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RehabMeasures Instrument

Craig Handicap Assessment and Reporting Technique

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Purpose

CHART: Based on the now outdated World Health Organization ICIDH framework, the Craig Handicap Assessment and Reporting Technique (CHART) was originally based on 5 domains, but was then revised to include Cognitive Independence for a total of 6 domains with 32 total items. Scores on each subscale range from 0-100 with total CHART score ranging from 0-600. Higher scores indicate a lesser degree of handicap or greater degree of social and community participation. 

  • Physical independence 
  • Cognitive independence 
  • Mobility 
  • Occupation 
  • Social integration 
  • Economic self-sufficiency

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Instrument Details

Acronym CHART / CHART-SF

Area of Assessment

Activities of Daily Living
Behavior
Cognition
Functional Mobility
Occupational Performance
Social Relationships
Social Support

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Brain Injury
  • Multiple Sclerosis
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • The Craig Handicap Assessment and Reporting Technique (CHART) is designed to assess how people with disabilities function as active members of their communities.
  • CHART-SF: Short form consists of 19 items that generate scores for the same 6 subscales of the full revised version. The CHART-SF takes less time to administer, and all CHART-SF subscales closely approximate scores from CHART long form except Economic Self Sufficiency.
  • Multidimensional analysis using data gathered from previous study entered into stepwise regression model reduced long form questions to short form reaching >90% of explained variance in all subscales except economic self-sufficiency (Whiteneck & Brooks, 1992).

Number of Items

32
Short: 19

Time to Administer

15 minutes

Varies with form used

Required Training

Reading an Article/Manual

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS in 2010; Updated by Punam Rajyaguru, SPT and Tiffany Ducato, SPT with burn, amputee, and MS populations in 2011; Updated by Candy Tefertiller PT, DPT, ATP, NCS, Jennifer Kahn PT, DPT, NCS and the SCI EDGE task force of the Neurology section of the APTA in 2012; Updated with references from the TBI population by Sue Saliga, PT, DHSc, CEEAA, Anna de Joya, PT, DSc, NCS, and the TBI EDGE task force of the Neurology Section of the APTA in 2012.

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

R

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

NR

NR

NR

LS

LS

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

R

R

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

No

Yes

Yes

Not reported

TBI EDGE

No

Yes

Yes

Not reported

Considerations

  • Proxy responder (caregivers) tended to rate a patient's impairment as more severe

  • Proxy / patient agreement tends to be lowest for the social integrations domain

  • CHART long form discriminates between people with TBI who report lower scores than those with other disabilities (Walker et al, 2003)

  • CHART-SF was developed using regression analysis and related statistical methods to select items from the CHART. Rescoring was completed so the CHART-SF has the same 0-100 ranges as the CHART. Its metric properties and equivalence to the CHART have not yet been evaluated.

  • CHART-SF sub-scales closely approximate the scores of the subscales gathered by the Original CHART

  • CHART-SF takes less time to administer than the Original CHART

  • CHART –SF may decreased the precision for smaller groups, however, use in larger groups can obviate the lack of precision by the change in confidence intervals. 

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Spinal Injuries

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Standard Error of Measurement (SEM)

Chronic SCI CHART-SF : (Tozato et al, 2005, n = 54; mean age = 42.5 (16.6) years; average Barthel Index Score = 75.6 (18.7) points; Calculated from Japanese sample using mean SD from test retest.

 

Domain 

SEM 

Chart Total Score 

40.71 

Physical 

8.2 

Mobility 

5.1 

Occupation 

14.8 

Economic self sufficiency 

Social Integration 

11.6

Normative Data

Chronic SCI: (Gontkovsky et al, 2009; n = 28, mean age = 42 (17) years; 68% = incomplete injury; AIS A = 32.1%, B = 32.1%, C = 14.4%. D = 21.4%)

 

Normative Data for the CHART-SF and CIQ:

 

CHART-SF

Mean (SD)

Range

Physical Independence 

47.0 (44.2) 

4–100 

Cognitive Independence 

66.5 (36.4) 

0–100 

Mobility 

69.6 (30.7) 

17–100 

Occupation 

38.3 (39.4) 

0–100 

Social Integration

72.8 (35.2) 

0–100 

Economic Self-Sufficiency 

38.4 (33.2) 

0–100 

Total 

332.6 (145.8) 

36–580

**The highest scores on the CHART-SF were in social integration; the lowest scores in occupation;

Test/Retest Reliability

Chronic SCI CHART : (Whiteneck et al 1992: n=135 subjects; mean age 33 years; mean time since injury 7 years (2-35 years); CHART administered by the same examiner ~1 week apart.)

  • Excellent reliability for overall CHART 0.93

 

Domain 

Test-retest Reliability

Chart Total Score

Excellent r=0.93 

Physical 

Excellent r=0.92 

Mobility 

Excellent r=0.95 

Occupation 

Excellent r=0.89 

Economic self sufficiency 

Excellent r=0.80 

Social Integration 

Excellent r=0.81

 

Chronic SCI CHART-SF : (Tozato et al, 2005, n = 54; mean age = 42.5 (16.6) years; average Barthel Index Score = 75.6 (18.7) points; Japanese sample, validity of CHART in Japanese.) 

Test-retest validity with a 21 to 25 day interval between assessments:

 

Domain 

Test-retest Reliability

Chart-SF Total Score 

Excellent r=0.78*** 

Physical 

Adequate r=0.53*** 

Mobility 

Excellent r=0.96*** 

Occupation 

Excellent r=0.86*** 

Economic self sufficiency 

Excellent r=1.00*** 

Social Integration 

Excellent r=0.78***

Interrater/Intrarater Reliability

Chronic SCI: (proxy inter-rater reliability, reviewed in Noonan et al, 2009, from Whiteneck 1992 and Cusick 2001, agreement between participant and a proxy (i.e. family member, caregiver), SCI n=224.)

 

 

1week (proxy)

Whiteneck 1992

2 weeks (proxy)

Cusick 2001

Overall

Excellent r=0.83

Excellent r=0.84

Physical

Excellent r=0.80

Adequate r=0.69

Mobility

Excellent r=0.84

Excellent r=0.86

Occupation

Excellent r=0.81

Adequate r=0.60

Economic self sufficiency

Adequate r=0.69

Adequate r=0.59

Social Integration

Poor r=0.28

Adequate r=0.57

Cognitive

 

Poor r=0.34

  • Consistently lower compared with test-retest reliability

Criterion Validity (Predictive/Concurrent)

Chronic SCI: (Gontkovsky et al, 2009)  

  • Adequate to Excellent correlation between the CIQ and CHART total scores (see table below)

  • Poor to Adequate correlation between CIQ and CHART domains

CHART-SF and CIQ Correlations:

 

CIQ

 

Home Integration

Social Integration

Productive Activity

Total

CHART-SF

       

Physical Independence

0.55**

0.01

0.14

0.33

Cognitive Independence

0.57**

0.43*

0.07

0.53**

Mobility

0.52**

0.68**

0.39*

0.73**

Occupation

0.56**

0.46*

0.41*

0.64**

Social Integration

0.47*

0.77**

0.34

0.73**

Economic Self-Sufficiency

0.25

0.01

0.37

0.24

Total

0.74**

0.57**

0.42*

0.79**

*p <0.05
**p <0.01
CIQ = Community Integration Questionnaire

 

Amputation or Spinal Cord Injury: (Masedo et al, 2005; n = 84 with spinal cord injury, n  = 38 with amputation; For SCI mean time since injury = 13.96 (9.36) years)

CHART and FIM Correlations for SCI and Amputee Participants:

           

                                     CHART Sub-scales

 

Physical

 

Mobility

 

Total Score

 

FIM-SR

SCI

AMP

SCI

AMP

SCI

AMP

Self-care

0.52*

-0.08

0.32*

-0.12

0.27**

0.20

Sphincter

0.52*

--

0.32*

--

0.30*

--

Mobility

0.46*

0.21

0.26**

-0.10

0.24**

-0.04

Locomotion

0.13

0.17

0.26**

0.13

0.23**

0.13

Motor

0.51*

0.09

0.33**

0.18

0.29**

0.39**

Total score

0.49*

0.02

0.30*

0.37*

0.26*

0.54*

p < 0.01
p < 0.05

 

Construct Validity

Chronic SCI: (Tozato et al, 2005). Discriminant validity evidence established with employed versus unemployed Japanese SCI patients.

  • Employed respondents demonstrated significantly higher subscores than unemployed respondents in all CHART subscales except social integration

 

Discriminant Validity:

Domain

employment status

mean (SD)

t-value

p

Physical Independence

employed

95.5 (8.9)

4.795***

0.0001

 

unemployed

84.2 (23.9)

   

Mobility

employed

89.7 (16.9)

11.092***

0.0001

 

unemployed

58.5 (27.8)

   

Occupation

employed

79.5 (28.3)

15.030***

0.0001

 

 

unemployed

23.4 (31.8)

   

Social integration

employed

66.0 (33.5)

0.997

0.319

 

unemployed

62.2 (29.6)

   

Economy

employed

81.4 (24.8)

3.799***

0.0001

 

unemployed

67.7 (32.0)

   

Chart-J Total Score

employed

424.7 (54.1)

11.39***

0.0001

 

unemployed

305.4 (84.5)

   

*p < 0.05
**p < 0.01
***p < 0.001

Content Validity

Not statistically assessed

Face Validity

Not statistically assessed

Floor/Ceiling Effects

SCI: (Hall et al, 1998)

  • Lower and incomplete injury (e.g. less severe) demonstrated substantial ceiling effects on all CHART sub-scales

Brain Injury

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Normative Data

 

Chronic TBI : (Srinivasan, 2009; n = 34; age, R = 18 -65; mean time post TBI = 5 – 12 months)

Mean CHART Scores in Chronic TBI Population:

 

CHART Category

Growth Hormone Deficient

Growth Hormone Sufficient

Physical Independence

93.8 (4.8) 

94.6 (3.9) 

Cognitive Independence

64.3 (12.4) 

88.3 (4.1) 

Mobility

84.2 (7.0) 

93.9 (2.6) 

Occupation

71.7 (14.5) 

82.4 (5.3) 

Social Integration

89.2 (7.1) 

94.9 (2.2)

 

Traumatic Brain Injury: (Corrigan et al, 1998; n=95; mean age at time of injury=32.4; mean age at time of interview=35.2; gender=70% male; administration of test: 6 months to 5 years after in-patient rehabilitation; CHART long form) 

Mean scores

CHART 

6 mo-1 yr 

1-2 yrs 

2-3 yrs 

3-4 yrs 

4-5 yrs 

Total 

81.44 

73.72 

73.02 

83.03 

84.76 

Physical 

96.64 

92.33 

88.89 

99.73 

93.81 

Mobility 

93.72 

93.05 

92.22 

95.32 

93.69 

Social 

89.11 

85.05 

75.17 

86.55 

93,38 

Economic 

70.83 

54.76 

56.94 

60.23 

65.63 

Occupation 

56.89 

43.43 

51.89 

73.32 

77.31

 

Traumatic Brain Injury: (Hall et al, 2001; n=48; mean age=37; gender, male=77%; average of 5 years post-injury; CHART long form) 

Mean scores

Physical independence 

90.28 

Cognitive independence 

75.5 

Mobility 

86.69 

Occupation 

63.68 

Social Integration 

86.46 

Economic self-sufficiency 

70.83 

Total 

488.74 

 

Criterion Validity (Predictive/Concurrent)

TBI: (Resnik, et al, 2011; n = 68; mean age = 27.1 (5.6) years; mean time post injury = 397.6 (270.6) days)

  • No CRIS subscale was correlated with the CHART Occupational Function subscale

  • CRIS Satisfaction with Participation subscale was correlated with the CHART Social Integration subscale (r = 0.26)

Concurrent and Discriminant Validity of Community Reintegration of Servicemember Subscales: Pearson Product Moment Correlations

 

Extend of Participation

 

Perceived Limitations

 

Satisfaction with Participation

 

Measure (CHART)

r

p-value

r

p-value

r

p-value

Occupational Function

-.04

0.721

-.12

0.314

-.12

0.310

Social Integration

0.17

0.150

0.22

0.064

0.26

0.025

Construct Validity

Traumatic Brain Injury: (Hall et al, 2001; n=48; mean age=37; gender, male=77%; average of 5 years post-injury; CHART long form)

  • The strongest relations were between the CHART cognition subscale (.84) and the Neurobehavioral Functioning Inventory memory/attention subscale (-.83).

Floor/Ceiling Effects

Chronic TBI: (Hall et al, 2001, n = 48, all participants received rehabilitation 2 to 9 (mean = 5) years previously)

 

For Chronic TBI patients, the CHART demonstrated pronounced ceiling effects that effected between 25 to 81% of participants.

CHART Ceiling Effects:

 

 

     
 

Cases

No. Cases

% at Ceiling

Ceiling Score

Physical independence

39

48

81

95-100

Cognition

12

48

25

95-100

Mobility

27

48

56

95-100

Occupation

17

48

35

95-100

Social integration

33

48

69

95-100

Mixed Populations

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Normative Data

Various Diagnosis's: (Walker et al, 2003; = 1110 community-based, non-hospitalized participants with spinal cord injury (n=236), traumatic brain injury (n=242), multiple sclerosis (n=248), stroke (n=223), burn (n=70), and amputation (n=91); interviewed twice with a two week interval between them.

 

Mean CHART Scores Across Diagnosis:

 

 

 

   

 

 

 

 

Total

SCI

TBI

MS

Stroke

Ampu-tation

Burn

Physical independence*

90.65 

84.48 

94.15 

95.21 

82.20 

97.36 

99.31 

Cognitive independence*

85.50 

93.62 

77.44 

88.37 

74.14 

96.87 

96.40 

Mobility*

79.04 

77.34 

83.50 

78.33 

68.26 

90.19 

91.53 

Occupation*

64.46 

67.83 

69.63 

68.67 

36.51 

81.80 

86.37 

Social integration*

75.52 

79.12 

73.97 

82.07 

60.83 

82.74 

81.75 

Economic selfsufficiency*

77.32 

71.13 

79.08 

84.78 

76.40 

69.11 

70.67 

Total

491.34 

483.26 

496.11 

502.37 

425.83 

526.27 

532.00

*p < 0.001

**Significant differences in means scores observed by impairment category in all 6 subscales.

 

Cerebral Palsy : (Tyler, 2002; n = 50; mean age = 39.68 (13.01) years) 

  • The association between average pain intensity and global disability, as measured by the CHART, was weak and NS (r = -.21)

Test/Retest Reliability

Various Diagnosis's: (Walker et al, 2003) 

  • 2 week interval for test-retest reliability

Test Re-test reliability Interclass Correlations (ICC):

 

 

 

     

 

 

SCI

TBI

MS

Stroke

Ampu-tation

Burn

Physical Idependence

0.71 

0.77 

0.77 

0.86 

0.99 

0.82 

Cognitive Idependence

0.70 

0.83 

0.79 

0.91 

0.95 

0.95 

Mobility

0.89 

0.82 

0.89 

0.89 

0.86 

0.93 

Occupation

0.72 

0.77 

0.83 

0.74 

0.84 

0.88 

Social Integration

0.73 

0.78 

0.80 

0.75 

0.86 

0.93 

Economic Self-sufficiency

0.81 

0.82 

0.75 

0.80 

0.84 

0.94 

Total

0.87 

0.92 

0.92 

0.95 

0.90 

0.95

Bibliography

Cusick, C. P., Brooks, C., et al. (2001). "The use of proxies in community integration research." Archives of physical medicine and rehabilitation 82(8): 1018. 

Gontkovsky, S. T., Russum, P., et al. (2009). "Comparison of the CIQ and CHART Short Form in assessing community integration in individuals with chronic spinal cord injury: a pilot study." NeuroRehabilitation 24(2): 185-192. Find it on PubMed

Hall, K. M., Bushnik, T., et al. (2001). "Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals." Arch Phys Med Rehabil 82(3): 367-374. Find it on PubMed

Masedo, A. I., Hanley, M., et al. (2005). "Reliability and validity of a self-report FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain." Am J Phys Med Rehabil 84(15725790): 167-176.

Noonan, V. K., Miller, W. C., et al. (2009). "A review of instruments assessing participation in persons with spinal cord injury." Spinal Cord 47(6): 435-446. Find it on PubMed

Resnik, L., Gray, M., et al. (2011). "Measurement of community reintegration in sample of severely wounded servicemembers." Journal of Rehabilitation Research and Development 48(2): 89-102. Find it on PubMed

Srinivasan, L., Roberts, B., et al. (2009). "The impact of hypopituitarism on function and performance in subjects with recent history of traumatic brain injury and aneurysmal subarachnoid haemorrhage." Brain Injury 23(7): 639-648. Find it on PubMed

Tozato, F., Tobimatsu, Y., et al. (2005). "Reliability and validity of the Craig Handicap Assessment and Reporting Technique for Japanese individuals with spinal cord injury." Tohoku J Exp Med 205(4): 357-366. Find it on PubMed

Tyler, E. J., Jensen, M. P., et al. (2002). "The reliability and validity of pain interference measures in persons with cerebral palsy." Archives of Physical Medicine and Rehabilitation 83(2): 236-239. Find it on PubMed

Walker N, M. D., Brooks CA, Whiteneck GG. (2003). "Measuring participation across impairment groups using the Craig Handicap Assessment Reporting Technique." American Journal of Physical Medicine and Rehabilitation 82(12): 936-941. Find it on PubMed

Whiteneck, G., Charlifue, S., et al. (1992). "Guide for use of the CHART: Craig handicap assessment and reporting technique." Englewood (CO): Craig Hospital.

Wilde, E. A., Whiteneck, G. G., et al. (2010). "Recommendations for the use of common outcome measures in traumatic brain injury research." Archives of physical medicine and rehabilitation 91(11): 1650-1660. e1617.

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