(TFTS-N): Reference Data for School Age Children

Academy of Pediatric Physical Therapy
Journal Discussion
April 2016:
Ar#cle:
TimedFloortoStand-Natural(TFTS-N):ReferenceDataforSchoolAge
Children
WeingartenG,LiebersteinM,ItzkowitzA,VialuC,DoyleM,KaplanS.Timedfloortostand-natural(TFTS-N):Referencedatafor
schoolagechildren.PediatrPhysTher.2016;28:71-76.
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Journal Discussion Facilitators
REGIONV:
DebRose,PT,DPT,PCS(VirginiaStateRepresenta_ve)
ConnieJohnson,PT,DSc(RegionVDirector)
JenniferHogue,PT,MSPT,NCS(WestVirginiaStateRepresenta_ve)
KarenGreeley,PT,DScPT(MarylandStateRepresenta_ve)
DoraGosselin,PT,DPT,PCS,CCI,C/NDT(NorthCarolinaState
Representa_ve)
SueCecere,PT,MHS(Sec_ononPediatricsVicePresident)
Journal Discussion Facilitators
REGIONIII:
LisaKenyon,PT,DPT,PhD,PCS(MichiganStateRepresenta_ve),
Kris#nHurley,PT,DPT(WisconsinStateRepresenta_ve)
Journal Discussion Facilitators
REGIONI:
ErinBompiani,PT,DPT,PCS(OregonStateRepresenta_ve),
KrisNakaji,PT,PCS(CaliforniaStateRepresenta_ve)
ToreyGilbertson,PT,DPT,PCS(WashingtonStateRepresenta_ve),
LisaMilkavich,PT(UtahStateRepresenta_ve)
Academy of Pediatric Physical Therapy
Journal Discussion
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LEARNING OBJECTIVES
FOR JOURNAL DISCUSSION:
Followingthisjournaldiscussion,par#cipantswillbeableto:
1.  Discusskeyaspectsofthecri#calappraisalforthe
selectedjournalar#cle.
2.  Analyzetherelevanceofthisknowledgetotheirown
se_ng.
Article
TimedFloortoStand-Natural(TFTS-N):ReferenceDatafor
SchoolAgeChildren
WeingartenG,LiebersteinM,ItzkowitzA,VialuC,DoyleM,KaplanS.Timedfloortostand-natural(TFTS-N):
Referencedataforschoolagechildren.PediatrPhysTher.2016;28:71-76.
Study Purpose / Hypothesis:
Purpose:ToestablishreferencedatafortheTFTS-Nbasedonalargediversegroup
oftypicallydevelopingschool-agechildrentakingintoaccountage,sex,andBMI.
Hypotheses:Notapplicable.
Rationale:
Ra#onale:RelevancewithIDEAmandateregardingevalua#onintheschoolse_ng(p.72)
• School-basedPTsarerequiredtouseavarietyofvalidandreliabletoolstodetermineskilldelays
andtosetinterven_ongoals.
• Norma_vevaluesfortestsandmeasuresthatarecontextuallyrelevanttoschoolsefngsare
importanttoassessfunc_on.
• Norma_veTFTS-NdatabyageandsexforchildrenwithTDwouldbeusefultoPTstodetermine
whetherchildrenwithdisabili_esperformthistransi_oninamannerfunc_onallyequivalenttotheir
ageandsex-matchedpeers.
Rationale:
Ra#onale:Importanceoftransi#onsforschoolsuccess(p.71-72)
Transi#onsoccurfrequentlyinclassroomandareimportantforschoolsuccess:
• Priorstudiescitedwithinthear_cle:
• Haveshown15-20transi_onsinafirstgradeclasseachdayand25%ofthedayforPre-K
studentsfortypicallydevelopingchildren.{6,7}
• Teachersreportedthatindependenttransi_onsare“veryimportant”or“essen_al”forschool
success.{6}
• Teachersreportedlyfocusonthespeedofthetransi_onratherthanthemovement
strategies.{8}
Background:
TFTS-NisadaptedfromtheTFTS(originallyadaptedfromTUG)
• Standardizedtestthatmeasurestheefficiencyoffloortostandtransferswithinthehomeandschoolenvironment(p.75)
TheTFTS-Nguidelinesreflecttypicalschoolbehaviorsinwhichstudentsarenotallowedtorun(moveatanaturalpace)andare
expectedtostandupontheteacher’srequest.”(p.71-72)
TFTS-Nwasfoundreliableandvalidina2015studybyWeingartenandKaplan.¹(p.72)
• Acceptablerangeofintratesterreliability
• Strongintertesterreliability—TFTS-Namong5testerswaspreviouslyestablishedasstrong(ICC(3,1)=0.988)
• Test-retestreliability
• TFTS-Nhasfacevalidityformeasuringthetransi_onofmovinginandoutofsifngonthefloor.
STUDYDESIGN:
•  Partofalargecross-sec#onalstudythatincludedgenera#ngnorma#vevaluesfor
otherassessmentsaswell(includingTimedUpandDownStairs,TimedUpandGo,30
secondwalktest,ShuFleRun).OnlyTFTS-Nresultsarereportedinthisstudy.
•  Conductedby5PTspartoftheNewYorkCityDepartmentofEduca#on(NYCDOE),
eachwithatleast10yearsofexperience.
•  ApprovedbyNYCDOEIRB.
POPULATION:
Aconveniencesampleof1650students:
• Thepopula_onrepresentedallfiveNYCboroughs
• 20elementaryandmiddleschoolspar_cipated(ofthe138NYCschoolscontacted)
• Agerange:5-14years(narrowedfromeligible5-17yostudents).
Exclusioncriteria:
•  Individualsnotbetween5and17yearsofage
•  HavinganIEP
•  Lackofparentalconsent
•  Hxoforthopedicsurgeryorinjuryinthelast6mos
•  Hxofgene#corneurologicaldisorder
POPULATION:
Subjectcharacteris_cs:
• 1,476completedthetest
• 174oftherecruited1,650wereexcludedforvariousreasons(inabilitytofollow
direc_ons,absenceonthedayoftes_ng,reloca_ontoanotherschool,havinganIEP,
refusaltopar_cipate,schedulingconflict)
POPULATION:
Subjectcharacteris_cs:
• Female=839/Male=637
• Ages5-14years
• Allagegroupswellrepresentedexcept14yearolds(n=11)and13yearolds(n=42)
• Ethnicallydiverse
• BMIcategoriesasdefinedbyCenterforDiseaseControlparameters:{12}
• underweight≤5thpercen_le(41%ofsubjects)
• healthy=5th-85thpercen_les(63.7%ofsubjects)
• overweight=85th-95thpercen_le(16.3%ofsubjects)
• obese≥95thpercen_le(15.9%ofsubjects)
RESEARCHPROCEDURES:
•  Tes#ngwascompletedover1-2daysoftes#ng(assumingTFTN-Swasperformed
alongwithotherassessmenttoolsbeingstudied)inlargeopenspace(gymor
hallway)
•  Subjectswerede-iden#fiedondatacollec#onsheets-codedwithnumbersfor
anonymity.
RESEARCHPROCEDURES,con#nued:
•  Procedurewasdescribedindetailmakingbothstudyandassessmenttoolvery
reproducibleinclinicorclassroomse_ng.(p.72-73)
•  HeightandWeightrecording:Specificscaleandmeasuringtoolwerenamed,
alongwithwhatdecimalplacewhichtorecord.(p.72)
•  BMIcalculatorfromwww.blubberbuster.com/height_weight.htmlwas
used.
RESEARCHPROCEDURES,con#nued:
•  Twotrialswereconductedtoensureperformancevariabilitywascaptured.
•  Studentsweregivenunlimitedtrialsasneededtocompletethetest
accordingtotheguidelines.
•  Thisisacommontask,sonoconcernsaboutmotorlearningorfa#gue
sincethetaskistypicallyperformedmul#ple#mesaday.
RESEARCHPROCEDURES,con#nued:
HowtoconductTFTS-Nassessment:
• 
Equipmentneeded:twopiecesoftape(3metersapart),#mer
• 
Explainanddemonstratethetest:
•  Promptsmustbeconsistentfortesters:
For5-8yo:“WhenIsaygo,standup,walktotheline,turnaround,walkbacktothestar#ngline,
andsitbackdown,crisscrossapplesauce.”
For9-17yo:“WhenIsaygo,standup,walktotheline,turnaround,walkbacktothestar#ngline,
andsitbackdownwithlegscrossed.”
“Walk,don’trun.1,2,3,Go.”
Studentmaytransi#onfromsi_ngtostandinginanymanner.
Tobecounted:bothfeetmustpassthesecondline,andsubjectmustsitbehindthestartline(legscrossed);not
countediftheyrun,triporfallduringthetrial.
STATISTICALANALYSIS:
•  SPSSVersion20soowareusedforalldata.
•  Descrip#veanalyses-runfortestsbyage,genderandBMI,ethnicdistribu#on,and
frequencyoftrials
•  Pairedttests-usedtodeterminedifferencebetween1stand2ndtrials
•  Pearsonr-todeterminehowcloselythetwotrialscorrelatedwithinagesandoverall
•  Independentttests-usedtocomparemalev.female#mes
•  One-wayanalysisofvariance(ANOVA)w/Bonferroniposthocanalyses-tocompare
#mesacrossBMIcategoriesw/inagegroups.
Table1:TFTS-N#mesforgenderandage.
TheaverageTFTS-N_mesacrossagegroupsrangedfrom7.91±1.65secondsto8.98±1.62seconds(withanoverall
differenceof1.06seconds).
Independentttestsyieldednodifferencesbetweenmalesandfemaleswithineachagebyyear.
Table2&3:Correla#onbetweenageandnumberofaFemptsfortrials
• 
Reasonablyconsistentperformances(moreconsistentwithincreasingage):
• 
• 
Trial1avg_meacrossages:8.38seconds(+or-1.61seconds)
Trial2avg_meacrossages:8.21seconds(+or-1.63seconds
Table4:TFTS-NwithBMIcategoryandage:
8yo,10yo,and12yowith“healthyBMI”werefasterby1sec(approx.)comparedtosameagepeersin“obeseBMI”
category.
NOTE:Theauthorsconcludethatthedifferenceofapproximately1secondisnotfunc_onallyrelevantintheschool
sefng.
AUTHORS’
DISCUSSION AND CONCLUSION:
ThisstudyoftheTFTS-Nprovidesnormreferencedvaluesforalargediverse,urbansampleoftypically
developing5-14yos.
The“Total”averagescoresreportedinTable1(p.74)canbeusedasreferencerangesforeachagegroup.
• Nosta_s_callysignificantdifferencebetweengenders,ORbetweentheBMIcategories
Thegreatervariabilitybetweentrialsinyoungerstudentsmaybearesultofdifferencesincogni#ve
processing.
“Theverysmalldifferenceof0.17secondsbetweentrials1and2isnotfunc#onallyimportant,asitisless
than1second.”(p.75)
• 
“IfaPTisshorton_meorastudenthasdifficultywiththetask,1trialwouldmostlikelybe
sufficientforobtainingafunc_onallyusefulbaseline_meontheTFTS-Nwhenthetes_ng
proceduresandcriteriaaremet,especiallyinolderchildren.”(p.75)
AUTHORS’
DISCUSSION AND CONCLUSION:
• TFTS-Nisastandardizedtestthatmeasurestheefficiencyoffloortostandtransfers
withinthehomeandschoolenvironment(p.75)
• Usefultestforschool-basedPTsbecauseitsimulatesthefunc_onaltaskof
transi_oningtoandfromthefloor,whichoccursmul_ple_mesaday(p.75)
• Whenateacherreportsconcernsaboutastudent’sabilitytotransi_onefficiently
duringcircle_meorwithinotherschoolsefngs,theTFTS-Nmaybeappropriateto
determinehow1student’sspeedcomparestootherage-matchedchildrenwithTD(p.
75)
AUTHORS’
DISCUSSION AND CONCLUSION:
• TFTS-Nprovidesareferencetouseforstudentswithdisabili_es
whoareplacedinregularclassrooms,andmayprovidea
reasonabletargetrangeforsefnggoals(p.75)
• Standarddevia_onsarelessthan2secondsforallagegroups(p.
75):
• Evenastudentwhotransi_onswithin2standarddevia_ons,or4secondsofthe
referencevalue,maywellbefunc_onallyperformingwithinanacceptablerangefor
schoolorclassroomtransi_ons.
AUTHORS’
DISCUSSION AND CONCLUSION:
• “TherapistsshouldusetheTFTS-Ninconjunc_onwithother
examina_onandevalua_onresultstodetermineaneedfor
physicaltherapyservicesandtosetgoalsforanIEP.”(p.75)
• “…whentheTFTS-Ntes_ngproceduresareusedrepeatedly(eg,
monthlyandquarterly),PTscanusetheresultstomonitorstudent
progressorassesstheefficacyoftreatmentinterven_onsdirected
attransi_onsfromandtothefloor.”(p.75)
AUTHORS’
DISCUSSION AND CONCLUSION:
LIMITATIONSOFTHESTUDY:
• Observa_onofactualperformance(withintheclassroom)inconjunc_onwithTFTS-Nscoresis
importantfordeterminingfactorsthatcontributetoperformancewithtransi_ons
• Sefngfortes_ng(emptyhallwayorgym)wasnotanaccuraterepresenta_onofatypicalclassroom
environmentinwhichdistrac_ons,andobstaclesmaycontributetoperformance.
• Theneedtoaccomplishaddi_onaltaskswhile“upandabout”intheclassroomisnotreflectedinthe
TFTS-Nvalues(i.e.,taskssuchasretrievalofclassroommaterialsorwri_ngontheboard)
• “Addi_onaltes_ngofchildrenwithatypicaldevelopment,withspecificdisabili_esorwith
cogni_vechallenges,maybeadvantageous,withtheaimofexpandingtheuseoftheTFTS-Nfor
allchildren.”(p.76)
REVIEWERS’
DISCUSSION AND CONCLUSION:
STRENGTHS:
Largesamplesize(except13and14yearolds)
Procedurewelldescribedforrepeatability
REVIEWERS’
DISCUSSION AND CONCLUSION:
LIMITATION/POTENTIALFORBIAS:
Thetestdoesnotassessthequalityofthestudent’s
movement.
REVIEWERS’
DISCUSSION AND CONCLUSION:
APPLICABILITY:
Func#on-basedassessmenttoolforallpediatricse_ngs(Clinic/
classroom/communityscreenings)withatleast3metersof
clinicalspace.
Usefulforchildrenbetweentheagesof5-14yo:cancompare
theirspeedintransi#onstootherstheiragewithtypical
development.
•  Similartothe6MWTortheTUG,thisreferencedatacanshow
howclients“chalk-up”totheirpeers.
•  Thedatamayprovideusefulinforma#onfor:
• 
• 
• 
DeterminingPTplanofcare.
Providingatargetrangeforsefnggoalsforclassroomorclinic.
Alwaysusewithotherfunc6onalobserva6onsorassessmentswhense:nggoals
ordeterminingPTeligibility.
•  TFTS-Nfromsessiontosession:Canbeusedtotrack
progressover#me.
• 
• 
Researchhasnotreportedwhatcons_tutesameaningfulchangewhichis
necessarytouseasanevalua_vemeasure.
Asthear_clestates,“whentheTFTS-Ntes_ngproceduresareused
repeatedly(eg,monthlyandquarterly),PTscanusetheresultstomonitor
studentprogressorassesstheefficacyoftreatmentinterven_onsdirectedat
transi_onsfromandtothefloor.”(p.75)
Discussion Questions:
1. 
2. 
3. 
No#ngthefrequencyofyoungstudentstransi#oningfromthefloortostand:doyou
thinkthatyouwillu#lizetheTFTS-Nreferencedatawithingoalwri#ngandinevalua#on
inyourprac#ce?Doyouthinkyouhaveadequatedetailstoperformthetes#ng
procedureinyourse_ng?
Howwouldyouexplainthisprocedureandinterprettheresultstofamiliesandother
teammembers?
Thear#clecitespriorstudieshaveshownteachersarelessinterestedinthequalityor
methodoftransi#oningfromthefloor,butmoreconcernedabouthowmuch#me
transi#onstake.PTmaybemoreinterestedinthequalityofmovementormethodof
movingupfromfloor.HowdoPTsbalancethesepriori#es?
Discussion Questions, continued:
White
Asian/Pacific
Islander
Black/AfricanAmerican
Other/Mul#ple
TFTS-NSubjects
29.3%
24.3%
15.9
10.1
US
77.4%
5.6%
13.2
2.5
4.Thechildreninthestudyrepresentadiversepopula#on.Dothesubjectsrepresentthe
demographicbreakdowninyourcommunity?Doyouthinkthismayhaveimpactedthefindings?
5.CouldyouusethistooltoassistyoutocreateinclusivegoalswithotherIEPteammembers?
Discussion Questions, continued:
6.Doyouthinkthedatawasinfluencedbythetypicalac#vitylevelintheenvironment
(urban)versusac#vitylevelsforchildreninotherenvironments(ruralorsuburban)?Wouldit
beusefultoreplicatethisstudyinanothergeographicarea?
7.Whatdothinktheoutcomeswouldbewithchildrenwithdisabili#es?Wouldtheoutcome
beimpactedbytheuseofortho#csorassis#vedevices?Whatotherfactors(personal,
environmental)mightimpactthespeedofperformingthistaskforchildrenwithandwithout
disabili#es?
8.Whatdoyouthinkaboutthebreakdownofthesamplepopula#onintermsofBMI?Doesit
reflectthepopula#onyousee?Wereyousurprisedtherewasnodifference?Whathaveyou
observed?
Discussion Questions, continued:
9.TheauthorsprovidetheTFTS-Nreferencevaluesbutnotethatchildrenwhoperform2
standarddevia#onsabovethemeanreferencevalueforanagegroupmaybeacceptable.
Howmightyouinterpretthisinyourse_ng?Whenis#meoftransi#onfromfloorcrucialin
yourse_ng?
10.Whatinterven#onsdoyouprovidetoimprovefloortostandtransi#ons?Whathaveyou
foundeffec#ve?
Discussion Questions, continued:
11.Whatother“func#onalobserva#ons”ortests/measuresdoyouincludeinyour
evalua#onforfloortostandtransi#ons?
12.Overalltakehome:
Whatweresomestrengthsofthisstudy?Whatdidyoulikeaboutthestudy?
Whatweresomeweaknessesofthestudy?
Whatfuturestudiesdoesthisstudysuggesttoyou?
ASPECIALTHANKSTOTHEMANYCONTRIBUTORSTOTHISJOURNALDISCUSSION:
•  Ar#cleselec#on,appraisalanddiscussionques#onsby:
AcademyofPediatricPhysicalTherapySchool-basedSIG(Chair,LaurieRay)
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RegionVI-KarenPryor
•  Ar#cleappraisalreviewandcontribu#onsby:
LisaKenyon,PT,DPT,PhD,PCS
KimberlyKlug,PT,DSc,PCS
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