Comprehensive Coordination Scale (CCS)

Evidence Reviewed as of before: 11-11-2021
Author(s)*: Sandra R. Alouche; Marika Demers; Roni Molad ; Mindy F. Levin

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)
Parties du corps testées Type de test Test Éléments comportementaux notés
Membre supérieur Unilatéral Finger-to-Nose (FTN) Spatial : Stabilité, souplesse, précision
Temporel : Vitesse
Tronc et bras Unilatéral Arm-Trunk Coordination test (ATC) Spatial : Précision, coordination inter-articulations
Membre supérieur (dextérité fine) Unilatéral Finger Opposition (FOT) Spatial : Sélectivité
Temporel : Temps
Coordination inter-membres = les deux membres supérieurs Bilatéral Alternate movements of two upper limbs (ILC-2) Spatial : Compensation
Temporel : Synchronicité/temps
Membre inférieur Unilatéral Lower Extremity MOtor COordination Test (LEMOCOT) Spatial : Souplesse, précision
Temporel : Vitesse
Coordination des quatre membres = membres supérieurs et membres inférieurs Bilatéral Alternate movements of both hands and feet (ILC-4) Temporel : Temps/complexité

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 screening 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 Internal consistency:
One study has reported high Internal consistency of the CCS in a stroke population (Molad et al., 2021).

Test-retest:
One study examined test-retest reliability of the CCS within a stroke population and reported excellent test-retest reliability (ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).

Intra-rater:
One study examined intra-rater reliability of the CCS within a stroke population and reported excellent intra-rater reliability (ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).

Inter-rater:
One study examined intra-rater reliability of the CCS within a stroke population and reported excellent intra-rater reliability (ICC = 0.98, 95% CI: 0.95-0.99; Molad et al., 2021).

Validity Content:
One study has examined the content validity of the CCS. Using a Delphi Study done by a panel of experts. The CCS was found to have strong content validity (Alouch et al., 2021).

Criterion:
Concurrent:
Concurrent validity of the CCS has not been examined within a stroke population.
Predictive:
Predictive validity of the CCS has not been examined within a stroke population.

Construct:
Convergent/Discriminant:
One study has examined convergent validity of the CCS within a stroke population and reported: Adequate convergent validity 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 Validity of the upper-limb Interlimb Coordination Test (ICL2), a subscale of the CCS, within a stroke population and reported that the ICL2 is able to distinguish between aged-match healthy individiuals and chronic stroke 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 responsiveness of the CCS within a stroke 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 validity 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 stroke. 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. There were no floor/ceiling effects for the total score of the CCS and CCS-Bilateral subscale. 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.

Reliability

Internal consistency:
Molad et al. (2021) assessed the Internal consistency of the CCS in a sample of 30 chronic stroke survivors, using principal component analysis and confirmatory factor analysis. The authors reported excellent Internal consistency (composite reliability = 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 of the CCS.

Predictive:
No studies have reported on the predictive validity of the CCS.

Construct:
Convergent/Discriminant:
Molad et al. (2021) examined the convergent validity in a sample of 30 chronic stroke survivors. convergent validity of the total CCS was measured with the Fugl-Meyer Assessment (total score and motor score). Adequate convergent validity 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 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 was moderately correlated with the Fugl-Meyer Assessment (total score and motor score) and the Box and Blocks. The CCS-Bilateral subscale 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 of the ILC2 subscale in a sample of 13 stroke 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 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.

Responsiveness

 The responsiveness for the CCS has not been established.

Measurement error:
Molad et al. (2021) examined the measurement error in a sample of 30 chronic stroke survivors. The standard error of the measurement (SEM) was calculated based on the standard deviation (SD) of the sample and the reliability of measurement.  The minimal detectable change (MDC) 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 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.

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