Research topic: Evaluating the usability of adult-based sports activity scales with pediatric patients, and investigating the development and the validity of a new pediatric sports activity scale
Research results: Applied results of adult-based sports activity scale evaluation to develop a new pediatric scale, which is being tested for reliability, construct validity, content validity, criterion validity, and responsiveness to change
Patient care application of results: Appropriate outcome measures that will aid in effective intervention and research to improve treatment for children and adolescents
Simplified patient care application: Effective intervention and research to improve treatment for children and adolescents
Measuring Pediatric Treatment Outcomes
OREF grant recipient is developing a valid pediatric outcome assessment tool
Jay D. Lenn
Patient feedback on treatment outcomes plays a critical role in both clinical practice and research. Questionnaires or rating scales provide information about symptoms, the effect of injury on joint and muscle function, the effects on functional abilities and activities, and changes in any of these factors after treatment.
One such type of patient-derived outcome assessment is a sports activity scale. Several of these scales are available, but they were initially developed and validated with adult patients and are not necessarily valid assessment tools in pediatrics.
Mininder S. Kocher, MD, associate director of sports medicine at Boston Children's Hospital, defined the dilemma this way: "Right now we're left with adult scales that we use with children and adolescents. And that's problematic. We don't use an adult blood pressure cuff on a child. Why should we use an adult outcome instrument with kids?"
To address this gap in measuring pediatric treatment outcomes, Dr. Kocher received a 2013 Pediatric Orthopaedic Society of North America/Orthopaedic Research and Education Foundation (POSNA/OREF) Research Grant in Pediatric Orthopaedics. Dr. Kocher and his research team are evaluating the usability of adult-based sports activity scales with pediatric patients, developing a pediatric sports activity scale and assessing the validity of the new tool.
The POSNA/OREF Research Grant in Pediatric Orthopaedics—a one-year, $30,000 award—funds clinical or basic science research that supports POSNA's mission to improve the care of children with musculoskeletal disorders and OREF’s mission to support excellence in orthopaedic research.
Assessing current tools
The need for a pediatric instrument is great. More than 38 million children and adolescents participate in organized sports in the United States. Annually, more than 2.6 million youth are seen in emergency rooms for injuries related to sports and recreation.1 Effective intervention and research to improve treatment for this population depend on the use of appropriate outcome measures.
The format may be confusing. The questions may be difficult to comprehend. Medical or sports terms may be unfamiliar. A scale may include activities that are not relevant to children or adolescent sports activities. A scale may leave out activities that are relevant. It may not consider the wide spectrum of activity levels within a single sport—from informal recreational programs to more rigorous travel-team programs.
Commonly used sports activity scales differ in format, the type of information requested, level of detail, and method of recording answers. But all of them are designed to elicit information about the type, frequency, and intensity of sports activity.
There are several reasons these scales, while valid for adult patients, may not be appropriate for assessing outcomes in children:
To examine these issues, Dr. Kocher and his team enrolled 60 participants who had been evaluated for lower-extremity sports injuries. There were an equal number of each sex and an equal number in each of three age groups: 10 to 12, 13 to 15, and 16 to 18. Each participant was assigned to complete one of five common sports activity scales: the Tegner Activity Scale, the Marx Activity Scale, the Cincinnati Sports Activity Scale, the KOOS Function in Sport and Recreation Scale, or the Knee Outcome Survey Sports Activity Scale.
Each patient then participated in a structured interview with a member of the research team. Dr. Kocher explained, "We talked to the kids about their comprehension of the questions. What problems they had with questions, which questions were relevant, which questions weren't. From that we got a lot of interesting data that have allowed us to develop a new outcome instrument for sports activity levels in kids."
Testing a new pediatric scale
In the second phase of the project, the researchers are assessing the new activity scale for test-retest reliability, construct validity, content validity, criterion validity, and responsiveness to change. "We need to determine whether the questions really ask what we think they’re asking and how those scores change over time with treatment," stated Dr. Kocher.
For this type of analysis, the investigators have recruited participants for three separate groups of 100 patients each to use the new pediatric sports activity scale. One group will complete the form once. One group will complete the form twice at an interval of two weeks. The other group will complete the form before surgical treatment and six months after surgery.
"I think the orthopaedic community understands that adult instruments may not be appropriate for children and adolescents," said Dr. Kocher. "But we need to point out the deficiencies with the current instruments and be able to demonstrate the reliability, validity and responsiveness of this new instrument."
The value of orthopaedic research
"Our field is driven by research and innovation," Dr. Kocher said. "That's never been more important than it is today. Our patients, their parents, our hospitals, the payers, the government—they all want to know the comparative effectiveness of treatments."
Dr. Kocher added that we need better data that can enable evidence-based comparisons. "Those data are going to come from high-quality research," he said. "And that has to be supported somewhere. For many of us doing clinical research, OREF support has been essential."
1 Sports and recreation safety fact sheet (2013). Safe Kids Worldwide. http://www.safekids.org/fact-sheet/sports-and-recreation-safety-fact-sheet-pdf. Accessed Dec. 3, 2014.