Mininder S. Kocher, MD


Published 6/1/2015
Jay D. Lenn

Measuring Pediatric Treatment Outcomes

OREF grant recipient is developing a valid pediatric sports activity scale

Patient feedback on treatment outcomes plays a critical role in both clinical practice and research. Questionnaires or rating scales provide information about symptoms, the effect of injuries on joint and muscle function, the effects on functional abilities and activities, and changes in any of these factors after treatment.

One such patient-derived outcome assessment is a sports activity scale. Several of these scales are available, but they were initially developed and validated with adult patients and are not necessarily valid assessment tools in pediatrics.

Mininder S. Kocher, MD, associate director of sports medicine at Boston Children’s Hospital, defined the dilemma this way: “Right now we’re using adult scales with children and adolescents. That’s problematic. We don’t use an adult blood pressure cuff on a child. Why should we use an adult outcome instrument with kids?”

To address this gap in measuring pediatric treatment outcomes, Dr. Kocher received a 2013 Pediatric Orthopaedic Society of North America/Orthopaedic Research and Education Foundation (POSNA/OREF) Research Grant in Pediatric Orthopaedics. Dr. Kocher and his research team are evaluating the usability of adult-based sports activity scales with pediatric patients, developing a pediatric sports activity scale, and assessing the validity of the new tool.

The POSNA/OREF Research Grant in Pediatric Orthopaedics—a 1-year, $30,000 award—funds clinical or basic science research that supports POSNA’s mission to improve the care of children with musculoskeletal disorders and OREF’s mission to support excellence in orthopaedic research.

Assessing current tools
The need for a pediatric instrument is great. More than 38 million children and adolescents participate in organized sports in the United States. Annually, more than 2.6 million youth are seen in emergency departments for injuries related to sports and recreation. Effective intervention and research to improve treatment for this population depend on the use of appropriate outcome measures.

Commonly used sports activity scales differ in format, the type of information requested, level of detail, and method of recording answers. But all of them are designed to elicit information about the type, frequency, and intensity of sports activity.

These scales, although valid for adult patients, may not be appropriate for assessing outcomes in children for several reasons, including the following:

  • The format may be confusing to a child.
  • The questions may be difficult for the child to comprehend.
  • The patient may be unfamiliar with the medical or sports terms used.
  • The scale may include activities that are not relevant to children or adolescent sports activities, or it might omit relevant activities.
  • The scale may not consider the wide spectrum of activity levels within a single sport—from informal recreational programs to more rigorous travel-team programs.
Mininder S. Kocher, MD
Dr. Kocher in the operating room
Courtesy of Mininder S. Kocher, MD

To examine these issues, Dr. Kocher and his team enrolled 60 participants who had been evaluated for lower-extremity sports injuries. Each of the three age groups (10–12 years; 13–15 years, and 16–18 years) had an equal number of male and female participants. Each participant was asked to complete one of five common sports activity scales: the Tegner Activity Scale, the Marx Activity Scale, the Cincinnati Sports Activity Scale, the KOOS Function in Sport and Recreation Scale, or the Knee Outcome Survey Sports Activity Scale.

Each patient then participated in a structured interview with a member of the research team. “We talked to the kids about their comprehension of the questions,” explained Dr. Kocher. “What problems did they have with the questions, which questions were relevant, which questions weren’t. That gave us plenty of interesting data that have allowed us to develop a new outcome instrument for sports activity levels in kids.”

Testing a new pediatric scale
In the second phase of the project, the researchers are assessing the new activity scale for test-retest reliability, construct validity, content validity, criterion validity, and responsiveness to change. “We need to determine whether the questions really ask what we think they’re asking and how those scores change over time with treatment,” stated Dr. Kocher.

For this type of analysis, the investigators have recruited three separate groups of 100 patients. One group will complete the form once. The second group will complete the form twice at an interval of 2 weeks. The third group will complete the form before surgical treatment and 6 months after surgery.

“I think the orthopaedic community understands that adult instruments may not be appropriate for children and adolescents,” said Dr. Kocher. “But we need to point out the deficiencies with the current instruments and be able to demonstrate the reliability, validity, and responsiveness of this new instrument.”

The value of orthopaedic research
“Our field is driven by research and innovation,” Dr. Kocher said. “That’s never been more important than it is today. Our patients, their parents, our hospitals, the payers, the government—they all want to know the comparative effectiveness of treatments.”

Dr. Kocher added that better data can enable evidence-based comparisons. “Those data are going to come from high-quality research,” he said. “And that research has to be supported. For many of us doing clinical research, OREF support has been essential.”

Jay D. Lenn is a contributing writer for OREF. He can be reached at

Additional Information
Sports and recreation safety fact sheet
(2013). Safe Kids Worldwide. Accessed Dec. 3, 2014.