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Selective Control Assessment of the Lower Extremity (SCALE)
Availability
Please visit this website for more information about the instrument: SCALE
Availability: Permission for use should be sought from the author, Dr. Eileen Fowler, efowler@mednet.ucla.edu.
Classification
Supplemental: Cerebral Palsy (CP)
Short Description of Instrument
Construct measured: Selective Voluntary Motor Control of the Lower Extremity.
Generic vs. disease specific: Disease specific.
Means of administration: Examiner administered.
Intended respondent: Administrator.
 
Background: The Selective Control Assessment of the Lower Extremity (SCALE) is a clinical tool developed to quantify selective voluntary muscle control of the hip, knee, ankle, subtalar joint, and toes in patients with spastic cerebral palsy (CP). It has been validated in participants ages 5 years through adulthood, including male and female individuals with spastic CP functioning at GMFCS levels I-IV with unilateral and bilateral involvement.
Comments/Special Instructions
Subject must be able to understand and follow verbal directions. Passive demonstration of each motion is provided first and passive range is noted. Then, the subject is asked to actively isolate each joint motion without moving any other joint Trials may be repeated for best effort. At each joint, a reciprocal joint motion is requested to an approximately 3 second count. Resisted total limb movements (synergies) can be used to verify force generating capacity if no motion is observed.
 
All tests are performed in a sitting position except the hip test which is performed in sidelying. The following recipricol motions are requested: hip flexion and extension with the knee extended (examiner supports the weight of the limb); knee extension and flexion; ankle dorsiflexion and plantarflexion with the knee extended; subtalar joint inversion and eversion; and toe flexion and extension.
Scoring
Each joint movement is scored 0 to 2 with 0, being unable to perform movement; 1, being impaired; and 2, being normal. For a grade of normal, the desired movement sequence is performed through at least 50% of the available passive range, within  the timing of the 3 sec. verbal count without movement of untested ipsilateral or contralateral joints. For a score of impaired, motion is isolated for part of the task  but one or more of the following errors is seen: movement occurs in only one direction, movement is less than 50% of available passive range, movement occurs at a non-tested joint (including mirroring), or time for execution exceeds approximate 3-second count. A grade of unable is given when the requested movement sequence is not initiated or it is performed using a synergistic mass movement pattern (simultaneous obligatory motion at two or more joints). A SCALE score for each limb is obtained by summing the five joint scores for a maximum of 10 points.
 
Administration Time: 15 minutes
Rationale/Justification
Strengths/Weaknesses: Can be performed quickly in a clinical setting without special equipment. Requires ability to understand and follow directions. Designed for spastic type of CP only (GMFCS levels I-IV).
 
Psychometric Properties: ICC for interrater reliability was 0.88 to 0.91. Intrater reliability of video recorded assessments was also high (ICC of .95–.96). Construct validity, as determined by Spearman’s Rank Correlation with GMFCS was -0.83. Content validity was based on review by 14 expert raters (mean agreement 91.9%). SCALE has shown discriminant ability to detect differences between affected and unaffected limb in unilateral CP and more and less affected limb in asymmetric bilateral CP. It has discriminant ability to detect differences between GMFCS Levels I and II, though not between III and IV. This may be due to underpowered validation studies. It demonstrated high concurrent validity with Fugl-Meyer Assessment and Manual Muscle Testing as well as a moderate negative correlation with Modified Ashworth Scale. SCALE scores were highly correlated with uncoupled hip and knee movement during the swing phase of gait.
References
Fowler EG, Staud L A, Greenberg M B, Oppenheim W L. Selective Control Assessment of the Lower Extremity (SCALE): development, validation, and interrater reliability of a clinical tool for patients with cerebral palsy. Dev Med Child Neurol. 2009;51(8), 607–614.
 
Additional References:
 
Balzer J, Marsico P, Mitteregger E, van der Linden M L, Mercer TH, van Hedel HJ. Construct validity and reliability of the Selective Control Assessment of the Lower Extremity in children with cerebral palsy. Dev Med Child Neurol. 2016;58(2), 167– 172.
 
Fowler EG& Goldberg EJ. The effect of lower extremity selective voluntary motor control on interjoint coordination during gait in children with spastic diplegic cerebral palsy. Gait Posture. 2009;29(1), 102–107.
 
Fowler EG, Staudt LA, Greenberg MB. Lower-extremity selective voluntary motor control in patients with spastic cerebral palsy: increased distal motor impairment. Dev Med Child Neurol. 2010;52(3), 264–269.
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