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RehabMeasures Instrument

Quality of Upper Extremity Skills Test

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Purpose

The QUEST is a criterion-referenced measure designed to evaluate the quality of upper extremity function in children 18 months to 8 years of age with spasticity.

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Instrument Details

Acronym QUEST

Area of Assessment

Upper Extremity Function

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$99.00

Cost Description

Cost of instrument beginning at $99.00 plus cost of equipment.

Diagnosis/Conditions

  • Brain Injury
  • Cerebral Palsy

Key Descriptions

  • 33 activity items separated among four domains:
    1) Dissociated movement
    2) Grasp
    3) Weight bearing
    4) Protective extension
  • 3 items for the tester to rate:
    1) Hand function
    2) Spasticity
    3) Cooperativeness
  • Item-level scores of 1 or 2, determined by quality of assessed position or movement:
    1) Movement quality is not achieved
    2) Movement quality is achieved
  • Item scores are summed; formulas are used to calculate percentages for each domain.
  • Domain percentages are summed and divided by number of domains to obtain total score.
  • Minimum score = < 0; Maximum score = 100

Number of Items

36

Equipment Required

  • Chair or seating system
  • Table just above waist level
  • Four 1” cubes
  • Cup
  • Regular size crayon or pencil
  • Blank paper
  • Cheerios cut into quarters
  • Mat
  • Toys including a puppet and bubbles

Time to Administer

30-45 minutes

Required Training

Reading an Article/Manual

Age Ranges

Infant

0 - 2

years

Preschool Child

2 - 5

years

Child

6 - 12

years

Instrument Reviewers

Angela Beard, BS, OTR/L

Body Part

Upper Extremity

ICF Domain

Activity

Measurement Domain

Motor

Considerations

  • The QUEST does not have structured administration guidelines, and therefore, may not be well-suited for use by inexperienced therapists. (Hickey & Ziviani, 1998)
  • A revision of the QUEST manual has been recommended by multiple researchers as it contains errors in the criteria listed for degrees of range of motion of the elbow and wrist.
  • The QUEST is an assessment of quality; therefore, a change in score will not always equate to a change in function or skill level.
  • Although administered in a play context, the QUEST is reportedly not playful and engaging, especially for children who are younger or have more significant impairments.  
  • QUEST scores relate to the child’s level of disability without regard to age.
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Cerebral Palsy

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Standard Error of Measurement (SEM)

Hemiplegic Cerebral Palsy: (Klingels et al, 2008; n = 21; mean age = 6.3 (1.25) years; L hemiplegia = 9, R hemiplegia = 12; House Classification level 1 = 3, level 3 = 1, level 4 = 8, level 5 = 3, level 6 = 1, level 7 = 5)

  • SEM for total score= 3.2%
  • SEM for score on hemiplegic side= 5%

Minimal Detectable Change (MDC)

Hemiplegic Cerebral Palsy: (Klingels et al, 2008)

  • MDC for total score: 7.11%
  • MDC for score on hemiplegic side: 13.8%

Minimally Clinically Important Difference (MCID)

Cerebral Palsy: (Law et al, 1991; n = 71; age range = 18 months to 8 years; quadriplegia = 43, hemiplegia = 28) 

  • MCID= 4.89 score units (p < .03)

Normative Data

Cerebral Palsy: (Sorsdahl et al, 2008; n = 26; age range = 2 to 13 years; hemiplegia = 5, diplegia = 14, dyskinesia = 2, tetraplegia = 5)

  • Mean (SD) QUEST Total Score; Assessor 1 (A1) = 61.8 (20.1), Assessor 2 (A2) = 60.2 (22.9)
  • Mean (SD) Dissociated Movement Domain Score; A1 = 62.3 (26.4), A2 = 52.3 (29.1)
  • Mean (SD) Grasp Domain Score; A1 = 59.5 (20.1), A2 = 63.8 (19.8)
  • Mean (SD) Weight-Bearing Domain Score; A1 = 77.0 (19.9), A2 = 81.8 (20.4)
  • Mean (SD) Protective Extension Domain Score; A1 = 61.8 (20.1), A2 = 60.2 (22.9)

(Wright et al, 2005; n = 6; mean age = 4.6 (1.0) years; GMFCS Level 3 = 2, Level 4 = 3, Level 5 = 1)

  • Mean (SD) QUEST Total Score; 41.2 (16.9)
  • Mean (SD) Dissociated Movement Domain Score; 59.8 (21.6)
  • Mean (SD) Grasp Domain Score; 31.4 (18.3)
  • Mean (SD) Weight-Bearing Domain Score; 47.1 (22.8)
  • Mean (SD) Protective Extension Domain Score; 26.4 (23.9)
 

Hemiplegic Cerebral Palsy: (Case-Smith et al, 2012; n = 18; mean age = 48.7 (12.19) months; R hemiplegia = 7, L hemiplegia = 11; CIMT intervention study)

  • Mean (SD) Grasp Domain Score

 

 

Pre-intervention

Post-intervention

1 month follow-up

6 month follow-up

3 hr group

4.50 (2.6)

4.50 (2.6)

5.25 (3.1)

6.13 (2.9)

6 hr group

4.14 (2.6)

5.0 (2.6)

5.73 (3.0)

5.86 (3.6)

 

 

Mean (SD) Dissociated Movement Score

 

 

Pre-intervention

Post-intervention

1 month follow-up

6 month follow-up

3 hr group

15.38 (5.9)

22.13 (6.0)

22.25 (6.3)

19.9 (5.5)

6 hr group

19.43 (9.0)

21.86 (9.1)

23.22 (8.5)

22.6 (7.2)

 

Test/Retest Reliability

Cerebral Palsy: 

  • Excellent test-retest reliability (p = .92) (Haga et al, 2007; n = 21; mean age = 38.8 (7.3) months; GMFCS Level 1 = 6, Level 2 = 4, Level 3 = 8, Level 4 = 1, Level 5 = 2)
  • Excellent test-retest reliability (ICC = 0.95) (DeMatteo et al, 1993; n = 17; age range 18 months to 8 years)

Interrater/Intrarater Reliability

Cerebral Palsy:

  • Excellent inter-rater reliability (ICC = 0.95) (DeMatteo et al, 1993)
  • Adequate to Excellent inter-rater reliability (A1 & A2, p = .90, A1 & A3 p = .72, A1 & A2+A3 p = .87) (Haga et al, 2007)
  • Excellent inter-rater reliability (ICC = 0.96) (Klingels et al, 2008)
  • Excellent inter-rater reliability (ICC = 0.91) (Sorsdahl et al, 2008)
  • Adequate to Excellent inter-rater and intra-rater reliability for total score (ICC = 0.86, 0.96); dissociated movement (ICC = 0.92, 0.95); grasp (ICC = 0.67, 0.90); weight-bearing (ICC = 0.87, 0.94); protective extension (ICC = 0.85, 0.88) (Thorley et al, 2012; n = 31; mean age = 6.58 (2.42) years; GMFCS Level 1 = 16, Level 2 = 9, Level 3 = 1, Level 4 = 4, Level 5 = 1)
  • Adequate to Excellent intra-rater reliability (p range .63 to .95) (Haga et al, 2007)
  • Adequate intra-rater reliability for A1 (ICC = 0.69); Excellent intra-rater reliability for A2 (ICC = 0.89) (Sorsdahl et al, 2008)

Internal Consistency

Cerebral Palsy: (Thorley et al, 2012)

  • Excellent internal consistency (Cronbach’s alpha = 0.97)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

 

Cerebral Palsy: (Law et al, 1991) 

  • Excellent correlation with the Peabody Developmental Fine Motor Subscale (PDMS-FM) total score (r = 0.84)
  • Adequate to Excellent correlations between QUEST domains and PDMS-FM subscales (r = 0.58 to 0.83)

Construct Validity

Cerebral Palsy:

  • Adequate to excellent correlations between the QUEST total score and therapists’ ratings of left and right hand function (r = 0.72 and 0.58, respectively) (Law et al, 1991)
  • Adequate correlation between the QUEST total score and chronological age (r = 0.33) (Law et al, 1991)
  • Excellent correlation between QUEST total score and the Melbourne Assessment of Unilateral Upper Limb Function (MUUL) (r = 0.83) (Klingels et al, 2008)
  • Excellent correlation between QUEST total score and PDMS-FM (r = 0.84) (Law et al, 1991)
  • Poor correlation between QUEST total score and the Kinematic Dystonia Measure (r = -0.60) (Kawamura et al, 2012; n = 11; mean age = 9 years, range 4 years 1 month to 15 years 5 months; upper extremity dystonia)
  • Excellent correlation with the Modified Melbourne Assessment (MMA) (p = 0.90) (Randall et al, 2012; n = 30; mean age = 42.7 (10.8) months; hemiplegia = 20, diplegia = 2, tetraplegia = 1, quadriplegia = 7)

Responsiveness

Cerebral Palsy:

  • Moderate responsiveness at detecting change on grasp-release domain after 18 days of CIMT intervention and at 6 month follow-up (Effect Size (ES) = 0.48 and 0.53, respectively) (Case-Smith et al, 2012)
  • Moderate responsiveness at detecting change on Dissociated movement domain after 18 days and at 6 month follow-up (ES = 0.72 and 0.33, respectively) (Case-Smith et al, 2012)
  • Moderate responsiveness at detecting change of total score after 8 months of intervention (ES = 0.72) Domain scores vary (ES = 0.13 to 0.63) (Wright et al, 2005) 

Movement and Gait Disorders

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Normative Data

Congenital Muscular Dystrophy: (Meilleur et al, 2015; n = 21; mean age = 11.4 (5.18) years; LAMA-2 subtype = 8, COL6-RD subtype = 13)

  • Mean (SD) QUEST Total Raw Score; 5.62 (1.05)

Internal Consistency

Congenital Muscular Dystrophy: (Meilleur et al, 2015)

  • Excellent internal consistency (Cronbach’s alpha = 0.88)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity:

Congenital Muscular Dystrophy: (Meilleur et al, 2015)

  • Adequate correlations with the Motor Function Measure 32 total score (r = .392)

Brain Injury

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Test/Retest Reliability

Acquired Brain Injury: (Sakzewski et al, 2002; n = 16; mean age = 10.5 (2.8) years; ABI with upper limb movement impairment; Australian sample)

  • Excellent test-retest reliability (ICC = .93)

Interrater/Intrarater Reliability

Acquired Brain Injury: (Sakzewski et al, 2002) 

  • Excellent inter-rater reliability (ICC = 0.91 and 0.92)

Non-Specific Patient Population

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Content Validity

  • Items were developed based on extensive literature review and discussions with clinicians and clinical experts.

  • Items were selected if they were part of normal development from birth to 18 months, countered typical patterns of spasticity, and used as goals in therapy

  • Items were then grouped into domains and pilot-tested on 10 children with CP between the ages of 18 months and 8 years.

  • Items were reviewed and scoring criteria modified through consensus meeting of the investigators and 16 pediatric therapists. (DeMatteo et al, 1993)  

Bibliography

Case-Smith, J., DeLuca, S.C., et al. (2012). “Multicenter randomized controlled trial of pediatric constraint-induced movement therapy: 6-month follow-up.” Am J Occup Ther 66:15-23.

DeMatteo, C., Law, M., et al. (1993). “The reliability and validity of the quality of upper extremity skills test.” Phys Occup Ther Pediatr 13(2) 1-18. 

Haga, N., van der Heijden-Maessen, H.C., et al. (2007). “Test-retest reliability and inter and intrareliability of the quality of the upper extremity skills test in preschool age children with cerebral palsy.” Arch Phys Med Rehabil 88:1686-1689.

Hickey, A., Ziviani, J. (1998). “A review of the quality of upper extremities skills test (QUEST) for children with cerebral palsy.” Phys Occup Ther Pediatr 18(3/4):123-135.

Kawamura, A., Klejman, S., et al. (2012). “Reliability and validity of the kinematic dystonia measure for children with upper extremity dystonia.” J Child Neurol 27(7):907-913.

Klingels, K., De Cock, P., et al. (2008). “Comparison of the Melbourne assessment of unilateral upper limb function and the quality of upper extremity skills test in hemiplegic CP.” Dev Med Child Neurol 50:904-909. 

Law, M., Cadman, D., et al. (1991). “Neurodevelopmental therapy and upper-extremity inhibitive casting for children with cerebral palsy.” Dev Med Child Neurol 33:379-387.

Meilleur, K.G., Jain, M.S., et al. (2015). “Results of a two-year pilot study of clinical outcome measures in collagen VI and laminin alpha2-related congenital muscular dystrophies.” Neuromuscul Disord 25:43-54.

Randall, M., Imms, C., et al. (2012). “Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.” Dev Med Child Neurol 54:424-428.

Sakzewski, L., Ziviani, J., et al. (2002). “Test/retest reliability and inter-rater agreement of the quality of upper extremity skills test (QUEST) for older children with acquired brain injuries.” Phys Occup Ther Pediatr 21(2-3):59-67.

Sorsdahl, A.B., Moe-Nilssen, R., et al. (2008). “Observer reliability of the gross motor performance measure and the quality of upper extremity skills test, based on video recordings.” Dev Med Child Neurol 50:146-151. 

Thorley, M., Lannin, N., et al. (2012). “Reliability of the quality of upper extremity skills test for children with cerebral palsy aged 2 to 12 years.” Phys Occup Ther Pediatr 32(1):4-21. 

 Wright, F.V., Boschen, K., et al. (2005). “Exploring the comparative responsiveness of a core set of outcome measures in a school-based conductive education programme.” Child Care Health Dev 31(3):291-302.

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