Activity Measure for Post Acute Care

Last Updated

July 01, 2020

Purpose

The AM-PAC assesses activity limitations based on World Health Organization’s International Classification of Functioning, Disability and Health (ICF).

The Computer Adaptive Test (CAT) version of the AM-PAC selects items designed to match a patient’s functional abilities, reducing the total number of items on the assessment while increasing the measure's validity.

Conversion tables to CMS G-codes are available for all AM-PAC scales.

AM-PAC Activity Domains:
Applied Cognitive	Personal & Instrumental/Daily Activity	Movement & Physical/Basic Mobility
Communication	Grooming and Hygiene	Bend/Stand/Carry
Print Information	Feeding and Meal Prep	Ambulation
New Learning	Dressing	Transfers
Social	Instrumental	WC Skills

Link to Instrument

Instrument Details

Acronym AM-PAC

Area of Assessment

Activities of Daily Living
Cognition
Functional Mobility

Assessment Type

Patient Reported Outcomes

Administration Mode

Computer

Cost

Not Free

Cost Description

AM-PAC is free for academic research use; there is a charge for clinical/commercial use.

Diagnosis/Conditions

Arthritis + Joint Conditions
Cancer Rehabilitation
Parkinson's Disease & Movement Disorders
Spinal Cord Injury
Stroke Recovery

Stroke

Movement and Gait Disorders

Mixed Populations

Joint Pain and Fractures

AM-PAC can be a patient- or clinician-reported measure.
In each domain, AM-PAC scores have a mean of 50 and a standard deviation of 10.
AM-PAC Activity Domains:
1) Applied Cognitive
2) Personal & Instrumental/Daily Activity
3) Movement & Physical/Basic Mobility
4) Communication
5) Grooming and Hygiene
6) Bend/Stand/Carry
7) Print Information
8) Feeding and Meal Prep
9) Ambulation
10) New Learning
11) Dressing
12) Transfers
13) Social
14) Instrumental
15) Wheelchair Skills

Number of Items

5-8 per domain.
Inpatient short: 6 per domain.
Outpatient short: 15-18 per domain.

Computer adaptive test
Paper and Pencil for in-patient and out-patient short forms

Varies depending on AM-PAC version used; As a Computer Adaptive Test (CAT), the time to administer will slightly vary between patients.

Required Training

Reading an Article/Manual

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad and the Rehabilitation Measures Team; Updated by Tammie Keller Johnson PT, DPT, NCS and the TBI EDGE task force of the neurology section of the APTA in September 2012; Updated in 2019 by Bridget Hahn, OTD, OTR/L, Erin Thrasher, OTS, Carley Rowe, OTS, Carissa Studer, OTS and Mackenzie Traub, OTS. Reviewed in June 2020 by Rachel Bond, BA.

ICF Domain

Activity

Measurement Domain

Activities of Daily Living
Cognition
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	N/A	N/A	N/A	N/A

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	No	No	Yes	Not reported

Considerations

Can be administered with either a paper and pencil or computer-based version.
Accurate scoring can be obtained from either the setting-specific short form versions or Computer Adaptive Testing forms.
Recent work using patient-reported outcomes suggests that a short-form version of the Activity Measure for Post-Acute Care (AM-PAC) may be more sensitive than the FIM in assessing functional gains and losses once a patient returns to the community (Coster et al., 2006).
Haley et al, 2006, reported that fewer items (33%) and less time (44%) is required to complete the AM-PAC-CAT than the AM-PAC-66 (short form).

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Standard Error of Measurement (SEM)

AM-PAC Computer Adaptive Test (CAT): (Jette et al., 2007; n = 1815 retrospective study; patients diagnosed with spine, lower-extremity, and upper-extremity impairments)

Average Standard Error of Estimate by Ability Score:
Scale	Score Range
	10-29	30-49	50-69	70-90
Basic Mobility; Mean S.E.	4.45	2.16	1.99	3.19
95% C.I.	+/- 8.72	+/- 4.23	+/- 3.90	+/- 6.25
Daily Activity; Mean S.E.	2.60	1.98	5.32	N/A
95% C.I.	+/- 5.10	+/- 3.88	+/- 10.43	N/A
C.I. = Confidence Interval S.E. = Standard Error of Measurement

AM-PAC Inpatient Mobility Short Form: (Hoyer et al., 2017; n=118; mean age = 56.6)

Standard Error of Measurement (SEM)= 1.6

Minimal Detectable Change (MDC)

AM-PAC Computer Adaptive Test (CAT): (Jette et al., 2007)

Basic Mobility: MDC = 4.28
Daily Activity: MDC = 3.70

AM-PAC Inpatient Mobility Short Form: (Hoyer et al., 2017)

MDC_{95% CI}= 4.5.

Cut-Off Scores

AM-PAC Inpatient Mobility Short Form: (Hoyer et al., 2017; n=118; mean age = 56.6)

4-point ordinal scale, with a raw score range from 6-24
A score of 1 indicates that the participant was unable to perform the task and a score of 4 indicates the participant was independent in completing the task
A higher score indicates fewer limitations in functional performance

Medically Complex: (Jette et al., 2014)

Basic Mobility: 42.9
Daily Activity: 39.4

Normative Data

Patients with Hip Fracture: (Latham et al., 2008; n = 108; patients aged 65 or older; assessed within 17 days of surgical repair of a unilateral hip fracture; International Sample)

AM-PAC and Related Measure Norms:
AM-PAC Physical Mobility	mean (SD)	median (range)
Baseline	48.0 (10.0)	51.9 (19.2–62.7)
Week 12	59.7 (8.2)	60.2 (29.0–82.5)
AM-PAC Personal Care	mean (SD)	median (range)
Baseline	49.2 (8.0)	48.5 (22.0–68.0)
Week 12	57.0 (8.8)	58.2 (35.0–68.1)
PFP-10	mean (SD)	median (range)
Baseline	10.4 (9.9)	6.8 (0–45.2)
Week 12	24.5 (18.4)	21.3 (0–78.1)
SPPB	mean (SD)	median (range)
Baseline	4.7 (2.8)	5.0 (0–12.0)
Week 12	7.9 (2.6)	8.0 (0–12.0)
Gait speed (m/s)	mean (SD)	median (range)
Baseline	0.50 (0.28)	0.45 (0.01–1.33)
Week 12	0.77 (0.35)	0.76 (0.003–1.83)
6MWT (m)	mean (SD)	median (range)
Baseline	121.0 (103.0)	109.6 (0–408.1)
Week 12	251.0 (155.5)	259.0 (0–651.9)
SF-36 PF	mean (SD)	median (range)
Baseline	23.0 (21.8)	15.0 (0–90.0)
Week 12	57.5 (25.5)	57.5 (0–100)

Orthopedic outpatient: Individuals with spine, lower-extremtiy and upper extremity impairments: (Jette et al, 2007; n = 1815 seen in outpatient clinics)

Domain	n	Admission Mean (SD)	Discharge Mean (SD)
Total	1703	63.26 (9.19)	68.71 (8.41)
Spine	666	63.57 (7.78)	68.40 (8.59)
EU	462	68.42 (8.24)	71.20 (7.74)
LE	575	58.75 (9.16)	67.07 (8.26

Medically Complex: (Jette et al., 2014)

First Visit “6-Clicks” Patient Scores

Daily activity	39.9 (39.2, 39.4)
Basic mobility	43.8 (43.7, 44.0)
Patients discharged to home
Daily activity	44.9 (44.8, 45.0)
Basic mobility	50.7 (50.6, 50.9)
Patients discharged to institution
Daily activity	34.9 (34.8, 35.0)
Basic mobility	38.5 (38.4, 38.6)

Test/Retest Reliability

Postacute Care Patients: (Andres et al., 2003; n = 25; mean age = 65.0 (range = 23-87) years; Impairments, Neurologic = 32%, Orthopdedic = 32%, Medically complex = 36%; mean time between assessments = 2.7 to 3.5 (range 1 to 7) days)

Test-retest Reliability:
	Strength	ICC	95% CI
Personal and instrumental	Excellent	0.96	0.92–0.98
Movement and physical	Excellent	0.97	0.92–0.98
Applied cognition	Excellent	0.91	0.70–0.96
CI = Confidence Interval

AM-PAC Inpatient Mobility Short Form: (Hoyer et al., 2017; n=118; mean age = 56.6)

Excellent: ICC= 0.91-0.96

Interrater/Intrarater Reliability

Postacute Care Patients: (Andres et al., 2003; proxy = primary physical, occupational therapist or family member)

Interrater Reliability:
	Strength	ICC	95% CI
Personal and instrumental	Excellent	0.90	0.73–0.94
Movement and physical	Excellent	0.86	0.68–0.96
Applied cognition	Adequate	0.68	0.55–0.89
CI = Confidence Interval

Internal Consistency

AM-PAC Inpatient Mobility Short Form: (Hoyer et al., 2017; n=118; mean age = 56.6)

Excellent: Cronbach’s alpha= 0.94-0.96

Medically Complex: (McDonough et al., 2016, convenience sample of n=235 patients in outpatient setting)

Good: Cronbach’s alpha= > 0.80 in the score range from 17~56, and more limited performance for scores beyond 56. The IRT-based internal consistency reliability: 0.86, which is comparable to that of the full item bank (0.89).

Criterion Validity (Predictive/Concurrent)

Patients with Hip Fracture: (Latham et al., 2008)

Adequate to Excellent convergent validity (see below)

*Performance-Based and Self-Report Function Measure Correlations at Week 12**
	AM-PAC Physical Mobility	AM-PAC Personal Care	SF-36 PF	PFP-10	SPPB Total
AM-PAC Physical Mobility	1	0.71	0.84	0.64	0.65
AM-PAC Personal Care		1	0.68	0.63	0.55
SF-36 PF			1	0.69	0.67
PFP-10				1	0.73
SPPB Total					1
Gait Speed Value
6MWT
r < .31 = Poor r .31 to .59 = Adequate r > .6 = Excellent
SF-36 PF = Medical Outcomes Study 36-Item Short Form Health Survey Physical Function Scale PFP-10 = Physical Functional Performance Test SPPB = Short Physical Performance Batter 6MWT = Six-Minute Walk Test *Spearman Correlations

Medically Complex: (Jette et al., 2014, n=84,466, Mean Age=69, SD=15.6).

Sensitivity, Specificity, and Predictive Values for Various Basic Mobility and Daily Activity Scores

Sensitivity, Specificity, and Predictive Values for Various Basic Mobility

Basic Mobility Score, scale (raw)	Sensitivity	Specificity	Positive Predictive Value	Negative Predictive Value
25.0 (6.5)	0.03	0.98	0.56	0.50
27.5 (7.5)	0.04	0.97	0.58	0.50
29.6 (8.5)	0.09	0.94	0.61	0.51
31.4 (9.5)	0.11	0.93	0.61	0.51
33.1 (10.5)	0.16	0.90	0.62	0.52
34.6 (11.5)	0.23	0.87	0.64	0.53
36.0 (12.5)	0.30	0.84	0.65	0.54
37.4 (13.5)	0.34	0.82	0.65	0.55
38.8 (14.5)	0.39	0.80	0.65	0.57
40.1 (15.5)	0.44	0.77	0.66	0.58
41.5 (16.5)	0.51	0.73	0.66	0.58
42.9 (17.5)	0.62	0.67	0.65	0.64
44.5 (18.5)	0.80	0.54	0.63	0.73
46.6 (19.5)	0.85	0.49	0.63	0.77
49.0 (20.5)	0.90	0.42	0.61	0.81
51.8 (21.5)	0.93	0.37	0.60	0.84
55.1 (22.5)	0.96	0.29	0.58	0.89
59.0 (23.5)	0.98	0.21	0.56	0.93

Sensitivity, Specificity, and Predictive Values for Various Daily Activity

Daily Activity Score, scale (raw)	Sensitivity	Specificity	Positive Predictive Value	Negative Predictive Value
18.6 (6.5)	0.02	0.98	0.52	0.50
21.5 (7.5)	0.03	0.97	0.52	0.50
24.1 (8.5)	0.04	0.96	0.53	0.50
26.3 (9.5)	0.05	0.95	0.54	0.50
28.2 (10.5)	0.07	0.94	0.55	0..50
29.8 (11.5)	0.10	0.93	0.56	0.51
31.3 (12.5)	0.14	0.90	0.57	0.51
32.7 (13.5)	0.19	0.86	0.58	0.52
34.0 (14.5)	0.27	0.81	0.59	0.53
35.3 (15.5)	0.39	0.73	0.59	0.54
36.6 (16.5)	0.53	0.66	0.61	0.58
38.0 (17.5)	0.64	0.60	0.61	0.62
39.4 (18.5)	0.77	0.49	0.60	0.68
41.1 (19.5)	0.88	0.37	0.58	0.75
43.2 (20.5)	0.93	0.30	0.57	0.82
45.7 (21.5)	0.97	0.23	0.56	0.88
49.1 (22.5)	0.98	0.19	0.55	0.92
52.8 (23.5)	0.99	0.16	0.54	0.93

Construct Validity

AM-PAC Computer Adaptive Test (CAT): (Jette et al., 2007)

Significant differences in basic mobility were observed in the subject’s acuity level and surgical status.

AM-PAC Difference Scores for Basic Mobility and Daily Activity:
Scale	Acuity			Postsurgical Treatment
Basic Mobility	< 35 days	> 35 days	Difference	Yes	No	Difference
Admission	63.45 (9.39)	62.85 (9.63)	0.60	59.00 (10.14)	64.69 (8.37)	-5.70*
Discharge	70.11 (8.17)	68.14 (8.30)	1.97*	66.73 (7.79)	69.34 (8.52)	-2.61*
Increase	6.62 (8.60)	5.22 (7.94)	1.40*	7.85 (8.62)	4.65 (7.57)	3.20*
Daily Activity	< 35 days	> 35 days	Difference	Yes	No	Difference
Admission	56.31 (8.28)	56.18 (8.43)	0.13	54.32 (8.19)	57.88 (7.67)	-3.56*
Discharge	61.85 (5.96)	60.12 (7.06)	1.73*	60.70 (6.67)	60.95 (6.50)	-0.25
Increase	5.53 (7.60)	3.89 (6.95)	1.64*	6.38 (8.10)	3.07 (6.24)	3.31*
*p < 0.05

Content Validity

The AM-PAC was developed using the World Health Organization’s International Classification of Functioning, Disability and Health (ICF).

Face Validity

Items for the original prototype of the AM-PAC were created based on the ICF activities domain. Items relevant to individuals in post-acute care setting were chosen. The items were reviewed by 10 experts and feedback was provided by individuals with disabilities. (Haley et al., 2004)

Many items were selected from existing legacy measures.

Floor/Ceiling Effects

Rehabilitation Patients: (Coster et al., 2006; n = 516; mean age = 68.3 (14.97) years; data collected at 1, 6, and 12 months after discharge)

Excellent: No floor effects were observed across 3 assessments
Adequte: Physical and Movement Activity scales demonstrated low ceiling effects (less than 1% at 12 months)
Adequate: Personal Care and Instrumental scales had higher ceiling effects (16% at 12 months)
Poor: Applied Cognitive scale demonstrated the largest ceiling effects (27% at 1 month; 44% at 12 months)

Medically Complex: (McDonough et al., 2016, n=235)

Fair
- Percent with highest score (ceiling) of the Applied Cognition Scale by impairment group.

Short Form (15 items)

	Subjects n	Short Form (15 items)
		Mean score (SD)	Floor n(%)	Ceiling n( %)
Outpatient	235		0	65(27.7)
Neurological	97	47.2(10.1)	0	14(14.4)
Medically complex	39	51(9.2)	0	12(30.8)
Orthopedic	99	55.1(8.3)	0	39(39.4)

Full Item Bank (44 items)

	Subjects n	Full Item Bank (44 items)
		Mean Score (SD)	Floor n(%)	Ceiling n(%)
Outpatient	235		0	62(26.4)
Neurological	97	47.5(10.2)	0	12(12.4)
Medically complex	39	52.6(10.1)	0	12(30.8)
Orthopedic	99	56.9(8.8)	0	38(38.4)

Responsiveness

Rehabilitation Patients: (Coster et al., 2006)

Standard Response Means between 3 diagnostic groups (neurological, orthopedic, complex medical) ranged between -0.02 and 0.10 (small)
Mean positive changes ranged from 8.35 to 13.23 points from 1 to 6 months
Mean positive changes ranged from 4.64 and 7.56 points from 6 to 12 months

Orthopedic outpatient: Individuals with spine, lower-extremtiy and upper extremity impairments (Jette et al., 2007; n = 1815 seen in outpatient clinics)

Domain	n	Difference	Effect Size	SRM
Total	1703	5.45 (7.97)	0.59	0.68
Spine	666	4.83 (7.56)	0.62	0.64
EU	462	2.78 (6.87)	0.34	0.40
LE	575	8.32 (8.35)	0.91	1.00

Standard Error of Measurement (SEM)

Neurologic Cases: (Jette et al., 2015)

Basic Mobility: SEM=3.16 (n=102)
Daily Activity: SEM= 3.46 (n=105)

Minimal Detectable Change (MDC)

Neurologic Cases: (Jette et al., 2015)

Basic Mobility: MDC_{90% CI}=7.36 (n=102)
Daily Activity: MDC_{90% CI}=8.06 (n=105)

Neurologic Cases: (Jette et al., 2014; Mean Age=69, SD=15.6; n=10,085).

Basic Mobility: MDC_{90%CI =}4.72
Daily Activity: MDC_{90%CI =}5.49

Test/Retest Reliability

Neurologic Cases: (Jette et al., 2015)

Basic Mobility
- Excellent: ICC= 0.97 (n=102)
Daily Activity
- Excellent: ICC= 0.96 (n=105)

Interrater/Intrarater Reliability

Neurologic Cases:(Jette et al., 2015)

Basic Mobility (n=102)
- Excellent interrater reliability: ICC: r=.921, CI=0.830, 0.965
Daily Activity (n=105)
- Excellent interrater reliability: ICC= r=.907, CI=.801, 0.958

Internal Consistency

Neurologic Cases:(Jette et al, 2014)

Excellent:
- Bed Mobility: Cronbach’s alpha=.957
- Daily Activity: Cronbach’s alpha=.911

Neurologic Cases: (Robinson-Smith, Harmer, Sheeran, & Bellino Vallo, 2016; n=10)

Excellent:
- Bed Mobility: Cronbach’s alpha= .947
- Daily Activity: Cronbach’s alpha= .967

Floor/Ceiling Effects

Neurologic Cases: (Sandel et al, 2013; n=222)

Floor Effect:

Poor

Domains at Baseline	No, n (%)	Yes, n (%)
Basic Mobility (n = 222)	214 (96.40)	8 (3.60)
Daily Activity (n = 222)	216 (97.30)	6 (2.70)
Applied Cognitive (n = 222)	222 (100.0)	0 (0.00)
At 6 months
Basic Mobility (n = 220)	217 (98.64)	3 (1.36)
Daily Activity (n = 220)	219 (99.55)	1 (0.45)
Applied Cognitive (n = 220)	219 (99.55)	1 (0.45)

Ceiling Effect:

Poor

Baseline	No, n (%)	Yes, n (%)
Basic Mobility (n = 222)	211 (95.05)	11 (4.95)
Daily Activity (n = 222)	196 (88.29)	26 (11.71)
Applied Cognitive (n = 222)	198 (89.19)	24 (10.81)
At 6 months
Basic Mobility (n = 220)	214 (97.27)	6 (2.73)
Daily Activity (n = 220)	212 (96.34)	8 (3.64)
Applied Cognitive (n = 220)	196 (89.09)	24 (10.91)

Responsiveness

Neurologic Cases: (Jette et al., 2014)

Mean absolute differences between the scores for the first visit and last visit were 5.71 (95% CI=5.61, 5.80) for basic mobility and 4.61 (95% CI=4.49, 4.73) for daily activity
Standardized Response Means
- Basic Mobility: 1.06 (95% CI=1.04, 1.08)
- Daily Activity: 0.95 (95% CI=0.95, 0.97)

Minimal Detectable Change (MDC)

Hip Fracture: (Latham, 2008; n=108; mean age= 78.9; mean AMPAC physical mobility at baseline= 48.0; mean AMPAC physical mobility at 12 weeks= 59.7)

Distribution-Based Measures of Responsiveness (Baseline to Week 12)

Assessment	ES (Cohen’s d)	SRM	SE of Mean	MDC₉₀	Percentage Who Exceed MDC₉₀ (Baseline to Week 12) (%)
AM-PAC Physical Mobility	1.28	1.43	1.73	4.02	90.9
AM-PAC Personal Care	0.93	1.22	1.60	3.72	74.0

Minimally Clinically Important Difference (MCID)

Hip Fracture: (Latham, 2008)

MCID for mobility= 4.3
MCID for daily activity= 3.7

Normative Data

Hip Fracture: (Latham, 2008)

Study Sample Patient Characteristics

Assessment	Mean	Median	Range
AM-PAC Physical Mobility (0-100) Baseline	48.0+10.0	51.9	19.2-62.7
AM-PAC Physical Mobility (0-100) Week 12	59.7+8.2	60.2	29.0-82.5
AM-PAC Personal Care (0-100) Baseline	49.2+ 8.0	48.5	22.0-68.0
AM-PAC Personal Care (0-100) Week 12	57.0+8.8	58.2	35.0-68.1

Internal Consistency

Hip Fracture: (Latham, 2008)

Adequate: Cronbach’s Alpha= 0.93

Floor/Ceiling Effects

Hip Fracture: (Latham, 2008)

No subjects reached the floor or the ceiling at either time point for the AM-PAC Personal Care scale or AM-PAC Physical Mobility scale.

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Sandel, M. E., Jette, A. M., Appelman, J., Terdiman, J., TeSelle, M., Delmonico, R. L., ... & Chan, L. (2013). Designing and implementing a system for tracking functional status after stroke: A feasibility study. PM&R, 5(6), 481-490.

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Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Cost Description

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Cut-Off Scores

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Face Validity

Floor/Ceiling Effects

Responsiveness

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Test/Retest Reliability

Interrater/Intrarater Reliability

Internal Consistency

Floor/Ceiling Effects

Responsiveness

Minimal Detectable Change (MDC)

Minimally Clinically Important Difference (MCID)

Normative Data

Internal Consistency

Floor/Ceiling Effects

Bibliography

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