- One 2.54 cm-diameter sticker (FNT)
- One target (sphere of 2.54 cm-diameter or a cube of similar dimensions) on an adjustable height support (ATC)
- Two 5 cm-diameter stickers placed 30 cm (centre-to-centre) apart and attached to a cardboard (LEMOCOT test)
Client suitability
Can be used with:
- Individuals with neurological disorders
Should not be used with:
- No information availble
In what languages is the measure available?
Summary
| What does the tool measure? | Temporal and spatial aspects of coordination. |
| What types of clients can the tool be used for? | The CCS can be used with patients with neurological disorders. |
| Is this a screening Testing for disease in people without symptoms. or assessment tool? | Assessment tool. |
| Time to administer | 10-15 minutes. |
| ICF Domain | Body function. |
| Other Languages | French Canadian, Portuguese (both not published) |
| Measurement Properties | |
| Reliability Reliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . | Internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More : One study has reported high internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More of the CCS in a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population (Molad et al., 2021). |
Test-retest:
One study examined test-retest reliability A way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the CCS within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population and reported excellent test-retest reliability A way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).
Intra-rater:
One study examined intra-rater reliability This is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the CCS within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population and reported excellent intra-rater reliability This is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
(ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).
Criterion:
Concurrent:
Concurrent validity To validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the CCS has not been examined within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population.
Predictive:
Predictive validity A form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the CCS has not been examined within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population.
Construct:
Convergent/Discriminant:
One study has examined convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the CCS within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population and reported: Adequate convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
with Fugl-Meyer-Total Score (ρ=0.602; p=0.001) and Fugl-Meyer-Motor Score (ρ=0.585; p validity The degree to which an assessment measures what it is supposed to measure.
of the upper-limb Interlimb Coordination Test (ICL2), a subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the CCS, within a stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More population and reported that the ICL2 is able to distinguish between aged-match healthy individiuals and chronic stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More survivors (Molad & Levin, 2021).
Psychometric Properties
Overview
A literature search was conducted to identify all relevant publications on the psychometric properties of the Comprehensive Coordination Scale (CCS) in individuals with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More . We identified two studies.
Floor/Ceiling Effects
Molad et al. (2021) examined floor/ceiling effects of the CCS in a sample of 30 participants with chronic stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More . There were no floor/ceiling effects for the total score of the CCS and CCS-Bilateral subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. For the CCS-UL and CCS-LL subscales, 3.3% and 6.7% of participants reached the maximal score, respectively. Ten percent of participants scored 0 or 30 on the CCS-Unilateral subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
.
Reliability
Internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More :
Molad et al. (2021) assessed the internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More of the CCS in a sample of 30 chronic stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More survivors, using principal component analysis and confirmatory factor analysis. The authors reported excellent internal consistency A method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. More (composite reliability Reliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
= 0.938). Factor analysis of the entire CCS revealed two components explaining 99% of the variance: Factor 1: movement quality (8 items), Factor 2: endpoint performance (5 items).
Intra-rater:
Molad et al. (2021) assessed the intra-rater reliability of the CCS in 30 chronic stroke survivors. The intra-rater reliability was evaluated with intraclass correlation coefficients (ICC) with 95% confidence intervals (CI). The CCS has excellent intra-rater reliability (ICC = 0.97; 95%; CI: 0.93-0.98). All four subscales also have excellent intra-rater reliability: CCS-UL subscale (ICC = 0.96; 95%; CI: 0.92-0.98), CCS-LL subscale (ICC = 0.79; 95%; CI: 0.36-0.92), CCS-Unilateral (ICC = 0.98; 95%; CI: 0.96-0.99) and CCS-Bilateral scores (ICC = 0.95; 95%CI: 0.89-0.97).
Inter-rater:
Molad et al. (2021) assessed the inter-rater reliability of the CCS in 30 chronic stroke survivors. The inter-rater reliability was evaluated with intraclass correlation coefficients (ICC) with 95% confidence intervals (CI). The CCS has excellent inter-rater reliability (ICC = 0.98; 95%; CI: 0.95-0.99). All four subscales also have excellent inter-rater reliability: CCS-UL subscale (ICC = 0.96; 95%; CI: 0.91-0.98), CCS-LL subscale (ICC = 0.76; 95%; CI: 0.25-0.9), CCS-Unilateral scores (ICC = 0.99; 95%; CI: 0.97-0.99) and CCS-Bilateral (ICC = 0.95; 95%; CI: 0.89-0.98).
Validity
Content:
Alouche et al. (2021) conducted a 3-phase content validation supporting the importance, level of comprehension and feasibility of the CCS in identifying and quantifying coordination of movements made by individuals with neurological deficits in a clinical setting. First, a literature review was performed to generate unilateral and bilateral tests of UL, LL, and trunk coordination currently used in clinical practice or research studies for the CCS. From the 2761 studies reviewed, 5 tests were selected: FTN, ATC, LEMOCOT, ILC2, and ILC4. A Delphi study, using a structured questionnaire with open-ended questions, was done with 8 expert clinicians and researchers to identify the relative importance of each test, test element, and rating scales, the level of comprehension of the instructions, and the feasibility of each test. Then, a focus group meeting was held with 6 experts to refine the instructions and the rating scales. A consensus was reached to add the Finger Opposition Test (FOT) to the final version of the CCS to assess the selectivity and timing of finger movements.
Criterion:
Concurrent:
No studies have reported on the concurrent validity To validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the CCS.
Predictive:
No studies have reported on the predictive validity A form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the CCS.
Construct:
Convergent/Discriminant:
Molad et al. (2021) examined the convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
in a sample of 30 chronic stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More survivors. Convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the total CCS was measured with the Fugl-Meyer Assessment (total score and motor score). Adequate convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the CCS with FMA-Total Score (ρ=0.602; p=0.001) and FMA-Motor Score (ρ=0.585; p<0.001) was obtained. The convergent validity A type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the subcales was measured with the Fugl-Meyer Assessment, prehension and pinch strength, Box and Blocks and 10-meter walk test. CCS-UL and CCS-Unilateral scores were moderate to strongly correlated with the Fugl-Meyer Assessment (total score and motor score), prehension and pinch strength, Box and Blocks and 10-meter walk test. The CCS-LL subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was moderately correlated with the Fugl-Meyer Assessment (total score and motor score) and the Box and Blocks. The CCS-Bilateral subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was moderately correlated with the Fugl-Meyer Assessment (total score and UL motor score) and the Box and Blocks.
Known Group:
Molad & Levin (2021) examined the known group validity The degree to which an assessment measures what it is supposed to measure.
of the ILC2 subscale Many measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
in a sample of 13 stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More survivors and 13 healthy participants. They compared ILC2 scores with trunk and upper limb kinematics during synchronous bilateral anti-phase forearm rotations in 4 conditions: self-paced internally-paced, fast internally-paced, slow externally-paced, and fast externally-paced. Healthy participants had near maximal ILC2 scores and high temporal and spatial coordination indices. However, participants with stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More had lower ILC2 scores and used trunk and shoulder compensations to perform the task. ILC2 scores distinguished between healthy participants and participants with chronic stroke Also called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. More .
Responsiveness
The responsiveness The ability of an instrument to detect clinically important change over time.
for the CCS has not been established.
Measurement error:
Molad et al. (2021) examined the measurement error in a sample of 30 chronic stroke Also called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. More survivors. The standard error of the measurement (SEM) was calculated based on the standard deviation (SD) of the sample and the reliability Reliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of measurement. The minimal detectable change (MDC) Minimal Detectable Change (MDC) refers to the minimal amount of change outside of error that reflects true change by a patient between two time points (rather than a variation in measurement). at the 95% confidence level was computed. The CCS SEM was 1.80 points and the MDC95 was 4.98 points. The SEM and MDC values for the CCS, the CCS-UL, CCS-Unilateral and CCS-bilateral were less than 17%. Only the CCS-LL had an MDC greater than 17%. For the CCS and all subscales, the SEM was smaller than the MDC.
References
Alouche, S.R., Molad, R., Demers, M., Levin, M.F. (2021) Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase Content Validity Process. Neurorehabil Neural Repair. 35(2):185-193. doi: 10.1177/1545968320981955. PMID: 33349134.
Molad, R., Alouche, S.R., Demers, M., Levin, M.F. (2021) Development of a Comprehensive Outcome Measure for Motor Coordination, Step 2: Reliability and Construct Validity in Chronic Stroke Patients. Neurorehabil Neural Repair. 35(2):194-203. doi: 10.1177/1545968320981943. PMID: 33410389.
Molad, R., & Levin, M. F. (2021) Construct validity of the upper-limb Interlimb Coordination Test (ILC2) in stroke. Neurorehabil Neural Repair [epub ahead of print]. doi: 10.1177/1545968321105809. PMID: 34715755
See the measure
The tool is available as supplementary material in:
Alouche SR, Molad R, Demers M, Levin MF. Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase content validity Refers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
Process. Neurorehabil Neural Repair. 2021 Feb;35(2):185-193. doi: 10.1177/1545968320981955. [Supplementary materials]
The CCS manual can be accessed on the Open Science Framework website:
Marika Demers, Mindy F Levin, Roni Molad, and Sandra Alouche. 2021. “Comprehensive Coordination Scale.” OSF. July 12. osf.io/8h7nm.
The information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.
*The authors have no direct financial interest in any tools, tests or interventions presented in STROKE ENGINE.
STROKE ENGINE is financially supported by CPSR. © 2024 STROKE ENGINE team. All rights reserved.STROKE ENGINE was built with the goal of bridging the gap in knowledge translation between research findings and current clinical practice in stroke rehabilitation.
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