy and sensitivity, which did not influence the group effect results in this study, is counterbalanced by the large reduction in testing burden.

To examine the sensitivity of the Short Form Activity Measure for Post-Acute Care (AM-PAC) in comparison to the Functional Independence Measure (FIM) across a 12-month period after discharge from rehabilitation hospital.Prospective longitudinal study. Patients were recruited while receiving inpatient services from facilities in the north-east USA and interviewed 1, 6 and 12 months thereafter.Convenience sample of 516 patients at baseline (65% retention at the final follow-up) receiving rehabilitation services for neurological, lower extremity orthopedic, or complex medical conditions. Mean age 68.3 years; 47% male.AM-PAC Physical and Movement, Personal Care and Instrumental, and Applied Cognitive Activity scales; FIM Motor and Cognitive scales.All 3 AM-PAC scales were sensitive to both positive and negative change across the follow-up period. Standardized response means for the AM-PAC were consistently larger than for the FIM across patient and severity groups. A greater percentage of patients showed positive change that exceeded the minimal detectable change on the AM-PAC than on the FIM both 6- and 12-month follow-ups.The short-form AM-PAC scales are more sensitive measures of change in functional activity performance over time in the general population of persons who receive inpatient rehabilitation services compared to the FIM. Thus, the AM-PAC offers a short, comprehensive, and sensitive measure of positive and/or negative change in patients' ability to perform important activities of daily life.

Over the past decade, the methods and science used to describe changes in outcomes of physical therapy services have become more refined. Recently, emphasis has been placed not only on changes beyond expected measurement error, but also on the identification of changes that make a real difference in the lives of patients and families. This article will highlight a case example of how to determine and interpret "clinically significant change" from both of these perspectives. The authors also examine how to use item maps within an item response theory model to enhance the interpretation of change at a content level. Recommendations are provided for physical therapists who are interpreting changes in the context of clinical practice, case reports, and intervention research. These recommendations include a greater application of indexes that help interpret the meaning of clinically significant change to multiple clinical, research, consumer, and payer communities.

Backgrond and Objective Measuring physical functioning (PF) within and across postacute settings is critical for monitoring outcomes of rehabilitation; however, most current instruments lack sufficient breadth and feasibility for widespread use. Computer adaptive testing (CAT), in which item selection is tailored to the individual patient, holds promise for reducing response burden, yet maintaining measurement precision. We calibrated a PF item bank via item response theory (IRT), administered items with a post hoc CAT design, and determined whether CAT would improve accuracy and precision of score estimates over random item selection. Methods 1,041 adults were interviewed during postacute care rehabilitation episodes in either hospital or community settings. Responses for 124 PF items were calibrated using IRT methods to create a PF item bank. We examined the accuracy and precision of CAT-based scores compared to a random selection of items. Results CAT-based scores had higher correlations with the IRT-criterion scores, especially with short tests, and resulted in narrower confidence intervals than scores based on a random selection of items; gains, as expected, were especially large for low and high performing adults. Conclusion The CAT design may have important precision and efficiency advantages for point-of-care functional assessment in rehabilitation practice settings.

To examine score agreement, precision, validity, efficiency, and responsiveness of a computerized adaptive testing (CAT) version of the Activity Measure for Post-Acute Care (AM-PAC-CAT) in a prospective, 3-month follow-up sample of inpatient rehabilitation patients recently discharged home.Longitudinal, prospective 1-group cohort study of patients followed approximately 2 weeks after hospital discharge and then 3 months after the initial home visit.Follow-up visits conducted in patients' home setting.Ninety-four adults who were recently discharged from inpatient rehabilitation, with diagnoses of neurologic, orthopedic, and medically complex conditions.Not applicable.Summary scores from AM-PAC-CAT, including 3 activity domains of movement and physical, personal care and instrumental, and applied cognition were compared with scores from a traditional fixed-length version of the AM-PAC with 66 items (AM-PAC-66).AM-PAC-CAT scores were in good agreement (intraclass correlation coefficient model 3,1 range, .77-.86) with scores from the AM-PAC-66. On average, the CAT programs required 43% of the time and 33% of the items compared with the AM-PAC-66. Both formats discriminated across functional severity groups. The standardized response mean (SRM) was greater for the movement and physical fixed form than the CAT; the effect size and SRM of the 2 other AM-PAC domains showed similar sensitivity between CAT and fixed formats. Using patients' own report as an anchor-based measure of change, the CAT and fixed length formats were comparable in responsiveness to patient-reported change over a 3-month interval.Accurate estimates for functional activity group-level changes can be obtained from CAT administrations, with a considerable reduction in administration time.

In this article, we review the limitations of traditional rehabilitation functional outcome instruments currently in use within the rehabilitation field to assess Activity and Participation domains as defined by the International Classification of Function, Disability, and Health. These include a narrow scope of functional outcomes, data incompatibility across instruments, and the precision vs feasibility dilemma. Following this, we illustrate how contemporary measurement techniques, such as item response theory methods combined with computer adaptive testing methodology, can be applied in rehabilitation to design functional outcome instruments that are comprehensive in scope, accurate, allow for compatibility across instruments, and are sensitive to clinically important change without sacrificing their feasibility. Finally, we present some of the pressing challenges that need to be overcome to provide effective dissemination and training assistance to ensure that current and future generations of rehabilitation professionals are familiar with and skilled in the application of contemporary outcomes measurement.

This case report describes a fitness program for children with disabilities and provides preliminary information about the safety and feasibility of the program.Nine children, 5 to 9 years of age with physical or other developmental disabilities, participated in a 14-week group exercise program held 2 times per week followed by a 12-week home exercise program. Energy expenditure index, leg strength (force-generating capacity of muscle), functional skills, fitness, self-perception, and safety were measured before intervention, after the group exercise program, and again after the home exercise program.No injuries occurred, and improvements in many of the outcome measures were observed. More improvements were observed after the group exercise program than after the home program, and adherence was better during the group exercise program.This case report demonstrates that a group exercise program of strength and endurance training may be a safe and feasible option for children with disabilities. Further research is needed to evaluate the effectiveness of a group fitness program and optimal training parameters.

Objective To examine whether the range of disability in the medically complex and postsurgical populations receiving rehabilitation is adequately sampled by the new Activity Measure--Post-Acute Care (AM-PAC), and to assess whether computer adaptive testing (CAT) can derive valid patient scores using fewer questions. Design Observational study of 158 subjects (mean age 67.2 yrs) receiving skilled rehabilitation services in inpatient (acute rehabilitation hospitals, skilled nursing facility units) and community (home health services, outpatient departments) settings for recent-onset or worsening disability from medical (excluding neurological) and surgical (excluding orthopedic) conditions. Measures were interviewer-administered activity questions (all patients) and physical functioning portion of the SF-36 (outpatients) and standardized chart items (11 Functional Independence Measure (FIM), 19 Standardized Outcome and Assessment Information Set (OASIS) items, and 22 Minimum Data Set (MDS) items). Rasch modeling analyzed all data and the relationship between person ability estimates and average item difficulty. CAT assessed the ability to derive accurate patient scores using a sample of questions. Results The 163-item activity item pool covered the range of physical movement and personal and instrumental activities. CAT analysis showed comparable scores between estimates using 10 items or the total item pool. Conclusion The AM-PAC can assess a broad range of function in patients with complex medical illness. CAT achieves valid patient scores using fewer questions.

The purposes of this study were to: (1) describe the symptoms, daily life problems and parental concerns related to oral health for children with special health care needs; and (2) examine the effectiveness of oral rehabilitation under general anesthesia at improving quality of life (QOL).A single-group design measuring change over time was used. Family caregivers of 107 children with special needs, for whom oral rehabilitation under general anesthesia was recommended, completed a QOL survey upon dental examination.Seventy-three children underwent oral rehabilitation, and 50 completed a follow-up survey. The most frequent survey responses before oral rehabilitation were: (1) spontaneous toothache and pain with hot/cold temperatures (oral symptoms); (2) difficulty eating and sleeping (daily life problems); and (3) worrying about eating and nutrition (parental concerns). Severity ratings for oral symptoms, daily life problems, and parental concerns were significantly lower (P.001), and scores for oral well-being were significantly higher (P.001) following oral rehabilitation.Family caregivers of special health care needs patients report a variety of oral symptoms, daily life problems, and concerns attributable to their child's oral health that impact QOL. Oral rehabilitation under general anesthesia is effective at improving QOL for special health care needs children and their families.

Haley SM, Raczek AE, Coster WJ, Dumas HM, Fragala-Pinkham MA. Assessing mobility in children using a computer adaptive testing version of the Pediatric Evaluation of Disability Inventory. Objective To assess score agreement, validity, precision, and response burden of a prototype computerized adaptive testing (CAT) version of the Mobility Functional Skills Scale (Mob-CAT) of the Pediatric Evaluation of Disability Inventory (PEDI) as compared with the full 59-item version (Mob-59). Design Computer simulation analysis of cross-sectional and longitudinal retrospective data; and 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 Four hundred sixty-nine children with disabilities and 412 children with no disabilities (analytic sample); 41 children without disabilities and 39 with disabilities (cross-validation sample). Interventions Not applicable. Main outcome measures Summary scores from a prototype Mob-CAT application and versions using 15-, 10-, and 5-item stopping rules; scores from the Mob-59; and number of items and time (in seconds) to administer assessments. Results Mob-CAT scores from both computer simulations (intraclass correlation coefficient [ICC] range, .94–.99) and field administrations (ICC=.98) were in high agreement with scores from the Mob-59. Using computer simulations of retrospective data, discriminant validity, and sensitivity to change of the Mob-CAT closely approximated that of the Mob-59, especially when using the 15- and 10-item stopping rule versions of the Mob-CAT. The Mob-CAT used no more than 15% of the items for any single administration, and required 20% of the time needed to administer the Mob-59. Conclusions Comparable score estimates for the PEDI mobility scale can be obtained from CAT administrations, with losses in validity and precision for shorter forms, but with a considerable reduction in administration time.

Objective To develop and pilot test the Home and Community Environment instrument (HACE), a self-report measure designed to characterize factors in a person's home and community environment that may influence level of participation. Design A cross-sectional survey. Subjects Sixty-two adults recruited from community organizations and an outpatient rehabilitation center. Methods Six environmental domains were assessed: (i) home mobility; (ii) community mobility; (iii) basic mobility devices; (iv) communication devices; (v) transportation factors; and (vi) attitudes. Descriptive statistics, Kappa statistics and Kruskal-Wallis tests were used to ascertain whether persons were capable of assessing characteristics of their environment, could do so reliably and whether the distribution of environmental factors differed by type of living situation. Results Participants were capable of characterizing their home environment and most aspects of their community with acceptable reliability. The median percent agreement of the 6 environmental domains ranged from 75% to 100% (median Kappa values ranged from 0.47 to 1.0). Percent agreement for individual HACE items ranged from 58% to 100%. The lowest reliability values were observed in the community mobility domain. As hypothesized, individuals who lived in private homes characterized home and community mobility factors differently from those who lived in multi-unit complexes; evidence of HACE's validity. Conclusion HACE is a promising self-report instrument for assessing characteristics of an individual's home and community environments. Additional research is needed to assess its utility for rehabilitation research.

Coster WJ, Haley SM, Ludlow LH, Andres PL, Ni PS. Development of an applied cognition scale to measure rehabilitation outcomes. Objective To examine the structure and content coverage of an item pool of new items based on the Activity categories from the International Classification of Functioning, Disability and Health and items from existing instruments to measure the applied cognition dimension of function. Design Prospective study. Setting Four postacute care rehabilitation settings (inpatient, transitional care, home care, outpatient) in an urban-suburban area of northeast United States. Participants Convenience sample of 477 patients (mean age, 62.7y) receiving rehabilitation services for neurologic, orthopedic, or complex medical conditions. Interventions Not applicable. Main outcome measures Participants were administered applied cognition items from the new Activity Measure for Post-Acute Care, the Medical Outcomes Study 8-Item Short-Form Health Survey, and an additional setting-specific measure: the FIM instrument (inpatient rehabilitation); the Minimum Data Set (skilled nursing facility); the Minimum Data Set–Post Acute Care (postacute settings); or the Outcome Assessment and Information Set (home care). Rasch (partial-credit model) analyses were conducted to examine item fit, item coverage, scale unidimensionality, and category difficulty estimates. Results The majority of items (46/59) could be located along a single continuum. Relatively few people were performing at the lower end of the difficulty scale, and about 25% were at ceiling. Conclusions The proposed definition of applied cognition dimension provides a useful guide for item development to measure this dimension. Further work is needed to determine how best to measure function in this domain for people at the upper and lower ends of the continuum.

To assess the concurrent and predictive validity of the Late-Life Function and Disability Instrument (LLFDI).Cross-sectional.University-based human physiology laboratory.One hundred one men and women aged 80.8 +/- 0.4.A short physical performance battery (SPPB) and a self-paced 400-m walk (400-m W) were used as performance tests of lower extremity function. The LLFDI was used to assess self-reported function and physical disability. Partial correlations adjusted for age and body mass index were used to determine the concurrent and predictive validity of the LLFDI. Statistical significance was accepted at P.004 using a testwise correction.LLFDI Overall Function scores were moderately associated with the SPPB (r=0.65, P.001), 400-m W gait speed (r=0.69, P.001), and measures of lower extremity function. Correlations of the two lower extremity subscores of the LLFDI (correlation coefficient (r)=0.63-0.73, P.001) were greater than for the LLFDI upper extremity subscores (r=0.19-0.26, P.004). Performance measures of function predicted disability limitations in the range of r=0.37-0.44 (P.001) and disability frequency in the range of r=0.16-0.20 (P.004).These findings support the concurrent and predictive validity of the LLFDI. Results support the use of the LLFDI scales as a substitute for physical performance tests when self-report is a preferred data-collection format.

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.

To develop and field-test a physical performance measure (MPS-PPM) for individuals with Mucopolysaccharidosis I (MPS I), a rare genetic disorder.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.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, p0.05) and lower scores on the Leg Function (r = -0.67, p0.05) and Endurance (r = -0.65, p0.05) 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.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.

Haley SM, Coster WJ, Andres PL, Kosinski M, Ni P. Score comparability of short forms and computerized adaptive testing: simulation study with the Activity Measure for Post-Acute Care. Arch Phys Med Rehabil 2004;85:661–666. Objective To compare simulated short-form and computerized adaptive testing (CAT) scores to scores obtained from complete item sets for each of the 3 domains of the Activity Measure for Post-Acute Care (AM-PAC). Design Prospective study. Setting Six postacute health care networks in the greater Boston metropolitan area, including inpatient acute rehabilitation, transitional care units, home care, and outpatient services. Participants A convenience sample of 485 adult volunteers who were receiving skilled rehabilitation services. Interventions Not applicable. Main outcome measures Inpatient and community-based short forms and CAT applications were developed for each of 3 activity domains (physical & mobility, personal care & instrumental, applied cognition) using item pools constructed from new items and items from existing postacute care instruments. Results Simulated CAT scores correlated highly with score estimates from the total item pool in each domain (4- and 6-item CAT r range, .90–.95; 10-item CAT r range, .96–.98). Scores on the 10-item short forms constructed for inpatient and community settings also provided good estimates of the AM-PAC item pool scores for the physical & movement and personal care & instrumental domains, but were less consistent in the applied cognition domain. Confidence intervals around individual scores were greater in the short forms than for the CATs. Conclusions Accurate scoring estimates for AM-PAC domains can be obtained with either the setting-specific short forms or the CATs. The strong relationship between CAT and item pool scores can be attributed to the CAT's ability to select specific items to match individual responses. The CAT may have additional advantages over short forms in practicality, efficiency, and the potential for providing more precise scoring estimates for individuals.

Objective The objective of this study was to evaluate the payment implications of substituting the Minimum Data Set-Post Acute Care (MDS-PAC) for the FIM trade mark instrument for use in the planned prospective payment system (PPS) for inpatient rehabilitation hospitals. FIM trade mark is a trademark of the Uniform Data System for Medical Rehabilitation, a division of UB Foundation Activites, Inc. Research design We used a prospective cross-sectional design using consecutive sampling. Subjects We studied all Medicare admissions with stays of 3 days or more over a 2-month period to 50 inpatient rehabilitation hospitals in 22 states. Measurements and methods Each participating institution completed both the FIM and the MDS-PAC assessments on all participants. Items from the MDS-PAC were combined and translated to create "FIM-like" items. We assessed agreement of classification into prospective payment cells using FIM assessment data and also using MDS-PAC data. Statistical adjustments were applied to improve the level of agreement. Results The mean differences between the FIM motor and cognitive scales and their MDS-PAC translations were 2.4 (mean = 45) and 0.0 (mean = 28), respectively, with scale correlations of.85 and.84. Weighted kappas on individual items ranged from.32 to.64. There were substantial hospital-specific differences in scoring. Payment cell classification using FIM data agreed with that using MDS-PAC data only 56% of the time. Twenty percent of the facilities experienced revenue shifts larger than 10%. Conclusion Despite better item-level agreement than previously observed, poor payment cell agreement and substantial revenue shifts indicated that the MDS-PAC should not be substituted for the FIM trade mark instrument in the rehabilitation hospital PPS.

Background Rehabilitation outcome measures routinely include content on performance of daily activities; however, the conceptual basis for item selection is rarely specified. These instruments differ significantly in format, number, and specificity of daily activity items and in the measurement dimensions and type of scale used to specify levels of performance. We propose that a requirement for upper limb and hand skills underlies many activities of daily living (ADL) and instrumental activities of daily living (IADL) items in current instruments, and that items selected based on this definition can be placed along a single functional continuum. Objective To examine the dimensional structure and content coverage of a Personal Care and Instrumental Activities item set and to examine the comparability of items from existing instruments and a set of new items as measures of this domain. Methods Participants (N = 477) from 3 different disability groups and 4 settings representing the continuum of postacute rehabilitation care were administered the newly developed Activity Measure for Post-Acute Care (AM-PAC), the SF-8, and an additional setting-specific measure: FIM (in-patient rehabilitation); MDS (skilled nursing facility); MDS-PAC (postacute settings); OASIS (home care); or PF-10 (outpatient clinic). Rasch (partial-credit model) analyses were conducted on a set of 62 items covering the Personal Care and Instrumental domain to examine item fit, item functioning, and category difficulty estimates and unidimensionality. Results After removing 6 misfitting items, the remaining 56 items fit acceptably along the hypothesized continuum. Analyses yielded different difficulty estimates for the maximum score (eg, "Independent performance") for items with comparable content from different instruments. Items showed little differential item functioning across age, diagnosis, or severity groups, and 92% of the participants fit the model. Conclusions ADL and IADL items from existing rehabilitation outcomes instruments that depend on skilled upper limb and hand use can be located along a single continuum, along with the new personal care and instrumental items of the AM-PAC addressing gaps in content. Results support the validity of the proposed definition of the Personal Care and Instrumental Activities dimension of function as a guide for future development of rehabilitation outcome instruments, such as linked, setting-specific short forms and computerized adaptive testing approaches.

Background Efforts to evaluate the effectiveness of a broad range of postacute care services have been hindered by the lack of conceptually sound and comprehensive measures of outcomes. It is critical to determine a common underlying structure before employing current methods of item equating across outcome instruments for future item banking and computer-adaptive testing applications. Objective To investigate the factor structure, reliability, and scale properties of items underlying the Activity domains of the International Classification of Functioning, Disability and Health (ICF) for use in postacute care outcome measurement. Methods We developed a 41-item Activity Measure for Postacute Care (AM-PAC) that assessed an individual's execution of discrete daily tasks in his or her own environment across major content domains as defined by the ICF. We evaluated the reliability and discriminant validity of the prototype AM-PAC in 477 individuals in active rehabilitation programs across 4 rehabilitation settings using factor analyses, tests of item scaling, internal consistency reliability analyses, Rasch item response theory modeling, residual component analysis, and modified parallel analysis. Results Results from an initial exploratory factor analysis produced 3 distinct, interpretable factors that accounted for 72% of the variance: Applied Cognition (44%), Personal Care & Instrumental Activities (19%), and Physical & Movement Activities (9%); these 3 activity factors were verified by a confirmatory factor analysis. Scaling assumptions were met for each factor in the total sample and across diagnostic groups. Internal consistency reliability was high for the total sample (Cronbach alpha = 0.92 to 0.94), and for specific diagnostic groups (Cronbach alpha = 0.90 to 0.95). Rasch scaling, residual factor, differential item functioning, and modified parallel analyses supported the unidimensionality and goodness of fit of each unique activity domain. Conclusions This 3-factor model of the AM-PAC can form the conceptual basis for common-item equating and computer-adaptive applications, leading to a comprehensive system of outcome instruments for postacute care settings.

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 &#45 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.

Standardized pediatric assessment tools such as the Pediatric Evaluation of Disability Inventory (PEDI) numerically quantify changes during rehabilitation through test scores, but they are unable to provide client-specific information regarding important changes in function. The purpose of this study was to identify the smallest change in PEDI scores during inpatient rehabilitation that was considered to be a minimal clinically important difference (MCID) by physical therapists and other clinicians.A retrospective review was done of the medical charts of 53 children and youth (1-19 years of age) discharged from an inpatient rehabilitation hospital. Fifteen clinicians (5 physical therapists, 6 occupational therapists, and 4 speech and language pathologists) who were masked to the PEDI scores provided ratings of the magnitude of functional changes during inpatient rehabilitation using a Likert scale and a visual analog scale (VAS). Ratings by clinicians were reduced to 4 categories, including the MCID, and compared with PEDI change scores.The MCIDs ranged from 6 to 15 points (X=11.5, 95% confidence interval= +/- 2.8) for all PEDI scales. Likert scale and VAS ratings were correlated (tau =.73-.80).Across all scales, PEDI change scores on the order of about 11% (0-100 scale) appear to be meaningful to clinicians during a child's or adolescent's inpatient rehabilitation. These data can serve as a starting point for interpreting group and individual changes on the PEDI during physical therapy intervention in inpatient rehabilitation.

This study describes the physical disability of 30 children and adolescents with Pompe disease (23 males, 7 females; mean age 7 years 7 months, SD 5 years 6 months; range 6 months to 22 years 1 month) using a disease-specific functional instrument. Data were collected by telephone interview with parents using a modified version of the Pediatric Evaluation of Disability Inventory. The sample included mostly males of Caucasian origin, recruited from several countries. Disability profiles in mobility and self-care skills were heterogeneous because functional status was not related to chronological age. Most children had severe functional deficits: nearly two-thirds of the sample was non-ambulatory and could not perform age-expected self-care skills. Three-quarters of the children used a ventilator. Two children were able to participate in age-appropriate sports and peer activities. Although the mean chronological age of the sample was 7 years 7 months, the mean age-performance for self-care skills was under 2 years 6 months and under 1 year 6 months for mobility. Implications of physical disability findings for individuals with Pompe disease are discussed.

Purpose Enabling valuable research findings to be used by the field requires a strategic approach to dissemination and utilization rather than simply making constituencies aware of the information. This article describes a conceptual framework for the dissemination and utilization of information, along with examples of its use by the Boston University Roybal Center for Enhancement of Late Life Function. Design and methods The framework identifies dissemination/utilization goals of exposure, experience, expertise, and embedding ("4 E") and relates each goal to strategies targeted for specific users. Results and implications The Boston University center exposed the field to information through presentations, print- and Web-based information, provided consumers and family members with new findings through motivational videotapes, developed expertise-level training programs, and embedded the new findings within organizations and systems. The 4 E framework can translate critical research outcomes into useful information to assist the field to better care and support available for individuals in late life.

To describe re-admission rates, identify reasons for re-admission and examine characteristics of children requiring re-admission to inpatient pulmonary rehabilitation.Retrospective record review of infants and toddlers (less than three years of age) requiring oxygen or ventilator support discharged from an inpatient paediatric pulmonary rehabilitation programme between 1992 and 1999.Forty-one initial admissions resulted in 45 readmissions with a mean re-admission rate of 1.1 (SD = 1.41) re-admissions per child. Children with re-admissions (n = 22, 54%) required significantly more ventilator support (p = 0.001) and nursing care (p = 0.001) and were transferred to acute care more frequently (p = 0.002) than children without re-admissions. One-half of the children re-admitted to inpatient pulmonary rehabilitation were re-admitted two or more times.Based on this cohort of children, dependence on supplemental oxygen and/or mechanical ventilation and medical complexity may be indicators that children will require re-admission to rehabilitation following a transfer back to acute care. Further examination of re-admission rates and reasons and children's clinical characteristics may have predictive value and provide practice improvement opportunities.

A consecutive series of 107 children and young persons with traumatic brain injury (TBI) admitted to a hospital-based inpatient rehabilitation program was assessed to determine whether lower extremity spasticity could be utilized as an early clinical marker for recovery of ambulation. Presence of spasticity was determined by clinical examination at admission, and the ability to ambulate safely indoors (15.24 m) was evaluated at discharge. Sensitivity, specificity and positive and negative predictive values for spasticity were calculated. Lower extremity spasticity is a sensitive (71.4%) and specific (81.5%) predictor of the inability to ambulate at discharge. The absence of lower extremity spasticity, however, was a better predictor of ambulation recovery than the presence of spasticity was a predictor of nonambulatory status at hospital discharge. Implications for spasticity assessment and prognosis in terms of ambulation and recovery are discussed.

Background Efforts to evaluate the effectiveness of clinical and community-based interventions designed to impact late-life disability have been hindered significantly by limitations in current instrumentation. More conceptually sound and responsive measures of disability are needed. Methods Applying Nagi's disablement model, we wrote questionnaire items that assessed disability in terms of frequency and limitation in performance of 25 life tasks. We evaluated their validity and test-retest reliability with 150 ethnically and racially diverse adults aged 60 and older who had a range of functional limitations, using factor analysis and Rasch analytic techniques to examine and refine the instrument. Results Our analyses resulted in a 16-item disability component with two dimensions, one focused on frequency of performance and the other addressing limitation in performance of life tasks, with two disability domains within each dimension. The frequency dimension consisted of a personal and a social role domain, and the limitation dimension consisted of an instrumental and a management role domain. Expected differences in summary scores of known-functional limitation groups support the validity of this instrument. Test-retest intraclass correlations of the reproducibility of each overall dimension summary score were moderate to high (intraclass correlation coefficients .68-.82). Conclusions The Late-Life Function and Disability Instrument has potential to assess meaningful concepts of disability across a wide variety of life tasks with relatively few items.

This article describes mobility recovery for children and youth with traumatic and non-traumatic brain injury during hospital-based rehabilitation.A retrospective, descriptive pre-test/post-test design was used.One hundred and fifty-seven individuals with brain injury who were admitted for rehabilitation over a 5-year period were enrolled in this study. The Paediatric Evaluation of Disability Inventory (PEDI) was used to document functional mobility at admission and discharge from the rehabilitation programme. The PEDI mobility classification system consisting of seven discrete levels of mobility was developed to provide clinically relevant and succinct outcome information.The majority of children with brain injury (69%) improved one or more mobility classification levels. Children in the traumatic brain injury group made greater changes (p = 0.001) in mobility recovery than children in the non-traumatic group.Information about recovery using a well-defined functional classification system may assist with programme evaluation and facilitate optimal service delivery.

Background and Purpose. The purpose of this study was to describe variation in functional mobility outcomes among children and youth with different diagnoses and belonging to groups with different practice patterns from an inpatient pediatric rehabilitation hospital setting. Subjects. A sample of 138 individuals between the ages of 1 and 22 years (X̄=9.4, SD=5.3) was enrolled. Methods. Physical therapists administered the “Mobility” domain of the Pediatric Evaluation of Disability Inventory at the time of admission and at the time of discharge. Mobility level (combined admission and discharge scores) and amount of change between and within 4 diagnostic groups (traumatic brain injury, non–traumatic brain injury, orthopedic, and neurological) and 5 neuromuscular and musculoskeletal practice pattern groups were calculated, and post hoc analyses were done for specific contrast comparisons. Results. Mobility scores between admission and discharge for all subgroups were different. Practice pattern groups were useful for identifying variations in level of motor performance. Diagnostic groups best described differences in mobility change during inpatient rehabilitation. Discussion and Conclusion. The use of practice patterns as grouping categories may enhance our understanding of variation in clinical outcomes of children during inpatient rehabilitation.

Physical and mental impairments represent the two 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 paper 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, two 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 (ICF) 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 five 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 three 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, 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.

Background and Purpose. The purpose of this study was to examine the validity of the Peabody Developmental Gross Motor Scale (PDMS-GM) as an evaluative measure of infants receiving physical therapy. Subjects and Methods. Infants who attended an early intervention program (N=124) were grouped by diagnosis: cerebral palsy, Down syndrome, hydrocephalus, preterm with developmental delay, full term with developmental delay, and other. The PDMS-GM was administered to each infant three times over a 6-month period by a therapist who did not provide treatment. Results. Mean scaled scores and age-equivalent scores increased for each group. Individual change was examined using the reliable change index. The results indicated that the change in total raw score for 62% of the infants was greater than what could be attributed to measurement error. When minimal clinically important change was defined as 10 scaled score points, the index of responsiveness was equal to 0.5. This finding indicates that a sample size of 68 subjects per group would be needed when the PDMS-GM is used as an outcome measure in research. Conclusion and Discussion. The mean change scores for each group support the use of the PDMS-GM as an evaluative measure. For many infants, particularly infants with cerebral palsy, the PDMS-GM was not responsive to change over a 6-month period. The index of responsiveness suggests that the PDMS-GM should be used only as an outcome measure in large clinical trials. The PDMS-GM is not recommended for evaluating the direct effects of physical therapy but is recommended for providing a global measure of change in motor development as part of a multidimensional assessment.

Indexes developed to measure physical functioning as an essential component of general health status are often based on sets of hierarchically-structured items intended to represent a broad underlying concept. Rasch Item Response Theory (IRT) provides a methodology to examine the hierarchical structure, unidimensionality, and reproducibility of item positions (calibrations) along a scale. Data gathered on the 10-item Physical Functioning Scale (PF-10) from a large sample of Medical Outcomes Study patients (N = 3445) were used to examine the hierarchical order, unidimensionality, and reproducibility of item calibrations. Rasch-IRT analyses generated an empirical item hierarchy, confirmed the unidimensionality of the PF-10 for most patients, and established the reproducibility of item calibrations across patient populations and repeated tests. These findings support the content validity of the PF-10 as a measure of physical functioning and suggest that valid Rasch-IRT summary scores could be generated as an alternative to the current Likert summative scores. Unidimensionality and reproducibility of the item scale are essential prerequisites for the development of Rasch-based person measures of physical functioning that can be used across populations and over repeated tests.

Context is a fundamental consideration in physical therapy assessment and in the interpretation of physical disablement. Specification of context may include physical requirements of a task such as the demands for speed or a specific degree of accuracy, or the social context in which an activity is performed such as dressing for work versus dressing for leisure activities. Context also encompasses individual factors such as the importance of particular activities within the person's culture or value system, or the specific types of roles requiring physical functioning that a person resumes upon discharge from physical therapy. Data are presented to illustrate the differences in performance across related physical tasks and between self-care and mobility tasks in home and school settings in children with severe functional delays. These data highlight the potential impact of context on performance. Implications for future development of functional assessments are discussed, particularly in light of the importance of incorporating contextual information in the clinical interpretation of disablement outcomes for patient groups and individual patients.

Background and Purpose. Although individuals with low back pain frequently receive treatment from a physical therapist, few published studies exist that describe who sees a physical therapist for their low back pain nor is much known about physical therapy episodes of care for this condition. Secondary analysis of data from the American Physical Therapy Association's Survey of Physical Therapy Outpatient Practice provides new descriptive data on services provided to a national, representative sample of patients discharged from hospital-based and private outpatient practices. In addition, specific hypotheses were tested on clinical and background factors believed to influence low back pain episodes of care. Subjects. Patients with low back pain represented over 25% of all outpatient discharges from physical therapy practices. Methods. A mail survey was conducted with representatives of a national probability sample of facilities that provided outpatient physical therapy services. Data were provided on each facility and on a discharge sample of patients treated at each facility. Results. On average, episodes of care extended over 5 weeks and consisted of 11 therapy visits, for an average charge of $766.70. Duration and charge for low back episodes of care did not differ, on average, in private versus hospital-based practices. Certain aspects of care, however, did vary across regions of the country. Episodes of care charged to workers' compensation were costlier than those charged to other insurance carriers, and whites were charged less, on average, than nonwhites. Duration of back symptoms was related to intensity, duration, and charges incurred for the episode of care. Conclusion and Discussion. Further research is needed to understand the reasons for the relationships observed in this study, as well as studies that relate care provided by physical therapists to specific patient outcomes. Further research is also needed to compare outcomes achieved across different health professions.

The measurement of post-traumatic amnesia in children is a common clinical index of the extent of brain injury. The only published paediatric test, the Children's Orientation and Amnesia Test (COAT), has been standardized on a sample of children in a school setting who had not been injured or hospitalized. Two questions arise in the use of this test: are the published norms valid for hospitalized children with non-neurological trauma? and does the COAT offer better discriminative power or clinical utility over the adult test, the Galveston Orientation and Amnesia Test (GOAT)? This paper describes scores on the COAT for 28 children hospitalized with non-neurological injuries and compares them with the published scores. The hospitalized children scored within normal limits when compared with the school sample. In addition, 23 children with neurological traumatic injuries were given both the COAT and the GOAT. Failure rate was higher for the COAT. Some implications for the use of the COAT in paediatric trauma are discussed.

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.