Clinical

tool for assessment of selective

voluntary motor control in patients with
spastic cerebral palsy

American Academy of Cerebral Palsy and Developmental Medicine

Montreal, September 2017
Disclosure Information
AACPDM 71st Annual Meeting | September 13-16, 2017

Speaker Names: Marcia Greenberg, Kristin Krosschell, Loretta Staudt,

Theresa Moulton

Disclosure of Relevant Financial Relationships

I have no financial relationships to disclose.

Disclosure of Off-Label and/or investigative uses:

I will not discuss off label use and/or investigational use in my presentation
Clinical Tools For Assessment of
Selective Voluntary Motor Control
In Patients with Spastic Cerebral Palsy

SCALE: Selective Control Assessment

of the Lower Extremity
&
TASC: Test of Arm Selective Control

Presenters

SCALE
Marcia B. Greenberg MS, PT, KEMG
Loretta A. Staudt MS, PT
Center for Cerebral Palsy at UCLA

TASC
Kristin J. Krosschell, PT, DPT, MA, PCS
Theresa Sukal-Moulton, PT, DPT, PhD
Northwestern University

Spastic Cerebral Palsy

Multiple Impairments

spasticity
weakness

impaired
selective voluntary sensory
motor control disturbance
 Selective Voluntary Motor Control (SVMC)

The ability to perform isolated joint movements

upon request, without using mass

flexor/extensor patterns and without undesired

movement at other joints, such as mirroring

Overview of SVMC

• Results from damage to the corticospinal tracts – pathways

for voluntary movement responsible for fine control
• Important for treatment planning and surgical decision
making
• While only assessed in patient’s with spastic CP, it has a
separate mechanism from spasticity
• Used as screening for selective posterior rhizotomy

Corticospinal Tracts

• Commonly injured in CP
• White matter damage of prematurity (e.g. PVL)
• Responsible for voluntary movement
Force
hip foot and ankle
−
− Speed arm
− Timing
face
− Pattern
 Tools

• Lower extremity – SCALE

− Developed at UCLA (Fowler et al 2009)
− Hip, knee, ankle, subtalar joint, toes
• Upper extremity – TASC
− Developed at Northwestern University
− Shoulder, elbow, forearm, wrist, fingers, thumb
• Both ask patient to perform selective movement
task
• Similar administration and scoring

Scoring

• SVMC at each joint is graded as:

− Normal = 2 points
− Unable/Absent = 0 points
− Impaired = anything else = 1 point

• SCALE
 5 joints for a maximum of 10 points per limb
• TASC
 8 movement patterns for a maximum of 16 points per limb

SCALE Validity and Reliability

• Content validity
• 14 expert clinicians
• Rated content, administration and grading
• Mean agreement 91.9%
• Recommendations incorporated into final tool
• Construct validity
• Interrater reliability
 SCALE: Construct Validity
n = 51
n = 51
rs= -0.83
rs= -0.83
p<0.001
p<0.001

SCALE Interrater Reliability

SCALE Validity and Reliability

Balzer et al (Dev Med Child Neurol 2016)

• German translation of SCALE
• 38 participants
• Validity
• Similar results to UCLA using GMFCS
• Inter-rater reliability
• ICC >.9; p <.001
• Intra-rater reliability (video)
• ICC >.9; p <.001
 Overview of SCALE

• Patient is able to follow directions

• Minimum age typically 4 years

• Hip, knee, ankle, subtalar and toe motion

• Non-synergistic movement task

• Check available passive ROM

• Move within 3 second verbal count

• Move ONLY the joint being tested

• Grade best performance

Scoring System

  
  
3 6    
3 6

Example of scores for a child with spastic diplegic CP

Maximum score per each lower limb = 10

Grading

• Normal
− Completes isolated movement within 3 seconds
• Unable
− Does not move requested joint or
− Cannot perform movement out of synergy
• Impaired
− Less than 50% available motion
− Slower than 3 second verbal count
− Mirror movements of contralateral limb
− Motion at other joints
− Movement occurs only in one direction
 Grading Guidelines

• Only grade what you observe – no assumptions

• If contracture is present
− Grade movement that you see, not palpate
− Note contracture in descriptor section
− Area for comments

Hip

Starting position

“flex”” “extend” ““flex”

”

Knee

Starting position

“extend” “flex” “extend”

Ankle
“Starting position”

“move foot up” “down” “up”

Subtalar
Joint
Starting position

“in” “out” “in”

Toes

Starting position

“flex” “extend” “flex”

Administration and Grading Guidelines
• Hip
− Tight hamstrings restricted ROM
− Can use hip extension with knee flexed
• Knee
− Allowed to lean back on hands
− Watch for trunk movement
• Ankle
− Can flex knee to 20o
− Must observe at least 15o arc of motion
• Subtalar
− Need active eversion
• Toes
− Motion at all five toes

Resisted Extensor Synergy

Resisted Flexor Synergy

(“Confusion Test”)
 Descriptors for Impaired Grade

• Mirrors motion on opposite limb

• Motion slower than 3 sec verbal count
• Moves one direction only
• Movement of other joints
• Motion less than 50% of range
• Contractures/spasticity interfere , knee, ankle)
• Ankle: inverts/everts, not pure dorsiflexion
• Ankle: primarily moves toes

Clinical Examples: Videos

• Each joint

• Each grade

• Patient example
SCALE: Research and Clinical Decision Making
Loretta Staudt, MS, PT

• Research
− Proximal to distal impairment
− SVMC and gait
− Force production
− Mirror movements

• Clinical decision making

− Selective posterior rhizotomy
− Hamstring lengthening
− Exercise design
 Test of Arm Selective Control (TASC)
Clinical tool for assessment of selective voluntary motor control
in patients with spastic cerebral palsy

Clinical use of the TASC

Kristin J. Krosschell, PT, DPT, MA, PCS
American Academy of Cerebral Palsy and Developmental
Medicine
Montreal, September 2017

Test of Arm Selective Control

• Designed to differentiate and describe selective
voluntary movement control in the upper limb of
those with cerebral palsy

• Background
» NIH Task Force on Childhood Motor Disorders
» No scales to specifically examine UE selective
control
» Modeled after Selective Control Assessment
of Lower Extremity (SCALE)

TASC
 TASC General Directions
Location: Minimize distractions, document
setting (location, others present, time of day,
etc)
Seating: Choose appropriately (90/90, no
arms)

Must be able to follow simple motor

commands.

1.Proximal to distal, less impaired side 1st

2.Check PROM
3.Demonstrate the task
4.Ask the patient to perform
a. Within 3 sec cadence
b. Without moving other joints/limbs
c. Up to 3 attempts allowed.
5.Instructions/verbal cues may be modified
to maximize performance

TASC test items

1.Shoulder abd/add
2.Shoulder flex/ext
3.Elbow flex/ext (concentric/eccentric)
4.Forearm supination/pronation
5.Wrist ext/flex
6.Finger/thumb ext/flex
7.Thumb opposition (‘neat’ or tip to tip pincer)
8.Thumb ext/flex (key grip)

Scoring

2 • Performs completely (>50% of available range)

without movement at other joints
• Within a 3 second cadence
• Without mirror movement
1 • Completes ≤ 50% of available ROM
• Performs slower than 3 second cadence
• Movement occurs only in 1 direction, or motion
at another joint (including mirror movements)
occurs.
0 • Does not complete the task, or only does so with
other joint movement
 Reduced ROM
• Consider:
» Contractures
» Non-standard start positions
» Available ROM

Movement properties and descriptors

• Spastic catch
• Muscle tightness
• ↓ ROM
• Motion slow
• Extra movement
• Mirror movements
• No palpable contraction
• Movement in only one direction

• Flexion and/or extension synergy influence

TASC
Scoresheet
 Starting position 1
(Items 1-3)
Correct alignment
shoulder neutral
Poor alignment
elbow
extended

wrist neutral

Fingers extended
as required by
task

Starting position 2
(Items 4-8)

shoulder neutral

elbow 90◦ examiner may lightly

support elbow if
needed

Fingers flexed or
wrist neutral extended as
required by task

Meet our patient

• 7 year old
• R hemi

ü ü
ü

• What might you hypothesize as primary

issues based on the next few videos?
 Shoulder ABD/ADD
Start position 1

“UP, DOWN, UP”

“Raise your arm to the side as high as you can (with the palm of your hand
facing down), bring it down, and then raise it again. Try to keep your elbow,
wrist and fingers straight while you do this.”

Left Shoulder Abduction/Adduction

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Shoulder Abduction/Adduction

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Shoulder flexion/extension
Start position 1

“Raise your arm to the front

“UP, DOWN, UP”
as high as you can, with your
thumb pointing to the ceiling,
bring it down, and then raise it
again. Try to keep your elbow,
wrist and fingers straight while
you do this”

Left Shoulder flexion/extension

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Shoulder flexion/extension

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Elbow flexion/extension
Start position 1

“UP, DOWN, UP”

“Bend your elbow up as far as you can while your thumb points towards the
ceiling, straighten your elbow and then bend it again”

Left Elbow flexion/extension

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Elbow flexion/extension

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Forearm supination/pronation
Start position 2

“UP, DOWN, UP”

"Turn your hand so that I can see the inside of your hand, the back of your
hand and then the inside of your hand again."

Left Forearm supination/pronation

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Forearm supination/pronation

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Wrist extension/flexion
Start position 2

“OUT, IN, OUT”

“Move your wrist so you hand comes

out, in, and then out again.”

Left Wrist extension/flexion

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Wrist extension/flexion

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Finger and thumb flexion/extension
Start position 2
“Open your hand
wide, make your
hand into a fist, and
then open it wide
again.”

“OPEN, CLOSE, OPEN”

Left Finger-thumb extension/flexion

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Finger-thumb extension/flexion

2 q > 50% available ROM

q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
Thumb opposition (thumb to 1st finger tip to tip)

Start position 2

“CLOSE, OPEN, CLOSE”

“Move your thumb and index finger together to make a circle like this (demo).
Straighten your thumb and finger out. Make a circle again.”

Left Thumb opposition (pincer)

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Right Thumb opposition (pincer)

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 Thumb extension (key grip)
Start position 2

“UP, DOWN, UP”

“Keep your fingers flexed and your thumb straight. Lift your thumb up, down and up.”

Left Thumb extension (key grip)

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint

Left Thumb extension (key grip)

2 q > 50% available ROM
q within a 3 second count
q without mirror movement
1 q ≤ 50% available ROM
q slower than 3 second count
q movement occurs only in one
direction
q motion at another joint
q mirror movements
0 q No AROM
q Immediate or obligatory
motion at another joint
 TASC
Scoresheet

TASC team members

NIH Task Force members PTHMS Synthesis students
Kristin J Krosschell, PT, DPT, MA, PCS Kat Block, PT, DPT
Theresa Sukal Moulton, PT, DPT, PhD Alexi Block, PT, DPT

Deborah Gaebler Spira, MD Erin Salzman, PT, DPT

Jessica Barnum, PT, DPT
Darcy Fehlings, MD
Katie Warner, SPT
Eileen Fowler, PT, PhD
Elizabeth Byrne, SPT

Acknowledgements: Andrew Robertson, SPT

NIH Task Force on Childhood Erin Cameron, SPT
Movement Disorders Shannon Murphy, SPT
Sanger Funds
Local clinics for hosting and recruiting
Clinical tools for assessment of
selective voluntary motor control in
patients with spastic cerebral palsy
Research in UE SVMC and
Relationship to TASC

American Academy of Cerebral Palsy and

Developmental Medicine
Annual Meeting, September 2016
Theresa Sukal-Moulton, PT, DPT, PhD
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