Research Report

Feasibility, Reliability, and Agreement

of the WeeFIM Instrument in Dutch
Children With Burns
Anuschka S. Niemeijer, Heleen A. Reinders-Messelink, Laurien M. Disseldorp,
Marianne K. Nieuwenhuis
A.S. Niemeijer, PhD, Association
of Dutch Burn Centres, Burn Center, Martini Hospital, PO Box
30.033, 9700 RM, Groningen, the
Netherlands. Address all correspondence to Dr Niemeijer at:
a.niemeijer@mzh.nl.
H.A. Reinders-Messelink, PhD,
Center for Rehabilitation, University Medical Center Groningen,
University of Groningen, Groningen, the Netherlands, and
Rehabilitation Center Revalidatie
Friesland, Beetsterzwaag, the
Netherlands.
L.M. Disseldorp, MSc, Association
of Dutch Burn Centres, Burn Center, Martini Hospital, and Center
for Human Movement Sciences,
University Medical Center Groningen, University of Groningen.
M.K. Nieuwenhuis, PhD, Association of Dutch Burn Centres, Burn
Center, Martini Hospital.
[Niemeijer AS, Reinders-Messelink
HA, Disseldorp LM, Nieuwenhuis
MK. Feasibility, reliability, and
agreement of the WeeFIM instrument in Dutch children with
burns. Phys Ther. 2012;92:
958 966.]
2012 American Physical Therapy
Association
Published Ahead of Print:
March 30, 2012
Accepted: March 21, 2012
Submitted: November 17, 2011

Background. Burns occur frequently in young children. To date, insufficient data

are available to fully describe the functional consequences of burns. In different
patient populations and countries, the WeeFIM instrument (WeeFIM) often is used
to measure functional independence in children.
Objective. The purpose of this study was to examine the psychometric properties
of the WeeFIM instrument for use in Dutch burn centers.

Design. This was an observational study.

Methods. The WeeFIM instrument was translated into Dutch. All clinicians who
rated the children with the instrument passed the WeeFIM credentialing examination. They scored consecutive children (n134) aged 6 months to 16 years admitted
to Dutch burn centers with acute burns during a 1-year period at 2 to 3 weeks, 3
months, and 6 months postburn. To examine reliability, 2 raters scored a child at the
same time (n52, 9 raters) or the same rater scored a child twice within 1 week
(n7, 3 raters).

Results. After a few weeks, the WeeFIM assessment could be administered in less
than 15 minutes. Clinicians thought it was difficult to rate a child aged between 2 and
4 years as well as the cognitive items. Nevertheless, reliability was good (all intraclass
correlation coefficients [1,1] were above .80). The standard error of measurement
was 3.7.

Limitations. Intrarater reliability was based on only 7 test-retest measurements.

Within our clinical setting, it turned out to be difficult to schedule the same rater and
patient twice in one week for repeated assessments. Assessments for interrater
reliability, on the other hand, worked out well.
Conclusions. The WeeFIM instrument is a feasible and reliable instrument for use
in children with burns. For evaluation of a childs individual progress, at least 11
points improvement should be observed to state that a child has significantly
improved.

Post a Rapid Response to

this article at:
ptjournal.apta.org
958

Physical Therapy

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

July 2012

Psychometric Properties of the WeeFIM Instrument

o date, insufficient data are

available to fully describe the
disabling consequences of
burns.1 Burns might have a major
impact on population health,
because they frequently occur in
children aged 0 to 4 years,2,3 and
many of these children experience
permanent consequences of their
injuries from childhood to adolescence. It is important to measure the
health outcomes of children and
youth with disabilities because public health services and rehabilitation
interventions are driven by analysis
of appropriate outcomes.4 Therefore, a standard core set for the measurement and reporting of functional
outcome in children after burns
needs to be developed.1
The functional consequences of
burns can be described with the
International Classification of
Functioning, Disability and Health
(ICF) and the International Classification of Functioning, Disability
and HealthChildren and Youth
Version (ICF-CY) as a framework.5
These classifications encompass
functioning as a universal human
experience that can be conceptualized and classified at 3 different
dimensions: body function and
structure, the performance of personal activities, and participation in
communal life. Burns directly affect
body function and structures. In
addition, consequences of burns
may become apparent at the activity
or participation domain. An activity
is defined as the execution of a task
or action by an individual, and participation is defined as involvement
in a life situation. Activity limitations, therefore, are difficulties an
individual may have in task execution, and participation restrictions
are problems with involvement in a
particular life situation. Problems or
deviations at one level do not automatically imply problems at other
levels, although associations are
likely to exist.
July 2012

Regarding the activity and participation domains, in pediatric burns

progress has been made with the
development of burn-specific selfreport instruments.6 9 To assess
the participation/quality of life
domain, the EQ-5D instrument is
used in patients with burns10 and is
undergoing further testing in the
Dutch pediatric population. Selfreport instruments, however, can be
biased by memory or social desirability, which results in other outcomes
than if items would be rated by a
professional. The availability of a
generic instrument concerning the
activity domain rated by the professional is needed for children with
burns, as it enables a quantitative
description of the disabling consequences of burns and comparison
of functional outcomes after burns
with outcomes in other groups.
In other specific groups of children,
several instruments rated by the professional are used, such as the Pediatric Evaluation of Disability Inventory (PEDI),11 the Vineland Adaptive
Behavior Scales (VABS II),12 the

Gross Motor Function Measure

(GMFM),13 and the WeeFIM instrument (WeeFIM).14 Of the approximately 15 to 20 instruments regularly used to measure the activity
domain, only the WeeFIM instrument and the PEDI are reported by
the professional and can be used in
young children (0 4 years of age). In
children with developmental disabilities and acquired brain injury, high
correlations are found between the
WeeFIM instrument and the PEDI,
indicating that the 2 tests measure
similar constructs.15 The advantage
the WeeFIM instrument has over the
PEDI is that it takes far less time to
complete.
Whether the WeeFIM instrument
can be added to our standard core
set for the measurement and reporting of functional outcome of children with burns depends first of all
on the feasibility, reliability, and
agreement of the instrument in this
population. It is important that measurement instruments be valid and
reliable, as they are essential tools for
clinicians, therapists, and research-

The Bottom Line

What do we already know about this topic?
Burns might have a major impact on population health, because they
frequently occur in young children 0 to 4 years of age. Many of these
children have permanent consequences of their injuries from childhood
to adolescence.

What new information does this study offer?

This study shows that the WeeFIM instrument, which is frequently used
to measure functional independence in children, is a feasible and reliable
instrument for use with children with burns.

If youre a caregiver, what might these findings mean

for you?
Your childs clinician needs to find an improvement of more than 11
points on the WeeFIM instrument before he or she can state that the child
is functioning more independently.

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

Physical Therapy f

959

Psychometric Properties of the WeeFIM Instrument

Table 1.

ents) were not showing up at

appointments (n2), or there were
logistical problems (n11).

Number of Children Seen at Different Periods Postburn per Age Groupa

Age
Group

2/3
Weeks
Postburn

3
Months
Postburn

6
Months
Postburn

Total

01 year

61

30

15

106

23 year

24

15

48

46 year

13

25

7 years
Total n
a

36

23

11

70

134

77

38

249

72% of the children were lost to follow-up.

ers, not only in identifying children

with impairments or disabilities, but
also in evaluating development and
assessing the efficacy of interventions. In several studies, the WeeFIM
instrument has been found to be
valid and reliable.16 18 Concepts
such as validity, reliability, agreement, and responsiveness, however,
are relative, as they are situationspecific and highly dependent on
the study population and measurement circumstances.19 The psychometric properties of the WeeFIM
instrument have not been studied
in the Netherlands, nor in children
with burns. Serghiou et al20 used the
WeeFIM instrument to track functional outcomes of patients with
burns, but they did not study the
psychometric properties of the
instrument in these patients. Moreover, they misinterpreted the levels
of independence among the young
age group (6 months 6 years) in
their study.20 Therefore, the purpose
of this study was to examine the feasibility, reliability, and agreement
when the WeeFIM instrument is
used in children with burns who
have been admitted to Dutch burn
centers.

Method
Selection of Participants
In each of the 3 dedicated Dutch
burn centers, at least 3 clinicians
who had regular contact with children with burns (eg, nurse, nurse
practitioner, occupational therapist,
960

Physical Therapy

child life specialist) were selected as

raters of the WeeFIM instrument.
Selected raters read the Dutch translation of the WeeFIM manual and
practiced assessing children. Experiences were shared with each other,
and uncertainties were discussed. In
September 2009, the obligatory credentialing WeeFIM examination was
taken and passed by all raters, after
which 9 raters started administering
the WeeFIM instrument.
The instrument was administered to
all consecutive children who were
between 6 months and 16 years of
age and admitted to 1 of the 3 centers for more than 24 hours with
acute burns. Inclusion started in
September 2009 and lasted 1 year. In
one of the centers, due to internal
communication problems, it was
possible that some children were not
assessed based on the extent of their
injury. As a result, in the first months
of the inclusion period, children
with more severe burns were less
likely to be included. A total of 16
children were included at that center. In the other 2 centers, 137 children were eligible for the study, and
118 children were included. In these
centers, the WeeFIM instrument was
not administered for the following
reasons: children (and parents) were
not communicating in a language the
raters could understand (n2), the
child had an electrical injury (n1),
children were transferred to other
hospitals (n3), children (and par-

As shown in Table 1, a total of 134

children (16 from 1 burn center
118 from the other 2 burn centers)
were included. Furthermore, the
table shows that most children
admitted to the burn centers were
very young and that many children
(72%) were lost to follow-up. The
fact that many children were unable
to complete all assessments at all
time points might influence the conclusions that can be drawn from the
current data. In the present study,
feasibility was partly evaluated by
the assessment of inclusion rate.
Therefore, inclusion rate was evaluated only on the basis of data gathered in the 2 centers where 137 children were found to be eligible for
the study. The other feasibility or
reliability measures assessed in this
study are not thought to be influenced by the possible bias in the
data.
Instruments
The WeeFIM instrument. The
WeeFIM instrument was used to
examine basic daily living and functional skills in children. The instrument measures the level of functional independence, which has
been defined as the childs consistent and usual performance, as well
as the level of assistance needed by
the child to perform daily living tasks
effectively. The WeeFIM instrument
was developed for use in children
between the ages of 6 months and 7
years (but with application through
adolescence) across health, developmental, educational, and community
settings.21 The instrument can be
administered by either direct observation or interview, can be used by
multiple disciplines, and takes
approximately 15 minutes to administer.16,22 The instrument is derived
from the FIM, which is a functional
independence measure for adults. It

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

July 2012

Psychometric Properties of the WeeFIM Instrument

contains 18 items that cover 3 major
domains: 8 items for self-care, 5
items for mobility, and 5 items for
cognition. Each item is rated on a
7-point scale ranging from total assistance (1) to complete independence
(7). American normative data, based
on a sample of more than 500 children in good health and without disability, are available for the total
score, as well as scores on the different domains.23 The WeeFIM instrument is reliable in both children with
disabilities and those without disabilities.22,24,25 In children with developmental disabilities in the United
States, the intraclass correlation coefficients (ICCs) for different subscales
were greater than .90.25 Indexes of
responsiveness in children with disabilities indicated reliable and statistically significant changes over
time.26 Further testing of psychometric properties also has been done,
suggesting distinct motor and cognitive scales and an age-specific item
hierarchy.27,28
Translational process of the
WeeFIM instrument. Translation
and cultural adaptation of the
WeeFIM II Clinical Guide14 was
done based on the 2-panel
method.29,30 The WeeFIM questionnaire and manual were translated
into Dutch by 2 translators with varied but suitable profiles (M.K.N.,
H.A.R-M.). They informed themselves about the questionnaire (eg,
underlying
conceptual
model,
design, content) and subsequently
translated the questionnaire and
manual. They discussed and resolved
inconsistencies, some after consultation with the publisher. Upon completion of the first draft, a person
who was informed regarding both
content and language abilities
(A.S.N.) read through and corrected
the whole document. These corrections then were checked against the
original American text. In addition,
one author (M.K.N.) translated the
credentialing
examination
into
July 2012

Dutch. After 3 months, both authors

completed the examination, in
which 2 cases had to be scored. One
translator (H.A.R-M.) completed the
original examination with the American manual. The other author
(M.K.N.) scored the translated cases
with the Dutch manual. Both authors
discussed their item scores, and if
there were any differences in scoring, the original text and the Dutch
translation were compared. Due to
this procedure, at one place in the
Dutch manual an and/or term was
altered. This latest version was used
by all raters.
Global Impression of Change.
The Global Impression of Change
(GIC), a questionnaire with 2 items,
was used to obtain a global impression of change considered important
by patients and clinicians. The first
item involved the severity of the condition, which could be scored on a
7-point scale from normal to
severe. The second item involved
the global change with regard to the
start of treatment, ranging on a 7
point-scale from complete recovery to much worse.31 As an
anchor for change, the GIC was
rated by both the primary caregiver
and the attending clinician. If the
child was over the age of 12 years,
he or she completed the GIC as
well. The GIC was used to provide
an external meaning for change.32
Procedure and Design
To test the feasibility of the WeeFIM
instrument in Dutch burn centers, it
was administered to all consecutive
children 2 to 3 weeks postburn. If
children were seen for follow-up on
clinical indication at approximately
3 and 6 months postburn, they were
reassessed with the WeeFIM instrument. Starting in April 2010, each
time the WeeFIM instrument had to
be administered, 2 WeeFIM raters, if
possible, were scheduled for the
appointment (n52) or 2 appointments were planned within 1 week

by the same rater (n7) to get

an indication of the interrater and
intrarater reliability, respectively. If
2 people administered the WeeFIM
instrument, they were in the same
room but did not communicate
about scores. The raters were randomly selected from those available.
The GIC was assessed at 3 and 6
months postburn.
Data Analysis
All analyses were done using SPSS/
PASW Statistics version 16 (SPSS Inc,
Chicago, Illinois). An alpha level of
.05 was adopted. Feasibility was evaluated by the assessment of inclusion
rate, the frequency of missing
answers per item, and administration
time. Inclusion rate was evaluated
based only on the information gathered in the 2 centers where no
communication problems existed. A
learning effect might be reflected
in the time needed to administer
the WeeFIM instrument. Therefore,
weeks passed from the start of the
measurements (September 2009)
was examined as a predictor for
assessment time.
Internal consistency reliability was
determined using the Cronbach
alpha for all items. Reliability was
evaluated by the Spearman correlation between the scores of both raters. This correlation gave an impression of whether 2 raters agreed on
ordering. Whether they also agreed
on magnitude was indicated by ICCs.
The ICC values measured the extent
of consensus on use of the instrument by those who administered it.
Although ICCs have primarily been
used for interval data, they can be
applied without distortion to ordinal
data when intervals are assumed to
be equivalent.33 In the present study,
ICCs were calculated for the whole
group. As the scores on the WeeFIM
instrument are known to have a ceiling effect from the age of 7 years
(resulting in high consensus
between raters), ICCs also were cal-

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

Physical Therapy f

961

Psychometric Properties of the WeeFIM Instrument

culated for the subgroup of children
younger than 7 years.
As each child was rated by a different
set of staff members randomly
selected from those available, the
one-way single-measures ICC (1,1)
was calculated.34 An ICC between
.60 and .69 was interpreted as substantial interrater reliability, an ICC
larger than .70 was interpreted as
acceptable, and an ICC higher than
.80 was interpreted as outstanding.35
It was important to know whether a
difference in individual scores was
due to random error (eg, due to differences between raters) or that
change was larger than expected by
chance. For this purpose, the standard error of measurement (SEM)
was calculated for the total test
score. The SEM is an estimate of the
unsystematic variance in an individuals score. The SEM was calculated
as the standard deviation of the difference in test scores gathered by 2
raters at the same moment or gathered within a 1-week period. The
95% confidence interval of a single
score X equals X 1.96 SEM. As
outliers can have a major impact on
the standard deviation of the difference scores, the 95% limits of agreement also were determined.36
The minimal or least detectable difference (LDD) represents the minimal individual change that must be
observed between 2 measurements
before it can be concluded that a
systematic change has occurred.
Taking .05 as the significance level,
the LDD equaled 2 1.96 SEM.
The LDD is a statistical, distributionbased method. In addition, an
anchor-based method was used that
gave an impression concerning the
minimally important change (MIC).31
To calculate the MIC, changes in perceptions of relevant people about
the illness or recovery measured
with the GIC provided an external
criterion.
962

Physical Therapy

Role of the Funding Source

This study was supported by a grant
from the Dutch Burns Foundation.

Results
Feasibility
From September 2009 until October
2010, a total of 134 children were
included. Due to communication
problems in 1 of the 3 centers, in
only 2 centers did personnel try to
include all eligible children from the
start of the study. The inclusion rate
in those 2 centers was above 80%. In
all record forms filled out (n249),
only one missing answer was
observed: item 6 (toileting) had not
been rated in a child who was fully
independent in bladder and bowel
management.
Administration time often was missing (31% of the 249 record forms).
The average time recorded as
needed for the interview and for
filling out the WeeFIM record form
was 13 minutes (SD6.8); 83% of
the interviews were completed
within 15 minutes (range1 60
minutes; n170 measurements).
Time elapsed since the beginning of
the study showed that more experience administering the WeeFIM
instrument resulted in less time
needed to complete the test
(F1,1679.69, P.002). Administration time was not influenced by the
age of the child (F16,1521.20,
P.27, not significant). Longer
administration times (40 minutes)
were observed if scores were
obtained by observation instead of
interviewing the primary caregivers
(n4).
Reliability
The Cronbach alpha for internal consistency was .981 over 18 items measured in 134 children a few weeks
after the burn accident. Over all measurements, including those at 3 or 6
months postburn, the Cronbach
alpha was .984. A value of .80 and

higher was considered good for confirmatory purposes.37

The WeeFIM instrument was administered by 2 raters on 52 occasions.
The Spearman rank correlation coefficients were .98 (total score), .95
(self-care), .99 (mobility), and .94
(cognition). All ICC values for interrater reliability per item, subscale
score, and total score for the total
group were above .80 (Tab. 2),
which is outstanding.35 For the
younger group of children (aged
below 7 years), the interrater ICCs
were nearly all outstanding, except
for eating, transfer to shower or tub,
and 3 cognition items in which the
lower bound of the 95% confidence
interval was below .80.
For 7 children, one rater administered the WeeFIM twice. The Spearman rank coefficients for these ratings were higher than those found
for different raters scoring at the
same time: .99 (total score), .99 (selfcare), .97 (mobility), and .95 (cognition). The intrarater ICCs also were
outstanding (.80).
Agreement
The SEM for the WeeFIM total score
was 3.7 points. The 95% confidence
interval based on the SEM was
(1.96 SEM) 7.25, which is comparable to the 8 points for the 95%
limits of agreement.36 In 25% of all
cases (total n59), WeeFIM total
scores were exactly the same.
The Figure shows that difference
between observers was not related
to the degree of independence (total
score). The correlation between raters differences on the WeeFIM
instrument and age in months was
.15, which was interpreted as low.
The LDD on the total score between
2 raters was 2 1.96 3.710.3
points. Thus, a WeeFIM score should
improve at least 11 points or more
between measurements before a

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

July 2012

Psychometric Properties of the WeeFIM Instrument

Table 2.
Reliability Measures for Test Items of the WeeFIM Instrument: Spearman Rank Correlation Coefficients (rs) With Age in Months
and Between the Ratings of 2 Staff Members and Interrater Reliability Intraclass Correlation Coefficients (ICCs) and 95%
Confidence Intervals (95% CI) for the Whole Group (n52) and for Children Younger Than 7 Years of Age (n34)

WeeFIM Test Items and Domains

rs

95% CI

Interrater
ICC (1,1),
Children <7
Years of Age

1. Eating

.765

.951

.944

.905.968

.882

2. Grooming

.851

.943

.970

.948.982

.938

95% CI
.779.939
.880.968

3. Bathing

.828

.974

.994

.990.997

.938

.967.992

4. Dressing-upper body

.773

.919

.977

.961.987

.945

.894.972

5. Dressing-lower body

.737

.937

.972

.952.984

.937

.879.968

6. Toileting

.795

.985

.974

.956.985

.911

.830.954

7. Bladder management

.794

.999

.998.999

.998

.995.999

8. Bowel management

.799

.95

.965

.941.980

.931

.867.965

9. Transfers: chair or wheelchair

.643

.942

.948

.911.969

.951

.905.975

.772

.937

.954

.922.973

.909

10. Transfers: toilet

Age

Interrater
ICC (1,1),
Whole Group

1.0

.826.953
a

11. Transfers: tub, shower

.637

.936

.926

.874.957

.878

12. Transfers: walk, wheelchair, crawl

.429

.907

.918

.862.952

.895

.801.946

.772.937

.908.976

13. Transfers: stairs

.546

.983

.971

.951.983

.953

14. Comprehension

.851

.904

.926

.874.957

.847a

.717.920

.605.883

15. Expression

.824

.890

.895

.825.938

.779

16. Social interaction

.725

.919

.931

.883.960

.850a

.723.922

17. Problem solving

.815

.948

.973

.953.984

.912

.832.955

18. Memory

.787

.945

.956

.924.974

.905

.819.951

Self-care

.808

.95

.996

.993.998

.989

.978.995

Mobility

.717

.99

.987

.977.992

.977

.955.988

Cognition

.823

.94

.971

.950.983

.922

.851.960

Total score

.793

.98

.996

.992.997

.989

.979.995

The lower bound of the 95% CI for this ICC is lower than .80.

child can be regarded as statistically

significantly improved.
In addition to the LDD, the scores on
the GIC were used to get an impression concerning the MIC.31 However, filling out the GIC took extra
time and effort. Therefore, an
interim analysis on the GIC data
(n27) was performed. After 3 or 6
months, change scores on the
WeeFIM instrument were not differentiating between groups perceived
as more or less ill or recovered. For
most children, both parents and clinicians regarded the severity of the
illness as normal and the child as
much recovered after 3 months. The
July 2012

WeeFIM scores of the children who

were perceived as not ill by the clinician changed between 3 and
48 (n26). The score of the child
perceived as minimally ill improved
by 30 points and fell within the
change scores obtained from the
other children (3 and 48 points).
Only 4 parents regarded their child
as minimally to moderately ill. The
change scores of these children also
fell within the range of change
obtained by the other children.

Discussion
The goal of this study was to find out
whether the WeeFIM instrument is
feasible and reliable for use in chil-

dren with burns admitted to Dutch

burn centers. Interviewing a child
and the parents is considered feasible and takes approximately 10 to 15
minutes. Moreover, the reliability of
the WeeFIM scores is good. A standard measurement error of 4 points
has to be taken into account by the
clinician who wants to monitor the
individual child. This standard measurement error means that the true
score of a child with, for example, a
total score of 50 lies with a 95% probability between 42 and 58. This child
has significantly improved between
2 consecutive measurement occasions if the score changes 11 points
or more, thus from 50 to more than

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

Physical Therapy f

963

Psychometric Properties of the WeeFIM Instrument

described by Serghiou et al,20 can
easily occur in this age group and
these items. The relatively low ICC
values for some of the cognitive
items in children younger than 7
years of age might reflect the difficulty the WeeFIM raters in the Dutch
burn centers experienced. Recently,
the WeeFIM 0 3 module for children between 0 and 3 years of age
has become available,39 which might
solve these problems. Nevertheless,
this study shows that it is possible
to measure functional outcome in
Dutch children with burns in a reliable way with the WeeFIM instrument. Moreover, the differences
between raters are not related to
the level of independence or age of
the child, whereas, as expected,
independence levels do correlate
with age.
Figure.
Scatterplot (Blant-Altman plot) of difference in WeeFIM scores between observers and
total WeeFIM score.

61 points. For the clinician, this LDD

of 11 points allows a statistical interpretation of improvement. An indication for the MIC could not be
derived from the GIC due to less variance in the observed changes.
After a few weeks in which each
rater used the WeeFIM instrument at
least once, the instrument was
administered, on average, in 10 to 15
minutes. This time interval also is
mentioned in the WeeFIM manual
and was reported by other
authors.16,22,38 This is an important
finding, as administration time was
one of the criteria to explore in evaluating the use of the WeeFIM instrument instead of the PEDI. Raters
found it difficult to report how much
time they spent administering the
WeeFIM instrument, which resulted
in 31% missing data on administration time. Often the raters interviewed the parents or child during
the changes of wound dressing and
other regular care activities. Under
964

Physical Therapy

such circumstances, they did not

record time, as they felt that the
extra time needed was only some
seconds to write down 18 numbers
on the record form. Another aspect
of feasibility is the number of missing
answers. In our study, only one
answer is missing. A high answer
rate is to be expected, as the guidelines prescribe that if a child does
not perform a functional activity,
even though the assessor knows the
child can do it, that item should be
rated level 1 (total assistance).
The Cronbach alpha shows that the
internal consistency of the Dutch
translation of the WeeFIM instrument is high when used in Dutch
children with burns. The reliability
of the instrument expressed in ICC
values also is good, even though the
raters experienced difficulties scoring 2- and 3-year-old children and the
cognitive items in general. We
believe that misinterpretation of
capability and actual performance, as

A strength of this study is that high

ICC values were found even though
the one-way single-measures ICC
(1,1) often is lower than all other
kinds of ICCs.34 The interrater reliability values confirm that a child
considered as very dependent by
one clinician often was thought to
be very dependent by a colleague as
well, and vice versa. The intrarater
reliability values were even better. In
other countries where the psychometric properties of the WeeFIM
instrument have been studied, high
ICC values also have been found.38,40
In addition, the interrater reliability
values were not based on a fixed set
of clinicians. They were based on a
set of changing clinicians who were
available on the day the researcher
wanted the WeeFIM instrument to
be administered. Therefore, the
results of this study indicate that the
WeeFIM instruments subscale measures can be generalized to other clinicians in the Netherlands who want
to use the translated version of the
WeeFIM instrument.
A limitation of our study, however, is
that only 7 test-retest measurements

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

July 2012

Psychometric Properties of the WeeFIM Instrument

were available to calculate the intrarater reliability. At the burn centers,
it turns out to be easier to schedule 2
different examiners at the same time
than the same rater to administer the
instrument again within a short
period. For the interpretation of the
intrarater reliability measurements,
we feel that test effects are visible
when administering the WeeFIM
instrument within a 1-week period.
In some cases, for example, the
interview leads to another perception of parents about their childs
capabilities, which leads to other
responses within a few days (memory of the previous interview leads
to additions or a more realistic view
about the performances of the
child). Nevertheless, both intrarater
and interrater ICC values were more
than acceptable. The intrarater values were better than the interrater
values, most likely because variance
of tester did not exist. In clinical
practice, however, high interrater
reliability is especially important, as
patients are observed by the available clinician. This study shows that
the WeeFIM values are reliable, independent of the rater.
A strength of this study is that we
tried to measure the MIC and the
LDD. In many studies, the terms
reliability and agreement are
used interchangeably. However,
they are conceptually different,
although both provide information
about the quality of measurements.19
Clinical test theory is used to
describe the measurement error.
Based on the SEM of 3.7 points, a
difference between measurements
should be at least 11 points before a
clinician can state that an individual
child has improved. This LDD is
lower than but comparable to the 13
points needed to state progress in
independence with the FIM instrument that is used in adults.24 The
change in scores does not seem to be
associated with opinions about the
illness or recovery, as expressed in
July 2012

the GIC questionnaire. Clinicians

perceive most children with burns
as much recovered and not ill after
a few months. Parents, however,
perceive their children as not totally
recovered. Some parents explained
to us that scars were present, and
they, therefore, perceived their child
as not recovered. They hoped that
full recovery would imply no lasting
signs of burn injury. Regardless of
the impression of change, WeeFIM
change scores show much variance
within a 3-month period. An
improvement in WeeFIM scores,
however, is normal in children with
typical development as functional
independence develops. Regular
development, recovery, difference
in independent behavior due to hospital stay, and measurement error are
all factors that can lead to better
WeeFIM scores a few months after
burn injury. It is important to realize
that clinical interpretation is never
so straightforward that a clinician
can decide based on one test outcome. An experienced clinician
observing nonsignificant improvement (less than 11 points) on the
WeeFIM instrument can still regard
it as real improvement when
changes in other outcome measures
point in the same direction.
In conclusion, the clinicians in
Dutch burn centers are able to measure functional independence with
the WeeFIM instrument in a reliable
way. The WeeFIM instrument is feasible and reliable to be administered
during consultation hours. For the
evaluation of individual improvement, an LDD of 11 points has to be
taken into account. The results are
similar to those found in other
populations.
Further research on the data gathered in this study is necessary to
determine whether a license will be
granted by the Uniform Data System
for Medical Rehabilitation for use of
the WeeFIM instrument within the

burn centers. The fact that the

WeeFIM instrument can be used in a
reliable way in Dutch burn centers
does not mean that the test is valid
for use in this population. A high
level of consistency among items
was found, indicating high internal
validity. However, whether the
instrument and available norms are
valid to determine and follow up on
the level of independent functioning
in the children admitted to Dutch
burn centers needs to be examined
as well. Nevertheless, the results of
the present study are generally favorable for adding the WeeFIM instrument to our standard core set for
the measurement and reporting of
functional outcome of children with
burns.
Dr Niemeijer, Dr Reinders-Messelink, and Dr
Nieuwenhuis provided concept/idea/research design and writing. Ms Disseldorp
provided data collection. Dr Niemeijer provided data analysis. Dr Niemeijer and Dr
Nieuwenhuis provided project management
and participants. Dr Nieuwenhuis provided
fund procurement and facilities/equipment.
Dr Reinders-Messelink, Ms Disseldorp, and
Dr Nieuwenhuis provided consultation
(including review of manuscript before
submission).
The authors thank the following people for
their dedication to this study: Margriet van
Baar, Anita Boekelaar, Ina Boerma, Anneke
Dumans, Helma Hofland, Paula Gieles, Ina
van Ingen Schenau, Hennie Schouten,
Anneke van de Steenoven, Kitty Stoker,
Miranda Venema, Martijn van der Wal, and
Jan-Kees Zuiker. They also thank the members of the Centre for Functional Assessment
Research of the Uniform Data System for
Medical Rehabilitation (UDSMR), State University of New York at Buffalo, for making it
possible to use the WeeFIM instrument in the
Netherlands and for their feedback.
This study was approved by the medical ethical committees of the Maasstad Hospital in
Rotterdam, the Red Cross Hospital in Beverwijk, and the Martini Hospital in Groningen.
An oral presentation of this research was
given at the 14th European Burns Association Congress; September 14 17, 2011; The
Hague, the Netherlands.
This study was supported by a grant from
the Dutch Burns Foundation.

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

Physical Therapy f

965

Psychometric Properties of the WeeFIM Instrument

The use of the WeeFIM instrument to collect
data for this research study was authorized
and conducted in accordance with the terms
of a special purpose license granted to the
licensee by the Uniform Data System for
Medical Rehabilitation (UDSMR), a division of
U. B. Foundation Activities Inc. The licensee
has not been trained by UDSMR in the use
of the WeeFIM instrument, and the patient
data collected during the course of this
research study have not been submitted to
or processed by UDSMR. No implication is
intended that such data have been or will be
subjected to UDSMRs standard data processing procedures or that the data are otherwise
comparable to data processed by UDSMR.
WeeFIM and FIM are trademarks of UDSMR.
DOI: 10.2522/ptj.20110419

References
1 Van Baar ME, Essink-Bot ML, Oen IM, et al.
Functional outcome after burns: a review.
Burns. 2006;32:19.
2 National Burn Repository, Version 6.0,
2010, Report of Data From 2000 2009.
Chicago, IL: American Burn Association;
2011.
3 Steinvall I, Fredrikson M, Bak Z, Sjoberg F.
Mortality after thermal injury: no sexrelated difference. J Trauma. 2011;70:
959 964.
4 Lollar DJ, Simeonsson RJ, Nanda U. Measures of outcomes for children and youth.
Arch Phys Med Rehabil. 2000;81(suppl
2):S46 S52.
5 International Classification of Functioning, Disability and Health: ICF. Geneva,
Switzerland: World Health Organization;
2001.
6 Kazis LE, Liang MH, Lee A, et al. The development, validation, and testing of a health
outcomes burn questionnaire for infants
and children 5 years of age and younger:
American Burn Association/Shriners Hospitals for Children. J Burn Care Rehabil.
2002;23:196 207.
7 Van Baar ME, Essink-Bot ML, Oen IM, et al.
Reliability and validity of the Health Outcomes Burn Questionnaire for infants and
children in the Netherlands. Burns. 2006;
32:357365.
8 Daltroy LH, Liang MH, Phillips CB, et al.
American Burn Association/Shriners Hospitals for Children Burn Outcomes Questionnaire: construction and psychometric
properties. J Burn Care Rehabil. 2000;21:
29 39.
9 Van Baar ME, Essink-Bot ML, Oen IM, et al.
Reliability and validity of the Dutch version of the American Burn Association/
Shriners Hospital for Children Burn Outcomes Questionnaire (518 years of age).
J Burn Care Res. 2006;27:790 802.
10 Ostera C, Willebranda M, Dyster-Aasa J,
et al. Validation of the EQ-5D questionnaire in burn injured adults. Burns. 2009;
35:723732.

966

Physical Therapy

11 Haley SM, Coster WJ, Ludlow L, et al. Pediatric Evaluation of Disability Inventory
(PEDI). Boston, MA: Boston University
Center for Rehabilitation Effectiveness;
1992.
12 Sparrow SS, Cicchetti DV, Balla DA.
Vineland II: A Revision of the Veneland
Adaptive Behavior Scales, I: Survey/Caregiver Form. Circle Pines, MN: American
Guidance Service; 2005.
13 Russell DJ, Rosenbaum PL, Avery LM, Lane
M. Gross Motor Function Measure,
GMFM-66 and GMFM-88, Users Manual.
London, United Kingdom: Mac Keith
Press; 2002. Clinics in Developmental
Medicine No. 159.
14 The WeeFIM II Clinical Guide, Version
6.0. Buffalo, NY: Uniform Data System for
Medical Rehabilitation; 2006.
15 Ziviani J, Ottenbacher KJ, Shephard K,
et al. Concurrent validity of the Functional
Independence Measure for Children
(WeeFIM) and the Pediatric Evaluation of
Disabilities Inventory in children with
developmental disabilities and acquired
brain injuries. Phys Occup Ther Pediatr.
2001;21:91101.
16 Ottenbacher KJ, Msall ME, Lyon N, et al.
Measuring developmental and functional
status in children with disabilities. Dev
Med Child Neurol. 1999;4:186 194.
17 Msall ME. Measuring functional skills in
preschool children at risk for neurodevelopmental disabilities. Ment Retard Dev
Disabi Res Rev. 2005;11:263273.
18 Aybay C, Erkin G, Elhan AH, et al. ADL
assessment of non-disabled Turkish children with the WeeFIM instrument. Am J
Phys Med Rehabil. 2007;86:176 182.
19 Kottner J, Audige L, Brorson S, et al.
Guidelines for Reporting Reliability and
Agreement Studies (GRRAS) were proposed. J Clin Epidemiol. 2011;64:96 106.
20 Serghiou MH, Rose MW, Pidcock FS, et al.
The WeeFIM instrument: a paediatric measure of functional independence to predict longitudinal recovery of paediatric
burn patients. Dev Neurorehabil. 2008;
11:39 50.
21 Msall ME, DiGaudio K, Rogers BT, et al.
The Functional Independence Measure for
Children (WeeFIM): conceptual basis and
pilot use in children with developmental
disabilities. Clin Pediatr (Phila). 1994;33:
421 430.
22 Sperle PA, Ottenbacher KJ, Braun SL, et al.
Equivalence reliability of the Functional
Independence Measure for Children
(WeeFIM) administration methods. Am J
Occup Ther. 1997;51:35 41.
23 Msall ME, DiGaudio K, Duffy LC, et al.
WeeFIM-normative sample of an instrument for tracking functional independence in children. Clin Pediatr (Phila).
1994;33:431 438.
24 Ottenbacher KJ, Hsu Y, Granger CV,
Fiedler RC. The Functional Independence
Measure: its use to identify rehabilitation
needs in stroke survivors. Arch Phys Med
Rehabil. 1996;74:12911294.

25 Ottenbacher KJ, Msall ME, Lyon NR, et al.

Interrater agreement and stability of the
Functional Independence Measure for
Children (WeeFIM): use in children with
developmental disabilities. Arch Phys Med
Rehabil. 1997;78:1309 1315.
26 Ottenbacher KJ, Msall ME, Lyon N, et al.
The WeeFIM instrument: its utility in
detecting change in children with developmental disabilities. Arch Phys Med
Rehabil. 2000;81:13171326.
27 Chen CC, Bode RK, Granger CV, Heinemann AW. Psychometric properties and
developmental differences in childrens
ADL item hierarchy: a study of the
WeeFIM instrument. Am J Phys Med Rehabil. 2005;84:671 679.
28 Tsuji T, Liu M, Toikawa H, et al. ADL structure for nondisabled Japanese children
based on the Functional Independence
Measure for Children (WeeFIM). Am J
Phys Med Rehabil. 1999;78:208 212.
29 Swaine-Verdier A, Doward LC, Hagell P,
et al. Adapting quality of life instruments.
Value Health. 2004;7(suppl 1):S27S30.
30 McKenna SP, Doward LC. The translation
and cultural adaptation of patient-reported
outcome measures. Value Health. 2005;8:
89 91.
31 Van der Windt DA, Van der Heijden GJ, de
Winter AF, et al. The responsiveness of the
Shoulder Disability Questionnaire. Ann
Rheum Dis. 1998;57:82 87.
32 De Vet HC, Ostelo RW, Terwee CB, et al.
Minimally important change determined
by a visual method integrating an anchorbased and a distribution-based approach.
Qual Life Res. 2007;16:131142.
33 Portney LG, Watkins MP. Foundations of
Clinical Research: Applications to Practice. Upper Saddle River, NJ: Prentice Hall;
2000.
34 Shrout PE, Fleiss JL. Intraclass correlations:
uses in assessing rater reliability. Psychol
Bull. 1979;86:420 428.
35 Landis JR, Koch GG. The measurement of
observer agreement for categorical data.
Biometrics. 1977;33:159 174.
36 Bland JM, Altman DG. Statistical methods
for assessing agreement between two
methods of clinical assessment. Lancet.
1986;8:307310.
37 Miller MB. Coefficient alpha: a basic introduction form the perspectives of classical
test theory and structural equation modeling. Structural Equation Modelling.
1995;2:255273.
38 Jongjit J, Komsopapong L, Saikaew T, et al.
Reliability of the Functional Independence
Measure for Children in normal Thai children. Pediatr Int. 2006;48:132137.
39 Niewczyk PM, Granger CV. Measuring
function in young children with impairments. Pediatr Phys Ther. 2010;22:4251.
40 Liu M, Toikawa H, Seki M, et al. Functional
Independence Measure for Children
(WeeFIM): a preliminary study in nondisabled Japanese children. Am J Phys Med
Rehabil. 1998;77:36 44.

Volume 92 Number 7
Downloaded from http://ptjournal.apta.org/ by Emma Horton on July 19, 2012

July 2012

Copyright of Physical Therapy is the property of American Physical Therapy Association and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.