Comprehensive Coordination Scale (CCS)

Purpose

The Comprehensive Coordination Scale (CCS) is a measure of coordination of multiple body segments at both motor performance (endpoint movement) and quality of movement (joint rotations and interjoint coordination) levels based on observational kinematics.

In-Depth Review

Purpose of the measure

 The Comprehensive Coordination Scale (CCS) is a measure of coordination of multiple body segments at both motor performance (endpoint movement) and quality of movement (joint rotations and interjoint coordination) levels based on observational kinematics. Coordinated movements are defined as movements of one or more limbs or body segments that occur together in identifiable temporal (i.e., timing) and spatial (i.e., positional/angular) patterns, concerning the desired action. It can be measured at a specific point in time during the movement or over the whole movement time.

The CCS can be used by healthcare professionals to assess coordination in older adults and individuals with various neurological conditions. The CCS is composed of six different tests: the Finger-to-Nose Test, the Arm-Trunk Coordination Test, the Finger Opposition Test, the Interlimb Coordination (synchronous anti-phase forearm rotations) Test, the Lower Extremity MOtor COordination Test (LEMOCOT) and the Four-limb Coordination (Upper and lower limb movements) Test.

Available versions

The CCS was developed by Alouche et al. (2021) from valid and reliable tests used in clinical practice and research to assess complementary aspects of motor coordination of the trunk, upper limb (UL), lower limb (LL) and combinations of them. Behavioral elements used to perform each test were identified and rating scales were developed to guide observational kinematic analysis by expert consensus (Alouche et al., 2021).

Features of the measure

 Items:
The CCS consists of 6 different tests used in either clinical practice or research to assess complementary aspects of motor coordination of the trunk, upper limb (UL), lower limb (LL) and combinations of them.

1. Finger-to-Nose Test (FTN)
2. Arm-Trunk Coordination Test (ATC)
3. Finger Opposition Test (FOT)
4. Interlimb Coordination Test (ILC-2)
5. Lower Extremity MOtor COordination Test (LEMOCOT)
6. Four-limb Coordination Test (ILC-4)

Body parts tested	Type of test	Test	Behavioral elements scored
Upper limb	Unilateral	Finger-to-Nose (FTN)	Spatial: Stability, smoothness, accuracy Temporal: Speed
Trunk and arm	Unilateral	Arm-Trunk Coordination test (ATC)	Spatial: Accuracy, interjoint coordination
Upper limb (fine dexterity)	Unilateral	Finger Opposition (FOT)	Spatial: Selectivity Temporal: Timing
Interlimb coordination=both upper limbs	Bilateral	Alternate movements of two upper limbs (ILC-2)	Spatial: Compensation Temporal: Synchronicity/ timing
Lower limb	Unilateral	Lower Extremity MOtor COordination Test (LEMOCOT)	Spatial: Smoothness, accuracy Temporal: Speed
Four-limb coordination = upper limbs and lower limbs	Bilateral	Alternate movements of both hands and feet (ILC-4)	Temporal: Timing/ complexity

Scoring:
Multiple behavioral elements of each test are scored on separate rating scales ranging from 3 (normal coordination) to 0 (impaired coordination) to assess different elements of motor behavior needed to perform the action.
The CCS includes a total of 13 rating scales for the 6 tests.
The CCS score ranges from 0 to 69 points, with higher scores indicating better motor coordination. The CCS total score represents a coordination score for the whole body.
The CCS scores can be broken into 4 subscores: UL, LL, Unilateral, Bilateral.
UL: 54 points (includes FTN-24 points, ATC-12 points, FOT-12 points, and ILC2-6 points).
LL: 12 points (includes LEMOCOT-12 points).
Unilateral: 30 points (includes FTN-12 points, ATC-6 points, FOT-6 points, and LEMOCOT-6 points).
Bilateral: 9 points (includes ILC2-6 points and ILC4-3 points).
The manual describes the initial position, the instructions, and the detailed scoring.

What to consider before beginning:
The CCS is scored based on observational kinematics.

Time:
The CCS takes approximately 10-15 minutes to administer (Molad et al., 2021).

Training requirements:
The healthcare professional should read the CCS manual available on Open Science Framework:  Marika Demers, Mindy F Levin, Roni Molad, and Sandra Alouche. 2021. “Comprehensive Coordination Scale.” OSF. July 12. osf.io/8h7nm.

 Equipment:

• Chair with back support and without armrests (suggested seat height: 46 cm)
• Footstool, if needed
• Targets:
  • 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)
• Stopwatch / timer
• Table (optional, suggested height: 72 cm)
• Pillow (optional)

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?

English

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 screeningTesting 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
ReliabilityReliability 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 consistencyA 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.: One study has reported high internal consistencyA 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. of the CCS in a strokeAlso 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. population (Molad et al., 2021). Test-retest: One study examined test-retest reliabilityA 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 strokeAlso 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. population and reported excellent test-retest reliabilityA 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 reliabilityThis 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 strokeAlso 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. population and reported excellent intra-rater reliabilityThis 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). Inter-rater: One study examined intra-rater reliabilityThis 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 strokeAlso 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. population and reported excellent intra-rater reliabilityThis 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 = 0.98, 95% CI: 0.95-0.99; Molad et al., 2021).
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: One study has examined the content validityRefers 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. of the CCS. Using a Delphi Study done by a panel of experts. The CCS was found to have strong content validityRefers 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. (Alouch et al., 2021). Criterion: Concurrent: Concurrent validityTo 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 strokeAlso 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. population. Predictive: Predictive validityA 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 strokeAlso 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. population. Construct: Convergent/Discriminant: One study has examined convergent validityA 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 strokeAlso 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. population and reported: Adequate convergent validityA 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<0.001) (Molad et al, 2021). Known Groups: One study has examined the known-group validityThe degree to which an assessment measures what it is supposed to measure. of the upper-limb Interlimb Coordination Test (ICL2), a subscaleMany 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 strokeAlso 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. population and reported that the ICL2 is able to distinguish between aged-match healthy individiuals and chronic strokeAlso 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. survivors (Molad & Levin, 2021).
Floor/Ceiling Effects	One study reported excellent floor and ceiling effects for the CCS (Molad et al., 2021).
Does the tool detect change in patients?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. of the CCS within a strokeAlso 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. population.
Acceptability	The CCS is non-invasive and quick to administer. The use of visual observation instead of complex and costly motion analysis equipment to analyze movement makes this scale clinically accessible and easy to use.
Feasibility	The CCS is free and is suitable for administration in various settings. The assessment requires minimal specialist equipment or training. It takes 10-15 minutes to be completed.
How to obtain the tool?	Alouche SR, Molad R, Demers M, Levin MF. Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase Content ValidityRefers 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.

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 strokeAlso 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.. 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 strokeAlso 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.. There were no floor/ceiling effects for the total score of the CCS and CCS-Bilateral subscaleMany 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 subscaleMany 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 consistencyA 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.:
Molad et al. (2021) assessed the internal consistencyA 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. of the CCS in a sample of 30 chronic strokeAlso 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. survivors, using principal component analysis and confirmatory factor analysis. The authors reported excellent internal consistencyA 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. (composite reliabilityReliability 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 validityTo 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 validityA 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 validityA 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 strokeAlso 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. survivors. Convergent validityA 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 validityA 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 validityA 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 subscaleMany 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 subscaleMany 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 validityThe degree to which an assessment measures what it is supposed to measure.
of the ILC2 subscaleMany 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 strokeAlso 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. 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 strokeAlso 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. had lower ILC2 scores and used trunk and shoulder compensations to perform the task. ILC2 scores distinguished between healthy participants and participants with chronic strokeAlso 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..

Responsiveness

 The responsivenessThe 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 strokeAlso 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. survivors. The standard error of the measurement (SEM) was calculated based on the standard deviation (SD) of the sample and the reliabilityReliability 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 validityRefers 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.