School-based physical therapists (PTs) need valid, objective measures of function that are reliable among clinicians and across settings. This improves documentation consistency so when children move or clinicians are newly assigned to children treated by other PTs, tests are conducted in the same way, and results can be compared over time. As per 2011-2012 demographic data, approximately 1 083 024 students were enrolled in grades prekindergarten to 12 in 1474 regional schools of the New York City Department of Education (NYCDOE) across the 5 boroughs1 and the NYCDOE employed 338 PTs. The student population is highly diverse, with 39.5% Hispanic/Latino, 28.8% Black/African American, 14.5% white, 15.3% Asian/Pacific Islander, 0.3% mixed, 0.5% American Indian, and 1.0% unknown.1 Therapists transfer between boroughs, districts, and schools to meet the caseload needs, and students transfer between schools and districts because of home relocations and placement needs. The physical therapy department encourages clinicians to use standardized, reliable tests to ensure that all students receive uniform evaluation processes.
Physical therapists in educational settings work with students to fully access their school environment. The School Functional Assessment (SFA) “measure(s) a student's performance of functional tasks that support his or her participation in the academic and social aspects of an elementary school program (grades K-6),”2 including the student's ability to participate in transitions, classroom activities, mealtime, playground/recess, bathroom, and transportation. It further examines Activity Performance of Physical Tasks, and in the domain of Maintaining and Changing Positions, includes the items: “moves from floor to chair or wheelchair” and “raises self from floor to standing position.” The SFA uses a 4-point criterion reference for scoring from “Does not perform” to “Performs consistently” but lacks more sensitive measures to compare a student's level of functioning over time, in relevant functional contexts, or to age-matched peers.2
The Timed Floor to Stand (TFTS) is a common standardized test that has face validity as it simulates the school functional task of transitioning to and from the floor.3 Children are required to transition within the school environment throughout the day. When transitions are not smooth or efficient, they absorb vital classroom and academic time4 that can disturb lesson flow. Classroom transitions include moving between centers in different areas of the classroom and between locations within and outside of the school. Floor to stand transitions occur during circle time, when negotiating play centers, during crafts and reading sessions or when breaking into project groups. During physical education, students transition to and from the floor for attendance, exercise routines, and various games. First-grade students with typical development (TD) were observed to transition 15 to 20 times per day4 and prekindergarten children may spend up to 25% of their day transitioning within the classroom.5 Teachers report that it is “very important” or “essential” for students to be able to transition independently in the school and classroom environments for school success.4
The TFTS was adapted from the Timed Up and Go (TUG) test3,6 and has been used as part of a battery of tests to describe physical performance in patients with mucopolysaccharidosis type I,7 and in children and young adults with TD.3 Reliability calculations are available for a battery of tests inclusive of the TFTS, but not for the individual TFTS. Fragala-Pinkham et al8 used the TFTS as a stand-alone test for children with disabilities pre- and postgroup aquatic exercises, but no reliability data were reported. The population tested, the number of subjects, and the test results from prior studies are illustrated in Table 1. On average, children with TD transitioned 56% quicker3 than children with various disabilities8 and 68% quicker than children and adults with mucopolysaccharidosis type I.7
While the TFTS would be useful for clinicians,7 no reliability data on the procedures of the TFTS as a separate measure have been found. Haley et al3 tested 150 students with TD from the northeast United States, aged 5 to 22 years, using the TFTS as part of a battery of tests; 89.3% were Caucasian. In 2 studies, the TFTS was performed as an outcome measure on samples of 20 or fewer children with disabilities.7,8 Based on the diverse demographics of NYC, the limitations that urban environments place on families and the challenges of access to outdoor recreation, it is not known if the available norms apply to an urban, ethnically diverse cohort.
To complete the TFTS in prior studies, subjects sat on the floor in a cross-legged position, stood up from the floor, walked as quickly as possible for 3 m (9 ft 10 in), turned around, walked back to the starting line, and sat back down on the floor with legs crossed. Thus, the TFTS test measures the time to stand up from and sit down on the floor, which complements the SFA. It is an appropriate and practical measure for PTs to use in school settings due to its simplicity and contextual relevance, allows for varied movement patterns to complete the task, and focuses on the speed of the transition.
The purposes of this study were to establish the intertester, intratester, and test-retest reliability of the TFTS as a stand-alone measure for school-aged children with TD in preparation for determining norms for a diverse, urban cohort, and justify its use by school-based PTs as an appropriate measure. This study had approval from the NYCDOE Internal Review Board.
This study used a repeated-measures design to establish the reliability of the TFTS across 2 trials among 5 PTs working for the NYCDOE. This was part of a larger reliability study that included the Timed Up and Down Stairs (TUDS) and the TUG; only the TFTS results are presented.
Five PTs working in the NYCDOE, each with a minimum of 10 years of experience, volunteered to administer the tests. Consent forms were sent to approximately 200 students attending a public summer school general education program in Queens, New York, requesting parent permission for student participation in the 3 tests, including the TFTS. Exclusion criteria included having an Individual Educational Plan, indicating that the student was receiving special education or related services, lack of parent/guardian consent, a history of orthopedic surgery or injury in the last 6 months, or a history of a genetic or neurological disorder.
Data Collection Procedures
Phase I consisted of standardizing the testing procedures for the TFTS, including the physical setup, directions to the subjects, conditions for repeat testing, and training and practicing the tests on one another until the PTs were comfortable and fluent with the testing procedures. The TFTS setup included 2 pieces of tape (1″ × 36″) placed on the gymnasium floor 3 m apart,3 as determined by a Rolatape (RT204) measuring wheel. Each student was asked to sit on the floor with his or her legs crossed behind the first piece of tape. Laminated cue cards for the test were printed to ensure consistency of prompts during the assessment process. The Haley et al3 directions were revised to be more succinct, to provide simpler administration of the test among therapists, and for easier understanding by the students. The phrase, “walk, don't run,” was substituted for “walk as fast as you can” since students are expected to transition at a natural and comfortable pace within the classroom. Hereafter, the designation of TFTS-N is used to refer to the “natural” pace version of this test. The sitting position descriptions were changed to age-appropriate language for school settings based on clinician experience. The testers had approximately 3 hours of training on the setup and procedures for the 3 tests. After each PT was comfortable with his or her knowledge of and efficiency with the tests, a consensus was reached to proceed with reliability testing.
The following instructions were read to all subjects from a preprinted card: “When I say go, stand up, walk to the line, turn around, walk back to the starting line, and sit back down, crisscross applesauce” (for 5- to 8-year-olds) or “with your legs crossed” (for 9- to 17-year-olds). “Walk, don't run. 1, 2, 3, GO.” Super Sport digital stopwatches (JW91) were used to record the time from the cue “go” until the child was sitting still, fully cross-legged on the floor.
The start time began with “Go” because in school, students are required to transition on the teacher's command, as opposed to when they actually initiate getting up from the floor. The end time was changed to when the student's legs quieted. This means that the student's legs were no longer moving and were settled in a crisscross posture. The TFTS-N verbal directions, the start and end prompts, and the end position are described in Table 2. The test was repeated if the student did not pass the second line with both feet, did not sit back down with legs crossed behind the starting line, or ran, tripped, or fell. It was acceptable to have 1 foot step over the line and the other foot swing through, as long as the student's full body passed the line. Students were given unlimited trials to complete the test according to the guidelines. The repeated trials were done immediately after a failed trial.
Phase II consisted of recruiting and testing subjects. Students with completed consent forms participated in a single day of testing. They were split into 2 groups based on class schedules. Each group was brought to the school gymnasium and given a folder with their completed consent form, a student assent form to sign, and 5 data collection sheets to be completed by the 5 testers. The folder and all forms had a coded student ID to ensure anonymity of the subjects.
Student height was measured with a Charder HM200P PortStad Stadiometer. Students stood wearing shoes with their backs against the height rod. The head stopper was lowered to the top of the head (hair styles and accessories were flattened or removed) and height was recorded to the nearest 1/8 of an inch. Weight was measured using a Lifesource Precision Health Scale ProFIT/IntelliSCALE (UC-321) and recorded to 2 decimal places. Outer garments and heavy items in pockets were removed. Body mass index rank and percentile were calculated using an online body mass index calculator for ages 2 to 20 years (www.blubberbuster.com/height_weight.html). Students stood or sat in a single row at least 3 feet away from the starting line to limit distraction while waiting their turns for testing. Three tests were completed in the following order: the TUDS, the TUG, and the Timed Floor to Stand. For each test, an initial explanation and demonstration of the task were given to the group. The first subject completed the test and went to the back of the line. The 5 testers were positioned to observe the subject's performance without seeing the other tester's record sheets or timers. The process was repeated so that each subject performed 2 trials per test. The time between trials for the TFTS-N was at least 15 minutes. The waiting time was sufficient as no child was out of breath or complained of fatigue, and learning effects are negligible since this task is performed numerous times a day.
A description of the sample and the time to perform the TFTS-N are described in Table 3. Paired t tests were used to determine differences between the 2 trials. Intra-class Correlation Coefficients (ICCs) were used to determine intratester reliability within each of the 5 testers, test-retest reliability between the 2 trials for all testers combined, and intertester reliability among the 5 testers using the average time of each clinician's measures from the 2 trials. SPSS Version 20 was used for all calculations.
Twenty-seven elementary school children with TD representing grades 3 to 6 volunteered to be tested; 5 were omitted on the basis of the exclusion criteria, resulting in a sample of 22. Of the 22 subjects, 15 were male and 7 were female, ranging from 8 years 7 months to 12 years 7 months (mean = 10 years, SD = 1.13) (Table 3). The sample was ethnically diverse and representative of NYC demographics, with 3 (14%) identifying as Asian/Pacific Islander descent, 8 (36%) as Latino/Hispanic, 4 (18%) as Black/African American, and 7 (32%) as white/Caucasian. Three students reported having asthma and 1 student checked “other” for the medical alerts but did not specify a condition.
Thirteen subjects completed both TFTS-N trials on the first attempt. Eight subjects repeated at least 1 trial and 1 subject repeated both trials. Repeat testing was due to tester error with the stopwatch, or student errors including not crossing the second line, or sitting on or before the starting line rather than behind it. Total testing time ranged from 25 to 41 minutes, depending on the size of the group. The time to complete the TFTS-N ranged from a mean of 6.27 ± 0.30 to 8.45 ± 0.68 seconds for this sample.
Intratester reliability for the TFTS-N was established using a paired t test between trials 1 and 2 within clinicians (see Table 4), and a 2-way mixed, absolute, single-measure ICC (Table 5). The average measures between trials 1 and 2 differed by less than 0.14 seconds within clinicians, with t(21) = −0.208 to −0.722, P > .05; no comparisons were statistically or clinically different. The ICC (3,1) ranged from 0.713 to 0.800, indicating good to excellent intratester reliability9 when using TFTS-N procedures after training.
Intertester reliability for the TFTS-N was established using the average of the 2 trial measures for each clinician and a 2-way mixed, absolute, single-measure ICC. The resulting ICC (3,1) = 0.988 indicates an excellent level of agreement among raters when using TFTS-N procedures after training.
Test-retest reliability was established by comparing all 22 measures from Trial 1 with those of Trial 2, thus collapsing all clinicians together, using a 2-way mixed, absolute, average measure ICC. The resulting ICC (3,3) = 0.871 indicates a good level of test-retest reliability between trials, when using TFTS-N procedures after training.
Reliability and Validity
The TFTS-N is a reliable and valid stand-alone test when a cue card is used with alternate readings for younger and older children, and reminders not to run. Intra-, inter-, and test-retest reliability levels are strong, suggesting that, with practice using the standardized procedures, measures taken by more than 1 clinician should be reliable. The average time to complete the test ranges from 6.27 to 8.45 seconds for 8- to 13-year-old children with TD. No significant difference in time between trials was found, and the average differences in this sample were all less than 0.15 seconds, which is not clinically significant in the school setting. Thus, 1 trial may be sufficient for establishing a TFTS-N baseline measure; however, this should be reexamined with larger samples across a wider age range. Face validity is assumed for the TFTS-N as the test requires the student to transition to and from the floor from a circle sitting position with a short walk in between, reflective of functional transitions in classroom settings. The TFTS-N has context validity for school settings where children are not encouraged to move as fast as they can, but rather at a natural speed.
Timed Floor to Stand Implications
When students score low in the SFA domain of transitions and changing positions, or if the task of transitioning from the floor to standing and back to floor sitting is a functional Individual Educational Plan goal, measuring the TFTS-N may be appropriate to establish a reliable baseline for treatment and/or to compare student performance to age- or disability-matched peers. The test is portable and inexpensive to set up, making it very practical for PTs traveling among school sites. The modified directions are easy to demonstrate and administer and are well understood by children with TD. Multiple trials do not affect the results in children with TD; the TFTS-N is equivalent to the transitions children perform throughout the school day. No learning or fatigue factors were observed and it did not require extensive energy expenditures for children with TD. This study was performed in an empty gymnasium without any environmental distractions. In school settings, it may be difficult to find a quiet, empty area to test a student. Evaluations and tests administered in small areas, with other students or furniture around, or with disruptive noises, may affect a child's ability to follow directions. The TFTS-N allows students to transition between the floor and standing, using their preferred movement patterns. The variability in strategies observed during TFTS-N testing is consistent with prior research, indicating that there are many ways to transition between functional positions.10
This study established the reliability of the TFTS-N. It is not clear how long it would take to train an individual clinician on this single test, as training occurred for 3 different standardized tests; nor is it known if individualized training for the TFTS-N would result in the same level of reliability. Additional study of PTs who did not develop the procedures for the TFTS-N is needed. It is recommended that PTs who use the TFTS-N establish their own levels of reliability before using the test for clinical measures.
This study measured a small sample of children with TD from 8 to 13 years of age who were able to follow verbal directions and understand a demonstration. It is not known if the test would retain its high level of reliability if used with younger children, or children who have cognitive or physical challenges. The ranges of time established for reliability testing should not be misconstrued as norms for these age ranges. Larger sample sizes within each age group are necessary to establish normative data.
The TFTS-N demonstrates strong intra-, inter-, and test-retest reliability for public school students ranging in age, gender, and ethnicity, when tested by PTs who are trained and who use the established procedures. The TFTS-N is an appropriate stand-alone test for school-based PTs to administer during evaluations to establish measures of baseline performance, as it is inexpensive and portable and has contextual relevance. Additional studies are needed to establish norms for the TFTS-N across a wider age range and with diverse student samples.
The authors thank the NYCDOE, including the Office of Related and Contractual Services, the Office of Related Services, and Carlo Vialu, PT, the Director of Physical Therapy; the PTs who were instrumental in the study design and testing of the students: Frank Covino, MS, PT; Maura Doyle, PT, DPT, PCS; Adina Itzkowitz, MS, PT; and Michael Leiberstein, PT; the PTs who assisted with the children: Liann Arnold-Liebman, PT, DPT; Caren Goldberg, MS, PT; Deborah Salwen, PT; Sujeeta Sippy, PT, DPT; Hea Jung Fico, MPT, DPT; and Michelle Frohlich, DPT; the schools that participated, including their administrators and PTs and the children who volunteered for testing.
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Keywords:Copyright © 2015 Academy of Pediatric Physical Therapy of the American Physical Therapy Association
activities of daily living; child; disability evaluation; exercise test/methods; female; humans; male; motor skills; reproducibility of results