Responsiveness and Predictive Validity of the Participation Measure–3 Domains, 4 Dimensions in Survivors of Stroke

  • Feng-Hang Chang
    Corresponding author Feng-Hang Chang, ScD, OTR/L, Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, 250 Wu-Hsing Street, Taipei City 11031, Taiwan.
    Graduate Institute of Injury Prevention and Control, College of Public Health, Taipei Medical University, Taipei, Taiwan

    Department of Physical Medicine and Rehabilitation, School of Medicine, Taipei Medical University, Taipei, Taiwan
    Search for articles by this author
  • Pengsheng Ni
    Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts
    Search for articles by this author
Published:August 14, 2019DOI:



      To examine the responsiveness and predictive validity of the Participation Measure–3 Domains, 4 Dimensions (PM-3D4D) in people receiving outpatient rehabilitation following stroke.


      Prospective cohort observational study.


      Outpatient rehabilitation settings.


      Volunteer patients (N=269) with stroke (mean age ± SD [y], 55.36±12.46; 70.26% male).


      Not applicable.

      Main Outcome Measures

      The PM-3D4D was designed to measure 3 domains (Productivity, Social, and Community) and 4 dimensions (Diversity, Frequency, Desire for change, and Difficulty) of participation in individuals with rehabilitation needs. All participants completed the PM-3D4D, the Participation Assessment with Recombined Tools-Objective (PART-O), the Participation Measure for Post-Acute Care (PM-PAC), and the EuroQol-5-Dimension (EQ-5D) at the baseline assessment and again following 3 months of outpatient rehabilitation.


      Significant mean changes in scores were observed for most of the PM-3D4D subscales, with the largest score change observed in the Difficulty subscale (standardized response mean=0.57∼0.88). The minimal detectable change and meaningful clinically important differences were calculated for each subscale. The Frequency and Difficulty dimensions of the PM-3D4D demonstrated significantly greater responsiveness than the PART-O and PM-PAC, respectively. The baseline PM-3D4D scores, except for Desire for change subscales, were significantly correlated with the PART-O, PM-PAC, and EQ-5D scores after 3 months of rehabilitation.


      This study provides evidence supporting the responsiveness and predictive validity of the PM-3D4D in survivors of stroke. Among all subscales of the PM-3D4D, the Difficulty dimensional scale demonstrated the greatest responsiveness. The Desire for change dimension of the PM-3D4D showed less responsiveness, and we recommend that it be used as a goal-setting tool rather than an outcome measure. The PM-3D4D can potentially be used to predict participation outcomes and the health-related quality of life following rehabilitation interventions.


      List of abbreviations:

      CI (confidence interval), EQ-5D (EuroQol-5-Dimension), HRQoL (health-related quality of life), MDC (minimal detectable change), MDC90 (minimal detectable change with a confidence level of 90%), MCID (meaningful clinically important difference), PART-O (Participation Assessment with Recombined Tools-Objective), PM-3D4D (Participation Measure–3 Domains, 4 Dimensions), PM-PAC (Participation Measure for Post-Acute Care), SRM (standardized response mean), USER-Participation (Utrecht Scale for Evaluation of Rehabilitation Participation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • World Health Organization
        The atlas of heart disease and stroke.
        (Available at:)
        • Teasell R.W.
        • McRae M.P.
        • Finestone H.M.
        Social issues in the rehabilitation of younger stroke patients.
        Arch Phys Med Rehabil. 2000; 81: 205-209
        • Kersten P.
        • Low J.T.
        • Ashburn A.
        • George S.L.
        • McLellan D.L.
        The unmet needs of young people who have had a stroke: results of a national UK survey.
        Disabil Rehabil. 2002; 24: 860-866
        • Whiteneck G.G.
        • Dijkers M.P.
        Difficult to measure constructs: conceptual and methodological issues concerning participation and environmental factors.
        Arch Phys Med Rehabil. 2009; 90: S22-S35
        • Chang F.H.
        • Coster W.J.
        • Helfrich C.A.
        Community participation measures for people with disabilities: a systematic review of content from an international classification of functioning, disability and health perspective.
        Arch Phys Med Rehabil. 2013; 94: 771-781
        • Whiteneck G.G.
        • Dijkers M.P.
        • Heinemann A.W.
        • Bogner J.A.
        • Bushnik T.
        • Cicerone K.D.
        • et al.
        Development of the Participation Assessment With Recombined Tools–Objective for Use After Traumatic Brain Injury.
        Arch Phys Med Rehabil. 2011; 92: 542-551
        • Gandek B.
        • Sinclair S.J.
        • Jette A.M.
        • Ware Jr., J.E.
        Development and initial psychometric evaluation of the participation measure for post-acute care (PM-PAC).
        Am J Phys Med Rehabil. 2007; 86: 57-71
        • Chang F.H.
        • Coster W.J.
        Conceptualizing the construct of participation in adults with disabilities.
        Arch Phys Med Rehabil. 2014; 95: 1791-1798
        • Chang F.H.
        • Liou T.H.
        • Ni P.
        • Chang K.H.
        • Lai C.H.
        Development of the Participation Measure–3 Domains, 4 Dimensions (PM-3D4D): a new outcome measure for rehabilitation.
        Arch Phys Med Rehabil. 2017; 98: 286-294
        • Chang F.H.
        Measuring participation of rehabilitation patients: test-retest reliability and mode of administration concordance of the Participation Measure--3 Domains, 4 Dimensions (PM-3D4D).
        Arch Phys Med Rehabil. 2017; 98: 1622-1627
        • Chang F.H.
        • Chang K.H.
        • Liou T.H.
        • Whiteneck G.G.
        Validation of the Participation Measure-3 Domains, 4 Dimensions (PM-3D4D).
        Arch Phys Med Rehabil. 2017; 98: 2498-2506
        • van der Zee C.H.
        Responsiveness of four participation measures to changes during and after outpatient rehabilitation.
        J Rehabil Med. 2011; 43: 1003-1009
        • Deyo R.A.
        • Diehr P.
        • Patrick D.L.
        Reproducibility and responsiveness of health status measures statistics and strategies for evaluation.
        Control Clin Trials. 1991; 12: S142-S158
        • Liang M.H.
        Longitudinal construct validity: establishment of clinical meaning in patient evaluative instruments.
        Med Care. 2000; 38: II84-II90
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research: applications to practice.
        Prentice Hall, New Jersey2008
        • Wen P.S.
        • Waid-Ebbs J.K.
        • Graham D.P.
        • Helmer D.A.
        Psychometric properties of 2 participation measures in veterans with mild traumatic brain injury.
        Arch Phys Med Rehabil. 2018; 99: S86-S93
        • Chang F.H.
        • Ni P.
        • Coster W.J.
        • Whiteneck G.G.
        • Jette A.M.
        Measurement properties of a modified measure of participation for persons with spinal cord injury.
        J Spinal Cord Med. 2016; 39: 476-483
        • Tsuchiya A.
        • Ikeda S.
        • Ikegami N.
        • et al.
        Estimating an EQ-5D population value set: the case of Japan.
        Health Econ. 2002; 11: 341-353
        • Chang T.J.
        • Tarn Y.H.
        • Hsieh C.L.
        • Liou W.S.
        • Shaw J.W.
        • Chiou X.G.
        Taiwanese version of the EQ-5D: validation in a representative sample of the Taiwanese population.
        J Formos Med Assoc. 2007; 106: 1023-1031
        • Cohen J.
        Statistical Power Analysis for the Behavioral Sciences.
        Lawrence Erlbaum Associates, New York1988
        • Shrout P.E.
        • Fleiss J.L.
        Intraclass correlations: uses in assessing rater reliability.
        Psychol Bull. 1979; 86: 420-428
        • Rai S.K.
        • Yazdany J.
        • Fortin P.R.
        • Aviña-Zubieta J.A.
        Approaches for estimating minimal clinically important differences in systemic lupus erythematosus.
        Arthritis Res Ther. 2015; 17: 143
        • White J.
        • Magin P.
        • Attia J.
        • Sturm J.
        • McElduff P.
        • Carter G.
        Predictors of health-related quality of life in community-dwelling stroke survivors: a cohort study.
        Fam Pract. 2016; 33: 382-387
        • Silva S.M.
        • Corrêa F.I.
        • Faria C.D.
        • Pereira G.S.
        • Attié E.A.
        • Corrêa J.C.
        Reproducibility of the items on the Stroke Specific Quality of Life questionnaire that evaluate the participation component of the International Classification of Functioning, Disability and Health.
        Disabil Rehabil. 2016; 38: 2413-2418
        • van der Zee C.H.
        • Baars-Elsinga A.
        • Visser-Meily J.M.A.
        • Post M.W.
        Responsiveness of two participation measures in an outpatient rehabilitation setting.
        Scand J Occup Ther. 2013; 20: 201-208
        • Post M.W.
        • van der Zee C.H.
        • Hennink J.
        • Schafrat C.G.
        • Visser-Meily J.M.
        • van Berlekom S.B.
        Validity of the Utrecht Scale for evaluation of rehabilitation-participation.
        Disabil Rehabil. 2012; 34: 478-485
        • Cardol M.
        • de Haan R.J.
        • van den Bos G.A.
        • de Jong B.A.
        • de Groot I.J.
        The development of a handicap assessment questionnaire: the Impact on Participation and Autonomy (IPA).
        Clin Rehabil. 1999; 13: 411-419
        • Holbrook M.
        • Skilbeck C.E.
        An activities index for use with stroke patients.
        Age Ageing. 1983; 12: 166-170
        • Harwood R.H.
        • Rogers A.
        • Dickinson E.
        • Ebrahim S.
        Measuring handicap: the London Handicap Scale, a new outcome measure for chronic disease.
        Qual Health Care. 1994; 3: 11-16