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Measures of Change

VanSant, Ann F. PT, PhD, FAPTA

doi: 10.1097/PEP.0b013e318182a829


This issue contains some remarkable contributions. Remarkable because they demonstrate how rapidly pediatric physical therapy is moving forward. We are developing a cache of test instruments that can be used to successfully document our interventions for children with a variety of disabling conditions. These tests are not only useful in documenting the change that arises as a result of physical therapy but also the change that is promoted through pharmacological interventions. We seem now to have “gotten it” with respect to the importance of measures with strong psychometric properties. Further, this issue of the journal demonstrates the need to validate our measures when applied to new populations.

The reports of Finkel and colleagues1 demonstrate the validity of using the Test of Infant Motor Performance (TIMP) for children with spinal muscular atrophy, – type I. Katz-Leurer et al2 took the Modified Functional Reach Test (MFRT), the Timed Up and Go test (TUG), and hand-held dynamometry measures3 and examined their reliability in children with traumatic brain injury. This work paves the way for objective documentation of treatments for these children.

Fergus et al4 adapted the motor activity log that has good reliability in adults with hemiplegia undergoing constraint-induced movement therapy (CIMT) for use with children undergoing this treatment. This instrument, detailed in an appendix, is available online ( The authors acknowledge the need for studies of psychometric properties. Any change to a reliable and valid instrument must be followed by reexamination of the psychometric properties of the test instrument. I expect this challenge will be met with further development of this instrument for use with children with hemiplegia.

We also include in this issue a report of an assessment protocol developed in anticipation of a randomized control trial (RCT) of Botox and casting for children with equinus gait. Kelly et al5 emphasize the need for these assessments to be sensitive to changes that are anticipated as a result of these interventions. Further, these authors are concerned with testing within appropriate domains of the International Classification of Functioning, Disability and Health (ICF). Measures of body structure and function were found to be sensitive to change, as were measures of activity captured with the GMFM-66; but the authors are also concerned with clinically meaningful change, and raise the continuing concern that statistically significant differences are not always reflective of clinically meaningful change.

Bjornson et al's6 examination of the relationships among measures of ambulation activity performance, health status, and quality of life keeps the debates surrounding the influence of our interventions for the activity and participation domains of the ICF in the forefront. Their study also reflects the trends toward using self-report of quality of life and health status by children and adolescents rather than solely using the reports of parents. These authors also highlight direct measures of activity during daily life rather than reports of such activity. These authors suggest that our interventions, although important for issues related to the health status of children and youth, may not be related to children's quality of life. I would expect that we will continue to see additional studies developing measures of fundamental constructs within the domains of the ICF and examining the relationships among these domains.

Murphy et al7 demonstrate a successful application of goal attainment scaling to document achievement in behavioral objectives for children in a hippotherapy program. Notable in their work is the acknowledgement that parental perspectives of the outcomes of this therapy differed from those documented by the therapists.

And finally, as we see increasing numbers of systematic reviews being published, I would call the reader's attention to the use by Figueiredo et al8 of the PEDro scale to assess the rigor of the articles in their review. Systematic reviews are a form of research using measurement tools in a manner that is analogous to the use of test instruments in traditional research. The PEDro has undergone examination of some of its psychometric properties,9,10 but like most scales used to assess RCTs, much more work needs to be done to assure that the scales used in systematic reviews are of the highest quality. The authors of a recent report in Physical Therapy 11 point to the need for such instruments to be developed in a scientifically rigorous manner and subjected to the same type of examination of their psychometric properties as test instruments used in RCTs. Notably, scales used to assess RCTs do not rate the reliability and validity of outcome measures used in the studies that are the subject of the review! Further, Olivio et al10 point to the need to assure that scales developed for one “population” of studies are reliable and valid instruments for other “populations” of intervention studies. The PEDro was developed specifically for rating physical therapy studies, but is it equally valid for all areas of physical therapy? Do we need a more specific type of scale for use with pediatric physical therapy studies?

These articles addressing measurement issues are reflective of the concerns of clinical researchers in our profession. They demonstrate certain progress toward our growth in pediatric physical therapy. But I dream of even greater accomplishments. I dream of the day when pediatric physical therapists would be routinely using strong instruments in their clinic practice; would be concerned with their status as highly reliable testers; and would be contributing the results of their tests and measures to a universal databank that would allow us to answer even more questions about our interventions.

Finally, in the literature produced by our colleagues in orthopedic physical therapy we can see increasing emphasis on research on diagnostic tests. We are making headway on that front as well, but most of this work in pediatric physical therapy is concerned with diagnostic decisions in early infancy. I do not dispute that such work is fundamental, but I would suggest that we need to take the necessary steps to engage in research related to diagnostic classifications for children that will lead to even greater refinement in our ability to discriminate those who need and will most benefit from our services. The notion of episodic care for children with chronic disabling conditions suggests that changes occurring during childhood lead to the need for intervention. What are the signs demonstrated by these children that indicate this need for service? These collections of signs that appear during childhood and portend the need for service are diagnostic. Issues related to diagnosis in children with chronic disabling conditions are begging for our attention.

Ann F. VanSant, PT, PhD, FAPTA


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1. Finkel R, Hynan L, Glanzman A, et al. The test of infant motor performance: reliability in spinal muscular atrophy type I. Pediatr Phys Ther. 2008;20:242–246.
2. Katz-Leurer M, Rotem H, Lewitus H, et al. Functional balance tests for children with traumatic brain injury: within-session reliability. Pediatr Phys Ther. 2008;20:254–258.
3. Katz-Leurer M, Rottem H, Meyer S. Hand-held dynamometry in children with traumatic brain injury: within-session reliability. Pediatr Phys Ther. 2008;20:259–263.
4. Fergus A, Buckler J, Farrell J, et al. Constraint-induced movement therapy for a child with hemiparesis: a case report. Pediatr Phys Ther. 2008;20:271–283.
5. Kelly B, MacKay-Lyons M, Berryman S, et al. Assessment protocol for serial casting after botulinum toxin A injections to treat equinus gait. Pediatr Phys Ther. 2008;20:233–241.
6. Bjornson K, Belza B, Kartin D, et al. The relationship of physical activity to health status and quality of life in cerebral palsy. Pediatr Phys Ther. 2008;20:247–253.
7. Murphy D, Kahn-D'Angelo L, Gleason J. The effect of hippotherapy on functional outcomes for children with disabilities: a pilot study. Pediatr Phys Ther. 2008;20:264–270.
8. Figueiredo EM, Ferreira GB, Moreira RCM, et al. Efficacy of ankle-foot orthoses on gait of children with cerebral palsy: systematic review of literature. Pediatr Phys Ther. 2008;20:207–223.
9. Maher GG, Sherrington C, Herbert RD, et al. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;713–721.
10. Foley NC, Bhogal Sk, Teasell RW, et al. Estimates of quality and reliability with the Physiotherapy Evidence-Based Database scale to assess the methodology of randomized controlled trials of pharmacological and nonpharmacological interventions. Phys Ther. 2006;86:817–824.
11. Olivio SA, Macedo LG, Gadotti IC, et al. Scales to assess the quality of randomized control trials: a systematic review. Phys Ther. 2008;88:156–175.
© 2008 Lippincott Williams & Wilkins, Inc.