Secondary Logo

Journal Logo

RESEARCH REPORTS

Development and Initial Validation of the Pediatric Neuromuscular Recovery Scale

Ardolino, Elizabeth M. PT, PhD; Mulcahey, Mary Jane PhD, OTR/L; Trimble, Shelley PT; Argetsinger, Laura PT, DPT; Bienkowski, Marci PT, DPT; Mullen, Courtney PT, DPT; Behrman, Andrea L. PT, PhD, FAPTA

Author Information
doi: 10.1097/PEP.0000000000000285
  • Free

INTRODUCTION AND PURPOSE

To build scientific evidence supporting pediatric practice and rehabilitation after spinal cord injury (SCI), robust and psychometrically valid outcome instruments are needed. The utility of an outcome measure for children in comparison to adults is challenged by the added complexity of both the child's developmental stage at the time of injury and expected developmental trajectory. The inherent aspects of growth and development in children, both cognitively and physically, make adult clinical outcome measures for SCI less applicable and potentially invalid for use in children.

With anticipation for SCI clinical trials in both the adult and pediatric population, and a greater understanding about the plasticity of the nervous system, there is a concerted effort in neurorehabilitation to ensure outcome instruments are capable of evaluating not only functional improvement but also neuromuscular capacity. Neuromuscular capacity is a subdomain of the International Classification of Functioning, Disability, and Health activity domain, and represents a person's ability to perform a specific task in a standardized environment.1 For example, a child who uses a tenodesis grip to pick up a pencil has the capability of completing this action, yet has not recovered the capacity to perform this action as she/he would have before injury. Outcome instruments that allow compensation during function are likely less responsive to neuromuscular change as compared with instruments designed to evaluate neuromuscular capacity.

The Neuromuscular Recovery Scale (NRS) was developed as a tool to assess neuromuscular capacity to perform specific functional tasks without compensation in adults with SCI.2 The NRS assesses the ability to perform a series of functional tasks, movements, and transitions (eg, sit, sit to stand, and walk) using preinjury movement patterns and disallows compensation for weakened or paralyzed muscles by stronger muscles, substitutions, or devices. On the basis of the performance across 14 items, an overall “phase” score is calculated ranging from a low level to a high level of neuromuscular recovery (phases 1a-4c). Recent findings in adults with SCI indicate good construct validity3 and excellent interrater reliability (intraclass correlation coefficient: 0.97; confidence interval: 0.94-0.99)4 and test-retest reliability (intraclass correlation coefficient: 0.99; confidence interval: 0.96-0.99).5

Despite strong psychometric properties, application of the NRS to children has been challenging. Limitations of the NRS when used with children who have been tested in our clinics include the complexity of test instructions; test items that are developmentally inappropriate; and the need to factor motor development into the scaling of motor recovery. Moreover, the conceptual framework of “preinjury movement” may be less applicable to children injured young and who have not experienced motor planning, development, and execution of advanced movement. As SCI clinical trials and treatments expand, development and validation of instruments that will be used by physical and occupational therapists to measure primary endpoints of neuromuscular capacity should include children. Thus, the objective of this study was to adapt the Adult NRS for use with the pediatric population with SCI and to establish initial content validity for children ages 1 to 12 years.

METHODS

Mixed methods were used to create items and scaling levels for the Pediatric NRS, evaluate content validity and, establish standardization for instructions, test administration, and equipment. The study was conducted in 3 iterative stages.

Stage I: Initial Scale Development

Focus group methodology was used to develop the initial Pediatric NRS. Participants (N = 7) were researchers and clinical experts in pediatric SCI: 2 physical therapists and 1 occupational therapist with experience in evaluating and designing outcome measures, as well as in evaluating and treating adults and children with SCI; 4 were physical therapists with extensive experience in evaluating and treating children with SCI. The group convened via phone conference or webinar once a week over 3 months. The group began developing the Pediatric NRS by reviewing the Adult NRS and either modifying items for the pediatric population or deeming them inappropriate. In parallel, a literature review of pediatric outcome measures was performed to determine whether other scales measuring pediatric neurological capacity existed, as well as to identify potential gaps in the NRS with respect to pediatric relevance. One instrument, the Segmental Assessment of Trunk Control (SATCo),6 was adapted and incorporated into the Sitting Within Base of Support Item of the Pediatric NRS because of the similarity of its conceptual basis as it focuses on incremental static, active, and reactive trunk control using appropriate biomechanics without compensation. Concurrent validity of the SATCo has been established, and good reliability scores were reported with children developing typically and children with neuromuscular disabilities (primarily cerebral palsy).7

Each group member suggested new items and the list was finalized by majority agreement as to item relevance to recovery in children with SCI. The administration and scoring of each item was then developed by pairs of team members and then reviewed and revised by the group.

Stage II: Preliminary Evaluation for Content Validity

Delphi methodology8 was used to evaluate content validity of the Pediatric NRS items and scoring options. A Delphi technique is a process used to obtain a consensus among a group of experts using a series of questionnaires. It is characterized by the use of experts, controlled feedback, and 2 or more rounds of sequential questionnaires while preserving anonymity. This process prevents friction among respondents, allows for facilitation of the group in generating a consensus, and ensures that each individual's opinion is equally weighted.

Participants. A purposive sampling technique was used to establish a panel of experts for the Delphi study. Thirteen participants were recruited, with an aim to have a distribution of occupational therapists, physical therapists, and physicians. Experts had to be a pediatric physiatrist, pediatrician, occupational therapist, or physical therapist, and have at least 2 years of experience in pediatric SCI. All participants required access to the Internet to take part in the online survey. This study was approved by the University of Louisville's Institutional Review Board, and all participants provided informed consent. Participants were compensated for their time. None of the team members from Stage I participated in this Delphi study.

Procedure. The Delphi process took place over 4 rounds, through surveys administered electronically. This process was led by a Delphi facilitator, one of the primary investigators, who did not participate in the survey rounds. Before the first round, there was a training conference call with all participants led by the Delphi facilitator. The training included an overview of the project and an orientation to the background and objectives of the Pediatric NRS. Emphasis was on the conceptual basis of the Pediatric NRS as an instrument designed to measure uncompensated motor recovery. Participants were provided with a draft of the scale and instruction manual and given the opportunity to ask questions regarding the study procedures, as well as the purpose and administration of the scale. Although the participants introduced themselves on the call, once the Delphi study began, all comments submitted through the electronic survey remained anonymous.

During Round 1, the first draft of the Pediatric NRS was posted on an electronic survey instrument. Each participant was given a username and password to enter the secure survey Web site. In the survey, the participants were presented with each item of the scale, and were asked specific questions about the importance of including the item, the appropriateness of the scoring, the age appropriateness of the task, and the clarity of the wording. Participants were encouraged to write comments to improve the items and the scale as a whole and make suggestions for additional items.

Consensus on an item was considered to be reached when there was 80% agreement among the experts.8 Any item on the scale that did not reach 80% agreement was revised on the basis of the comments provided by the experts. The revised scale was then posted on the Web site, and participants were again sent a secure link to access the survey. This process was repeated 3 times, for a total of 4 Delphi rounds. During the first 2 rounds, participants were asked similar questions about the clarity and appropriateness of each of the items. In the last 2 rounds, the participants were asked whether the item was ready for the next stage of testing (ie, field testing with children) by considering the scoring criteria and clarity of the wording.

Stage III: Field Testing With Children

One month after the completion of the Delphi process, all members of the original focus group met face to face for 2.5 days to review the items and scaling as well as to begin field testing the scale with children. The first purpose of this meeting was to test the practicality of the scale, and the second was to standardize the set-up of each item, the instructions to the child, the equipment used, and the sequence of the item administration. During this meeting, the team tested 5 children with SCI, and reviewed videos of 2 children developing typically performing items on the scale. Field testing continued after this weekend, and additional 5 typically developing children, aged 22 months to 11 years, were tested by the 2 pediatric physical therapy team members located at Frazier Rehabilitation, to ensure that all items on the scale were at an age-appropriate level (Table 1).

TABLE 1 - Demographics of Children Tested During Field Testing
Participant Pub ID Age, mo TD/SCI Gender Race Age at Injury, mo Neurological Level of Injury AIS Classification Primary Means of Mobility Method of Testing
N129 22 TD Male W In-person
N131 29 TD Male W Video
N126 43 TD Male PI/W In-person
N130 43 TD Female W In-person
N132 47 TD Female W Video
N127 75 TD Female B/W In-person
N128 126 TD Male B In-person
P4 48 SCI Female W 2 C5-7 a Wheelchair In-person
P2 69 SCI Male W 36 C5-6 AIS B Wheelchair In-person
P10 79 SCI Male W 5 C1 AIS D Ambulatory In-person
P5 107 SCI Female W 32 T3-4 AIS B Wheelchair In-person
P11 143 SCI Female W 138 T4 AIS D Ambulatory In-person
Abbreviations: AIS, American Spinal Injury Association Impairment Scale; B, black; PI, Pacific Islander; SCI, spinal cord injury; TD, typically developing; W, white.
aChild too young for reliable AIS assessment

During field testing, the examiner ensured that all movement was completed without compensations. For children developing typically, this required the use of demonstration of the task, as well as verbal cues, to guarantee that the child performed the task according to the instructions. Children with SCI not only required these age-appropriate verbal cues and demonstrations but also required verbal cues or demonstration to redirect performance if the task was initially performed using compensatory strategies. During the “in-hand manipulation” assessment, for example, a child was encouraged to keep her palm “down” while attempting to manipulate pennies from the palm to fingertips. With palms up, the child notably used gravity (ie, a compensation) to move the pennies forward to the fingertips as opposed to actual manipulation of the pennies with her fingers.

RESULTS

Stage I: Initial Scale Development

At the completion of the 3-month focus group, the Pediatric NRS consisted of 13 items, scored on a 12-point scale. Ten of the 13 items were tested in sitting, standing, or during transitional movements in a typical clinical environment. The remaining 3 items were tested in the body weight support/treadmill environment and were similar to the Adult NRS, although modified for object height and treadmill speeds. We modified the SATCo (ie, eliminated testing the level: “below the rib cage”) and incorporated it into the item “Sitting Within Base of Support.”

Stage II: Preliminary Evaluation of Content Validity

Thirteen experts (5 physical therapists, 5 occupational therapists, and 3 MDs) completed all 4 rounds of the Delphi process. The experts represented all geographic areas of the United States and a wide variety of experience with pediatric SCI (11.5 ± 6.2 years).

Delphi Study. Results of the Delphi study are summarized in Table 2. All of the 13 items developed by the focus group were retained. Appendices A and B provide the reader with examples of the initial and final drafts of 2 items (Dynamic Standing and Object to Mouth). Note that the final draft of Dynamic Standing contains 3 separate score cards, as the scoring for this item was modified to meet the typical development of standing across 3 different age ranges: 1 to 2, 3 to 5, and 6 to 12 years.

TABLE 2 - Summary of Results From the Delphi Process
Item Item Description Round 1 Round 2 Round 3 Round 4
Importance of Item Scoring Criteria Clear Scoring Followed Logical Progression Level of Assistance Scoring Criteria Clear Scoring Followed Logical Progression Item Ready for Next Stage of Testing Item Ready for Next Stage of Testing
Supine Transition Child moves from supine into sitting position 100% 69.20% 100% N/A 99%
Maintaining Sitting Within Base of Support Child's sitting balance is tested statically, actively, and reactively with decreasing levels of support 100% 50% 61.50% 66.67% 80% 95%
Maintaining Sitting Outside Base of Support Child's sitting balance is tested while leaning or reaching outside base of support with decreasing levels of support 92.3% 69.23% 92.3% 91.2% 83.33%
Object to Mouth Child brings a juice box to mouth and places it back on a table 100% 53.9% 91.7% N/A 76.92% 76.92% 100%
Reaching Overhead Child reaches up to touch an examiner's hand 100% 90.9% 76.7% N/A 76.7% 92.31%
In-hand Manipulation Child picks up various objects and manipulates them 100% 50% 76.9% N/A 61.54% 100% 92.31%
Sit to Stand Child transitions from sitting on a bench to standing with decreasing levels of support 100% 83.33% 83.33% N/A
Static Standing Child maintains static standing balance with decreasing levels of support 100% 84.62% 100% N/A
Dynamic Standing Child maintains standing balance while reaching outside base of support with decreasing levels of support 100% 69.23% 83.33% N/A 91.67% 92.31%
Walking Child attempts weight shifting in standing and eventually walking forward with decreasing levels of support 100% 100% 100% N/A
Stand Adaptabilitya Child attempts to maintain independent standing with appropriate kinematics with decreasing BWS 76.92% 100% 100% N/A
Step Retraininga Child walks on treadmill with decreasing BWS and increasing speeds, with trainer assistance to maintain appropriate kinematics 91.67% 100% 100% N/A
Step Adaptabilitya Child attempts independent stepping with appropriate kinematics with decreasing BWS 91.67% 100% 100% N/A
Abbreviations: BWS, body weight support; N/A, not applicable.
aRequires use of body weight support equipment.

During the first round of the Delphi process, 12 of the 13 items reached an 80% consensus on inclusion importance. The item Stand Adaptability did not reach agreement on level of importance with 77% agreement. Several experts indicated they were unsure about including this item, because it is conducted in the body weight support/treadmill environment, fearing it would limit use of the Pediatric NRS. However, the other 2 treadmill items (Step Retraining and Step Adaptability) did reach the 80% agreement on inclusion importance. Because of the importance of the item content in Stand Adaptability for measuring recovery, the item was retained.

For clarity of wording and scoring, 6 items reached 80% agreement (Sit to Stand, Static Standing, Walking, Stand Adaptability, Step Retraining, and Step Adaptability). The wording and scoring of the remaining 7 items (Supine Transition Into Sitting, Sitting Within Base of Support, Sitting Outside Base of Support, Object to Mouth, Reaching Overhead, Shape Holding and Manipulation, and Dynamic Standing) were modified and exposed to Round 2. One item (Maintaining Sitting Within Base of Support) did not reach 80% agreement on level of assistance. The assistance levels were clarified and incorporated into the scoring of the item. The modifications, answers to questions posed by some experts, and written feedback from the experts were shown to the panel participants in Round 2.

After the second round, only 4 items did not reach an 80% consensus on the appropriateness of the item's scoring (Object to Mouth, Reaching Overhead, Shape Holding and Manipulation, and Dynamic Standing). The scoring was again modified. The feedback provided by the experts, along with modifications to the items, was sent to the participants in a third Delphi round.

After Round 3, only one item had not reached 80% consensus (Object to Mouth) because of confusion about sequencing the scoring levels. This item was further revised, and presented to the experts in the fourth round survey. After Round 4, all items had reached an 80% level of agreement.

Stage III: Field Testing the Pediatric NRS With Children

A total of 12 children (7 typically developing, 5 with SCI) were tested on the Pediatric NRS developed through the Delphi technique. The parents of all of the children provided informed consent, and all children older than 7 years provided assent, as approved by the University of Louisville Institutional Review Board. After this testing, several items required minor edits to the instructions. Sit to Stand, Shape Holding, and Manipulation required extensive edits. When the scoring levels for all items were compared, the degree of difficulty of the scoring levels for Sit to Stand did not match the other test items. As the scale is ordinal in nature, the response choices for all items need to be indicative of similar levels of function. Therefore, the scoring for Sit to Stand was revised. Fine motor manipulation and a bimanual component were added to the Shape Holding and Manipulation task. Both of the items were retested on children with and without SCI in the weeks after the field testing weekend. All children were videotaped, and those recordings were further reviewed by the research team on biweekly conference calls.

After 2 days of iterative modification and field testing, we established a standardized equipment list (Appendix C) and phase cards. Language across and within items for implementation and scoring was established for consistency and standardization.

DISCUSSION

In this study, we carried out a systematic, iterative process using mixed methods to develop and examine the content validity of the Pediatric NRS. Eleven Adult NRS items were modified and 2 completely new items were developed. All items and scaling were developed and field-tested with children developing typically and children with SCI. Although there are capacity measures for adults with SCI,2,4–5,9 this is the first work to develop a pediatric SCI capacity scale that evaluates neuromuscular recovery, in the context of pediatric function, without reliance on devices or compensation.

The development, selection, and scaling of items were exposed to systematic scrutiny by the Delphi study participants and research team. Multiple revisions addressed Delphi participants' feedback on lack of clarity in wording; developmental appropriateness of the sequence; logic of the progression from “unable” to “fully recovered per task demands;” practicality; and need for standardization. In final form, the scaling resembles that used on the Adult NRS. For each item, scores reflect age-appropriate skills from the lowest score (1A; unable) to the highest score (4C; fully “recovered” relative to task demands). After administering the test, the score for each item is circled on a score card, allowing the tester to determine the lowest scoring items. Within and across items, scores reflect neuromuscular capacity within a “hierarchical” manner of task difficulty and recovery. The validity of this hierarchy was demonstrated on the Adult NRS3 as persons with less recovery scored low on items and those with more recovery scored high on items. Thus, the concept of scaling on the Pediatric NRS is also one of “recovery,” characterized by a stair-step sequence of low to high difficulty. Administration during field testing formed the basis for standardization of start and stop positions, instructions, and equipment. Initial field testing revealed the need to demonstrate tasks, provide oral directions, and provide motivation for performance to ensure movement is without compensation. The Pediatric NRS is somewhat complex with respect to administration and scoring because of the challenge of evaluating motor capacity in young children with SCI across ages from 1 to 12 years. Three age categories were developed for the instrument on the basis of normative values for specific tasks as well as other pediatric outcome measure age ranges.10,11 Items representing age-appropriate motor development, height/size of objects, and treadmill speeds differentiated the 3 age-specific categories. In addition, certain subphases are excluded until the appropriate age of the child.

By design, the Pediatric NRS is a measure of motor capacity and the scale is not intended as the sole indicator of a child's function. In addition, the scale is not designed to assess the developmental sequence of motor development. Rather, the intent of the scale is to capture incremental improvements in neuromuscular capacity2 associated with therapeutic interventions. The items and scoring of the Pediatric NRS were designed to provide a valid indicator of a child's neuromuscular recovery capacity. The instrument could be used as a baseline assessment before initiating an intervention, to detect progression of recovery after a designated number of therapy sessions, and at discharge. Although motivated by implementation of activity-based therapies targeting recovery (eg, locomotor training or neuromuscular electrical stimulation in children post-SCI), the Pediatric NRS may also be useful in evaluating effectiveness of other physiological, pharmacological, medical, or surgical interventions on neuromuscular capacity without compensation.12,13 Responsiveness studies on the Pediatric NRS will be useful to support its use in the clinic and research.

Limitations

All of the children with SCI tested in this study had chronic injuries. Therefore, the applicability of this scale to children with acute SCI who have not yet developed new movement strategies is unknown. Another limitation in our field testing sample was that the youngest child with SCI was 4 years of age. However, by testing children developing typically from 22 months to 11 years, we were able to ensure the age-appropriateness of each of the items.

Like the Adult NRS, the Pediatric NRS evaluates neuromuscular recovery within the context of “normal” biomechanics. However, unlike SCI in adulthood, pediatric-onset SCI is associated with a high risk for complex musculoskeletal complications such as hip subluxation, neuromuscular scoliosis, and upper limb complications.14 The utility and validity of the Pediatric NRS in the presence of musculoskeletal complications will require careful evaluation. As 90% of children with SCI develop fixed musculoskeletal deformities,15 further revisions of the scaling and scoring instructions may be warranted so that neuromuscular capacity and recovery can be evaluated within this context.

Future Studies

Further work on the Pediatric NRS is needed to evaluate the validity of scoring phases and to examine the reliability of the items as a function of age at time of examination. Further modifications may be warranted for items that mature over a large developmental period, such as the upper limb items. Future work will consider testing the psychometric properties of the scale in other populations.

Ideally, validation studies of a new measure involve comparison to “gold-standard” instruments and examination of scores across known groups. A challenge to validating the Pediatric NRS is the lack of gold-standard instruments that evaluate neuromuscular recovery in pediatric SCI. Future validation studies may include use of contemporary imaging techniques that provide an objective comparison between changes in the spinal cord and neurorecovery as measured by the Pediatric NRS.16

CONCLUSIONS

This preliminary validation study included the use of a focus group, the Delphi process, and initial field testing. The use of this systematic process resulted in a scale with content validity, which is the first of its kind in measuring neuromuscular capacity after pediatric SCI. The Pediatric NRS is not intended to replace current pediatric outcome measures, but may be used to complement these tests and provide more details about a child's incremental improvements in function. Further testing of the Pediatric NRS will include the assessment of the scale's intra- and interrater reliability. Future studies are needed to establish construct validity.

ACKNOWLEDGMENTS

The authors thank Lisa Clayton (University of Louisville) for her coordination of the study and Laura Westberg (Program Manager, Kosair Charities Center for Pediatric NeuroRecovery at the University of Louisville) for organizing the writing team in their completion of the manuscript. In addition, the authors acknowledge MacKenzie Roberts, PT, DPT (Frazier Rehab Institute/University of Louisville) for her thoughtful review of the manuscript. Thanks especially to the children who participated and families who gave of their time for the field testing of the Pediatric Neuromuscular Recovery Scale.

REFERENCES

1. Marino RJ. Domains of outcomes in spinal cord injury for clinical trials to improve neurologic function. J Rehabil Res Dev. 2007;44(1):113–122.
2. Behrman AL, Ardolino E, Vanhiel LR, et al. Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Arch Phys Med Rehabil. 2012;92:1046–1054. doi:10.1016/j.apmr.2011.04.027.
3. Velozo C, Moorhouse M, Ardolino E, et al. Validity of the Neuromuscular Recovery Scale: a measurement model approach. Arch Phys Med Rehabil. 2015;96(8):1385–1396. doi:10.1016/j.apmr.2015.04.004.
4. Basso DM, Velozo C, Lorenz D, Suter S, Behrman AL. Inter-rater reliability of the Neuromuscular Recovery Scale for spinal cord injury. Arch Phys Med Rehabil. 2015;96(8):1397–1403. doi:10.1016/j.apmr.2014.11.026.
5. Behrman AL, Velozo C, Suter S, Lorenz D, Basso DM. Test-retest reliability of the Neuromuscular Recovery Scale. Arch Phys Med Rehabil. 2015;96(8):1375–1384. doi:10.1016/j.apmr.2015.03.022.
6. Butler PB, Saavedra S, Sofranac M, Jarvis SE, Woollacot MH. Refinement, reliability, and validity of the segmental assessment of trunk control. Pediatr Phys Ther. 2010;22:246–257. doi:10.1097/PEP.0b013e3181e69490.
7. Bañas BB, Gorgon EJ. Clinimetric properties of sitting balance measures for children with cerebral palsy: a systematic review. Phys Occup Ther Pediatr. 2014;34(3):313–334. doi:10.3109/01942638.2014.881952.
8. Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32:1008–1015.
9. Marino RJ, Kern SB, Leiby B, Schmidt-Read M, Mulcahey MJ. Reliability and validity of the capabilities of upper extremity test (CUE-T) in subjects with chronic spinal cord injury. J Spinal Cord Med. 2015;38(4):498–504.
10. Folio MK, Fewell R. Peabody Developmental Motor Scales: Examiner's Manual. 2nd ed. Austin, TX: PRO-ED, Inc; 2000.
11. Deitz JC, Kartin D, Kopp K. Review of the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2). Phys Occup Ther Pediatr. 2007;27(4):87–102.
12. Angeli CA, Edgerton VR, Gerasimenko YP, Harkema SJ. Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans. Brain. 2014;137(Pt 5):1394–1409. doi:10.1093/brain/awu038.
13. Edgerton VR, Roy RR. A new age for rehabilitation. EurJ Phys Rehabil Med. 2012;48:99–109.
14. Parent S, Dimer J, Dekutoski M, Roy-Beaudry M. Unique feature of pediatric spinal cord injury. Spine. 2010;35(21 suppl):S202–208.
15. Mulcahey MJ, Gaughan JP, Betz RR, et al. Neuromuscular scoliosis in children with spinal cord injury. Top Spinal Cord Inj Rehabil. 2013;19(2):96–103. doi:10.1310/sci1902-96.
16. Mulcahey MJ, Samdani AF, Gaughan JP, et al. Diagnostic accuracy of diffusion tensor imaging for pediatric cervical spinal cord injury. Spinal Cord. 2013;51:532–537. doi:10.1038/sc.2013.36.

APPENDIX A - Example of Item Revisions After the Delphi Process for Dynamic Standing Initial Draft
Dynamic Standing
(1A) Unable (1B) Unable (1C) Unable
(2A) Unable (2B) Unable (2C) Able to maintain standing with assistance at the legs, while handing a toy that requires bimanual hold forward to another person, with appropriate kinematics at the trunk and pelvis
(3A) Able to maintain standing with assistance at the legs while reaching anteriorly/laterally:
5″ if <4 y
10″ if ≥4 y
With appropriate kinematics of the trunk and pelvis
(3B) Able to maintain standing while handing a toy that requires a bimanual hold to another person, with appropriate kinematics of the trunk, pelvis, and legs (3C) Able to maintain standing with while reaching anteriorly/laterally:
5″ if <4 y
10″ if ≥4 y
With appropriate kinematics of the trunk, pelvis, and legs
(4A) Able to shift their body weight laterally with appropriate kinematics at trunk, pelvis, and legs (4B) Able to shift body weight onto single limb and lift contralateral leg in attempt to contact a stationary ball (size dependent on child's size) without loss of balance (4C) Able to maintain standing during moderate perturbations at the trunk, with appropriate kinematics at the trunk, pelvis, and legs

-
Dynamic Standing
Ages 1-2 y
Verbal cue: “Stand up tall and do as I ask”
(1A) Unable to maintain standing with support at the trunk, pelvis, and legs while handing a ball forward to another person (1B) Able to maintain standing with support at the trunk, pelvis, and legs while handing a ball to another person (1C) Able to maintain standing with support at the pelvis, and legs, with inappropriate kinematics at the trunk while handing a ball to another person
(2A) Able to maintain standing with support at the pelvis, and legs, with appropriate kinematics at the trunk while handing a ball to another person (2B) Able to maintain standing with support at the legs, with inappropriate kinematics at the trunk and pelvis while handing a ball to another person (2C) Able to maintain standing with support at the legs with appropriate kinematics at the trunk and pelvis while handing a ball to another person
(3A) Able to maintain standing with support at the legs while reaching forward and then laterally to the left and right slightly outside BOS (3B) Able to maintain standing with appropriate kinematics of the trunk, pelvis, and legs while handing a ball to another person (3C) Able to reach laterally right and left, shifting body weight outside base of support with appropriate kinematics at trunk, pelvis, and legs
(4A) Able to maintain standing during moderate perturbations at the trunk, with appropriate kinematics at the trunk, pelvis, and legs (4B) Able to shift body weight onto single limb and lift contralateral leg to kick a stationary ball without loss of balance. Assess with either leg (4C) Able to maintain standing while reaching forward and then laterally outside BOS with appropriate kinematics of the trunk, pelvis, and legs
Starting position: Standing with feet shoulder width apart.
Ending position: Same as starting position.
Starting phase: 3B; 1B: If unable to perform task as in 3B, begin assessment at 1B.

-
Dynamic Standing
Ages 3-5 y
Verbal cue: “Stand up tall and do as I ask”
(1A) Unable to maintain standing with support at the trunk, pelvis, and legs while handing a ball forward to another person (1B) Able to maintain standing with support at the trunk, pelvis, and legs while handing a ball to another person (1C) Able to maintain standing with support at the pelvis, and legs, with inappropriate kinematics at the trunk while handing a ball to another person
(2A) Able to maintain standing with support at the pelvis, and legs, with appropriate kinematics at the trunk while handing a ball to another person (2B) Able to maintain standing with support at the legs, with inappropriate kinematics at the trunk and pelvis while handing a ball to another person (2C) Able to maintain standing with support at the legs with appropriate kinematics at the trunk and pelvis while handing a ball to another person
(3A) Able to maintain standing with support at the legs while reaching forward at least 5″, then laterally at least 4″ to the left and right (3B) Able to maintain standing with appropriate kinematics of the trunk, pelvis, and legs while handing a ball to another person (3C) Able to reach laterally right and left, shifting body weight outside base of support with appropriate kinematics at trunk, pelvis, and legs
(4A) Able to maintain standing during moderate perturbations at the trunk, with appropriate kinematics at the trunk, pelvis, and legs (4B) Able to shift body weight onto single limb and lift contralateral leg to kick a stationary ball without loss of balance. Assess with either leg (4C) Able to maintain standing while reaching forward at least 5″ and laterally at least 4″ with appropriate kinematics of the trunk, pelvis, and legs
Starting position: Standing with feet shoulder width apart.
Ending position: Same as starting position.
Starting phase: 3B; 1B: If unable to perform task as in 3B, begin assessment at 1B.

-
Dynamic Standing
Ages 6-12 y
Verbal cue: “Stand up tall and do as I ask”
(1A) Unable to maintain standing with support at the trunk, pelvis, and legs while handing a ball forward to another person (1B) Able to maintain standing with support at the trunk, pelvis, and legs while handing a ball to another person (1C) Able to maintain standing with support at the pelvis, and legs, with inappropriate kinematics at the trunk while handing a ball to another person
(2A) Able to maintain standing with support at the pelvis, and legs, with appropriate kinematics at the trunk while handing a ball to another person (2B) Able to maintain standing with support at the legs, with inappropriate kinematics at the trunk and pelvis while handing a ball to another person (2C) Able to maintain standing with support at the legs with appropriate kinematics at the trunk and pelvis while handing a ball to another person
(3A) Able to maintain standing with support at the legs while reaching forward at least 6″, then laterally at least 5″ to the left and right (3B) Able to maintain standing with appropriate kinematics of the trunk, pelvis, and legs while handing a ball to another person (3C) Able to reach laterally right and left, shifting body weight outside base of support with appropriate kinematics at trunk, pelvis, and legs
(4A) Able to maintain standing during moderate perturbations at the trunk, with appropriate kinematics at the trunk, pelvis, and legs (4B) Able to shift body weight onto single limb and lift contralateral leg to kick a stationary ball without loss of balance. Assess with either leg (4C) Able to maintain standing while reaching forward at least 6″, then laterally at least 5″ with appropriate kinematics of the trunk, pelvis, and legs
Starting position: Standing with feet shoulder width apart.
Ending position: Same as starting position.
Starting phase: 3B; 1B: If unable to perform task as in 3B, begin assessment at 1B.

APPENDIX B - Example of Item Revisions After the Delphi Process for Object to Mouth Initial Draft
Object to Mouth
Verbal Cue: “Pick up juice box. Pretend to drink and place back on table”
Test right arm fully, then left arm. Support should be provided to the child to attain and maintain appropriate trunk and pelvis position during the task.
(1A) Unable (1B) Initiate shoulder flexion to move arm forward with inappropriate kinematics
□ Right
□ Left
(1C) Complete shoulder flexion and initiate elbow flexion to place hand on table with inappropriate kinematics
□ Right
□ Left
(2A) Perform shoulder flexion and elbow flexion to place hand on table, then complete elbow extension with forearm in neutral (sliding along table) with appropriate kinematics
□ Right
□ Left
(2B) Perform shoulder flexion and elbow flexion, then extension with forearm in neutral (bring hand to mouth)
□ Right
□ Left
(2C) Reach arm forward to grasp cup placed arm's length away. Complete motion same as 2B but while holding empty cup. Wrist and finger extension may be inappropriate kinematics
□ Right
□ Left
(3A) Same as 2C and place hand to empty cup with appropriate kinematics and extend all fingers/thumb to empty cup width, grasp with thumb pointing opposite direction as fingers
□ Right
□ Left
(3B) Same as 3A and grab empty cup with initiation of finger flexion may be inappropriate while maintaining wrist position with appropriate kinematics
□ Right
□ Left
(3C) Same as 3B and grab and lift empty cup to their mouth using finger flexion with inappropriate kinematics
□ Right
□ Left
(4A) Same as 3C and grab and lift empty cup to their mouth with finger flexion and place back on table with appropriate kinematics
□ Right
□ Left
(4B) Same as 3C and grab and lift empty cup to their mouth with finger flexion and place back on table with appropriate kinematics and release with extension of fingers
□ Right
□ Left
(4C) Same as 4B and grab and lift full cup with lid to their mouth with finger flexion and place back on table with appropriate kinematics and release with extension of fingers
□ Right
□ Left

-
Object to Mouth
Ages 1-12 y
Verbal Cue: “Pick up juice box. Pretend to drink and place back on table”
Test right arm fully, then left arm. Support should be provided to the child to attain and maintain appropriate trunk and pelvis position during the task.
(1A) Unable to initiate shoulder forward flexion toward table with inappropriate kinematics (1B) Start with hand in lap, initiate shoulder forward flexion toward table with inappropriate kinematics (1C) Start with hand in lap, perform shoulder forward flexion, and initiate elbow flexion and achieve hand on table with appropriate kinematics
(2A) Start with arm on table, perform elbow flexion to bring hand to mouth, using elbow flexors (2B) Start with hand in lap, perform shoulder and elbow flexion to place hand on table with forearm neutral, fully extend elbow toward juice box (sliding along table) with appropriate kinematics (2C) Arm on table, reach toward half-full (3 oz) juice box, and extend fingers and thumb to width of juice box. Wrist and finger extension may be with inappropriate kinematics (eg, tenodesis grasp). Cannot grasp juice box
(3A) Hand in lap, reach forward and grasp half-full juice box with appropriate wrist. Finger kinematics may be inappropriate. May be able to lift to mouth with inappropriate kinematics (3B) Hand in lap, reach forward and grasp half-full juice box with appropriate wrist and finger kinematics. May be able to lift to mouth with inappropriate wrist kinematics (3C) Hand in lap, grasp and lift half-full juice box using appropriate kinematics of wrist and fingers
(4A) Hand in lap, grasp and lift half-full juice box to mouth with appropriate kinematics of wrist and fingers. Place box back on table and release with inappropriate kinematics (4B) Hand in lap, grasp and lift half-full juice box to mouth with appropriate kinematics of wrist and fingers. Place box back on table and release with appropriate kinematics (4C) Hand in lap, grasp and lift full juice box (6 oz) to mouth with appropriate kinematics of wrist and fingers. Place box back on table and release with appropriate kinematics
Support should be provided to the child to attain and maintain appropriate trunk and pelvis position during the task. This item is not testing trunk control but only arm function.
Start position: Sit on bench in 90/90/90 position and pelvis in neutral relative to vertical and trunk supported as required to maintain a stable and aligned trunk. Support should not be provided to the scapulae. If child achieved 4C for “Sit—outside base of support” then child can sit independently for testing this item.
End position: Same as start position.
Start phase: 4C: If child cannot perform 4C, assess the performance using phases 1A through 4B to determine capacity for object to mouth and score per guidelines.

APPENDIX C - Pediatric Neuromuscular Recovery Scale Equipment List
Equipment needed
  • Mat table

  • Height adjustable bench

  • Height adjustable table

  • Three visual targets (eg, stickers)

  • Dycem

  • Toy (for targeting)

  • Stopwatch

  • 12″ air-filled ball

  • Yardstick

  • Velcro

Equipment needed specific to upper extremity function testing
  • Half-full juice box (3 oz of fluid)

  • Full juice box (6 oz of fluid)

  • 1″ square block

  • Bubbles (small plastic container)

  • Fat magic marker

  • Skinny magic marker

  • Three crayons

  • Three pennies

  • Double-ended magic marker

  • 0.5 lb weight (sand-filled tube)

  • 1 lb weight (sand-filled tube)

Equipment needed specific to treadmill-based testing
  • 12″ air-filled ball

  • 1″, 2″, and 4″ objects (eg, foam squares)

  • Body weight support and treadmill system with harness

  • Able to adjust and document treadmill speed

    • Able to provide additional safety overhead during testing if falls, trips, imbalance

    • Ergonomic seating and ease in access to child for tester/technicians—highly recommended

      • Leg trainer

      • Trunk/pelvis trainer

  • Adjustable harness for pediatric population


Keywords:

child; outcome measure; pediatric; recovery; spinal cord injury; validity

© 2016 Wolters Kluwer Health, Inc. and Academy of Pediatric Physical Therapy of the American Physical Therapy Association