A Multidimensional Rasch Analysis of the Functional Independence Measure Based on the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database.

A number of studies have evaluated the psychometric properties of the Functional Independence Measure (FIM™) using Rasch analysis, although none has done so using the National Institute on Disability, Independent Living, and Rehabilitation Research Traumatic Brain Injury Model Systems National Database, a longitudinal database that captures demographic and outcome information on persons with moderate to severe traumatic brain injury across the United States. In the current study, we examine the psychometric properties of the FIM as represented by persons within this database and demonstrate that the FIM comprises three subscales representing cognitive, self-care, and mobility domains. These subscales were analyzed simultaneously using a multivariate Rasch model in combination with a time dependent concurrent calibration scheme with the goal of creating a raw score-to-logit transformation that can be used to improve the accuracy of parametric statistical analyses. The bowel and bladder function items were removed because of misfit with the motor and cognitive items. Some motor items exhibited step disorder, which was addressed by collapsing Categories 1-3 for Toileting, Stairs, Locomotion, Tub/Shower Transfers; Categories 1 and 2 for Toilet and Bed Transfers; and Categories 2 and 3 for Grooming. The strong correlations (r = 0.82-0.96) among the three subscales suggest they should be modeled together. Coefficient alpha of 0.98 indicates high internal consistency. Keyform maps are provided to enhance clinical interpretation and application of study results.

New English and Spanish social health measures will facilitate evaluating health determinants.

OBJECTIVE: To develop psychometrically sound, culturally relevant, and linguistically equivalent English and Spanish self-report measures of social health guided by a comprehensive conceptual model and applicable across chronic illnesses. METHODS: The Patient-Reported Outcomes Measurement Information System (PROMIS) Social Health Workgroup implemented a mixed methods approach to evaluate earlier results (v1.0); expand and refine domain definitions and items; translate items into Spanish; and obtain qualitative feedback. Computer-based and paper/pencil questionnaire administration was conducted with a variety of U.S. respondent samples during 2009-2012. Analyses included exploratory factor analysis (EFA), confirmatory factor analysis (CFA), two-parameter logistic item response theory (IRT) modeling, evaluation of differential item functioning (DIF), and evaluation of criterion and construct validity. RESULTS: Qualitative feedback supported the conceptualization of the Social Health domain framework (Social Function and Social Relationships subcomponents). Validation testing participants (n = 2,208 English; n = 644 Spanish) were diverse in terms of gender, age, education, and ethnicity/race. EFA, CFA, and IRT identified 7 unidimensional factors with good model fit. There was no DIF by language, and good evidence of criterion and construct validity. CONCLUSIONS: PROMIS English and Spanish language instruments (v2.0), including computer-adaptive tests and fixed-length short forms, are publicly available for assessment of Social Function (Ability to Participate in Social Roles and Activities, and Satisfaction with Social Roles and Activities) and Social Relationships (Companionship; Emotional, Informational and Instrumental Support; and Social Isolation). Measures of social health will play a key role in applications that use ecologic (or determinants of health) models that emphasize how patients' social environments influence their health.

Ensuring comprehensive assessment of urinary problems in prostate cancer through patient-physician concordance.

OBJECTIVES: To examine the concordance between clinicians and men diagnosed with prostate cancer on a clinician-derived pathophysiological classification of the following self-reported urinary complications: storage (irritative), voiding (obstructive), and leakage/incontinence. MATERIALS AND METHODS: Fourteen urology experts classified 37 urinary function questionnaire items into 3 primary conceptual dimensions (e.g., storage [irritative], voiding [obstructive] and urinary leakage/incontinence) that would best reflect each item's content. In addition, 218 patient participants provided responses to the 37 items. Using classifications by experts to develop the conceptual framework, the structure was tested using confirmatory factor analyses with patient data. RESULTS: Expert consensus was achieved in the classification of 31 out of 37 items. Using the 3-factor conceptual framework and patient data, the fit indices for the overall correlated factor model suggested an acceptable overall model fit. The analyses of the separate domains showed acceptable fit for the storage/irritative domain and the leaking/incontinence domain. The dimensionality of the voiding/obstructive domain was too difficult to estimate. CONCLUSIONS: Our analysis found items that conceptually and psychometrically support 2 constructs (leaking/incontinence and storage/irritative). The consistency of this support between the groups suggests a clinical relevance that is useful in treating patients. We have conceptual support for a third hypothesis (voiding/obstructive), although there were too few items to assess this psychometrically. Relative motivating factors of bother and urinary complaints were not addressed and remain an unmet need in this field.

Self-scoring templates for motor and cognitive subscales of the FIM instrument for persons with spinal cord injury.

OBJECTIVE: To provide self-scoring templates for the FIM instrument's motor and cognitive scales that enable clinicians to monitor progress during rehabilitation using equal-interval Rasch-calibrated measures instead of ordinal raw scores. DESIGN: Secondary analysis of a prospective, observational cohort study. SETTING: Six geographically dispersed hospital-based rehabilitation centers in the United States. PARTICIPANTS: Subset of consecutively enrolled individuals with new traumatic spinal cord injuries discharged from participating rehabilitation centers (N=1146). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Subscores of the FIM instrument, including a 13-item motor scale, a 5-item cognitive scale, an 11-item (without sphincter control items) motor scale, a 3-item transfer scale, a 6-item self-care scale, a 3-item self-care upper extremity scale, and a 3-item self-care lower extremity scale. RESULTS: KeyForms for the FIM instrument scales allow clinicians and investigators to estimate patients' functional status and monitor progress. In cases with no missing data, the look-up tables provide more accurate estimates of patients' functional status. CONCLUSION: Clinicians can use KeyForms and look-up tables for FIM instrument subscales to monitor patients' progress and communicate improvement in equal-interval units.

Measuring enfranchisement: importance of and control over participation by people with disabilities.

OBJECTIVE: To evaluate the psychometric properties and validity of an expanded set of community enfranchisement items that are suitable for computer adaptive testing. DESIGN: Survey. SETTING: Community setting. PARTICIPANTS: Individuals with disabilities (N=1163) were recruited from an online panel generation company (51%), former rehabilitation inpatients (18%), disability community organizations (13%), a registry of rehabilitation patients (10%), and Traumatic Brain Injury and Spinal Cord Injury Model System facilities (8%). Inclusion criteria were a self-identified disability, aged ≥18 years, and the ability to read and speak English. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Community enfranchisement. RESULTS: Exploratory and confirmatory factor analyses of the 48 enfranchisement items suggested 2 distinct subsets of items: (1) importance of participation and (2) control over participation. Principal components analysis of the residuals suggested that the 2 item sets are unidimensional. Rating scale analysis provided evidence that the 2 item sets fit the Rasch model. Importance and control were moderately correlated with each other and with disability severity. CONCLUSIONS: Importance of participation and control over participation define 2 distinct sets of participation enfranchisement. Preliminary evidence supports their validity.

Emotion assessment using the NIH Toolbox.

One of the goals of the NIH Toolbox for Assessment of Neurological and Behavioral Function was to identify or develop brief measures of emotion for use in prospective epidemiologic and clinical research. Emotional health has significant links to physical health and exerts a powerful effect on perceptions of life quality. Based on an extensive literature review and expert input, the Emotion team identified 4 central subdomains: Negative Affect, Psychological Well-Being, Stress and Self-Efficacy, and Social Relationships. A subsequent psychometric review identified several existing self-report and proxy measures of these subdomains with measurement characteristics that met the NIH Toolbox criteria. In cases where adequate measures did not exist, robust item banks were developed to assess concepts of interest. A population-weighted sample was recruited by an online survey panel to provide initial item calibration and measure validation data. Participants aged 8 to 85 years completed self-report measures whereas parents/guardians responded for children aged 3 to 12 years. Data were analyzed using a combination of classic test theory and item response theory methods, yielding efficient measures of emotional health concepts. An overview of the development of the NIH Toolbox Emotion battery is presented along with preliminary results. Norming activities led to further refinement of the battery, thus enhancing the robustness of emotional health measurement for researchers using the NIH Toolbox.

Developing an emotional distress item bank for cancer patients.

Emotional distress is common among cancer patients during and after treatment. Many instruments have been used to measure emotional distress; however, none of them has emerged as a standard. Although the diversity of instruments has some merit, the lack of a common measure limits our ability to compare studies. This paper describes how we constructed a 46-item emotional distress bank. Using expert judgment, we selected a pool of items with emotional content from this six-instrument set. Rasch rating scale analysis helped us identify a set of general distress items with good model fit and a measurement gap causing floor effects. Additional items were written to augment the measure where found deficient. The resulting set of items reflects a spectrum of positive and negative affect. The measure demonstrated excellent reliability (person separation reliability = .96) and a wide range of emotional distress and was able to distinguish among levels of disease severity.

The symptom inventory disability-specific short forms for multiple sclerosis: construct validity, responsiveness, and interpretation.

OBJECTIVES: To test the cross-sectional and longitudinal construct validity of the disability-specific short forms of the Symptom Inventory for multiple sclerosis, to compare its internal consistency reliability and construct validity with those of the original (1999) 29-item short form of the Symptom Inventory, and to provide for the new disability-specific short forms interpretation metrics for use in sample size calculation for future research. DESIGN: A Web-based longitudinal study, with data collected at baseline and 6 months after baseline. Correlations evaluated the overlap among disease-specific and generic patient-reported outcome measures. Responsiveness was assessed by using symptom transition scores and modified standardized response means. Interpretation guidelines were provided by using Cohen's effect size and crosswalks to the disease-specific and generic quality-of-life measures. SETTING: National Multiple Sclerosis Registry. PARTICIPANTS: People with multiple sclerosis (N=1142) who participated in the North American Research Committee on Multiple Sclerosis Registry. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Symptom Inventory; the disease-specific Performance Scales and the Patient-Determined Disease Steps; the generic Short Form 12. RESULTS: The Symptom Inventory evidenced convergent and divergent validity, and the disability-specific short forms evidenced similar psychometric performance as the 1999 short form but had slightly better alpha reliability. They also evidenced moderate responsiveness to clinically important change, with more responsiveness among those with mild and moderate disabilities than among those with severe disabilities. Effect sizes were larger among patients who reported symptom improvement, rather than deterioration, suggesting that the tool would be more useful in clinical research focused on testing whether an intervention improves symptom experience, particularly for patients with mild and moderate disabilities. Crosswalks provided graphic and numeric links between the Symptom Inventory and other patient-reported outcomes. CONCLUSIONS: The Symptom Inventory can be useful for elucidating the patient's experience, but it varies considerably across and within disability groupings. Directions for future research are discussed.

Development of a measure of skin care belief scales for persons with spinal cord injury.

OBJECTIVES: To develop and validate a measure of skin care beliefs and to describe the skin care behaviors of persons with spinal cord injury (SCI). DESIGN: A mixed-methods design was used to develop the Skin Care Beliefs Scales (SCBS). The health belief model framed the hypotheses. Phase 1 included item development, content validity testing, and pilot testing. Phase 2 included testing the scale structure (principal components analysis), internal consistency reliability, test-retest reliability, and relationships between the belief scales and care behaviors. SETTING: Two acute rehabilitation hospitals and Internet websites. PARTICIPANTS: Patients with SCI (N=462; qualitative/pilot n=56; psychometric study n=406) participated. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The pilot and phase 2 studies, respectively, used 146-item and 114-item versions of the SCBS. A skin care activity log was used to record skin care behaviors. RESULTS: Content validity indicated that the items were relevant and clear. The analysis resulted in 11 independent scales reflecting 3 general beliefs (susceptibility, severity, self-efficacy) and barrier and benefit behavior-specific scales for skin checks, wheelchair pressure reliefs, and turning and sitting times. With the exception of skin check barriers (α=.65), Cronbach alphas of the scale ranged from .74 to .94. Test-retest intraclass correlations were fair to excellent (range, .42-.75). Construct validity was supported. Hierarchical linear regression indicated that turning benefits, barriers, susceptibility, and self-efficacy were significant predictors of turning time. Benefits or barriers were correlated significantly with skin check and pressure relief adherence (ρ range, -.17 to -.33). Self-efficacy was correlated with wheelchair pressure relief (ρ=.18). Skin care behavior adherence varied widely (eg, 0%-100%). CONCLUSIONS: The scales showed acceptable reliability and validity. Further testing with larger samples is desirable.

The symptom inventory disability-specific short forms for multiple sclerosis: reliability and factor structure.

OBJECTIVE: To further the development of the 99-item Symptom Inventory (SI) for multiple sclerosis (MS) using modern test theory methods to create 3 disability-specific short forms for MS patient subgroups identified using Performance Scale (PS) items. DESIGN: A web-based cross-sectional study. SETTING: National MS Registry. PARTICIPANTS: People with MS (N=1532) who participate in the North American Research Committee on Multiple Sclerosis Registry. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The SI; the disease-specific PS and the Patient-Determined Disease Steps; and the generic Short-Form 12. RESULTS: When the original SI subscales did not demonstrate unidimensionality, exploratory factor analysis was conducted yielding 14 factors that could be classified using the structure of the PS. Confirmatory factor analysis confirmed the unidimensionality of the hand function, vision, fatigue, cognitive, bowel/bladder, spasticity, and pain scales. The mobility scale was split into mobility and use of assistive devices; the sensory scale was split into sensory and vasomotor. Item response theory analyses revealed good model fit. CONCLUSIONS: This study provides empirical support for a 10-scale symptom measure for use in MS clinical research, with short forms in 5 scales tailored to have good specificity for people with mild, moderate, and severe disability and single forms for the remaining 5 scales. The PS items can serve as a screener for these disability-specific short forms, which provide choice and flexibility that are similar to a computerized adaptive test but without the reliance on real-time computer infrastructure.

Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention study.

OBJECTIVES: : To assess the efficacy of acupuncture in treating insomnia in traumatic brain injury (TBI) survivors as compared to medication, to determine whether acupuncture has fewer cognitive and affective adverse effects than does medication. PARTICIPANTS: : Twenty-four adult TBI survivors, randomized to acupuncture or control arms. SETTING: : Outpatient rehabilitation clinic. MEASURES: : Insomnia Severity Index (degree of insomnia); actigraphy (sleep time); Hamilton Depression Rating Scale (depression); Repeatable Battery for the Assessment of Neuropsychological Status and Paced Auditory Serial Addition Test (cognitive function) administered at baseline and postintervention. RESULTS: : Sleep time did not differ between the treatment and control groups after intervention, whereas cognition improved in the former but not the latter. CONCLUSION: : Acupuncture has a beneficial effect on perception of sleep or sleep quality and on cognition in our small sample of patients with TBI. Further studies of this treatment modality are warranted to validate these findings and to explore factors that contribute to treatment efficacy.

Factors influencing therapists' decision-making in the acceptance of new technology devices in stroke rehabilitation.

OBJECTIVE: The aims of this study were to identify factors or barriers in therapists' decisions to acquire and use new technology devices (NTDs) and to examine rating differences across therapy disciplines. DESIGN: Literature review, key informant interviews, and focus group sessions were conducted to define a conceptual framework of acceptance/resistance of NTDs and to develop survey items. The survey was subsequently mailed to therapists. RESULTS: The survey responses showed that billability of services, having a sufficient caseload using a device, and initial cost were the most important factors in acquisition decisions; that patient acceptance, suitability for the setting, and logistics were the most important factors in use decisions; and that negative patient outcomes, problems with reimbursement, and perceived lack of patient interest were the most significant barriers to their use. Patient safety, motivation, and cognition were the most important patient considerations in the therapist's decision to use NTDs with a particular patient, whereas lack of progress, unavailability of the participants post discharge, and requiring too much patient effort were the most significant barriers to the use of NTDs with particular patients. Some rating variations existed across disciplines. CONCLUSIONS: This study confirmed that rehabilitation therapists consider clinical and practical factors, as well as the match between the patient and the device, when making acquisition and use decisions of NTDs. Research and education implications were discussed.

Development and validation of participation and positive psychologic function measures for stroke survivors.

OBJECTIVE: To evaluate the reliability and validity of Neurologic Quality of Life (NeuroQOL) item banks that assess quality-of-life (QOL) domains not typically included in poststroke measures. DESIGN: Secondary analysis of item responses to selected NeuroQOL domains. SETTING: Community. PARTICIPANTS: Community-dwelling stroke survivors (n=111) who were at least 12 months poststroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Five measures developed for 3 NeuroQoL domains: ability to participate in social activities, satisfaction with participation in social activities, and positive psychologic function. RESULTS: A single bank was developed for the positive psychologic function domain, but 2 banks each were developed for the ability-to-participate and satisfaction-with-participation domains. The resulting item banks showed good psychometric properties and external construct validity with correlations with the legacy instruments, ranging from .53 to .71. Using these measures, stroke survivors in this sample reported an overall high level of QOL. CONCLUSIONS: The NeuroQoL-derived measures are promising and valid methods for assessing aspects of QOL not typically measured in this population.

Measuring participation: the Patient-Reported Outcomes Measurement Information System experience.

OBJECTIVES: To describe the lessons learned in the initial development of Patient-Reported Outcomes Measurement Information System social function item banks. DESIGN: Development and testing of 2 item pools within a general population to create item banks that measure ability to participate and satisfaction with participation in social activities. SETTING: Administration via the Internet. PARTICIPANTS: General population members (N=956) of a national polling organization registry participated; data for 768 and 778 participants were used in the analysis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Measures of ability to participate and satisfaction with participation in social activities. RESULTS: Fifty-six items measuring the ability to participate were essentially unidimensional but did not fit an item response theory model. As a result, item banks were not developed for these items. Of the 56 items measuring satisfaction with participation, 14 items measuring social roles and 12 items measuring discretionary activities were unidimensional and met item response theory model assumptions. Two 7-item short forms were also developed. CONCLUSIONS: Four lessons, mostly concerning item content, were learned in the development of banks measuring social function. These lessons led to item revisions that are being tested in subsequent studies.

Measuring social health in the patient-reported outcomes measurement information system (PROMIS): item bank development and testing.

PURPOSE: To develop a social health measurement framework, to test items in diverse populations and to develop item response theory (IRT) item banks. METHODS: A literature review guided framework development of Social Function and Social Relationships sub-domains. Items were revised based on patient feedback, and Social Function items were field-tested. Analyses included exploratory factor analysis (EFA), confirmatory factor analysis (CFA), two-parameter IRT modeling and evaluation of differential item functioning (DIF). RESULTS: The analytic sample included 956 general population respondents who answered 56 Ability to Participate and 56 Satisfaction with Participation items. EFA and CFA identified three Ability to Participate sub-domains. However, because of positive and negative wording, and content redundancy, many items did not fit the IRT model, so item banks do not yet exist. EFA, CFA and IRT identified two preliminary Satisfaction item banks. One item exhibited trivial age DIF. CONCLUSION: After extensive item preparation and review, EFA-, CFA- and IRT-guided item banks help provide increased measurement precision and flexibility. Two Satisfaction short forms are available for use in research and clinical practice. This initial validation study resulted in revised item pools that are currently undergoing testing in new clinical samples and populations.

Psychometric validation of the Manual Ability Measure-36 (MAM-36) in patients with neurologic and musculoskeletal disorders.

OBJECTIVES: To evaluate the psychometric properties of the Manual Ability Measure-36 (MAM-36), a new hand function outcome measure, and to examine differences in manual abilities and item parameters in patients with neurologic and musculoskeletal conditions. DESIGN: Convenience sample from 2 time periods, cross-sectional. SETTING: Outpatient rehabilitation units and private hand clinics. PARTICIPANTS: Patients (N=337; mean age, 50.3+/-14.9y) with a variety of neurologic and musculoskeletal (orthopedic) diagnoses. Most of these individuals were community dwelling, and all had residual functional limitations in the hand(s). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Rasch analysis was performed on MAM-36 data to evaluate both scale structure and psychometric properties, which include rating distribution, step measures, item fit, separation, and dimensionality. A t test was performed to examine the differences in manual abilities in patients with the 2 conditions. Uniform differential item functioning (DIF) between neurologic and musculoskeletal groups was examined. (DIF occurs when subgroup members within the sample with the same level of the underlying trait being measured respond differently to an individual item.) Manual ability estimates were recalibrated with step and common item anchoring; they were compared with those derived from the original analysis. RESULTS: The 36 items measured a single construct with no misfitting items. The scale was used as intended. The items can reliably separate the participants into 5 ability strata. Neurologic patients had a significantly lower mean manual ability than musculoskeletal patients. Fourteen items exhibited DIF. However, DIF had no effect on either scale quality or calibration of manual ability. We decided that a single rating scale is appropriate for both groups. CONCLUSIONS: This study showed that the MAM-36 has more than adequate psychometric properties and can be used as a generic outcome measure for patients with a wide variety of clinical diagnoses.

Improving measurement properties of the Patient Health Questionnaire-9 with rating scale analysis.

OBJECTIVE: The goal of this study was to explore the psychometric properties of the Patient Health Questionnaire-9 (PHQ-9; R. L. Spitzer, K. Kroenke, & J. B. W. Williams, 1999). METHOD: Factor analysis and Rasch rating scale analysis were used to examine the psychometric properties of the PHQ-9. The sample consisted of 202 adults with spinal cord injury (SCI). RESULTS: The PHQ-9 items appear to form a usefully unidimensional scale. One "double-barreled" item, "Moving or speaking so slowly that other people could have noticed or being so fidgety or restless that you've been moving around a lot more than usual," misfit the Rasch model. Category probability curves indicate respondent difficulty in distinguishing between the 2 intermediate rating scale categories: several days and more than half the days. Combining these categories eliminated this problem and resulted in all items fitting the measurement model. CONCLUSIONS: The measurement properties of the PHQ-9 can be improved by collapsing rating scale categories and by restructuring several double- and triple-barreled items. Adopting these changes may improve sensitivity in measuring depression after SCI.

Bilingual health literacy assessment using the Talking Touchscreen/la Pantalla Parlanchina: Development and pilot testing.

OBJECTIVE: Current health literacy measures are too long, imprecise, or have questionable equivalence of English and Spanish versions. The purpose of this paper is to describe the development and pilot testing of a new bilingual computer-based health literacy assessment tool. METHODS: We analyzed literacy data from three large studies. Using a working definition of health literacy, we developed new prose, document and quantitative items in English and Spanish. Items were pilot tested on 97 English- and 134 Spanish-speaking participants to assess item difficulty. RESULTS: Items covered topics relevant to primary care patients and providers. English- and Spanish-speaking participants understood the tasks involved in answering each type of question. The English Talking Touchscreen was easy to use and the English and Spanish items provided good coverage of the difficulty continuum. CONCLUSION: Qualitative and quantitative results provided useful information on computer acceptability and initial item difficulty. After the items have been administered on the Talking Touchscreen (la Pantalla Parlanchina) to 600 English-speaking (and 600 Spanish-speaking) primary care patients, we will develop a computer adaptive test. PRACTICE IMPLICATIONS: This health literacy tool will enable clinicians and researchers to more precisely determine the level at which low health literacy adversely affects health and healthcare utilization.

Measuring fatigue for children with cancer: development and validation of the pediatric Functional Assessment of Chronic Illness Therapy-Fatigue (pedsFACIT-F).

Fatigue is a major concern for cancer patients of all ages. The lack of an appropriate assessment tool has impeded our understanding of its prevalence and significance, specifically in the pediatric cancer population. This paper documents the reliability and validity of the pediatric Functional Assessment of Chronic Illness Therapy-Fatigue (pedsFACIT-F) in a comprehensive manner. The 11-item PedsFACIT-F was developed via literature review, feedback from patient/parent/clinician, and a face-to-face consensus meeting. Its reliability and validity were examined on the basis of data from 159 pediatric patients with cancer via classical test theory and Rasch analysis. Results showed that the pedsFACIT-F demonstrated good internal consistency (Cronbach alpha), acceptable item-total correlations, and met the unidimensionality assumption set by confirmatory factor analysis. All items had acceptable fit statistics in the Rasch analysis and demonstrated stable measurement properties by age, sex, and cancer type. Scores on the pedsFACIT-F significantly discriminated between patients with and without anemia and among patients with different functional status; clinically relevant minimally important differences were estimated accordingly. The pedsFACIT-F was significantly correlated to the PedsQL Multidimensional Fatigue Scale. In conclusion, the pedsFACIT-F demonstrates satisfactory reliability and validity and can be a useful tool in clinical trials and other research.

Outcomes in two post-acute non-inpatient rehabilitation settings.

BACKGROUND: Although several attempts have been made to look into the "black box" of inpatient rehabilitation, little is known about therapy effectiveness in outpatient settings. METHOD: This study described the characteristics of 167 persons with stroke referred to one of two outpatient settings-a comprehensive rehabilitation program or a single modality outpatient clinic within one system of care; the services provided in each setting; and the relationship of patient and therapy characteristics to rehabilitation outcomes. RESULTS: Differences were found in the characteristics of persons referred to each setting and the amount and intensity of therapy provided. The amount of therapy provided was positively related to initial status (greater need results in more therapy), but better outcomes appeared to be more strongly related to the match between the need and amount of therapy provided than to the amount provided (more therapy does not necessarily result in better outcomes).