JHT READ FOR CREDIT ARTICLE #147. Modification of the Upper Limb Functional Index to a Three-point Response Improves Clinimetric Properties Charles Philip Gabel, MSc Faculty of Science, Centre for Healthy Activities, Sport and Exercise, University of the Sunshine Coast, Queensland, Australia Lori A. Michener, PhD, PT, ATC Department of Physical Therapy, Virginia Commonwealth University, Virginia, USA Markus Melloh, MD, MPH Section of Medical and Surgical Sciences, Department of Orthopaedic Surgery, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand Brendan Burkett, PhD Faculty of Science, Centre for Healthy Activities, Sport and Exercise, University of the Sunshine Coast, Queensland, Australia ABSTRACT: Study Design: Observational two-stage. Introduction: To achieve optimal clinimetric properties for outcome measures, both practical and psychometric, ongoing improvements are re- quired. Purpose of the Study: To evaluate if the Upper Limb Functional Index (ULFI) clinimetric properties are improved by modification to a three-point response option and to verify the factor structure. Methods: Stage 1, calibration (n ¼ 139) used ULFI dichotomous responses, and stage 2, validation (n ¼ 117) used a three-point re- sponse option. The clinimetric properties were compared in phys- ical therapy outpatients with the QuickDASH as the reference standard. Repeated measurements were made at two to four weekly intervals. Results: The ULFI three-point response option improved relia- bility [intraclass correlation coefficient (2,1) ¼ 0.98], internal consis- tency (a ¼ 0.92), QuickDASH concurrent validity (r ¼ 0.86), and responsiveness. Minimal detectable change (90% confidence inter- val) was 7.9%, and factor structure was unidimensional. Missing responses were ,0.5%, and practical characteristics were un- changed. Conclusions: The enhanced reliability and reduced errors with unchanged practicality demonstrate the ULFI improvements through modification to a three-point response option. Level of Evidence: 2c. J HAND THER. 2010;23:41–52. Upper limb function and impairment are assessed by a variety of patient-reported outcomes (PROs) that reflect health at the activity and participation level. 1e3 Recent systematic reviews found that no cur- rent PROs had positive ratings for all clinimetric properties, 4 and further research was needed. 5 The original Upper Limb Functional Index (ULFI) pub- lished in 2006 with a dichotomous response option 6 was not included in these reviews because it was pub- lished after the review inclusion cut-off date. 4 The original ULFI was concurrently validated with multi- ple response option PROs, the Disabilities of the Arm, Shoulder, and Hand (DASH) 7 and the Upper Extremity Functional Index. 8 Comparative analysis showed the original ULFI as the preferred PRO mea- sure, mostly because of enhanced practical character- istics; however, the ULFI had slightly lower reliability, responsiveness, and higher error with change scores. 6 These shortcomings were thought to be because of only ‘‘Yes’’ or ‘‘No’’ response options 9 without an ‘‘in- termediate’’ option. 10,11 Without this third option, an individual’s response may become less precise and inconsistent. 12 To improve the original ULFI psycho- metric properties and provide a three-point response option (ULFI 3-pt ), the questionnaire instructions re- quired modification and the clinimetric properties of psychometrics and practicality reassessed concur- rently with an accepted criterion standard. The QuickDASH was selected as the criterion, as it was advocated for the assessment of upper limb musculoskeletal conditions. 13e16 The QuickDASH SCIENTIFIC/CLINICAL ARTICLE Presented at the 7th Triennial Congress of the International Federation of Societies for Hand Therapy, Sydney, 11the15th March 2007. Correspondence and reprint requests to Charles Philip Gabel, MSc, Faculty of Science, Centre for Healthy Activities, Sport and Exercise, University of the Sunshine Coast, PO Box 760, Coolum Beach, Queensland 4573, Australia; e-mail: <cp.gabel@bigpond.com>. 0894-1130/$ e see front matter Crown Copyright Ó 2010 Published by Elsevier Company. All rights reserved. doi:10.1016/j.jht.2009.09.007 JanuaryeMarch 2010 41