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Cerebral Palsy Profile of Health and Function Computer Adaptive Test

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Purpose

The CP-PRO is a parent-reported assessment of physical functioning that includes upper extremity skills, lower extremity skills, activity, and global physical health.

Acronym CP-PRO/CP-CAT

Area of Assessment

Activities & Participation
Bodily Functions

Assessment Type

Patient Reported Outcomes

Administration Mode

Computer

Cost

Not Free

Populations

Cerebral Palsy

Key Descriptions

  • The CP-PRO is a computer adaptive test that first presents questions in the middle of the ability range, and then directs questions to the appropriate ability level based on the person’s response to previous items
  • The CP-PRO has a five-point difficulty scale: unable to do, with much difficulty, with some difficulty, with little difficulty, and without difficulty
  • The UE CP-PRO can be administered as a short-form (10-item).
  • The CP-PRO can be obtained through a sub-licensing agreement through the University of Utah. Please email: jacob.kean@hsc.utah.edu

Number of Items

Lower extremity: 85 item bank (includes core and assistive device items) (Gorton et al, 2010), 91 item bank (Tucket et al, 2009a)
Upper extremity: 55 item bank (Grampurohit et al, 2019) (15 item stopping rule), 53 item bank (Tucker et al, 2009b) (5, 10, or 15 item stopping rule), 46 item bank (Montpetit et al, 2011) (15 item stopping rule)
Activity: 36 item bank (Haley et al, 2009a) ) [5, 10 & 15 item stopping rule]
Global physical health: 37 item bank (Haley et al, 2009b) [5, 10 & 15 item stopping rule]

Equipment Required

  • Computer or tablet

Time to Administer

5 minutes

5 minutes for the LE CP-PRO (Mulcahey, 2015)

Required Training

No Training

Age Ranges

2 - 20

years

Instrument Reviewers

This instrument summary was authored by Namrata Grampurohit, PhD, OTR/L at Jefferson University and Majd Jarrar, MS, OTR/L at University of Washington in December, 2018.

Body Part

Upper Extremity
Lower Extremity

ICF Domain

Activity
Participation

Measurement Domain

General Health
Motor
Activities of Daily Living

Considerations

Computer adaptive test can be limited to 5, 10, 15, or 20 items

Scoring is based on a T-metric where mean is 50 and standard deviation is 10 for the summary score. Other types of scores such as centiles can also be obtained.

Cerebral Palsy

back to Populations

Standard Error of Measurement (SEM)

Cerebral Palsy: (Gorton et al, 2010; n = 308 [quadriplegia = 89, diplegia = 145, hemiplegia = 73], mean age = 10.66 + 4 years)

  • SEM of LE CP-PRO < 2.2 (SD = 2)

Minimal Detectable Change (MDC)

Cerebral Palsy: (Gorton et al, 2010; n = 308 [quadriplegia = 89, diplegia = 145, hemiplegia = 73], mean age = 10.66 + 4 years)

  • SEM of LE CP-PRO < 2.2 (SD = 2)

Minimally Clinically Important Difference (MCID)

Cerebral Palsy: (Mulcahey et al, 2015; n = 255, mean age = 11.6 + 3.8 years)

  • Minimally important difference in LE CP-PRO scores as measured by parent anchor scores of perceived change in lower extremity mobility following surgery
    • At 12 months: 0.65 to 1.67
    • At 24 months: 1.1 to 1.31

Test/Retest Reliability

Cerebral Palsy: (Haley et al, 2010; n = 91 parents, children’s mean age = 9.9 + 4.12 years)

  • Excellent test-retest reliability (n = 27) for overall scores across the four sub-scales (ICC = 0.91), and for sub-scales of LE CP-PRO (ICC = 0.96), UE CP-PRO (ICC = 0.86), Activity CP-PRO (ICC = 0.88), and Global physical health CP-PRO (ICC = 0.94).
  • Excellent marginal reliability for LE CP-PRO (0.97, n = 91)), UE CP-PRO (0.96, n = 91), and Activity CP-PRO (0.95, n = 91) and greater than legacy measures Functional Assessment Questionnaire 22 (0.82, n = 61), Wee-FIM mobility and transfers (0.88, n = 42), Wee-FIM motor (0.85, n = 42), Wee-FIM self-care (0.74, n = 42). Pediatric Outcomes Data Collection Instrument (PODCI) basic mobility (0.87, n = 66), PODCI Upper extremity (0.91, n = 66), PODCI sports (0.81, n = 66), Pediatric Quality of Life Daily Activity (0.71, n = 55). Marginal reliability is a measure of how precise the measure is overall.

Internal Consistency

Cerebral Palsy: (Tucker et al, 2009b; n = 180 parents, children’s mean age = 10.5 + 4.08 years [children with quadriplegia = 28%, diplegia = 49%, hemiplegia = 22%])

  • Excellent Reliability with simulated UE CP-PRO of 5, 10, and 15 items for the full UE CP-PRO item bank (ICC > 0.93)

Cerebral Palsy: (Tucker et al, 2009a; n = 190 parents, children’s mean age 10.58 + 4.08 years [children with quadriplegia = 30%, spastic diplegia = 48%, hemiplegia = 22%])

  • Excellent Reliability of the LE CP-PRO (Cronbach’s alpha = 0.99)
  • Excellent Reliability with simulated LE CP-PRO of 5, 10, and 15 items with the 45-item full bank (ICC > 0.93, r > 0.91)

Cerebral Palsy: (Haley et al, 2009a; n = 308, mean age = 10.7 + 4.0 years)

  • Excellent Reliability with simulated CP-PRO of 5, 10, and 15 items for the full item bank (ICC > 0.93)

Criterion Validity (Predictive/Concurrent)

Cerebral Palsy: (Gorton et al, 2010; n = 308 [quadriplegia = 89, diplegia = 145, hemiplegia = 73], mean age = 10.66 + 4 years)

  • Excellent concurrent validity with Functional Assessment Questionnaire walking scale (r = 0.82, p < 0.001), Pediatric Outcomes Data Collection Instrument (PODCI) transfers and basic mobility sub-score  (r  = 0.85, p < 0.001), Wee-FIM lower extremity sub-score (r = 0.83, p < 0.001), and Pediatric Quality of Life Inventory CP overall score (r =  0.76, p < 0.001).

Cerebral Palsy: (Tucker et al, 2009b; n = 180 parents, children’s mean age = 10.5 + 4.08 years, children with quadriplegia = 28%, diplegia = 49%, hemiplegia = 22%)

  • Excellent concurrent validity of UE CP-PRO with Pediatric Outcomes Data Collection Instrument Upper extremity domain(r = 0.79)

Cerebral Palsy: (Tucker et al, 2009a; n = 190 parents, children’s mean age 10.58 + 4.08 years [children with quadriplegia = 30%, spastic diplegia = 48%, hemiplegia = 22%])

  • Excellent concurrent validity of LE CP-PRO with Pediatric Outcomes Data Collection Instrument transfers and basic mobility sub-scores (r > 0.85), Functional Assessment Questionnaire (r > 0.71)

Cerebral Palsy: (Haley et al, 2009a; n = 308, mean age = 10.7 + 4.0 years)

  • Excellent concurrent validity between Activity CP-PRO and Pediatric Outcomes Data Collection Instrument physical and sports subscale (r = 0.86), WeeFIM (r = 0.79), and PedsQL-CP daily activity scores (r = 0.74).

Cerebral Palsy: (Haley et al, 2009b; n = 306 (diplegia = 144, hemiplegia = 73, quadriplegia = 88), mean age = 10.8 +  4 years)

  • Excellent correlation between CP-PRO global score and the global function of the  Pediatric Outcomes Data Collection Instrument (PODCI) (r = 0.71)and overall score of the Pediatric Quality of Life Inventory CP version (r = - 0.75)
  • Excellent correlation between CP-PRO pain subscore and the pain sub score of the Pediatric Outcomes Data Collection Instrument (PODCI) (r = 0.70), and pain items of Pediatric Quality of Life Inventory CP (r = - 0.65)
  • Excellent correlation between CP-PRO fatigue subscore and the physical function scores  of the Pediatric Outcomes Data Collection Instrument (PODCI) (r = 0.71) and the fatigue items of Pediatric Quality of Life Inventory CP (r = - 0.68)

Cerebral Palsy: (Haley et al, 2010; n = 91 parents, children’s mean age = 9.9 + 4.12 years)

  • Excellent concurrent validity between LE CP-PRO and Pediatric Outcomes Data Collection Instrument basic mobility (r = 0.88), Wee-FIM motor (r = 0.89), Wee-FIM transfer and locomotion (r = 0.91), Functional Assessment Questionnaire (r = 0.78)
  • Excellent concurrent validity between UE CP-PRO and Pediatric Outcomes Data Collection Instrument upper extremity (r = 0.85), and Wee-FIM selfcare (r = 0.82)
  • Excellent concurrent validity between Activity CP-PRO and the Pediatric Quality of Life Inventory CP version activity items (r = 0.80) and Pediatric Outcomes Data Collection Instrument sports (r = 0.83)
  • Adequate concurrent validity between Global Physical Health CP-PRO and the Pediatric Quality of Life Inventory CP version  (r = 0.59)

Cerebral Palsy: (Montpetit et al, 2011; n = 305 parents, children's mean age = 10.7+ 4 years)

  • Excellent concurrent validity between UE CP-PRO and the WeeFIM (r = 0.65) and the Pediatric Outcomes Data Collection Instrument (PODCI) Upper Extremity subscale (r = 0.80)

Construct Validity

Cerebral Palsy: (Tucker et al, 2009b; n = 180 parents, children’s mean age = 10.5 + 4.08 years, children with quadriplegia = 28%, diplegia = 49%, hemiplegia = 22%)

  • UE CP-PRO Discriminated among MACS levels

Cerebral Palsy: (Haley et al, 2009b; n = 306 [diplegia = 144, hemiplegia = 73, quadriplegia = 88], mean age = 10.8 + 4 years)

  • The general factor, pain and fatigue sub-score discriminated among Gross Motor Function Classification System levels
  • The general factor, pain and fatigue sub-score discriminated by type of cerebral palsy

Cerebral Palsy: (Haley et al, 2009a; n = 308, mean age = 10.7 + 4.0 years)

  • Activity CP-PRO discriminated among known groups of upper extremity and gross motor severity levels (p < 0.001)
  • 5, 10 and 15-item simulated CP-PRO computer adaptive test was able to discriminate among GMFCS and MACS levels (p < 0.001).

Cerebral Palsy: (Tucker et al, 2009a; n = 190 parents, children’s mean age 10.58 + 4.08 years [children with quadriplegia = 30%, spastic diplegia = 48%, hemiplegia = 22%])

  • LE CP-PRO 5, 10, 15 and full item bank discriminated among known groups of CP type and GMFCS levels (p < 0.001)

Content Validity

Cerebral Palsy: (Gorton et al, 2010; n = 308 [quadriplegia = 89, diplegia = 145, hemiplegia = 73], mean age = 10.66 + 4 years)

Fit to Rasch Measurement Theory (Item fit, Differential Item Functioning)

  • Acceptable item fit statistics was found for LE85 with the exception of two walker items and nine core items but those items were kept after expert review because of the importance of their content.
  • Differential item functioning (DIF) evaluates whether subgroups respond differently. No DIF was found for any of the 42 core items. One wheelchair item showed DIF for age (‘transfer between a seat and his/her wheelchair’), one for GMFCS level (‘wheeling, moves in line without bumping into other people’), and two for both MACS and GMFCS level (‘wheel across level outdoor surfaces’, ‘wheeling, can change direction’). The items were retained because of the limited number of respondents using wheelchair.

Cerebral Palsy: (Dumas et al, 2008; n = 27 parents of children with cerebral palsy, children’s mean age = 10.3 + 3.3 years, children’s type of cerebral palsy - hemiplegia (22%), diplegia (48%), and quadriplegia (30%))

  • Cognitive interviews with parents of children with cerebral palsy were conducted to improve item clarity, relevance, context, attribution, problem with wording and tone, and definition for item responses were expanded

Cerebral Palsy: (Tucker et al, 2008)

  • The conceptual framework of physical functioning in cerebral palsy is described along with the description of constructs of lower extremity skills, upper extremity skills, activity and global physical health.
  • Item bank development is described for a computer adaptive test.

Cerebral Palsy: (Tucker et al, 2009a; n = 190 parents, children’s mean age 10.58 + 4.08 years [children with quadriplegia = 30%, spastic diplegia = 48%, hemiplegia = 22%])

  • Confirmatory factor analysis supported unidimensional model (comparative fit index = 0.98) for 45 out of 91 basic lower extremity and mobility items of the LE CP-PRO.
  • Acceptable item fit (mean square infit < 1.4). Six items with marginal infit were retained due to importance of content for the LE CP-PRO.
  • Differential item functioning across GMFCS levels noted for one item (‘My child can creep, crawl, or scoot within a room’) of the LE CP-PRO.

Cerebral Palsy: (Tucker et al, 2009b; n = 180 parents, children’s mean age = 10.5 + 4.08 years, children with quadriplegia = 28%, diplegia = 49%, hemiplegia = 22%)

  • For the UE CP-PRO, a unidimensional model was supported for 49 of the 53 items.

Cerebral Palsy: (Haley et al, 2009b; n = 306 (diplegia = 144, hemiplegia = 73, quadriplegia = 88), mean age = 10.8 +  4 years)

  • For the Global Physical Health CP-PRO - Two factor model had significantly better fit than one-factor model (P < 0.001)
  • Confirmatory factor analysis suggested separate
    pain and fatigue sub-factors.

Cerebral Palsy: (Haley et al, 2009a; n = 308, mean age = 10.7 + 4.0 years)

Fit to Rasch Measurement Theory (Item fit, Differential Item Functioning)

  • Differential item functioning (DIF) evaluates whether subgroups respond differently. No DIF was noted for MACS level. For age, moderate DIF noted for one item (‘climbs and moves on high playground equipment’). For CP diagnosis, moderate DIF noted for two items (‘hops and skips while playing games with other children of similar age, such as during hopscotch or a relay race’ and ‘prepares to eat a meal’) for children with hemiplegia or diplegia. For GMFCS level, three items showed moderate DIF for greater gross motor severity (‘prepares to eat a meal,’ ‘crosses a quiet 2-lane neighborhood street,’ and ‘keeps up with other children of similar age while walking upstairs’). None of the items with DIF were removed due to relevance to the population.

Floor/Ceiling Effects

Cerebral Palsy: (Haley et al, 2009a; n = 308, mean age = 10.7 + 4.0 years)

  • Excellent with ceiling and floor effects of 1% and 3.6% respectively for Activity CP-PRO. Small gaps around the T-score of 50-60 were noted in content coverage.

Cerebral Palsy: (Tucker et al, 2009a; n = 190 parents, children’s mean age 10.58 + 4.08 years [children with quadriplegia = 30%, spastic diplegia = 48%, hemiplegia = 22%])

  • Excellent with ceiling and floor effects of 1.5% and 0% respectively for LE CP-PRO. No gaps in content coverage.

Responsiveness

Cerebral Palsy: (Grampurohit et al, 2019; n = 97, mean age = 11.37 + 4.06 years)

  • After upper extremity surgery
    • Moderate change in UE CP-PRO from baseline to 6 months  (Effect size = 0.40, Standard response mean = 0.53)
    • Large change in UE CP-PRO from baseline to 6 months for children within the Manual Ability Classification System level-II (Effect size = 0.70; Standard response mean = 0.70)
    • UE CP-PRO more responsive than Pediatrics Outcomes Data Collection Instrument Upper Extremity (Effect size = 0.18, Standard response mean = 0.25)

Cerebral Palsy: (Mulcahey et al, 2015; n = 255, mean age = 11.6 + 3.8 years)

  •  After lower extremity surgery
    • Small change in LE CP-PRO from baseline to 6 months (Standard response mean = 0.07)
    • Moderate change in LE CP-PRO from baseline to 12 months (Standard response mean = 0.45), and 24 months (Standard response mean = 0.58)
  • LE CP-PRO more responsive than Pediatrics Outcomes Data Collection Instrument Mobility/Transfer Domain at 12 months (Standard response mean = 0.22), Pediatrics Outcomes Data Collection Instrument Sports/Physical Functioning Domain at 12 months (Standard response mean = 0.22), Timed Up and Go at 12 (Standard response mean = 0.08) and 24 months (Standard response mean = 0.15)
  • After lower extremity surgery by Gross Motor Function Classification System Levels
    • At 6 & 12 months: Moderate Change in LE CP-PRO at GMFCS Level I (Standard response mean 6 mon = 0.35, 12 mon = 0.73) and III (Standard response mean 6 mon = 0.35, 12 mon = 0.74)
    • At 24 months: Large Change in LE CP-PRO at GMFCS Levels I (Standard response mean = 0.82) and III (Standard response mean = 1.11); Moderate Change in LE CP-PRO at GMFCS Level II (Standard response mean = 0.30)
  • LE CP-PRO did better than Pediatrics Outcomes Data Collection Instrument Sports/Physical Functioning, Transfer/Mobility Domain and Timed Up and Go for all timepoints in Levels I and III.

Bibliography

Dumas, H., Watson, K., Fragala-Pinkham, M. A., Haley, S., Bilodeau, N., Montpetit, K., Gorton III, G. E., Mulcahey, MJ., Tucker, C., (2008). Using Cognitive Interviewing for Test Items to Assess Physical Function in Children with Cerebral Palsy. Pediatric Physical Therapy. 20(4):356-62. doi: 10.1097/PEP.0b013e31818ac500

Gorton, G. E., Watson, K., Tucker, C. A., Tian, F., Montpetit, K., Haley, S. M., & Mulcahey, M. J. (2010). Precision and content range of a parent‐reported item bank assessing lower extremity and mobility skills in children with cerebral palsy. Developmental Medicine & Child Neurology, 52(7), 660-665.

Grampurohit, N., Slavin, M., Ni, P., Jette, A., Kozin, S., Mulcahey, M. J.(2019) Responsiveness of the Cerebral Palsy Profile of Health and Function. Journal of Hand Surgery (In press)

Haley, S. M., Ni, P., Fragala-Pinkham, M. A., Skrinar, A. M., Corzo, D.  (2005) A computer adaptive testing approach for assessing physical functioning in children and adolescents. Developmental Medicine and Child Neurology, 47, 113-120.

Haley, S. M., Chafetz, R. S., Tian, F., Montpetit, K., Watson, K., Gorton, G., & Mulcahey, M. J. (2010). Validity and reliability of physical functioning computer-adaptive tests for children with cerebral palsy. Journal of Pediatric Orthopedics, 30(1), 71-75.

Haley, S. M., Fragala-Pinkham, M. A., Dumas, H. M., Ni, P., Gorton, G. E., Watson, K., … Tucker, C. A. (2009a). Evaluation of an Item Bank for a Computerized Adaptive Test of Activity in Children With Cerebral Palsy. Physical Therapy, 89(6), 589–600. DOI: 10.2522/ptj.20090007

Haley, S. M., Ni, P., Dumas, H. M., Fragala-Pinkham, M. A., Hambleton, R. K., Montpetit, K., ... & Tucker, C. A. (2009b). Measuring global physical health in children with cerebral palsy: illustration of a multidimensional bi-factor model and computerized adaptive testing. Quality of Life Research, 18(3), 359-370.

Montpetit, K., Haley, S., Nathalie B., Ni, P., Tian, F., Gorton, G., Mulcahey, M. J. (2011) Content Range and Precision of a Computer Adaptive Test of Upper Extremity Function for Children With Cerebral Palsy. Physical & Occupational Therapy In Pediatrics, 31:1, 90-102, DOI: 10.3109/01942638.2010.523449

Mulcahey, M. J., Slavin., M. D., Ni, P., Vogel, L., Kozin, S., Haley, S.,  & Jette, A. Computer Adaptive Tests Detect Change Following Orthopaedic Surgery in Youth with Cerebral Palsy. J Bone Joint Surg Am. 2015;97:1482-94 http://dx.doi.org/10.2106/JBJS.O.00179

Tucker C., Haley, S., Dumas, H., Fragala-Pinkham, M. A., Watson, K., Gorton, G., Montpetit, K., Bilodeau, N. (2008) Physical Function for Children and Youth with Cerebral Palsy: Item Bank Development for Computer Adaptive Testing. Journal of Pediatric Rehabilitation Medicine: An Interdisciplinary Approach. 245-253.

Tucker, C. A., Gorton, G. E., Watson, K., Fragala-Pinkham, M. A., Dumas, H. M., Montpetit, K., Bilodeau, N., Ni, P., Hambleton, R. K., Haley, S. M. (2009a) Development of a Parent-report Computer-adaptive Test to Assess Physical Functioning in Children with Cerebral Palsy I: Lower-extremity and Mobility Skills. Dev Med Child Neurol. 51(9):717-24. doi: 10.1111/j.1469-8749.2009.03266.

Tucker, C., Montpetit, K., Bilodeau, N., Dumas, H., Fragala-Pinkham, M. A., Watson, K., Gorton, G., Pengsheng, N., Hambleton, R., Mulcahey, M. J., Haley, S. (2009b) Development of a Parent-report Computer-adaptive Test to Assess Physical Functioning in Children with Cerebral Palsy II: Upper-extremity Skills. Dev Med Child Neurol. 51(9):725-31. doi:10.1111/j.1469-8749.2009.03267

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