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Clinical Rehabilitation 2010; 24: 887–900

A systematic review of arm activity measures for children


with hemiplegic cerebral palsy
K Klingels, E Jaspers, A Van de Winckel Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation
Sciences, Katholieke Universiteit Leuven, P De Cock Department of Paediatrics, Faculty of Medicine, Katholieke University
Leuven, G Molenaers Department of Musculoskeletal Sciences, Faculty of Medicine, Katholieke University Leuven and
H Feys Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke University
Leuven, Heverlee, Belgium

Received 26th June 2009; revised manuscript accepted 16th February 2010.

Objective: To identify psychometrically sound and clinically feasible assessments


of arm activities in children with hemiplegic cerebral palsy for implementation in
research and clinical practice.
Data sources: PubMed, CINAHL, Cochrane Library, Web of Science and reference
lists of relevant articles were searched.
Review methods: A systematic search was performed based on the following
inclusion criteria: (1) evaluative tools at the activity level according to the
International Classification of Functioning, Disability and Health; (2) previously used
in studies including children with hemiplegic cerebral palsy aged 2–18 years; (3) at
least one aspect of reliability and validity in children with cerebral palsy should be
established. Descriptive information, psychometric properties and clinical utility
were reviewed.
Results: Eighteen assessments were identified of which 11 met the
inclusion criteria: eight functional tests and three questionnaires. Five
functional tests were condition-specific, three were generic. All functional
tests measure different aspects of activity, including unimanual capacity
and performance during bimanual tasks. The questionnaires obtain information
about the child’s abilities at home or school. The reliability and validity have been
established, though further use in clinical trials is necessary to determine the
responsiveness.
Conclusions: To obtain a complete view of what the child can do and what the
child actually does, we advise a capacity-based test (Melbourne Assessment of
Unilateral Upper Limb Function), a performance-based test (Assisting
Hand Assessment) and a questionnaire (Abilhand-Kids). This will allow
outcome differentiation and treatment guidance for the arm in children with
cerebral palsy.

Introduction
Address for correspondence: Katrijn Klingels, Department of
Rehabilitation Sciences, Katholieke University Leuven,
Children with hemiplegic cerebral palsy are faced
Tervuursevest 101, 3001 Heverlee, Belgium. with a variety of motor and sensory impairments
e-mail: Katrijn.Klingels@faber.kuleuven.be that have an impact on their arm functioning.1
ß The Author(s), 2010.
Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav 10.1177/0269215510367994
888 K Klingels et al.

Adequate assessment of arm function in these clinical tools appropriate for assessing arm func-
children is crucial not only to outline treat- tion in children with hemiplegia. The descriptive
ment, but also to measure the efficacy and to information, clinical utility and psychometric
allow follow-up over time. According to the properties of the selected outcome measures will
International Classification of Functioning, be assessed. This review offers a flexible frame-
Disability and Health (ICF), the upper limb can work to support the selection of suitable outcome
be assessed at the level of body function, activity measures for arm activities.
and participation.2 For the hemiplegic child,
spasticity and/or dystonia, weakness, impaired
dexterity and coordination deficits are problems
at the level of body function. Arm activity limita- Methods
tions reflect the difficulties experienced during
reaching, grasping, manipulating and releasing Papers were selected through an electronic search
objects with the hemiplegic arm and hand. As of the following databases (January 2009):
many daily activities involve these functional PubMed, CINAHL, Cochrane Library and Web
tasks, limitations in arm activities can hinder the of Science. Keywords (MeSH) for the search strat-
child’s participation in school and leisure activities. egy included ‘cerebral palsy’ and ‘upper extrem-
Over the last two decades, several measurement ity’. To focus search results, these keywords were
tools have been designed to assess arm activities in combined with text words for ‘outcome assess-
children with hemiplegic cerebral palsy. These ment’, ‘questionnaire’ and ‘activity’. Identified
tools each involve different clinically relevant assessments were subsequently searched individu-
aspects. As expressed in the ICF, a differentiation ally, combined with terms such as ‘psychometric
can be made between the qualifiers ‘capacity’ and properties’, ‘reliability’ and ‘validity’. Reference
‘performance’. Capacity refers to the child’s ability lists from included articles were hand-searched to
to execute a task on the highest probable level detect further relevant papers.
of functioning that the child may reach in a stan- Two authors (KK and EJ) assessed the title and
dardized environment. Quality of movement abstract of each study to identify and select the
(e.g. active range of motion, fluency, accuracy), outcome assessments. Tools were included if they
dexterity and movement speed are all components met the following inclusion criteria: (1) evaluative
of capacity. Performance refers to the child’s spon- tools at the ICF level of activity; (2) previously
taneous use of the hemiplegic hand during activi- used in studies including children with cerebral
ties or play.3 To obtain a complete representation palsy aged 2–18 years; (3) at least one aspect of
of the child’s abilities, these different qualifiers of reliability and validity in children with cerebral
arm function have to be considered. In addition, palsy should be established.
to allow implementation in research and clinical Both condition-specific assessments developed
practice, the selected outcome measures should specifically for children with cerebral palsy and
have sound psychometric properties, such as reli- generic assessments were included. The latter
ability, validity and the ability to detect clinically assessments focus on discriminating between typi-
important differences. cally developing children and children with a
Currently, several clinical measures are avail- developmental delay, arising from a broad range
able to assess arm function. However, in the pre- of disabilities.
sent state of outcome measurements for arm Tools were excluded if they: (1) were not pub-
activities in children with cerebral palsy, there is lished in English; (2) primarily assessed impair-
little consistency about their use in research and ments or participation restrictions; and (3) were
clinical practice. This lack of consistency compli- instruments based on individually identified goals.
cates the identification of suitable measurement In the case of disagreement, the selected out-
tools for follow-up and treatment. To the best of come measure was discussed with a third author
our knowledge, there has been no systematic over- (HF) until consensus was reached.
view and comparison of these tools. Therefore, the A data extraction sheet based on the
aim of this study was to give a systematic review of Outcome Measures Rating Form4 allowed for
Arm activity measures for children with cerebral palsy 889

the comparison of descriptive information, clinical These were further reviewed to evaluate their psy-
utility and psychometric properties of the selected chometric properties. Seven assessments were
assessments: excluded. The selected instruments were classified
as functional tests, either condition-specific (n ¼ 5)
 Descriptive information was gathered for each or generic (n ¼ 3), and questionnaires (n ¼ 3).
assessment to determine target population, pur- The condition-specific functional tests were the
pose, content, number of domains/items and Quality of Upper Extremity Skills Test (QUEST9),
scoring criteria. the Melbourne Assessment of Unilateral Upper
 Clinical utility entailed the administration Limb Function (Melbourne Assessment10), the
format, test duration and scoring time, required Shriners Hospital for Children Upper Extremity
equipment and need for rater training. Evaluation (SHUEE11), the Assisting Hand
 Psychometric properties addressed the reliability Assessment (AHA12) and the Video Observations
and validity of the outcome assessment. Aarts and Aarts (VOAA13). Generic functional
tests included the Bruininks-Oseretsky Test
Reliability was defined as the extent to which the of Motor Proficiency (BOTMP14), the Peabody
assessment produces consistent and reproducible Developmental Motor Scales (PDMS15) and the
results on repeated administration (test–retest) Jebsen-Taylor Hand Function Test (Jebsen-
when used by the same rater (intra-rater) or when Taylor test16).
used by different raters (inter-rater).5 The following The selected questionnaires were the
guidelines were used for the interpretation of the Abilhand-Kids,17 the Revised Pediatric Motor
reliability coefficients. Intraclass correlation coeffi- Activity Log (PMAL-revised18) and the Pediatric
cients (ICC) above 0.80 were considered excellent; Evaluation of Disability Inventory (PEDI19).
0.60–0.79 adequate; below 0.60 poor. Kappa coef-
ficients between 0.81 and 1.00 were considered as
an almost perfect agreement, 0.61–0.80 as a sub-
stantial agreement and 0.41–0.60 as a moderate Descriptive information
agreement.6 In addition, the standard error of mea- Functional tests
surement (SEM), the smallest detectable difference Descriptive information on the tests is presented
(SDD) and the minimal clinically important differ- in Table 1. The majority of the functional tests
ence were reported. The SEM provides an absolute evaluate the child’s upper limb capacity, while
index of reliability as it indicates the variability of only the AHA and the VOAA evaluate the upper
scores around the subject’s true score. The SDD is limb performance during bimanual tasks.
required to conclude whether the subject shows a The QUEST and the Melbourne Assessment
real improvement rather than a difference in score are evaluative tools that measure upper limb qual-
due to measurement error. The SDD equals the ity of movement by means of various unimanual
SEM  1.96  ˇ2.7 The minimal clinically impor- items.9,10 While the QUEST focuses on dissociated
tant difference is referred to as the smallest change movements, grasp, weight bearing and protective
in measurement that is considered to be meaningful extension, the Melbourne Assessment assesses
based on clinicians’ ratings.8 Validity is the extent items that involve reach, grasp, release and manip-
to which an evaluation tool actually measures what ulation. Items are further subdivided into subitems
it is intended to measure.5 Content, construct and which are scored on a dichotomous scale for the
concurrent validity were reviewed. QUEST and a 3- to 5-point ordinal scale for the
Melbourne Assessment.
The SHUEE is a more recently developed tool
that consists of two sections.11 The first section
Results incorporates different subscales at the level of
body function, such as range of motion and
The search strategy is outlined in Figure 1. muscle tone. The second section includes three com-
Eighteen assessments were identified, of which 11 ponents: spontaneous functional analysis, dynamic
assessments met the predefined inclusion criteria. positional analysis and grasp–release analysis.
890 K Klingels et al.

[Mesh term] [Text word]


“CP” and “upper extremity” AND “outcome assessment” 63 papers
AND “activity” 50 papers
AND “questionnaire” 18 papers

Studies selected based on title and abstract 29 papers

Identified assessments related to arm activity n =18

Excluded assessments n =3
1) Individually identified problems/goals based on a semi-
structured interview
COPM20 & GAS21
2) Primarily assesses participation restriction
WeeFIM22

Outcome assessments at the level of activity n =15

Excluded assessments n=4


Psychometric evaluation
1) Psychometric properties not established, children aged <
2 years
EDPA23
2) Psychometric properties not established in children with
CP
BBT24, PPT25 & CHAQ26

Outcome assessments evaluated n = 11

5 Condition-specific tests

Questionnaires n=3 Functional tests n = 8

3 Generic tests

Figure 1 Flow diagram of selection of outcome assessments. COPM, Canadian Occupational Performance Measure;
GAS, Goal Attainment Scale; WeeFIM, Functional Independence Measure for children; EDPA, Erhardt Developmental
Prehension Assessment; BBT, Box and Block test; PPT, Purdue Pegboard Test; CHAQ, Childhood Health Assessment
Questionnaire.
Table 1 Descriptive information of the selected instruments to measure upper limb activities

Target population Capacity Performance Norm- Criterion-


referenced referenced
Diagnosis Age Unimanual Bimanual Unimanual Bimanual

Functional tests
QUEST9 CP 18 months–8 years þ þ
Melbourne CP 5–15 years þ þ
Assessment10
SHUEE11 Hemiplegia 3–18 years þ þ þ
AHA12 Hemiplegia or 18 months–12 years þ þ
Erb’s paresis
VOAA13,27 CP 2.5–10 years þ þ
BOTMP subtest 814 Children with DD 4.5–14.5 years þ þ þ
PDMS-2-FM15 Children with DD 0–6 years þ þ þ
Jebsen-Taylor test16 Children with DD 5–18 years þ þ
Questionnaires
Abilhand-Kids17 CP 6–15 years þ þ þ
PMAL-Revised18 CP 7 months–8 years þ þ þ
PEDI19 Children with DD 6 months–7.5 years þ þ þ þ þ

CP, cerebral palsy; DD, developmental disabilities; þ, description applicable for the instrument; QUEST, Quality of Upper Extremity Skills Test; SHUEE,
Shriners Hospital for Children Upper Extremity Evaluation; AHA, Assisting Hand Assessment; VOAA, Video Observations Aarts and Aarts; BOTMP, Bruininks-
Oseretsky Test of Motor Proficiency; PDMS-2-FM, Peabody Developmental Motor Scales – Fine Motor abilities; PMAL-Revised, Revised Pediatric Motor
Acivity Log; PEDI, Pediatric Evaluation of Disability Inventory.
Arm activity measures for children with cerebral palsy
891
892 K Klingels et al.

The different components are scored on a 2- to 6- the child to perform the required tasks is scored on
point ordinal scale. a 3-point ordinal scale.
The AHA assesses how effectively the hemiple- The PMAL-revised documents the spontaneous
gic hand is actually used in bimanual activities.12 use of the affected arm in every day activities.18
The spontaneous use is evaluated during a semi- The original PMAL has been modified based on
structured play session with toys requiring biman- a Rasch analysis. The revised version consists of
ual handling. The items that are scored include 22 unimanual and bimanual tasks. For each task,
general use, arm use, grasp and release, fine both the amount of use and the quality of move-
motor adjustments, coordination and pace. All ment of the affected arm are rated on a 3-point
items are scored from 0 (does not do) to 4 (effec- ordinal scale.
tive use). The PEDI quantifies a child’s level of ability
The VOAA is a recently developed observa- and dependency in many daily activities.19 The
tional tool to measure the spontaneous arm use questionnaire incorporates three domains: self-
by means of a computer software program.13,27 care, mobility and social functioning. For each
The duration and frequency of specific behaviours domain, functional skills are rated dichotomously
of the affected arm are calculated during different and caregiver assistance is rated on a 6-point ordi-
bimanual activities, such as making a sandwich, nal scale ranging from ‘total assistance’ to
playing with Lego blocks, removing a shoe, string- ‘independence’.
ing beads and decorating a muffin.
The BOTMP and PDMS-2 are designed to mea-
sure gross and fine motor abilities. Subtest 8 of the Clinical utility
BOTMP can be used to evaluate fine motor skills Table 2 shows that the administration time for
in terms of speed and dexterity.14 This subtest all functional tests is approximately 10–15 min-
involves eight tasks, such as placing pennies in a utes, except for the more extensive PDMS-2-FM.
box, sorting shape cards, stringing beads and For the video-based assessments, the scoring after-
making dots. Tasks are scored on a 7- to 10- wards takes another 10–30 minutes. The duration
point scale. The fine motor abilities of the to fill in the questionnaires ranges from 10 to
PDMS-2 are divided into two subtests, including 60 minutes.
grasping and visuomotor integration.15 Items are Another issue is the difference in costs to obtain
scored on a 3-point ordinal scale. The raw scores the assessment. While some tools can be down-
from the BOTMP and PDMS-2 can be converted loaded for free, others require the purchase of
into a standard score with an age equivalent. standardized materials. Administering and scoring
The Jebsen-Taylor test measures movement the AHA and the VOAA requires a certificate that
speed in seven unimanual tasks.16 The time to can only be obtained after attending a specific
carry out the task is registered and compared rater training course. For the other functional
with norm values.28 The test was modified for chil- tests, rater training is only recommended to stan-
dren with hemiplegic cerebral palsy whereby the dardize the scoring system between raters and to
writing task was removed, and the time to carry aim for an optimal reliability of the assessment.
out each task was reduced from 3 to 2 minutes to
avoid frustration.29,30
Psychometric properties
Data on the psychometric properties are pre-
Questionnaires sented in Table 3. All reported reliability results
The Abilhand-Kids and PMAL-revised are con- are based on the population of children with cere-
dition-specific, and the PEDI is a generic question- bral palsy. The intra-rater, inter-rater and test–
naire. All questionnaires are completed by the retest reliability have been established for all
child’s parents or caregivers. condition-specific functional tests, except for the
The Abilhand-Kids comprises 21 mainly biman- test–retest reliability of the SHUEE. The reliability
ual daily activities.17 The difficulty experienced by of all condition-specific and generic functional
Table 2 Clinical utility of the selected instruments to measure upper limb activities

Administration Test duration Equipment to be purchased Rater


format training
Administration Scoring time Manual Standardized
time (minutes) (minutes) material

Functional tests
QUEST9 Direct observation/ 15 15–30 þ  
video recording
Melbourne Video recording 15 15–30 þ þ 
Assessment10
SHUEE11 Video recording 15 15–30 Free  
download
12
AHA Video recording 10–15 15–30 þ þ þ
VOAA13,27 Video recording 10 20 þ þ þ
BOTMP subtest 814 Direct observation 15 þ þ 
PDMS-2-FM15 Direct observation 20–30 þ þ 
Jebsen-Taylor test16 Direct observation 10–15 þ þ 
Questionnaires
Abilhand-Kids17 Parent questionnaire 10 Free  
download
18
PMAL-Revised Parent questionnaire 5–15 3 þ  
PEDI19 Direct observation or 45–60 þ  
structured parent interview

þ, required for test administration; –, not required for test administration.


QUEST, Quality of Upper Extremity Skills Test; SHUEE, Shriners Hospital for Children Upper Extremity Evaluation; AHA, Assisting Hand Assessment; VOAA,
Video Observations Aarts and Aarts; BOTMP, Bruininks-Oseretsky Test of Motor Proficiency; PDMS-2-FM, Peabody Developmental Motor Scales – Fine
Motor abilities; PMAL-Revised, Revised Pediatric Motor Acivity Log; PEDI, Pediatric Evaluation of Disability Inventory.
Arm activity measures for children with cerebral palsy
893
894

Table 3 Psychometric properties of the selected instruments to measure upper limb activities

Reliability Validity

Intra-rater Inter-rater Test–retest SEM SDD Construct Content Concurrent

Functional tests
K Klingels et al.

QUEST31–33 ICC 0.69–0.89 ICC 0.90–0.96 ICC 0.95 5.0% 13.8% þ þ PDMS-2-FM Rp 0.84
(inter)
Melbourne ICC 0.97 ICC 0.95–0.99 ICC 0.97–0.98 3.2% 8.9% þ þ PEDI self-care Rs 0.94
Assessment33–36 (inter)
PEDI total Rs 0.72
SHUEE11 Rp 0.98–0.99 ICC 0.89–0.90     þ þ Jebsen-Taylor Rp –0.76
w 1.00 w 1.00 PEDI self-care Rp 0.47
AHA12,37 ICC 0.99 ICC 0.97–0.98 ICC 0.98–0.99 1.5 54 þ þ   
(inter)
1.2
(intra)
VOAA13,27  0.63–0.85  0.62–0.67     þ þ   
ICC 0.96–1.00 ICC 0.95–1.00 ICC 0.87–1.00
BOTMP Rp 1.00a Rp 0.94 Rp 0.86 2.0 5.5 þ þ   
subtest 814,30 (retest)
PDMS-2-FM15,38   ICC 0.98 ICC 0.92–0.99 1.3 3.6 þ þ QUEST Rp 0.84
(retest)
a
Jebsen-Taylor Rp 0.99 Rp 0.99 Rp 0.99   þ þ SHUEE Rp –0.76
test16,28,30
Questionnaires
Abilhand-Kids17     Rp 0.91   þ þ Grip strength Rp 0.56
BBT Rp 0.66
Purdue Rp 0.45
Pegboard
PMAL-Revised18     ICC 0.93–0.94   þ þ   
PEDI39   ICC 0.99 ICC 0.91–0.98  11.5%b þ þ Melbournec Rs 0.72–0.94
SHUEE Rp 0.47

ICC, intraclass correlation coefficient; Rs, Spearman rho correlation coefficient; Rp, Pearson correlation coefficient; , kappa coefficient; w, weighted kappa;
þ, established in children; –, not established in children; QUEST, Quality of Upper Extremity Skills Test; SHUEE, Shriners Hospital for Children Upper
Extremity Evaluation; AHA, Assisting Hand Assessment; VOAA, Video Observations Aarts and Aarts; BOTMP, Bruininks-Oseretsky Test of Motor
Proficiency; PDMS-2-FM, Peabody Developmental Motor Scales – Fine Motor abilities; PMAL-Revised, Revised Pediatric Motor Acivity Log; PEDI,
Pediatric
a
Evaluation of Disability Inventory.
b
Intrarater reliability established based on video recordings.
c
MCID-value.
Concurrent validity only established for the self-care domain of the PEDI.
Arm activity measures for children with cerebral palsy 895

tests is excellent, except for a slightly lower reli- questionnaire such as the Abilhand-Kids,
ability for some tasks of the VOAA. For all PMAL-revised or the PEDI.
questionnaires, test–retest reliability is very high. Comparison of the different condition-specific
Inter-rater reliability has only been reported for tests shows that the QUEST is suitable to evaluate
the PEDI and is excellent. For the tests with the quality of movement of the affected arm in
real-time scoring, as well as for the questionnaires, very young children as it comprises domains
the assessment of intra-rater reliability is not appli- related to motor development, such as dissociated
cable. The SEM and SDD have been established movements, weight bearing and protective exten-
for the QUEST,33 Melbourne Assessment,33 sion. For children from 5 years of age on, the
AHA,37 BOTMP14 and PDMS-2-FM.15 For the Melbourne Assessment can be used. This test
PEDI, the minimal clinically important difference entails a more detailed scoring of the quality of
(11.5%) was reported.8 movement compared to the dichotomous scoring
Both construct and content validity have been of the QUEST, and it includes also aspects such as
established for the selected functional tests and speed, accuracy and fluency. Since the Melbourne
questionnaires. The concurrent validity was eval- Assessment is validated for children up to the age
uated for the majority of the assessments. of 15 years, the test is more appropriate for long-
Although most tests have a good concurrent term follow-up.33 The SHUEE, on the other hand,
validity, correlations below 0.60 were found is the only test that provides a detailed analysis of
between the SHUEE and the self-care domain of the position of the thumb, fingers, wrist, forearm
the PEDI and between the Abilhand-Kids and the and elbow. This aspect is particularly relevant to
Purdue Pegboard test.25 evaluate the effect of interventions at the level of
The Rasch rating scale methodology was body function, such as botulinum toxin A injec-
applied during the construction of the AHA, tions or surgery.
Abilhand-Kids, PMAL-revised and PEDI. This Although the latter three tests were included as
statistical procedure provides sound evidence for measures at the level of activity, there may be
unidimensionality and adequate hierarchic scale some ambiguity relating these measures to the
structure of these assessments. It also transforms ICF framework. For the Melbourne Assessment,
the original ordinal scale into an interval scale several subitems score aspects at the body function
measuring a continuum.40 level (i.e. range of motion, fluency). The QUEST
also measures items at the body function level (i.e.
dissociated movements) and in the SHUEE the
dynamic positional analysis may fit in this level.
Discussion Still, these tests incorporate grasping and manip-
ulation abilities and items are assessed in the con-
This study offers an overview of arm activity mea- text of activities. However, the fact that the above-
surements for children with hemiplegic cerebral mentioned outcome measures span different ICF
palsy. Eleven psychometrically sound and clini- levels may complicate the clinical interpretation of
cally feasible outcome assessments were identified. the results.
The selected instruments included eight functional Apart from the capacity, it is also important to
tests, either condition-specific or generic, and three assess a child’s performance. In these tests children
questionnaires. The majority of the assessments are not specifically asked to execute the task with
measure capacity with standardized items in test their affected hand, but encouraged to use it in
situations where children show what they can do play or daily activity, where bimanual handling
when asked to. The capacity of the hemiplegic side is required. This aspect is measured in the AHA
can be measured with the QUEST, Melbourne and the VOAA. The AHA comprises a detailed
Assessment, SHUEE, Jebsen-Taylor test, evaluation of the different functions of the hemi-
BOTMP or the PDMS-2-FM. Performance- plegic arm and hand administered in a play ses-
based tests or questionnaires measure what chil- sion. The VOAA can be used to calculate the exact
dren actually do in daily life. This aspect can be quantity of use of the hemiplegic hand during
measured with the AHA, VOAA or with a daily activities. Both tests are suited to evaluate
896 K Klingels et al.

the effect of therapy modalities which aim to the hemiplegic side. If the difference between
improve the involvement of the hemiplegic arm capacity and actual performance is large, the
during daily activities (e.g. constrained-induced child may have potential for a more effective per-
movement therapy). formance. Intervention can thus focus on estab-
Generic tests are designed for children with a lishing a useful spontaneous behaviour and
broad range of developmental disabilities and learning to use the underlying capacity (e.g. con-
have a discriminative ability. The BOTMP and straint-induced movement therapy or task-
the PDMS-2-FM cover a wide variety of skills, oriented training). If the child is fully using his
such as use of pen or scissors. These tests describe or her capacities but with a poor result, interven-
aspects of age-related hand function, but they give tion should focus on improving the biomechanical
little or no information concerning the quality prerequisite for handling objects, for example
of movement of the hemiplegic arm and hand. strength training, botulinum toxin A injections
Thus, they are less suitable for clinical guidance. or a surgery. Therefore, measures of hand function
The most important contribution of these norm- for both capacity and performance are needed to
referenced tests for children with cerebral palsy is allow outcome differentiation and to guide
their use in identifying a child’s need and eligibility treatment.3
for therapy services by determining the extent of A further important criterion to select tests or
the child’s delay or dysfunction.3 The Jebsen- questionnaires is the fulfilment of psychometric
Taylor test is a short unimanual test to score the properties. The reliability and validity of both
movement speed during unimanual fine motor the functional tests and the questionnaires have
activities, a component not addressed in other been established. Only for the VOAA test are
measures. additional validity studies necessary.
Standardized tests do not necessarily reflect how The Melbourne Assessment and the QUEST
the child actually performs in their normal envi- have frequently been used in clinical trials that
ronment. This information on ‘real life’ function- investigate the effects of botulinum toxin A injec-
ing may be gathered through direct enquiry from tions42–46 as well as the self-care domain of the
the child and/or the child’s parents. The Abilhand- PEDI.42,45,46 Some studies have suggested that
Kids is a short questionnaire focused on arm func- the Melbourne Assessment might not be suffi-
tion during daily activities and gives information ciently sensitive to changes brought about by bot-
for goal setting in occupational therapy. The ulinum toxin A treatment,42,44,46 while the QUEST
PEDI covers a broad domain of the child’s func- and the self-care domain of the PEDI seem
tioning, whereby both the activity level and more sensitive.42,46 The AHA and the raw scores
aspects of the participation level are considered. of the generic tests have shown change in interven-
A drawback to use the PEDI is a ceiling effect in tion studies focusing on forced use therapy,47
the group of children with hemiplegia as they often constraint-induced movement therapy29,48,49
compensate with their healthy side for the prob- and hand–arm bimanual intensive training
lems experienced with the affected side.41 The (HABIT).50 The SHUEE, the VOAA, the
recently revised PMAL has been specifically devel- Abilhand-Kids and the revised-PMAL have not
oped to evaluate the effects of constraint-induced been used in intervention studies so far.
movement therapy. The two subscales of the The SEM, the SDD and the minimal clinically
PMAL-revised allow differentiation between important difference are very useful concepts in
‘how often’ versus ‘how well’ a child uses his hemi- intervention studies to establish that a change
plegic arm and hand.18 has really occurred for a child. These measures
In the historical development of assessment have been reported for the QUEST,33 Melbourne
tools, there is a clear trend to shift from the eval- Assessment,33 AHA,37 BOTMP,14 PDMS-2-FM15
uation of capacity to performance. Comparing and PEDI.8 The values are acceptable and
what a child is able to do with his hemiplegic correspond to reported measurement errors of
arm, and what the child actually does allows the other arm scales in stroke patients (e.g. the
clinician to make a comprehensive analysis of the Action Research Arm Test and Brunnström–
child’s abilities and the ‘developmental non-use’ of Fugl–Meyer Test).51 In future research, these
Arm activity measures for children with cerebral palsy 897

values should be determined for the other Conclusion


assessments.
A strong asset of the AHA, the Abilhand-Kids, Results of this systematic review identified five con-
the PEDI and the PMAL-revised is that these dition-specific functional tests, three generic tests
tests are developed by means of a Rasch analysis. and three questionnaires suitable to measure arm
Besides the stronger statistical properties, a Rasch- activities in children with hemiplegic cerebral palsy.
based scale also provides the therapist information All assessments measure different aspects of activity,
on which items have already been mastered and including capacity and performance. The reliability
which items can be reached in the near future by and validity have been established though further use
practice.40 in clinical trials will be necessary to determine the
The most prominent barrier for clinicians to reg- responsiveness and research utility of the assess-
ularly use standardized tests is the time required to ments. To obtain a complete view of what the child
administer and score them. For the selected instru- can do and what the child actually does in different
ments, test duration ranges from 10 to 60 minutes. settings, we would suggest combining a capacity-
Video-taped tests requiring subsequent scoring based test (Melbourne Assessment), with a
take more time. Moreover, these tests necessitate performance-based test (AHA) and a questionnaire,
the availability of a video set-up and a spacious Abilhand-Kids. The selection of these tests is based
setting. These aspects as well as other aspects of on the content, clinical utility and psychometric
clinical utility, such as the difference in costs, can properties. Other assessments could be considered
also play a decisive role in the selection of to evaluate specific therapy modalities. This review
instruments. can offer a framework to help the therapist choose
Thus far, two reviews have been published on among the various assessments in order to guide and
outcome measures in children with cerebral palsy, evaluate treatment interventions for arm and hand
one on measures of gross motor function and function in children with cerebral palsy.
mobility52 and a second on participation mea-
sures.53 Although reviews on arm activity mea-
sures are available in other conditions, such as Clinical messages
children with congenital transverse or longitudinal
reduction deficiency of the arm54 and adults with  Arm activities can be measured with several
stroke,55 this is the first review that systematically reliable and valid measurement tools, each
assessed the quality of arm activity measures addressing different aspects of unimanual
in children with hemiplegic cerebral palsy. and bimanual activities.
Nonetheless, there are some limitations that must  A combination of capacity and perfor-
be considered. It is possible that we have missed mance-based measures is crucial for a
tools that are used in clinical practice, but have not better understanding of the child’s abilities
been applied in research. However, we considered in order to guide and evaluate treatment
it appropriate to only include measures with strategies.
some evidence of psychometric evaluation.
Furthermore, studies assessing psychometric char- References
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