Elsevier

Journal of Hand Therapy

Volume 23, Issue 1, January–March 2010, Pages 41-52
Journal of Hand Therapy

Scientific/Clinical Article
Modification of the Upper Limb Functional Index to a Three-point Response Improves Clinimetric Properties

https://doi.org/10.1016/j.jht.2009.09.007Get rights and content

Abstract

Study Design

Observational two-stage.

Introduction

To achieve optimal clinimetric properties for outcome measures, both practical and psychometric, ongoing improvements are required.

Purpose of the Study

To evaluate if the Upper Limb Functional Index (ULFI) clinimetric properties are improved by modification to a three-point response option and to verify the factor structure.

Methods

Stage 1, calibration (n = 139) used ULFI dichotomous responses, and stage 2, validation (n = 117) used a three-point response option. The clinimetric properties were compared in physical therapy outpatients with the QuickDASH as the reference standard. Repeated measurements were made at two to four weekly intervals.

Results

The ULFI three-point response option improved reliability [intraclass correlation coefficient (2,1) = 0.98], internal consistency (α = 0.92), QuickDASH concurrent validity (r = 0.86), and responsiveness. Minimal detectable change (90% confidence interval) was 7.9%, and factor structure was unidimensional. Missing responses were <0.5%, and practical characteristics were unchanged.

Conclusions

The enhanced reliability and reduced errors with unchanged practicality demonstrate the ULFI improvements through modification to a three-point response option.

Level of Evidence

2c.

Section snippets

Purpose of the Study

  • 1.

    To determine whether psychometric and practical characteristics are improved when the original ULFI is modified from dichotomous to a three-point response option (ULFI3-pt).

  • 2.

    To investigate the factor structure of the ULFI3-pt.

Modification of the Original ULFI to a Three-point Response

To modify the wording of the original ULFI and produce the ULFI3-pt, two focus groups were formed. The first had five patients with different upper limb conditions; the second had five clinicians that included two physical therapists, two certified hand therapists, and one occupational therapist. Each group independently developed methods to provide the ULFI3-pt with the desired three-point response option where the third point was central between “Yes” and “No.”10, 11, 12 The consensus

Psychometric Characteristics

These are presented for each PRO in both stages in Table 2 with the construct validity in Table 3. The values for the QuickDASH are invalid for summation to a single repeated score because of the bidimensional factor structure (the presence of two underlying constructs or themes).28, 51 They are provided for comparison to the other PROs and previous QuickDASH studies.

Discussion

The ULFI3-pt demonstrated validity and reliability as a three-point response scale questionnaire. The improved reliability over the original ULFI reduced the measurement error, which in turn made the questionnaire more sensitive to change. The additional “Half Mark” response option was accepted by most of the participants in most of their responses. The similar demographic factors, psychometric values, and criterion validity between the calibration and validation stages indicated consistency

Conclusions

The ULFI3-pt improved the original ULFI psychometric properties without the loss of clinical utility and demonstrated a unidimensional factor structure. Practical characteristics were retained and a high overall performance score for both the “Measurement of outcome measures” and “Bot” clinimetric summary performance scales. These characteristics were both preferable and superior to the QuickDASH, which had questionable validity because of its bidimensional structure. The findings indicated

Acknowledgments

This research was supported by the University of the Sunshine Coast. We thank all participating patients, general practitioners, and therapists for their time and effort. The study was approved by the Human Research Ethics Committee of the University of the Sunshine Coast. We wish to thank Lukas Staub for statistical editing and Selena Horner of Red Cedar Physical Therapy for her invaluable contribution of patient's data.

Quiz: Article # 147

Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue. There is only one best answer for each question.

  • #1.

    The ULFI

    • a.

      is being introduced as a new outcome measure in this issue of the JHT

    • b.

      has been previously described in an earlier issue of the JHT

    • c.

      was developed at the Fulbright Institute of the University of Louisiana

    • d.

      is a research tool, not intended to be used clinically

  • #2.

    The 3-point response option proved to be

    • a.

      more time consuming to administer

    • b.

      less time

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