Original research Featured article| Volume 102, ISSUE 1, P97-105, January 2021

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Development of a Multidimensional, Multigroup Measure of Self-Care for Inpatient Rehabilitation

Published:October 05, 2020DOI:



      To develop and evaluate a measure of clinician-observed and patient-performed self-care function for use during inpatient rehabilitation.


      Retrospective analysis of self-care assessments collected by therapists using confirmatory factor analysis (CFA) followed by multidimensional item response theory (MIRT).


      Freestanding inpatient rehabilitation hospital in the Midwestern United States.


      Inpatients (N=7719) with stroke, traumatic brain injury, spinal cord injury, neurologic disorders, and musculoskeletal conditions.


      Not applicable

      Main Outcome Measures

      A total of 19 clinician-selected self-care measures including the FIM and patient-performed, clinician-rated measures of balance, upper extremity function, strength, changing body position, and swallowing. Clinicians completed assessments on admission and at least 1 interim assessment.


      CFA was completed for 3 patient groups defined by their highest level of balance (sitting, standing, walking). We reduced the number of items by 47.5% while maintaining acceptable internal consistency; unidimensionality within each item set required development of testlets. A recursive analysis defined a self-care measure with sensitivity (Cohen dmax−min =1.13; Cohen dlast−first.=0.91) greater than the FIM self-care items (dmax−min.=0.94; dlast−first .=0.83). The CFA models provided good to acceptable fit (root mean square error of approximations 0.03-0.06). Most patients with admission FIM self-care ratings of total assistance (88%, 297 of 338) made improvements on the MIRT self-care measure that were undetected by the FIM; the FIM detected no change for 26% of these patients (78 of 297). The remaining 74% (219 of 297) improved on the MIRT-based measure an average of 14 days earlier than was detected by the FIM.


      This MIRT self-care measure possesses measurement properties that are superior to the FIM, particularly for patients near its floor or ceiling. Methods assure accommodation for multidimensionality and high levels of sensitivity. This self-care measure has the potential to improve monitoring of self-care and manage therapy effectively during inpatient rehabilitation.


      List of abbreviations:

      ARAT (Action Research Arm Test), BBS (Berg Balance Scale), BTA (Bilateral Task Assessment), CAT (computerized adaptive test), CFA (confirmatory factor analysis), FGA (Functional Gait Assessment), FIST (Function in Sitting Test), IRF (inpatient rehabilitation facility), IRT (item response theory), MASA (Mann Assessment of Swallowing Ability), MIRT (multidimensional item response theory), QI (quality indicator), UEF (upper-extremity function)
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        • Keith R.A.
        • Granger C.V.
        • Hamilton B.B.
        • Sherwin F.S.
        The functional independence measure: a new tool for rehabilitation.
        Adv Clin Rehabil. 1987; 1: 6-18
        • Centers for Medicare and Medicaid Services
        IRF-PAI and IRF QRP manual.
        (Available at:) (accessed February 20, 2020)
        • Centers for Medicare and Medicaid Services
        Inpatient rehabilitation facility PPS.
        (Available at:) (accessed February 20, 2020)
        • Wright B.D.
        • Linacre J.M.
        Observations are always ordinal; measurements, however, must be interval.
        Arch Phys Med Rehabil. 1989; 70: 857-860
        • Merbitz C.
        • Morris J.
        • Grip J.C.
        Ordinal scales and foundations of misinference.
        Arch Phys Med Rehabil. 1989; 70: 308-312
        • Heinemann A.W.
        • Linacre J.M.
        • Wright B.D.
        • Hamilton B.B.
        • Granger C.
        Relationships between impairment and physical disability as measured by the functional independence measure.
        Arch Phys Med Rehabil. 1993; 74: 566-573
      1. PROMIS® instrument development and validation scientific standards.
        (Available at:) (accessed February 20, 2020)
        • Hambleton R.K.
        • Swaminatan H.
        • Rogers H.J.
        Fundamentals of item response theory.
        Sage, Newbury Park1991
        • Gorman S.L.
        • Radtka S.
        • Melnick M.E.
        • Abrams G.M.
        • Byl N.N.
        Development and validation of the function in sitting test in adults with acute stroke.
        J Neurol Phys Ther. 2010; 34: 150-160
        • Gorman S.L.
        • Rivera M.
        • McCarthy L.
        Reliability of the Function in Sitting Test (FIST).
        Rehabil Res Pract. 2014; 2014: 1-6
        • Berg K.
        • Wood-Dauphinee S.
        • Williams J.I.
        • Gayton D.
        Measuring balance in the elderly: preliminary development of an instrument.
        Physiother Can. 1989; 41: 304-311
        • La Porta F.
        • Caselli S.
        • Susassi S.
        • Cavallini P.
        • Tennant A.
        • Franceschini M.
        Is the Berg Balance Scale an internally valid and reliable measure of balance across different etiologies in neurorehabilitation? A revisited Rasch analysis study.
        Arch Phys Med Rehabil. 2012; 93: 1209-1216
        • Wrisley D.M.
        • Marchetti G.F.
        • Kuharsky D.K.
        • Whitney S.L.
        Reliability, internal consistency, and validity of data obtained with the functional gait assessment.
        Phys Ther. 2004; 84: 906-918
        • Wrisley D.M.
        • Kumar N.A.
        Functional Gait Assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults.
        Phys Ther. 2010; 90: 761-773
        • Beninato M.
        • Ludlow L.H.
        The Functional Gait Assessment in older adults: validation through Rasch modeling.
        Phys Ther. 2015; 96: 456-468
        • Lyle R.C.
        A performance test for assessment of upper limb function in physical rehabilitation treatment and research.
        Int J Rehabil Res. 1981; 4: 483-492
        • Chen H.F.
        • Lin K.C.
        • Wu C.Y.
        • Chen C.L.
        Rasch validation and predictive validity of the Action Research Arm Test in patients receiving stroke rehabilitation.
        Arch Phys Med Rehabil. 2012; 93: 1039-1045
        • Hsieh C.L.
        • Hsueh I.P.
        • Chiang F.M.
        • Lin P.H.
        Inter-rater reliability and validity of the Action Research Arm Test in stroke patients.
        Age Ageing. 1998; 27: 107-114
        • Van der Lee J.H.
        • De Groot V.
        • Beckerman H.
        • Wagenaar R.C.
        • Lankhorst G.J.
        • Bouter L.M.
        The intra- and interrater reliability of the Action Research Arm Test: a practical test of upper extremity function in patients with stroke.
        Arch Phys Med Rehabil. 2001; 82: 14-19
        • Nijland R.
        • Van Wegen E.
        • Verbunt J.
        • Van Wijk R.
        • Van Kordelaar J.
        • Kwakkel G.
        A comparison of two validated tests for upper limb function after stroke: the Wolf Motor Function Test and the Action Research Arm Test.
        J Rehabil Med. 2010; 42: 694-696
        • Wang Y.C.
        • Magasi S.R.
        • Bohannon R.W.
        • et al.
        Assessing dexterity function: a comparison of two alternatives for the NIH toolbox.
        J Hand Ther. 2011; 24: 313-321
        • Mathiowetz V.
        • Weber K.
        • Kashman N.
        • Volland G.
        Adult norms for the nine hole peg test of finger dexterity.
        Occup Ther J Res. 1985; 5: 24-38
        • Canny M.L.
        • Thompson J.M.
        • Wheeler M.J.
        Reliability of the Box and Block Test of Manual Dexterity for use with patients with fibromyalgia.
        Am J Occup Ther. 2009; 63: 506-510
        • Matsumoto J.
        • Morrow D.
        • Kaufman K.
        • et al.
        Surgical therapy for tremor in multiple sclerosis: an evaluation of outcome measures.
        Neurology. 2001; 57: 1876-1882
        • Mathiowetz V.
        • Weber K.
        • Volland G.
        • Kashman N.
        Reliability and validity of grip and pinch strength evaluations.
        J Hand Surg Am. 1984; 9: 222-226
        • Mann G.
        MASA: the Mann Assessment of Swallowing Ability.
        1st ed. Cengage Learning, Boston2002
        • Dungan S.
        • Gregorio D.
        • Abrahams T.
        • et al.
        Comparative validity of the American Speech-Language-Hearing Association’s national outcomes measurement system, functional oral intake scale, and G-codes to Mann Assessment of Swallowing Ability scores for dysphagia.
        Am J Speech Lang Pathol. 2019; 28: 424-429
        • Crary M.A.
        • Carnaby Mann G.D.
        • Groher M.E.
        Initial psychometric assessment of a Functional Oral Intake Scale for dysphagia in stroke patients.
        Arch Phys Med Rehabil. 2005; 86: 1516-1520
        • Rehabilitation Institute of Chicago
        Functional Assessment Scale manual.
        Rehabilitation Institute of Chicago, Chicago1998
        • O’Neil K.H.
        • Purdy M.
        • Falk J.
        • Gallo L.
        The dysphagia outcome and severity scale.
        Dysphagia. 1999; 14: 139-145
        • National Quality Forum
        Measure evaluation criteria.
        (Available at:) (accessed February 20, 2020)
        • D’Aquilla M.A.
        • Smith T.
        • Organ D.
        • Litchman S.
        • Reding M.
        Validation of a lateropulsion scale for patients recovering from stroke.
        Clin Rehabil. 2004; 18: 102-109
        • Bergego C.
        • Azouvi P.
        • Samuel C.
        • et al.
        Validation d’une échelle d’évaluation fonctionnelle de l’héminégligence dans la vie quotidienne: l’échelle CB [Validation of a functional assessment scale of hemineglect in daily life: The CB scale].
        Ann Readapt Med Phys. 1995; 38: 183-189
        • Muthén L.
        • Muthén B.
        Mplus user’s guide (version 8.0).
        Muthén & Muthén, Los Angeles2017
        • Chen W.H.
        • Thissen D.
        Local dependence indexes for item pairs using item response theory.
        J Educ Behav Stat. 2008; 22: 265-289
        • Glas C.A.W.
        • Wainer H.
        • Bradlow E.T.
        MML and EAP estimation in testlet-based adaptive testing.
        Computerized adaptive testing: theory and practice. Kluwer Academic Publishers, New York2005
        • Browne M.W.
        • Cudeck R.
        Alternative ways of assessing model fit.
        Sociol Methods Res. 1992; 21: 230-258
        • Hu L.T.
        • Bentler P.M.
        Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives.
        Struct Equ Modeling. 1999; 6: 1-55
        • Cai L.
        High-dimensional exploratory item factor analysis by a Metropolis-Hastings Robbins-Monro algorithm.
        Psychometrika. 2010; 75: 33-57
        • Samejima F.
        Estimation of latent ability using a response pattern of graded scores.
        Psychometrika. 1969; 34: 1-97
        • Weeks J.P.
        plink: an R package for linking mixed-format tests using IRT-based methods.
        J Stat Softw. 2015; 35: 1-33
        • Stocking M.L.
        • Lord F.M.
        Developing a common metric in item response theory.
        Appl Psychol Meas. 1983; 7: 201-210
        • Centers for Medicare and Medicaid Services
        Final fiscal year 2018 payment and policy changes for Medicare inpatient rehabilitation facilities (CMS-1671-F).
        (Available at:) (accessed February 20, 2020)
        • Cortina J.M.
        What is coefficient alpha? An examination of theory and applications.
        J Appl Psychol. 1993; 78: 98-104
        • Torchiano M.
        Package “effsize”: efficient effect size computation.
        CRAN Package, 2017
        • Chalmers R.P.
        Generating adaptive and non-adaptive test interfaces for multidimensional item response theory applications.
        J Stat Softw. 2016; 71: 1-33