SHUEE Test Scoring and Interpretation

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Shriners Hospital Upper Extremity Evaluation (SHUEE) Test Scoring and Interpretation Scoring

The SHUEE data collection form consists of 2 pages. The first page is primarily descriptive and requires no scoring. The second page is utilized during the video taped portion and requires scoring of the Spontaneous Functional Analysis (SFA), the Dynamic Positional Analysis(DPA), and the Grasp/Release(GRA) segments on the actual SHUEE form. The SFA score is circled and the DPA score is marked in the grid with a check mark.

Spontaneous Functional Analysis (SFA)

In order to assess the client’s actual function of the affected extremity, a spontaneous use score is recorded. For this portion of the scoring, a modified House scale is used. The scale is shown in Table II. The SFA is recorded for 9 of the 16 tasks.     During these nine tasks, the examiner will first evaluate the client for spontaneity of use. The Spontaneous use score should always be completed first. Optimal score would be to achieve a score of 5, spontaneous use partial to complete. It is important to remember during administration that the client is presented with the task but no verbal reference is made to use of the affected limb. After observation, the evaluator will circle the number that correlates with the House definition of spontaneous use. It is important to note that for task #7, cutting Play-Doh® with knife task, the SFA is determined by the initial grasp of either fork or knife, whereas the DPA requires grasp of knife with involved extremity.  For video examples of each activity level, click on the Example identifiers in Table II.

Class  Designation Activity Level Video Examples  
0 Does not use. Extremity not utilized in any capacity for completion of task Example 1
Example 2
1 Poor Passive Assist Uses as stabilizing weight only Example 1
Example 2
2 Passive Assist Can only onto object placed in hand; may stabilize the object by other hand Example 1
Example 2
3 Passive Assist Can actively grasp object and stabilize object for use by other hand Example 1
Example 2
4 Active Assist Can actively grasp and stabilize object for use by other hand; may manipulate object with affected hand Example 1
Example 2
5 Spontaneous use, partial to complete Performs bimanual activities easily; may use the hands spontaneously or without reference to the other hand Example 1
Example 2

Dynamic Positional Analysis (DPA)

Once the SFA is completed for a task, the evaluator will then record the second score, DPA. If the client did not use the affected limb for initial task completion, then the limb is touched and encouraged to be used. The second score for each of the 16 activities is related to joint and limb segment movement. The DPA documents the dynamic, segmental alignment of the extremity when performing the task. Clients who perform tasks on demand (i.e. not spontaneously) can still be effectively evaluated using this portion of the evaluation. The DPA score can be recorded at any time during the task. The DPA assesses five functional/anatomical segments.

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Thumb Segment Alignment

Static House Score – see Grasp and Release Analysis section

Thumb In Palm – Any combination of metacarpophalangeal joint (MCP) flexion or interphalangeal joint (IP) flexion resulting in the thumb being placed beneath the fingers, in the palm. No visible web space is seen, from any angle at the first web space.

Picture of a thumb in palm

Thumb Web Space Closed – No visible space at the first web space. Thumb is adducted and may have a hyperextended IP joint, but does not cross index metacarpal into palm. No visible web space is seen, from any angle at the first web space.

Picture of Thumb Web Space Closed

Thumb Web Space Open – Thumb MCP in abduction.  Any visible web space constitutes an “open” score. Client able to extend or abduct thumb to grasp object. Client does not have to maintain abducted posture to be given this score.

Picture of Thumb Web Space Open

Finger Segment Alignment

Fingers are graded as a group because they frequently move in composite flexion or extension. The tasks used for thumb evaluation are used for finger evaluation.

Flexion – MCP maintained in greater than 45° flexion. Fingers are held in palm, in variable flexion pattern at DIP joints.

Finger Segment Alignment - Flexion

Neutral – Fingers are held in midrange with adequate alignment for task. Fingers easily fluctuate between flexion and extension patterns with no joint aberrations.

Finger Segment Alignment - Neutral

Extension – Fingers are held in hyperextension at MCP or IP joints. Associated swan neck deformities or extensor splaying may also be present.

Finger Segment Alignment - Extension

Wrist Segment Alignment

Flexion – Wrist is held in flexed position throughout task; with or without ulnar deviation; any measurement between 0° – 80° of flexion

Wrist Segment Alignment - Flexion

Anatomical neutral – Wrist in anatomical neutral position of 0º for all or portion of task; with or without ulnar deviation.

Wrist Segment Alignment - Anatomical neutral

Extension – Wrist extends past anatomical neutral position for all or portion of the task; any measurement between 0° – 70° of extension.

Wrist Segment Alignment - Extension

Ulnar deviation – Wrist is held in an ulnarly deviated position throughout task; any measurement between 0° – 30°.

Wrist Segment Alignment - Ulnar Deviation

Neutral – Wrist is in the neutral plane; within 5° of neutral. 

Wrist Segment Alignment - Neutral

Radial deviation – Wrist is held in a radial deviated position throughout task; any measurement between 0° – 20°.

Wrist Segment Alignment - Radial Deviation

Forearm Segment Alignment

Extreme pronation – Excessive pronation, no active supination, resulting in palm away from body; any measurement 91° or greater.

Forearm Segment Alignment - Extreme pronation

Pronation – Pronated at rest with no active supination during task, resulting in palm to floor; any measurement 0° – 90°.

Forearm Segment Alignment - Pronation

Neutral – Active movement from pronated position to neutral, resulting in 0° palm towards body.

Forearm Segment Alignment - Neutral

Supination – Active movement beyond neutral to supination with palm open to face. Anything 0° – 90°.

Forearm Segment Alignment - Supination

Elbow Segment Alignment

Extreme flexion – Client is unable to actively extend past 90º.

Elbow Segment Alignment - Extreme Flexion

Flexion – Client is unable to extend past 30º.

Elbow Segment Alignment - Flexion

Extension – Client is able to extend between 30º and 0º.

Elbow Segment Alignment - Extension

Graph of elbow segment alignment

The thumb/finger tasks were chosen to elicit thumb abduction and the use of the fingers with in a neutral range. The wrist tasks encourage wrist extension with no ulnar or radial deviation. The forearm tasks elicit supination. The elbow tasks require elbow extension. An “x” is placed on the grid that corresponds to the segmental alignment of the extremity.

Grasp and Release Analysis (GRA)

The GRA records if the client can or cannot grasp and release the object with the wrist in the three different positions. A yes (Y) or no (N) for grasp and release is provided contingent on clients ability to close and open fingers with the wrist maintained in each position. The optimal outcome would be for the client to open and close the fingers grasping the bead with the wrist in all three positions.

Click here for examples of optimal grasp and release for each position.

Flexion Release

Grasp and Release Analysis - Flexion Release

Flexion Grasp

Grasp and Release Analysis - Flexion Grasp

Neutral Grasp

Grasp and Release Analysis - Neutral Grasp

Neutral Release

Grasp and Release Analysis - Neutral Release

Extension Release

Grasp and Release Analysis - Extension Release

Flexion Grasp

Grasp and Release Analysis - Flexion Grasp

Comments

This space is available to document the quality of the grasp and release, the tightness of the web space, the MCP instability, or any other factor that the evaluating therapist deems necessary for complete evaluation.  The static position of the thumb can be recorded here with the House[3] thumb scale.

SHUEE Scoring Form

Since the SHUEE was created to present a descriptive profile for comparing the dynamic segmental alignment of the upper extremity, pre and post intervention, a SHUEE Scoring Form summary sheet was designed so the evaluator could review numerous SHUEE scores. This form provides a total score and a percentage for each of the scoring sections.

The following describes the manner in which the marks on the second page of the SHUEE form are converted to a numerical fashion and documented on the SHUEE Scoring form.

Spontaneous Functional Analysis
  • Nine tasks are scored
  • Modified House Scale 0 to 5 (less to more spontaneous) is used
  • Highest possible score equals 45 (normal spontaneous use)
Calculation
  • Sum numbers of tasks scored at each house level (0-5)

(from SHUEE form)

SFA Scoring

(from Summary Form)

Spontaneous Function Analysis part 1

Multiply sum number of tasks at each house level by the numerical value of each House level

Spontaneous Function Analysis part 2

  • Sum these values to determine the total score    0+1+4+12+4=21
  • Divide total score by highest possible score
  • Multiply by 100
  • Express score as percentage of normal or optimal score

Spontaneous Function Analysis part 3

Dynamic Positional Analysis
  • 5 segments analyzed
  • 4 tasks for each segment
  • score: 0 to3(pathological alignment to normal or optimal alignment)
  • Highest possible score equals 72 (normal or optimal alignment)
Calculation
  • Convert positional scores to numerical values

Dynamic Positional Analysis Scoring part 1

  • Sum the scores for each anatomical segment

(from SHUEE scoring form)

Dynamic Positional Analysis Scoring part 2

(from Summary form)

Dynamic Positional Analysis Scoring part 3

  • Sum the segment scores to determine the total score
  • Divide the total score by the highest possible score
  • Multiply by 100
  • Express score as percentage of normal or optimal score

Dynamic Positional Analysis Scoring part 4

Grasp and Release Analysis
  • Two hand functions analyzed in 3 wrist positions
  • Score: 0 to 3 (pathological alignment to normal or optimal alignment)
  • Highest possible score = 6 (normal or optimal function)
Calculation
  • Convert N/Y scores to numerical values by assigning a single point to the yes marks and a 0 to the no marks
  • Sum the scores for each wrist position
  • Sum the 3 wrist position scores to determine the total score
  • Divide the score by highest possible score
  • Multiply by 100
  • Express score as percentage of normal or optimal score

(from SHUEE scoring form)

Grasp and Release Analysis part 1

(from Summary form)

Grasp and Release Analysis part 2

Note: If the client has previously had a wrist fusion and is able to grasp and release in neutral, the client would receive a score of 2/2 in the Neutral column.  For this special case, the final percentage should be calculated as 100% as it is not possible for the client to perform grasp and release in flexion and extension.

Interpretation of Results

When reviewing the score sheet and results of the SHUEE, each client and their family dynamics should be considered individually. General guidelines for interpretation of results are as follows.

With respect to the SFA, if a client demonstrates neglect of their hand (score of 0) or uses their hand as a gross weight bearing surface (score of 1) for the majority of their scores then the trend would favor more definitive intervention such as fusion (arthrodesis). Typically, due to neglect, the client would have a difficult time with a prolonged rehabilitation. Likewise if the client scores in the 3, 4, and 5 range, they are actively engaging the affected hand in activities. This would favor transfer strategies or Botox intervention. The rehabilitation participation would be favored.

The DPA scores allow a documented reference to the position of the hand during activities. The lowest score correlates with the greatest amount of positional misalignment. If four of the four wrist tasks were graded as a 0 or 1, a fusion (arthrodesis) would be considered. However if the client is able to come to a neutral position or even attain correct alignment for at least two of the four tasks, then the transfer or Botox strategies could be entertained.

In the grasp and release section, if the client is unable to grasp and release in any position then a fusion (arthrodesis) with a release for positioning may be indicated. If the client is able to grasp and release in flexion and neutral but not in extension, then release with tendon transfers may be indicated.

The SHUEE does not conclude with a cumulative score thus a specific score does not equal a particular intervention. The SHUEE is a documentation of the client’s spontaneous and dynamic positional analysis so that an individualized treatment plan of care can be obtained and recorded in an objective manner.

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SHUEE Introduction

Objectives

This manual provides the examiner with an overview of the administration
and interpretation of the Shriners Hospital Upper Extremity Evaluation (SHUEE).
Evaluator training prior to clinical application of the SHUEE should include:

  • Reading this manual
  • Viewing the Key Interpretation video
  • Completing the Video Proficiency test

Information regarding the assembly of a test kit has also been provided in this manual.

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SHUEE Test Administration

The Shriners Hospital Upper Extremity Evaluation (SHUEE) utilizes the following testing materials.

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Testing Materials

Billfold style wallet to hold paper money

Billfold style wallet to hold paper money

8 x 10 sheet of standard weight paper

8 x 10 sheet of standard weight paper

Two 2″ in diameter and approximately 1/2″ thick, flat sided, wooden beads. Stiff cord for stringing beads

Two 2″ in diameter and approximately 1/2″ thick, flat sided, wooden beads. Stiff cord for stringing beads

Three dollar sized bills made of standard weight paper

Three dollar sized bills made of standard weight paper

Four plastic coins of any size

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SHUEE Case Studies

Shriners Hospital Upper Extremity Evaluation (SHUEE) Case Studies

The following section includes 3 case studies for viewing and scoring.  The key gives explanation to the scores and will refer you to the section of the manual which explains the correct score.  You can print out blank scoring forms by clicking the Forms link above.  Score each case on your own and then view the provided scores by clicking the appropriate link.  Questions in regards to scoring can be directed to the authors.

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SHUEE References

Shriners Hospital Upper Extremity Evaluation (SHUEE) References

  • Trombly CA. Evaluation of biomechanical and physiological aspects of motor performance. Occupational Therapy for Physical Dysfunction, 4th Ed., Williams & Wilkins, Baltimore, Maryland; 1995, pp 126-130.
  • Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Therapy 1986; 67:206-207.
  • House J, et al. A dynamic approach to the thumb-in-palm deformity in cerebral palsy.