Participation Assessment with Recombined Tools-Objective

Last Updated

December 27, 2013

Purpose

The PART-O 17 and the original measure (PART-O) item combines items from widely used instruments in TBI rehabilitation research based on the International Classification of Functioning, Disability, and Health’s concept of this participation domain description, which includes involvement in life situations – a key outcome of rehabilitation. It has 3 subscales (productivity, social relations, and out and about in the community). Scoring options include overall, balanced scoring, and Rasch scoring.

Link to Instrument

Instrument Details

Acronym PART-O

Area of Assessment

Activities of Daily Living

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

The Traumatic Brain Injury Model Systems (TBIMS) website provides links to the manual and rating sheet that can be used freely but not altered.

Diagnosis/Conditions

Brain Injury Recovery
Spinal Cord Injury
Stroke Recovery

Spinal Injuries

Brain Injury

This instrument was developed via consolidation of three participation/community integration measures commonly used in TBI research:
·         Community Integration Questionnaire - both original (CIQ) and revised
(CIQ-2) versions
·         Participation Objective, Participation Subjective (POPS)
·         Craig Handicap and Assessment Reporting Technique (CHART)

Number of Items

24 (Revised to 17)

15-30 minutes

15 minutes for the PART-O 17 item measure (30 minutes for the 24 item PART-O)

Required Training

No Training

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Intially reviewed by Candy Tefertiller, PT, DPT, ATP, NCS, Jennfer H. Kahn, PT, DPT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Anna de Joya, PT, DSc, NCS, Coby Niridier, PT, DPT, and the TBI EDGE task force of the Neurology Section of the ATPA in 5/2012.

ICF Domain

Participation

Measurement Domain

Activities of Daily Living
Participation & Activities

Professional Association Recommendation

Common Data Elements

Supplemental: Traumatic Brain Injury (TBI)

Exploratory: Cerebral Palsy (CP)

More information here

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 (VEDGE) 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 for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

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 based on SCI AIS Classification:

	AIS A/B	AIS C/D
SCI EDGE	LS	LS

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)
SCI EDGE	No	No	No	Not reported
TBI EDGE	No	No	Yes	Not reported

Considerations

There are 2 scoring algorithms that evolved from studies using PART-O. The first algorithm takes the overall score and assumes more participation is better. The second algorithm assumes that a balance of participation across each of the domains is better. Rasch scoring has been established for the 24-item PART-O measure (Malec et al, 2017).

PART-O and PART-O assess ICIDH2 domains d3, d4, d6, d7, d8, and d9 with a total of 19 main concepts of participation using refined ICF linking rules (Ballert, Hopfe, Mauder, & Prodinger, 2019).

TBI EDGE task-force reviewed measures of each ICF domain with regards to validation, use, and clinical utility for the TBI populations at each level of care. A delphi process was used to assess measures for inclusion as a recommended TBI measure using a 4-point rating that ranged from 1 (not recommended) to 4 (highly recommended). PART-O retained a rating of 2 (Reasonable to use but limited study in target group) with a notation that there were growing number of studies, and clinicians working with TBI should monitor ongoing evidence emerging from TBIMS. (McCulloch et al, 2016).

Future research to determine whether Balanced Total Score algorithm vs. Averaged Total score algorithm should be used to most appropriately understand participation and its relationship with other constructs (Bogner et al 2011).

There is the potential of reducing the number of PART-O items or the implementation of computer adaptive testing to reduce respondent burden and allow more efficient measurement (Whiteneck, 2011).

Authors recommend that the PART-O be scored by summing item responses after items are scored on a point scale of 0 to 5 (eg, dichotomous questions scored no=0 and yes=5) (Whitenck, 2011).

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Test/Retest Reliability

Whiteneck, Gassaway, and Ketchum, 2019, spinal cord injury; n=103)

Excellent Pearson test-retest coefficient=0.966 (95% CI, 0.950-0.977)

Internal Consistency

Rasch analysis was used to evaluate internal consistentcy
Infit and outfit were calculated and items falling outside of accepted range of 0.6 - 1.4 were removed.

Criterion Validity (Predictive/Concurrent)

(Whiteneck, Gassaway, and Ketchum, 2019, spinal cord injury; n=80)

Reliability Change Index = ±3.10

Construct Validity

(Whiteneck, Gassaway, and Ketchum, 2019, spinal cord injury; n=80)

Excellent correlation between Chart-SF and PART-O (r=0.788)

Content Validity

(Whiteneck, Gassaway, and Ketchum, 2019, spinal cord injury; n=376)

Psychometric properties from Rasch analysis of developmental and validation samples

Psychometric Properties	Developmental Sample	Validation Sample
Person separation	2.00	1.91
Person reliability	0.80	0.79
Item separation	11.01	8.57
Item reliability	0.99	0.99
First contrast eigenvalue	1.76	1.80
Maximum item infit mean square	1.26	1.20
Maximum item outfit mean square	1.32	1.28
No. of items with disordered responses	0.00	1.00
Total no. of disordered responses	0.00	1.00
Percent of cases at floor	0.00	0.00
Percent of cases at ceiling	0.00	0.00

Standard Error of Measurement (SEM)

(Bogner et al, 2017, n=224, mean age = 39.85 (18.18) persons with a moderate-severe TBI enrolled in the Traumatic Brain Injury Model Systems National Database)

Total score SEM = 0.21
Out and About subscale SEM = 0.33
Productivity subscale SEM = 0.36
Social subscale SEM= 0.35

Normative Data

Traumatic Brain Injury:

(Whiteneck et al, 2011; n = 400; 1 to 15 years post-injury; 71% male; mean age = 36.6(17.0) years, mean score: 45.4 +/- 9.3 points)

Negative correlation found with age (-0.23; p < 0.001)
Significant differences found with education level p = 0.001
Significant differences found with marital status and ethnicity (p < 0.001)

(Ehrler, 2018, n=1947, community-dwelling participants post-TBI)

	Year 1 post-TBI	Year 2 Post-TBI	Year 5 post-TBI
Malec et al (2016) Rasch-adjusted PART-O	53.31 (8.45)	53.72 (8.34)	53.45 (9.23)
Malec et al (2016) raw score	11.19 (3.54)	11.35 (3.58)	11.29 (3.80)
Averaged total score	1.70 (0.66)	1.73 (0.68)	1.73 (0.72)
Productivity domain	1.19 (0.96)	1.24 (0.98)	1.28 (0.99)
Social relations domain	2.28 (0.93)	2.31 (0.96)	2.29 (0.99)
Out and about domain	1.62 (0.72)	1.65 (0.74)	1.62 (0.76)

Test/Retest Reliability

(Bogner et al, 2017, n=224, mean age = 39.85 (18.18) persons with a moderate-severe TBI enrolled in the Traumatic Brain Injury Model Systems National Database)

Total score ICC = 0.90 (CI 0.87-0.92)
Out and About subscale ICC = 0.79(CI 0.73-0.83)
Productivity subscale ICC = 0.87(CI 0.83-0.90)
Social subscale ICC = 0.87(CI 0.83-0.90)

Interrater/Intrarater Reliability

Internal Consistency

Rasch analysis was used to evaluate internal consistentcy
Infit and outfit were calculated and items falling outside of accepted range of 0.6 - 1.4 were removed.

(Wen, Waid-Ebbs, Graham, Helmer, 2018, n=102, mean age = 34.65(6.9), veterans with mild TBI)

Acceptable Cronbach’s α= 0.65
Misfit item appears to be “Do you live with your spouse or significant other?”” (information-weighted mean square= 1.45, information-weighted z-standardized.= 3.3)

Criterion Validity (Predictive/Concurrent)

Traumatic Brain Injury:

(Whiteneck et al, 2011)

Concurrent Validity: PART-O was associated strongly with other participation and functional measures, particularly those assessed at follow-up concurrently with participation data collection, rather than at rehabilitation discharge
Excellent correlation with the Mayo-Portland Participation Index (M2PI) (0.69; p < 0.001); assessed concurrently with self-report items
Adequate to Excellent correlations (p < 0.001) were found with Cognitive FIM (0.61), Motor FIM (0.59), Supervision Rating Scale (SRS) (-0.64), Glasgow Outcome Scale-Extended (GOS-E) (0.61), and Disability Rating Scale (DRS) scores (-0.70) at follow-up; all indicating that greater functional independence was associated with greater participation
Adequate correlations (but statistically significant at p < 0.001) were found between PART-O and functional measures assessed at inpatient rehabilitation discharge (Cognitive FIM, r = 0.33; Motor FIM, r = 0.36; DRS, r = -0.32), although in 26% of cases, discharge was 5 or more years before PART-O assessment
Adequate correlation with the Satisfaction With Life Scale (SWLS) score at follow-up (r = 0.34; p < 0.001)

Construct Validity

Traumatic Brain Injury:

(Whiteneck et al, 2011)

Using Rasch rating scale analysis to evaluate the psychometric properties of participation items drawn from 3 instruments:
- Set of 24 items was developed that covered a broad range of participation content
- Formed a measure with person separation of 2.47, person reliability of 0.86, item spread of 4.25 logits, item separation of 11.36, and item reliability of 0.99
- Items were well targeted on the sample with only 1 item misfitting
Principal component analysis of residuals:
- Rasch-derived measure accounted for 88.1% of the item variance.
- Only 1.1% of the variance was explained by the next factor
- Authors conclude that the 24-item PART-O is essentially unidimensional.
Correlation with legacy measures: (p < 0.001)
- Excellent correlation with CIQ-2 (0.83)
- Excellent correlation with CHART-SF (based on the sum of the 5 included subscales) (0.82)
- Excellent correlation with the POPS objective component (0.79)
Excellent correlation: CIQ-2 Social Integration subscale and the CHART-SF Mobility subscale had the highest correlations with PART-O (0.79 and 0.78, respectively) (p < 0.001)
Excellent subscale correlations (greater than 0.60) with PART-O included (p < 0.001):
- CHART-SF Occupation (0.66), Social Integration (0.62), Cognitive Independence (0.60)
- CIQ-2 Productivity (0.62)
- POPS Interpersonal (0.63) and Community (0.63)
Adequate subscale correlations (greater than 0.50) with PART-O included (p < 0.001):
- CHART-SF Physical Independence (0.54)
- CIQ-2 Home Integration (0.52)
Three POPS subscale correlations with PART-O were slightly lower, but still significant (p < 0.001): Major Life Areas (0.48), Domestic (0.48), and Transportation (0.36)
Demographic and injury related variations in participation: No significant differences were found by sex, cause, or years post-injury, but a significant negative correlation was found between PART-O score and age (-0.23; p < 0.001), indicating that older people had lower participation measures
PART-O scores were not related to severity of injury, reflected by Glasgow Coma Scale (GCS) scores and days to emerge from post-traumatic amnesia (PTA), but were related weakly to days of unconsciousness (r = 0.11; p < 0.04), with greater severity associated with less participation

Content Validity

Traumatic Brain Injury:

(Whiteneck et al, 2011)

Pool of 69 items formed by combining the CHART, CIQ-2, and POPS;
Items grouped together in content areas such as autonomy in self-care, household management, social activities, and work and pilot tested with 13 persons with TBI via telephone interviews Interviewers completed the M2PI after they had administered items from the CIQ-2, CHART, and POPS
Rasch analysis used to reduce 69 items to 24 items requiring five rounds of measuring item infit and outfit values
24 items had a spread of 4.25 logits between the item least often endorsed and the item most often endorsed
All infit statistics were within boundaries for goot fit (0.7-1.40) except 1 item: Number of time respondent socializes with friends by telephone or at home in a typical week, but was retained due to relevance of content to construct of participation
24 PART-O demonstrated person separation of 2.47 and person reliability of 0.86. Item separation was 11.36 with item reliability of 0.99; demonstrating ability to reliability measures differences in participation

(Wen, Waid-Ebbs, Graham, Helmer, 2018, n=102, mean age = 34.65(6.9), veterans with mild TBI)

Rasch Analysis

Summary Statistics	PART-O (17 Items)
No. of item misfit (%)	1 (5.9)
Item reliability	0.96
Item separation	5.24
Range of item difficulty, logits	−1.00 to 0.90
Person reliability	0.78
Person separation	1.87
Strata	2.8
Cronbach α	0.65
Person mean ± SD, logits	−0.25±0.47
Ceiling/floor	0/0
Eigenvalue of primary dimension (% of variance explained)	9.8 (36.6)
Eigenvalue of first contrast (% of variance explained)	2.9 (10.7)

Floor/Ceiling Effects

(Wen, Waid-Ebbs, Graham, Helmer, 2018, n=102, mean age = 34.65(6.9), veterans with mild TBI)

No floor or ceiling effects found

Construct Validity

Spinal Cord Injury, Stroke, Traumatic Brain Injury, General Population:

(Bogner et al, 2011; spinal cord injury, stroke and traumatic brain injury n = 220; general population who self-reported disability n = 366; general population who self-reported no disability n = 284; Mean age: spinal cord injury, stroke and traumatic brain injury: 43.10 (12.67); general population no disability: 45.50 (11.42); general population with disability: 49.95 (10.35))

Excellent correlation between the PART-O Averaged Total Score and the PART-O Balanced Score for the combined sample (Spearman rho = 0.84), and similar correlations were found when each group was examined separately.
Poor correlations of the domain scores with each other for the combined sample, but as expected, stronger correlations with the total scores. Similar patterns of association were observed when the groups were considered singly.
Item-subscale correlations:

Correlations Between Domain Scores, 3 Samples Separately and Combined
Score
Sample	Productivity	Social Relations	Out and About	PART-O Averaged Total
General Population: no disability
Productivity	1.00
Social Relations	0.21	1.00
Out and About	0.19	0.28	1.00
PART-O Averaged Total	0.65	0.74	0.67	1.00
PART-O Balanced Total	0.56	0.30	0.75	0.84
General Population: disability
Productivity	1.00
Social Relations	0.31	1.00
Out and About	0.32	0.28	1.00
PART-O Averaged Total	0.74	0.74	0.67	1.00
PART-O Balanced Total	0.71	0.30	0.76	0.84
SCI, Stroke and TBI
Productivity	1.00
Social Relations	0.24	1.00
Out and About	0.26	0.28	1.00
PART-O Averaged Total	0.76	0.70	0.64	1.00
PART-O Balanced Total	0.74	0.39	0.64	0.84
Combined
Productivity	1.00
Social Relations	0.34	1.00
Out and About	0.28	0.31	1.00
PART-O Averaged Total	0.74	0.77	0.64	1.00
PART-O Balanced Total	0.68	0.42	0.74	0.84

Content Validity

Spinal Cord Injury, Stroke, Traumatic Brain Injury, General Population:

(Bogner et al, 2011)

The following process was utilized to develop the three content domains of PART-O: productivity, social relations, and community involvement which also decreased 24 items to 17 items
A consensus process was used to determine which items were critical for inclusion in the total score and how the items were to be classified in each of 3 content domains
Researchers from the National Institute on Disability and Rehabilitation Research TBI and Spinal Cord Injury Model Systems evaluated the items to ensure that each reflected an aspect of participation relevant to most of the population
A consumer advisory group consisting of persons with brain injury, family members, rehabilitation professionals, and advocates serving on the Research Committee of the Ohio Valley Center reviewed the researchers’ initial classifications and suggested alternative classifications, with their primary focus on items for which the researchers had not achieved consensus
Input from the advisory group was consolidated with that of the researchers. Items for which there was consensus were assigned to a domain

Normative Data

(Chang et al. 2019; N= 269; mean age 55.36 +/-12.46; 70.6% male, patients receiving outpatient rehabilitation for stroke)

PART-O
	Mean ± SD at the Baseline (N=269)	Mean ± SD at Post-Rehab (N=233)	Mean ± SD of Score Change
Social	2.83±0.71	2.93±0.73	0.10±0.29 ^∗
Community	0.80±0.40	0.98±0.45	0.15±0.29^∗
Productivity	0.60±0.69	0.64±0.73	0.02±0.53
All	1.41±0.41	1.51±0.45	0.09±0.22^∗

Interrater/Intrarater Reliability

(Malec, Whiteneck, & Bogner, 2016)

Excellent Rasch analysis found inter-rater reliability (person reliability =0.80)

Internal Consistency

(Malec, Whiteneck, & Bogner, 2016)

Rasch analysis found item misfit using the 0-5 scale. Reducing rating scales to 3 levels (except the dichotomous items) demonstrated good fit and person reliability (0.81)

Construct Validity

Brandenburg, Worrall, Rodriguez, and Bagraith, 2015 list the PART-O as a frequency measure of participation used in populations with aphasia which has items that do correspond to participation as defined in the WHO-ICF 2001 concept of participation categories of d7, d8, and d9.

(Chang et al. 2019; N= 269; mean age 55.36 +/-12.46; 70.6% male)

Moderate to Fair correlation with PM-3D4D

Baseline PM-3D4D	Postrehabilitation Spearman Correlation (P Value)
PART-O
Social	0.33 (<.0001)^∗
Community	0.58 (<.0001)^∗
Productivity	0.50 (<.0001)^∗
Total	0.60 (<.0001)^∗

Found to be less sensitive to change than PM-3D4D.

Content Validity

(Malec, Whiteneck, & Bogner, 2016).

Rasch metrics across samples

Variable	Year 1: Sample 1	Year 1: Sample 2	Year 2	Year 5	Year 10	Years 15–25	Final Calibration Sample
Calibration sample n	458	463	474	469	502	498	9677
Person reliability/separation	0.81/2.07	0.76/1.79	0.79/1.92	0.80/2.00	0.80/1.97	0.79/1.97	0.80/1.98
Item reliability/separation	1.00/15.60	1.00/15.19	1.00/16.54	1.00/16.68	1.00/17.59	1.00/17.59	1.00/71.86
Infit range	0.83–1.31	0.85–1.25	0.84–1.27	0.83–1.38	0.89–1.28	0.81–1.21	0.81–1.32
Outfit range	0.76–1.36	0.83–1.34	0.73–1.51	0.72–1.46	0.88–1.34	0.66–1.31	0.71–1.39
Eigenvalue for the first contrast in principal component analysis	1.5	1.8	1.5	1.5	1.6	1.6	1.4

Responsiveness

(Chang et al. 2019; N= 269; mean age 55.36 +/-12.46; 70.6% male)

	Standardized Response Measure (95% CI)
Social	0.33 (0.22-0.44)
Community	0.53 (0.41-0.67)
Productivity	0.04 (-0.09 to 0.16)
All	0.40 (0.28-0.53)

Bibliography

Bogner, J. A., Whiteneck, G. G., et al. (2011). "Comparison of scoring methods for the participation assessment with recombined tools-objective." Archives of Physical Medicine and Rehabilitation 92(4): 552-563.

Bogner, J. A., Whiteneck, G. G., MacDonald, J., Juengst, S. B., Brown, A. W., Philippus, A. M., … Corrigan, J. D. (2017). Test-Retest Reliability of Traumatic Brain Injury Outcome Measures: A Traumatic Brain Injury Model Systems Study. Journal of Head Trauma Rehabilitation, 32(5), E1. http://doi.org/10.1097/htr.0000000000000291

Brandenburg, C., Worrall, L., Rodriguez, A., & Bagraith, K. (2015). Crosswalk of participation self-report measures for aphasia to the ICF: what content is being measured? Disability & Rehabilitation, 37(13), 1113. http://doi.org/10.3109/09638288.2014.955132

Chang, F. H., & Ni, P. (2019). Responsiveness and Predictive Validity of the Participation Measure–3 Domains, 4 Dimensions in Survivors of Stroke. Archives of physical medicine and rehabilitation, 100(12), 2283-2292.

Erler, K. S., Whiteneck, G. G., Juengst, S. B., Locascio, J. J., Bogner, J. A., Kaminski, J., & Giacino, J. T. (2018). Predicting the Trajectory of Participation After Traumatic Brain Injury: A Longitudinal Analysis. Journal of Head Trauma Rehabilitation, 33(4), 257. http://doi.org/10.1097/htr.0000000000000383

Malec, J. F., Whiteneck, G. G., & Bogner, J. A. (2016). Another look at the PART-O using the traumatic brain injury model systems national database: scoring to optimize psychometrics. Archives of physical medicine and rehabilitation, 97(2), 211-217.

Malone, C., Erler, K. S., Giacino, J. T., Hammond, F. M., Juengst, S. B., Locascio, J. J., ... & Bodien, Y. G. (2019). Participation Following Inpatient Rehabilitation for Traumatic Disorders of Consciousness: A TBI Model Systems Study. Frontiers in Neurology, 10.

McCulloch, K. L., de Joya, A. L., Hays, K., Donnelly, E., Keller Johnson, T., Nirider, C. D., … Ward, I. (2016). Outcome Measures for Persons With Moderate to Severe Traumatic Brain Injury: Recommendations From the American Physical Therapy Association Academy of Neurologic Physical Therapy TBI EDGE Task Force. Journal of Neurologic Physical Therapy, 40(4), 269.

Wen, P. S., Waid-Ebbs, J. K., Graham, D. P., & Helmer, D. A. (2018). Psychometric properties of 2 participation measures in veterans with mild traumatic brain injury. Archives of physical medicine and rehabilitation, 99(2), S86-S93.

Whiteneck, G. G., Gassaway, J., & Ketchum, J. M. (2019). Transforming a Traumatic Brain Injury Measure of Participation Into a Psychometrically Sound Spinal Cord Injury Participation Measure. Archives of Physical Medicine & Rehabilitation, 100(12), 2293–2300. https://doi.org/10.1016/j.apmr.2019.06.020

Whiteneck, G. G., Bogner, J. A., et al. (2011). "Advancing the measurement of participation." Archives of Physical Medicine and Rehabilitation 92(4): 540-541.

Whiteneck, G. G., Dijkers, M. P., et al. (2011). "Development of the participation assessment with recombined tools-objective for use after traumatic brain injury." Archives of Physical Medicine and Rehabilitation 92(4): 542-551.

Last Updated

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

Test/Retest Reliability

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Standard Error of Measurement (SEM)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Internal Consistency

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Floor/Ceiling Effects

Construct Validity

Content Validity

Normative Data

Interrater/Intrarater Reliability

Internal Consistency

Construct Validity

Content Validity

Responsiveness

Bibliography

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