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Shriners Hospital Upper Extremity Evaluation

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Purpose

The Shriners Hospital Upper Extremity Evaluation (SHUEE) is a video-based assessment that was designed for use with patients with hemiplegic type cerebral palsy. The SHUEE provides a pre- and post-intervention evaluation that looks at Spontaneous Functional Analysis (SFA), Dynamic Positional Analysis (DPA), and Grasp and Release Analysis (GRA) of the affected upper extremity while performing functional tasks. It is used for patients aged 3-18 years of age.

Link to Instrument

https://cdn-links.lww.com/permalink/jbjs/c/jbjs_2017_03_12_davids_326_sdc1.pdf

Acronym SHUEE

Area of Assessment

Activities of Daily Living
Range of Motion

Assessment Type

Performance Measure

Cost

Free

Actual Cost

$0.00

Cost Description

Although there are no costs to purchase the assessment, there are many pieces of equipment required to administer the assessment.

CDE Status

Supplemental: Cerebral Palsy—Outcomes and Endpoints, Motor Function: https://www.commondataelements.ninds.nih.gov/sites/nindscde/files/Doc/CP/CP_CDE_Highlight_Summary.pdf

 

Populations

Pediatric Disorders
Cerebral Palsy

Key Descriptions

  • The assessment is divided into two parts. Part 1 measures the following for the affected limb: active and passive range of motion, tone and the performance of seven ADLs. Part 2 measures the spontaneous use of the affected limb and the segmental alignment of the extremity while performing the task.
  • Description/Scoring:
    Part 1:
    Measures:
    - AROM and PROM for affected shoulder, arm and hand,
    - Tone using a Modified Ashworth Scale
    - Seven ADLs with a scoring of Independent, Dependent or Assist
    No scoring required

    Part 2:
    A) Spontaneous Functional Analysis (SFA)
    - Assesses spontaneous function of the affected extremity
    - Score recorded for 9 of 16 tasks
    - 6-point scale (0=low/patient does not use, and 5= high/optimal/spontaneous use)

    B) Dynamic Positional Analysis (DPA)
    - Assesses 1) dynamic, segmental alignment of the extremity when performing the task, 2) five functional/anatomical segments, and 3) joint movements and degree of movements
    - 5 segments analyzed, 4 tasks for each segment
    - 4-point scale (0 = low, pathological alignment, 3 = high, normal alignment)
    Highest score is 72 (optimal alignment)

    C) Grasp and Release Analysis (GRA)
    - Assesses whether patient can or cannot grasp and release the object with the wrist in the three different positions with Binary score scale (0 = cannot grasp and release, 1= can grasp and release)

    Final scores are calculated as a percentage of the maximum possible for each section.

Number of Items

58 total items assessed

Part 1
- Passive and Active ROM: 15 hand, arm and shoulder positions
- Tone: single rating for affected upper limb
- ADL’s: 7 tasks

Part 2
- Spontaneous Functional Analysis (SFA): 16 tasks
- Dynamic Positional Analysis (DPA): 16 tasks about ADL’s
- Grasp and Release Analysis (GRA): grasp and release in three wrist positions

Equipment Required

  • Video recorder with tripod
  • Billfold style wallet to hold paper money
  • 8 x 10 sheet of standard weight paper
  • Two 2" in diameter and approximately 1/2" thick, flat sided, wooden beads
  • Stiff cord for stringing beads
  • Three dollar-sized bills made of standard weight paper
  • Four plastic coins of any size
  • One wide-mouth 2-2 1/2" screw cap and clear 16-ounce bottle
  • One can Play-Doh®
  • Standard fork and knife (not child size)
  • Shoe with tie fastener
  • Sock
  • Cracker
  • Stickers of any size or type
  • One 30" ball

Time to Administer

15-60 minutes

Required Training

Reading an Article/Manual

Required Training Description

There are no required trainings, but the manual recommends that evaluators:
• Read the manual
• View the Key Interpretation video
• Complete the Video Proficiency test

Age Ranges

Preschool Children

3 - 5

years

Children

6 - 12

years

Adolescents and Young Adults

13 - 18

years

Instrument Reviewers

Johanna Kalmus, Kayla Gehrke,, Annie Goodrich, and Alyssa Arian (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

Body Part

Upper Extremity

ICF Domain

Body Structure
Body Function
Activity

Measurement Domain

Activities of Daily Living
Motor

Professional Association Recommendation

None found--last searched 7/25/2023.

Considerations

  • Suitable for children 3+ years old
  • Useful for measuring change in unimanual function 
  • Easy to administer: approximately 15 minutes, free online manuals available
  • Available translations: Portuguese.

Cerebral Palsy

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Standard Error of Measurement (SEM)

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020; n = 21; mean age = 8.7 (4.0); right hemiplegia n = 13; left hemiplegia n = 13; Brazilian sample)

  • SEM (calculated) for Spontaneous Functional Analysis (SFA): 1.47
  • SEM (calculated) for Dynamic Positional Analysis (DPA): 6.85
  • SEM (calculated) for Grasp and Release Analysis (GRA): 0.59

 

Minimal Detectable Change (MDC)

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020)

  • MDC (calculated) for SFA: 4.07 
  • MDC (calculated) for DPA: 18.98
  • MDC (calculated) for GRA: 1.65

 

Normative Data

Hemiplegic Cerebral Palsy: (Davids et al., 2006; n = 18; mean age = 11.2 years; male = 12)

  • Mean (SD) SFA score: 26.7 (5.9) 
  • Mean (SD) DPA wrist score: 5.3 (1.6) 
  • Mean (SD) GRA score: 5.36 (0.9)

Interrater/Intrarater Reliability

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020; five physical therapist raters; practice experience 1-10 years)

  • Excellent interrater reliability
    • SFA (ICC = 0.996)
    • DPA (ICC = 0.987)
      • Thumb (ICC = 0.986)
      • Fingers (ICC = 0.994)
      • Wrist (ICC = 0.929)
      • Forearm (ICC = 0.996)
      • Elbow (ICC = 1.00)
    • GRA (ICC = 1.00)
  • Excellent intrarater reliability (over first and second evaluation)
    • SFA (ICC = 0.997)
    • DPA (ICC = 0.990)
      • Thumb (ICC = 0.964)
      • Fingers (ICC = 0.994)
      • Wrist (ICC = 0.957)
      • Forearm (ICC = 0.995)
      • Elbow (ICC = 0.956)
    • GRA (ICC = 1.00)

 

Hemiplegic Cerebral Palsy: (Jose et al., 2019; n = 7; mean age = 10.14; Indian sample; interrater reliability assessed by scoring 10 patient videos by pediatric orthopedic consultant, a pediatric orthopedic fellow and an orthopedic resident; intrarater reliability assessed by review of videos by the same clinician after a 2 week interval.)

  • Excellent interrater reliability (ICC = 0.97)
  • Excellent intrarater reliability (ICC = 0.98)
 

Hemiplegic Cerebral Palsy: (Davids et al., 2006; n = 11; mean age = 11.8 years; male = 5)

  • Excellent interrater reliability (4 occupational therapists) 
    • SFA (ICC = 0.90)
    • DPA (ICC = 0.89)
  • Excellent intrarater reliability (3 occupational therapists) 
    • SFA (ICC = 0.99)
    • DPA (ICC = 0.98)

 

 

Internal Consistency

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020)

  • Excellent for total SHUEE (all items): Cronbach’s alpha = 0.887 (95% CI: 0.745-0.970)
  • Adequate for DPA: Cronbach’s alpha = 0.777 (95% CI: 0.415-0.942)
  • Excellent for SFA: Cronbach’s alpha = 0.988* (95% CI: 0.972-0.997)
  • Excellent for GRA: Cronbach’s alpha = 0.933* (95% CI: 0.831-0.983)

*Scores higher than .9 may indicate redundancy in the scale questions.

 

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Hemiplegic Cerebral Palsy: (Davids et al., 2006; n = 20; mean age = 10.8 years; male = 11)

  • Adequate concurrent validity of the SFA portion of the SHUEE with the self-care scaled score of the Pediatric Evaluation of Disability Inventory (PEDI) (r = 0.47)

Construct Validity

Convergent validity:

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020)

  • SFA:
    • Excellent construct validity with part 1- functional skills scale of the self-care domain of PEDI (r = 0.68)
    • Excellent construct validity with Manual Ability Classification System (MACS) (r = -0.68) indicates that greater spontaneous use of the upper limb is correlated with better manual skills
    • Excellent construct validity with part II- caregiver assistance scale of the self-care domain of PEDI (r = 0.75)
    • Excellent construct validity with the Pediatric Upper Extremity Motor Activity (PMAL) scales of frequency (r = 0.86), quality (r = 0.86), and spontaneity (r = 0.80)
  • DPA:
    • Excellent construct validity with part 1- functional skills scale of the self-care domain of PEDI (r = 0.62)
    • Excellent construct validity with part II- caregiver assistance scale of the self-care domain of PEDI (r = 0.63)
    • Adequate construct validity with MACS (r = -0.54) indicates that increased quality of upper limb movement is correlated with better manual skills
    • Excellent construct validity with the PMAL scales of frequency (r = 0.83), quality (r = 0.83), and spontaneity (r = 0.76)

 

Hemiplegic Cerebral Palsy: (Wagner, 2015)

  • Excellent construct validity of SFA with Selective Control of the Upper Extremity Scale (SCUES) (r = 0.69)

 

Hemiplegic Cerebral Palsy: (Gün et al., 2020; n = 112; mean age = 7.29 (2.51); male = 68 (61%))

  • Excellent convergent validity of SFA with Assessment of Children’s Hand Skills (ACHS) (r = 0.86)  
  • Excellent convergent validity of DPA with ACHS (r = 0.78)
  • Excellent convergent validity of GRA with ACHS (r = 0.86)

 

Floor/Ceiling Effects

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020; n = 21; mean age = 8.7 (4.0))

  • Adequate ceiling effect of 19.1% found for the SFA and 4.8% found for the DPA
  • Poor ceiling effect of 61.9% found for the GRA
  • Adequate floor effect of 14.3% found for GRA
  • Excellent floor effects of 0% found for both SFA and DPA

 

Responsiveness

Hemiplegic Cerebral Palsy: (Davids et al., 2006; n = 18; mean age = 11.2 years; subgroup received flexor carpi ulnaris to extensor carpi radialis brevis tendon transfer, a common orthopedic surgical intervention designed to improve wrist alignment)

  • Statistically significant differences in SFA (p < 0.05) and DPA (p < 0.01) before and after tendon transfer but not in GRA (p = 0.82)

Mean scores (SD) on the components of the Shriners Hospital Upper Extremity Evaluation before and after tendon transfer

 

Measure

 

Score Before Tendon Transfer*

 

Score After Tendon Transfer*

 

Difference*

 

P  Value (Paired T Test)

 

 

SFA

 

 

 26.7 (5.9)

 

 

30.1 ​​(5.9)

 

 

3.4 (5.4)

 

 

0.017

 

 

DPA

 

 

5.3 (1.6)

 

 

11.7 (0.7)

 

 

6.4 (1.6)

 

 

 

<0.001

 

 

GRA

 

5.36 (0.9)

 

5.43 (1.5)

 

0.07 (1.1)

 

0.82

*Values are the mean (SD). 

 

 

Hemiplegic Cerebral Palsy: (Nicolini-Panisson et al., 2020; n = 5, subgroup who received Botulinum Toxin Type A (BTX-A) and physical therapy (PT) treatment; Brazilian sample)

  • Statistically significant differences in SFA and DPA before and after treatment (p < 0.05) but not in GRA (p = 0.37)

Mean scores on the components of the Shriners Hospital Upper Extremity Evaluation Before and After Treatment with Botulinum Toxin and physical therapy

 

Measure

 

Score Before BTX-A and PT (n = 5)*

 

 

Score Before BTX-A and PT (n = 5)*

 

 

Difference*

 

P-value

 

 

SFA

 

 

          19.2 (8.2)

 

 

          22.8 ​​(10.2)

 

 

3.6 (4.0)

 

 

0.02

DPA

          42.4 (11.2)

          53.6 (7.2)

11.2 (6.3)

 

0.01

 

GRA

           4.2 (1.8)

           4.4 (1.7)

0.2 (0.5)

 

0.37

 

*Values are the mean (SD).

 

 

Hemiplegic Cerebral Palsy: (Jose et al., 2019; subgroup who received surgical treatment to alter/repair upper limb structures; scores gathered 7.4 months post-surgery)

  • No statistically significant differences found across all three domains before and after surgery (p > 0.05).

Mean scores on the components of the Shriners Hospital Upper Extremity Evaluation Before and After Surgical Treatment of upper limb

 

 

 

Measure

 

 

 

Preoperative Score* (n = 7)

 

 

 

 

Postoperative Score* (n = 7)

 

 

 

 

Mean of paired Differences

 

 

 

   p

 

 

SFA

 

 

60.93  (6.50)

 

 

63.90 ​​(7.54)

 

 

2.97

 

 

0.259

 

DPA

 

69.32 (8.01)

 

72.47 (7.20)

 

3.15

 

 

0.229

 

 

GRA

 

66.46 (27.22)

 

71.42 (23.00)

 

4.96

 

0.334

*Values are the mean (SD).

 

 

 

 

Pediatric Disorders

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Standard Error of Measurement (SEM)

Children with Rheumatic Diseases (Leblebici et al., 2021; n = 20; mean age = 13.65 (2.70); mean time post diagnosis = 3.9 (4.2) years; right hemiplegia n = 17, left hemiplegia n = 3; Turkish sample)

  • SEM (calculated) for Total Score for entire group: 0.62

 

Minimal Detectable Change (MDC)

Children with Rheumatic Diseases (Leblebici et al., 2021)

  • MDC (calculated) for Total Score for entire group: 1.72

 

Normative Data

Children with Rheumatic Diseases (Leblebici et al., 2021)

  • Mean (SD) SHUEE total score: 112.55 (3.56)
  • Mean (SD) SHUEE subscale scores:
    • SFA: 44.70 (0.57)
    • DPA: 62.85 (3.11)
    • GRA: 5 (1.02)

 

Test/Retest Reliability

Children with Rheumatic Diseases (Leblebici et al., 2021; 1 week between assessments)

  • Excellent test-retest reliability for SHUEE Total Score: ICC = 0.97
  • Excellent test-retest reliability for the following SHUEE Subscales:
    • DPA: (ICC = 0.97)
    • GRA: (ICC = 0.95)
  • Adequate test-retest reliability for the SHUEE SFA subscale:  (ICC = 0.82)

 

 

Interrater/Intrarater Reliability

Children with Rheumatic Diseases (Leblebici, 2021; physical therapist observers with at least 5 years of professional experience)      

  • Excellent interrater reliability 
    • SHUEE Total Score: (ICC = 0.82)
    • SHUEE Subscales
      • SFA: (ICC = 0.92)
      • DPA: (ICC = 0.81)
  • Adequate interrater reliability for GRA SHUEE Subscale: (ICC = 0.65)   
  • Excellent intrarater reliability 
    • SHUEE Total Score: (ICC = 0.97)
    • SHUEE Subscales
      • SFA: (ICC = 0.82)
      • DPA: (ICC = 0.97)
      • GRA: (ICC = 0.95)

 

 

Internal Consistency

Children with Rheumatic Diseases (Leblebici, 2021))

  • Excellent internal consistency
    • SHUEE total score: Cronbach’s alpha = 0.85
    • SHUEE SFA: Cronbach’s alpha = 0.97
  • Adequate internal consistency
    • SHUEE DPA: Cronbach’s alpha = 0.70
    • SHUEE GRA: Cronbach’s alpha = 0.74

 

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Children with Rheumatic Diseases (Leblebici, 2021)

  • Excellent concurrent validity was determined between SFA and Jebsen-Taylor Hand Function Test (r = -0.63; p = 0.003)

 

Content Validity

“​​Content validity was based on the five children’s ability to perceive the instructions. The children understood the instructions comfortably and tried to implement them. (p. 5037)” 

Floor/Ceiling Effects

Children with Rheumatic Diseases (Leblebici, 2021) 

  • Excellent floor and ceiling effects: No floor or ceiling effects were found—none of the patients had the lowest or highest score when considering the total score of SHUEE.

Bibliography

Davids, J.R., Peace, L.C., Wagner, L.V., Gidewall, M.A., Blackhurst., D.W., & Robertson, M.W. (2006). Validation of the Shriners Hospital for Children Upper Extremity Evaluation (SHUEE) for children with hemiplegic cerebral palsy. The Journal of Bone & Joint Surgery, 88(2), 326-333. https://pubmed.ncbi.nlm.nih.gov/16452744/

Gilmore, R., Sakzewski, L., & Boyd, R. (2009). Upper limb activity measures for 5- to 16-year-old children with congenital hemiplegia: A systematic review. Developmental Medicine and Child Neurology, 52(1), 14-21. https://pubmed.ncbi.nlm.nih.gov/19811513/

Gun, F., Temizkan, E., & Bumin, G. (2021). Validity and reliability of the Turkish versions of assessment of Children’s Hand Skills and Children’s Hand-Skills Ability Questionnaire in children with hemiplegic cerebral palsy. Child: Care, Health, and Development, 47(2), 191-200. https://pubmed.ncbi.nlm.nih.gov/33338287/ 

Jose, P.S., Radhakrishna, V.N., Sahoo, B., & Manhuri, V. (2019). An assessment of the applicability of Shriners Hospital Upper Extremity Evaluation as a decision-making tool and outcome measure in upper limb cerebral palsy in Indian children. Indian Journal of Orthopedics, 53(1),15-19.  https://pubmed.ncbi.nlm.nih.gov/30905978/

Leblebici, G., Ovacik, U., Gungor, F., Davis, J.R., Tarakci, E., & Kasapcopur, O. (2021). Validity and reliability of “Shriners Hospital for Children Upper Extremity Evaluation” in children with rheumatic diseases. Clinical Rheumatology, 40, 5033-5040. https://doi.org/10.1007/s10067-021-05866-6

Nicolini-Panisson, R.D., Tedesco, A.P., Davis, J.R., Wagner, L.V., Mattiello, R., & Donadio, M.V.F. (2020). Brazilian version of the Shriners Hospital Upper Extremity Evaluation (SHUEE): Translation, cultural adaptation, and evaluation of psychometric properties. Revista Paulista de Pediatria, 38(2018328), 1-7. https://pubmed.ncbi.nlm.nih.gov/32374805/

Wagner, L.V., Davis, J.R., & Hardin, J.W. (2015). Selective Control of the Upper Extremity Scale: Validation of a clinical assessment tool for children with hemiplegic cerebral palsy. Developmental Medicine and Child Neurology, 58(6), 612-617. https://pubmed.ncbi.nlm.nih.gov/26526592/

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