Lena Krumlinde-Sundholm

The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability

The Manual Ability Classification System (MACS) has been developed to classify how children with cerebral palsy (CP) use their hands when handling objects in daily activities. The classification is designed to reflect the childs typical manual performance, not the childs maximal capacity. It classifies the collaborative use of both hands together. Validation was based on the experience within an expert group, a review of the literature, and thorough analysis of children across a spectrum of function. Discussions continued until consensus was reached, first about the constructs, then about the content of the five levels. Parents and therapists were interviewed about the content and the description of levels. Reliability was tested between pairs of therapists for 168 children (70 females, 98 males; with hemiplegia [n=52], diplegia [n=70], tetraplegia [n=19], ataxia [n=6], dyskinesia [n=19], and unspecified CP [n=2]) between 4 and 18 years and between 25 parents and their childrens therapists. The results demonstrated that MACS has good validity and reliability. The intraclass correlation coefficient between therapists was 0.97 (95% confidence interval 0.96-0.98), and between parents and therapist was 0.96 (0.89-0.98), indicating excellent agreement.

The Assisting Hand Assessment: current evidence of validity, reliability, and responsiveness to change

The Assisting Hand Assessment (AHA) provides a new perspective of hand function evaluation relevant for children with unilateral upper limb disabilities. It measures how effectively the involved hand is actually used for bimanual activity, which, for these children, might be the most important aspect of their hand function. The aim of this paper is to report the conceptual framework and the evidence for validity, reliability, and responsiveness to change for the measures. Previously, the AHA has been evaluated for children aged 18 months to 5 years and excellent inter‐ and intrarater reliability was demonstrated. This paper reports further evidence of construct validity and reliability for the AHA measures involving an extended age range of children with hemiplegic cerebral palsy or obstetric brachial plexus palsy from 18 months to 12 years of age (mean age 4y 11mo [SD 2y 9mo] range 18mo–12y 8mo). A Rasch measurement model was used to analyze 409 assessments from 303 children (170 males, 133 females). The analysis generated a scale demonstrating large capacity to reliably separate and spread personal ability measures, indicating sensitivity to change and a hierarchy of the items ranging them from easy to hard. Aspects of item fit, relationship between age and ability measures, and development of assisting hand function are discussed.

Effects of constraint-induced movement therapy in young children with hemiplegic cerebral palsy: an adapted model.

The aim of this study was to evaluate the effects of a modified version of constraint-induced (CI) movement therapy on bimanual hand-use in children with hemiplegic cerebral palsy (CP; age range 18 mo to 4 y) and to make a comparison with conventional paediatric treatment. Twenty-one children (13 females, eight males) completed the CI therapy programme and 20 children (12 males, eight females) served as a control group. Children in the CI therapy group were expected to wear a restraint glove for 2 hours each day over a period of 2 months. The training was based on principles of motor learning used in play and in motivational settings. To evaluate the effect of treatment, the Assisting Hand Assessment (AHA) was used. Assessments took place on three occasions: at onset, after 2 months, and 6 months after the first assessment. A significant interaction was found between group and AHA measure (ANOVA, F(2,74) = 5.64, p = 0.005). The children who received CI therapy improved their ability to use their hemiplegic hand significantly more than the children in the control group after 2 months, i.e. after treatment. Effect size was high after treatment and remained medium at 6 months. As the treatment was tailored to each childs capacity and interests, little frustration was experienced by the children.

Development of the Assisting Hand Assessment: A Rasch-built Measure intended for Children with Unilateral Upper Limb Impairments

The purpose of this paper was to report on the first step in the development of a new instrument, the Assisting Hand Assessment (AHA), that measure the effectiveness with which a child with unilateral impairment makes use of his/her affected hand in bimanual activity performance. The assessment is intended for children with hemiplegic cerebral palsy or obstetric brachial plexus palsy, from age 18 months to 5 years. The AHA is conducted through observations of performance skills exposed during play where toys requiring bimanual handling are used. The validity and reliability of the measures were explored using a Rasch measurement model for analysis. In the AHA, 22 items consisting of observable actions are scored on a 4-point rating scale evaluating the quality of the performance. The Rasch analysis suggests that the test rationale, the usefulness of the assisting hand, does form a unidimensional construct and that the items represent the tested phenomenon well. The results show potential for the AHA to become a useful tool for both clinical practice and research.

Functional outcome at 5 years in children with obstetrical brachial plexus palsy with and without microsurgical reconstruction

Between 1987 and 1998, 470 patients visited the national clinic for obstetrical brachial plexus palsies at the Karolinska Hospital, Stockholm, Sweden. This study reports on 247 children examined at 5 years of age using a special protocol for testing the sensory and motor function of the hand. The children were distributed in various groups depending on the number of injured nerves, whether they had some muscle activity in their biceps or deltoid muscles at 3 months of age, and whether any operations with nerve reconstruction had been performed. The shoulder range of movement in C5–6 palsies was significantly better in the group which had been operated on (operated group), but otherwise there were no differences between children who had been operated on (non‐operated group) and those who had not. A decrease in grip strength and bimanual function in level C5–6 palsies was found, though these roots should not innervate the distal hand. Outcome was not influenced by the number of avulsions in upper‐plexus palsies or whether the operation took place before or after the age of 6 months. The group with extensive lesions (C5‐Th1) had the most root avulsions, showing a correlation between increased avulsions and decreased hand function. This study does not support operating on children with no activity of the biceps and deltoid muscles at 3 months of age, as other authors have concluded. Rather, it favours waiting for a late recovery.

Test-retest and alternate forms reliability of the assisting hand assessment.

OBJECTIVEnThe Assisting Hand Assessment (AHA) has earlier demonstrated excellent validity and rater reliability. This study aimed to evaluate test-retest reliability of the AHA and alternate forms reliability between Small kids vs School kids AHA and the 2 board games in School kids AHA.nnnDESIGNnTest-retest and alternate forms reliability was evaluated by repeated testing with 2 weeks interval.nnnSUBJECTSnFifty-five children with unilateral cerebral palsy, age range 2 years and 3 months to 11 years and 2 months.nnnMETHODSnIntraclass correlation coefficients and smallest detectable difference were calculated. Common item and common person linking plots using Rasch analysis and Bland-Altman plots were created.nnnRESULTSnIntraclass correlation coefficients for test-retest was 0.99. Alternate forms intraclass correlation coefficients were 0.99 between Small kids and School kids AHA and 0.98 between board games. Smallest detectable difference was 3.89 points (sum scores). Items in common item linking plots and persons in common person linking plots were within 95% confidence intervals, indicating equivalence across test forms.nnnCONCLUSIONnThe AHA has excellent test-retest and alternate forms reliability. A change of 4 points or more between test occasions represents a significant change. Different forms of the AHA give equivalent results.

Comparing tests of tactile sensibility: aspects relevant to testing children with spastic hemiplegia

Children with hemiplegic cerebral palsy (CP) commonly exhibit tactile sensory deficiencies in their hands in addition to their motor problems. The aim of this study was to compare and evaluate the usefulness of some common tests of tactile sensibility for use with children with hemiplegic CP. Twenty‐five children with hemiplegia aged between 5 and 18 years, and 19 control individuals participated. All children were examined with Semmes‐Weinstein monofilaments, two‐point discrimination (2PD), stereognosis of familiar objects, stereognosis of forms, and functional sensibility. Dexterity, spasticity, and bimanual task performance were also assessed. Results from the different sensory tests deviated greatly. We found three tests to be useful: 2PD of 3mm spacing, which was the most sensitive test, stereognosis of familiar objects, and functional sensibility assessed through the Pick‐up test (comparing performance with and without the influence of vision). Stereognosis of forms and threshold values of touch (Semmes‐Weinstein monofilaments) are seemingly less useful tests for children with CNS impairments. Deficient sensibility was strongly related to dexterity. Aspects concerning the testing methodology are discussed.

Longitudinal development of hand function in children with unilateral cerebral palsy

Aim The aim of this study was to describe how the usefulness of the hemiplegic hand develops in children with unilateral cerebral palsy (CP) aged between 18 months and 8 years.

Reporting outcomes of the Assisting Hand Assessment: what scale should be used?

The Assisting Hand Assessment (AHA) is now a well-established and frequently used evaluative tool. It measures how effectively children with unilateral hand dysfunction actually use their involved hand collaboratively with their well-functioning hand to perform bimanual tasks. Since the first publication about the AHA in 2003, several studies have reported on different psychometric properties, which have important implications for interpretation of outcomes. However, significant variation in the reporting of results in intervention studies using the AHA emphasizes a need for clarification. This paper aims to provide recommendations for how to report AHA outcomes, where improved consistency will facilitate comparison of data across studies. The AHA produces two types of ordinal level scores at the score form: raw scores and a percentage score. The AHA version 4.4 includes 22 test items each rated on a 4-point scale, giving a raw score range of 22 to 88 points, with the higher number indicating higher ability. These raw scores are also

Self-care and mobility skills in children with cerebral palsy, related to their manual ability and gross motor function classifications

Aimu2002 The aim of this study was to investigate the acquisition of self‐care and mobility skills in children with cerebral palsy (CP) in relation to their manual ability and gross motor function.