Comprehensive Coordination Scale (CCS) COMPREHENSIVE COORDINATION SCALE (CCS) Assessment Protocol and Scale Description ‘Overview ‘The Comprehensive Coordination Scale (CCS) was developed to assess coordination of multiple body segments at both motor performance (endpoint movement) and quality of movement (joint rotations and interjoint coordination) levels based on observational kinematics. Coordinated movements are defined as movements of ‘one or more limbs or body segments that occur together in identifiable temporal (i. timing) and spatial (i.e. positional/angular) pattems, with respect to a desired action. It can be measured at a specific point in time during the movement or over the whole movement time. ‘The CCS can be used by healthcare professionals to assess coordination in older adults and individuals with various neurological conditions. It was constructed from valid and reliable tests commonly used in clinical practice or research studies. ‘The CCS is composed of six different tests: the Finger-to-Nose Test, the Arm-Trunk Coordination Test, the Finger Opposition Test, the Interlimb Coordination (synchronous anti-phase forearm rotations) Test, the Lower Extremity Motor COordination Test (LEMOCOT) and the Four-limb Coordination (Upper and lower limb movements) Test For each test, rating scales ranging from 3 (normal coordination) to 0 (impaired coordination) assess different ‘elements of motor behavior needed to perform the action. Body parts tested _| Type of test | Test Behavioral elements scored Spatial: Stability, smoothness, accuracy Temporal: Speed Upper limb Unilateral | Finger-to-Nose (FTN) ‘Am-Trunk Coordination Trunk and arm Unilateral | ect (are) Spatial: Accuracy, interjoint coordination Upper limb (fine dexterity) Interlimb coordination Unilateral | Finger Opposition FOT) | PHAN Selecaly Alternate movements of two | Spatial: Compensation =both upperlimbs —_| Bilateral upper limbs (ILC-2) Temporal: Synchronicity! timing Lower Extremity MOtor Lower im Unilateral | COordination Test Senta Grocers, accuracy (LEMOCcOT) i Feurti coortraton [| atemate moverens of | Temporal Ting omploaly both hands and feet (ILC-4) lower limbs. Material needed ‘+ Chair with back support and without armrests (suggested seat height: 46 om) + Foot stool, if needed + Targets © One 2.54 cm-diameter sticker (Finger-to-Nose test) © One targat (sphere of 2.54 cm-diameter or a cube of similar dimensions) on an adjustable height support (Arm-Trunk Coordination Test) ‘© Two 5 cm-diameter stickers placed 30 om (centre-to-cantra) apart and attached to a cardboard (LEMOCOT test) Stopwateh | timer Table (optional, suggested height: 72 om) * Pillow (optional) © McGill University 2020 1|P agComprehensive Coordination Scale (CCS) Administration of the CCS ‘+ Forall tests, the individual is seated in an armless chair with his/her back against the back of the chair and both feet fiat on the floor or foot stool. Tests are performed with eyes open, unless otherwise indicated Individuals may look at their limbs while performing the tasks, except for the ATC test. Each test is demonstrated to the individual once by the examiner. ‘Tho individual practices each test until he/she has understood the test (up to a maximum ofS trials) Each unilateral testis performed with each side of the body. For tests in which the speed and number of repetitions are assessed, two trials are needed. One trial should be used to assess speed or the number of repetitions, and the second trial should be used to score the behavioral elements, Each behavioral element should be analyzed and scored independently of the other elements. In the case of restricted range of mation (i... joint contracture), the evaluator may adapt the test. Any modifications should be noted. Note: For an optimal assessment, the tests may be video-recorded. Because of the speed-accuracy trade-off, the evaluator must ensure that the subject is really trying to move as fast as possible while still performing the movement correctly. For repetitive tasks, the individual should continue to perform the task, even if mistakes are made, until the examiner says "Stop" 4. Finger-to-Nose Test (FTN) Task Description The individual is seated on a chair facing a wall. The target (2.54 cm-diameter sticker) is placed on the wall at the level of the individuals nose in the sagittal plane. The chair is placed at a distance so that the target is, located at one arm’s length of the individual Arm's length is defined as the distance between the superior-lateral border of the acromion process (ie... acromial angle) to the tip of the index finger when the arm is outstretched. The same distance should be used to test each arm. If itis not possible to use a wall for the test (2.9. ICU, bed), then the target can be placed on a clipboard and held by the examiner at the height of the individual's nose and at the distance of the individual's arm length. Initial Position: The individual is positioned with the tip of their index finger on the tip of their nose, with shoulder held in 70-90° shoulder flexion and abduction. The other arm should be aligned along the body in a relaxed position and ‘not on the lap, in order to prevent the contralateral arm to be used to support the trunk. FINISH ‘Note any changes to the initial position ifthe test cannot be administered as described (e.g. ifthe hand cannot open or the finger cannot be extended, then another part of the hand, such as the second metacarpal joint can substituted for the tip of the finger) Task: The task is to move the tip of the index finger from the tip of the nose to the target on the wall and back to the nose, touching each point in an alternate manner. The elbow should be kept elevated throughout the task. The task should be completed in a fast, yet comfortable manner that allows individuals to perform the task. Instructions to the individual: ‘Sit back and try to keep your back against the chair. Start with your finger on your nose and Keep your elbow elevated. Move the pad of the index finger of your leftright hand between the tip of your nose and the target in a fast and comfortable way, in order to alternately touch your nose and the target. | will say when to start and stop.” © McGill University 2020 2|P agComprehensive Coordination Scale (CCS) Trials: Two trials are done, in addition to the familiarization trials. Trial 1: Assess the time required to perform 5 complete movement cycles. A complete movement cycle is defined as movement of the finger from the nose to the target and back to the nose. Trial 2: Score the 4 behavioral elements based on the movement from the nose to the target. Behavioral elements and scoring a) Trunk Stability The capacity to keep the trunk stable against the chair during the movement of the hand from the nose to the target How to score: ‘© Ascore of 3 is given when there is no trunk movement, such that the whole movement from the ‘nose to the target is accomplished by changes in arm joint angles. © Ascore of 2 is given when less than half of the hand movement to the target is accomplished by movement of the trunk (flexion, rotation or flexion accompanied by rotation) © A score of 1 is given when half or more than half of the hand movement to the target is accomplished by movement of the trunk. © Asscore of 0 is given when the attempt to cover the entire nose-to-target distance is accomplished by movement of the trunk, despite @ minimal movernent of the arm (< Som). b) Arm movement ‘The capacity to maintain the specified arm position (i.e. maintain shoulder flexion/abduetion such that the elbow is elevated) while moving the hand from the nose to the target How to score: © Ascore of 3 is given when elbow elevation (upper arm at 70-90° of shoulder flexion/abduction) is maintained throughout the task ‘Ascore of 2is given when elbow elevation is maintained in haf or more than haf of the repetitions. A score of 1 is given when elbow elevation is maintained in less than half of the repetitions. A score of 0 is given when the subject is unable to maintain the elbow elevation. ) Movement Smoothness ‘The capacity to move the hand from the nose to the target in a single movement. A single movement is defined as one that consists of a single acceleration and deceleration (Le., there is no jerkiness or discontinuities in the movement) How to score: ‘© Ascore of 3 is given when a single movement (i0., acceleration/deceleration) is done. © Ascore of 2 is given when the movement is slighty jerky (2 sub-movements occur) © Ascore of 1 is given when the movement is moderately jerky (3 sub-movements occur). © Ascore of 0 is given when the movement is very jerky (> 3 sub-movements occur), d) Endpoint accuracy (dysmetria) ‘The capacity to touch within the 2.54 em target. How to score: ‘A score of 3 is given when the finger touches the target in every single movement cycle. ‘A score of 2 is given when the finger touches the target in more than half of the trials, ‘A score of 1 is given when the finger touches the target in less than half ofthe trials. A score of 0 is given when the finger does not touch the target Arm-Trunk Coordination Test (ATC) Task Description The individual is seated in the chair. The target is placed on an adjustable support at the level of the subject's, mid-sternum in the midline at a distance equal to 2/3 arm's length (as defined above). The same distance is, used for each arm, “This is approximately equal to the position of the nose when the individual bends forward at the hip while keeping the trunk and head straight. © McGill University 2020 3|P agComprehensive Coordination Scale (CCS) “Note that if there is a limitation in movement of one arm, then the distance of the target should be equalized between arms based the limited distance. Initial Position: The individual is positioned with the arm elevated to approximately 70° shoulder flexion and approximately 30° shoulder abduction. The elbow is held at ~120° extension and the forearm is pronated so that the palm faces the floor. The tip of the extended index finger is positioned over the target, but without touching it as shown in the figure. The other arm is aligned along the body in a relaxed position. Note any changes to the initial position ifthe test cannot be administered as described (o.4,, if the hand cannot open or the finger cannot be extended, then another part of the hand, such as the second metacarpal oint can substituted for the tip of the finger). Task: The task isto hold the finger slightly above the target while moving the trunk forward as a block (ie. the trunk and START Pee the head move as a single unt. Neck flexion is not alowed.) to touch the finger with the tip ofthe nose by flexing the hips. This task should be performed with the eyes closed, The task should be completed in a fast, yet comfortable manner so that the task is performed accurately The final position is held for 1 sec. Note that healthy subjects can keeo the finger over the target around 80-100% of the time. In order to maintain the hand in the same position, the influence of the trunk movement on the hand position must be neutralized by appropriate changes in the arm joint angles. Instructions to the individual: “Start with your back against the chair. Place your finger over the target. Close your eyes and bend forward by moving your trunk and head in one block in order to reach your finger with your hose. Do nat mave your finger. Do this in a fast and comfortable way and hold the final position for 1 second’. ‘Trials: One trial is done, in addition to the familiarization trials, to score the 2 behavioral elements. Behavioral elements and scoring a) Endpoint Accuracy ‘The capacity to maintain the finger position over the target while the trunk is flexed. How to score: © Ascore of 3is given when the finger remains in the same place above the target while the nose is brought to the finger. © Ascore of 2 is given when the finger moves more than 2 cm with respect to the target during trunk flexion. ‘© Ascore of 1 is given when the finger moves more than 4 cm with respect to the target during trunk flexion. © Ascore of 0 is given when the finger moves the same amount as the trunk moves. b) Shoulder-Eibow Coordination ‘The capacity to move the shoulder and elbow together while maintaining the position of the finger over the target How to score: ‘© Ascore of 3is given when the shoulder and the elbow move together, elbow elevation is maintained (Shoulder at 70-80° flexion/abduction) throughout the task and the finger remains above the target © Asscore of 2 is given when the shoulder and the elbow move together but less than is required to maintain the finger over the target (.e., the finger deviates from the target). © Asscore of 1 is given when only one joint angle (shoulder or elbow) moves, and the finger deviates from the target. © McGill University 2020 4|P agComprehensive Coordination Scale (CCS) © Ascore of 0s given when both the shoulder and elbow joints are maintained in the same position throughout the task (i.e. only the trunk moves to try to accomplish the task), and the finger deviates from the target. 3. Finger Opposition Test (FOT) Task Description The individual is seated in the chair. Forearms are supported by a table or a pillow placed on the individual's thighs. Initial Position: The individual is positioned with the elbows supported in 90° flexion. The forearm is in the neutral position and the hand is open ‘Task: The task consists of repeating a sequence of six thumb-finger opposition movements in the following order: index, middle, ring, lt, ring, middle, while trying to maintain’ a constant ‘speed. The task should be executed in a fast, yet comfortable manner in order to perform the task accurately. ‘START 1ST FINGER. ATH FINGER, Instructions to the subject: “Sit back and keep your back against the chair. Place your elbows on the table or pillow. Open your lefuright hand. Touch the thumb with the tip of each finger separately and in a sequence (index, middle, ring, litte, ring, middle), repetitively, in @ fast and comfortable way, returning the hand to the ‘open position between each movement. | will say when to start and stop”. Trials: Two trials are done, in addition to the familiarization trials. Trial 1: Count the number of repetitions (ie. finger oppositions) in 10s Trial 2: Score the 2 behavioral elements. Behavioral elements and scoring a) Selectivity ‘The capacity to perform thumb-finger opposition in the correct sequence. How to score: ‘© Ascore of 3 is given when opposition between the thumb and each finger is done in the correct sequence, and the hand returns to the open position between movements. © Ascore of 2s given when opposition between the thumb and each finger is done with errors in the sequence, although the returns to the open position between movements. © Ascore of 1 is given when opposition between the thumb and each finger is done with errors in the sequence and the hand tends to close or does close. ‘© Ascore of 0 is given when opposition is not possible, b) Timing The capacity to maintain a constant frequency of the finger-thumb opposition movements. How to score: To score timing, compare with the other side. ‘Ascore of 3s given when the frequency of movements is high and constant across the sequence ‘Ascore of 2's given when the frequency of movements is low” and constant across the sequence. ‘A score of 1 is given when the frequency of movements is irregular for only part of the sequence. A score of 0 is given when the frequency of movements is irregular for the whole sequence. oo00 * A Low frequency is defined as less than 20 rep ns in 10 seconds (ie., 2 Hz). © McGill University 2020 5|P ageComprehensive Coordination Scale (CCS) 4. Interlimb Coordination Test (ILC-2) - Bilateral Upper Limb Movements Task Description Initial Position: The individual is seated in the chair. The right hand is placed on the right thigh, palm facing down, while the left hand is placed on the left thigh, palm facing up. The elbows should be relaxed and kept close to the trunk ‘Task: The task consists of the performance of rapid antiphase — starT FINISH pronation-supination movements of both forearms for 10s. Seated Participants must maintain their forearms on their thighs with both arms held close to the trunk. Anti-phase pronation/supination movements are performed. The task should be completed in a fast, yet comfortable manner so that the task is performed correctly * From the starting position, the individual should lift both hands, rotate the forearms 180" and tap the thighs. Repeat. The hands SRoUld not wr ! be rolled on the thigh, t Instructions to the individual: “Sit back and keep your back against the Chair. Place the palm of your right hand on your right thigh. Place the back of your left hand on your left thigh. Keep the elbows rataxed and ciose to your body throughout the task. At the signal, lit and tum each hand at the same time (Le. f your palm is up, tum it down. If your palm is down, turn it up) in a fast and comfortable way repetitively. | will say when to start and stop.” Trials: Two trials are done, in addition to the familiarization trials. Trial 1: Count the number of repetitions in 10 s. A complete repetition is defined as a synchronous, opposite {otation of both hands within the available range of motion. Trial 2: Score the 2 behavioral elements. Behavioral elements and scoring a) Synchronicity/Timing (dysdiadochokinesis) ‘The capacity to perform synchronous movements of both hands. * This element is scored only with respect to the timing of the altemative movements, regardless of the degree of rotation of each forearm or the elbow or shoulder positions. How to score: © Ascore of 3s given when alternate movements of both hands are done synchronously (i, at the same time and timing) throughout the test. © Asscore of 2 is given when alternate movements of both hands are done synchronously, haif or more than half ofthe time. © Asscore of 1 is given when altemate movements of both hands are done synchronously less than half of the time. © A score of 0 is given when movements of the hands are done separately (i.e. there is no synchronicity to the movements of the hand). b) Compensation The capacity to perform the task without using compensatory movements of the shoulders and elbows. “This element is scored with respect to the degree to which one or both arms are abducted from the trunk. How to score: ‘© Ascorte of 3is given when the task is performed while both arms are maintained close to the trunk and using the full range of pronation and supination. © Asscore of 2 is given when the task is performed while both arms are maintained close to the trunk. Using a partial range of pronation and supination. © A.score of 1 is given when the task is performed while only one arm is maintained close to the trunk. A score of 0 is given when the task is performed while neither arm is maintained close to the trunk. © McGill University 2020 6 |P agComprehensive Coordination Scale (CCS) 5. Lower Extremity MOtor COordination Test (LEMOCOT) - Lower Limb Coordination Task Description The individual is seated in the chair. The task is to move the big toe of one foot alternatively between two targets placad on the floor in the sagittal direction in line with the lag Initial Position: For the setup position, both feet are resting flat on the floor, without shoes. Two 5 cm diameter round stickers, 30 om (center-to-center) apart, attached to a cardboard, are used as targets. The proximal target is placed under the heel of the tested lag when the knee is flexed to 90°. For the initia position, the individual's, big t0® is placed on the proximal target. The arms are resting along the sides of the body or on the thighs. The individual may need some help to place their toe on the proximal target Task: The task is to move the big toe of one foot SETUP START FINISH altematively from one target to another. The task should be completed in a fast, yet comfortable manner so that the task is performed corractty Instructions to the individual: "Sit back and keep your back j against the chair. Place your big toe over the target closest rf ) to you. Move your big toe between the close and far target Y it | in a fast and comfortable way to alternatively touch the j~ yo middle of each targot. | wil say when to start and stop.” - ° Trials: Two trials are done, in addition to the familiarization trials, Trial 1: Count the number of accurate touches of the big toe on either target in 10 s. Trial 2: Score the 2 behavioral elements. Behavioral elements and scoring a) Movement Smoothness The capacity to move the foot from one target to another in a single movement. A single movement is defined as one that consists of a single acceleration and deceleration (Le., there is no jerkiness or discontinuities in the movement) How to score: © Asscore of 3 is given when movement is smooth in each direction (i.e., not jerky or discontinuous; done in a single movement). 2 Ascore of 2s given when movement is slightly jerky in one or both directions (2 sub-movements). © Asscore of 1 is given when movement is moderataly jerky in one or both directions (3. sub- movements). © Ascore of 0 is given when movement is very jerky in one or both directions (>3 sub-movements). b) Endpoint accuracy (dysmetria) ‘The capacity to touch within the 5 cm targets. How to score: Ascore of 3 is given when the tos always touches both targets. A score of 2 is given when the toe touches the target on haif or more than half of the repetitions. ‘A score of 1 is given when the toe touches the target on less than half of the repetitions. ‘A score of 0 is given when the toe does not touch the target © McGill University 2020 7|P agComprehensive Coordination Scale (CCS) 6, Interlimb Coordination Test (ILC-4) — Bilateral Upper and Lower Limb Movements. Task Description The individual is seated in the chair. The task is performed without shoes. The task is to move both wrists and both ankies together in an anti-phase pattern. Initial Position: The individual keeps both heels resting on the floor, ‘with the feet in dorsiflexion (toes off the floor). Both knees are flexed to around 120° (where full extension equals 180°). Both hands are placed palm down on the thighs. FINISH Task: Movements of the wrists and ankles are simultaneously reversed (.¢., wrists move into extension at the same time as the feet move down to the floor). Then the opposite movements are done, again simultaneously, to return each joint to the initial position, Instructions to the subject: “Sit back and keep your back against the chair. Start with the palms of your hands touching your thighs and your toes up away from the floor. Keeping your wrists on your thighs, raise your hands up and lower your feet to the floor, while keeping your heels on the floor. Then, ower your hands to your thighs and raise your toes. ‘Switch the positions of your hands and feet repetitively in a fast and comfortable way. | will say when to start and stop’ Trials: Two trials are done, in addition to the familiarization trials. Trial 1: Count the number of repetitions in 10 s. A complete repetition is defined as a synchronous, opposite movement of the feet and hands (feet down and hands up, or feet up and hands down) Trial 2: Score the behavioral element. Behavioral elements and scoring a) Complexity/Timing ‘The capacity to coordinate the timing of the movements of the hands and feet. How to score: © Ascore of 3 is given when altemate and opposite movements between both hands and both feet are made synchronously (:.6., at the same time and with the same timing) all the time, © Ascore of 2 is given when alterate and opposite movements between both hands and both feet are synchronous at least half ofthe time. © Asscore of 1 is given when alterate and opposite movements between both hands and both feet are synchronous less than haif of the time. © Ascore of 0s given when movements of hands and feet are done in a haphazard way without any synchronization, Total score and subscores: The CCS total score is 69 points, with higher scores indicating better motor coordination. The CCS total score Tepresents a full body coordination score. ‘The CCS scores can be broken down as follows: ‘Subscore | Total score | included sub-tests (points) Upper limb 54 FIN (24 points), ATC (12 points), FOT (12 points), ILC2 (6 points) Lower limb | i LEMOCOT (12 points) Unilateral 30 FIN (12 points), ATC (6 points), FOT (6 points) and LEMOCOT (6 points) Bilateral 3 TLC2 (6 points) and ILC4 (5 points), © McGill University 2020 8 |P ag