Evaluation measures for children with cerebral palsy

Abstract

Abstract. Cerebral palsy is a well-recognized neurodevelopmental condition. The most recent definition describes cerebral palsy as a group of disorders of movement and posture, causing activity limitation. An important step in the process of (re)habilitation is evaluation of functional abilities of an individual. To be as accurate as possible in the evaluation of functioning, proper measurement instruments have to be used. There are many different measurement tools for children with cerebral palsy, several of them are presented in the article.

Full text

K. Grol ege r Sršen et al /Measures in cerebral palsy
Review Article
Evaluation measures for children with cerebral
palsy
Katja Groleger Sršen
University Rehabilitation Institute, Ljubljana, Slovenia
Abstract. Cerebral palsy is a well-recognized neurodevelopmental condition. The most recent definition describes
cerebral palsy as a group of disorders of movement and posture, causing activity limitation. An important step in
the process of (re)habilitation is evaluation of functional abilities of an individual. To be as accurate as possible in
the evaluation of functioning, proper measurement instruments have to be used. There are many different
measurement tools for children with cerebral palsy, several of them are presented in the article.
Key words: Measurement instruments, child, cerebral palsy
1. Introduction
Cerebral palsy (CP) is a well-recognized
neurodevelopmental condition. The most recent
definition describes CP as a group of disorders of
movement and posture, causing activity
limitation, that are attributable to non-progressive
disturbances that occurred in the developing
infant or fetal brain (1). The motor disorders of
CP are often accompanied by disturbances of
sensation, cognition, communication, perception,
behavior and epilepsy. Difficulties in the complex
coordinated activity of feeding may also be
present in the most severe forms of CP.
An important step in the process of
(re)habilitation is evaluation of functional
abilities of an individual. According to the
International Classification of Functioning,
Disability and Health (2), functioning is an
umbrella term for body functions, body
structures, activities and participation. It denotes
the positive aspects of interaction between an
individual (with a health condition) and the
individual's contextual factors (environmental
and personal). Activity limitations (rather than
the term ‘disability’) are difficulties an individual
Correspondence: Katja Groleger Sršen
University Rehabilitation Institute of the Republic of
Slovenia Linhartova 51 1000 Ljubljana Slovenia
E-mail: katja.groleger@ir-rs.si
Phone: +386 1 4758352
Fax: +386 1 4372070
may have in executing activities. Participation
limitations (rather than the term ‘handicap’) are
problems an individual may experience in
involvement in life situations (2).
To be as accurate as possible in the evaluation
of functioning, proper measurement instruments
have to be used. In the process of choosing
between different instruments, we have to know
who we want to evaluate and what the aim of the
evaluation is. It is important to choose an
instrument with good psychometric properties
and, if possible, the one that is widely used, so
that various findings can be compared with those
of other studies. It is generally not easy to
develop a new instrument since that is a very
time-consuming and financially demanding
enterprise and requires expertise in the science of
measurement development.
The European Research Group on Health
Outcomes has set guidelines for cross-cultural
adaptation. The adapted instrument has to meet
criteria of content, semantic and conceptual
equivalence (3).
There are numerous instruments already
available for evaluation of children with cerebral
palsy. In the following text some of them are
shortly presented.
1. 1. Classification systems
There are several systems widely used to
classify children with CP according to some
specific feature. Traditional systems are taking
into account the distributional pattern of an
affected limb (like diplegia, hemiplegia) with an
added modifier describing the predominant type

of muscular tone (e.g. spastic, dystonic). Recently
Bax and co-authors proposed four major
classification dimensions (4):
 motor abnormalities
 associated impairments
 anatomic and radiological findings
 causation and timing
Within the first dimension they proposed firstly
to take into the account the nature and typology
of motor disorder and secondly the functional
motor abilities (4). There are several functional
classification systems in the literature, most
known are: The Gross Motor Classification
System (5), The Manual Ability Classification
System (MACS) (6), The Bimanual Fine Motor
Function (BFMF) (7) and The Communication
Function Classification System (CFCS) (8).
Lately there was a new classification system
introduced for children and adults with
developmental disorder, the Dysphagia
Management Staging Scale (DMSS) (9).
2. The gross motor function classification
system – expanded and revised version
(GMFCS - E&R)
The original GMFCS was published more than
a decade ago by Palisano and co-workers (5). The
classification is based on self-initiated movement
with particular emphasis on sitting and walking. 5
levels of system are clinically meaningful.
Distinctions between levels of motor functions
are based on functional limitations, the need on
assistive technology (including mobility devices
such as walkers, crutches and canes) and wheeled
mobility. There are precise descriptions of all
five levels for different age bands: just before 2nd
birthday, between 2nd and 4th birthday, between
4th and 6th birthday, between 6th and 12th birthday.
Children that were prematurely born are to be
considered at the corrected age when they are
classified just before 2nd birthday. The focus is on
what a child is usually able to perform in motor
function in home, school and community settings.
It is not about best capacity but ordinary
performance and without judgments about quality
of movement and prognosis. The scale is ordinal
and with no intention that differences between
levels would be considered equal or that children
with CP would be equally distributed among 5
levels. The standard user instructions and
complete guide to the GMFCS are available at
www.fhs.mcmaster.ca/canchild.
In 2007 a revised and extended version was
published (10). The aim was to refresh the
original system taking into account new ideas of
ICF (2). 5 levels of the expanded and revised
system are based on functional distinctions that
are meaningful in daily life. New is also an
additional age band for youth from 12 to 18 years
of age. Descriptions for 6 to 12 years and 12 to
18 years age band reflect also the impact of
personal (e.g., energy demands and social
preferences) and environmental factors (e.g.,
distances in school and home environment) on
methods on mobility.
Both versions were proved to be valid and
reliable (11-14). Both were translated in several
languages and again proved to be reliable (15,16).
Also high reliability of parents report was proved
(17,18). This could help professionals and parents
to communicate about the child’s situation, its
abilities, needs and prognosis.
Morris and Bartlett (19) were writing in details
about the impact and utility of GMFCS. They
found out that GMFCS has been used in both
observational and experimental research to
describe study samples and to explore the role of
severity of functional limitations as an effect
modifier. The GMFCS is appearing useful as a
longer term outcome for perinatal and neonatal
studies. The GMFCS provides a simple method
for researchers to describe the functional abilities
of children with CP so that clinicians can readily
determine whether their patient is similar to or
different from those described in a study (19).
Morris and Bartlett wrote are also implications of
research to clinical practice. Clinicians benefit
from knowing the clinical course of children in
each of the five GMFCS levels to establish likely
outcomes. The impact of the GMFCS on clinical
practice might begin during disclosure of the
diagnosis, by using the system to help families
understand a child’s current abilities and
prognosis, and subsequently in planning for
future equipment needs and types of intervention.
The GMFCS can help enormously when setting
functional goals collaboratively with families. It
can also be used to clarify expected outcomes
with therapeutic interventions, orthoses,
pharmaceutical interventions or surgery
interventions for children at different levels (19).
All that was written for the impact and utility of
GMFCS we can assume also for MACS.
3. The manual ability classification system
(MACS)
The purpose of MACS was to provide a
systematic method for classification of children
with CP between 4 and 18 years of age, based on
their ability to handle objects in daily activities
(http://www.macs.nu/index.php). Age appropriate
activities and objects are to be considered. It

K. Grol ege r Sršen et al /Measures in cerebral palsy
Review Article
helps us to determine the level that best
corresponds with the child's usual abilities at
home, at school and in the wider social
environment. The level should be determined
with the aid of information obtained from a
person who knows the child well, not by special
testing. It should represent the cooperation of
both hands in activities and not each hand
separately (6).
The scale is, as in GMFCS, ordinal and with no
intention that differences between levels would
be considered equal or that children with CP
would be equally distributed among 5 levels.
Distinctions among levels are based on child’s
ability to handle objects and need for help or
adaptations (6).
Content validity and reliability was proved for
MACS (6, 20). It was also translated in some
other languages and validated again (21, 22).
4. The bimanual fine motor function
(BFMF)
Similarly also BFMF offers us a system for
classification of children with CP from age of 4
years. It was described by Beckung et al in 2002
(7). In the BFMF, manipulation and gripping
ability in both hands is classified in a five-level
system. Data on validity and reliability of the
BFMF has to date not been published. It is used
as a classification system for Surveillance of CP
in Europe (23).
5. The communication function
classification system (CFCS)
The CFCS for individuals with CP is a five-
level classification system currently under
development at Michigan State University (8).
Design and development of the CFCS attempts to
address a number of issues in CP including a
general lack of knowledge regarding the
communication abilities of individuals with CP.
The system is designed to be a quick and simple
instrument used by a person familiar with the
individual to be classified. Variables of
communication ability used within the CFCS
include sender roles (being able to communicate
a message to someone), receiver roles (being able
to understand a message from someone), pace of
communication, and the degree of familiarity
with a communication partner. Data on validity
and reliability of the CFCS has to date not been
published.
6. Dysphagia management staging scale
(DMSS)
The classification in one of 5 levels is based on
feeding and swallowing disorder with particular
emphasis on different stages of eating and
swallowing (9). Judgments of level of disorder
are made on three categories of information:
Signs and symptoms of swallowing and feeding
disorder: these may include reference to oral
preparation, oral initiation, pharyngeal and
esophageal phases, as well as to indirect signs
and symptoms, such as anorexia and rumination.
Intervention strategies that are used to manage
ingestion activities including eating, drinking and
taking oral medications.
Adequacy of nutrition, hydration and
respiratory health as known to be related to
swallowing and feeding disorder. The standard of
adequacy considers both chronic and chronic
intermittent effects (9).
There are also normative data available for the
population of children and adults with
developmental disorders. No data are yet
available specifically on children with CP.
It can be used in the combination with the
Dysphagia Disorder Survey (9).
7. General measurement instruments for
evaluation of functioning
7. 1. Pediatric evaluation of disability inventory
(PEDI)
PEDI is an instrument designed to assess
capability and performance of functional
activities of typically developing young children
aged from 6 months to 7.5 years (24). It can be
used either as a parental report or as a structured
interview conducted by a rehabilitation
professional. It was developed to discriminate
between non-disabled and disabled children.
Based on assessments of disabled children,
service providers should be able to design
rehabilitation programs and evaluate their
efficacy (24).
PEDI measures capability and performance of
functional activities in three content domains:
self-care, mobility and social function (24).
Capability is measured by identification of
functional skills for which the child has
demonstrated mastery and competence. These
skills, rated on the Functional Skills Scales of the
PEDI, are a direct measure of functional
capability of a child, and provide sufficient detail
to identify the clinical patterns of limitations in
functional skill attainment. Performance of daily
functional activities is measured by the level of

caregiver assistance that is needed to accomplish
them. The Caregiver Assistance Scale is the
measure of the extent of help the caregiver
provides in typical daily situations. The third
part, the Modification Scale, adds to knowledge
of the actual performance of functional activities.
It is a measure of environmental modifications
and equipment used by a child in routine daily
activities. The PEDI consists of 197 functional
skill items and 20 items that assess caregiver
assistance and modifications (24).
7. 2. Scoring
In Part I of the PEDI, the format is
dichotomous, so the questions can be scored
either ’capable’ or ‘not capable’. A score is
positive when a child has mastered a particular
skill. In the Caregiver Assistance scale (Part II)
there are six rank-ordered response choices,
ranging from 0 (totally dependent) to 5
(independent). Every item has its own score
criteria in the PEDI manual. PEDI was proved to
be valid and reliable instrument (24-29). Since
there is also a social function domain it is more
prone to lose validity after transfer to another
cultural environment. Several authors reported
that normative scores are not applicable for their
population of children (30-34). To summarize,
the results confirming the existence of inter-
cultural differences are a strong argument for
renorming the PEDI before introducing the
instrument into practice. Nevertheless, PEDI is a
useful instrument for detection and evaluation of
functional deficits, as well as for follow-up and
assessment of efficacy of pediatric rehabilitation
programs. When comparing validity and
reliability of different instruments for measuring
health and well-being of children with spastic
form of CP, PEDI demonstrated higher internal
consistency than the Pediatric Outcomes Data
Collection Instrument (PODCI) and Child Health
Questionnaire (34).
In comparison with the GMFM, the PEDI
mobility scale detected the most significant
health differences between children with
hemiplegia, diplegia, and quadriplegia. The PEDI
social function scale detected the largest
differences in cognitive function between
children with an IQ of less than 70 compared
with those with an IQ of 70 or greater.
8. Functional independence measure
(FIM)
The FIM (35) is an 18-item, seven level ordinal
scale from independent (7) to total assistance (1).
Each item is operationally defined in terms of
these 7 levels. The Uniform Data System for
Medical Rehabilitation (UDS) provides training
materials, a shared database for participating
facilities, and requires overall 80% accuracy of
raters at each facility for qualifying members.
The FIM was intended to be sensitive to change
in an individual over the course of a
comprehensive inpatient medical rehabilitation
program, aged from 7 to 99 years of age. The
FIM can be completed in approximately 20-30
minutes in conference, by observation, or by
telephone interview. Rasch analysis defines two
FIM dimensions, labeled motor and cognitive. It
was designed to assess areas of dysfunction in
activities which commonly occur in individuals
with any progressive, reversible or fixed
neurologic, musculoskeletal and other disorders.
FIM items: eating, grooming, bathing, dressing
upper body, dressing lower body, toileting,
bladder management, bowel management, bed,
chair, wheelchair transfer, toilet transfer, tub and
shower transfer, walking/wheelchair locomotion,
stairs, comprehension, expression, social
interaction, problem solving and memory (35).
FIM interrater reliability in the clinical setting
was reported by Hamilton et al (36). It was
concluded that the 7-level FIM was reliable when
used by trained/tested inpatient medical
rehabilitation clinicians.
Kidd et al reported results of a study in which
the FIM was compared to the Barthel Index to
determine its validity, reliability and ease of use
in two groups of 25 patients undergoing
neurorehabilitation (37). The FIM was considered
to be more valid than the Barthel Index, and
equally reliable in the assessment of disability.
When the two disability scores were compared
using subjective and objective assessment the
agreement between them was comparable,
although neither was high.
9. Wee-FIM
The WeeFIM is derived from the Functional
Independence Measure (FIM). It describes
consistent and usual performance to criterion
standards of functional skills for children ages six
months to eight years. The WeeFIM includes 18
items on a seven-level ordinal scale. A score of
one reflects total assistance and a score of seven
reflects complete independence. The test-retest
reliability and concurrent validity were tested and
proved (38,39). The WeeFIM was stated as a
useful tool for assessing functional status in
children with neurodevelopmental disabilities
(38). Its reliability and stability was also proved.
Equivalence reliability was examined by
comparing ratings obtained when using personal
assessment with ratings collected during a

K. Grol ege r Sršen et al /Measures in cerebral palsy
Review Article
telephone interview. No statistically significant
differences were found for individual items,
subscale scores or total WeeFIM values (40).
King et al. are reporting that while the WeeFIM
adequately reflects the severity of neurological
involvement in pediatric orthopedic patients, it
either does not demonstrate sensitivity in those
aspects of the disease treated by orthopaedists,
particularly with ambulatory cerebral patients
where the WeeFIM mobility scale cannot
differentiate post operative changes, or the
patients did not improve (41). The WeeFIM was
designed to measure the burden of care, which it
accurately reflects. However, in the population
tested, it lacks construct validity for important
issues to musculoskeletal surgery and has a
significant ceiling effect in the mobility domain.
They recommend against its general use in this
population for assessment of mobility outcomes
(41).
10. Special measurement instruments for
evaluation of functioning
10. 1. The Gross motor function measure
(GMFM)
The GMFM was designed and validated for
children with CP and is used widely as a clinical
and research outcome measure (42). The original
GMFM, now referred to as the GMFM-88, is
comprised of 88 items grouped into five
functional dimensions: lying and rolling; sitting;
crawling and kneeling; standing; walking,
running and jumping. The items are arranged
within dimension by difficulty. Each item is
scored on a four-point rating scale from 0 to 3,
with 0 indicating that the child cannot initiate the
item and 3 indicating that the child can complete
the item (as defined in the GMFM manual). Each
of the scoring options within the 88 items is
explicitly defined, in order to describe clearly the
motor behavior to be observed and scored.
Percent scores for each dimension are summed
and averaged to obtain a total GMFM-88 score.
There is considerable evidence of the reliability,
validity and responsiveness of the GMFM-88 for
children with cerebral palsy. Recently it was
confirmed also for children with Down syndrome
(43).
While the GMFM has been useful to document
gross motor function in a systematic way, one
limitation of the measure is that the scoring (and
thus interpretation) is based on ordinal level data.
The Rasch analysis of the GMFM was done and
an interval level measure with improved
interpretability of scores was created (44). The
adaptation of the new interval-level scoring
system for the GMFM-66, for children with CP,
is an improvement over the GMFM-88 percent
scores. Of the 88 original items, 66 have been
found to contribute to a unidimensional group of
items that measure gross motor function. A
computer program, the GMAE, has been
developed to compute reliable person ability
estimates, based on the responses to these 66
items. Because the assumption of test-free
measurement has been validated, not all of these
items need to be tested to estimate a child’s gross
motor ability, however the more data available
for a subject, the more accurate the estimate of
gross motor function.
The use of GMFM is very wide. Lately GMFM
was selected as a European consensus tool for
follow-up of children treated with botulinum
toxin. In the consensus GMFM and GMFCS have
been expanded to provide a graphical framework
on how to treat the motor disorders in children
with CP. This is intended to facilitate
communication between parents, therapists and
medical doctors concerning (1) achievable motor
function, (2) realistic goal-setting and (3)
treatment perspectives for children with CP (45).
It is used also in follow up of CP children after
intrathecal baclofen therapy (ITB) in combination
with PEDI. Ramstad reported on changes across
all ICF dimensions after the TBI (46). It is used
to follow up the effects of different therapy
apporaches (47, 48).
10. 2. The Gross motor performance measure
(GMPM)
The GMPM was developed as an observational
instrument to measure changes in quality of
movement in children with CP. Validity,
reliability and responsiveness of this measure was
investigated quite some time ago (49). Few years
later it was found that the measure is
differentially responsive to changes in "stable"
and "responsive" groups (50). Although
assessment of the quality of movement in
children with CP is difficult, the development of
the GMPM has facilitated this process.
Interobserver reliability was in the 'fair to good'
category. Reliability scores improved over time
with continual use of the GMPM. A greater
number of individual item scores moved from the
'fair to good' category to the 'excellent' category.
Results from this study indicate that it is possible
to assess reliably the quality of movement in
children with CP (51).

11. Assisting hand assessment (AHA)
The Assisting Hand Assessment was designed
to evaluate change in assisting hand function in
bimanual activity performance of children with
hemiparetic CP and children with obstetric lesion
of brachial plexus. AHA is conducted by
observing object-related actions. A semi-
structured play is videotaped and then scored
according to criteria in the Manual. 22 items are
scored on a 4-point scale rating the quality of
performance. The original Swedish version of
AHA was proved to be reliable, valid and
sensitive to a small change (52-54). Also most
recent study (55) is presenting data about the
excellent test-retest reliability of AHA. Besides,
it was proved, that a change of 4 points or more
between test occasions represents a significant
change. It was already translated to other
languages and proved to be reliable tool (56).
AHA was used in several studies for evaluation
of efficacy of therapy. Elliasson et al. reported
that the children who received constraint induced
movement therapy (CIMT) improved their ability
to use their hemiplegic hand significantly more
than the children in the control group after 2
months, i.e. after treatment. Effect size was high
after treatment and remained medium at 6 months
(57). Also Wallen et al reported on efficacy of
modified CIMT (58). To evaluate the hand
function they used AHA and the Melbourne
Assessment of Unilateral Upper Limb Function.
Gordon et al used the same instrument but to
evaluate the hand-arm bimanual intensive therapy
(HABIT), using the principles of motor learning,
and neuroplasticity, to address these bimanual
impairments in children with hemiplegic form of
CP (59). The results suggested that for a carefully
selected subgroup of children with hemiplegic
CP, HABIT appears to be efficacious in
improving bimanual hand use (59).
Based on data form recent study by Holmefur
and co-workers AHA can be also used to discuss
future development of affected hand use in
bimanual tasks in children with unilateral CP
(60).
12. ABILHAND-Kids
The ABILHAND-Kids is a parent-report,
performance-based questionnaire with excellent
clinical utility and psychometric properties (61).
It is a tool that was developed for measuring
manual ability in children with CP. The Rasch
measurement model was used. ABILHAND-kids
consists of 21 mostly bimanual items. It also
provides guidelines for goal setting and treatment
planning. Its range and measurement precision
are appropriate for clinical practice. The
ABILHAND-kids measures are significantly
related to school education, type of CP, and gross
motor function. A high reliability and a good
reproducibility over time were reported (61).
13. The Quality of upper extremity skills
test (QUEST)
This test was designed to evaluate the quality of
upper extremity function in four domains:
dissociated movement, grasp, protective
extension and weight bearing. It was designed to
be used with children, who exhibit neuromotor
dysfunction with spasticity and has been
validated with children 18 months to 8 months of
age. It is a criterion referenced measure with
excellent reliability. It correlates strongly with
another measure of hand function, the Peabody
Developmental Fine Motor Scales (62). Haga and
co-workers reported that test-retest reliability was
strong; intra-observer agreement and agreement
between various observers were moderate to
strong in preschool-age children with CP (63).
14. Melbourne assessment of unilateral
upper limb function
It is a quantitative test of quality of movement
in children with neurological impairment. Randall
et al reported results which indicate that it is a
reliable tool for measuring the quality of
unilateral upper-limb movement in children with
CP (64). They found high internal consistency of
test items and moderate to high agreement both
within and between raters for all test items. Test-
retest results revealed moderate to high intra-rater
reliability for item totals for each rater and high
reliability for test totals. Reliability was proved
also for French translation of a test (65). Klingels
et al compared the Melbourne Assessment of
Unilateral Upper Limb Function and the QUEST
in hemiplegic CP (66). Both showed high
interrater reliability. Correlation analysis
indicated that different dimensions of upper limb
function are addressed in both scales.
15. Dysphagia disorders survey (DDS)
The Dysphagia Disorder Survey was developed
specifically for screening adults with
developmental disability for dysphagia and
related eating disorders (9). However, children
were included in the sample population used for
standardizing the survey. Authors report on
clinical experience that indicate that the DDS
may be used to survey children from 2 years old

K. Grol ege r Sršen et al /Measures in cerebral palsy
Review Article
to 21 years old and that the survey is appropriate
for use in non-residential as well as residential
populations. It identifies the relative severity and
characteristics of disorder among individuals in
the group thereby, aiding in setting priorities for
clinical evaluations and treatments.
DDS consists of two parts: Related factors and
Feeding and swallowing competency. Part 1
includes nutritional and mealtime management
issues that have been found to be related to
dysphagia in this population (Body Mass Index,
restrictions in food texture and viscosity,
dependence in eating, need for special feeding
utensils to accommodate impaired oral motor
competencies, need for special positioning
strategies, and unstable body postures). Special
feeding techniques and strategies that compensate
for impairments in body postural control and
swallowing and feeding capabilities, or may be
unsafe or maladaptive are also considered in this
section. Part 2 addresses the task components of
oral preparatory, oral and pharyngeal phases of
swallowing that have been found to be
dysfunctional in dysphagia and unsafe eaters.
Test validity and inter-item reliability were
determined on a preliminary version of the DDS
in a study of 626 people with developmental
disability who resided in a government-run,
residential facility (9). The study included the
total population of the facility. The age range was
3 to 78 years old, but the population was
primarily adult. Forty-seven percent were self-
feeders. The remaining 53% required assistance
or were fed all their nourishments. All subjects in
this study were nourished with oral feeding.
Callis and co-workers report on incidence of
different severity levels of dysphagia in children
with CP (67). They observed clinically apparent
presence and severity of dysphagia which were
assessed with a standardized mealtime
observation, DDS and a dysphagia severity scale.
Of all 166 participating children, 1% had no
dysphagia, 8% mild dysphagia, 76% moderate to
severe dysphagia, and 15% profound dysphagia,
resulting in a prevalence of dysphagia of 99%.
Dysphagia was positively related to severity of
motor impairment, and, surprisingly, to a higher
weight for height. Low frequency of parent-
reported feeding problems indicated that actual
severity of dysphagia tended to be underestimated
by parents. Proactive identification of dysphagia
is warranted in this population, and feasible using
a structured mealtime observation. Children with
problems in the pharyngeal and esophageal
phases, apparent on the DDS, should be referred
for appropriate clinical evaluation of swallowing
function (67).
16. Canadian occupational performance
measure (COPM)
The Canadian Occupational Performance
Measure is an individualized, client-centred
measure designed for use by occupational
therapists to detect change in a client's self-
perception of occupational performance over time
(68). The COPM is designed for use with clients
with a variety of disabilities and across all
developmental stages. It was adapted also to be
used with children. It is a standardized, valid
instrument (68, 69). It is designed as an outcome
measure, with a semi-structured interview format
and structured scoring method. Change scores
between assessment and reassessment using the
COPM are the most meaningful scores derived
from this assessment. Originally published in
1991, with the latest fourth edition released in
May 2005, the COPM has been used in more than
35 countries and has been translated into over 20
languages. The COPM has undergone extensive
research in many different occupational therapy
practice situations. The majority of clients and
therapists indicate that the measure is easy to
administer, taking 20-40 minutes.
17. The Children's assessment of
participation and enjoyment (CAPE) and
the preferences for activities of children
(PAC)
CAPE and PAC are two companion measures of
children's participation (70). Both are self-report
measures of children's participation in recreation
and leisure activities outside of mandated school
activities. The CAPE is a 55-item questionnaire
designed to examine how children and youth
participate in everyday activities outside of their
school classes. It provides information about five
dimensions of participation, which includes
diversity, intensity and enjoyment of activities. It
also provides information about the context in
which children and youth participate in these
activities. The PAC was designed to examine
children's preferences for involvement in each
activity.
Both measures contain 55 activities related to
children's day-to-day participation in activities
outside of the school curriculum. The CAPE
takes 30-45 minutes and PAC 15-20 minutes to
complete. Both measures are appropriate for
children and youth (with and without disabilities)
between 6 and 21 years of age. Both measures
demonstrated sufficient internal consistency, test-

retest reliability, content validity, and construct
validity (70,71). Data on good internal
consistency of Spanish version are also available
(72).
Palisano and co-workers studied factors that
might influence social and community
participation of children and youth with CP (73).
They also wanted to identify the types of
activities in which social and community
participation are highest. Participants completed
CAPE and GMFCS level was determined by the
researchers. They found out that youth did a
higher percentage of activities with friends and
others and outside the home than children.
Children and youth in level I did a higher
percentage of activities with friends and others
compared with children and youth in levels II and
III and in levels IV and V. Differences were not
found between females and males. Findings
cannot be attributed only to GMFCS level.
Authors concluded that the ability to walk
without restrictions is desirable for social and
community participation. For children and youth
with CP who have limitations in mobility,
physical therapists have roles as consultants for
accessibility, activity accommodations, and
assistive technology and as advocates for
inclusive environments (73).
18. Conclusion
As CP is a very diverse group of disorders of
movement and posture, causing activity limitation
and often accompanied by disturbances of
sensation, cognition, communication, perception,
behavior and epilepsy, it is also very demanding
to choose a proper evaluation measure. There are
many different measurers for children with CP,
covering almost all ICF dimensions. By choosing
the right ones it enables us to see a child with all
his problems and abilities and at the same time as
a whole person, who wants to participate in its
social environment.
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