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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.

CDE Status

Not a CDE -- last searched 7/5/2023.

Diagnosis/Conditions

  • Brain Injury Recovery
  • Cerebral Palsy

Populations

Non-Specific Patient Population
Movement and Gait Disorders
Cerebral Palsy
Brain Injury

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
  • Small bench (optional)
  • Quest manual/score sheets

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 (original)

Megan Pfohl, Julia Wilcox, Nicole Nobles-Fisher, Molly Corwin (Master of Occupational Therapy Students) and Danbi Lee, PhD, OTD, OTR/L (faculty mentor), Division of Occupational Therapy, Department of Rehabilitation Medicine, University of Washington, Seattle (August, 2022 update)

 

Body Part

Upper Extremity

ICF Domain

Activity

Measurement Domain

Motor

Professional Association Recommendation

None found -- last searched 7/5/2023.

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 the quality of movements; therefore, a change in score will not always equate to a change in function or skill level.
  • It is difficult to obtain adequate cooperation from preschool age children during the administration of the QUEST, so it may not be as accurate with that age group (Haga, 2007).
  • QUEST scores relate to the child’s level of disability without regard to age.
  • QUEST results should only be reported for individual limbs (Thorley et. al., 2012).
  • Posture items in the grasp domain show little relationship with total scores (Thorley et. al., 2012).
  • Domains demonstrated better construct validity, therefore scores should be reported by domain as opposed to total scores.
  • Recent studies have expanded the age range under study from 18 months – 8 years to 2-12 years (Thorley et al., 2011) and 2-16 years (Sakzewski et al., 2002 and Thorley et al., 2012).
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Cerebral Palsy

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Standard Error of Measurement (SEM)

Hemiplegic Cerebral Palsy: (Klingels et al, 2008; n = 21; females (n = 16), males (n = 6); 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)

 

Hemiplegic Cerebral Palsy (Klingels et al., 2008)

  • Mean score: 73.1% (SD=13.2, range 49.0–97.2%)
  • Mean score for hemiplegic side only: 50.6% (SD 25.6, range 3.1–96.7%)

 

Test/Retest Reliability

Cerebral Palsy: (DeMatteo et al, 1993; n = 17; age range 18 months to 8 years)

  • Excellent test-retest reliability (ICC = 0.95)

Preschool Aged Children with Cerebral Palsy (Haga et al., 2007; n = 21; males (n = 12), females (n = 9); mean age: 38.8 (7.3) months, range = 2 to 4.5 years; GMFCS Level 1 = 6, Level 2 = 4, Level 3 = 8, Level 4 = 1, Level 5 = 2; 1 to 4 weeks between assessments)

  • Acceptable to Excellent test-retest reliability for Total Score and the four domains (p range 0.85-0.94)
    • Total Score ρ = 0.92
    • Dissociated movements ρ = 0.85
    • Grasp ρ = 0.84
    • Weight Bearing ρ = 0.85
    • Protective Extension ρ = 0.94 

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 (Jan.); 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 (Jan.))

  • 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)
  • Excellent correlation for total scores (r = 0.86); however 14 items had poor fit (Thorley, 2012 (Nov.); n = 94 (Total of 170 QUEST assessments); mean age = 6y, 10mo (2y, 11mo); age range = 2-16 years; GMFCS Level for all QUESTS: Level 1 = 88 Level 2 = 35, Level 3 = 18, Level 4 = 22, Level 5 = 7)
    • Redundancy in QUEST items and poor fit when total scores were calculated indicated domains should be analyzed separately

 

Content Validity

Children with Cerebral Palsy (DeMatteo, 1993)

  • Items were developed based on an extensive literature review and discussions with clinical experts
  • Items were pilot tested by therapists on a group of children with cerebral palsy, ages 18 months to 10 years

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., Cusick, A., Novak, I., & Boyd, R. (2012). Construct validity of the Quality of Upper Extremity Skills Test for children with cerebral palsy. Developmental Medicine and Child Neurology, 54(11), 1037–1043. https://doi.org/10.1111/j.1469-8749.2012.04368.x 

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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