Adaptation and Psychometric Properties of the Gross Motor Function Measure for Children Receiving Treatment for Acute Lymphoblastic Leukemia

The information in this paper has been presented at the Pediatric Oncology Group of Ontario's 2007 Conference. The objectives of this study were to adapt dimensions D and E of the Gross Motor Function Measure (GMFM) for children receiving treatment for acute lymphoblastic leukemia (ALL) and to determine the psychometric properties of the measures in this population. Twenty children/adolescents receiving treatment for ALL participated and 91 charts were reviewed. Seven dimension D and 13 dimension E items were selected for the adapted test (GMFM-ALL) based on clinical attributes and.statistical analyses. Analyses of variance used to calculate variance components determined the following generalizability coefficients: inter-rater reliability of GMFM:D, 0.99; GMFM:E, 0.99; GMFM-ALL:D, 0.99; GMFM-ALL, 0.99; test-retest reliability of GMFM:D, 0.97; GMFM:E, 0.96; GMFM-ALL:D, 0.95; GMFM-ALL:E, 0.94. Paired T-tests demonstrated significant, positive score changes during a period of clinically observed change: GMFM:D t = 6.40, p < 0.001; GMFM:E t = 7.31, p < 0.001; GMFM-ALL:D t= 6.86, p< 0.001; GMFM-ALL:E t= 6.85, p < 0.001 demonstrated construct validity. Acute lymphoblastic leukemia (ALL) is the most common form of childhood cancer. Cure rates of 80% have been achieved with the use of multiagent chemotherapy and prophylactic central nervous system interventions.1 However, these treatments can result in impairments of body function and structure including pain, sensory loss, muscle weakness, contractures, coordination and balance problems, fatigue, decreased fitness, avascular necrosis, osteopenia, and fractures.2-9 These impairments may be associated with gross motor functioning and participation in various aspects of a child's life, both during and following treatment.2-4 Therefore, in addition to the overall goal of disease cure, treatment for children with ALL includes interventions to limit the associated primary and secondary impairments and maximize activity and participation. Reliable, valid, and clinically feasible (safe, economical, time efficient, and acceptable to patients) measurement tools are necessary to describe and measure changes in motor functioning, determine treatment goals, and to assess the effectiveness of interventions. Standardized assessments of gross motor skills used to evaluate gross motor functioning in children who are receiving treatment for ALL include the Timed Up and Go, Timed Up and Down Stairs, 9-Minute Run-walk,9 Movement ABC,2 Gross Motor Function Measure (GMFM),4,10 and Bruininks-Oseretsky Test of Motor Proficiency.4,10 Challenges encountered when testing the gross motor activities of these children include fatigue, decreased endurance, behavioural problems, pain, distractibility, frustration with abilities, and scheduling challenges. Of greater concern, some standardized tests involve items that may put the children with osteopenia at risk for injury. These include jumping off heights, jumping hurdles, jumping and turning, or higher-level balance skills items that put the lower functioning children at risk for falling.11 Another measurement problem in this group is the wide age span the disease affects, from infancy to adolescence, which limits the use of some tests in certain age groups. The GMFM12 is a clinical measure of gross motor skills that was developed to evaluate gross motor function change in children with cerebral palsy. It is a criterion-referenced measure consisting of 88 items that are grouped into 5 dimensions: A-Lying and Rolling; B-Sitting; C-Crawling and Kneeling; D-Standing; E-Walking, Running, and Jumping. Test items are considered to be measurable, clinically important, and potentially able to show change in gross motor function. They were selected based on a review of relevant literature and judgments of clinicians. All items can be performed successfully at 5 years of age in children who do not have gross motor problems. Children are rated by observation of their performance of the individual items which are scored on a 4-point ordinal scale of 0 to 3 (0 = does not initiate; 1 = initiates, <10% of the task; 2 = partially completes, 10% to <100% of the task; 3 = completes the task) as outlined in the criterion descriptors. GMFM items can be summed to calculate raw and percent scores for each dimension and a total score if all dimensions are administered. A unidimensional, interval scale 66-item GMFM, comprised of a subset of the 88 items, has been developed using Rasch analysis. Both versions have been shown to be reliable, valid, and responsive to change when used with children with cerebral palsy.12 Although developed for children with cerebral palsy, the GMFM has been found to be reliable for use in children with osteogenesis imperfecta11 and reliable and responsive to change in children with Down Syndrome.13 Additionally, guidelines for administration have been developed to maximize adherence and reduce administration time for use in children with Down syndrome.12 Dimensions D and E of the GMFM include items that are clinically appropriate for children receiving treatment for ALL. The items test functional skills that are relevant to the daily and recreational activities affected by the impairments encountered by children with ALL, provide meaningful feedback to families, and can be used as activities for gross motor programming. Testing requires minimal equipment. There is also a lesser risk for fractures and other injuries when performing the GMFM compared to other measures of gross motor function,11 an important consideration in children with ALL who are at risk for fractures by virtue of osteopenia. However a more concise test would be optimal to address issues such as fatigue, decreased endurance, compliance, and time restraints. Additionally, the psychometric properties of a measure are specific to the populations on which it has been developed and tested and should not be generalized to other populations without being evaluated for those groups.14 Sections of the GMFM have been used in pilot studies of children receiving treatment for ALL,10 but the reliability and validity has not been established. The first objective of this study was to adapt dimensions D: Standing and E: Walking, Running, Jumping of the GMFM to develop a more concise measure specific to the needs of children with ALL. This version will be referred to as the GMFM-ALL. The second objective was to determine the test-retest and interrater generalizability of dimensions D and E of the GMFM and the GMFM-ALL when administered to children receiving treatment for ALL. The third objective was to evaluate construct validity of the GMFM and GMFM-ALL for children receiving treatment for ALL. The Research Ethics Board of Hamilton Health Sciences and the Faculty of Health Sciences, McMaster University, approved all aspects of the study. Informed consent/assent was obtained from the parents/children involved in the reliability portion of the study. Approval for a retrospective review of medical charts/health records was received for access to previous assessments.

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