SCALE: Selective Control Assessment of the Lower Extremity

Score Sheet
Date: _______________ Patient’s Name: __________________________________ DOB: __________________ GMFCS level: _____

Diagnosis: spastic diplegia spastic quadriplegia spastic hemiplegia R L other: ___________________________

Left Right
Grade Hip Knee Ankle STJ Toes Hip Knee Ankle STJ Toes
Normal (2 points)
Impaired (1 point)
Unable (0 points)
Total Limb Score L= R=

Resisted Synergy
knee extension with resisted limb extension
dorsiflexion with resisted limb flexion

Descriptors
hip flexion contracture
adductor contracture or spasticity
knee flexion contracture
hamstring tightness
plantar flexion contracture
plantar flexor spasticity
inverts or everts, not pure dorsiflexion
primarily moves toes
mirrors motion on opposite limb
motion slower than 3 second verbal count
moves one direction only (note motion achieved)
movement of other joints
motion < 50% of available ROM

Other comments regarding test: ___________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________

________________________________
Examiner

Version 2.3, Copyright 2009 – University of California Los Angeles/Orthopaedic Hospital Center for Cerebral Palsy
 SCALE: Directions for administration
The patient must be able to follow simple motor commands. To test this ability, ask the patient to move his or her least affected body part.
Before asking the patient to perform each joint test, passively move the joint to assess ROM. To assure understanding, demonstrate the
movement sequence while supporting the limb. The language in the instructions to the patient is suggested and may be modified as
needed to elicit optimum performance for individual patients. To guide patients in the desired speed of movement, provide a verbal
three-second count during the task. Multiple attempts are allowed and feedback to improve performance is acceptable.

General instructions to patient – “I am going to ask you to move in a certain way. Move the way I ask you to move. Try not to move any
other part of your body. If you have any questions or you don’t understand what I am asking you to do, please tell me.”

Hip
Position – Side lying with the hip and knee fully extended. Support the limb medially at the knee and ankle. For stability, you may flex the
lower untested limb. The tested motion is hip flexion while keeping the knee extended. Assess hip flexion ROM with the knee extended, as
it may be limited by hamstring tightness. If the patient has difficulty with this task because of hamstring tightness, then ask him or her to
extend, flex then extend the hip while keeping the knee flexed 90o. Evaluate hip extension ROM to assure an adequate arc of motion to
assess performance of the task.
Instructions to patient – Ask the patient to flex, extend then flex the hip while keeping the knee extended. For example: “Move your leg
forward, back then forward again while keeping your knee straight. I will take you through the motion first, and then I’d like you to do it
yourself.”

Knee
Position – The remaining tests are done in sitting with legs over the edge of the exam table. During the remaining tests you may allow the
patient to lean back on his or her hands so the trunk is approximately 20o from vertical to compensate for hamstring tightness.
Instructions – Ask the patient to extend, flex then extend the knee while keeping the hip flexed. For example: “Straighten your knee as
much as you can, then bend it and straighten again. Try to do this without leaning further back or moving your other leg. I will take you
through the motion first, and then I’d like you to do it yourself.”
Limb Extension Synergy – If quadriceps weakness is suspected, limb extension synergy may be assessed. Allow the patient to lean back
on his or her hands or be supported so the trunk is approximately 45o from vertical. Position the limb in hip and knee flexion with ankle
dorsiflexion. Ask the patient to push against your hand, extending the knee and plantar flexing the foot and toes. Resist at the metatarsal
heads and compare knee extension excursion to the amount achieved during the knee selective voluntary motor control test.

Ankle
Position – Sitting, as in the knee extension test. The knee is extended and the examiner supports the calf. Assess passive ankle
dorsiflexion ROM with the knee extended. The knee may be flexed to approximately 20o if needed to accommodate hamstring and/or
gastrocnemius tightness.
Instructions to patient – Ask patient to dorsiflex, plantar flex then dorsiflex the ankle while maintaining knee extension. For example:
“Keeping your knee straight while I support your leg, move your foot up, down then up again. I will take you through the motion first, then
I’d like you to do it yourself.”
Limb Flexion Synergy (Confusion Test) – If dorsiflexor muscle weakness is suspected, limb flexion synergy may be assessed. Ask the
patient to flex the hip while keeping the knee flexed. Resist hip flexion at the distal thigh. Compare dorsiflexion excursion to the amount
achieved during the ankle selective voluntary motor control test.

Foot/Subtalar Joint
Position – Sitting, as in the knee and ankle tests. The calf is supported.
Instructions to patient – Ask patient to invert, evert then invert while maintaining knee extension. For example: “Move your ankle in, then
out then in again while I support your leg. I will take you through the motion first, then I’d like you to do it yourself.”

Toes
Position – Sitting, as in the ankle test. The heel is supported.
Instructions to patient – Ask patient to flex, extend then flex toes without moving ankle or knee. For example: “Curl all your toes down,
then up then down again while I support your leg. I will take you through the motion first, then I’d like you to do it yourself.”

Version 2.3, Copyright 2009 – University of California Los Angeles/Orthopaedic Hospital Center for Cerebral Palsy
 SCALE: Selective Control Assessment of the Lower Extremity
Instructions for Grading

Each joint is scored either 2,1 or 0 points. These are summed for a Total Limb Score. The number of points for each grade is in parentheses. For each
joint, check the joint score and all applicable descriptors on the SCALE Score Sheet.

Hip
Normal (2) Flexes, extends then flexes again. During flexion, movement occurs without knee flexion, within a three-second verbal count and
without mirror movement (the same movement on the contralateral limb). If alternate hip extension test is used, extends, flexes then
extends again. During extension, movement occurs without knee extension, within a three-second verbal count and without mirror
movement.
Impaired (1) One or more of the following occur: extends or flexes < 50% of available range of motion in the test position, performs task slower
than three-second verbal count, exhibits mirror movements, movement occurs in only one direction or motion at untested joint
occurs.
Unable (0) Does not flex or extend hip or does so only with simultaneous knee movement.

Knee
Normal (2) Extends, flexes and extends again. Movement occurs within three-second verbal count, without motion of the trunk or other joints
and without mirror movement. A Normal grade may be given if the knee extends > 50% of available range of motion in the test
position.
Impaired (1) One or more of the following occur: extends < 50% of available range of motion, performs task slower than three-second verbal
count, exhibits mirror movements, movement occurs in only one direction or motion at untested joint occurs.
Unable (0) Does not extend or only extends with simultaneous hip or ankle movement.

Ankle
Normal (2) Dorsiflexes, plantar flexes and dorsiflexes again. Movement occurs within a three-second verbal count, without motion at other joints
and without mirror movement. At least 15o of ankle motion in the sagittal plane must be observed.
Impaired (1) One or more of the following occur: dorsiflexes < 50% of available passive range of motion in the test position or active range during
Limb Flexion Synergy, performs task slower than three-second verbal count, exhibits mirror movements, movement occurs in only
one direction or motion at untested joint occurs. An “Impaired” grade is given if the motion is accompanied by toe extension or ankle
inversion.
Unable (0) Does not dorsiflex or only dorsiflexes with hip and knee flexion.

Foot/Subtalar Joint
Normal (2) Inverts, everts and inverts again. Movement occurs within a three-second verbal count, without motion at other joints and without
mirror movement. Active eversion must occur.
Impaired (1) One or more of the following occur: inverts or everts < 50% of available range of motion, performs task slower than three-second
verbal count, exhibits mirror movements, movement occurs in only one direction or motion at untested joint occurs.
Unable (0) Does not invert or evert or movement occurs only in synergy pattern. May dorsiflex, plantar flex or not move ankle at all.

Toes
Normal (2) Flexes, extends and flexes again. Movement occurs within a three- second verbal count, without motion at other joints and without
mirror movement. Motion should occur at all five toes.
Impaired (1) One or more of the following occur: flexes or extends < 50% of available range of motion, performs task slower than three- second
verbal count, exhibits mirror movements, movement occurs in only one direction or motion at untested joint occurs.
Unable (0) Does not flex or extend toes.

Difference between Unable and Impaired

Unable (total synergy) has simultaneous movement at two or more joints. For every degree of motion at
the desired joint, concomitant obligatory motion that is a part of the synergy pattern occurs at another joint
in the limb. Patients with impaired motor control may be able to move the desired joint through a small arc
of motion without any other joint motion, however a portion of the motion is accompanied by motion at an
adjacent joint.

Difference between Impaired and Normal

Normal motor control is the ability to isolate joint motion through more than 50% of the available ROM
within a three-second verbal count in an alternating fashion. The motion occurs without accompanying
motion at any other joints of either limb. The inability to perform this task is impaired.

Version 2.3, Copyright 2009 – University of California Los Angeles/Orthopaedic Hospital Center for Cerebral Palsy
 DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Selective Control Assessment of the Lower Extremity (SCALE):

development, validation, and interrater reliability of a clinical tool
for patients with cerebral palsy
1
EILEEN G FOWLER PHD PT | LORETTA A STAUDT MS PT 2 | MARCIA B GREENBERG MS PT 1 | WILLIAM L
1
OPPENHEIM MD

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 Normal selective voluntary motor control (SVMC) can be defined as the ability to
Accepted for publication 9th September 2008. perform isolated joint movement without using mass flexor ⁄ extensor patterns
Published online 12th February 2009. 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
LIST OF ABBREVIATIONS
Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool
CST Corticospinal tract
developed to quantify SVMC in patients with cerebral palsy (CP). This paper
ICC Intraclass correlation coefficient
describes the development, utility, validation, and interrater reliability of SCALE.
PWM Periventricular white matter
SCALESelective Control Assessment of the
Content validity was based on review by 14 experienced clinicians. Mean agree-
Lower Extremity ment was 91.9% (range 71.4–100%) for statements about content, administra-
SVMC Selective voluntary motor control tion, and grading. SCALE scores were compared with Gross Motor Function
Classification System Expanded and Revised (GMFCS-ER) levels for 51 partici-
ACKNOWLEDGMENTS pants with spastic diplegic, hemiplegic, and quadriplegic CP (GMFCS levels I
We acknowledge statistical consultation from – IV, 21 males, 30 females; mean age 11y 11mo [SD 4y 9mo]; range 5–23y).
Jeffrey Gornbein, and contributions from Beth Construct validity was supported by significant inverse correlation (Spearman’s
Trevino, Sarah Copeland, and Evan Goldberg. r=-0.83, p<0.001) between SCALE scores and GMFCS levels. Six clinicians rated
We thank all of the clinical experts and the 20 participants with spastic CP (seven males, 13 females, mean age 12y 3mo [SD
volunteer patients and their families for their
5y 5mo], range 7–23y) using SCALE. A high level of interrater reliability was
participation, and the Lena Longo Foundation
demonstrated by intraclass correlation coefficients ranging from 0.88 to 0.91
and the Brianna Fund for financial support.
(p<0.001).

Children with spastic cerebral palsy (CP) exhibit multiple or posture.’5 The term ‘selective voluntary motor control’
impairments that contribute to functional motor deficits. (SVMC) differentiates the deliberate performance of iso-
Although spasticity and contractures may be more obvious lated movements upon request from habitual selective
impairments, underlying deficits in selective motor control muscle activation during functional tasks, such as walking.
can negatively affect function to a greater degree.1,2 Assess- Voluntary movement is produced through the cortico-
ment of selective motor control in lower extremities in spinal tracts (CSTs), which control both directionality and
patients with CP has received little attention, despite force production.6 Damage to the CSTs interferes with
growing support for it as a predictive factor of functional the force, speed, timing, and pattern of volitional move-
ability.1–4 ments.7 Injury to CSTs within the periventricular white
Selective motor control has been defined as ‘... the matter (PWM) has been correlated with motor disability
ability to isolate the activation of muscles in a selected in CP.8 Damage to PWM was the most common finding
pattern in response to demands of a voluntary movement 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
present in more than one-third of those with hemiplegia the ‘selective motor control of dorsiflexion’ test could not
and quadriplegia.9 be found in the literature, and a wide range of interrater
Evidence of SVMC impairment in CP has been shown. reliability was reported.20 Valid and reliable tests have
Timing errors in muscle recruitment during attempted been developed for assessment of recovery stages in adults
maximal voluntary contractions exemplify the inability to after stroke,21,22 but they are not ideal for patients with
recruit an individual muscle group selectively without CP. Administration includes practice on the ‘non-affected
inappropriate antagonist muscle activity.10 In addition, side’ and testing in standing, which limits applicability for
simultaneous associated movements at contralateral joints, patients with bilateral lower-extremity involvement and
for example mirror movements, have been described.11 interferes with observation of mirroring.
Mass patterns of flexion and extension, which have histori- A valid, reliable assessment method that has clinical util-
cally been referred to as ‘synergies,’ are seen in the absence ity is needed for SVMC assessment of the entire lower
of SVMC.12 In patients with CP, these flexor and extensor extremity in patients with spastic CP. The purpose of this
patterns of the lower extremities are described as persis- paper is to describe the development of a clinical tool enti-
tence of the immature patterns observed during typical tled Selective Control Assessment of the Lower Extremity
infant kicking13 and stepping.14 Tightly coupled hip, knee, (SCALE) and present evidence of its validity and interrater
and ankle movements occur in term and preterm infants reliability.
with and without damage to white matter. These move-
ments become disassociated or uncoupled over time in METHOD
infants without brain lesions, but persist in preterm infants Participants were individuals with spastic CP and clini-
with damage to white matter.13 These mass movement cians. Clinicians participating in content validation were
patterns are observed and have been measured using recruited from physical therapy clinics, hospitals, and uni-
electromyography during gait and voluntary movement in versities. Participants with CP were recruited from the
children and adults with CP.12,14–16 UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy.
Clinical examinations of SVMC in children with CP The institutional review board at this institution approved
have been described,2,3,17–19 but a detailed tool to evaluate the study. Informed consent was obtained from all partici-
the entire lower limb has not been validated. Assessments pating clinicians, and informed assent ⁄ consent was
vary as to the joint(s) tested, positions used, task(s) obtained from all participants with CP and ⁄ or their parent
required, and grading criteria. Staudt and Peacock3 used or legal guardian.
SVMC as a prognostic factor when selecting candidates
for selective posterior rhizotomy. These examination The SCALE tool
methods were further developed by Fowler et al.18 as a The SCALE tool was designed for clinical administration
measure of severity to select and categorize participants in and scoring by healthcare professionals, to be used in less
a randomized controlled trial. Grading was limited to than 15 minutes without specialized equipment. The tool
knee and ankle joints with an overall limb classification of includes ‘Directions for Administration,’ ‘Instructions for
‘good’, ‘fair’, or ‘poor’ SVMC. Mirror movements, Grading,’ and a ‘Score Sheet.’ Hip, knee, ankle, subtalar,
reciprocation, and speed were not considered. Boyd and and toe joints are assessed bilaterally. One representative
Graham17 introduced a 0- to 4-point scale to assess ankle reciprocal movement that varies from the mass
dorsiflexion after botulinum toxin injections of the plantar flexor ⁄ extensor patterns is chosen to assess SVMC for each
flexors. Examiners were required to identify visually which joint. Evaluations are performed in the sitting position,
muscles were the primary or secondary movers. This test except for hip flexion, which is tested in the side-lying
was called ‘selective motor control of dorsiflexion’. Others position to allow for adequate joint excursion. Sitting and
have described it as a measure of CST function,20 side-lying positions allow evaluation of patients who are
although SVMC does not appear to be the primary focus. unable to stand, permit observation of contralateral limb
Specific muscles used to achieve dorsiflexion took movements, and enable the patient to visualize their limb
precedence over the use of mass patterns in the scoring. in case of proprioceptive deficits. The following factors
Although others have graded mass limb flexion during were used to develop the assessment and grading criteria:
dorsiflexion as the lowest level of SVMC,2,19 this test (1) ability to move each joint selectively; (2) involuntary
graded total limb flexion higher than recruitment of movement at other joints including the contralateral limb;
accessory muscles (toe extensors). Substitution of toe (3) ability to reciprocate movement; (4) speed of move-
extensors during dorsiflexion may occur in the presence of ment; and (5) generation of force as demonstrated by
plantar flexor contractures or tibialis anterior weakness excursion within the available range of motion. These were
and may not indicate SVMC impairment. Validation of based on components of CST function described in the lit-

608 Developmental Medicine & Child Neurology 2009, 51; 607–614

erature7 and methods of motor control assessment that Content validity
have been used historically.12,21 Content validity is ‘... the extent to which a measure is a
For each joint, the examiner first demonstrates the task complete representation of the concept of interest’ and is
by passively moving the limb through the desired move- established by evaluation of the instrument by knowledge-
ment sequence using a three-second verbal cadence. The able peers.25 Content validity of the SCALE tool was
approximate passive range of motion is noted for compari- established using written feedback from 14 expert clini-
son with the observed range during the patient’s active cians. Expert clinicians were defined as those having 10 or
effort. The patient is then asked to perform the desired more years of experience in evaluating patients with CP
motion at approximately the same speed without moving (experience range 10–40y, mean: 21y 2mo). They included
other joints of the extremity being tested or the contralat- 12 physical therapists, one occupational therapist, and one
eral limb. If unsuccessful, feedback is provided and addi- physician. Clinicians participated in an educational session
tional attempts are allowed. that included an overview of test administration using
The hip assessment is performed with the patient in videos or photographs of patients. They were provided
side-lying position. The examiner supports the weight of with written procedures and the prototype SCALE tool.
the limb but does not assist the movement. The patient is Participants were given an opportunity to ask questions
asked to flex, extend, and flex the hip while maintaining the and completed a written feedback form containing 32
knee in extension. This movement pattern was chosen over statements about the tool design (Table I). For each state-
hip extension because it was easier for patients to perform ment, participants were asked to check ‘agree’, ‘disagree’,
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. Table I: Selective Control Assessment of the Lower Extremity (SCALE)
The remainder of the assessment is performed in the sit- expert feedback form statements

ting position. The patient is asked to perform the following

Each of 32 statements was rated as Agree, Disagree, or Undecided
movement patterns: knee extension and flexion; ankle
Statements rated for each of five tests: hip, knee, ankle, subtalar,
dorsiflexion and plantar flexion with the knee extended;
and toe joints (20 statements)
subtalar inversion and eversion; and toe flexion and exten-
1. The position used is optimal for assessment of the desired
sion in a reciprocating pattern to a verbal cadence (e.g. motion.
‘flex, extend, flex’). SVMC is graded at each joint as ‘Nor- 2. The instructions for the patient are clear.
mal’ (2 points), ‘Impaired’ (1 point), or ‘Unable’ (0 points). 3. The movements requested ⁄ demonstrated are appropriate to
A grade of ‘Normal’ is given when the desired move- determine the selective motor control for the joint(s).
ment sequence is completed within the verbal count with- 4. The support or assistance given to the patient is appropriate for
out movement of untested ipsilateral or contralateral the test.
lower extremity joints. A grade of ‘Impaired’ is given Statements rated for grading (seven statements)
when the patient isolates motion during part of the task, 1. The speed is appropriate (within three-second verbal cadence).
2. The range of motion required for the tests is appropriate to
but demonstrates any of the following errors: movement
adequately differentiate between scores of Normal, Impaired,
occurs in only one direction; observed movement is less
and Unable.
than 50% of the approximate available passive range of
3. The criteria are clear to adequately differentiate between scores
motion found during the passive demonstration; move-
of Normal, Impaired, and Unable.
ment occurs at a non-tested joint (including mirror move- 4. The grades Unable and Impaired are clearly distinguishable.
ments); or the time for execution exceeds the approximate 5. The descriptions provided to elucidate the difference between
3-second verbal cadence. A grade of ‘Unable’ is given grades of Unable and Impaired are adequate.
when the requested movement sequence is not initiated 6. The grades Normal and Impaired are clearly distinguishable.
or when it is performed using a synergistic mass flexor or 7. The descriptions provided to elucidate the difference between
extensor pattern. A synergistic mass movement pattern is grades of Normal and Impaired are adequate.
defined as a simultaneous, obligatory flexor or extensor Statements rated for overall test (five statements)

pattern at two or more joints.23,24 If the patient does not 1. The order of test administration is appropriate.
2. The inclusion of a resisted flexor synergy pattern is needed or
initiate the requested movement sequence, extensor and
useful.
flexor synergy patterns may be elicited using manual resis-
3. The inclusion of a resisted extensor synergy pattern is needed
tance to verify muscle force-generating capacity. A
or useful.
SCALE score for each limb is obtained by summing the
4. The Total Limb Score is needed or useful.
points assigned to each joint for a maximum of 10 points 5. The Total Limb Score categories are appropriately distributed.
per limb.

SCALE Validity and Reliability Eileen G Fowler et al. 609

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

Totala (n=20) Team A (n=10) Team B (n=12) Table III: Characteristics of participants for construct validity (n=51)

Age (y:mo) Age (y:mo)

Mean (SD) 12:3 (5:5) 10:4 (3:11) 13:7 (5:10) Mean (SD) 11:11 (4:9)
Range 7:0–23:0 7:0–17:6 7:0–23:0 Range 5:1–23:0
Sex (n) Sex (n)
Female 13 6 9 Female 30
Male 7 4 3 Male 21
Distribution of impairment (n) Distribution of impairment (n)
Diplegia 16 8 9 Diplegia 35
Hemiplegia 3 1 3 Diplegia with hemiplegic overlay 5
Quadriplegia 1 1 0 Hemiplegia 6
GMFCS level (n) Quadriplegia 5
I 3 1 3 GMFCS level (n)
II 6 4 3 I 10
III 8 3 5 II 12
IV 3 2 1 III 19
IV 10
a
Two participants were evaluated by both teams of raters. GMFCS,
Gross Motor Function Classification System. GMFCS, Gross Motor Function Classification System.

610 Developmental Medicine & Child Neurology 2009, 51; 607–614

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

 factor affecting functional mobility, a perfect correlation
Table V: Interrater reliability of SCALE
between these two assessments was not expected. Impair-
ments such as balance, spasticity, contractures, bone and
Group Limb ICC 95% CIs p value
joint deformity, weakness, obesity, or de-conditioning are
A Left 0.88 0.69, 0.97 <0.001 other contributing factors that may explain the wider range
A Right 0.89 0.72, 0.97 <0.001 of scores obtained for patients requiring hand-held mobil-
B Left 0.90 0.77, 0.97 <0.001 ity devices for walking (GMFCS level III). For example,
B Right 0.91 0.79, 0.97 <0.001 the individual with highest SCALE score within GMFCS
level III (Fig. 1) had vision impairment. Although he could
SCALE, Selective Control Assessment of the Lower Extremity.
walk short distances without assistance, he routinely used a
raters are presented in Table V. ICCs ranged from 0.88 to walker. The participant with the lowest SCALE score at
0.91 and all were significant at p<0.001. GMFCS level III relied on good upper-body strength and
was able to ambulate using a walker, despite lack of lower
Construct validity extremity SVMC. We found that SCALE assessment for
SCALE scores were significantly inversely correlated with individuals assigned to GMFCS level V was not feasible as
GMFCS levels (Spearman’s rank correlation coefficient= most had a predominant motor disorder of dyskinesia
)0.83, p<0.001). The mean SCALE score declined from rather than spasticity, and many were unable to follow
15.0 for participants at GMFCS level I to 3.1 for partici- motor commands.
pants at GMFCS level IV (Fig. 1). SCALE scores showed Interrater reliability of clinical assessments was high
a clear downward trend; however, scores for participants at among six raters representing four different clinical special-
GMFCS level III showed considerable overlap in range ties with a wide range of experience. Not all differences
with participants at levels II and IV. among scores can be attributed to raters because perfor-
mance of patients on repeat testing may vary with practice,
DISCUSSION boredom, or fatigue. Because of this, only three consecu-
These results support content validity, construct validity, tive assessments were performed. Videotaped assessment
and interrater reliability of the SCALE tool. Content valid- could have been used to increase the number of raters
ity was substantiated by strong overall agreement among assessing a single testing session; however, this study was
14 expert clinicians and feedback was used for amendments designed to evaluate reliability of both administration and
and clarifications to the tool. Construct validity of SCALE scoring as would occur in a clinical setting.
was demonstrated by significant correlation with another Clinical utility is supported by both expert assessment
severity measure, the GMFCS. Because SVMC is only one 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
20
requires minimal training, can be performed within 10 to
18
15 minutes, and does not require equipment. Because the
16 2
Total SCALE score

2
14 2 ability to follow simple motor commands is necessary, it is
2
12 3 2 least suitable for patients under 4 years of age and those
4
10 2 with severe motor and intellectual impairments (GMFCS
8 2 2 V). Although scoring may not be possible for these
6 patients, SVMC can be described based on observations of
2
4 4
spontaneous movements. In our experience, patients classi-
2 2
3
fied at GMFCS level V were more likely to have dyskine-
0
I II III IV sia, which SCALE was not designed to address. Although
GMFCS-ER designed for use in CP, SCALE may be useful for assess-
ment of patients with other types of neurological involve-
Figure 1: Relationship between total Selective Control Assessment
ment such as hereditary spastic paraparesis, traumatic brain
of the Lower Extremity (SCALE) scores (sum of left and right) and injury, multiple sclerosis, or stroke.
Gross Motor Function Classification System - Expanded and Revised
version (GMFCS-ER) levels (n=51). Numerals to the right of symbols CONCLUSION
indicate the number of participants who share the same data point. Evidence for construct and content validity is presented
Spearman's rank correlation coefficient = –0.83, p<0.001. here as the first step in the validation of SCALE. Recent
work has shown that SCALE scores are correlated with

612 Developmental Medicine & Child Neurology 2009, 51; 607–614

laboratory measures of intersegmental coordination during SUPPORTING INFORMATION
gait,29 further supporting its validity. This study demon- Additional supporting information may be found in the online
strated high interrater reliability of the SCALE total limb version of this article:
scores. Ongoing research is examining SVMC impairment Appendix SI: SCALE: Selective Control Assessment of the
at individual joints. Studies of intrarater, test–retest reli- Lower Extremity.
ability, and long-term stability of SCALE scores are under- 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
way. SVMC assessment is believed to be most important
link you directly to the article).
for use as a prognostic indicator for treatment planning. As
Please note: Wiley-Blackwell are not responsible for the
there is a wide range of responses to various treatments in content or functionality of any supporting materials supplied
this population of patients, SVMC ability may guide the by the authors. Any queries (other than missing material)
selection of medical, surgical, or rehabilitative interven- should be directed to the corresponding author for the article.
tions. Introduction of SCALE should provide a meaningful
and universal tool for clinicians and researchers.

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1. Ostensjo S, Carlberg EB, Vollestad NK. 2006; 296: 1602–08. (PEDALS)—a randomized controlled trial
Motor impairments in young children 10. Tedroff K, Knutson LM, Soderberg GL. protocol for a stationary cycling interven-
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Lankhorst GJ, Becher JG. Prospective 11. Bhattacharya A, Lahiri A. Mirror move- The treatment of gait problems in cerebral
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 and reliability of a system to classify gross Motor Function Classification System, Exp- control on interjoint coordination during
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Livingston M. GMFCS-E&R. Gross lower extremity selective voluntary motor

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614 Developmental Medicine & Child Neurology 2009, 51; 607–614

 DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Lower-extremity selective voluntary motor control in patients with

spastic cerebral palsy: increased distal motor impairment
EILEEN G FOWLER 1 | LORETTA A STAUDT 2 | MARCIA B GREENBERG 3

1 UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy, and Tarjan Center for Disabilities at UCLA, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
2 UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy, and Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
3 UCLA ⁄ Orthopaedic Hospital Center for Cerebral Palsy, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.
Correspondence to Dr Eileen G Fowler at University of California, Los Angeles ⁄ 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 AIM Multiple impairments contribute to motor deficits in spastic cerebral palsy (CP). Selective
Accepted for publication 15th October 2009. voluntary motor control (SVMC), namely isolation of joint movement upon request, is important,
Published online 18th January 2010. but frequently overlooked. This study evaluated the proximal to distal distribution of SVMC
impairment among lower extremity joints.
LIST OF ABBREVIATIONS METHOD Using a recently developed tool, the Selective Control Assessment of the Lower
CST Corticospinal tract Extremity (SCALE), we evaluated the SVMC of the hip, knee, ankle, subtalar joint, and toes in a
PDC Proximal to distal concordance cross-sectional, observational study of 47 participants with spastic, diplegic, hemiplegic, and
SCALE Selective Control Assessment of the quadriplegic CP (22 males, 25 females; mean age 11y 9mo, SD 4y 8mo; Gross Motor Function
Lower Extremity Classification System levels I–IV).
SVMC Selective voluntary motor control
RESULTS Statistically significant decreases in SCALE scores from hip to toes were found using the
Page statistical test for trend (p<0.001). Statistically significant differences (p<0.05) were found
between all joint pairs, except toes versus subtalar, toes versus ankle, and right ankle versus sub-
talar joints. Cross-tabulation of score frequencies for all pairs revealed that proximal joint scores
were higher or equal to distal ones 81 to 100% of the time. Excluding toes versus subtalar joints,
proximal scores exceeded distal ones 94 to 100% of the time.
INTERPRETATION We confirmed increasing proximal to distal SVMC impairment, which may have
implications for treatment and research.

Individuals with cerebral palsy (CP) have limitations in motor frequent abnormal magnetic resonance imaging (MRI) finding
function resulting from multiple impairments including spas- associated with the spastic diplegic form of CP and it is found
ticity, contractures, weakness, and diminished selective motor in more than one-third of those with hemiplegia and quadri-
control. Selective motor control has been defined as ‘… the plegia.6 Strong correlations between damage to the CSTs and
ability to isolate the activation of muscles in a selected pattern motor impairment have been reported for children with CP.5,7
in response to demands of a voluntary movement or posture.’1 The CSTs have a specific anatomical arrangement as they
Selective voluntary motor control (SVMC) describes the per- descend from the motor cortex to the spinal motor neuron
formance of specific isolated joint movements upon request, as pools.8–10 In the periventricular area, motor fibers leading to
opposed to the habitual activation of selected muscles during the lower extremities are more likely to be damaged than those
functional tasks.2 SVMC at the ankle is a strong predictor of supplying the upper extremities because of their more medial
functional movement ability in children with CP,3 and SVMC position.10 This anatomical relationship has been confirmed
has been used as a prognostic factor in selecting candidates for in recent studies using MRI tractography.11,12 The somato-
selective posterior rhizotomy.4 We recently reported the topic organization of the lower extremity in the sensorimotor
development, validity, and reliability of the Selective Control cortex suggests that distal lower-extremity tracts are closer to
Assessment of the Lower Extremity (SCALE).2 SCALE is a the ventricle and more vulnerable than those of proximal
clinical tool designed to assess SVMC of the entire lower lower-extremity muscles (Fig. 1). Evidence exists of increased
extremity by summing the scores for five joints (hip, knee, distal impairment of lower-extremity motor function in chil-
ankle, subtalar joint, and toes). dren with spastic CP,13–15 but studies specifically examining
Voluntary isolated joint movements require activation of the relationship between SVMC of proximal compared with
the corticospinal tracts (CSTs). In patients with CP, damage distal lower-extremity joints have not been reported. Tedroff
to these tracts commonly occurs in the periventricular area.5 et al.13 evaluated the temporal sequence of muscle recruitment
Damage to the periventricular white matter is the most during maximal voluntary contractions in patients with

264 DOI: 10.1111/j.1469-8749.2009.03586.x ª The Authors. Journal compilation ª Mac Keith Press 2010
 Ankle Knee
Table I: Participant characteristics (n=47)
Hip
Age (y:mo)
Arm Mean (SD) 11:9 (4:8)
Range 5:1–23:0
Characteristic (n)
Face Sex
Male 22
Female 25
Distribution of impairment
Diplegia (three had hemiplegic overlay) 35
Hemiplegia 6
Quadriplegia 6
GMFCS-ER level
I 10
II 10
III 18
IV 9

GMFCS-ER, Gross Motor Function Classification Scale, Expanded and

Figure 1: Representation of corticospinal tracts as they relate to lateral
Revised edition.
ventricles (adapted from Aicardi and Bax10).

pump within the past year, (4) botulinum toxin injections

hemiplegic and diplegic CP compared with participants with- within 5 months, or (5) musculoskeletal injury within the past
out disability. Inappropriate activation of non-agonists before month.
agonists was more prevalent in distal than proximal muscula- One of three experienced raters performed the SCALE
ture in children with CP. During gait, Wakeling et al.14 assessment for the right and left lower extremity of each
reported that disordered muscle firing occurred more fre- participant. These raters previously demonstrated a high
quently in distal than proximal musculature in children with level of interrater reliability with intraclass correlation coeffi-
spastic diplegia. In addition, greater muscle weakness has been cients ranging from 0.88 to 0.91.2 Each participant was
quantified at the ankle joint than at more proximal joints.15–17 asked to perform specific non-synergistic reciprocal move-
The aim of this study was to analyse the distribution of ments and scores of unable 0, impaired 1, or normal 2 were
SVMC scores among lower-extremity joints in patients with assigned for the hip, knee, ankle, subtalar, and toe joints for
spastic CP using the SCALE tool. We hypothesized that each side.2 All tests were performed in the sitting position,
SVMC impairment would be greater in distal than proximal with the exception of the hip test, which was performed
joints. side-lying with the limb supported by the examiner. The
patient was asked to perform the following reciprocal move-
METHOD ment patterns: (1) hip flexion and extension with the knee
This cross-sectional, observational study was approved by the extended, (2) knee extension and flexion, (3) ankle dorsiflex-
University of California, Los Angeles, institutional review ion and plantarflexion with the knee extended, (4) subtalar
board. All participants with CP, or their parent or legal guard- inversion and eversion, and (5) toe flexion and extension. A
ian, provided informed assent and consent. Forty-seven indi- normal score (2) was given when the participant demon-
viduals with spastic CP who attended the UCLA ⁄ Orthopaedic strated isolated reciprocal joint motion through at least 50%
Hospital Center for Cerebral Palsy interdisciplinary clinic in of the available passive range of motion within an approxi-
Los Angeles volunteered to participate. Consecutive individu- mately 3-second verbal count. Unable (0) was assigned if the
als who met inclusion criteria were invited to enroll. It was participant could not move the joint or if the attempted
important to include participants across the spectrum of sever- movement occurred in a synergistic pattern (simultaneous
ity, based on Gross Motor Function Classification System one-to-one movement at two or more joints of the same
(GMFCS) level. There were a minimum of nine participants limb). A grade of impaired (1) was given if one or more of
representing each GMFCS level (I–IV). Previous work the following occurred: (1) the range of active movement
revealed that the SCALE assessment could not be performed was less than 50% of the participant’s available passive range
for patients at GMFCS level V.2 This sample size was consid- of motion, (2) movement occurred in only one direction, (3)
ered sufficient, based on previous work showing significant the task was performed slower than a 3-second verbal count,
correlation between GMFCS levels and SCALE scores for 51 (4) motion at untested joints occurred (including mirror
participants.2 Participant characteristics are presented in movement of the opposite limb). (See Data S1, the SCALE
Table I. The following inclusion criteria were used: (1) diag- Score Sheet, Directions for Administration, and Instructions
nosis of spastic CP, (2) ability to follow simple directions, and for Grading, supporting information, published online.)
(3) age between 4 and 25 years. The following exclusion crite- Individual joint SCALE scores were compared using non-
ria were used: (1) history of lower-extremity musculotendinous parametric repeated measures methods (Friedman procedure);
transfer or joint fusion, (2) neurosurgical or musculoskeletal the corresponding test for trend (Page test)18 was computed to
surgery within the past year, (3) initial placement of baclofen analyse the relation among joints from hip to toes for the left

Selective Voluntary Motor Control in Patients with CP Eileen G Fowler et al. 265
 2.0
1.8

Mean SCALE score

1.6 a
1.4
a
1.2
1.0
left b
0.8
0.6 right
0.4 c
0.2
0.0
Hip Knee Ankle STJ Toes
Joint

Figure 2: Mean Selective Control Assessment of the Lower Extremity (SCALE) scores by joint for left and right lower extremities. A score of 0.0 indicates the
participant was unable to isolate or used the full synergy pattern, 1.0 indicates impaired motor control, and 2.0 indicates normal isolated movement. Error bars
represent one standard deviation (+ for left and ) for right). a, significant differences for all joint pairs on both left and right (p<0.05); b, left ankle score was
significantly different from left hip, knee, and subtalar joint scores (p<0.05); c, right ankle joint score was significantly different from right hip and knee
(p<0.05) and showed a tendency toward a difference from the subtalar joint score (p=0.065). Specific p values for all joint pairs are given in Table II.
STJ, subtalar joint.

and right lower limbs. Additionally, score frequencies for all

Table II: Comparison between SCALE scores for five joints on the right
pairs of joints were cross-tabulated for the left and right sides.
and left with individual p values (Friedman test) and overall trend (Page
When the proximal joint score was equal to or greater than
test)
the distal joint, we called this proximal to distal concordance
(PDC). The percentage of PDC was calculated for all combi-
Joint comparison Left p value Right p value
nations of joint pairs within each limb. One hundred per cent
PDC indicated that distal joint scores never exceeded those of Hip vs knee 0.023 <0.001
proximal joints. StatXact 8.0 (Cytel Inc, Cambridge, MA, Hip vs ankle <0.001 <0.001
Hip vs subtalar joint <0.001 <0.001
USA) was used for statistical computations. Hip vs toes <0.001 <0.001
Knee vs ankle <0.001 <0.001
RESULTS Knee vs subtalar joint <0.001 <0.001
Knee vs toes <0.001 <0.001
Mean SCALE scores showed greater SVMC impairment in Ankle vs subtalar joint 0.023 0.065
distal than proximal joints bilaterally (Fig. 2). A statistically Ankle vs toes 0.227 0.180
significant decrease in SCALE scores from hip to toes was Subtalar joint vs toes 0.424 0.774
Overall trend <0.001 <0.001
found using the Page statistical test for trend (p<0.001). Signif-
icant differences were found between all pairwise SCALE Significant at p=0.023 and p<0.001. SCALE, Selective Control
score comparisons involving the hip and the knee joints bilat- Assessment of the Lower Extremity.
erally. The left ankle scores were significantly different from
all other joint scores except the toes. The right ankle joint These results support the concept of increased vulnerability of
scores differed from the hip and knee scores and showed a ten- CSTs associated with distal lower-extremity musculature. Pre-
dency toward a difference from the subtalar joint score vious research examining muscle strength15–17 similarly found
(p=0.065) Comparisons between scores for toes versus subta- increased deficits in distal joints. Impaired SVMC may be
lar, and toes versus ankle, did not show a significant difference associated with the observations reported in these studies. To
for either limb. Table II presents p values for all pairwise com- determine the relative influence of muscle strength (force-gen-
parisons using the Friedman test. The percentage PDC for erating capacity) and SVMC (neurological recruitment by
cross-tabulations of joint score frequencies ranged from 81 to CSTs) on movement production, both test positioning and
100% (Fig. 3). Excluding comparisons between score frequen- the movement pattern requested must be examined. In design-
cies for toes and subtalar joints, the percentage PDC was 94 to ing the SCALE ankle assessment for isolated motion out of
100% (Fig. 3). Distal joint scores exceeded proximal ones for synergy, we positioned the knee in extension when requesting
only nine limbs (seven participants) when comparisons involv- ankle dorsiflexion. To verify force-generating ability at the
ing the toes were excluded. ankle, a flexor synergy pattern was elicited separately by resist-
ing hip flexion and noting the active ankle dorsiflexion. This
DISCUSSION phenomenon has been referred to as the ‘confusion test’.19
To our knowledge, this is the first study to report SVMC of Participants in the present study with an absence of SVMC at
the hip, knee, ankle, subtalar, and toe joints in individuals with the ankle (a SCALE score of 0) could demonstrate active ankle
spastic CP. Our hypothesis of greater distal than proximal dorsiflexion only when using the total flexor synergy pattern.
SVMC impairment within each limb was mostly confirmed. Wiley and Damiano15 found greater ankle dorsiflexor strength

266 Developmental Medicine & Child Neurology 2010, 52: 264–269

 a Knee Ankle STJ Toes
0 1 2 0 1 2 0 1 2 0 1 2
0 6 2 0 8 0 8 0 8
Hip 1 1 15 Hip 1 12 4 Hip 1 15 1 Hip 1 10 6
PDC 96% 2 10 13 PDC 100% 2 3 13 7 PDC 100% 2 6 13 4 PDC 100% 2 5 16

Ankle STJ Toes

0 1 2 0 1 2 0 1 2
0 7 0 7 0 7
Knee 1 16 10 1 Knee 1 20 7 Knee 1 14
4 13
PDC 98% 2 7 6 PDC 100% 2 2 7 4 PDC 100% 2 2 9 2

STJ Toes
0 1 2 0 1 2
0 22 1 0 20 3
Ankle 1 7 9 1 Ankle 1 3 14
PDC 96% 2 4 3 PDC 94% 2 5 2

Toes
0 1 2
0 20 9
STJ 1 3 11
PDC 81% 2 2 2

b Knee Ankle STJ Toes

0 1 2 0 1 2 0 1 2 0 1 2
0 7 1 0 8 0 8 0 7 1
Hip 1 3 7 Hip 1 9 1 Hip 1 10 Hip 1 9 1
PDC 98% 2 15 14 PDC 100% 2 4 22 3 PDC 100% 2 11 14 4 PDC 98% 2 8 20 1

Ankle STJ Toes

0 1 2 0 1 2 0 1 2
0 10 0 10 0 9 1
Knee 1 9 13 1 Knee 1 14 8 1 Knee 1 11 12
PDC 98% 2 2 10 2 PDC 98% 2 5 6 3 PDC 98% 2 4 9 1

STJ Toes
0 1 2 0 1 2
0 21 0 19 2
Ankle 1 8 13 2 Ankle 1 5 18
PDC 96% 2 1 2 PDC 96% 2 2 1

Toes
0 1 2
0 22 7
STJ 1 2 12
PDC 85% 2 3 1

Figure 3: Cross-tabulations of Selective Control Assessment of the Lower Extremity score frequencies for (a) left and (b) right lower-extremity joints showing
the percentage proximal to distal concordance (PDC). Shaded zones indicate relationships that violated PDC because the distal joint scores exceeded the
proximal joint scores. STJ, subtalar joint.

deficits when the knee was extended rather than flexed, dem- activated a muscle other than the intended prime mover
onstrating the influence of impaired SVMC. Although these first, especially when the prime mover was a more distal
investigators concluded that distal muscles were generally muscle. These results are consistent with our findings of
weaker than proximal muscles, the hip extensors were an decreased ability to perform isolated joint motion distally.
exception, being weaker than the ankle muscles. As the As Tedroff et al. did not specify whether the participants
SCALE hip test was performed in an antigravity side-lying performed isolated joint motion out of synergy, and we
position, minimizing the need for muscle force-generating did not record electromyograms, direct comparisons are
capacity, we found that SVMC at the hip exceeded that found limited.
at the ankle. Excluding comparisons involving the toes, PDC exceptions
Tedroff et al.13 reported that during maximal voluntary in our study were rare, and could have been caused by scor-
contractions, children with spastic CP more frequently ing errors or other factors affecting patient performance, such

Selective Voluntary Motor Control in Patients with CP Eileen G Fowler et al. 267
as impaired motor planning. Some exceptions to the PDC movement in adults after stroke and is an indicator of the
appeared to be related to the presence of either restricted highest level of recovery for the lower extremity.23 Another
range of motion or mirror movements. Contractures or possible explanation is that moving only one of multiple
severe spasticity can mask underlying SVMC. One 15-year- toe joints was sufficient to obtain a SCALE score of 1,
old participant with spastic diplegia (GMFCS level I) had a reducing the relative potential for a score of 0 at the toes
subtalar score of 2, whereas the more proximal ankle joint compared with the subtalar joint. Finally, there may be
was scored 1, owing to restricted range of motion. As this greater capacity for sparing of corticospinal fibers associ-
study supports increased proximal SVMC, it is possible that ated with toe movement owing to greater density of CSTs.
this participant’s ankle would have been scored 2 if tested at In early mapping studies of the human motor cortex, the
a younger age, before contracture development. The higher area of cortical representation for the great toe was
score at the subtalar joint predicts greater functional exceeded only by the tongue, mouth, thumb, and fingers.8,9
improvement after contracture release than if the score were More recent studies indicate that both toe musculature
1 or 0. This is one example of how SVMC assessment, par- and tibialis anterior have a higher density of associated
ticularly as part of a periodic evaluation for children with monosynaptic corticospinal projections than proximal
spastic CP during development, may be helpful in predicting lower-limb musculature.24
the potential for functional improvement after a specific SVMC assessment and the proximal to distal distribution of
treatment. impairment can be useful in treatment planning and in consid-
Mirror movements are simultaneous, obligatory move- ering prognoses for the development of motor function in
ments that occur at contralateral joints during active young children with CP. Based on the proximal to distal
movement. In adults without disability, most CSTs are increase in SVMC impairment, patients who are assigned a
crossed; however, extensive ipsilateral tracts are normally score of 2 at the ankle or subtalar joint are more likely to have
present in early development. In hemiparetic CP, there is scores of 2 at the knee and hip. Although examining SVMC at
evidence that surviving contralateral tracts may be compet- the individual joint level can be helpful in treatment planning,
itively displaced by persistent ipsilateral tracts20,21, which the SCALE total limb score is more useful when describing a
may be responsible for mirroring.22 Using the SCALE patient’s overall functional ability. For example, we have
tool, a score of 1 is given at a joint when the same move- shown that SCALE total limb scores are significantly related
ment pattern is observed contralaterally. Mirror move- to the performance of simultaneous hip flexion and knee
ments negatively affected the PDC in the less involved extension, as normally occurs, during the terminal swing phase
limb for some participants with asymmetrical CP. In par- of gait.25
ticular, two participants with spastic hemiplegia could iso- We believe this is the first systematic evaluation and
late movement of their ankle joint on their non- comparison of SVMC among multiple lower-extremity
hemiplegic side, but received scores of 1 owing to mirror joints in individuals with spastic CP. It confirms the
ankle movement on their hemiplegic side. Mirroring did increase in severity of impairment from proximal to distal
not occur during subtalar joint testing on their non-hemi- joints. Although previous research supports greater impair-
plegic sides, giving these limbs a score of 2 at the more ment in distal muscles and joints, this phenomenon has
distal joint. Although the presence of mirroring is more received little attention. Anatomical and physiological
likely to reflect a primary pathology for the hemiplegic mechanisms contributing to these findings require further
limb, we assigned the SVMC impairment for the limb study. Our results support selective vulnerability of the
being assessed, as it is movement of this limb that elicits corticospinal tracts innervating distal musculature owing to
the abnormal movement pattern and any resulting func- their proximity to the ventricles. Although the participants
tional problems. The effects of obligatory mirror move- in this study had a clinical diagnosis of spastic CP, damage
ments on functional lower-extremity motor tasks such as to the periventricular white matter was not documented in
walking are unknown and require further study. this sample. Newer technologies allow documentation of
The most frequent exceptions to the PDC occurred precise damage to white matter tracts using MRI with dif-
when the toes were graded as 1 and the subtalar joint was fusion tensor imaging. This may be useful in elucidating
graded as 0, indicating absent subtalar SVMC with sparing the relation between the injury and functional impairment;
at the toes. There are several possible explanations for these studies are currently in progress.
these findings. One may be that the toes are not truly
distal anatomically. Although the insertions of the toe mus- SUPPORTING INFORMATION
culature are more distal, the origin of muscles controlling Additional supporting information is available for this article online:
the ankle, subtalar joint, and toes are similar. In addition, Data S1: The Selective Control Assessment of the Lower Extremity
control of the subtalar joint appears to be more challenging (SCALE), Score Sheet, Directions for Administration and Instructions for
than that of other joints. We observed that isolated motion Grading.
Please note: Wiley-Blackwell are not responsible for the content or func-
of the subtalar joint was the most difficult movement
tionality of any supporting materials supplied by the authors. Any queries
sequence for participants with CP to understand and per-
(other than missing material) should be directed to the corresponding
form. Similar observations have been reported for patients author of the article).
after stroke. Eversion was described as a challenging

268 Developmental Medicine & Child Neurology 2010, 52: 264–269

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