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A Review of the Quality of Upper Extremities Skills Test (QUEST) for Children
with Cerebral Palsy

Article in Physical & Occupational Therapy in Pediatrics · June 1998

DOI: 10.1300/J006v18n03_09

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 Physical & Occupational Therapy In Pediatrics

ISSN: 0194-2638 (Print) 1541-3144 (Online) Journal homepage: http://www.tandfonline.com/loi/ipop20

A Review of the Quality of Upper Extremities Skills

Test (QUEST) for Children with Cerebral Palsy

Annabel Hickey & Jenny Ziviani

To cite this article: Annabel Hickey & Jenny Ziviani (1998) A Review of the Quality of Upper
Extremities Skills Test (QUEST) for Children with Cerebral Palsy, Physical & Occupational
Therapy In Pediatrics, 18:3-4, 123-135

To link to this article: http://dx.doi.org/10.1080/J006v18n03_09

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 A Review of the Quality
of Upper Extremities Skills Test (QUEST)
for Children with Cerebral Palsy
Annabel Hickey
Jenny Ziviani
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ABSTRACT. Disorder of movement is the main featurc of cerebral

palsy. Yet, until recently, no easy-to-use validated measure of upper
limb quality of movement has been available for childrcn with cerebral
palsy. The Quality of Upper Extremities Skills Test (QUEST) was
developed to meet this need. The QUEST was developed for children
aged 18 months to 8 years and this review finds that initial reliability
and validity data are promising. The ability of the test to detect change,
however, is less clear and there is little support for its discriminative
properties. Some suggestions are made regarding administration and
scoring procedures. Notwithstanding these limitations, the QUEST is
identified as an important first step to the measurement of upper ex-
tremity quality of movement for children with cerebral palsy. [Article
copies uvuiluble for a fee @om nie Huworili Dociirnerii Deliveiy Service:
1-500-342-9678.E-nzuil address: ~etir2fo~uhu~ori~ipressiiic.coi~zJ

THE NEED FOR A MEASURE OF UPPER LIMB

QUALITY OF MOVEMENT

To gain a true picture of clinical progress in children with cerebral palsy,

therapists involved in their management need to measure quality (how the

Annabel Hickey, BApp Sc(OT) is a candidate for a Masters in Medical Science,

Faculty of Medicine and Sciences, University of Newcastle. Jenny Ziviani, PhD. is
Associate Professor, Department of Occupational Therapy, The University of
Queensland.
Address correspondence to: Jenny Ziviani, PhD, Department of Occupational
Therapy, The University of Queensland, Brisbane, Australia 4072.
Physical & Occupational Therapy in Pediatrics, Vol. 18(3/4) 1998
0 1998 by The Haworth Press, Inc. All rights reserved. 123
 124 PHYSICAL & OCCUR4TIONAL THERAPY IN PEDIATRICS

child performs a task) as well as function (what the child can do). Many
researchers believe that for children with cerebral palsy, available instru-
ments are not sensitive enough to detect clinically significant changes
brought about by intervention. Frequently parents and clinicians report im-
provements in quality of movement where no changes are found on measures
of function.’?’ Abnormal movement is characteristic of cerebral palsy, yet
functional measures are task-focused and do not directly assess the way in
which movement is performed. When evaluating interventions aimed at im-
proving movement, changes in its quality such as control, speed and smooth-
ness must be monitored, o r vital information can be lost.
The lack of an objective measure of arm and hand quality of movement is
especially of concern for younger children with cerebral pals whose in-
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volvement in intensive early intervention requires evaluation.14 The Mel-

bourne Assessment of Unilateral Upper Limb Functions is currently being
refined for children with neurological impairment and when completed may
be an excellent assessment tool for children with cerebral palsy; however, this
test will not be suitable for children under five years of age. Some standard-
ized tests, such as the Bruininks-Oseretsky Test of Motor Proficiency,6 in-
clude items about quality of movement but the high level motor tasks de-
manded arc unsuitable f o r preschool children and would be impossible to
perform for most children with cerebral palsy. Other methods (such as 3-di-
mcnsional kinematic analysis) require expensive equipment, a fixed location,
or generate unwieldy amounts of data for analysis rendering them impractica-
ble.778 Hence, for lack of anything better, many researchers and clinicians
develop their own criteria and scales to rate quality of Unfor-
tunately, reporting of validity, reliability, and procedures for administration
and scoring is rare for these ‘home made’ measures.I2 This lack of informa-
tion restricts their further development and use by others. The need exists for
a psychometrically sound measure of upper extremity movement quality in
children with cerebral palsy.

DESCRIPTION OF THE QUEST

Introduction to the QUEST

The QUEST was developed in 3091 specifically for children with spastic
cerebral palsy in order to provide one of several outcome measures for a
clinical trial on upper limb casting.13 Its stated aim was to evaluate move-
ments that, according to neuro-developmental theory, are thought to be the
basis of functional hand use. The QUEST is a criterion-referenced measure
that assesses upper limb movement o n 34 items divided into four domains
 Clinical Concerns 125

with administration and scoring reported to take between 30 and 45 minutes.

The items were designed to detect clinical changes in movement that occur
prior to changes in skills. The QUEST was also constructed to be a discrimi-
native measure of quality of movement, measure components of hand func-
tion, and provide information about movement and postural responses. The
authors advise using the QUEST together with a hand function measure such
as the Peabody Developmental Motor Scales14 fine motor subtest (PDMS-
FM) to determine functional skill attainment.15 This recommendation is
based on the premise that the QUEST provides information about the quality
of movement while the PDMS-FM measures task achievement. To date, the
only published reports about the instrument are by the developer^.'^^.'^^'^
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Target Population

The QUEST was developed for children aged 18 months to 8 years with
muscle spasticity resulting from neurological impairment and affecting the
upper extremities. The test was designed to reflect severity of impairment of
quality of movement regardless of age except for grasp items which are not
suitable for children under 18 months.17

Content

The QUEST groups upper limb movement into four domains. Each do-
main focuses on areas of difficulty typically seen in children with spastic
cerebral palsy: (a) Dissociated Movements, (ability to voluntarily isolate
movement at the shoulder, elbow, wrist and fingers); (b) Grasps (which also
rates sitting postures during grasps of 1 inch cube, cereal, pencil or crayon);
(c) Weight Bearing (ability to lean on the arms in prone or 4-point kneeling,
sitting and while reaching); and (d) Proteclive Extension (using the arms to
stop oneself from falling forward, backward and to the side). In addition to
the four domains of movement the QUEST also has three scales: Hand
Function, Spasticity and Co-operativeness. The authors state that these scales
give therapists an opportunity to compare their sukjective impressions with
test scores and are not intended for inclusion in the summary scores.

Item Selection

Items selected for inclusion needed to be: (1) part of normal development
up to 18 months, (2) a common movement problem in the presence of spas-
ticity, and (3) a consistent goal of treatment. The original test included a play
section to observe performance in a naturalistic way but this was later re-
moved as it made the test too long. Initial piloting of the QUEST was on 10
childrcn with cerebral palsy, aged 18 months to 8 years. The test developers
 126 PHYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

and 16 therapists specializing in pediatrics reviewed the items. Items were

excluded that could not be defined or seemed inappropriate for the domain
groupings.

Item Format and Scoring

The QUEST item selection and scoring conforms to the requirement of

criterion based assessment which examines performance in relation to prede-
termined criteria.la Within each of the four domains several movements are
assessed and scored on a dichotomous scale as either being present or absent
so that a child with no motor impairments should easily achieve the move-
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ment. The total number of ’yes’ and ‘no’ responses provide the raw score for
each domain. This is then weighted and transformed from a score range of 50
to 100 into a final score range of zero to 100 (a score below zero is possible if
sitting postures during grasp are ‘atypical’). The final score referred to con-
fusingly as standardized, is not a norm-referenced score, as the term would
suggest, but a percentage. Children with no ma.jor motor disability should
easily achieve 100. Summation of the percentage scores for each domain and
division by the number of domains tested produces a total test score. This
scoring system allows for administration of either some or the entire test.
Beyond the summed score, three scales record clinical impressions. Subjec-
tive impressions of hand function are rated on three 11-point scales ranging
from zero (poor) to 10 (good) for left, right and, bilateral hand use. Dcfini-
tions of the scale are only given for the highest and lowest ratings. Spasticity
is rated for each hand as none, mild, moderate or severe with definitions for
each category. Co-operativeness ratings (not, somewhat and very) help to
give an indication of the child’s behavior on the day of testing.

PSYCHOMETRIC PROPERTIES

Reliability

Test reliability refers to the concept of score accuracy. Scores must be

reasonably consistent if we are to have any confidence in them.19 Three
studies reported in the test manual and by DeMatteo et aI.,l5 examined the
reliability of the total score and individual domains. Posture, although a part
of the grasp domain, was treated separately for reliability measures. The
reason for this is not stated, but is probably due to the different nature of the
scoring. All three groups assessed inter-rater reliability and one evaluated
test-retest reliability; however, the table in the manual reports only two of the
three inter-rater reliability studies. Findings and methods of assessment for
all studies were extracted from the manual and are summarized in Table 1.
 Clinical Corzcerris 127

TABLE 1. lntraclass Correlation Coefficient for Inter-Rater and Test-Retest

Reliability of the QUEST
Domains at Movement

Study* Reliability Assessed by: Total Dissociated Grasp Posture Protective Weight
Score movement exlension Bearing

1 Inter- 2OTs 0.95 Not No1 Not Not Not

N = 16 ObSeNer reported reported reported reported reported
2 Inter- Research 0.96 0.91 0.91 Not 0.80 0.61
N = 71 ObSeNer coordinator B complete
child's OT
3 Inter- Bobservers 0.90 0.93 0.88 0.51 0.72 0.80
N = 17 obsenrer of video-tape
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assessment
blinded to
order
Test-retest Tests 2 weeks 0.95 0.95 0.93 0.?9 0.75 0.85
apart of same
child, scored
from video

*All studies reported in DeMatteoet al., 1992 B 1993.

Inter-rater reliability, which is concerned with variations in scoring be-

tween two or more raters of the same subject, was reported to be excellent for
total score in all three studies ranging from 0.90 to 0.96. Domain inter-rater
reliability reported in two studies ranged from 0.51 for posture to 0.93 for
Dissociated Movement. Test-retest reliability (the consistency of test vari-
ables o n different occasions in the absence of change) was high for total score
at 0.95 and in the domains ranged from 0.75 (Protective Extension) to 0.95
(Dissociated Movements).

VaLidity

Validity is a broad concept referring to an instrument's ability to measure

what it purports to measure.19 Content validity refers to the extent to which
items in the test reflect its theoretical basis. This i s fundamental to test
development and although it can not be statistically determined, it is sup-
ported by evidence of independent review of experts and theoretical justifica-
tions. Review of the test should consider whether the theoretical domain of a
test matches its stated objectives and is reflected in the items.19 Content
validity is indirectly referred to in the QUEST manual in the section describ-
ing test development. The authors state that the theoretical basis was devel-
oped through reviewing the literature and consultation with experts and prac-
titioners in the field throughout the test construction. The four domains
chosen were based on neurodevelopmental theories of the areas that consti-
tute hand function. The QUEST was then piloted on 10 children and further
 128 PNYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

reviewed by I6 clinical pediatric therapists who further refined the scoring

criteria.
Construct validity is in part based on content validity but also requires
further definition of the relationship of the test to abstract and theoretical
constructs." For the QUEST, construct validity was assessed by correlating
QUEST total scores with therapists' ratings of left and right hand function on
an 11-point scale and with chronological age. Correlations with hand func-
tion ratings were reported to be high for the left hand (0.72), and moderate for
the right (0.58). The correlation between QUEST total score and chronologi-
cal age was low at 0.33. No explanation was offered as to why hand function
correlations should differ for the left and right hands. This difference is more
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likely to be related to poor reliability of the 11-point scale (where only zero
and ten is defined) than representing actual differences in the way that the
QUEST assesses left and right hand function. Furthermore, descriptions of
Hand Function data collection are vague,I5>l7needing clarification as to who
rated hand function and the number of observations made. The low correla-
tion between age and total score was not surprising to the developers as the
intention of the QUEST was to measure severity of movement disorder
regardless of age. Correlations between age and the different domains, how-
ever, could provide useful information as age and grasp are likely to have a
high positive association. Unfortunately these details were not reported.
Concurrent validity can be used t o support construct validity by compar-
ing test items with similar criteria.I9 The developers evaluated this aspect by
correlating QUEST scores with a developmental hand function test, the Pea-
body Developmental Motor Fine Motor Subscale (PDMS-FM). In the manu-
al they call this coizstriict validity1' and elsewhere criterion ~a1idity.l~From
their description the terms concurrent, or concurrent-criterion validity would
be more accurate.19'21 Seventy-one children with spastic hemiplegic and
quadriplegic cerebral palsy aged 18 months to 8 years were assessed three
times on the two instruments during the clinical trial on upper limb casting.13
Assessments were conducted at baseline and again six and nine months later
by assessors unaware of treatmcnt status. The manual presents only one set of
correlations and does not mention from which measurement period they were
taken. Although the authors report that the finding were similar for the three
assessments, data should be included from all three unless there is strong
justification for doing otherwise. In the data presented, Pearson product mo-
ment correlation coefficients were used for calculations. Correlations were
high (0.84) between the total scores of the two tests. Correlations between
QUEST domains and PDMS-FM subscores (coordination, grasp, hand use,
manual dexterity) ranged from moderate (0.58) to high (0.83). The grasp
domain of the QUEST correlated most highly (0.77 to 0.83), followed by
 Clinical Coricerns 129

Dissociated Movements (0.69 to 0.78), Weight Bearing (0.67 to 0.75), and

Protective Extension (0.58 to 0.69).

Responsivity to Clinical Change

The QUEST was developed primarily as a measure of change. Because no

treatment for children with cerebral palsy has definitively been shown to be
effective, no objective standard exists against which we can compare the
ability of the QUEST to detect change. Deyo and Centor state that in the
absence of a ‘gold standard’ . . . “no single observation can prove critical or
d e f i n i t i ~ e . ” ~ ~ (To
p ~address
” ~ ) this problem the developers explored respon-
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sivity in three ways: (1) identifying the smallest amount of clinically signifi-
cant change during a clinical trial on wrist casting, (2) correlating QUEST
change scores with PDMS-FM change scores, and (3) correlating the percep-
tion of change of therapists and parents with QUEST change scores. The first
exploration in the casting clinical trial considered improvements of 4.89
QUEST score units (p < .03) between treatment groups to he the smallest
difference of clinical significance when an assessor unaware of the status of
the child and a treating therapist scored each child.13 The second measure of
responsivity correlated change in QUEST scores over six months with
PDMS-FM change scores over the same time period. Correlations were low
between the QUEST and PDMS-FM change scores (0.29); however, the
value of correlating change scores of the QUEST and PDMS is questionable.
The PDMS was developed to discriminate performance not evaluate change
and no evidence has been reported that it is responsive to ~ h a n g e . ~The ~?~’
third approach to evaluating responsivity required therapists and parents
involved in the study to rate their perceptions of changes in hand function on
an 11-point scale. Zero was defined as “no change” and ten as “much
improvement.” Again correlation with QUEST scores was low at 0. I3 for
therapist and - .05 for parents. The authors speculate that the reason for this
low correlation with functional skills is that the QUEST detects clinically
significant changes of quality of movement which often occur prior to im-
provement in skill level. Another reason for low correlations could be due to
a problem with the scale which required ratings of perception of change in
hand function. Only zero and 10 are defined which could weaken its reliabil-
ity. As the responsiveness data is inconclusive, further research into the
QUEST’S ability to detect clinical change is needed.

Discrimination of Individual Differences

Strong correlations between the QUEST and the PDMS-FM (0.84) lead
the developers to suggest that the QUEST could be useful as a discriminative
 130 PHYSCAL & OCCUPATIONAL THERAPY IN PEDIATRICS

measure. Discrimination usually refers to identifying differences between

individuals at a point in time.21 Further explanation is needed as to why a
correlation with the PDMS-FM is an indicator of discriminative properties in
the QUEST. The ‘Interpretation of Scores’ section implies that the QUEST
discriminates according to age and severity of disability, supported by an
unexplained table of QUEST score means and standard deviations from the
casting trial examined by age and severity. In this context severity is not
defined. If the QUEST has shown discriminative potential the developers
need to support it with the appropriate data.
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QUALITATIVE PROPERITIES OF THE QUEST

Reading a test manual and reviewing psychometric properties is only part

of the picture of test use. Claims made in manuals, such as ease and time of
administration, do not always match with clinical experience. By way of
reviewing “applicability” we used the QUEST on several children with
spastic cerebral palsy of differing ages. Test developers were consulted prior
to QUEST administration in order to clarify a number of issues that were
unclear in the manual (these will be detailed later).
Administration and Scoring

We found the manual’s estimate of 30 to 45 minutes for administration and

scoring to be realistic in practice. Administration took 10 to 20 minutes and
scoring 10 minutes. Further, we found administration particularly well suited
to the needs of children with cerebral palsy. The child must demonstrate and
hold a position for 2 seconds without physical help but movement can be
facilitated through any other means such as verbal encouragement or using a
favorite toy. The non-standardized instructions allowed therapists to accom-
modate to different ages and, to intellectual and other impairments that are so
often present in children with cerebral palsy.’3 One restriction we thought
potentially limited the use of the QUEST as an evaluation tool was that the
child cannot wear any devices on the upper limb during testing. Such a
condition seems unnecessarily restrictive as therapists often wish to evaluate
the effectiveness of devices for upper limb m ~ v e m e n t . ~ ~ - ’ ~
The score sheets are logically set out and allow for comments on testing
conditions such as seating inserts used, lower limb orthotics, time of day and
who was present. Diagrams supplement the text t o prompt the examiner
regarding testing position. To help the flow of the assessment and scoring we
reduced the size of the proforma so that two pages fitted on to one. To
improve scoring completion we provided the total possible number of re-
sponses at the bottom of each page.
 Clinical Concerns I31

The manual contains ideas to promote movement but the poor quality of
expression makes some of the them difficult to understand. For example, the
suggestions for elbow items are unclear in respect of what movement is being
promoted when all that is listed is “‘give me five, ’ place the block oiz their
hnnd, stickers OH thepalm” (p. 21). ‘Give me five’ may be encouraging forearm
pronation and ‘stickers on the palm’ supination. Placing a block on the hand
could be used for either. More fully explained examples are needed.
After discussions with one of the QUEST developers we made some
changes to the forms and provided additional instructions to the manual due
to errors or lack of clarity in the manual or score form. For example, ‘half
range’ estimates for elbow and wrist items are incorrect in the manual (dis-
cussion with author) and the degrees are not given on the score sheet. We
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corrected this by making elbow and wrist items on the form easier to follow
by clearly defining the degrees of “half range”: that is, elbow 75 degrees,
wrist extension 35 degrees and wrist flexion 45 degrees. (Figure 1 summa-
rizes the changes to instructions.)
We found that the scoring for some items did not allow us to record
clinically significant change. The criterion of ‘complete supination’ when
tlexing and extending the elbow and wrist has the potential to miss improve-
ments of increasing supination occurring during the movement. Four items
are used to rate grasp of the pencil: dynamic tripod, static tripod, digital
pronate and palmar supinate. Unless a child demonstrates one of these grips
he or she scores zero. As there is no score for a grasp that is ‘normal’ but not
listed, skills in this area may be missed. For example one child had dynamic
finger movements with thumb abducted rather than opposed and thus scored
zero for the whole section as she did not fit into any of the categories. The
recently developed Melbourne Assessment5 addresses the problem of rating
pencil grasp by including a variety of grasps acceptable at each level.

Age Range of the QUEST

Although the QUEST was validated on children aged 18 months to 8

years, we used the QUEST on some children aged 9 and 11 and found that the
instructions worked equally well for all the children. The scores seemed to
reflect severity of movement disorder, and not developmental level. If others
support our experience, then the QUEST could be suitable for older children
and adults.

Examiner Qualifications and Training

No recommendations are made in the manual about qualifications and

training of test administrators. The flexibility of test administration will be
welcome to the therapist experienced in cerebral palsy but does not seem
 132 P W S I C A L & OCCUPATIONAL THERAPY IN PEDIATRICS

FIGURE 1. Instructions on QUEST Administration and Scoring

A: QUEST Administration
Additional comments on the QUEST that are not clear in the manual
1. Grasp domain:
a)ltem grasp of pencil or crayon
Let the child pick up the pencil anyway they can, even if it is with the other hand and positioned. We want to see
the grasp itself as opposed to how they get to the grasp.
2. Item “Weight bearing”
Many children assume the position but do not bear much weight. For example a child in 4 point kneeling may
shift most of their weight backwards. Facilitate a weight shifl to ensure that the child bears weight. You can
encourage this by putting Play-Doh under the hands and get them to flatten it.
3. General
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Remember to do everything possible to help the child do an item.

N5. Demonstration,physicalpositioning and verbal prompts st?ouldbe used to separate out planninglcomprehension
problems from abilw issues.

6: QUEST Scoring
1. Elbow and wrist range of motion.
This is incorrect in the manual (report from author). Half range for the elbow is 75 degrees. Half range for the
wrist is 35 degrees for extension and 45 degrees for flexion.
2. Not Tested Category
Only use if an item was not administered. Ifa child cannot do an item for any reason then the score is No.

structured enough for inexperienced therapists. To further assist therapists

learning to use the QUEST we made a training video to practise scoring and
to provide an example of test administration. Such a video would be a useful
addition to the test.
More information is needed to ensure that examiners can interpret and
apply the findings. Even though results lead logically to areas of movement
that need therapy according to neurodevelopmental theories of movcment,
there is an assumption that the examiner has a sound knowledge of the theory.
Example score sheets in the manual provide a guide on how to fill out the
forms but not on clinical application. The “Interpretation of Scores” section
of the manual offers little useful information and could be replaced by a
chapter focusing on the implication for treatment based on QUEST results.
Information that QUEST scores be used to rate children against themselves to
measure change would be helpful. QUEST scores could be analyzed in the
context of a functional assessment and the child’s age and personal goals. The
Pediatric Evaluation of Disability Inventory27and The Miller Assessment for
Preschoolers2xcontain models for such a chapter.
Discussion

Preliminary studies suggest that the QUEST is a potentially useful tool to

measure the quality of upper limb movement in children with spastic cerebral
 Clitiicul Cotzcertis 133

palsy. So far, the instrument has shown excellent inter-observer reliability

(0.96) and test-retest reliability (0.95) for total scores. Item selection is well
grounded in a theoretical and clinical context, and high to moderate construct
validity measures support the notion that inferences about quality of move-
ment can be made from QUEST scores. Concurrent-criterion validity find-
ings strengthen the construct validity. High to medium correlations with a
hand function test (PDMS-FM) suggest that the QUEST and PDMS-FM
measure similar, but not identical, aspects of movement. High correlations
with the Grasp domain suggest that this section of the QUEST is the more
functionally and developmentally orientated domain. The moderate correla-
tions between the PDMS-FM and the other three domains suggest that while
quality of movement relates to hand function, the QUEST provides unique
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information. The developers propose that this information is related to re-

flexes and motor control.” Data about the QUEST’S sensitivity to change is
inconclusive. Nevertheless, the preliminary work on its responsivity is an
advance on most other tools used for evaluation in this population, the ma.jor-
ity of which have never considered an instrument’s ability to detect
change.” 3
At present not enough evidence is available to support the use of the
QUEST as a discriminative tool to detect different abilities between individu-
als. Furthermore, the poorly defined 11-point scales used in assessment of
construct validity and responsivity may weaken findings. Shorter well-de-
fined scales, similar to that used by Deyo and Centor,-)-)could bc used in
further development of the test. Reporting of psychometric development
could be strengthened by: including missing data such as age correlations
with all domains, reorganizing some of the material such as discriminative
data, accurately using terms such as percentage instead of ‘-standardized”
scores, and more clearly explaining some procedures such as Hand Function
data collection. The three scales included at the end of the test: Hand Func-
tion, Spasticity, and Co-operativeness are ignored in the psychometric analy-
sis of the test. No support is documented for reliability and n o description of
development is provided for any of the scales.15 The Hand Function and
Spasticity ratings seem to be a remnant of test validation studies and their
omission would not appear to alter scoring and interpretation. Ratings of
behavior and the severity of spasticity provide useful information that would
fit well in the demographic section of the test, whereas the 11 -point hand
function-rating scale should probably be omitted unless reliability can be
established.
At this early stage of development, the QUEST appears suitable for clini-
cal use to assess the upper limb movement of children with cerebral palsy.
The potential of the QUEST to be used as an evaluation tool is stronger than
its use to discriminate between children with cerebral palsy. The initial psy-
 134 PEIYSICAL & OCCUPATIONAL THERAPY IN PEDIATRICS

chometric properties of the test suggest that it may be a sound tool to use in
clinical practice. Clinical application suggests that it is practical and easy to
learn, but that the manual and score sheets require some minor changes and
clarifications. In conclusion, while several measures of upper limb fiinctiorz
are available, the QUEST is the only criterion referenced test of quality of
movement that can be used on children as young as 18 months. The lack of
tests in this area probably reflects the difficulties in developing such a mea-
sure. Despite need for further development, the QUEST is the best available
tool for the difficult task of assessing upper limb quality of movement in
children with cerebral palsy.
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2. MacKinnon J, Noh S, Lariviere J, MacPhail A, Allan D, Laliberte D. A study
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3. Parette HP, Hourcade JJ. A review of therapeutic intervention research on
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