Property of Marianne Beninato and George Fulk Not to be used without permission

• Apply concepts of MDC and MCID to the
• Understand the limitations of the
• Discuss the ways that the proper

  ◦

  

  Pt is a 66 year old male with first time right MCA stroke. Prior to his stroke he was working full time as an architect. He is married with 3 grown children, 2 of whom live near by.

  

   Case Presentations (GF)  Limitations, cautionary notes (MB)  Future Research (MB)  Questions (MB and GF)

   Distribution-based methods  Diagnostic Test (Anchor) Method

   Minimal Clinically Important Difference

   Minimal Detectable change

  Measures of Change and Their Interpretation

  ◦

   Error, reliability, Standard Error of Measurement

  Review of Measurement Properties

  Health (ICF)

  Marianne Beninato, DPT, PhD MGH Institute of Health Professions George Fulk, PT, PhD Clarkson University

   Introduction (MB)  Overview of Measurement (MB) ◦ International Classification of Functioning, Disability and

  The authors have nothing to disclose

  

  interpretation of change scores can inform patient management and clinical decision making

  interpretation of outcome measures in various settings and patient subgroups

  interpretation of change scores on outcome measures

  Compare and contrast the Minimal Detectable Change (MDC) and Minimal Clinically Important Difference (MCID)

  

  Apply the ICF framework to be able to categorize outcome measures according to the ICF

  

  Define important psychometric properties of outcome measures

  

  You are seeing him in the acute care hospital for his PT initial evaluation.

   

  What will you decide to assess? Essential to evidence-based practice

   Which clinical assessment tools will you use?  Guides clinical decision making 

  How will you interpret the scores?

   

  How will you know if your patient is getting Frameworks for assessing health and disease better?

  ◦ The ICF (WHO, 2001) ◦ “Significantly” better?

  Better than what?

  ◦ ◦ Based on what reference point? 

  Between groups vs Within Patient change

   Replaces ICIDH and Nagi Model Health Condition

  

  A meaningful and practical system that can be used by various consumers for health policy, quality assurance and outcome

  Body

  evaluation in different cultures

  Function Activity Participation 

  Aims

  Structure To provide scientific basis for understanding and

  ◦ studying health and health-related states, outcomes and determinants

  Contextual To establish a common language for describing

  Factors ◦ health and health-related states in order to improve communication between different users.

  Environmental Personal Factors Factors Health Condition

  Body Function Activity Participation Body

  Structure Function Activity Participation Structure

  Physiologic Execution of task Involvement in Contextual functions or or action life situations

  Factors anatomical parts Negative aspect: Negative aspect: of the body Limitation Restrictions Negative aspect:

  Environmental Personal Factors Factors Impairment

• Relationships among components are not unidirectional or linear or proportional

  Hi Mat ‣

  ‣ Trunk Control Test

  ‣ Tinetti POMA

  ‣ Timed Up and Go

  Stroke Rehabilitation Assessment of Movement

  Postural Assessment Scale for Stroke Patients ‣

  Mobility Scale for Acute Stroke ‣

  Motor Activity Log ‣

  Jebsen Taylor Arm Function Test ‣

  Functional Reach ‣

  ‣ Wolf Motor Function Test

  Functional Independence Measure ‣

  Functional Gait Assessment ‣

  Functional Ambulatory Categories ‣

  Falls Efficacy Scale** ‣

  Dynamic Gait Index ‣

  Chedoke Hand Arm Inventory ‣

  Performance Measure ‣

  Block & Box Test  Brunnel Balance Test  Canadian Occupational

  (BEST) 

  ‣ Trunk Impairment Scale

  BOLD

  10 Meter Walk Test  Action Research Arm Test  Activity-specific Balance

  Adalaide Activities Profile BOLD – not included in StrokEdge

  ◦ Activity: “How difficult was it to bathe yourself?”

  ◦ BSF: “How would you rate the strength of your leg affected by your stroke?”

  Example: Stroke Impact Scale

  

  Include items from more than one ICF component

  

  Some measures are Hybrid

  

  Frenchay Index ‣

   Assessment of Life Habits

  Stroke-Specific Quality of Life ‣

  Stroke Impact Scale** ‣

  SF-36 ‣

  30 ‣

  Stroke Adapted Sickness Impact Scale

  Satisfaction with Life Scale ‣

  Living ‣

  Impact Scale  Modified Rankin Scale  Reintegration to Normal

   EuroQOL  Goal Attainment Scale  Modified Fatigue

  Confidence Scale**  Arm Motor Ability Test  Berg Balance Scale  Balance Evaluation Systems Test

  9 Hole Peg Test 

  ‣

  NIH Stroke Scale

  Dynomometry

  ‣

  Chedoke-McMaster Stroke Assessment

  ‣

  Fugl-Meyer Sensory Assessment

  ‣

  Fugl-Meyer Assessment of Motor Function

  ‣

  ‣

  6 Minute Walk Test 

  ‣ DTR’s, Ashworth Scale

  Contextual Factors Environmental Factors

  Structure Activity Participation Personal Factors

  Health Condition Body Function

  Environmental Factors

  Internal influences on functioning Particular background of individual’s life and living, and comprise features of the individual that are not part of health condition

  Physical, social and attitudinal environment in which people live

  Personal Factors External influences on functioning

• – Limb Movement

  Motricity Index

  ‣

  Nottingham Assessment of Somatosensation

   5 times Sit to Stand 

  VO2 Max

  ‣

  Tardieu Spasticity Scale

  ‣

  Subscales

  Stroke Rehabilitation Assessment of Movement

  ‣

  Semmes Weinstein Monofilaments

  ‣

  Rivermead Motor Assessment

  ‣

  Rivermead Assessment of Somatosensory Performance

  ‣

  Rate of Perceived Exertion

  ‣

• – Mobility Subscale

  Orpington Prognostic Scale

  ‣

• – not included in StrokEdge

  ◦ Participation: “How much of the time have you been limited in your social activities?”

   (Powell and Myers, J Gerontol A Biol Med Sci 1995;

  ABC scale

  

  If possible, measure in various domains of ICF

  50:28-34)  If possible, include measures of personal  (Hellstrom and

  Falls Efficacy Scale for Stroke factors Lindmark, Clin Rehabil 1999;13:509-17)

  

  This is not always possible or appropriate

  

  Root questions are not about how well or how _{Condition Health} often the activities are performed but how the person feels about doing them _{Structure Function Activity Participation Body}

   “How confident are you that you _{Contextual Factors} could…without losing your balance _{Environmental Factors Factors Personal}

  

  Decide what you will be using OM for

  ◦ Measuring change 

  Responsiveness

  ◦ Prediction ◦ Aspect of validity

  

  Are reference psychometrics available?

  ◦ Small but relevant change

  Reliability

  ◦

  Meaningful

  ◦

  Validity

  ◦ 

  

  Avoid floor or ceiling effect Group Comparisons

  (≥20 % floor or ceiling

  effect)

  t -tests, ANOVA ◦

  

  Match with

  ◦ Limits of interpretability health condition (diagnosis)

  ◦ practice setting

  ◦ patient subgroup (i.e. stroke severity etc)

  ◦ stage of recovery

  ◦ Sources of Error Examples

  

  Why do we take

   Normal variability in

  measurements? patient performance related to factors such as

  ◦ Descriptive

  Patient Variability fatigue Differentiation

  ◦  Disease state is more or

  Detect change

  ◦

  less stable

    Familiarity, expertise

  Patient’s cognitive state

  with the instrument Rater Variability

   Practiced, standardized

  technique

   Scoring not clearly

  Measurement Instrument defined _{Adapted from Beninato and Portney, 2011JNPT;35: 75-81}  Instrument not stable

  

  Differentiating among patients

  

  Random

  ◦ Will people with more impairment consistently ◦ Scores taken at different time

  have lower scores and vice versa? in a truly unchanging person Interclass correlation coefficient (ICC)

  ◦

  will be bell shaped i.e. normal

  ◦ Unitless measure

  distribution

  ◦ Scored 0 to 1 

  Systematic

  ◦ Higher score is better ◦ Scores will be skewed to

  greater than or less than the mean _{http://en.wikipedia.org/wiki/File:Intraclass_correlation_coefficient_graph.png}

  

  Consistency of measured values from a truly

  2

  2 SEM = + SD T2 )/2 x √(SD T1 √1 – ICC

  unchanged patient

  Mean SD SD Pooled SD ◦ Standard Error of Measurement (SEM)

  ICC ^{2 2 - ICC SEM} BBS T1 T2 + SDT2 )/2 √1 √(SDT1

  ◦ SEM =

  1

  s √ – r

  XX Flansbjer

  s is pooled SD of 2 sets of stable scores

  PM R 52.0 .88

  4.3

  3.8 4.05 .3464

  1.40

   r is reliability coefficient (ICC)

  XX 2012;4:165-170

  

  SEM quantifies random error taking into

  Hiengkaew

  account stability at baseline and test re-test

  Arch Phys Med 46.2 .95 7.64 7.87 7.76 .2236

  1.73

  reliability Rehabil

  2012;93:1201- 

  In same units as outcome measure 1208

  

  SEM assumptions:

  ◦ A truly stable group of individuals

  The means between T1 and T2 should not be

  

  substantially different

  ◦ Normal distribution of the difference in scores

  between T1 and T2

  

  Interpreting reliability studies

  ◦ The sample studied should resemble your patient ◦ Your actual error could vary depending on your

  reliability _{Beninato M, Portney LG, JNPT, 2011;35:75-81}

  Initial Exam Follow-up Berg 45 Berg 49 Improvement?? 1 ^st Berg 44

  Initial Exam Follow-up Berg 45 Berg 49 Improvement?? 1 ^st Berg 42

ERROR ERROR

ERROR ERROR

  2 ^nd Berg 49

  ◦ For MDC usually 90%

  MDC = SD

  diff

   x z Or

   MDC = SEM x √2 x z

  ◦ SEM x √2 = SD diff

  ◦

  z Indicates level of confidence

  (z=1.65) or 95% (z=2.0) confidence

  measurement period

  ◦ Nomenclature: MDC 90 z scores

  

  Interpreting MDC

  ◦ Based on change in unchanged people ◦ If our patient exceeds the MDC

  90

   value, we can be 90% certain that this change represents real change and not noise or error

  3 ^rd Berg 46

  

  ◦ Patients’ true values do not change from over

  3 ^rd Berg 50

  MDC

  1 ^st Berg 48

  2 ^nd Berg 45

  3 ^rd Berg 48

  1 ^st Berg 47

  2 ^nd Berg 49

  3 ^rd Berg 52

  Thanks to P. Levangie and D. Gross for image idea 

  

  Normal distribution of difference scores reflecting only random error

  Smallest amount of change that can be considered above measurement error

  

  Or the smallest amount of change that is REAL change

  

  Quantifies the variability of responses in truly unchanged patients

  

  Assumes

  2 ^nd Berg 45

  ◦

  

  MDC

   90 = SEM x √2 x 1.65 Beyond the threshold of measurement error is

  the threshold for important change

   

  MDC of BBS in people with Chronic Stroke: Commonly known as MCID

  90 

  Flansbjer 2012

  ◦ SEM = 1.40

  MDC = 3.27

  ◦

  90

• Hiengkaew 2012

  ◦ SEM = 1.73 ◦ MDC = 4.04

90 Distribution-based methods

• o

  Definition: “the smallest difference in score

  in the domain of interest which patient Effect size

  o

  perceive as beneficial and which would ES= M1-M2 mandate, in the absence of troublesome SD

  baseline

  side effects and excessive cost, a change in

  o Standardized response mean

  Jaeschke, et al, Control Clin patient’s management” o

  Trials1989;10:407-15 SRM = M1-M2 OR

  SD diff

  “The smallest difference in a score that is (Hayes and considered worthwhile or important” Woolley, Pharmacoeconomics 2000;18:419-23)

   7: A very great deal better

  15 Point Global 6: A great deal better

  Rating of 5: A good deal better

  ID 4: Moderately better C

  Change Scale

  Important? Who says so?

  ‣ M

   3: Somewhat better (GROC) ( Jaeschke,1989)

  Anchor-based methods

  ‣ 2: A little better

  ID

  External anchor used to define C

   1: About the same, hardly any better at all ‣

   M

  clinical importance 0: No change

  O o

  Achievement of goal, discharge home N

  −1: About the same, hardly any worse at all

  etc

  −2: A little worse o

  Direct survey

  −3: Somewhat worse o

  Global Rating of Change Scale (GROC) −4: Moderately worse often used

  −5: A good deal worse −6: A great deal worse −7: A very great deal worse

  

  People categorized as having achieved MCID or No MCID

   MCID of FIM 

  Identify change score on outcome measure

   n = 113

  that best categorizes people as achieving

  

  Used GROC +3 as MCID or No MCID

  MCID indicator

  

  Apply diagnostic Test Methods

  

  Cutoff score from

  ◦ Sensitivity

  ROC curve = 22

  ◦ Specificity  AUC = .85

  ◦ Positive and Negative Predictive Values ◦ Likelihood ratios Derived from Beninato et al., Arch Phys Med Rehabil. 2006;87:32-9

  MCID based on MCID based on the GROC the GROC

  <3 ≥3

  <3 ≥3 a b

  ≥ Positive Predictive Value a+b

  Positive Predictive Value

  score TP FP

  77

  3

  80 Change FIM ≥22

  a/a+b 77/80 = .96

  Score Change

  < c d

  Negative Predictive Value

  c+d

  Negative Predictive Value

  Score <22

  23

  10

  33 score FN TN

  d/c+d 10/33 = .30

  a+c b+d a+b+c+d 100 13 113

  Sensitivity (SN) a/a+c Sensitivity (SN) 77/100 = .77

  Specificity (SP) d/b+d Specificity (SP) 10/13 = .77

  Likelihood ratios

• +LR = SN/1-SP = .77/.33 = 2.33
• +LR = SN/1-SP
• -LR = 1-SN/SP = .33/.77 = .43
• -LR = 1-SN/SP

    The SEM is a estimate of error that takes into

  If my patient achieves a change score greater

  account variability in a stable group of patients

  than the MCID, then that change reflects

   The MDC and MCID are useful and informative

  important change

  threshold values for interpreting patient change  Need to be aware of the anchor that was used scores

   Important? Who says so?  MDC is an indication of achieving real change 

  Does my patient share characteristics with the

  (beyond measurement error)

  study sample

  MCID tells us that important change has taken  place Use of diagnostic test statistics tell us how

   accurate these estimates are.

  

30 Items across 3 domains

  ◦ 3: independent, grossly normal pattern without assistive device

  C: full movement withmarked deviation ◦ 2: able to complete movement comparable to unaffected side

   Mobility (Activity) ◦ 0: unable to perform ◦ 1:

  

  A: requires partial assistance with deviation 

  B: requires partial assistance grossly normal 

  ◦ 2: independent, grossly normal pattern with assistive device

   How do I interpret the score, what are norms for this time frame/time in the continuum of care?

  A: part of movement marked deviation 

   How much change necessary to be reasonably confident that my patient really changed?

   Important change?

   Predictive ability?

  Mean (SD) STREAM Total 75 (26.7) LE subscale 73 (33.3) UE subscale 75 (28.9) Mobility subscale 74 (25.9) Gait speed (m/s) 0.55 (0.38)

  Our patient: Total: 70 UE subscale: 68 LE subscale: 70 Mobility: 69

  Ahmed et al. Phys Ther. 2003; 83:617-630.

  B: part of movement comparable to unaffected 

  1: 

  66 y/o male: JR

  

   Acute care hospital 

  In patient rehabilitation hospital

  

  Out patient rehabilitation center

  

  Chronic

  Stroke Rehabilitation Assessment of Movement (STREAM)

  0: unable to perform ◦

  ◦ Our patient’s score

  

  Total: 70

   UE subscale: 68  LE subscale: 70 

  Mobility: 69

  

   UE and LE: (Body Structure/Function) ◦

C: Independently but abnormal movement pattern

  

  MCID?

  

  Our patient: Total:

   Hsueh et al.

70 MDC

  ◦ UE subscale: 14  UE subscale: 68

  ◦ LE subscale: 12.6 Need to increase to

  ◦ ◦

  82 

  LE subscale: 70

  Need to increase to ◦

  83 

  Mobility: 69

  Hsueh et al. Neurorehabil Neural Repair. 2008; 22:737-744.

   

  63 individuals a 8 days post stroke mean of 8 (SD=3)  Average LOS: 18 days post stroke days

  

  Initial scores of

   JR’s: Outcome

  subjects <63 Measures

   JR: initial total Berg Balance Scale ◦

   30/56

  STREAM: 70

  Fugl Meyer ◦

  

  ~20% probability he

  

  UE: 35/66 will be discharged

   LE: 18/34 home.

  Ahmed et al. PHYS THER.

  Dobrez D, et al. Am J Phys 2003; 83:617-630.

  Med Rehabil. 2010;89:198-204  How do I interpret the score, what are Days post BBS Score N

  Stroke norms for this time frame/time in the

  Mao et al. 14 days post 22.3 (22.2) 123 continuum of care?

  Stroke.2002; stroke 

  How much change necessary to be 33:1022- reasonably confident that my patient

  1027 really changed?

  9.2 (6.8) 19.6 (16.6)

  55 O’Dell et al. P M&R. days post Range: 0-

   Important change?

  2013;5:392- stroke

  54 

  Predictive ability? 399

  Our patient: 30/56

  

  31

  Time post stroke N Baseline score

  MDC

  Sanford et al 56 days

  12

  95

  =10.0

  95

  =8.9 Wagner et al

  14 months

  13

  35 UE: MDC

  95

  : 5.2 See et al

  54 months

  31 UE: MDC

  Stevensen et al

  90

  : 3.2 Sanford et al. Phys Ther. 1993;73:447-454.

  Wagner et al. Phys Ther. 2008;88:652-663. See et al. Neurorehabil Neural Rep. 2013.

  Our Patient: UE: 35/66 LE: 18/34

  Time post stroke MCID Anchor Accuracy Shelton et al 2001

  17 days 10 point =1.5 D/C FIM self care 10 point=1.9 point D/C FIM mobility

  FIM Self Care FIM Mobility Page et al 2012 UE motor 60 months MCID: 4.25-7.5

  Therapists’ perception of different UE movements/fu nction AUC: 0.61-0.70

  Sens: 0.53-

  0.64 Spec: 0.61-

  0.83 Arya et al 2011 UE motor 8.5 weeks MCID: 9-10 Patient GROC mRankin AUC: 0.84-0.98

  Sens: 0.80-

  0.97 Spec: 0.70-

  0.89

  Duncan et al. Stroke. 1992;23:1084-1089.

  Our patient: UE: 35/66 LE: 18/34 Total=53

  ◦ Mild: >80

  ◦ Moderate: 56-79

  ◦ 30.3 (23.3) days post stroke ◦ All subjects: 43.0 ◦ Assist: 35.5

  

  MDC

  90

  : 5.8

  ◦ Independent: 5.3, Standby: 5.0, Assist: 6.8

   MDC

  95

  : 6.9

  ◦ Independent: 6.3, Standby: 6.0, Assist: 8.1

  Stevensen et al. Aust J Physiother. 2001;47:29-38.

  Our Patient: 30/56 Need to improve >=39 to be 95% confident a real change occurred.

  

  MCID?

  

  Wee et al

  ◦ 313 subjects

  ◦ Mod severe: 36-55

  ◦ Severe: 0-35

  Stratified

  

  stroke

   57.1 (33.4)  Within 24 hours of

  ◦ Initial total motor:

  ◦ 105 subjects

  Duncan et al

  

  Wee et al. Arch Phys Med Rehabil. 2003;84:731-735. Our patient: admission score: 30 ~65% D/C home Family support: ~95% D/C home

  ◦ Admit BBS: 21

  ◦ 37 (22) days post stroke

FM MCID: JR: UE: 35/66, LE: 18/34

41 UE: MDC

LE: MDC

• 0.10 to 0.12 m/s Flansbjer et al 2005 16 months 0.89 m/s 1

  Our patient: 0.56 m/s Fulk et al. J Neurol Phys Ther. 2011;35:82-89.

  Time post stroke Mean GS MDC Stephenson et al 1999

  112 days 0.80 m/s 95% CI of change:

  st session 0.94 m/s 2 nd session Smallest Real

  Difference: -0.15 to 0.25 m/s Fulk et al 2008 35 days post stroke 0.45 m/s 1 st session 0.54 m/s 2 nd session MDC

  90 : All: 0.30 m/s

  Assistance: 0.07 m/s Used AD: 0.18 m/s

  Stephens et al. Clin Rehabil. 1999;13:171-181 Flansbjer et al. J Rehabil Med. 2005;37:75-82. Fulk et al. J Neurol Phys Ther. 2008;32:8-13.

  Our patient: 0.56 m/s Important Change in Gait Speed?

  Time post stroke Initial Gait Speed MCID Anchor Accuracy Fulk et al 2011

  56 to 139 days post stroke 0.56 (0.22) m/s

  0.17 m/s 0.19 m/s Patient GROC Therapist GROC Patient:

  AUC: 0.80 Sens/Spec: 0.73/0.73 Therapist: AUC: 0.58 Sens/Spec: 0.62/0.50 Tilson et al 2010 20 to 60 days post stroke

  0.18 (0.16) m/s 0.16 m/s 1 point improvement on the mRankin

  AUC: 0.69 Sens/Spec: 0.74/0.57

  Tilson et al. Phys Ther. 2010:90.

  Bohannon 1997 Tilson et al. Phys Ther. 2010 90:196 –208.

   5 point likert scale ◦

  1 could not do it at all ◦

  2 very difficult ◦

  3 somewhat difficult ◦

  4 a little difficult ◦

  5 not difficult at all  SIS-16  Stroke Impact

  Scale-8 domains

  ◦ Strength

  ◦ Hand Function

  ◦ Mobility

  ◦ ADLs

  ◦ Emotion

  ◦ Memory

  ◦ Communication

  Our patient: 0.56 m/s How much change in gait speed needs to occur to be confident that it is real?

   Mean: 0.39 (0.22) m/s

   3 months post stroke

  ◦

  ◦ Subacute stage of

  recovery

   Gait Speed ◦ 0.56 m/s

   Stroke Impact Scale (SIS)

  ◦

  65: total

  ◦ Strength: 65 ◦

  Hand Function: 54

  ◦

  Mobility: 68

  ◦

  ADLs: 68

  ◦

  Emotion: 68

  Memory: 75

  post stroke

   Important change?  Normative data with healthy individuals (M/F):

  Tilson et al ◦ 283 subjects, 60 days

  ◦ 60s: 1.36 / 1.30 ◦ 70s: 1.33 / 1.27 

  50s: 1.39 / 1.40

  ◦

  40s: 1.46 / 1.39

  ◦ 20s: 1.39 / 1.41 ◦ 30s: 1.46 / 1.42 ◦

   How much change necessary to be reasonably confident that my patient really changed?

  ◦

   How do I interpret the score, what are norms for this time frame/time in the continuum of care?

  SIS 16: 62

  ◦

  Social Participation: 52

  ◦

  Communication: 45

  ◦ Social Participation

  Duncan et al Huang et al 18 Our Patient 90-120 days months post post stokre stroke

  Total 65 

  Our Patient

   Chronic, 17.7 Strength 61.9 (22.0) 40.73 (20.0)

  65 Strength: 65 ◦

  months post stroke

  Memory 77.8 (19.1) 81.5 (19.2)

  75 ADLs: 68 ◦

  Strength = 24.0 ◦

  Emotion 74.3 (18.1) 59.6 (17.2)

  68 Mobility: 68 ◦

  ADL/IADL = 17.3 ◦

  Communication 81.0 (19.1) 89.7 (16.9)

  45 Hand Function: 54 ◦

  Mobility = 15.1 ◦

  ADL 66.5 (23.2) 67.4 (20.1)

  68 Hand function = 25.9 Mobility 60.2 (23.1) 79.2 (18.1) 68 ◦ Hand Function 55.9 (34.5) 29.6 (25.4)

  54 Social 58.9 (25.7) 47.9 (25.1)

  52 SIS-16 67.5 (21.2) 62.0 (12.3)

  62 Duncan et al. Stroke. 2002;33:2593- 2599.

  Lin et al. Neurorehabil Neural Rep. Huang et al. Neurorehabil Neural 2010;24:486-492.

  Repair.2010;24:559-566 MDC MDC MCID Acute/ MCID Acute/ Chronic Subacute Chronic Subacute

  STREAM Time post MCID Anchor Accuracy

  Total stroke

  STREAM

  14 Fulk et al 2 months

  9.4 Patient GROC Patient: AUC:

  UE

  SIS-16

  14.1 Therapist GROC

  0.72 STREAM

  13 Sens/Spec: LE

  0.81/0.63

  STREAM

  Therapist:

  Mobility

  AUC: 0.65

  Berg

  7 Sens/Spec:

  0.76/0.57 F-M total Lin et al 17.5 Strength: 9.2 Mean score of N/A F-M UE

  10 3-5 9-10 5-8

  months ADL: 5.9 subjects that

F-M LE

  9 Mobility: 4.5 reported 10-15% Gait 0.30 m/s 0.25 m/s 0.16 to 0.17

  Hand: 17.8  on overall

  Speed 0.12 m/s

  change

  SIS-16

  10 Fulk et al. Top Stroke Rehabil. 2010;17:477-483.

  Lin et al. Neurorehabil Neural Rep. 2010. 24:486-492 

  MCID depends on Anchor used

  

  What if there is no value for MDC or MCID for

  Motor FIM using GROC ratings MCID = 17 ◦

  my patient?

  points (Beninato et al 2006)

  Cautiously interpret the values available

  ◦ Motor FIM using change in mRS = 11 points

  ◦ (Wallace et al 2002)

  

  SEM and MDC depend on reliability

  

◦ Only scores are reliable, not outcome instruments Anchor should be closely related to construct

◦ Reliability is not transferable being measured

  MDC derived from research studies with strict Gait Speed by GROC survey

   ◦

   .175 m/sec SN .81, SP .81(Fulk et al 2012)

  methodology

  ◦ Gait speed by change in mRS ◦ Establish for your own practice group 

  .16 m/sec SN .74 SP .57 (Tilson et al) Riddle and Stratford. Is This Change Real, 2013, F.A Davis

  Beninato et al . Arch Phys Med Rehabil. 2006;87:32-9 Revicki D, et al.. J Clin Epidemiol. 2008; 61:102-109

  Wallace et al. J Clin Epidemiol. 2002;55:922-928 Wells G, et al. J Rheumatol. 2001; 28:406-412

  Tilson et al. Phys Ther. 2010; 90(2):196-208 Fulk et al JNPT 2011; 35:82-89

   

  Baseline scores Use of Diagnostic Test Methods to determine

  ◦ Lower baseline requires more change to achieve MDC

  MCID

  ◦ Additional information on accuracy of estimates

  Example (Beninato et al 2006)

  ◦ ◦ Little research available on this

   Admission FIM scores10-40 required 27 point change Gold Standard of

   Admission FIM scores 41-60 required 23 point change Change

  Yes No 

  Whether considering improvement versus

  a b ≥ a+b

  decline

  score TP FP Change Score

  < c d c+d score FN TN

  Beninato et al . Arch Phys Med Rehabil. 2006;87:32-9 a+c b+d a+b+c+d

  Wang et al. Phys Ther. 2011; 91:675-688 Beninato M, Portney LG, JNPT, 2011;35:75-81 Riddle and Stratford. Is This Change Real, 2013, F.A Davis

   MCID estimates needed for more outcome 

  Stroke Edge Resources

  measures

  ◦ ◦ Only 6 of 24 recommended by EDGE task force

  have established MCID scores

   

  MCID estimates for OMs at different 

  stages of recovery

  ◦

  severity levels 

  ◦

  Internet Stroke Center settings

  ◦

  ◦

  different anchors

  ◦

   MCID using different anchors

  ◦ Any one value of MCID is an estimate ◦ Need to consider different perspectives