The Pediatric Neuromuscular Recovery Scale: Development, validity, and reliability of a new assessment of neuromuscular capacity.

Research Report
Population: Pediatric

Shelley Trimble, PT, Pediatric NeuroRecovery and Translational Research Specialist, Frazier Rehab Institute

Elizabeth Ardolino, PhD, PT, Assistant Professor, University of St. Augustine for Health Sciences

MJ Mulcahey, PhD, OTR/L, Professor, Thomas Jefferson University

Marci Bienkowski, DPT, Physical Therapist, Shriners Hospitals for Children

Courtney Mullen, DPT, Physical Therapist, Shriners Hospitals for Children

Keywords: Plasticity, Spinal Cord Injury, Measurement, Neurorecovery

Purpose/Hypothesis: The Neuromuscular Recovery Scale (NRS) was developed to assess the capacity of adults post-spinal cord injury (SCI) to perform functional tasks without compensation and relative to performance one day prior to injury. Achievement of the task is not only assessed, but how the task is achieved is valued. For each item, scores reflect skills from the lowest score to the highest score. Within and across items, scores reflect neuromuscular capacity within a “hierarchical” manner of task difficulty and recovery. This new outcome measure is particularly relevant with the onset of activity-based therapies and research in neuroplasticity, regeneration, and physiological strategies to activate muscles below the lesion for adults and children. The purpose of this study was to: 1) adapt the NRS for use with the pediatric population with SCI, 2) establish content validity for children ages 1-12 years and 3) test inter-rater reliability.
Methods: Development and content validity were conducted in 3 phases. In Phase 1, the investigative team with SCI clinical and research expertise developed a draft Pediatric NRS (Peds NRS) by reviewing the current adult version, modifying items for the pediatric population or eliminating items inappropriate for children, and examining current pediatric outcomes for relevant motor items. Phase 2 used a Delphi method with input from 12 clinical pediatric experts (5 OTs, 5 PTs, 3 MDs) to review the draft Peds NRS. Any item on the scale that did not reach 80% agreement was revised based on comments from experts. In Phase 3, investigators tested the revised Peds NRS on a sample of children with SCI (n=5) and without (n=2). For inter-rater reliability testing, 25 children with SCI were tested and videotaped performing the Peds NRS. Fifteen raters (OTs, PTs, MDs) completed an online training course for scoring the Peds NRS. Raters then assessed videos via an online program. Overall and individual item scores will be compared across raters for consistency.
Results: The initial Peds NRS draft consisted of 13 items, 10 conducted off the treadmill and 3 on the treadmill, each scored on a 12-point scale. Through 4 rounds of Delphi questions and responses, the scoring was modified for 7 items until all reached 80% agreement. All items were maintained and no new items were added. After field testing, several items required modifications of tester instructions and item consistency and difficulty. Standardized equipment list and instruction manual for execution and scoring were finalized. Inter-rater reliability testing will be completed June 2015 with analysis completion to follow.
Conclusion: In this study, we adapted the NRS for the pediatric population, established content validity, and examined the inter-rater reliability of the tool.
Clinical Relevance: This new pediatric scale adds a unique tool for clinical and research assessment of task-specific, neuromuscular capacity after SCI, without reliance on devices or behavioral compensation.

Trimble, Shelley , PT; Ardolino, Elizabeth M, PhD, PT; Mulcahey, MJ , PhD, OTR/L; Bienkowski, Marci , DPT; Mullen, Courtney , DPT. The Pediatric Neuromuscular Recovery Scale: Development, validity, and reliability of a new assessment of neuromuscular capacity.. Poster Presentation. IV STEP Conference, American Physical Therapy Association, Columbus, OH, July 17, 2016. Online.