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Selective Control Assessment Of The Lower Extremity (SCALE): Development, Validation and Interrater Reliability of a Clinical Tool for Patients with Cerebral Palsy

Selective Control Assessment Of The Lower Extremity (SCALE): Development, Validation and Interrater Reliability of a Clinical Tool for Patients with Cerebral Palsy - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires, Related


Selective Control Assessment of the Lower Extremity (SCALE):
development, validation, and interrater reliability of a clinical tool
for patients with cerebral palsy
EILEEN G FOWLER PHD PT
1
|
LORETTA A STAUDT MS PT
2
|
MARCIA B GREENBERG MS PT
1
|
WILLIAM L
OPPENHEIM MD
1
1 Department of Orthopaedic Surgery, UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy and Tarjan Center, David Geffen School of Medicine at UCLA, Los Angeles,
CA, USA. 2 Department of Orthopaedic Surgery, UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy, and Department of Pediatrics, David Geffen School of Medicine
at UCLA, Los Angeles, CA, USA.
Correspondence to Dr Eileen G Fowler UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy, 22-64 Rehabilitation Center, 1000 Veteran Avenue, Los Angeles, CA
90095-1795, USA. E-mail: efowler@mednet.ucla.edu
PUBLICATION DATA
Accepted for publication 9th September 2008.
Published online 12th February 2009.
LIST OF ABBREVIATIONS
CST Corticospinal tract
ICC Intraclass correlation coefficient
PWM Periventricular white matter
SCALE Selective Control Assessment of the
Lower Extremity
SVMC Selective voluntary motor control
ACKNOWLEDGMENTS
We acknowledge statistical consultation from
Jeffrey Gornbein, and contributions from Beth
Trevino, Sarah Copeland, and Evan Goldberg.
We thank all of the clinical experts and the
volunteer patients and their families for their
participation, and the Lena Longo Foundation
and the Brianna Fund for financial support.
Normal selective voluntary motor control (SVMC) can be defined as the ability to
perform isolated joint movement without using mass flexor ⁄ extensor patterns
or undesired movement at other joints, such as mirroring. SVMC is an important
determinant of function, yet a valid, reliable assessment tool is lacking. The
Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool
developed to quantify SVMC in patients with cerebral palsy (CP). This paper
describes the development, utility, validation, and interrater reliability of SCALE.
Content validity was based on review by 14 experienced clinicians. Mean agree-
ment was 91.9% (range 71.4–100%) for statements about content, administra-
tion, and grading. SCALE scores were compared with Gross Motor Function
Classification System Expanded and Revised (GMFCS-ER) levels for 51 partici-
pants with spastic diplegic, hemiplegic, and quadriplegic CP (GMFCS levels I
– IV, 21 males, 30 females; mean age 11y 11mo [SD 4y 9mo]; range 5–23y).
Construct validity was supported by significant inverse correlation (Spearman’s
r=-0.83, p<0.001) between SCALE scores and GMFCS levels. Six clinicians rated
20 participants with spastic CP (seven males, 13 females, mean age 12y 3mo [SD
5y 5mo], range 7–23y) using SCALE. A high level of interrater reliability was
demonstrated by intraclass correlation coefficients ranging from 0.88 to 0.91
(p<0.001).
Children with spastic cerebral palsy (CP) exhibit multiple
impairments that contribute to functional motor deficits.
Although spasticity and contractures may be more obvious
impairments, underlying deficits in selective motor control
can negatively affect function to a greater degree.
1,2
Assess-
ment of selective motor control in lower extremities in
patients with CP has received little attention, despite
growing support for it as a predictive factor of functional
ability.
1–4
Selective motor control has been defined as ‘... the
ability to isolate the activation of muscles in a selected
pattern in response to demands of a voluntary movement
or posture.’
5
The term ‘selective voluntary motor control’
(SVMC) differentiates the deliberate performance of iso-
lated movements upon request from habitual selective
muscle activation during functional tasks, such as walking.
Voluntary movement is produced through the cortico-
spinal tracts (CSTs), which control both directionality and
force production.
6
Damage to the CSTs interferes with
the force, speed, timing, and pattern of volitional move-
ments.
7
Injury to CSTs within the periventricular white
matter (PWM) has been correlated with motor disability
in CP.
8
Damage to PWM was the most common finding
in brain scans of children with spastic diplegia, and was
ª The Authors. Journal compilation ª Mac Keith Press 2009
DOI: 10.1111/j.1469-8749.2008.03186.x 607
DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

present in more than one-third of those with hemiplegia
and quadriplegia.
9
Evidence of SVMC impairment in CP has been shown.
Timing errors in muscle recruitment during attempted
maximal voluntary contractions exemplify the inability to
recruit an individual muscle group selectively without
inappropriate antagonist muscle activity.
10
In addition,
simultaneous associated movements at contralateral joints,
for example mirror movements, have been described.
11
Mass patterns of flexion and extension, which have histori-
cally been referred to as ‘synergies,’ are seen in the absence
of SVMC.
12
In patients with CP, these flexor and extensor
patterns of the lower extremities are described as persis-
tence of the immature patterns observed during typical
infant kicking
13
and stepping.
14
Tightly coupled hip, knee,
and ankle movements occur in term and preterm infants
with and without damage to white matter. These move-
ments become disassociated or uncoupled over time in
infants without brain lesions, but persist in preterm infants
with damage to white matter.
13
These mass movement
patterns are observed and have been measured using
electromyography during gait and voluntary movement in
children and adults with CP.
12,14–16
Clinical examinations of SVMC in children with CP
have been described,
2,3,17–19
but a detailed tool to evaluate
the entire lower limb has not been validated. Assessments
vary as to the joint(s) tested, positions used, task(s)
required, and grading criteria. Staudt and Peacock
3
used
SVMC as a prognostic factor when selecting candidates
for selective posterior rhizotomy. These examination
methods were further developed by Fowler et al.
18
as a
measure of severity to select and categorize participants in
a randomized controlled trial. Grading was limited to
knee and ankle joints with an overall limb classification of
‘good’, ‘fair’, or ‘poor’ SVMC. Mirror movements,
reciprocation, and speed were not considered. Boyd and
Graham
17
introduced a 0- to 4-point scale to assess ankle
dorsiflexion after botulinum toxin injections of the plantar
flexors. Examiners were required to identify visually which
muscles were the primary or secondary movers. This test
was called ‘selective motor control of dorsiflexion’. Others
have described it as a measure of CST function,
20
although SVMC does not appear to be the primary focus.
Specific muscles used to achieve dorsiflexion took
precedence over the use of mass patterns in the scoring.
Although others have graded mass limb flexion during
dorsiflexion as the lowest level of SVMC,
2,19
this test
graded total limb flexion higher than recruitment of
accessory muscles (toe extensors). Substitution of toe
extensors during dorsiflexion may occur in the presence of
plantar flexor contractures or tibialis anterior weakness
and may not indicate SVMC impairment. Validation of
the ‘selective motor control of dorsiflexion’ test could not
be found in the literature, and a wide range of interrater
reliability was reported.
20
Valid and reliable tests have
been developed for assessment of recovery stages in adults
after stroke,
21,22
but they are not ideal for patients with
CP. Administration includes practice on the ‘non-affected
side’ and testing in standing, which limits applicability for
patients with bilateral lower-extremity involvement and
interferes with observation of mirroring.
A valid, reliable assessment method that has clinical util-
ity is needed for SVMC assessment of the entire lower
extremity in patients with spastic CP. The purpose of this
paper is to describe the development of a clinical tool enti-
tled Selective Control Assessment of the Lower Extremity
(SCALE) and present evidence of its validity and interrater
reliability.
METHOD
Participants were individuals with spastic CP and clini-
cians. Clinicians participating in content validation were
recruited from physical therapy clinics, hospitals, and uni-
versities. Participants with CP were recruited from the
UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy.
The institutional review board at this institution approved
the study. Informed consent was obtained from all partici-
pating clinicians, and informed assent ⁄ consent was
obtained from all participants with CP and ⁄ or their parent
or legal guardian.
The SCALE tool
The SCALE tool was designed for clinical administration
and scoring by healthcare professionals, to be used in less
than 15 minutes without specialized equipment. The tool
includes ‘Directions for Administration,’ ‘Instructions for
Grading,’ and a ‘Score Sheet.’ Hip, knee, ankle, subtalar,
and toe joints are assessed bilaterally. One representative
reciprocalmovementthatvariesfromthemass
flexor ⁄ extensor patterns is chosen to assess SVMC for each
joint. Evaluations are performed in the sitting position,
except for hip flexion, which is tested in the side-lying
position to allow for adequate joint excursion. Sitting and
side-lying positions allow evaluation of patients who are
unable to stand, permit observation of contralateral limb
movements, and enable the patient to visualize their limb
in case of proprioceptive deficits. The following factors
were used to develop the assessment and grading criteria:
(1) ability to move each joint selectively; (2) involuntary
movement at other joints including the contralateral limb;
(3) ability to reciprocate movement; (4) speed of move-
ment; and (5) generation of force as demonstrated by
excursion within the available range of motion. These were
based on components of CST function described in the lit-
608 Developmental Medicine & Child Neurology 2009, 51; 607–614

erature
7
and methods of motor control assessment that
have been used historically.
12,21
For each joint, the examiner first demonstrates the task
by passively moving the limb through the desired move-
ment sequence using a three-second verbal cadence. The
approximate passive range of motion is noted for compari-
son with the observed range during the patient’s active
effort. The patient is then asked to perform the desired
motion at approximately the same speed without moving
other joints of the extremity being tested or the contralat-
eral limb. If unsuccessful, feedback is provided and addi-
tional attempts are allowed.
The hip assessment is performed with the patient in
side-lying position. The examiner supports the weight of
the limb but does not assist the movement. The patient is
asked to flex, extend, and flex the hip while maintaining the
knee in extension. This movement pattern was chosen over
hip extension because it was easier for patients to perform
as they could easily visualize their limb. For patients with
severe hamstring tightness, the ability to extend the hip
with the knee flexed can be used as an alternative test.
The remainder of the assessment is performed in the sit-
ting position. The patient is asked to perform the following
movement patterns: knee extension and flexion; ankle
dorsiflexion and plantar flexion with the knee extended;
subtalar inversion and eversion; and toe flexion and exten-
sion in a reciprocating pattern to a verbal cadence (e.g.
‘flex, extend, flex’). SVMC is graded at each joint as ‘Nor-
mal’ (2 points), ‘Impaired’ (1 point), or ‘Unable’ (0 points).
A grade of ‘Normal’ is given when the desired move-
ment sequence is completed within the verbal count with-
out movement of untested ipsilateral or contralateral
lower extremity joints. A grade of ‘Impaired’ is given
when the patient isolates motion during part of the task,
but demonstrates any of the following errors: movement
occurs in only one direction; observed movement is less
than 50% of the approximate available passive range of
motion found during the passive demonstration; move-
ment occurs at a non-tested joint (including mirror move-
ments); or the time for execution exceeds the approximate
3-second verbal cadence. A grade of ‘Unable’ is given
when the requested movement sequence is not initiated
or when it is performed using a synergistic mass flexor or
extensor pattern. A synergistic mass movement pattern is
defined as a simultaneous, obligatory flexor or extensor
pattern at two or more joints.
23,24
If the patient does not
initiate the requested movement sequence, extensor and
flexor synergy patterns may be elicited using manual resis-
tance to verify muscle force-generating capacity. A
SCALE score for each limb is obtained by summing the
points assigned to each joint for a maximum of 10 points
per limb.
Content validity
Content validity is ‘... the extent to which a measure is a
complete representation of the concept of interest’ and is
established by evaluation of the instrument by knowledge-
able peers.
25
Content validity of the SCALE tool was
established using written feedback from 14 expert clini-
cians. Expert clinicians were defined as those having 10 or
more years of experience in evaluating patients with CP
(experience range 10–40y, mean: 21y 2mo). They included
12 physical therapists, one occupational therapist, and one
physician. Clinicians participated in an educational session
that included an overview of test administration using
videos or photographs of patients. They were provided
with written procedures and the prototype SCALE tool.
Participants were given an opportunity to ask questions
and completed a written feedback form containing 32
statements about the tool design (Table I). For each state-
ment, participants were asked to check ‘agree’, ‘disagree’,
Table I: Selective Control Assessment of the Lower Extremity (SCALE)
expert feedback form statements
Each of 32 statements was rated as Agree, Disagree, or Undecided
Statements rated for each of five tests: hip, knee, ankle, subtalar,
and toe joints (20 statements)
1. The position used is optimal for assessment of the desired
motion.
2. The instructions for the patient are clear.
3. The movements requested ⁄ demonstrated are appropriate to
determine the selective motor control for the joint(s).
4. The support or assistance given to the patient is appropriate for
the test.
Statements rated for grading (seven statements)
1. The speed is appropriate (within three-second verbal cadence).
2. The range of motion required for the tests is appropriate to
adequately differentiate between scores of Normal, Impaired,
and Unable.
3. The criteria are clear to adequately differentiate between scores
of Normal, Impaired, and Unable.
4. The grades Unable and Impaired are clearly distinguishable.
5. The descriptions provided to elucidate the difference between
grades of Unable and Impaired are adequate.
6. The grades Normal and Impaired are clearly distinguishable.
7. The descriptions provided to elucidate the difference between
grades of Normal and Impaired are adequate.
Statements rated for overall test (five statements)
1. The order of test administration is appropriate.
2. The inclusion of a resisted flexor synergy pattern is needed or
useful.
3. The inclusion of a resisted extensor synergy pattern is needed
or useful.
4. The Total Limb Score is needed or useful.
5. The Total Limb Score categories are appropriately distributed.
SCALE Validity and Reliability Eileen G Fowler et al. 609

or ‘undecided’. If they disagreed or were undecided, they
were asked to provide an explanation and suggest changes.
The frequency of each response was obtained for all state-
ments. A minimum of 90% ‘agree’ responses was set for
the content covered in each statement to be accepted with-
out amendments to the SCALE tool. Amendments to the
preliminary version of SCALE were made based on expert
feedback.
Interrater reliability
The interrater reliability of clinical administration and
scoring of SCALE was performed by two groups of three
trained raters for 20 participants with spastic CP. The six
raters included three physical therapists, one pediatrician,
one pediatric neurologist, and a pediatric orthopedic sur-
geon with a range of 1 to 29 years of experience in assess-
ing patients with CP. Standardized training on the
administration and scoring of SCALE was provided. To
participate as a rater, clinicians were required to score 20
videotaped examples (four for each of the five joints) with
an accuracy of 90% or higher and demonstrate appropriate
test procedures during a practice examination.
To minimize potential patient fatigue, consecutive
assessments were limited to three. Therefore, the six clini-
cians were divided into two teams (A and B), each contain-
ing three raters. Team A raters performed SCALE
examinations on 10 participants with CP, and Team B
examined 12 (Table II). The raters assessed the patients in
random order and there was no communication among
them about scores. Intraclass correlation coefficients
(ICCs) and corresponding 95% confidence intervals (CIs)
were calculated for the SCALE scores obtained for left and
right limbs separately for each team.
Construct validity
According to Sim and Arnell,
26
‘... evidence of construct
validity can be gained by seeking a positive correlation
between measures of the original concept and those of
other concepts to which the original concept is known to
be positively related.’ Construct validity of SCALE was
evaluated by determining the relationship between SCALE
scores and an independent assessment of function using
the expanded and revised edition of the Gross Motor
Function Classification System (GMFCS-ER).
27,28
This is
a five-level system that stratifies the severity of mobility
impairment up to the age of 18 years. Level I represents
the highest level of mobility, and level V the lowest. For
participants aged 19 years and older, the 13- to 18-year-
old age band was used to determine the level. Although
SCALE and the GMFCS measure different aspects of a
patient’s disability, individuals with higher SCALE scores
would be expected to have less overall impairment of lower
extremity function, resulting in a higher mobility level
(indicated by a lower GMFCS level).
Fifty-one individuals with spastic CP in GMFCS levels I
to IV, participated (Table III). Ten individuals with CP at
GMFCS level V were screened for participation, but none
were enrolled owing to one or more of the following fac-
tors: diagnosis of dyskinetic or mixed spastic ⁄ dyskinetic
CP; inability to consent to participate; or inability to follow
a simple motor direction. The SCALE assessment was
administered by one of two experienced therapists who
participated in the interrater reliability trials. Right and left
Table II: Characteristics of participants for interrater reliability
Total
a
(n=20) Team A (n=10) Team B (n=12)
Age (y:mo)
Mean (SD) 12:3 (5:5) 10:4 (3:11) 13:7 (5:10)
Range 7:0–23:0 7:0–17:6 7:0–23:0
Sex (n)
Female 13 6 9
Male 7 4 3
Distribution of impairment (n)
Diplegia 16 8 9
Hemiplegia 3 1 3
Quadriplegia 1 1 0
GMFCS level (n)
I313
II 6 4 3
III 8 3 5
IV 3 2 1
a
Two participants were evaluated by both teams of raters. GMFCS,
Gross Motor Function Classification System.
Table III: Characteristics of participants for construct validity (n=51)
Age (y:mo)
Mean (SD) 11:11 (4:9)
Range 5:1–23:0
Sex (n)
Female 30
Male 21
Distribution of impairment (n)
Diplegia 35
Diplegia with hemiplegic overlay 5
Hemiplegia 6
Quadriplegia 5
GMFCS level (n)
I10
II 12
III 19
IV 10
GMFCS, Gross Motor Function Classification System.
610 Developmental Medicine & Child Neurology 2009, 51; 607–614

SCALE scores were summed for each participant as an
overall representation of lower extremity SVMC ability for
comparison with GMFCS levels. Spearman’s rank
correlation coefficients were computed to examine the
relationship between the scores. All statistical analyses used
JMP version 6.0 (SAS, Cary, NC, USA) and SPSS version
15.0, (SPSS, Chicago, IL, USA).
RESULTS
Content validity
Responses from expert clinicians were tabulated and the
percentage agreement was determined for each statement
individually and for the total group of responses. Of the
total of 448 potential responses from all clinicians, 18 (4%)
were blank and not included in subsequent analyses. There
were 395 responses indicating ‘agreement’ with the tool
(91.9%; range 71.4–100%; Table IV).
Twenty-four of the 32 statements rated by the experts
met the 90% agreement criterion and no change was made
to the corresponding items on the SCALE tool. To meet
the 90% criterion, there could be no more than one ‘unde-
cided’ or ‘disagree’ response. Eight of the 32 statements
did not reach our minimum of 90% agreement (Table IV).
For these statements, at least two experts responded with
either ‘undecided’ or ‘disagree’. ‘Undecided’ was chosen
more frequently than ‘disagree’ (16 responses versus 5).
Explanations and suggestions associated with these state-
ments were critically examined and modifications to the
SCALE tool were made.
No suggestions or explanations were offered for state-
ments related to position or grading for testing at the knee;
therefore the associated SCALE items were not revised.
Some experts recommended that additional assessment of
hip extension with knee flexion be included. We chose only
one movement sequence per joint to limit complexity and
time requirements of SCALE. The option for use of an
alternative hip extension test was clarified in the
‘Directions for Test Administration.’ Two experts ques-
tioned the examiner’s support of the limb during the hip
test. Although use of a device such as a powder board
would eliminate potential examiner influence, it is not
practical in most clinical environments. Use of a supported
standing position was suggested, but not implemented,
because it would preclude use of the tool for severely
affected patients and would interfere with observation of
mirroring. Concern was expressed that the target popula-
tion might not comprehend the ankle movement sequence
instructions, so the patient instructions were simplified and
made more universally understandable. We clarified that
the script is suggested rather than mandatory, and that
modifications may be made to elicit optimum perfor-
mance. Although some experts checked ‘undecided’ or ‘dis-
agree’ for inclusion of resisted flexor and extensor synergy
patterns, others included strong written support of these
components. Confirming the patient’s ability to move
actively in the mass flexor ⁄ extensor patterns was consid-
ered to be an essential component of the clinical examina-
tion by the SCALE developers and several experts.
Although two experts questioned the usefulness of a total
limb score, one of them acknowledged its value for
research. Experts commented on the overall clinical useful-
ness and ease of administration of SCALE. The revised
SCALE tool incorporating all changes is presented in
Appendix SI (supporting information, published online).
Interrater reliability
The reliability testing showed relatively high ICCs. ICCs
and 95% CIs for the left and right limbs for both teams of
Table IV: Summary of expert responses
Number of responses
Agree Undecided Disagree Blank
Summary of responses to all 32 statements 395 23 12 18
Eight statements with less than 90% agreement:
Hip: The movements are appropriate to determine SVMC 10 2 1 1
Hip: Support or assistance given to patient is appropriate 12 2 0 0
Knee: Position used is optimal to assess desired motion 11 3 0 0
Ankle: The instructions for the patient are clear 12 1 1 0
Grading: ‘Unable’ and ‘Impaired’ are clearly distinguishable 12 2 0 0
Inclusion of a resisted flexor synergy pattern is needed or useful 11 2 1 0
Inclusion of a resisted extensor synergy pattern is needed or useful 10 3 1 0
The total limb score is needed or useful 12 1 1 0
SVMC, selective voluntary motor control.
SCALE Validity and Reliability Eileen G Fowler et al. 611

raters are presented in Table V. ICCs ranged from 0.88 to
0.91 and all were significant at p<0.001.
Construct validity
SCALE scores were significantly inversely correlated with
GMFCS levels (Spearman’s rank correlation coefficient=
)0.83, p<0.001). The mean SCALE score declined from
15.0 for participants at GMFCS level I to 3.1 for partici-
pants at GMFCS level IV (Fig. 1). SCALE scores showed
a clear downward trend; however, scores for participants at
GMFCS level III showed considerable overlap in range
with participants at levels II and IV.
DISCUSSION
These results support content validity, construct validity,
and interrater reliability of the SCALE tool. Content valid-
ity was substantiated by strong overall agreement among
14 expert clinicians and feedback was used for amendments
and clarifications to the tool. Construct validity of SCALE
was demonstrated by significant correlation with another
severity measure, the GMFCS. Because SVMC is only one
factor affecting functional mobility, a perfect correlation
between these two assessments was not expected. Impair-
ments such as balance, spasticity, contractures, bone and
joint deformity, weakness, obesity, or de-conditioning are
other contributing factors that may explain the wider range
of scores obtained for patients requiring hand-held mobil-
ity devices for walking (GMFCS level III). For example,
the individual with highest SCALE score within GMFCS
level III (Fig. 1) had vision impairment. Although he could
walk short distances without assistance, he routinely used a
walker. The participant with the lowest SCALE score at
GMFCS level III relied on good upper-body strength and
was able to ambulate using a walker, despite lack of lower
extremity SVMC. We found that SCALE assessment for
individuals assigned to GMFCS level V was not feasible as
most had a predominant motor disorder of dyskinesia
rather than spasticity, and many were unable to follow
motor commands.
Interrater reliability of clinical assessments was high
among six raters representing four different clinical special-
ties with a wide range of experience. Not all differences
among scores can be attributed to raters because perfor-
mance of patients on repeat testing may vary with practice,
boredom, or fatigue. Because of this, only three consecu-
tive assessments were performed. Videotaped assessment
could have been used to increase the number of raters
assessing a single testing session; however, this study was
designed to evaluate reliability of both administration and
scoring as would occur in a clinical setting.
Clinical utility is supported by both expert assessment
and high interrater reliability. SCALE is detailed yet sim-
ple enough for expedient examination of patients with a
wide range of physical and intellectual impairments. It
requires minimal training, can be performed within 10 to
15 minutes, and does not require equipment. Because the
ability to follow simple motor commands is necessary, it is
least suitable for patients under 4 years of age and those
with severe motor and intellectual impairments (GMFCS
V). Although scoring may not be possible for these
patients, SVMC can be described based on observations of
spontaneous movements. In our experience, patients classi-
fied at GMFCS level V were more likely to have dyskine-
sia, which SCALE was not designed to address. Although
designed for use in CP, SCALE may be useful for assess-
ment of patients with other types of neurological involve-
ment such as hereditary spastic paraparesis, traumatic brain
injury, multiple sclerosis, or stroke.
CONCLUSION
Evidence for construct and content validity is presented
here as the first step in the validation of SCALE. Recent
work has shown that SCALE scores are correlated with
Table V: Interrater reliability of SCALE
Group Limb ICC 95% CIs p value
A Left 0.88 0.69, 0.97 <0.001
A Right 0.89 0.72, 0.97 <0.001
B Left 0.90 0.77, 0.97 <0.001
B Right 0.91 0.79, 0.97 <0.001
SCALE, Selective Control Assessment of the Lower Extremity.
0
2
4
6
8
10
12
14
16
18
20
IVIIIIII
GMFCS-ER
T
o
t
a
l

S
C
A
L
E

s
c
o
r
e
2
2
2
2
3
4
2
2
2
4
2
2
3
2
Figure 1: Relationship between total Selective Control Assessment
of the Lower Extremity (SCALE) scores (sum of left and right) and
Gross Motor Function Classification System - Expanded and Revised
version (GMFCS-ER) levels (n=51). Numerals to the right of symbols
indicate the number of participants who share the same data point.
Spearman's rank correlation coefficient = –0.83, p<0.001.
612 Developmental Medicine & Child Neurology 2009, 51; 607–614

laboratory measures of intersegmental coordination during
gait,
29
further supporting its validity. This study demon-
strated high interrater reliability of the SCALE total limb
scores. Ongoing research is examining SVMC impairment
at individual joints. Studies of intrarater, test–retest reli-
ability, and long-term stability of SCALE scores are under-
way. SVMC assessment is believed to be most important
for use as a prognostic indicator for treatment planning. As
there is a wide range of responses to various treatments in
this population of patients, SVMC ability may guide the
selection of medical, surgical, or rehabilitative interven-
tions. Introduction of SCALE should provide a meaningful
and universal tool for clinicians and researchers.
SUPPORTING INFORMATION
Additional supporting information may be found in the online
version of this article:
Appendix SI: SCALE: Selective Control Assessment of the
Lower Extremity.
This material is available as part of the online article from
http://dx.doi.org/10.1111/j.1469-8749.2008.03186.x (this will
link you directly to the article).
Please note: Wiley-Blackwell are not responsible for the
content or functionality of any supporting materials supplied
by the authors. Any queries (other than missing material)
should be directed to the corresponding author for the article.
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Book Review: Clinical Manual of Child and
Adolescent Psychopharmacology
Edited by Robert L Findling
American Psychiatric Publishing, Inc., 2008
$US 62.00 (Paperback), 497 pages
ISBN 978-1-58562-250-4
This timely book is an essential tool in the clinician’s fast
changing therapeutic armamentarium. It is both small and
useful enough to warrant being carried around by a practi-
tioner as it is very relevant to all professionals who work
with children and adolescents.
The book is organized into 10 chapters, with manage-
able sections designed to support evidence-based best prac-
tice. Compared with similar books, it is mid-range in price.
It provides excellent value by demystifying the science
underpinning cutting edge psychopharmacotherapy, whilst
its ‘clinical pearls’ provide memorable take-home mes-
sages.
The experts cover developmental aspects vital in under-
standing fundamental differences between paediatric and
adult psychopharmacology and common pitfalls in the
area. The chapter on attention-deficit–hyperactivity disor-
der provides a timely overview of current potential safety
concerns around stimulant prescribing. It does so in a very
sensible manner. More emphasis on non-pharmacological
interventions as adjuncts would have been welcome given
more space. Disruptive behaviour disorders and aggression
are considered in a holistic manner whilst reminding clini-
cians of the need for children and parents to be empowered
to take personal responsibility. The anxiety and depression
chapters helpfully cover combination treatments with cog-
nitive behaviour therapy, as well as paediatric-specific
research on suicidality. All of which will prove reassuring
to prescribers and patients alike.
A chapter on bipolar disorders provides a very practical
approach to managing adverse effects and deft handling of
this potentially contentious area. Multimodal treatment
research in the field of autistic spectrum disorders provides
gratifying clarity with an excellent target symptom algo-
rithm. Tic disorders and their common comorbidities are
skilfully discussed.
The chapter dealing with schizophrenia and psychosis
provides very practical management tips for side effects.
Further discussion about metformin and statins as poten-
tial treatments for hyperglycaemia and hyperlipidaemia
arising from atypical antipsychotics would also have been
welcome.
The last chapter on disorders seen in general medical
settings commends this book to a wider medical reader-
ship. It considers sleep disturbance, delirium, and a range
of common medical conditions with psychiatric sequelae.
This comprehensive manual will empower practitioners
to join up research with best practice. Thus it promotes
both a more critical and a more thoughtful approach to
intelligent prescribing.
Richard Soppitt MBCHB MRCPSYCH MMEDSC
Honorary Senior Research Fellow, CHSS, Canterbury, UK.
614 Developmental Medicine & Child Neurology 2009, 51; 607–614