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
children is crucial not only to outline treat-
ment, but also to measure the efficacy and to
allow follow-up over time. According to the
International Classification of Functioning,
Disability and Health (ICF), the upper limb can
be assessed at the level of body function, activity
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-
tions reflect the difficulties experienced during
reaching, grasping, manipulating and releasing
objects with the hemiplegic arm and hand. As
many daily activities involve these functional
tasks, limitations in arm activities can hinder the
child’s participation in school and leisure activities.
Over the last two decades, several measurement
tools have been designed to assess arm activities in
children with hemiplegic cerebral palsy. These
tools each involve different clinically relevant
aspects. As expressed in the ICF, a differentiation
can be made between the qualifiers ‘capacity’ and
‘performance’. Capacity refers to the child’s ability
to execute a task on the highest probable level
of functioning that the child may reach in a stan-
dardized environment. Quality of movement
(e.g. active range of motion, fluency, accuracy),
dexterity and movement speed are all components
of capacity. Performance refers to the child’s spon-
taneous use of the hemiplegic hand during activi-
ties or play.3 To obtain a complete representation
of the child’s abilities, these different qualifiers of
arm function have to be considered. In addition,
to allow implementation in research and clinical
practice, the selected outcome measures should
have sound psychometric properties, such as reli-
ability, validity and the ability to detect clinically
important differences.
Currently, several clinical measures are avail-
able to assess arm function. However, in the pre-
sent state of outcome measurements for arm
activities in children with cerebral palsy, there is
little consistency about their use in research and
clinical practice. This lack of consistency compli-
cates the identification of suitable measurement
tools for follow-up and treatment. To the best of
our knowledge, there has been no systematic over-
view and comparison of these tools. Therefore, the
aim of this study was to give a systematic review of
clinical tools appropriate for assessing arm func-
tion in children with hemiplegia. The descriptive
information, clinical utility and psychometric
properties of the selected outcome measures will
be assessed. This review offers a flexible frame-
work to support the selection of suitable outcome
measures for arm activities.
Methods
Papers were selected through an electronic search
of the following databases (January 2009):
PubMed, CINAHL, Cochrane Library and Web
of Science. Keywords (MeSH) for the search strat-
egy included ‘cerebral palsy’ and ‘upper extrem-
ity’. To focus search results, these keywords were
combined with text words for ‘outcome assess-
ment’, ‘questionnaire’ and ‘activity’. Identified
assessments were subsequently searched individu-
ally, combined with terms such as ‘psychometric
properties’, ‘reliability’ and ‘validity’. Reference
lists from included articles were hand-searched to
detect further relevant papers.
Two authors (KK and EJ) assessed the title and
abstract of each study to identify and select the
outcome assessments. Tools were included if they
met the following inclusion criteria: (1) evaluative
tools at the ICF level of activity; (2) previously
used in studies including children with cerebral
palsy aged 2–18 years; (3) at least one aspect of
reliability and validity in children with cerebral
palsy should be established.
Both condition-specific assessments developed
specifically for children with cerebral palsy and
generic assessments were included. The latter
assessments focus on discriminating between typi-
cally developing children and children with a
developmental delay, arising from a broad range
of disabilities.
Tools were excluded if they: (1) were not pub-
lished in English; (2) primarily assessed impair-
ments or participation restrictions; and (3) were
instruments based on individually identified goals.
In the case of disagreement, the selected out-
come measure was discussed with a third author
(HF) until consensus was reached.
A data extraction sheet based on the
Outcome Measures Rating Form4 allowed for
 Arm activity measures for children with cerebral palsy
the comparison of descriptive information, clinical
utility and psychometric properties of the selected
assessments:
 Descriptive information was gathered for each
assessment to determine target population, pur-
pose, content, number of domains/items and
scoring criteria.
 Clinical utility entailed the administration
format, test duration and scoring time, required
equipment and need for rater training.
 Psychometric properties addressed the reliability
and validity of the outcome assessment.
Reliability was defined as the extent to which the
assessment produces consistent and reproducible
results on repeated administration (test–retest)
when used by the same rater (intra-rater) or when
used by different raters (inter-rater).5 The following
guidelines were used for the interpretation of the
reliability coefficients. Intraclass correlation coeffi-
cients (ICC) above 0.80 were considered excellent;
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
agreement.6 In addition, the standard error of mea-
surement (SEM), the smallest detectable difference
(SDD) and the minimal clinically important differ-
ence were reported. The SEM provides an absolute
index of reliability as it indicates the variability of
scores around the subject’s true score. The SDD is
required to conclude whether the subject shows a
real improvement rather than a difference in score
due to measurement error. The SDD equals the
SEM  1.96  ˇ2.7 The minimal clinically impor-
tant difference is referred to as the smallest change
in measurement that is considered to be meaningful
based on clinicians’ ratings.8 Validity is the extent
to which an evaluation tool actually measures what
it is intended to measure.5 Content, construct and
concurrent validity were reviewed.
Results
The search strategy is outlined in Figure 1.
Eighteen assessments were identified, of which 11
assessments met the predefined inclusion criteria.
889
These were further reviewed to evaluate their psy-
chometric properties. Seven assessments were
excluded. The selected instruments were classified
as functional tests, either condition-specific (n ¼ 5)
or generic (n ¼ 3), and questionnaires (n ¼ 3).
The condition-specific functional tests were the
Quality of Upper Extremity Skills Test (QUEST9),
the Melbourne Assessment of Unilateral Upper
Limb Function (Melbourne Assessment10), the
Shriners Hospital for Children Upper Extremity
Evaluation (SHUEE11), the Assisting Hand
Assessment (AHA12) and the Video Observations
Aarts and Aarts (VOAA13). Generic functional
tests included the Bruininks-Oseretsky Test
of Motor Proficiency (BOTMP14), the Peabody
Developmental Motor Scales (PDMS15) and the
Jebsen-Taylor Hand Function Test (Jebsen-
Taylor test16).
The selected questionnaires were the
Abilhand-Kids,17 the Revised Pediatric Motor
Activity Log (PMAL-revised18) and the Pediatric
Evaluation of Disability Inventory (PEDI19).
Descriptive information
Functional tests
Descriptive information on the tests is presented
in Table 1. The majority of the functional tests
evaluate the child’s upper limb capacity, while
only the AHA and the VOAA evaluate the upper
limb performance during bimanual tasks.
The QUEST and the Melbourne Assessment
are evaluative tools that measure upper limb qual-
ity of movement by means of various unimanual
items.9,10 While the QUEST focuses on dissociated
movements, grasp, weight bearing and protective
extension, the Melbourne Assessment assesses
items that involve reach, grasp, release and manip-
ulation. Items are further subdivided into subitems
which are scored on a dichotomous scale for the
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
incorporates different subscales at the level of
body function, such as range of motion and
muscle tone. The second section includes three com-
ponents: spontaneous functional analysis, dynamic
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-
point ordinal scale.
The AHA assesses how effectively the hemiple-
gic hand is actually used in bimanual activities.12
The spontaneous use is evaluated during a semi-
structured play session with toys requiring biman-
ual handling. The items that are scored include
general use, arm use, grasp and release, fine
motor adjustments, coordination and pace. All
items are scored from 0 (does not do) to 4 (effec-
tive use).
The VOAA is a recently developed observa-
tional tool to measure the spontaneous arm use
by means of a computer software program.13,27
The duration and frequency of specific behaviours
of the affected arm are calculated during different
bimanual activities, such as making a sandwich,
playing with Lego blocks, removing a shoe, string-
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
BOTMP can be used to evaluate fine motor skills
in terms of speed and dexterity.14 This subtest
involves eight tasks, such as placing pennies in a
box, sorting shape cards, stringing beads and
making dots. Tasks are scored on a 7- to 10-
point scale. The fine motor abilities of the
PDMS-2 are divided into two subtests, including
grasping and visuomotor integration.15 Items are
scored on a 3-point ordinal scale. The raw scores
from the BOTMP and PDMS-2 can be converted
into a standard score with an age equivalent.
The Jebsen-Taylor test measures movement
speed in seven unimanual tasks.16 The time to
carry out the task is registered and compared
with norm values.28 The test was modified for chil-
dren with hemiplegic cerebral palsy whereby the
writing task was removed, and the time to carry
out each task was reduced from 3 to 2 minutes to
avoid frustration.29,30
Questionnaires
The Abilhand-Kids and PMAL-revised are con-
dition-specific, and the PEDI is a generic question-
naire. All questionnaires are completed by the
child’s parents or caregivers.
The Abilhand-Kids comprises 21 mainly biman-
ual daily activities.17 The difficulty experienced by
the child to perform the required tasks is scored on
a 3-point ordinal scale.
The PMAL-revised documents the spontaneous
use of the affected arm in every day activities.18
The original PMAL has been modified based on
a Rasch analysis. The revised version consists of
22 unimanual and bimanual tasks. For each task,
both the amount of use and the quality of move-
ment of the affected arm are rated on a 3-point
ordinal scale.
The PEDI quantifies a child’s level of ability
and dependency in many daily activities.19 The
questionnaire incorporates three domains: self-
care, mobility and social functioning. For each
domain, functional skills are rated dichotomously
and caregiver assistance is rated on a 6-point ordi-
nal scale ranging from ‘total assistance’ to
‘independence’.
Clinical utility
Table 2 shows that the administration time for
all functional tests is approximately 10–15 min-
utes, except for the more extensive PDMS-2-FM.
For the video-based assessments, the scoring after-
wards takes another 10–30 minutes. The duration
to fill in the questionnaires ranges from 10 to
60 minutes.
Another issue is the difference in costs to obtain
the assessment. While some tools can be down-
loaded for free, others require the purchase of
standardized materials. Administering and scoring
the AHA and the VOAA requires a certificate that
can only be obtained after attending a specific
rater training course. For the other functional
tests, rater training is only recommended to stan-
dardize the scoring system between raters and to
aim for an optimal reliability of the assessment.
Psychometric properties
Data on the psychometric properties are pre-
sented in Table 3. All reported reliability results
are based on the population of children with cere-
bral palsy. The intra-rater, inter-rater and test–
retest reliability have been established for all
condition-specific functional tests, except for the
test–retest reliability of the SHUEE. The reliability
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
tests is excellent, except for a slightly lower reli-
ability for some tasks of the VOAA. For all
questionnaires, test–retest reliability is very high.
Inter-rater reliability has only been reported for
the PEDI and is excellent. For the tests with
real-time scoring, as well as for the questionnaires,
the assessment of intra-rater reliability is not appli-
cable. The SEM and SDD have been established
for the QUEST,33 Melbourne Assessment,33
AHA,37 BOTMP14 and PDMS-2-FM.15 For the
PEDI, the minimal clinically important difference
(11.5%) was reported.8
Both construct and content validity have been
established for the selected functional tests and
questionnaires. The concurrent validity was eval-
uated for the majority of the assessments.
Although most tests have a good concurrent
validity, correlations below 0.60 were found
between the SHUEE and the self-care domain of
the PEDI and between the Abilhand-Kids and the
Purdue Pegboard test.25
The Rasch rating scale methodology was
applied during the construction of the AHA,
Abilhand-Kids, PMAL-revised and PEDI. This
statistical procedure provides sound evidence for
unidimensionality and adequate hierarchic scale
structure of these assessments. It also transforms
the original ordinal scale into an interval scale
measuring a continuum.40
Discussion
This study offers an overview of arm activity mea-
surements for children with hemiplegic cerebral
palsy. Eleven psychometrically sound and clini-
cally feasible outcome assessments were identified.
The selected instruments included eight functional
tests, either condition-specific or generic, and three
questionnaires. The majority of the assessments
measure capacity with standardized items in test
situations where children show what they can do
when asked to. The capacity of the hemiplegic side
can be measured with the QUEST, Melbourne
Assessment, SHUEE, Jebsen-Taylor test,
BOTMP or the PDMS-2-FM. Performance-
based tests or questionnaires measure what chil-
dren actually do in daily life. This aspect can be
measured with the AHA, VOAA or with a
895
questionnaire such as the Abilhand-Kids,
PMAL-revised or the PEDI.
Comparison of the different condition-specific
tests shows that the QUEST is suitable to evaluate
the quality of movement of the affected arm in
very young children as it comprises domains
related to motor development, such as dissociated
movements, weight bearing and protective exten-
sion. For children from 5 years of age on, the
Melbourne Assessment can be used. This test
entails a more detailed scoring of the quality of
movement compared to the dichotomous scoring
of the QUEST, and it includes also aspects such as
speed, accuracy and fluency. Since the Melbourne
Assessment is validated for children up to the age
of 15 years, the test is more appropriate for long-
term follow-up.33 The SHUEE, on the other hand,
is the only test that provides a detailed analysis of
the position of the thumb, fingers, wrist, forearm
and elbow. This aspect is particularly relevant to
evaluate the effect of interventions at the level of
body function, such as botulinum toxin A injec-
tions or surgery.
Although the latter three tests were included as
measures at the level of activity, there may be
some ambiguity relating these measures to the
ICF framework. For the Melbourne Assessment,
several subitems score aspects at the body function
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.
Still, these tests incorporate grasping and manip-
ulation abilities and items are assessed in the con-
text of activities. However, the fact that the above-
mentioned outcome measures span different ICF
levels may complicate the clinical interpretation of
the results.
Apart from the capacity, it is also important to
assess a child’s performance. In these tests children
are not specifically asked to execute the task with
their affected hand, but encouraged to use it in
play or daily activity, where bimanual handling
is required. This aspect is measured in the AHA
and the VOAA. The AHA comprises a detailed
evaluation of the different functions of the hemi-
plegic arm and hand administered in a play ses-
sion. The VOAA can be used to calculate the exact
quantity of use of the hemiplegic hand during
daily activities. Both tests are suited to evaluate
896 K Klingels et al.
the effect of therapy modalities which aim to
improve the involvement of the hemiplegic arm
during daily activities (e.g. constrained-induced
movement therapy).
Generic tests are designed for children with a
broad range of developmental disabilities and
have a discriminative ability. The BOTMP and
the PDMS-2-FM cover a wide variety of skills,
such as use of pen or scissors. These tests describe
aspects of age-related hand function, but they give
little or no information concerning the quality
of movement of the hemiplegic arm and hand.
Thus, they are less suitable for clinical guidance.
The most important contribution of these norm-
referenced tests for children with cerebral palsy is
their use in identifying a child’s need and eligibility
for therapy services by determining the extent of
the child’s delay or dysfunction.3 The Jebsen-
Taylor test is a short unimanual test to score the
movement speed during unimanual fine motor
activities, a component not addressed in other
measures.
Standardized tests do not necessarily reflect how
the child actually performs in their normal envi-
ronment. This information on ‘real life’ function-
ing may be gathered through direct enquiry from
the child and/or the child’s parents. The Abilhand-
Kids is a short questionnaire focused on arm func-
tion during daily activities and gives information
for goal setting in occupational therapy. The
PEDI covers a broad domain of the child’s func-
tioning, whereby both the activity level and
aspects of the participation level are considered.
A drawback to use the PEDI is a ceiling effect in
the group of children with hemiplegia as they often
compensate with their healthy side for the prob-
lems experienced with the affected side.41 The
recently revised PMAL has been specifically devel-
oped to evaluate the effects of constraint-induced
movement therapy. The two subscales of the
PMAL-revised allow differentiation between
‘how often’ versus ‘how well’ a child uses his hemi-
plegic arm and hand.18
In the historical development of assessment
tools, there is a clear trend to shift from the eval-
uation of capacity to performance. Comparing
what a child is able to do with his hemiplegic
arm, and what the child actually does allows the
clinician to make a comprehensive analysis of the
child’s abilities and the ‘developmental non-use’ of
the hemiplegic side. If the difference between
capacity and actual performance is large, the
child may have potential for a more effective per-
formance. Intervention can thus focus on estab-
lishing a useful spontaneous behaviour and
learning to use the underlying capacity (e.g. con-
straint-induced movement therapy or task-
oriented training). If the child is fully using his
or her capacities but with a poor result, interven-
tion should focus on improving the biomechanical
prerequisite for handling objects, for example
strength training, botulinum toxin A injections
or a surgery. Therefore, measures of hand function
for both capacity and performance are needed to
allow outcome differentiation and to guide
treatment.3
A further important criterion to select tests or
questionnaires is the fulfilment of psychometric
properties. The reliability and validity of both
the functional tests and the questionnaires have
been established. Only for the VOAA test are
additional validity studies necessary.
The Melbourne Assessment and the QUEST
have frequently been used in clinical trials that
investigate the effects of botulinum toxin A injec-
tions42–46 as well as the self-care domain of the
PEDI.42,45,46 Some studies have suggested that
the Melbourne Assessment might not be suffi-
ciently sensitive to changes brought about by bot-
ulinum toxin A treatment,42,44,46 while the QUEST
and the self-care domain of the PEDI seem
more sensitive.42,46 The AHA and the raw scores
of the generic tests have shown change in interven-
tion studies focusing on forced use therapy,47
constraint-induced movement therapy29,48,49
and hand–arm bimanual intensive training
(HABIT).50 The SHUEE, the VOAA, the
Abilhand-Kids and the revised-PMAL have not
been used in intervention studies so far.
The SEM, the SDD and the minimal clinically
important difference are very useful concepts in
intervention studies to establish that a change
has really occurred for a child. These measures
have been reported for the QUEST,33 Melbourne
Assessment,33 AHA,37 BOTMP,14 PDMS-2-FM15
and PEDI.8 The values are acceptable and
correspond to reported measurement errors of
other arm scales in stroke patients (e.g. the
Action Research Arm Test and Brunnström–
Fugl–Meyer Test).51 In future research, these
 Arm activity measures for children with cerebral palsy
values should be determined for the other
assessments.
A strong asset of the AHA, the Abilhand-Kids,
the PEDI and the PMAL-revised is that these
tests are developed by means of a Rasch analysis.
Besides the stronger statistical properties, a Rasch-
based scale also provides the therapist information
on which items have already been mastered and
which items can be reached in the near future by
practice.40
The most prominent barrier for clinicians to reg-
ularly use standardized tests is the time required to
administer and score them. For the selected instru-
ments, test duration ranges from 10 to 60 minutes.
Video-taped tests requiring subsequent scoring
take more time. Moreover, these tests necessitate
the availability of a video set-up and a spacious
setting. These aspects as well as other aspects of
clinical utility, such as the difference in costs, can
also play a decisive role in the selection of
instruments.
Thus far, two reviews have been published on
outcome measures in children with cerebral palsy,
one on measures of gross motor function and
mobility52 and a second on participation mea-
sures.53 Although reviews on arm activity mea-
sures are available in other conditions, such as
children with congenital transverse or longitudinal
reduction deficiency of the arm54 and adults with
stroke,55 this is the first review that systematically
assessed the quality of arm activity measures
in children with hemiplegic cerebral palsy.
Nonetheless, there are some limitations that must
be considered. It is possible that we have missed
tools that are used in clinical practice, but have not
been applied in research. However, we considered
it appropriate to only include measures with
some evidence of psychometric evaluation.
Furthermore, studies assessing psychometric char-
acteristics included different types of cerebral
palsy with a varying degree of severity and with
varying ages. In this review, the results of these
studies are summarized. This must be kept in
mind when implementing measurement tools.
Another aspect that has not been addressed is
the possible bottom or ceiling effect of the mea-
sures. However, this has not been described in pre-
vious studies and thus this issue warrants further
attention.
897
Conclusion
Results of this systematic review identified five con-
dition-specific functional tests, three generic tests
and three questionnaires suitable to measure arm
activities in children with hemiplegic cerebral palsy.
All assessments measure different aspects of activity,
including capacity and performance. The reliability
and validity have been established though further use
in clinical trials will be necessary to determine the
responsiveness and research utility of the assess-
ments. To obtain a complete view of what the child
can do and what the child actually does in different
settings, we would suggest combining a capacity-
based test (Melbourne Assessment), with a
performance-based test (AHA) and a questionnaire,
Abilhand-Kids. The selection of these tests is based
on the content, clinical utility and psychometric
properties. Other assessments could be considered
to evaluate specific therapy modalities. This review
can offer a framework to help the therapist choose
among the various assessments in order to guide and
evaluate treatment interventions for arm and hand
function in children with cerebral palsy.
Clinical messages
 Arm activities can be measured with several
reliable and valid measurement tools, each
addressing different aspects of unimanual
and bimanual activities.
 A combination of capacity and perfor-
mance-based measures is crucial for a
better understanding of the child’s abilities
in order to guide and evaluate treatment
strategies.
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