R E S E A R C H R E P O R T

Functional Symmetry Observation Scale, Version 2: Development and Content

Validation Using a Modified Delphi Method
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Mary Rahlin, PT, DHS; Joyce Barnett, PT; Bernadette Sarmiento, PT

Rosalind Franklin University of Medicine and Science (Dr Rahlin), North Chicago, Illinois; Ability Occupational Therapy Services, LLC (Ms Barnett),
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Anchorage, Alaska; Independent Practitioner (Ms Sarmiento), Skokie, Illinois.

Purpose: To describe the development of the Functional Symmetry Observation Scale (FSOS) Version 2 and its content
validation.
Methods: The FSOS Version 2 is an observational assessment that quantifies symmetry in spontaneous movement and
posture in infants with congenital muscular torticollis, age birth to 18 months. Twenty expert pediatric physical therapists
were identified through purposive sampling and invited to participate in a modified Delphi study. Survey data were
collected on Qualtrics. Consensus was evaluated using median ratings and percent agreement on Likert Scale items.
Thematic analysis was performed for open-ended question responses.
Results: Thirteen experts completed Round 1 and 2 surveys. In Round 1, consensus was achieved on all but 1 item. The
scale was modified based on received feedback. In Round 2, consensus was achieved on all items (median rating of 4,
agreement at 85%-100%).
Conclusions: This study established the content validity of the FSOS Version 2. (Pediatr Phys Ther 2022;34:37–44)
Key words: infant, observation, scale, symmetry, torticollis, validity

INTRODUCTION AND PURPOSE careful observation of asymmetry is recommended by the CMT

One of the priority areas of the Academy of Pediatric Phys-
ical Therapy research agenda 2018-2020 was to “develop and
refine measurement tools to identify impairments and monitor
changes in the musculoskeletal, neuromuscular, and cardiores-
piratory systems.”1 Infants with congenital muscular torticollis
(CMT) frequently present with postural and functional asym-
metry attributed to the impairments of the musculoskeletal
and neuromuscular systems.2-5 Besides the characteristic asym-
metrical head posturing, usually with neck lateral flexion
to one side and head rotation to the opposite side, infants
with CMT typically demonstrate restricted cervical range of
motion and asymmetrical use of the trunk and upper and
lower extremities when engaged in functional tasks.2-5 Although
0898-5669/110/3401-0037
Pediatric Physical Therapy
Copyright © 2021 Academy of Pediatric Physical Therapy of the American
Physical Therapy Association
Correspondence: Mary Rahlin, PT, DHS, Department of Physical Therapy,
Rosalind Franklin University of Medicine and Science, 3333 Green Bay Rd,
North Chicago, IL 60064 (Mary.Rahlin@rosalindfranklin.edu).
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.pedpt.com).
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0000000000000847
evidence-based clinical practice guideline,2 until now, there
have been no torticollis-specific assessment instruments vali-
dated for an observational evaluation targeting the infant’s use of
both sides of the body during spontaneous movement and play.
Still photography is used to assess the habitual head devi-
ation from midline,3 the Muscle Function Scale captures the
imbalance in the neck lateral flexor musculature,4 and the
arthrodial protractor measurements are helpful in documenting
the differences in cervical rotation and lateral flexion range
of motion.6 However, none of these 3 instruments allows the
examiner to capture the infants’ spontaneous adaptations of
movement and posture to task and environment without restric-
tions imposed on them by physical handling.3,4,6 Furthermore,
none of these instruments captures the entire range of motor
behaviors that are observed in the infant’s body, in addition to
the head and neck.3,4,6 The first observational outcome measure
that addressed these problems, a short form of the Functional
Symmetry Observation Scale (FSOS), was developed for a ran-
domized clinical trial of 2 interventions for infants with CMT.5,7
The FSOS Version 1 was a 1-page video-based assessment
instrument that consisted of 9 items (Hand to Mouth, Head
Rotation, Head Righting, Trunk Incurvation, Functional Upper
Extremity Use, Lower Extremity Position/Movement, Movement
Transitions, Prone Mobility, and Upright Mobility). Each item
was scored on a 5-point ordinal scale from 0 to 4, with 0 desig-
nated as “not observed,” and the score of 4 assigned to the equal
use of both sides of the body.5 Scores 1 through 3 quantified
the amount of asymmetry by the percentage of time unequal

Pediatric Physical Therapy Functional Symmetry Observation Scale, Version 2 37

Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 use of both sides of the body was observed. The infant’s pos-
ture and movement were video recorded in 4 positions (supine,
prone, sitting, and standing). Each item was scored based on
the infant’s performance in all 4 positions while using a set of
individual score descriptors.
The intrarater reliability of the FSOS Version 1 was
examined in a small pilot study of 20 observations (intra-
class correlation coefficient [ICC](3,1) = 0.91, 95% confidence
interval: 0.79-0.96). Some difficulties with following the video
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recording procedure were reported. In addition, the require-
ment that the examiner estimate the percent of time that
asymmetry was observed across all 4 positions, and not in each
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position separately, made the score assignment process chal-
lenging. The results suggested the need for a more detailed form
of this instrument and for further standardization of its video
recording procedure.5
The purpose of this article is to describe the development
of the FSOS Version 2 and to report on content validation and
refinement of this scale using a modified Delphi method.8,9
METHODS
Development of the FSOS Version 2
The FSOS Version 2 was developed through a series of mod-
ifications applied to the first version of the scale. As the FSOS
Version 1, its Version 2 was designed as an observational assess-
ment instrument for infants with CMT, age range birth to 18
months. Both versions of the scale target the body structures
and functions, and activity components of the International
Classification of Functioning, Disability, and Health (ICF)10 by
assessing the spontaneous movement and posture in infants
engaged in functional tasks. Similar to Version 1, the FSOS,
Version 2 is a video-based assessment, with a 5- to 10-minute
recording made using a standardized procedure and scored at
a later time, with each item to be assessed on a 5-point ordinal
scale from 0 to 4 using a set of individual score descriptors. How-
ever, while the FSOS Version 1 had been focused on the amount
of observed asymmetry,5 Version 2 scoring criteria were modi-
fied to quantify symmetry in the use of both sides of the body as
the desired outcome of intervention for infants with CMT, with
the total score to be calculated as the sum of 4 positional scores.
The 1-page FSOS Version 1 Record Form was modified to
include a separate page for each of the 4 positional sections
of the new instrument (supine, prone, sitting, and standing),
with each section containing 8 items. The first 7 items were
identical to those in the FSOS Version 1, except for the Head
Righting item, which was replaced with Head Lateral Flexion
to reflect both the infant’s habitual head position at rest and
active antigravity movement of the head. The eighth item was
designated for the method of mobility specific to each posi-
tional section (Supine Mobility/Scooting, Prone Mobility, Sitting
Mobility/Scooting, and Upright Mobility).
Finally, the Individual Score Descriptors were modified to
reflect the changes made to the FSOS Record Form, including
the scoring criteria, item renaming, and inclusion of the new
mobility items. Supplemental Digital Content 1 (available at:
http://links.lww.com/PPT/A343) and 2 (available at: http://
links.lww.com/PPT/A344) represent the first page of the orig-
38 Rahlin et al
Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
inal FSOS Version 2 Record Form and its Individual Score
Descriptors, respectively.
Content Validation of the FSOS Version 2
This was an online survey study that employed modi-
fied Delphi methodology8,9 to build consensus among a group
of experts. Delphi methodology uses several rounds of open-
ended questionnaires to generate consensus among experts who
remain anonymous to each other, and to obtain and refine group
opinions on a topic while considering the individual views
of each participant. After the first survey round, researchers
analyze the feedback received from the expert panel and for-
mulate the questions to be used in the second round. The
feedback summary is shared with the participants between
the survey rounds. This process continues until consensus is
achieved.8,9 Delphi surveys have been used in a variety of
research areas, including the development and validation of
outcome measures.11-13
In the current study, we aimed to establish the content
validity of the FSOS Version 2, as defined by Portney and
Watkins,14 by determining, via expert opinion, that its indi-
vidual sections adequately sampled the entire set of postures
and movements physical therapists typically observe in infants
with CMT in each of the test positions, and that the Individual
Score Descriptors accurately reflected the entire range of motor
behaviors represented by the test items.
One of the modifications to the classical Delphi method8,15
was made because this study examined an already existing scale.
Instead of an open-ended questionnaire typically used in a
Delphi study with an aim to develop a new instrument,9,16 our
survey included a combination of Likert Scale items and open-
ended follow-up questions that invited the experts to explain the
ratings they selected and provide suggestions for improvement.
The second modification was that we planned an additional
intermediate step for a designated researcher to contact a spe-
cific expert or experts individually when a clarification of their
answers was deemed necessary based on the collected survey
responses. Such contact could occur via e-mail or Internet-based
audio- or videoconferencing.
Consensus on each Likert Scale questionnaire item was
defined as a 75% or greater agreement among respondents in
assigning a rating of 3 or greater to that item on a 4-point
scale, with 1 designated as “strongly disagree” and 4 as “strongly
agree.”16 The absence of a neutral answer option encouraged the
experts to select a more definitive response.11
Two survey rounds were planned, with an option to include
only one additional round, if necessary, because large changes
leading to consensus typically occur between Rounds 1 and 2.11
In each round, the experts received a link to an online Qualtrics
survey via e-mail, with attached documents to review, and had
3 weeks to enter their answers.16 The study flow is depicted in
the Figure.
Participants
This study was approved by the Institutional Review
Board. Purposive sampling was used to identify the potential
participants9 who were known to the researchers through their
Pediatric Physical Therapy
 Introductory E-mail sent
to 20 potential expert
group participants,
followed by 2 weekly
reminders
FSOS Version 2 Record
Form, Score
Descriptors, and Round
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Although some of the experts knew each other, their identity
Recruitment completed in 3
weeks
was not disclosed within the group, and their survey responses
Interest in participating were presented only in aggregate in the Results and Feedback
Summary documents they received after each round. At the end,
expressed by 14 experts
all participants were asked and gave permission via e-mail for
their names to be acknowledged in a publication or presentation
of the study results.
Data collected for 3 weeks
Survey completed by 13

1 Survey link sent to 14 experts Survey Content and Data Analyses

experts, followed by 2
weekly reminders
The Round 1 survey asked the participants for their names
Consensus achieved on all but and credentials, their years of experience as a pediatric phys-
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1 item ical therapist, and the areas of expertise in managing infants

Round 1 Survey data
analysis completed
Round 1 Expert
Feedback Summary,
FSOS Version 2 User
Guide, revised FSOS
documents, and Round 2
Survey link sent to 13
experts, followed by 2
weekly reminders
Round 2 Survey data
analysis completed
Thank you e-mail,
Round 2 Expert
Feedback Summary, and
Study Results Summary
sent to 13 experts
Fig. Study flow and step-by-step outcomes. FSOS indicates Functional Symmetry
Observation Scale.
Instrument revisions and User
Guide development necessary
No individual interviews
required
Round 2 Survey constructed
Data collected for 3 weeks
Survey completed by 13
experts
Consensus achieved on all
items
One clarification e-mail
message sent
No further FSOS Version 2
revisions necessary
All of the experts agreed to be
identified by name in the
study publications and
presentations
with CMT. After reviewing the FSOS Version 2 Record Form
and its Individual Score Descriptors (see Supplemental Digital
Content 1, available at: http://links.lww.com/PPT/A343 and 2
available at: http://links.lww.com/PPT/A344, respectively), the
experts answered a series of questions about the scale struc-
ture, content, and scoring criteria, and were invited to make
suggestions for improvement. They were asked to keep in mind
that this instrument targets the child’s spontaneous movement
and play, and that its administration does not involve physical
assistance or facilitation provided by the therapist or caregiver.
Based on the participants’ responses to the Likert Scale
items, the median ratings were identified and percent agree-
ment calculated to determine whether consensus was achieved.
The open-ended question responses were grouped by their key
themes. The results of these analyses guided the revisions made
to the FSOS documents and the researchers’ response to the
experts’ feedback, and the development of the Round 2 Survey.
The items on which consensus was achieved in Round 1 were
dropped unless the changes made to the FSOS Record Form
and the Individual Score Descriptors required that they remain
in the survey. The documents reviewed by the experts prior to
the completion of the Round 2 Survey are listed in the Figure.
The obtained data were analyzed similarly to Round 1.

work experience, clinical practice, or research and publication

in the area of management of infants with CMT. Twenty pediatric
physical therapists with at least 10 years of clinical, academic, or
research experience and expertise in management of infants with
CMT were invited to participate, with a goal to recruit at least
10. This sample size was selected to achieve balance between the
desire to obtain a robust number of ideas and points of view with
the need for the amount of generated data to be manageable.9
The selected sample size was comparable with that reported in
the 54 of 100 Delphi studies reviewed by Diamond et al,17 in
which the number of participants in the final round ranged from
fewer than 10 to 25.
Informed consent was obtained electronically from those
experts who agreed to take part in the study and checked the
appropriate box after reading the survey preamble. One of the
experts completed the entire Round 1 survey but did not mark
the box indicating the agreement to participate; however, that
consent was confirmed via a follow-up e-mail within 1 day of
the survey completion.
The researchers maintained the participants’ quasi-
anonymity9 throughout the study.
RESULTS
After receiving an introductory e-mail, 14 of 20 pediatric
physical therapists (70%) expressed interest in participating in
this study (Figure). Thirteen of 14 experts completed the sur-
veys in Rounds 1 and 2. Table 1 contains the information on the
participants’ level of education, specialty certification, pediatric
physical therapy experience, and areas of expertise in managing
infants with CMT. The members of the expert group resided
in Alaska, Arizona, California, Florida, Georgia, Illinois, New
Jersey, and New York, thus representing all of the 5 major
geographic regions of the United States.
Round 1
As indicated by data in Table 2, in the Round 1 survey, con-
sensus among 13 experts was achieved on all but 1 item. The
median rating of 3 or greater was obtained on all Likert Scale
questions, with percent agreement ranging from 75% to 100%
for those on which consensus was reached. The percent agree-
ment was lower than required (69%) for the item that examined

Pediatric Physical Therapy Functional Symmetry Observation Scale, Version 2 39

Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
 TABLE 1 Supplemental Digital Content 4, available at: http://links.lww.
Expert Group Characteristics (N = 13) com/PPT/A346). In addition, the FSOS Version 2 User Guide
was developed that contained the scale purpose, design, and
Characteristic n (%)
administration and scoring instructions. The authors’ response
Entry-level PT degree to the experts’ feedback and changes to the instrument imple-
BS 6 (46) mented after Round 1 are listed in Table 3 and displayed in
MS 1 (8) Supplemental Digital Content 3 (available at: http://links.lww.
DPT 6 (46)
Additional academic degrees
com/PPT/A345 and 4 (available at: http://links.lww.com/PPT/
MA, MS, or MBA 5 (38) A346. Specifically, the criteria for assigning the FSOS scores
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PhD 3 (23) were modified, several items were renamed, and extensive
PCS certification 3 (23) revisions were made to the Individual Score Descriptors.
Experience as a pediatric physical therapist, y
19 1 (8)
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22-30 6 (46)
40-48 6 (46)
Areas of expertise in management of infants with CMT
Clinical 12 (82)
Academic 4 (31)
Research 5 (38)
Abbreviations: BS, bachelor of science; CMT, congenital muscular torticollis;
DPT, doctor of physical therapy; MA, master of arts; MBA, master of business
administration; MS, master of science; PCS, board-certified clinical specialist
in pediatric physical therapy; PhD, doctor of philosophy.
the criteria for assigning the FSOS scores. Three researchers
reviewed the experts’ comments and identified 10 major themes
listed in Table 3. The participants’ answers to survey ques-
tions did not suggest the need for individual interviews, and,
therefore, none were conducted (Figure).
These results guided the revisions to the FSOS Record Form
(see Supplemental Digital Content 3, available at: http://links.
lww.com/PPT/A345) and the Individual Score Descriptors (see
Round 2
As indicated by data in Table 4, in Round 2, consensus
among 13 experts was achieved on all Likert Scale items, with
the median rating of 4 obtained throughout, and percent agree-
ment ranging from 85% to 100%. One participant marked
“strongly disagree” in response to the question regarding the
extent to which the experts agreed that the criteria for assigning
the FSOS scores listed in the Record Form were clearly stated.
Because no comment was provided for that rating, a follow-up
e-mail asking for clarification was sent, and the expert replied
that the response should have been “strongly agree.”
The major themes identified in the open-ended question
responses included the appreciation of the following improve-
ments to the instrument: clarity of the score assignment criteria,
a greater ease of differentiation between the scores of 2 and 3, the
scale’s ability to quantify the amount of symmetry observed in an
infant with CMT, and clarity and scope of the Individual Score
Descriptors. In addition, the experts expressed their excitement

TABLE 2
Status of Consensusa Among Experts on Likert Scale Questions: Round 1 (N = 13)

Questions Median Percent of Consensus

Please rate the extent to which you agree that: Rating Ratings ≥3 Reached

The FSOS items in the supine section represent the entire set of postures and movements physical therapists 3 100% Yes
typically observe in infants with CMT in that position
The FSOS items in the prone section represent the entire set of postures and movements physical therapists 4 92% Yes
typically observe in infants with CMT in that position
The FSOS items in the sitting section represent the entire set of postures and movements physical therapists 3 85% Yes
typically observe in infants with CMT in that position
The FSOS items in the standing section represent the entire set of postures and movements physical therapists 4 92% Yes
typically observe in infants with CMT in that position
The criteria for assigning the FSOS scores (0-5) listed on the Record Form are clearly stated. 3 69% No
The FSOS scoring criteria adequately quantify the amount of symmetry an infant with CMT may demonstrate. 3 92% Yes
The Individual Score Descriptors are clearly stated. 3 87% Yes
The Individual Score Descriptors accurately reflect the entire range of motor behaviors represented by each of
the FSOS items listed below:
• Hand to mouth 4 85% Yes
• Head rotation 4 92% Yes
• Head lateral flexion or head righting 4 92% Yes
• Trunk incurvation 4 92% Yes
• Upper extremity use 4 82% Yes
• Lower extremity position/movement 4 92% Yes
• Movement transitions 4 92% Yes
• Supine or prone mobility 4 92% Yes
• Sitting or upright mobility 4 75% Yes

Abbreviations: CMT, congenital muscular torticollis; FSOS, Functional Symmetry Observation Scale.
a Consensus on each Likert Scale questionnaire item was defined as a 75% or greater agreement among experts in assigning a rating of ≥3 to that item, with 1

designated as “strongly disagree” and 4 as “strongly agree.”

40 Rahlin et al Pediatric Physical Therapy

Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.

Round 1 Feedback Themes, Authors’ Responses, and Changes Implemented to the Functional Symmetry Observation Scale Version 2
Feedback Themes
1. Excitement about the new scale and its potential benefits, and
suggestions for future validation of the FSOS for other patient
populations
2. Insufficient clarity of the FSOS design, administration, and scoring
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3. Comments related to the FSOS score range being 0 to 4, not 0 to 5
as stated in the question asking to rate the score assignment criteria
4. Difficulty differentiating between the scores of 2 and 3 based on the
percentage of observation time; proposed alternative options for
the descriptors of scores 1-4
5. Limited utility of the “hand to mouth” item; issues with the “upper
extremity use” item scoring and score descriptors; requests to
include object manipulation under “upper extremity use”
6. Requests for clarification of the head rotation score descriptors;
requests for inclusion of the amount of head extension and flexion
into the head rotation score descriptors
7. Observations related to head lateral flexion, head righting, and head
tilt, and requests for clarification of how these terms should be
interpreted
8. Requests to include the symmetry of weight-bearing through trunk
in supine and prone positions, weight-bearing through pelvis in
sitting; and suggestions to add trunk rotation to the “trunk
incurvation” item
9. Requests to include additional positions
10. Relationship between the FSOS items and infant development
Abbreviation: FSOS, Functional Symmetry Observation Scale.
regarding the future clinical use of the FSOS and provided
suggestions for future research. The thematic analysis of the
participants’ comments indicated that no further revisions to
the FSOS Version 2 were necessary. This information, together
with the Rounds 1 and 2 Results Summary, was conveyed to the
experts via e-mail. The description of the final draft of the FSOS
Version 2 is provided next and accompanied by Supplemental
Pediatric Physical Therapy
Copyright © 2021 Academy of Pediatric Physical Therapy of the American Physical Therapy Association.
Unauthorized reproduction of this article is prohibited.
TABLE 3
Authors’ Response/Implemented Changes
N/A
• Reminded participants that the FSOS was a video-based assessment and
acknowledged that this had not been emphasized in the Round 1 survey
preamble
• Emphasized the lack of a penalty for the items that are not observed during the
FSOS administration as stated in the scoring instructions on each page of the
FSOS Record Form
• Developed the FSOS User Guide containing the scale purpose, design, and
administration and scoring instructions
• Apologized for the error in the wording of this survey question
• Clarified that the FSOS is scored on a 5-point scale, from 0 to 4
• Adopted a new wording which was still based on the observation frequency
but without the need to estimate the percentage of time a posture or
movement is observed
• Modified the FSOS Record Form and Individual Score Descriptors for all scale
items accordingly
• Moved the “hand to mouth” item after the “upper extremity use,” and
combined it with object manipulation into a “hand use” item
• Renamed the “upper extremity use” item as “arm use”
• Eliminated the percentage of observation time from the Individual Score
Descriptors
• Modified the Individual Score Descriptors for the head rotation item to
simplify scoring
• Emphasized head rotation and lateral flexion as the major determinants of
symmetry in head movements
• Clarified that the FSOS is not intended to be used for differential diagnosis but
rather to identify the lack of and quantify the amount of observed symmetry
• Renamed this item as “head lateral flexion and lateral head righting,” with its
new definition provided in the second column of the Individual Score
Descriptors document.
• Modified the Individual Score Descriptors for this item to simplify scoring
• Clarified the “trunk incurvation” item as an observation that is made in the
frontal plane and defined as the elongation on one side of the trunk and
shortening on the other, which can be observed with or without trunk rotation
• Explained that the FSOS is not intended to be used for differential diagnosis,
including when triplanar motions are observed, nor is it intended to measure
range of motion
• Explained that the FSOS is intended to easily identify and quantify postural
and functional symmetry or lack thereof
• Clarified that the FSOS uses 4 positions (supine, prone, sitting, and standing),
in which different postures (configurations of body parts) and movements are
observed
• Renamed prone position as prone/quadruped
• Modified the definition of the “movement transitions” item to “transitioning
from an observed position to any other”
• Clarified that its focus on postural and functional symmetry makes the FSOS
Version 2 distinct from the tests and measures that document the
developmental milestones achieved by the infant or target range of motion,
strength, or muscle tone
• Explained that this instrument is intended to quantify observed symmetry in
posture and movement regardless of the infant’s age or level of development,
and that this intent is reflected in its Individual Score Descriptors.
Digital Content 3 (available at: http://links.lww.com/PPT/A345
and 4 (available at: http://links.lww.com/PPT/A346.
Final Draft of the FSOS Version 2
As stated previously, the FSOS Version 2 is an observational,
video-based assessment instrument, which allows the examiner
Functional Symmetry Observation Scale, Version 2 41
 TABLE 4
Status of Consensusa Among Experts on Likert Scale Questions: Round 2 (N = 13)

Questions Median Percent of Consensus

Please rate the extent to which you agree that: Rating Ratings ≥3 Achieved

The criteria for assigning the FSOS scores (0-4) listed on the Record Form are clearly stated 4 92% Yes
The FSOS scoring criteria adequately quantify the amount of symmetry an infant with CMT may demonstrate 4 92% Yes
The Individual Score Descriptors are clearly stated 4 92% Yes
The Individual Score Descriptors accurately reflect the entire range of motor behaviors represented by each of
the FSOS items listed below:
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• Head rotation 4 100% Yes

• Head lateral flexion and head righting 4 92% Yes
• Trunk incurvation in frontal plane 4 100% Yes
• Arm use 4 100% Yes
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• Hand use 4 100% Yes

• Lower extremity use 4 85% Yes
• Movement transitions 4 100% Yes
• Supine or prone/quadruped mobility 4 100% Yes
• Sitting or upright mobility 4 100% Yes

Abbreviations: CMT, congenital muscular torticollis; FSOS, Functional Symmetry Observation Scale.
a Consensus on each Likert Scale questionnaire item was defined as a 75% or greater agreement among experts in assigning a rating of ≥3 to that item, with 1

designated as “strongly disagree” and 4 as “strongly agree.”

to capture the infants’ spontaneous adaptations of movement
and posture to task and environment without any restrictions
imposed on them by physical handling. The FSOS Version 2
User Guide that will be included with the tool once it becomes
available to clinicians and researchers contains the following
description of the standardized video recording procedure:
The test set-up includes a safe, padded observation area
(therapy mat, soft carpeting, etc) bordered on one side with a
stable elevated support surface (cube chairs, sofa, low table, etc).
The elevated area provides an opportunity for the infant to pull
to stand and take multiple cruising steps to both sides. Addi-
tional necessary equipment includes a video camera, a tripod,
and age-appropriate toys to be used to encourage looking,
reaching, movement transitions, and independent mobility.
The examiner positions the camera to capture the entire
observation area and guides the caregiver to do the following:
Undress the infant to the diaper or onesie.
Place the infant within the observation area for filming in
each of the 4 positions.
Provide appropriate manual trunk support in sitting and
standing positions when necessary for the infant’s skill
level.
Use toys, sounds, and other stimuli (but not physical han-
dling) to encourage visual tracking and spontaneous
movement to both sides in each of the 4 positions to test
as many of the scale items in each position as appropriate
for the infant’s skill level.
Maintain the infant within the observation area throughout
filming and reposition to capture all necessary views in
each position.
The FSOS Version 2 Record Form consists of 4 positional
sections (supine, prone/quadruped, sitting, and standing). Each
section includes 8 items scored on a 5-point ordinal scale
(0-4), with 1 indicating the absence of symmetry character-
ized by consistent use of one and the same side of the body
by the infant, and 4 indicating consistent, equal use of both
sides of the body (see Supplemental Digital Content 3, avail-
able at: http://links.lww.com/PPT/A345). The score of 0 (“not
observed”) indicates that the infant did not demonstrate a spe-
cific movement during the assessment. The number of items that
were not observed does not affect the positional score.
The finalized scale items include Head Rotation, Head Lat-
eral Flexion and Head Righting, Truck Incurvation, Arm Use,
Hand Use, Lower Extremity Use, Movement Transitions, and
Mobility in a specific position (see Supplemental Digital Con-
tent 3, available at: http://links.lww.com/PPT/A345). The first
column of the Individual Score Descriptors form (see Supple-
mental Digital Content 4, available at: http://links.lww.com/
PPT/A346) includes the scale items, with Item 8 (Mobility)
divided into 2 sections: (a) supine or prone/quadruped mobility
and (b) sitting or upright mobility. The second column lists
the definitions of the FSOS items intended to guide the related
observations by the examiner. The rest of the form contains
the FSOS scores 1 through 4, and their individual descrip-
tors customized for each of the 8 items. The Individual Score
Descriptors form is intended to guide the examiner’s selection of
the appropriate score on the FSOS Record Form while watching
the video recording of the infant’s posture and movement. The
scoring instructions are provided in every positional section of
the Record Form (see Supplemental Digital Content 3, available
at: http://links.lww.com/PPT/A345), and the FSOS total score is
obtained by adding the positional scores.
DISCUSSION
In this article, we described the development of the FSOS
Version 2 that quantifies symmetry in posture and sponta-
neous, unrestricted movement observed in infants with CMT,
and reported the results of its content validation conducted
using a modified Delphi method. Only 2 survey rounds were
necessary to achieve consensus among experts on all items,
which established the content validity of this instrument. Exten-
sive modifications of the Record Form and Individual Score

42 Rahlin et al Pediatric Physical Therapy

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Unauthorized reproduction of this article is prohibited.
 Descriptors were undertaken after Round 1, and the FSOS User
Guide was developed. The User Guide clarified for the experts
that the focus of the FSOS Version 2 on postural and functional
symmetry makes this instrument distinct from the tests and
measures that document the developmental milestones achieved
by the infant or target range of motion, strength, or muscle tone.
Such measures may assist clinicians in determining the possible
reasons for the lack of postural and functional symmetry that
the FSOS identifies and quantifies.
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The inherent reliability and validity concerns of the Delphi
method9 need to be discussed in relation to the current study.
According to Hasson et al,9 the reliability may be questioned
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because it is not known whether the same results may be
obtained when the same information is provided to several
expert panels. One way to address this issue may be by ensuring
the replicability of the study procedure. This may be accom-
plished by proper reporting of the study aim, sampling method
and criteria, the definition of consensus, the modifications to
the classical Delphi process, the criteria for dropping the survey
items in successive rounds, and to what extent the planned
steps were implemented.9,17 We believe that we followed these
recommendations. Additionally, the validity of results may be
affected by the survey response rates.9 In the current study,
the response to the introductory e-mail was high (70%); 13 of
14 experts who expressed their interest in participating (93%)
completed the Round 1 survey, and 100% of them finished the
study. Furthermore, the fact that the expert panel in our study
included highly-qualified individuals (Table 1) strengthened
the validity of results.
Although the content validity of the FSOS Version 2 has
been established, further research is necessary before this test
can be used in the clinic. Based on our original plan for estab-
lishing the psychometric properties of this instrument and
the comments received from the expert panel participants,
suggestions for future research include the following steps:
1) Pilot test the FSOS Version 2 to examine the feasibility
of its clinical use in infants with CMT.
2) Examine the intra- and interrater reliability of this
instrument.
3) Examine the construct validity of the FSOS Version 2 by
determining whether infants with greater limitations in
cervical range of motion or greater habitual head devia-
tion from midline measured by still photography score
lower on this test.
4) Compare the FSOS Version 2 scores obtained by clini-
cians new to working with infants with CMT and those
who are experienced in this area of practice.
5) Develop a “live” scoring procedure and compare its feasi-
bility and reliability to that of a video-based assessment.
6) Examine the FSOS Version 2 responsiveness to change
with intervention.
7) Validate this instrument for use in children with condi-
tions other than CMT that are characterized by decreased
postural and functional symmetry.
Once the FSOS Version 2 is properly piloted and its reli-
ability is established, it can be used clinically not only to
document the amount of symmetry exhibited by infants with
Pediatric Physical Therapy
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Unauthorized reproduction of this article is prohibited.
CMT during spontaneous movement and play, but also, as sug-
gested by one of the experts, to educate their parents/caregivers
about the behaviors infants develop because of this condi-
tion. Additional potential uses of this instrument will be to
track the child’s progress over time and evaluate and compare
intervention outcomes in future research studies.
CONCLUSIONS
The FSOS Version 2 is the first observational instrument
that quantifies symmetry in spontaneous posture and movement
in infants with CMT engaged in functional tasks. Its content
validity has been established by a panel of experts using a mod-
ified Delphi method. Further studies are necessary to bring this
instrument to the clinic, expand its use to other patient popu-
lations, and allow for its application as an outcome measure in
intervention efficacy research.
ACKNOWLEDGMENTS
The authors would like to thank the members of the expert
panel who participated in this study, including Elaine Becker,
PT, DPT, MA, PCS; Colleen Coulter, PT, DPT, PhD, MA; Char-
lene Fregosi, PT; Patricia Gallo, PT, MA; Nancy Haney, PT, MS;
Sandra L. Kaplan, PT, DPT, PhD, FAPTA; Magdalena Oledzka,
PT, DPT, PhD, MBA, PCS; Lisa Pinson, PT, DPT; Mary Pomeroy,
PT; Joanne Pygon, PT, DPT, PCS; Lisa N. Scher, PT; Monica
Sheppard, MS PT; and Myla Teemer, PT. We appreciate all of
their time, effort, attention to detail, opinions, comments, and
suggestions that contributed greatly to the refinement of the
FSOS Version 2 and validation of its content.
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Unauthorized reproduction of this article is prohibited.