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Reliability of Three Classification Systems Measuring Active Motion in Brachial Plexus Birth Palsy

Investigation performed at the Department of Orthopaedic Surgery, Children's Hospital, Boston, Massachusetts

Donald S. Bae, MD
Massachusetts General Hospital, 55 Fruit Street, GRB 622, Boston, MA 02114

Peter M. Waters, MD
David Zurakowski, PhD
Department of Orthopaedic Surgery, Children's Hospital, 300 Longwood Avenue, Hunnewell 2, Boston, MA 02115. E-mail address for P.M. Waters: peter.waters{at}tch.harvard.edu

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Several classification systems for the categorization of function in patients with brachial plexus birth palsy have been proposed. The purpose of this investigation was to determine the intraobserver and interobserver reliability of the modified Mallet Classification, Toronto Test Score, and Hospital for Sick Children Active Movement Scale in the evaluation of these patients.

Methods: Eighty children with brachial plexus birth palsy were evaluated by two trained examiners on two different occasions. Intraobserver and interobserver reliability was determined with use of the kappa statistic.

Results: On the basis of the kappa statistic, intraobserver reliability was good to excellent for individual elements of the modified Mallet Classification, Toronto Test Score, and Active Movement Scale in all age-groups. Interobserver reliability for individual elements of these three systems ranged from fair to excellent. When aggregate Toronto Test and modified Mallet scores were assessed, positive intraobserver and interobserver correlations were noted (Pearson r = 0.70 to 0.98, p < 0.001). Internal consistency (test-retest reliability) as determined by the Cronbach alpha for the aggregate Toronto Test and modified Mallet scores was excellent for each age-group ( > 0.90, p < 0.001).

Conclusions: The modified Mallet Classification, Toronto Test Score, and Active Movement Scale are reliable instruments for assessing upper-extremity function in patients with brachial plexus birth palsy. The natural history and surgical outcomes of these patients can now be conducted with use of these reliable outcomes instruments.

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