Hypertonia Assessment Tool (HAT) USER MANUAL First Edition
Contents
1. 1 positive circle score 0 Equal resistance not noted with bi directional movement 1 Equal resistance noted with bi directional movement 5 Equal resistance to passive stretch during bi directional movement of a joint RIGIDITY 0 Limb returns partially or fully to original 0 7 Maintenance of limb position a alter passiveanovement 1 Limb remains in final position of stretch 1 Ricmi SUMMARY SCORE HAT DIAGNOSIS Check box RIGIDITY Positive score 1 on either one or both of the Items 5 or 7 Yes _ No MIXED TONE Presence of 1 or more subgroups e g dystonia spasticity rigidity L Yes _ No HAT DIAGNOSIS Fill in all that apply2. Classification and definition of disorders causing hypertonia in childhood Pediatrics 2003 111 1 89 97 Jethwa A Mink J Macarthur C Knights S Fehlings T Fehlings D Development of the Hypertonia Assessment Tool HAT a discriminative tool for hypertonia in children Dev Med amp Child Neurol 2010 52 5 e83 e87 Hypertonia Assessment Tool HAT User Manual 3 Version Date June 1 2010 DEVELOPMENT OF THE HAT The framework for the development of the HAT included the following components item generation item reduction and reliability and validity assessment These components will be briefly described below with additional detail provided in the original reference 1 Item Generation The purpose of item generation was to build a comprehensive list of items that discriminated between the three subgroups spasticity dystonia and rigidity A preliminary list of items was generated from a panel small group sessions and telephone interviews with paediatric hypertonia experts After the item generation stage the HAT had fourteen items 2 Item Reduction The goal of item reduction was to decrease the number of items to make it practical to administer and retain the discriminative ability of the HAT A test of homogeneity of items was used to calculate the internal consistency of items within the three subgroups Items were eliminated from the HAT if the internal consistency of items in the subgroup increased to 0 7 0 9 when
3. designated limb remind the child to stay still and repeat the item Score 0 negative no involuntary movements or postures observed or positive involuntary movements or postures observed on the HAT Scoring Chart Increased Involuntary Movements or Postures with Purposeful Movement of a Distal Body Part A Ifthe child has changed the resting posture of their limb following the administration of item 1 return the limb to its original resting posture B Ask the child to carry out up to two of the following tasks for 10 seconds each Choose the task based on the child s ability but select from the top of the Hypertonia Assessment Tool HAT User Manual 6 Version Date June 1 2010 list first and then move down the list if necessary If the child has unilateral CP hemiplegic CP and has mirror movements omit task ii i Count to fifteen over a ten second period ii Open and close one hand into a fist 10 times iii Open and close eyes tight blinking 10 times iv Reach for an object placed at least a foot away from the hand Ask or encourage the child to reach for the object 3 times v Visually track a brightly coloured object e g small toy or light source e g flashlight moved horizontally back and forth in front of the child Complete 3 cycles C Observe for involuntary movements postures of the designated limb while the child carries out the task positive score If you see involuntary movements postures du
4. the item was removed The initial spasticity items verified moderate internal consistency and one item was eliminated The dystonia items demonstrated high internal consistency and no dystonia items were removed The rigidity items could not be evaluated as at least three items are required for the calculation 3 Evaluation of Reliability and Validity To evaluate Individual Item Validation Inter Rater Reliability Test Retest Reliability and Criterion Validity 25 children with cerebral palsy CP were recruited and were independently examined by three physicians who administered either the HAT or a paediatric neurological examination to identify the type s of hypertonia present After 2 weeks the same children were re examined using the HAT Individual Item Validation Each item on the HAT was assessed for its ability to agree with the paediatric neurological examination hypertonia diagnosis Four items were eliminated as they had less than 50 agreement Inter Rater Reliability To evaluate inter rater reliability a comparison of the HAT diagnoses by the two physicians was completed Inter rater reliability ranged from fair to excellent across the three subgroups gt Statistical agreement was assessed with positive and negative agreement and prevalence adjusted bias adjusted kappa PABAK The strength of the agreement was defined as slight 0 0 2 fair 0 21 0 4 moderate 0 41 0 6 substantial 0 61 0 8 or excellent
5. Hypertonia Assessment Tool HAT USER MANUAL First Edition June 2010 Authors Fehlings D Switzer L Jethwa A Mink J Macarthur C Knights S amp Fehlings T Sponsoring Institution Bloorview Kids Rehab Toronto ON Canada Research Funded by the Bloorview Children s Hospital Foundation and the National Institutes of Health We value your feedback s Please address all correspondence amp Bloor view commentary about the HAT to KIDS REHAB Dr Darcy Fehlings Bloorview Kids Rehab we 150 Kilgour Road Bloorview UNIVERSITY Toronto ON Canada M4G1R8 RESEARCH INSTITUTE le of TORONTO dfehlings bloorview ca TABLE OF CONTENTS HYPERTONIA ASSESSMENT TOOL OVERVIEW ecccsssseeceeeecesecesecneeeneeeeeeeeeaees 3 DEVELOPMENT OF THEHAT secre eee Rae Saag Pa ah cat ot at ek aad EAE 4 Ay AMC Generation eeni e a a ute mode E EE A iea 4 2 Jtem RECUCH Ois aa a aaa bo an 4 3 Evaluation of Reliability and Validity 0 cc ccscssccssscesneseecsscessecescesensesscessnee 4 Individual Item Valid ations cccseveccent ccteicvaeisecde ibaa te tisea tinea ina chavs abkeeentetiveateced 4 Int r Rater R liability iinssiriepena netoaren te eats Sas oa Satu Ja aa 4 Test Retest IOCUEADINLY ssrdastistsslaea aecoiescluoess 0b MleSDicheda pa ae acsautasealngag Ruaediadane cecmostideee 5 Critefion validity sescee eS cet Be Gases seca a Saeed casio Stats ance wee 5 Ongoing Work amp Future Directions occ caseidic ss
6. arm against gravity with your hand If the designated limb is the LEG e Note original position of the ankle e Move the ankle by 45 degrees into further dorsi or plantar flexion A After you have stopped the passive stretch of the limb observe if the forearm ankle remains in the last position of stretch or moves in the direction of the original position negative score Please note the movement can be slight 10 degree arc of joint movement and still score negative B Score 0 negative limb returns partially or fully to the original position or 1 positive limb remains in the final position of stretch on the HAT Scoring Chart SCORING OF THE HAT The HAT consists of seven items in total 2 spasticity items 2 rigidity items and 3 dystonia items Each item is scored using a yes no format The presence of at least one item of the subgroup confirms the presence of the subtype of hypertonia and the presence of items from more than one subgroup identifies the presence of mixed tone Hypertonia Assessment Tool HAT User Manual Version Date June 1 2010 HYPERTONIA ASSESSMENT TOOL HAT SCORING CHART Name Chart File Clinical Diagnosis Date of Birth Limb Assessed Gender C Male _ Female C Arm _ Left L Right HAT Assessor L Leg _ Left L Right Date of Assessment HYPERTONIA ASSESSMENT TOOL HAT SCORE SCORING GUIDELINES O negative HYpERTONIA HAT ITEM 0O negative or 1 positive
7. cc Sauces astacedehocastes eaves deg aaacdavsdeacsbabacease sees 5 HATADMINISTRA TION cninn ninnan ieira r a i cage ata syapusdeasbeadedvebsietee 6 Before Administrating the HAT co vsicsmatrt de uscnceectiskash ask adeae acl ae mamta 6 Administration of the HAT s cccjisassccusstventateateciiasdecaduanteciysneeindontecia ssa eeieorteceeenteseess 6 SCORING OFTHE HA TE sis t cbsevscussannessssenehansdatontevd avvatea banner aE AETERNA SRETEN E REAT 9 HYPERTONIA ASSESSMENT TOOL HAT SCORING CHART cecccceceeeeees 10 Hypertonia Assessment Tool HAT User Manual 2 Version Date June 1 2010 HYPERTONIA ASSESSMENT TOOL OVERVIEW Hypertonia is defined as abnormally increased resistance to externally imposed movement about a joint Spasticity dystonia and rigidity are three subtypes of neurologically mediated hypertonia Spasticity occurs when resistance to externally imposed movement increases with increasing speed of stretch and varies with the direction of joint movement and or resistance to externally imposed movement rises rapidly above a threshold speed or joint angle Dystonia is a movement disorder in which involuntary sustained or intermittent muscle contractions cause twisting and repetitive movements abnormal postures or both Rigidity is velocity independent bidirectional resistance to externally imposed movement While several scales existed to grade the severity of hypertonia in the paediatric
8. ches C Repeat steps i iv TWO times QUICKLY Stretch the limb as quickly as you can to the limb s end range Ensure that you don t stop the stretch at the Hypertonia Assessment Tool HAT User Manual 7 Version Date June 1 2010 Spastic Catch if one is present The Spastic Catch is defined as a rapid rise in resistance of the muscle It is challenging to maintain the speed of the stretch in both directions To aid in this pause at the end range before you stretch the limb back to its starting position D Assess for an increase in muscle resistance to stretch between the slow and the fast stretch If spasticity is present the fast stretch will have more resistance positive score E Score 0 negative no increased resistance noticed during fast stretch as compared to slow stretch or 1 positive increased resistance noticed during fast stretch compared to slow stretch on the HAT Scoring Chart 4 Presence of a Spastic Catch A During the same maneuver described in item 3 Table 1 assess for the presence of a rapid rise spastic catch in resistance at a particular joint angle when moving the limb during the two fast stretches positive score B Score 0 negative no spastic catch noted or positive spastic catch noted on the HAT Scoring Chart 5 Equal Resistance to Passive Stretch during Bi Directional Movement of a Joint A During the same maneuver described in item 3 assess for the presence of equal
9. gt 0 80 Hypertonia Assessment Tool HAT User Manual 4 Version Date June 1 2010 Test Retest Reliability To evaluate test retest reliability a comparison of the HAT diagnoses at both time points Test retest reliability ranged from moderate to excellent Criterion validity Criterion validity was measured by comparing the HAT diagnosis to the neurological diagnosis Across the subgroups the validity results were mixed However the HAT demonstrated higher positive agreement for identifying the presence of spasticity and dystonia whereas the HAT showed higher positive agreement for identifying the absence of rigidity The current version of the HAT consists of seven items in total 2 spasticity items 2 rigidity items and 3 dystonia items Ongoing Work amp Future Directions Ongoing work will focus on improving the HAT s psychometric properties with a particular focus on the dystonia items A research study evaluating the use of a videotape to assist with scoring of the dystonia items is currently underway As well future work on the HAT will include an evaluation of its use in children less than four years of age Hypertonia Assessment Tool HAT User Manual 5 Version Date June 1 2010 HAT ADMINISTRATION Before Administrating the HAT Children should be between 4 to 19 years of age and have hypertonia increased resistance to passive stretch of the muscle in at least one limb Determine the limb you will be assess
10. ing you can assess all limbs with hypertonia but do each limb separately and generate a HAT score for each limb The child youth should be supine on the examining table in comfortable unrestrictive clothing with their hand or foot of the limb you are examining bare e g out of splints and socks If possible their hands should be placed gently on their upper abdomen 4 Place a roll under the child s knees and a pillow under the child s head l 2 3 Administration of the HAT NOTE Complete ALL 7 items on one extremity before moving to the next hypertonic extremity It usually takes less than five minutes to complete the HAT assessment on one limb Items are listed in the suggested order of administration 1 2 Increased Involuntary Movements or Postures of the Designated Limb with Tactile Stimulus of a Distal Body Part A With the child at rest i ii iii Rub the skin of a distal body part of another limb e g shin or forearm Rub the length of the limb from the knee to the ankle or the elbow to the wrist in a straight line down the front of the limb completing 3 cycles Observe for any involuntary movements postures of the designated limb positive score Involuntary movements postures can be subtle and often consist of finger or toe flexion or wrist flexion Ensure the child does not have voluntary movements during this item If you are unsure if movements are voluntary or involuntary in the
11. population there was no available measure that differentiated the different forms of hypertonia This was the main objective for the development of the Hypertonia Assessment Tool HAT The HAT can be used in research to classify the hypertonia of the study participants thereby improving the ability of researchers and clinicians to interpret the results of the study Clinically a discriminative measure will help clinicians to better manage the specific type s of hypertonia present to improve treatment outcomes For example spasticity responds to tizanidine whereas dystonia improves with trihexyphenidyl The HAT is a seven item tool that has been developed for children youth between the ages of 4 to 19 years whereby an evaluator moves a child s arm or leg in a series of purposeful stretches and movements in order to observe movement increased tone and or resistance The presence of at least one HAT item per hypertonia subgroup spasticity dystonia rigidity confirms the presence of the subtype and the presence of items from more than one subgroup identifies the presence of mixed tone The HAT is capable of discriminating hypertonia subtypes for both the upper and lower extremities and takes approximately 5 minutes to conduct per limb assessed The following sections provide additional detail pertaining to the development of the HAT the administration of items and the scoring of the HAT Sanger TD Delgado MR Gaebler Spira D et al
12. resistance to passive stretch in both directions of limb movement during the two fast stretches positive score B Score 0 negative equal resistance not present with bi directional movement or 1 positive equal resistance present with bi directional movement on the HAT Scoring Chart 6 Increased Tone with Movement of a Distal Body Part A Identify one joint of your designated limb that demonstrated resistance in the stretches performed during item 3 e g elbow or ankle Perform two additional fast stretches moving the limb as described in Table 1 Pause between the two stretches i Before starting the 2 stretch ask the child to do one of the voluntary movements from item 2B e g count to 15 over a 10 second period open close one hand into a fist 10 times After they have completed 3 of the movements and continuing on to the fourth do the second fast stretch il Assess for an increase in tone in the 2 stretch compared to the first stretch positive score B Score 0 negative no increased tone noted with purposeful movement or positive greater tone noted with purposeful movement on the HAT Scoring Chart Hypertonia Assessment Tool HAT User Manual 8 Version Date June 1 2010 7 Maintenance of Limb Position After Passive Movement IF the designated limb is the ARM e Note original position of the elbow e Move the elbow by 45 degrees into either flexion or extension and support the weight of the fore
13. ring the first task you do not need to complete a second task D Score 0 negative no involuntary movements or postures observed or positive involuntary movements or postures observed on the HAT Scoring Chart 3 Velocity Dependent Resistance to Stretch A With the child at rest and supine i Support designated limb against gravity il Start the joint in full flexion or adduction iii Move joints of the limb through the child s full range to full extension or abduction as outlined in Table 1 iv Return to flexion or adduction Table 1 IF the designated limb is an UPPER extremity e Shoulder adduction abduction begin with shoulder in full adduction and elbow in flexion e Elbow flexion extension begin with elbow in full flexion e Forearm pronation supination begin with forearm in full pronation and hold the child s wrist to assess supination e Wrist flexion extension begin with wrist in full flexion If the designated limb is a LOWER extremity e Hip adduction abduction begin with hip in full adduction and knee in full extension e Knee flexion extension begin with knee flexed with hip in 90 flexion e Ankle dorsiflexion plantarflexion begin with ankle in full plantarflexion B Start with two slow stretches Ensure that you move the limb the same speed of stretch in both directions Note the end range of the stretch to ensure that you don t over stretch the limb during the two fast stret
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