DEVELOPMENTAL MEDICINE & CHILD NEUROLOGY ORIGINAL ARTICLE

Construct validity and reliability of the Selective Control

Assessment of the Lower Extremity in children with cerebral
palsy
JULIA BALZER 1 | PETRA MARSICO 1 | ELENA MITTEREGGER 2 | MARIETTA L VAN DER LINDEN 3 |
THOMAS H MERCER 3 | HUBERTUS J A VAN HEDEL 1

1 Pediatric Rehab Research Group, Rehabilitation Center for Children and Adolescents, University Children’s Hospital Zurich, Affoltern am Albis; 2 Regional Group
Zurich Foundation Cerebral Palsy (RGZ), Zurich, Switzerland. 3 Rehabilitation Sciences, School of Health Sciences, Queen Margaret University, Edinburgh, UK.
Correspondence to Julia Balzer, Pediatric Rehab Research Group, Rehabilitation Center for Children and Adolescents, University Children’s Hospital Zurich, M€uhlebergstrasse 104, CH-8910
Affoltern am Albis, Switzerland. E-mail: Julia.Balzer@kispi.uzh.ch

This article is commented on by Fowler on page 116 of this issue.

PUBLICATION DATA AIM Assessing impaired selective voluntary movement control in children with cerebral palsy
Accepted for publication 14th April 2015. (CP) has gained increasing interest. We investigated construct validity and intra- and
Published online 20th May 2015. interrater reliability of the Selective Control Assessment of the Lower Extremity (SCALE).
METHOD Thirty-nine children (21 males, 18 females) with spastic CP, mean age 12 years 6
ABBREVIATIONS months [range 6y 11mo–19y 9mo], Gross Motor Function Classification System (GMFCS)
FMA Fugl-Meyer Assessment levels I to IV, participated. Differences in SCALE scores were determined on joint levels and
ICC Intraclass correlation coefficient between patients categorized according to their limb distribution and GMFCS levels. SCALE
IQR Interquartile range scores were correlated with the Fugl-Meyer Assessment, Manual Muscle Test, and Modified
MAS Modified Ashworth Scale Ashworth Scale. To determine reliability, the SCALE was applied once and recorded on
MDC Minimal detectable change video.
MMT Manual Muscle Test RESULTS SCALE scores differed significantly between the less and more affected leg
SCALE Selective Control Assessment (p<0.001) and between most leg joints. Total SCALE scores differed significantly between
of the Lower Extremity GMFCS levels I and II. Correlations with Fugl-Meyer Assessment, Manual Muscle Test, and
SVMC Selective voluntary motor con- Modified Ashworth Scale were 0.88, 0.88, and –0.55 respectively. Intraclass correlation
trol coefficients were all above 0.9, with the minimal detectable change below 2 points.
INTERPRETATION The SCALE appears to be a valid and reliable tool to assess selective
voluntary movement control of the legs in children with spastic CP.

With an incidence of 2 to 3 per 1000 in Europe, cerebral the past decades, recent studies have indicated the impor-
palsy (CP) is the most common motor disorder in child- tance of SVMC in relation to motor performance.5–7 The
hood.1 Depending on the severity and location of the results of several studies suggest that a loss of SVMC inter-
congenital brain lesion, the appearance of positive and neg- feres much more with motor performance, such as walking,
ative motor signs are heterogeneous.2 Positive motor signs than, for instance, hypertonia and contractures.5–7 Further-
are associated with an involuntarily increased frequency or more, impaired selective activation can initiate and worsen
magnitude of muscle activity (i.e. hypertonia), whereas neg- a vicious cycle of limited active movement, joint contrac-
ative signs are characterized by insufficient muscle activity tures, hampered motor function, and diminished activity,
(i.e. muscle weakness) and their control (i.e. selective volun- thereby causing pain and appearance of secondary deformi-
tary motor control [SVMC]).2 Impaired SVMC has been ties in children with CP.8 Although the clinical importance
defined as the inability ‘to isolate the activation of muscles of physiological muscle activation is obvious, routinely
in a selected pattern in response to demands of a voluntary assessing selectivity is rare in the clinical environment,
movement or posture’.2 It is one of the most common which, in turn, hampers evaluation of therapy-induced
motor impairments of the lower extremity in children with changes in SVMC.9
spastic CP.2,3 As impaired SVMC can be caused by a reduc- This lack of clinical assessment might be explained by
tion of corticospinal drive as well as by increased input of the fact that testing SVMC is challenged by the coexis-
descending subcortical pathways, consensus about its exact tence of other motor signs. For instance, besides impaired
pathophysiological nature is still lacking.2–4 Although in SVMC, increased muscle tone or a lack of muscle strength,
comparison to other motor signs (e.g. hypertonia, muscle range of motion, sensory awareness, or stability in other
strength) improving SVMC has received little attention in joints can also result in limitations of movement quality.8

© 2015 Mac Keith Press DOI: 10.1111/dmcn.12805 167

Therefore, requirements of measures evaluating SVMC are What this paper adds
high and only a few tools exist in the rehabilitation setting, • The Selective Control Assessment of the Lower Extremity (SCALE) German
especially for young patients with bilateral involvement.5,9 version is a valid and reliable assessment for children with spastic CP.
Recently, a clinical tool, the Selective Control Assessment • Total SCALE scores differed significantly between Gross Motor Function
of the Lower Extremity (SCALE), was developed to assess Classification System levels I versus II.
SVMC of the lower extremity in children with CP.10 In
• Minimal detectable change of the SCALE is 2 points.

comparison to other SVMC tests,11 the SCALE’s testing

procedure favourably attempts to differentiate between follow simple instructions. Participants with an unstable
muscle weakness and a lack of selective control, by rating a situation regarding their tonus-regulating medications and/
joint movement as ‘normal’, when the patient is able to or who had a botulinum toxin injection within the last 6
move his/her joint selectively (i.e. without co- and mirror months, or any surgical correction within the last year,
movements and within the three verbal count [i.e. ‘extend, were excluded. The study was approved by the ethical
flex, and extend again’]), even if the patient can only per- committee of the Canton of Zurich (KEK-ZH-Nr.2011-
form 50% of the passive range of motion. Furthermore, 0404). Informed consent and assent were obtained from
the SCALE’s check box allows for a more precise descrip- parents and participants.
tion of the nature of impaired selectively (i.e. contractures,
mirror movements, co-movement on other joints), which Measurements
can add important clinical information. Its content validity In order to promote assessment of the SCALE in the Ger-
was approved by experienced clinicians and construct vali- man-speaking clinical environment, the SCALE was trans-
dity was excellent, as SCALE scores correlated well with lated into German according to international guidelines:17
the Gross Motor Function Classification System (1) translation into German by two independent native
(GMFCS).10 The SCALE confirmed increasing proximal German-speaking physiotherapists; (2) creation of a con-
to distal impairment in children with CP, which can be sensus version; (3) back-translation into English by a trans-
explained by the somatotopic organization of the lower lation company; and (4) endorsement by the authors of the
extremity in the sensorimotor cortex.12 Furthermore, the original version (see Appendix S1, online supporting infor-
SCALE’s interrater reliability was excellent with intraclass mation, for the final German SCALE version).
correlation coefficients (ICCs) ranging from 0.88 to 0.91.10 Testing procedures were standardized according to the
Three recent studies,13–15 all from the SCALE develop- assessment guidelines. All tests were carried out by the
ers, showed its predictive ability in relation to neurologi- same two experienced neuropaediatric physiotherapists,
cally-induced gait disorders. Despite these interesting and one assessing and one assisting. Tests were performed for
promising findings, its construct validity has not been fur- both legs within a maximum time-frame of 1 hour.
ther investigated. Therefore, the aim of this study was to SCALE administration required patients to perform spe-
further evaluate validity of the SCALE in children with cific isolated movement patterns at the hip, knee, ankle,
spastic CP. Based on results from previous studies, we subtalar, and toe joint. SVMC of each joint movement was
hypothesized that SCALE scores would differ significantly scored on a 3-point ordinal scale. SVMC was scored as
between adjacent or contralateral joint pairs (i.e. lower in ‘normal’ (2 points) if the patient could move the tested
distal joints, lower in more affected limbs, respectively), joint isolated (e.g. without moving other joints), within at
less and more affected limbs, and GMFCS levels. To least 50% of the possible range of motion, and at a physio-
establish concurrent validity of the SCALE, a high positive logical cadence cued verbally by the therapist (e.g. ‘flex,
correlation (p>0.70) between the SCALE and the Fugl- extend, flex’). If any deviation in performance occurred
Meyer Assessment (FMA) was expected. We further (movement performed slower, below 50% of range of
hypothesized that children with spastic CP and a high movement, with co-/mirror-/synergistic-movements), selec-
degree of muscle weakness and/or spasticity would score tivity was regarded as impaired (1 point). The score unable
low via the SCALE assessment. Finally, we hypothesized was given, if no joint movement could be made or mass-
that reliability would be excellent, with ICC values exceed- synergy-patterns occurred. SVMC was scored separately
ing 0.8 (see also Fowler et al.10) and accompanied by for each joint, for each limb, and for both limbs together.
acceptable levels of absolute measurement error. To analyze discriminant validity, patients were classified
according to their limb involvement and GMFCS18 level
METHOD (I–IV). The Manual Muscle Test (MMT) leg-score was
Participants used to determine the more and less affected leg. If MMT
In- and outpatients of the Rehabilitation Centre Affoltern scores were similar, further differentiation was based on
am Albis, University Children’s Hospital Zurich were Modified Ashworth Scale (MAS) scores.
recruited by convenience sampling. A minimum sample To assess the SCALE‘s concurrent validity, the FMA19
size of 25 to 30 participants was required, in order to pro- was measured. The FMA is a valid assessment tool for test-
vide an accurate estimate of the random error.16 Inclusion ing SVMC in stroke and contains specific items for testing
criteria were: diagnosis of CP, aged between 5 and 20 selectivity of the knee (FMA items IIIa; IVa) and ankle
years, ability to walk (GMFCS levels I–IV), and ability to joint (FMA items IIIb; IVb). Like the SCALE, the FMA

168 Developmental Medicine & Child Neurology 2016, 58: 167–172

uses a 3-point ordinal scale to score (0=cannot perform; Statistical analysis was performed with SPSS 17.0 (IBM,
1=performs partly; 2=performs fully) selectivity of the joint Armonk, NY, USA).
movement.
Furthermore, when correctly applied, the MMT should RESULTS
also reflect the selective activation of a muscle (group). We Forty-two children with spastic CP gave informed consent
therefore assessed strength of the hip and knee flexors and to participate in this study. One child did not complete the
extensors, and of ankle dorsi- and plantar-flexors by the assessments because of a lack of compliance. As allocation
MMT (0–5; Kendall et al.20). of the more and less affected leg was not possible in two
Despite spasticity and SVMC being different constructs, data sets, these data sets were omitted from all analyses.
spasticity can negatively influence SVMC and therefore we Therefore, demographic and clinical characteristics of 39
were interested in correlating the SCALE with MAS scores children with spastic CP (unilateral n=20; bilateral n=19)
(0–4; Bohannon and Smith21). We assessed the MAS also were available. The mean age was 12y 6mo (SD 3y 7mo).
for hip, knee, and ankle joints. The SCALE assessment was Eighteen children were female. Twenty-three children had
videotaped for (intra- and interrater) reliability testing, in a GMFCS level I, five had level II, eight level III and three
order to minimize participants’ strain. The camera was level IV. Further characteristics are presented in Table I.
positioned in front of the participant. This position allowed
observation of the tested joint movement and of possible Discriminant validity
compensatory and mirror movements of the contralateral SCALE scores of contralateral joint pairs (i.e. knee vs
limb, as well as of other body parts. Although an additional knee) of the less affected leg were significantly higher com-
video from the sagittal plane may have allowed for a more pared to those of the more affected leg, with the exception
accurate evaluation of the range of motion of the ankle and of the hip joint, p=0.157 (Fig. 1a). SCALE scores were
knee joint, none of the raters experienced difficulties in generally lower for distal compared to proximal joints for
evaluating whether the movement exceeded 50% of the both legs, with the exception of the ankle versus toes for
passive range of motion (one criterion that differentiates the less affected leg, and bilaterally for the subtalar joint
between normal or impaired SVMC) or not. For reliability on toes (Fig. 1a). SCALE limb scores were higher for the
testing the videotaped assessment was scored twice within a less affected limb (median=7; interquartile range [IQR]=0–
timeframe of 6 to 8 weeks after the first scoring. Rater(s) 10) compared to the more affected limb (median=5;
was (were) blinded to the results of the first scoring (intrar- IQR=0–9; p<0.001). When classifying participants in accor-
ater) or results from the other rater (interrater). dance with their diagnosis, statistically significant differ-
ences between the less and more affected limb were
Statistical analysis present for children with unilateral limb involvement (less
The Shapiro–Wilk test showed that most scores were not affected: median=9; IQR=7–10, vs more affected: med-
normally distributed, hence non-parametric statistical tests ian=4.5; IQR=3–6; p<0.001) and bilateral involvement (less
were used. affected: median=5; IQR=2.5–6, vs more affected: med-
Therefore, a Friedman test was performed to determine ian=6; IQR=3.5–7; p=0.003) (Fig. 1b).
whether SCALE scores differed between joint pairs of each
leg. Alpha was set at 0.05 (two-tailed). Post hoc differences
between adjacent joints (i.e. hip vs knee), as well as Table I: Participants characteristics
between sum scores of the more and less involved leg, were Spastic CP (n=39)
determined with the Wilcoxon signed rank test (to adjust
for multiple comparisons, alpha was set at 0.01). Differ- Measures Mean (SD) Median (IQR) Range

ences in total SCALE scores for children categorized via Scale

GMFCS level were evaluated with the Kruskal–Wallis test. Less affected leg (9/10) 6.6 (2.8) 7.0 (4.0) 0–10
More affected leg (9/10) 4.5 (2.0) 5.0 (3.0) 0–9
We defined a priori that we performed post hoc successive Total score (9/20) 11.2 (4.5) 13.0 (4.5) 0–19
pair-wise testing between adjacent GMFCS levels (e.g. FMA
level I vs II, level II vs III) with Mann–Whitney U tests Less affected leg (9/8) 5.7 (2.9) 8.0 (4.0) 0–8
More affected leg (9/8) 3.8 (2.5) 5.0 (3.5) 0–8
(post hoc tests: alpha=0.025). To further evaluate the valid- Total score (9/16) 9.6 (5.1) 11.0 (8.0) 0–16
ity of the SCALE Spearman’s rank correlation coefficients MMT
(q) between SCALE scores on joint, limb, and total levels Less affected leg (9/30) 24.8 (6.1) 28.0 (11.0) 10–30
More affected leg(9/30) 20.9 (5.5) 23.0 (9.0) 9–30
and FMA, MMT, and MAS scores were calculated. Rela- Total score (9/60) 45.6 (11.0) 49.0 (17.5) 20–59
tive intra- and interrater reliability was evaluated by ICCs MAS
(two-way mixed model; type absolute agreement) and cor- Less affected leg (9/24) 1.9 (3.1) 1.0 (2.5) 0–14
More affected leg (9/24) 3.4 (3.2) 2.0 (3.0) 1–16
responding 95% confidence intervals were calculated for Total score (9/48) 5.4 (6.0) 3.0 (5.0) 1–30
the less and more involved leg. Absolute reliability was
determined by the standard error of measurement CP, cerebral palsy; SD, standard deviation; IQR, interquartile range;
SCALE, Selective Control Assessment of the Lower Extremity; FMA,
(SEM=SD9√(1-r)) and the minimal detectable change Fugl-Meyer Assessment; MMT, Manual Muscle Test; MAS, Modi-
(MDC=SEM9√291.96). fied Ashworth Scale.

Validity and Reliability of Selectivity Testing in CP Julia Balzer et al. 169

 (a) SCALE on joint levels Wilcoxon signed Less affected More affected
ranks test (α≤.05) leg p value leg p value
2 Hip vs knee 0.020 <0.001
1,8 Overall p<0.001
Hip vs ankle <0.001 <0.001
1,6
SCALE joint score

Hip vs STJ <0.001 <0.001

1,4 p=0.157
Hip vs toes <0.001 <0.001
1,2
1 Knee vs ankle 0.002 <0.001
p=0.001
0,8 Knee vs STJ <0.001 <0.001
0,6 Knee vs toes 0.005 <0.001
p=0.007
0,4 Less affected leg Ankle vs STJ <0.001 0.013
p<0.001 p<0.001
0,2 More affected leg Ankle vs toes 0.001 0.257
0 STJ vs toes 0.564 0.058
Hip Knee Ankle STJ Toes

(b) SCALE and limb involvement (c) SCALE and GMFCS levels
p<0.001 p=0.002 20 Overall differences p<0.001
10
18

SCALE total score

SCALE limb score

8 16
14
6 12
10
4 8
6
4
p=0.007
2
2
0 0
Spastic Spastic Spastic Spastic GMFCS I GMFCS II GMFCS III GMFCS IV
unilateral unilateral bilateral bilateral (n=23) (n=5) (n=8) (n=3)
l. a. leg m. a. leg l. a. leg m. a. leg

Figure 1: Discriminant validity for children with spastic cerebral palsy. (a) SCALE and joint pairs: SCALE joint scores between more and less involved
limb and on adjacent pairs of joints: Friedman test and post hoc Wilcoxon signed rank test (post hoc tests: p values below 0.01 are considered signifi-
cant). (b) SCALE and limb distribution: total SCALE scores of less affected (l.a.) versus more affected (m.a.) leg in children with spastic unilateral and
bilateral limb involvement: Wilcoxon signed rank test. (c) SCALE and GMFCS levels: significant differences between all GMFCS levels (Kruskal–Wallis
test) and between GMFCS I versus II (post hoc Mann–Whitney U test: p values below 0.025 are considered significant). SCALE, Selective Control
Assessment of the Lower Extremity; STJ, subtalar joint; GMFCS, Gross Motor Function Classification System.

Furthermore, SCALE scores differed significantly between between adjacent or contralateral joint pairs, between more
GMFCS levels (p<0.018), and, more specifically, between versus less affected limb, or between GMFCS levels, we
GMFCS levels I and II (Fig. 1c). could partly confirm our hypotheses in line with previous
results.10
Correlations Concerning the SCALE’s ability to discriminate between
For the total SCALE score, high correlations22 between the more and less affected limb in children with hemi- and
FMA and MMT were found (Fig. 2).The magnitude of the diplegia, differences were significant for both groups, but
correlations between SCALE limb and joint scores, and for the latter subgroup the difference was below the MDC.
the clinical measures were comparable to those presented On joint level, SCALE scores of the hip joint did not
for the total scores. differ between the more and less impaired limb. This could
There was a negative moderate correlation between the be because of the limited number of participants with
SCALE and the MAS total scores. greater motor impairment at the hip (i.e. GMFCS level
IV) and the large number of children with near maximal
Reliability scores (ceiling effect, i.e. 10 participants had a maximum
With ICC values exceeding 0.9 for limb and 0.8 for joint total SCALE score for their less affected leg). SCALE
SCALE scores in children with spastic CP intra- and interr- scores at most distal joint pairs tended to be lower, with
ater reliability of the SCALE can be considered excellent. the exception for comparison between the subtalar joint
The MDC varied between 1.79 and 1.96 points (Table II). and the toes. This trend was observed previously by Fow-
ler et al.12 and Brunnstrom23 who reported that selective
DISCUSSION inversion and eversion were described as the most chal-
Construct validity, as well as intra- and interrater reliability lenging movements for children with CP, as well as adult
of the SCALE in children with spastic CP are supported stroke patients. As these movements rarely occur in isola-
by this study. Regarding the SCALE’s discriminant validity tion during daily activities (but frequently in combination

170 Developmental Medicine & Child Neurology 2016, 58: 167–172

 (a) Table II: Intra- and interrater reliability of the Selective Control Assess-
20

SCALE total score

ment of the Lower Extremity (SCALE)
15
Spastic CP (n=38)a
10
Intrarater reliability Interrater reliability
5 ρ=0.88 Less More Less More
(p<0.001) affected leg affected leg affected leg affected leg
0
0 5 10 15 20 Descriptive
FMA total score Mean 6.55 (2.86) 4.63 (2.16) 6.55 (2.86) 4.63 (2.16)
(SD)1
20 Mean 6.00 (2.81) 4.74 (2.50) 6.29 (2.94) 4.53 (2.16)
SCALE total score

(SD)2
15 Relative reliability
ICC 0.95 0.96 0.94 0.91
10 p value <0.001 <0.001 <0.001 <0.001
95% CI 0.90–0.97 0.93–0.98 0.89–0.97 0.84–0.96
5 Absolute reliability (SCALE points)
ρ=0.88 SEM 0.71 0.64 0.69 0.68
(p<0.001) MDC95 1.96 1.79 1.92 1.88
0
0 20 40 60 80 a
Because of a failure in a video recording of the SCALE, we could
MMT total score include data from only 38 participants in the reliability analyses.
CP, cerebral palsy; ICC, intraclass correlation coefficient; CI, confi-
dence interval; SD, standard deviation; SEM, standard error of mea-
(b) 20 surement; MDC95, minimum detectable change at 95% confidence
SCALE total score

interval.
15
between SCALE and MMT were also of similar magni-
10
tude. This could indicate that a correctly applied MMT
5 ρ=–0.55 will partially reflect the ability to selectively activate a mus-
(p<0.001) cle (group).
0
0 10 20 30 40
Regarding our additional hypothesis in relation to the
MAS total score
association between SVMC and spasticity, only a moderate
negative correlation was found, with a large variation of
SCALE scores in participants with low MAS scores
(Fig. 2b). This range of SCALE scores in children with
Figure 2: Spearman’s rank correlation coefficient (q) of total Selective
low spasticity might indicate that a mild level of spasticity
Control Assessment of the Lower Extremity (SCALE) scores and common
does not necessarily affect SVMC negatively, while a more
clinical assessments for children with spastic cerebral palsy. (a) concur-
clear inverse relationship between SCALE and MAS is
rent validity: SCALE versus Fugl-Meyer Assessment (FMA) and SCALE
seen in participants with higher MAS values. However, the
versus Manual Muscle Test (MMT). (b) correlation SCALE and Modified
latter would have to be confirmed in studies including par-
Ashworth Scale (MAS).
ticipants with a larger range of MAS values than reported
in our study in which the majority were only mildly
with the movement of other foot joints in supination or affected (i.e. mostly GMFCS levels I and II). In relation to
pronation) their movement performance might be experi- the functional interdependence of SVMC with muscle
enced as unusual. Another neurophysiological explanation weakness and spasticity, a possible influence of these
might be that the cortical representation of the lower impairments on the presented correlations cannot be
extremity is largest for the big toe.24 excluded. Furthermore, like Fowler et al.,10 we found a
The SCALE’s discriminant validity was reflected in an high inverse relationship (q≤ 0.80) between the severity of
overall difference between the GMFCS levels. Neverthe- CP (GMFCS levels) and the total SCALE score.
less, because of the small sample size, we could only find Our hypothesis, regarding reliability of the SCALE, was
significant differences between GMFCS levels I and II, and confirmed. We found excellent intra- and interrater reli-
interpretation should be handled with caution. Performing ability for the SCALE, as well as clinically acceptable val-
a power analysis (80% power, two-tailed alpha 0.05) ues of absolute reliability for SCALE limb scores. As these
revealed that a sample size of 19 participants in GMFCS results are based on a second rating of video recordings,
levels II and III, and 29 participants in GMFCS levels III the ICCs might be slightly higher than when rated via a
and IV, would be required to determine statistically signifi- second assessment, where interfering factors like the partic-
cant differences between these GMFCS levels. ipant’s compliance or state of health might have altered
The strong correlation between the SCALE and FMA, testing conditions. For future studies, accuracy of the video
illustrated in Figure 2, confirms that both assessments recordings could be improved by performing an additional
measure broadly similar constructs. Correlation coefficients video recording from the sagittal plane. However, our

Validity and Reliability of Selectivity Testing in CP Julia Balzer et al. 171

current values are similar to previously reported observa- A CK N O W L E D G E M E N T S
tions.10 In relation to the absolute reliability of the SCALE, We acknowledge contributions and approvals regarding the
our study showed that an increase of more than 2 SCALE retranslated SCALE version from the authors of the original
points for the more affected leg in children with CP could SCALE version (Eileen G Fowler, Loretta A Staudt, and Marcia
be considered a true change (MDC). A future study on the B Greenberg, Department of Orthopedic Surgery, UCLA/Ortho-
responsiveness of the SCALE will provide insight into pedic Hospital Center for Cerebral Palsy, Los Angeles, USA).
whether such changes can be achieved with current reha- We thank all volunteer in- and outpatients and parents for their
bilitative (e.g. training or botulinum toxin) or surgical participation. We are grateful to the therapists of the following
interventions (e.g. selective dorsal rhizotomy). In order to institutions: the RGZ – Stiftungzugunsten cerebral Gel€ahmter;
expand SCALE’s application from a diagnostic tool to an the Vivendra-Stiftung; and the ‘Schule f€ ur K€orper- und Mehr-
evaluative one, and to counteract the limitation of its ordi- fachbehinderte’ (SKB) Z€ urich for their assistance in recruiting
nal scale, it might be appropriate to consider combining the participants. This research project was funded by the Phys-
its test procedure with a neurophysiological measure.4,25 ioSwiss, Switzerland; Physiotherapy Science Foundation, Switzer-
With regard to the methodological limitations of this land; M€axi-Foundation, Switzerland; and the Swiss National
study, we should mention that grouping the results for the Science Foundation (Project 32003B_156646), Switzerland. None
less and more involved limb might have decreased variabil- of the funders were involved in the study design, data collection,
ity between participants, which could have resulted in analysis, and manuscript preparation and publication decisions.
lower correlation coefficients and ICC values. Neverthe- All ideas and decisions in relation to this study were made inde-
less, our observations are broadly comparable with previ- pendently by the authors. The authors have stated that they had
ous reports.9 no interests which might be perceived as posing a conflict or
In conclusion, previous results about the SCALE’s valid- bias.
ity, interrater reliability, and increased distal impairment of
SVMC were supported by this study. New evidence for SUPPORTING INFORMATION
construct validity of the SCALE in relation to common The following additional material may be found online:
clinical tests in children with spastic CP, as well as impor- Appendix S1: Selective Control Assessment of the Lower
tant reliability aspects such as intrarater reliability and Extremity (SCALE) – German version.
MDC values, were added.

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