Measurement Model Tests Children Cerebral Palsy Lessons

8/11/2019 Measurement Model Tests Children Cerebral Palsy Lessons

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! The Move & PLAY Study was supported throughfunds from the Canadian Institutes of HealthResearch (MOP 81107) and the US Department ofEducation, National Institutes of Disability andRehabilitation Research (H133G060254)

! Ethics approval was obtained from each academicinstitution and multiple clinical sites (n = 21approvals)

Acknowledgements

! Introduction: utility of conceptual models in clinicaldecision making from Move & PLAY

! Description of measurement model and tests/measures! Outcomes:

! Abbreviated version of the GMFM ! Child factors:

! Associated Health Conditions! Primary Impairments (distribution of involvement, spasticity,

quality of movement, balance)! Secondary Impairments (strength, endurance, range of

motion)! Discussion: utility of these tests/measures in clinical

decision making


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but the GMFM and GMFCS are notsufficient to inform decision-making

X

Personal Factors

Fixed

Modifiable

Activities=Capabilities(action by an individual)

Participation(involvement in a life

situation

Environmental Factors

Fixed

Modifiable

Impairments Activity Limitations Participation Restrictions

Disability

Function

Body Functions (physiological& psychological) Structure

Aspects of the Person Mediators Outcomes

PrimaryImpairments

SecondaryImpairments

Personal Factors

Environment Physical, Social, Attitudinal

RehabilitationServices

Activity

Participation


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Child CharacteristicsRelating to

Primary Impairments

Change inBasic Motor Abilities

Child CharacteristicsRelating to SecondaryImpairments

Participation

Activity

Child CharacteristicsRelating toPrimary Impairments



Participation

ActivityChild PersonalityCharacteristics




Participation


Family Ecology




Participation


Family Ecology

Health Care Services

but are physical therapists limited toconsidering outcomes of motor developmentalone?


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Population of Interest: Cerebral Palsy

Cerebral palsy (CP) describes a group of disorders of thedevelopment of movement and posture, causing activitylimitation, that are attributed to non-progressivedisturbances that occurred in the developing fetal orinfant brain. The motor disorders of cerebral palsy areoften accompanied by disturbances of sensation,perception, cognition, communication, and behaviour, byepilepsy, and by secondary musculoskeletal problems.

(Rosenbaum et al. 2007, page 9)

Outcomes of interest

Gross Motor Function

Also: self-care, participation and play

Selection of Indicators

Original conceptual model (Bartlett and Palisano, 2000)

Consensus among physical therapists

(Bartlett and Palisano, 2002) Research literature

Parsimony


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What does the literature say about influences on motordevelopment in young children with CP? Influences on motor development (continued)

Selection of Measures (Andresen, 2000)

Valid for children with CP and their families Reliable when used by the specified raters Feasible to administer in a community setting Length and content acceptable Easy to administer, score, and interpret If a determinant, has properties of a discriminative

tool, sensitive to variations among children andfamilies, not subject to ceiling or floor effects

If an outcome, has properties of an evaluative tool(i.e. is sensitive to change)

Development of Measures

Psychometric substudies

Pilot Testing

With children & families, as wel l as therapists

Review

By parent consultants

To present how we measured:

Abbreviated version of the Gross Motor FunctionMeasure

Associated health conditions

Body structures & functions factors (primaryimpairments)

Secondary impairments

To present some descriptive data and a case study

Purpose

! A convenience sample of 430 children with CP 18months to 5 years (mean age 3 y, 2 mo, 57% boys) andtheir caregivers (92% mothers) participated

! Recruited from multiple sites across Canada and theUnited States

! Across Gross Motor Function Classification System(GMFCS) levels: I = 154, II = 50, III = 53, IV = 76, and

V = 97 (Palisano et al. 1997)

! Sample is comparable to population-based studies ofchildren with CP from Canada, Australia and Sweden(based on the GMFCS levels)

Participants: Descriptive Data


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! 40-month-old boy with spastic diplegia, GMFCSlevel III

! Lives with two adults and one sibling

! Annual household income: $15,000 29,000(USD)

Participant: Case Study Juan

! Observational prospective study! Trained and reliable raters measured child

characteristics of primary impairments,secondary impairments, and gross motorfunction

! Parents completed an endurance questionnaire(secondary impairment) and a health conditionsquestionnaire

Methods

Focus on aspects of the child Measuring Gross Motor Function

! Developed a modified score form with the items indifficulty order: easiest to hardest

! Columns on left indicate dimension

! Entry points suggested for GMFCS and age

! Basal = 3 consecutive 3s

! Ceiling = 3 consecutive 0s

! Minimum of 15 items need to be scored

! Each item: CAPS start position, after colon maximum function for score of 3


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Psychometric Testing of the GMFM-66-B&C(Brunton and Bartlett, 2011)

Concurrent validity with GMFM-66

ICC = 0.987 (95% CI 0.972 - 0.994)

Test-retest reliability

ICC = 0.994 (95% CI 0.987 0.997)

Interrater reliability

ICC = 0.970 (95% CI 0.932 0.986)

Case Study: JuanInterpreting Change over Time

I II III IV V

N 147 78 107 121 117

mean change 3.0 0.8 3.3 2.5 3.6

sd change 15.6 15.5 12.4 11.8 13.2

probability interval of change in percentiles

50% 10.5 10.5 8.4 8.0 8.9

80% 20.0 19.9 15.9 15.1 16.9


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Time 1 1 Year LaterGMFM-66 46.9 49.0

Percentile 40th 45 th

! Change in GMFM score of 2.1 points

! GMFM-66 scores translate to percentile ranks of 40thand 45th, a difference of 5

! This amount of change means that Juan is developing asmight be expected (within + 16)

Health Conditions

We aimed to understand the functional impacts ofco-morbidities and associated health problems

Instrument was based on both the internationalconsensus definition of CP and the WHOsInternational Classification of Functioning,Disability and Health (to frame health conditionsfrom a functional perspective)

Measuring Health Conditions (Wong et al. in press)

Trained interviewers asked the parent: Does your child have problems:

seeing hearinglearning and understanding speaking or communicatingcontrolling emotions with seizuresinvolving the mouth with teeth and gumswith digestion with growthsleeping with repeated infectionsbreathing with skin

with the heart with pain

Item Responses and Analysis

Each of 16 items: Yes or NoTotal number of health conditions

If yes, parents were asked to what extent does thisproblem affect your childs daily activities:

1 not at all 2 to a very small extent 3 to a small extent 4 to a moderate extent 5 to a fairly great extent 6 to a great extent 7 to a very grea t exten t

Average extent affecting daily activities


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Results of theHealth Conditions Questionnaire

(Wong et al. In Press)

All children with CP, regardless of GMFCS level,have more health conditions and experience agreater impact than children without CP

Family income is associated with the total numberof health problems of children across all groups

Adjusted R 2 = 0.47 (p = 0.047)

Number of Health Conditions

Average Impact of Health Conditions

! Juan has 8 health conditions, as reported by his parent

! This is double the median value for most children in levelIII (and is consistent with what is known about childrenin low socioeconomic groups)

! The average impact of these conditions is 1.75(experienced by fewer than 25% of children in level III)

! Interpretation of the impact of health conditions is betterdone by looking at individual problems and cumulativeeffects for individual children

Case Study: Juan

! 8 health conditions:

Seeing small extent

Learning and Understanding very small extent

Speaking / communicating moderate extent

Emotions / behaviour moderate extent

Digestion small extent

Sleeping very great extent

Heart problems (prior patent ductus) not at all

Pain moderate extent

Case Study: (continued)

! For Children in GMFCS levels I & II, healthconditions are related

! Moderately to self-care and playfulness

! For Children in GMFCS levels III, IV & V, healthconditions are related

! In a small way to self-care

Preliminary Results re: relationships ofHealth Conditions with Outcomes


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Primary Impairments

Measuring Quality of Movement

Gross Motor Performance Measure (Boyce et al. 1999)(similar items as on the Gross Motor Function Measure)

1. Co-ordination: refers to the smooth and controlled useof movements in motor performance. Takes intoaccount timing, velocity, direction, force and amplitude

2. Dissociated movement: refers to isolated movement ofone part of the body independent from another part(one limb from the other, or segment of one from ortrunk independent from another segment).

Scored from 0 (severely abnormal) to 3 (normal withoutcues)

Averaged across available items / averaged both

Observations about MeasuringQuality of Movement

! Required extensive training by Virginia Wright (thenof Bloorview KidsRehab in Toronto)

! Performance on criterion testing target > 80% Agreement 15% completed at first attempt All but one completed after two attempts

! Perceived to be difficult to learn

Quality of Movement

! Juan, at 3 years 4 months, obtained 1.5 on bothcoordination and dissociation

! This results in an average score of 1.5 (i.e.between mildly and moderately abnormal interms of quality of movement)

! Compared to the group data on the previousslide, this is the median value for young childrenin GMFCS level III

Case Study: Juan Measuring Spasticity

Modified Ashworth Scale (Bohannon and Smith, 1987) Elbow flexors and hamstrings (one score representative of 3)one of each / averaged

! 6 point ordinal scale (0 to 4) 0 = no increase in tone (1) 1 = slight (2) 1+= slight + (3) 2 = considerable (4) 3 = more marked (5) 4 = rigid (6)


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Modified Ashworth Scale

! Juan obtained the following item scores:! Right elbow 2

! Left elbow 1

! Right hamstring 4

! Left hamstring 3

! His average spasticity score is 2.5

! This is also the median value for spasticity forchildren in level III

Case Study: Juan

Distribution of Involvement

Monoplegia 1

Hemiplegia 2

Diplegia 3

Triplegia 4

Quadriplegia 5

! Juan has spastic diplegia

! Not an unusual distribution of involvement forchildren in level IIII

Case Study: Juan

Over to Sally:

Early Clinical Assessment of Balance


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Reactive Postural Adjustments (RPA)


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Secondary Impairments

To be presented by Lynn and Doreen after the break

References continued

References continued References continued

Westcott, S.L. & Burtner P. (2004) Postural control for children: Implications forpediatric practice. Physical and Occupational Therapy for Children . 2004; 24,5-55.

Liu W.Y. Anticipatory Postural Adjustments in Children with Cerebral Palsy andChildren with Typical Development during Forward Reaching Tasks in Standing.

MCP Hahnemann University PhD Dissertation, 2001.

Horak, F.B. (2006) Postural orientation and equilibrium: What do we need to knowabout neural control of balance to prevent falls? Age & Ageing . 2006;35-S2, ii7-ii11.

Measurement Model Tests Children Cerebral Palsy Lessons

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