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Abstract

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

Aim  This systematic review aimed to compare the validity, reliability, evaluative validity, and clinical utility of upper limb activity measures for children aged 5 to 16 years with congenital hemiplegia.

Method  Electronic databases were searched to identify assessments that measure upper limb activity available for use and for which published validity and reliability data for the population are obtainable. Assessment items were coded according to the International Classification of Functioning, Disability and Health (ICF) categories to determine if at least 35% of the assessment items fell within the activity component of the ICF. Assessments that met these criteria were included in the review.

Results  Thirty-eight measures were identified, and five met the inclusion criteria. The best measure of unimanual capacity was the Melbourne Assessment of Unilateral Upper Limb Function (MUUL); however, the Shriners Hospital Upper Extremity Evaluation (SHUEE) and the Quality of Upper Extremity Skills Test (QUEST) could also be considered, depending on the type of information required. The performance-based measure of bimanual upper limb activity in children with hemiplegia with the best psychometric properties was the Assisting Hand Assessment (AHA). The ABILHAND-Kids is a parent-report, performance-based questionnaire with excellent clinical utility and psychometric properties.

Interpretation  Clinicians may choose to use more than one of these measures to detect changes in unimanual or bimanual upper limb activity.

List of Abbreviations
AHA

Assisting Hand Assessment

MUUL

Melbourne Assessment of Unilateral Upper Limb Function

QUEST

Quality of Upper Extremity Skills Test

SHUEE

Shriners Hospital Upper Extremity Evaluation

The need to measure outcomes effectively in children with a chronic health condition, such as cerebral palsy (CP), is important to guide and evaluate interventions, to monitor progress, to provide families with objective information, and to guide health policy.1,2

The International Classification of Functioning, Disability and Health (ICF) provides a framework for measuring and documenting health outcomes at the body function and structure level as well as in activities and participation.3 It also considers the influence of contextual factors, including personal and environmental factors, on a child’s health status.1 Outcome measures, therefore, need to address the multidimensional nature of the ICF not only by body structure and function, but also by activity and participation.

Increasingly, public bodies, such as the US Food and Drug Administration, recommend the use of valid and reliable outcome measures capable of detecting clinically significant change.4 Detecting change using an assessment tool that is not validated or proven reliable for the population, even if used and reported in other clinical trials, does not provide meaningful information about the outcome of an intervention.

Children with hemiplegia usually have difficulty with grasping, reaching, releasing, and manipulating objects with the impaired upper limb.5,6 Motor and sensory impairments can lead to children learning to perform tasks mainly with their unimpaired arm. This results in a secondary ‘developmental disregard’ or learned non-use of the impaired upper limb.6,7 Therefore, intervention is often focused on improving both unimanual and bimanual function of the upper limbs during activity.

Assessments with excellent psychometric properties and clinical utility that specifically measure the use of a child’s impaired upper limb, as well as bimanual use, are necessary to ensure accurate measurement of outcomes in clinical trials involving children with congenital hemiplegia. While conducting a current upper limb rehabilitation trial, the authors recognized the need for a systematic review of upper limb assessment measures for this population of children to guide selection of upper limb activity measures. The age range of 5 to 16 years is specified in line with the inclusion criteria of the current clinical trial.

Recent systematic reviews of measurement tools for children with CP have focused on activity limitation,8 activity and participation,9 participation,2 and self-concept.10 A recent review of measures of activity limitation focused on evaluative measures of mobility and gross motor function.8 In contrast, the current systematic review aims to compare the validity, reliability, evaluative validity, and clinical utility of upper limb activity measures for children aged 5 to 16 years with congenital hemiplegia. For the purpose of this review, activity was defined as the execution of a task or action by an individual.3

Method

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

Search strategy

A systematic search was undertaken of computerized databases, including Medline (1966–August 2008), CINAHL (1982–August 2008), EMBASE (1988–August 2008), AMED (1985–August 2008), PsychINFO (1806–August 2008), the Cochrane Library (August 2008), PEDro (August 2008), and OT Seeker (August 2008). The search strategy used the medical subject heading (MeSH) terms and text words for ‘cerebral palsy’ and ‘hemiplegia’. These were combined with search terms to limit the findings to the target age group. MeSH terms and text words for ‘outcome assessment’, ‘activity,’ and ‘upper limb’ were used to focus search results on activity measures of the upper limb. Targeted reference scanning and citation tracking of key articles were also used to minimize the chance of missing key studies.

Inclusion/exclusion criteria

To be included, an assessment had to meet the following a priori inclusion criteria: (1) it measures upper limb activity (including those which evaluate a combination of concepts falling within the activity and body function components of the ICF); (2) at least 35% of the assessment items should evaluate upper limb activity according to the ICF definition; (3) it must have published validity and reliability data for children aged 5 to 16 years with congenital hemiplegia; (4) it measures either bimanual or unilateral use of upper limbs and (5) the assessment is available for use.

Assessment tools were excluded if they were (1) not published in English (as a result of lack of translation services); (2) primarily assessed participation, body structures, body functions, school functioning, self-care, or health-related quality of life; (3) were a classification measure; or (4) were individualized, goal-setting tools. Classification measures discriminate and categorize and do not involve the same detailed exploration of upper limb activity which assessments allow11 and were, therefore, excluded. Individualized, goal-setting tools were not included as these assessments can measure components related to different body structures, function, daily living skills, and participation, rather than necessarily focusing on upper limb activity.

The titles and abstracts of articles were screened by the first author (RG). One key paper which had adequate detail to determine inclusion, as well as the score form for each assessment, was then reviewed by the first author and the third author (RB). If an assessment measured any component of upper limb activity and fulfilled the third inclusion criterion for published validity and reliability data for this population, then each item in the assessment was linked to the most specific ICF category, according to the updated linking rules presented by Cieza et al.12 Conflicting viewpoints were discussed until consensus was reached. Once items were linked to an ICF category, the percentage of items that measured upper limb activity and fell within the mobility chapter of the activity and participation component of the ICF was calculated. If 35% of items fell within this chapter, the assessment was included.

To illustrate the method for coding items, two items from the Quality of Upper Extremity Skills Test (QUEST) assessment were selected. The first item was ‘shoulder flexion’. This item was coded b7600 (third-level category: control of simple voluntary movement function; second-level category: control of voluntary movement function; chapter: neuromusculoskeletal and movement-related functions; and component: body function). This item did not, therefore, contribute to the overall percentage of items measuring upper limb activity. In contrast, the item ‘grasp of 1-inch cube’ was coded d4401 (third-level category: grasping; second-level category: fine hand use; chapter: mobility; and component: activities and participation). This item was included in the calculation for percentage of items measuring upper limb activity.

For some assessments, it was difficult to determine what an item consisted of. It was decided to include all items that contributed to the overall score for the assessment. For example, all range of motion and spasticity measurements, history-based activities of daily living information, and patient/family goals in the first part of the Shriners Hospital Upper Extremity Evaluation (SHUEE) assessment were excluded as they did not contribute to overall scores. This helped to distinguish between subjective or descriptive components of assessments and quantitative measures of upper limb function which could be subjected to psychometric testing. The title of potential assessments was then used for a further search in the databases to ensure that no article was missed. Relevant assessment manuals were sourced.

Data extraction and quality assessment

A modified version of the CanChild Outcome Measures Rating Form13 was used to extract descriptive information and grade the psychometric properties and clinical utility of the assessment tools. Recent reviews of participation outcome measures in CP and neuromotor assessments for preterm infants utilized this form.2,14 In another recent review of gross motor activity limitation measures for children with CP, the authors devised their own quality scale.8 The Outcome Measures Rating Form incorporates the ICF framework and was designed to rate the quality and clinical utility of outcome measures and it was, therefore, deemed the most appropriate scale to evaluate the assessment tools.

The characteristics (for both clinical and research settings) of the assessment tools extracted included the target population, age range, purpose of tool, format, content of the assessment, number of scales/items, time to administer, cost and availability of the manual, and training required.

An assessment was considered valid if it measured what it is supposed to measure.15 Information on validity included content, construct, criterion, and evaluative validity or responsiveness. Evaluative validity or responsiveness is the ability to detect minimal clinically important change over time.16 Reliability measures the degree to which a test is stable, measuring a construct in a reproducible and consistent way.13 Internal consistency, interrater reliability, intrarater reliability and test–retest reliability were evaluated.

There is little consensus in the literature regarding acceptable standards for reliability coefficients, and terminology is often used interchangeably. When interpreting the reliability coefficients, Portney and Watkins15 suggested that values below 0.50 represent poor reliability, values of 0.50–0.75 represent moderate reliability, and values above 0.75 represent good reliability. They present these values as a guideline only and emphasize that the degree of acceptable reliability depends on how the results will be applied; for instance, they propose a value of at least 0.90 when interpreting results for an individual. The above guidelines can also be applied to kappa statistics, which are appropriate for nominal data.15 The CanChild Outcome Measures Rating Form describes reliability coefficients above 0.8 as excellent, from 0.60 to 0.79 as adequate, and <0.60 as poor.13 Given the lack of consensus in the literature, this systematic review used the guidelines outlined in the CanChild Outcome Measures Rating Form, as well as considering the need for values to be above 0.90 in order to interpret results for an individual.

Results

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

Thirty-six assessments were identified by the search strategy, of which five met the predetermined inclusion criteria. The included measures were the ABILHAND-Kids,17 the Assisting Hand Assessment (AHA),18 the Melbourne Assessment of Unilateral Upper Limb Function (MUUL),19 the QUEST20 and the SHUEE.21 The characteristics of the included assessments are summarized in Table I. The combination of the original yield for these five assessments and additional title-based searching resulted in 17 papers reporting on these assessments. Thirty-one assessments were excluded. Table SI (supporting information published online) summarizes reasons for exclusion.

Table I.   Characteristics of included assessments
MeasureTarget populationType of activity measuredPercentage of items in activity domain of ICFPrimary purposePerformance or capacity
  1. aA revised version of the Melbourne Assessment of Unilateral Upper Limb Function (MUUL) capable of assessing children aged 30 months to 15 years was presented at the Australasian Academy of Cerebral Palsy & Developmental Medicine conference in 2008. ICF, International Classification of Functioning, Disability and Health; AHA, Assisting Hand Assessment; QUEST, Quality of Upper Extremity Skills Test; SHUEE, Shriners Hospital Upper Extremity Evaluation.

ABILHAND-Kids17Children with CP aged 6–15yManual ability81DiscriminativePerformance
AHA18Children with a unilateral disability aged 18mo–12yBimanual play82Discriminative EvaluativePerformance
MUUL40Children with CP or neurological impairment aged 30mo–15y40,aUnimanual46Discriminative EvaluativeCapacity
QUEST20Children with CP aged 18mo– 8yUnimanual (each arm scored separately)35EvaluativeCapacity
SHUEE21Children with hemiplegic CP aged 3–18yUnimanual81Discriminative EvaluativeCapacity

The ABILHAND-Kids, the AHA, the MUUL, the QUEST, and the SHUEE were specifically designed for assessment of children with CP or a unilateral disability. The ABILHAND-Kids and the AHA measure performance, i.e. what a child does. In contrast, the MUUL, the QUEST, and the SHUEE measure a child’s capacity, or maximum capability. The AHA and the QUEST are suitable for children aged 18 months and over, the MUUL for children 30 months and over, the SHUEE for children 3 years and over, and the ABILHAND-Kids for children 6 years and over.

In the case of all of the selected tools, published studies reporting data for children with congenital hemiplegia are available. In addition, studies reporting data for the AHA incorporate children with unimanual impairment, including brachial plexus palsy and congenital hemiplegia. The study describing data for the SHUEE included only children with hemiplegic CP. The validity and reliability of the MUUL, the ABILHAND-Kids, and the QUEST were investigated in children with various distribution and motor types of CP.

Validity and evaluative validity

Evidence for the validity and evaluative validity of the included assessments is reported in Table II. Most assessments had adequate content validity, although evidence was not reported for the SHUEE. All assessments also showed adequate construct validity. The MUUL established criterion validity by comparison with expert clinical assessment. The QUEST and the SHUEE attempted to establish criterion validity with several other functional assessments; however, no clear criterion standard is accepted in the literature.

Table II.   Evidence of content, construct, criterion, and evaluative validity
AssessmentContentConstructCriterionEvaluative
  1. GMFCS, Gross Motor Function Classification System; ICC, intraclass correlation coefficient; NA, no data available; PEDI, Pediatric Evaluation of Disability Inventory; PDMS-FM, Peabody Developmental Motor Scales – Fine Motor composite; SDD, smallest detectable difference; JTT, Jebson–Taylor Test of Hand Function; AHA, Assisting Hand Assessment; MUUL, Melbourne Assessment of Unilateral Upper Limb Function; QUEST, Quality of Upper Extremity Skills Test; SHUEE, Shriners Hospital Upper Extremity Evaluation.

ABILHAND-Kids17Based on existing scales and expert advice17 Rasch modelSignificant relationship with type of school education, CP and GMFCS17 Invariance verified across demographic and clinical subgroups of children with CP41NAPerson separation reliability estimate: r=0.94 (n=36)17
AHA18Developed by experts in field18 Rasch model (unidimensionality demonstrated for 91% of responses in 22-item version)36Discriminates between children with different levels of hand function (separation value=6.16) and levels of impairment not related to age18,36NAPerson separation reliability estimate: r=0.97 Ability to separate and distribute person ability measures which indicates sensitivity to change (18mo–12y, n=303, 409 assessments)36 SDD was less than four raw scores (n=55, 18mo–12y)26
MUUL40Literature review, review of existing assessments, workshops with experienced occupational therapist40Significant correlations with MUUL and PEDI on self-care (Spearman’s rho=0.939), mobility (0.783) and total functional skills (0.718)69Four experienced clinicians assessed according to their usual method. ICC between clinicians=0.92. Average correlation between clinician score and MUUL was 0.87 (n=11)19SDD=8.9% (5–8y, n=21)32
QUEST20Literature review, discussion with clinicians and expertsCorrelations between therapist’s judgement of child’s hand function and QUEST scores for right and left hands (n=71)20 Significant correlations with PDMS-FM and MUUL (r=0.84 for total score of QUEST and PDMS-FM; r=0.83 for total score of QUEST and MUUL)32 Smallest difference of clinical significance in casting trial was 4.89 score units (p<0.03)43 SDD=7.1% (total test score, 5–8y, n=21)32
SHUEE21NASignificant change in mean dynamic positional analysis score for the wrist post-tendon transfer (n=18)21Fair correlation between self-care scaled score of PEDI and spontaneous functional analysis score of SHUEE (r=0.47) Inverse correlation between non-dominant total time of the JTT and spontaneous functional analysis section of SHUEE21NA

Reliability

Details of the reliability of assessments are reported in Table III. Internal consistency has been claimed for the ABILHAND-Kids, the AHA, and the MUUL. Strong inter- and intrarater reliability were reported for the AHA, the MUUL, and the SHUEE. The QUEST reported strong interrater reliability and variable intrarater reliability evidence. The ABILHAND-Kids reported evidence for test–retest reliability; however, it only reported Pearson’s r correlation. The intraclass correlation coefficient reflects both correlation and agreement and has, therefore, become the preferred statistic.15 Excellent test-retest reliability has been claimed for the MUUL, the QUEST, and the AHA.

Table III.   Evidence of reliability
AssessmentInternal consistency (Cronbach’s coefficient alpha)Interrater (ICCs)Intrarater (ICCs) Test–retest
  1. CCC, concordance correlation coefficient; ICC, intraclass correlation coefficient; LOA, limits of agreement; NA, no data available; OBPP, obstetric brachial plexus palsy; r, Pearson’s product–moment correlation; AHA, Assisting Hand Assessment; QUEST, Quality of Upper Extremity Skills Test; MUUL, Melbourne Assessment of Unilateral Upper Limb Function; SHUEE, Shriners Hospital Upper Extremity Evaluation.

ABILHAND-Kids170.94 (person separation reliability estimate; n=113, 6–15y, variety of types of CP)17NANAr=0.91 (n=36)17
AHA180.97 (person separation reliability estimate: 409 assessments, 18mo–12y 8mo, hemiplegic CP and OBPP)360.98 (two raters) (18mo–5y 11mo; 16 children with congenital hemiplegia and two with OBPP)25 0.97 (20 raters) (19mo–4y 2mo; six children with congenital hemiplegia and two with OBPP)250.99 (20 raters)25Small kids AHA ICC=0.99; school kids AHA ICC= 0.98; alternate forms ICC=0.99 between small and school kids’ versions and 0.98 between board games26
MUUL400.96 (n=20, 5–16y, variety of types of CP)27 Trained and untrained raters=0.99280.95 (15 raters, total test scores, n=20)27 LOA=14%27 LOA with training=5%29 Original 12-item test: kappa=0.65 (first scoring, two raters) and 0.72 (second scoring) (n=20, variety of types of CP)19 0.99 (12 trained raters) 0.98 (12 untrained raters) (5y 5mo–12y)28 0.87 (first session, five raters, n=10) 0.88 (second session, five raters, n=10)300.97 (20 raters, n=20, total test scores, variety of types of CP)27 LOA=12%27 LOA with training=3.5%29 Original 12-item test: kappa=0.82 for first therapist and 0.79 for second therapist (n=20, variety of types of CP)19 0.97–0.99 (five raters, 10 children aged 10–17y)30 0.97 (two raters, 21 children aged 5–8y)32CCC=0.98 for first rater and 0.97 for second rater27
QUEST20NA0.95 (two raters, total test scores, n=16)20 0.96 (two raters, total test scores, n=71, 39% hemiplegia)20 0.90 (three raters, total test scores, n=1720 0.72–0.90 (Spearman’s correlation coefficient, used Wilcox signed-rank test to confirm no systematic differences, three raters, total test scores, n=21, 29% hemiplegia)31 0.96 (two raters, total test scores, n=21, 100% hemiplegia32 0.91 (two raters, total test scores, n=26, 5 with hemiplegia)330.69: assessor 1 and 0.89: assessor 2 (n=26, 2–13y)33 0.95: assessor 1 and 0.63: assessor 2 (Spearman’s correlation coefficient, n=21, 2y–4y6mo)310.95 (ICC for total test score)20 0.85–0.94 (Spearman’s correlation coefficient)31
SHUEE21NA0.90 (Spontaneous functional analysis) 0.89 (Dynamic positional analysis) Weighted kappa=1.00 (Grasp & release)(four raters, n=11, 100% hemiplegia))21r=0.99 (spontaneous functional analysis) r=0.98 (dynamic positional analysis) Student paired t-test – absolute value of mean difference between 2 scoring sessions statistically significant but not clinically important (three raters, n=11)21NA

Clinical utility

The clinical utility of the included assessments is reported in Table IV. Administration time varied across the assessments, from 10 to 45 minutes. Assessor training is required for the AHA; for the other assessments training is either not required or not specified. The AHA’s method of administration includes therapist observation of a child’s performance in upper limb activity, while the QUEST, the SHUEE, and the MUUL involve a therapist systematically administering items. The ABILHAND-Kids is administered by parent-completed questionnaire. The MUUL, the AHA, and the SHUEE use videotaped assessments that are scored later.

Table IV.   Clinical utility of included upper limb activity measures
AssessmentFormat of administrationAdministration time (min)Assessor training Manual/equipment Scales/itemsScoring
  1. NR, not required; NS, not specified; AHA, Assisting Hand Assessment; MUUL, Melbourne Assessment of Unilateral Upper Limb Function; QUEST, Quality of Upper Extremity Skills Test; SHUEE, Shriners Hospital Upper Extremity Evaluation.

ABILHAND-Kids17Parent-completed questionnaireNSNRFree online No equipment required21 activity questions: rated as impossible, difficult or easyOnline analysis. Calibrated in logits
AHA18Therapist-led play session. Video recorded, scored later10–15RequiredReceived during training (AU$860) Kit (AU$550)22 items assessing assisting hand general use, arm use, grasp-release, fine motor adjustment, coordination and paceRaw scores converted into percentage score. Calibrated in logits
MUUL40Therapist administers items in standardized procedure. Video recorded, scored later30Recommended but NRManual and kit (AU$720)16 upper limb activity items rated on quality and task achievementRaw scores converted to percentages
QUEST20Therapist administers items, non-standardized procedure30–45NR, but recommended by other papers33,44Free online34 items, four domains: dissociated movements, grasp, protective extension, weight bearing three subjective rating scales not included in total scoreRaw scores converted to percentages
SHUEE21Therapist administers items in standardized procedure. Video recorded, scored later15NRFree onlineTwo sections. First measures active and passive range of motion in upper limbs, spasticity, ADL performance and goals. Second section has three components: spontaneous functional analysis, dynamic positional analysis and grasp and release analysisPercentages of the maximum possible score for each section

Discussion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

This systematic review identified five assessments that measure different components of upper limb activity and are suitable for use with children with congenital hemiplegia. A combination of assessments would be required to measure both unimanual and bimanual upper limb activity in this group of children. Researchers and clinicians searching for valid and reliable assessment tools to measure upper limb activity in children with congenital hemiplegia are faced with many measures to choose from; however, in only a few cases are adequate psychometric properties reported in the literature. Assessments such as the Jebsen–Taylor Test of Hand Function22 and the Bruininks–Oseretsky Test of Motor Proficiency (2nd edn)23 are frequently used as outcome measures in clinical trials with children with congenital hemiplegia; however, there is no published study of validity and reliability in this population. In the case of the Peabody Developmental Motor Scales (2nd edn),24 reliability data are available for a small sample of children with congenital hemiplegia. However, these scales were not developed specifically for children with either CP or a unilateral impairment and, lacking validity data, failed to meet the third inclusion criterion for this review. Lack of adequate validity and reliability data for these assessments has implications for interpreting response to treatment, and further research is required to investigate these assessments in children with congenital hemiplegia.

When designing the second inclusion criterion for this review, we initially considered that included assessments should logically measure more items falling within the activity component of the ICF than in the body function component, i.e. a cut-off point of 50%. However, several unimanual measures frequently used by clinicians to evaluate upper limb activity in this population assess both upper limb activity and body function according to the ICF and failed to meet the 50% cut-off. To ensure that this review was useful for clinicians and researchers measuring both unimanual and bimanual performance, the cut-off point for the percentage of activity items included was reduced to 35%.

Validity and reliability psychometric data for children with congenital hemiplegia must have been published to meet the inclusion criteria for this review. This proved a necessary criterion to identify the assessments with sound psychometric properties for this particular population. The ABILHAND-Kids, the AHA, the QUEST, and the MUUL were identified as valid measures for children with congenital hemiplegia. With no criterion standard for measuring upper limb activity available, the MUUL was the only assessment to establish criterion validity. An experienced group of clinicians compared their usual upper limb assessment with the MUUL.19 The paper reporting psychometric data for the SHUEE described the concurrent validity evidence of the SHUEE in comparison with the Pediatric Evaluation of Disability Inventory and the Jebsen–Taylor Test of Hand Function. While presented in the criterion validity column of Table III, these assessments are not universally accepted as criterion standard measures of upper limb activity.

The AHA and the MUUL have established excellent internal consistency, test–retest reliability, and inter- and intrarater reliability.18,19,25–30,32,36 The ABILHAND-Kids assessment shows adequate internal consistency and test–retest reliability.17 The SHUEE and the QUEST demonstrate excellent interrater reliability.20,21,31–33 In the case of the QUEST, variable intrarater reliability and strong test–retest reliability have been reported.20,31,33 The discrepancy between strong interrater reliability and variable intrarater reliability found in the two studies related to the QUEST may be a result of small numbers of raters and depend on which round of assessment scores was used to determine the interrater reliability. Data for the SHUEE showed strong intrarater reliability using Pearson’s correlation coefficient to demonstrate correlation and Student’s paired t-tests to ensure that no systematic differences occurred.21

The AHA and ABILHAND-Kids assessments were both developed according to the Rasch measurement model, which is becoming a preferred way to construct tests for use in rehabilitation.34,35 Scales developed using a Rasch model are useful when measuring children across the spectrum of severity because of the requirement that items form a unidimensional linear scale capable of differentiating between children with varied abilities. The AHA and the ABILHAND-KIDS report good validity and reliability with items forming a unidimensional construct, reliably separating and spreading the measures of ability along the scale.17,18,25,26,36 The reported person separation reliability estimates also indicate sensitivity to change.36 An intervention study of modified constraint-induced movement therapy using the AHA showed a large effect size in children aged 18 months to 4 years.37 This is outside the age range of the current review, but a promising indicator for future studies. A further version of the AHA is being developed for adolescents but there is no published information available for this age group at present (Krumlinde-Sundholm L, personal communication 2008).

Clinical utility needs to be considered as well as the psychometric properties of assessment tools. The ABILHAND-Kids has excellent clinical utility, being available free online, complete with online analysis of data. It is quick to administer and is completed by parents, giving a different perspective on children’s manual ability in their everyday life. The MUUL manual specifies that it takes 30 minutes to administer and 30 minutes to score. The AHA manual does not specify the amount of time needed to score, although, in the authors’ experience, the AHA takes approximately 1 hour. The QUEST can be administered and scored within 45 minutes. The SHUEE takes 15 minutes to administer and scoring time was not reported in the manual. The AHA is the only assessment that requires formal training and so is more expensive. Both the AHA and the MUUL are accompanied by manuals detailing specific procedures for administration, scoring, interpretation, and presenting evidence for the psychometric properties of the test. Free online manuals are available for both the SHUEE and the QUEST. The SHUEE manual provides clear instructions and is linked to the paper presenting psychometric data. The QUEST manual presents initial reliability and validity data but lacks some clarity regarding administration and scoring of some items.

Clinicians may select an upper limb assessment tool to measure a specific aspect of upper limb activity. For clinicians who want to measure a change in unimanual function as a result of spasticity management or following surgery, the MUUL, the QUEST, or the SHUEE may be useful. Of these assessments, the MUUL presented the most thoroughly tested psychometric properties.

A clinician may also want to measure speed and dexterity, and there is no known test of speed and dexterity validated for children with CP. The Jebsen–Taylor Test of Hand Function22 has frequently been used as a measure of speed and dexterity; however, psychometric data reported for children with congenital hemiplegia are not available. The AHA measures how a child uses his or her impaired hand in bimanual function in a naturalistic environment. Clinicians may want to investigate this skill after intensive training of the impaired limb using therapies such as modified constraint-induced movement therapy or intensive bimanual training.

There are several potential limitations to this review. Articles were included only if they were published in English and, therefore, some assessments may have been excluded. A number of measures, such as the Assessment of Motor and Process Skills38 and the Wee-FIM,39 were excluded as their primary purpose is to measure self-care. They may also measure aspects of upper limb activity, but this is not the primary purpose of these assessments. There were also several individualized, goal-setting tools which can be used to measure change in upper limb activity which were not included because this was not their primary purpose. Further information on their psychometric properties and clinical utility can be found elsewhere.2

Conclusion

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

This systematic review identified five measures that assess upper limb activity in children with congenital hemiplegia. Published psychometric properties are available for all of these measures in this population of children. When measuring unimanual capacity, the MUUL had the most thoroughly tested validity and reliability evidence. For measurement of bimanual performance, the AHA had the most thoroughly tested validity and reliability evidence. This assessment, which uses naturalistic observation, combined with the MUUL, could be useful to measure the relationship between changes in unimanual capacity and bimanual performance. Both the MUUL and the AHA can be used to discriminate between individuals and evaluate change over time. The ABILHAND-Kids is a parent report and shorter assessment tool designed with a discriminative purpose, which provides a measure of overall manual ability from a parent’s perspective. Further studies of the evaluative validity of all tools are required to ensure clinically meaningful change of activity limitations is being measured in response to intervention.

References

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Method
  4. Results
  5. Discussion
  6. Conclusion
  7. References
  8. Supporting Information

Table SI: Excluded assessments.

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DMCN_3369_sm_TableS1.doc64KSupporting info item

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.