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Rehab Measures: Craig Handicap Assessment and Reporting Technique

Link to instrument

Available on the Craig Hospital website 

Title of Assessment

Craig Handicap Assessment and Reporting Technique  

Acronym

CHART / CHART-SF

Instrument Reviewer(s)

Initially reviewed by Jason Raad, MS in 2010; Updated by Punam Rajyaguru, SPT and Tiffany Ducato, SPT with burn, amputee, and MS populations in 2011; Updated by Candy Tefertiller PT, DPT, ATP, NCS, Jennifer Kahn PT, DPT, NCS and the SCI EDGE task force of the Neurology section of the APTA in 2012;
Updated with references from the TBI population by Sue Saliga, PT, DHSc, CEEAA, Anna de Joya, PT, DSc, NCS, and the TBI EDGE task force of the Neurology Section of the APTA in 2012.

Summary Date

1/18/2013 

Purpose

CHART: Based on the now outdated World Health Organization ICIDH framework, the Craig Handicap Assessment and Reporting Technique (CHART) was originally based on 5 domains, but was then revised to include Cognitive Independence for a total of 6 domains with 32 total items. Scores on each subscale range from 0-100 with total CHART score ranging from 0-600. Higher scores indicate a lesser degree of handicap or greater degree of social and community participation.

  • Physical independence
  • Cognitive independence
  • Mobility
  • Occupation
  • Social integration
  • Economic self-sufficiency

Description

The Craig Handicap Assessment and Reporting Technique (CHART) is designed to assess how people with disabilities function as active members of their communities.

CHART-SF: Short form consisting of 19 items that generate scores for the same 6 subscales of the full revised version. The CHART-SF takes less time to administer and all CHART-SF subscales closely approximate scores from CHART long form except Economic Self Sufficiency.

Multidimentional analysis using data gathered from previous study entered into stepwise regression model reducing long form questions to short form reaching >90% of explained variance in all subscales except economic self-sufficiency. (Whiteneck and Brooks 1992)

Area of Assessment

Activities of Daily Living; Behavior; Cognition; Coordination; Functional Mobility; Occupational Performance; Social Relationships; Social Support 

Body Part

Not Applicable 

ICF Domain

Activity; Participation 

Domain

ADL 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

Approximately 15 minutes to administer, varies with form used

Number of Items

CHART= 27, revised to 32 with addition of cognitive domain; CHART-SF=19   

Equipment Required

None

Training Required

None (Manual and documentation freely available)

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Free

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Lower Limb Amputation; Multiple Sclerosis; Spinal Cord Injury; Stroke; Traumatic Brain Injury 

Populations Tested

  • Spinal Cord Injury
  • Stroke
  • Traumatic Brain Injury
  • Multiple Sclerosis
  • Burn
  • Amputee Population

Standard Error of Measurement (SEM)

Chronic SCI CHART-SF : (Tozato et al, 2005, n = 54; mean age = 42.5 (16.6) years; average Barthel Index Score = 75.6 (18.7) points; Calculated from Japanese sample using mean SD from test retest.

Domain

SEM

Chart Total Score

40.71

Physical

8.2

Mobility

5.1

Occupation

14.8

Economic self sufficiency

0

Social Integration

11.6

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Chronic SCI: (Gontkovsky et al, 2009; n = 28, mean age = 42 (17) years; 68% = incomplete injury; AIS A = 32.1%, B = 32.1%, C = 14.4%. D = 21.4%)

Normative Data for the CHART-SF and CIQ:

CHART-SF

Mean (SD)

Range

Physical Independence

47.0 (44.2)

4–100

Cognitive Independence

66.5 (36.4)

0–100

Mobility

69.6 (30.7)

17–100

Occupation

38.3 (39.4)

0–100

Social Integration

72.8 (35.2)

0–100

Economic Self-Sufficiency

38.4 (33.2)

0–100

Total

332.6 (145.8)

36–580

**The highest scores on the CHART-SF were in social integration; the lowest scores in occupation;

Various Diagnosis's: (Walker et al, 2003; n = 1110 community-based, non-hospitalized participants with spinal cord injury (n=236), traumatic brain injury (n=242), multiple sclerosis (n=248), stroke (n=223), burn (n=70), and amputation (n=91); interviewed twice with a two week interval between them.

Mean CHART Scores Across Diagnosis:

Total

SCI

TBI

MS

Stroke

Amputation

Burn

Physical independence*

90.65

84.48

94.15

95.21

82.20

97.36

99.31

Cognitive independence*

85.50

93.62

77.44

88.37

74.14

96.87

96.40

Mobility*

79.04

77.34

83.50

78.33

68.26

90.19

91.53

Occupation*

64.46

67.83

69.63

68.67

36.51

81.80

86.37

Social integration*

75.52

79.12

73.97

82.07

60.83

82.74

81.75

Economic selfsufficiency*

77.32

71.13

79.08

84.78

76.40

69.11

70.67

Total

491.34

483.26

496.11

502.37

425.83

526.27

532.00

*p < 0.001

**Significant differences in means scores observed by impairment category in all 6 subscales.

Chronic TBI : (Srinivasan, 2009; n = 34; age, R = 18 -65; mean time post TBI = 5 – 12 months)

Mean CHART Scores in Chronic TBI Population:

CHART Category

Growth Hormone Deficient

Growth Hormone Sufficient

Physical Independence

93.8 (4.8)

94.6 (3.9)

Cognitive Independence

64.3 (12.4)

88.3 (4.1)

Mobility

84.2 (7.0)

93.9 (2.6)

Occupation

71.7 (14.5)

82.4 (5.3)

Social Integration

89.2 (7.1)

94.9 (2.2)

Cerebral Palsy : (Tyler, 2002; n = 50; mean age = 39.68 (13.01) years)

  • The association between average pain intensity and global disability, as measured by the CHART, was weak and NS (r = -.21)

Traumatic Brain Injury: (Corrigan et al, 1998; n=95; mean age at time of injury=32.4; mean age at time of interview=35.2; gender=70% male; administration of test: 6 months to 5 years after in-patient rehabilitation; CHART long form)

Mean scores

CHART

6 mo-1 yr

1-2 yrs

2-3 yrs

3-4 yrs

4-5 yrs

Total

81.44

73.72

73.02

83.03

84.76

Physical

96.64

92.33

88.89

99.73

93.81

Mobility

93.72

93.05

92.22

95.32

93.69

Social

89.11

85.05

75.17

86.55

93,38

Economic

70.83

54.76

56.94

60.23

65.63

Occupation

56.89

43.43

51.89

73.32

77.31

Traumatic Brain Injury: (Hall et al, 2001; n=48; mean age=37; gender, male=77%; average of 5 years post-injury; CHART long form)

Mean scores

Physical independence

90.28

Cognitive independence

75.5

Mobility

86.69

Occupation

63.68

Social Integration

86.46

Economic self-sufficiency

70.83

Total

488.74

Test-retest Reliability

Chronic SCI CHART : (Whiteneck et al 1992: n=135 subjects; mean age 33 years; mean time since injury 7 years (2-35 years); CHART administered by the same examiner ~1 week apart.)

  • Excellent reliability for overall CHART 0.93

Domain

Test-retest Reliability

Chart Total Score

Excellent r=0.93

Physical

Excellent r=0.92

Mobility

Excellent r=0.95

Occupation

Excellent r=0.89

Economic self sufficiency

Excellent r=0.80

Social Integration

Excellent r=0.81

Chronic SCI CHART-SF : (Tozato et al, 2005, n = 54; mean age = 42.5 (16.6) years; average Barthel Index Score = 75.6 (18.7) points; Japanese sample, validity of CHART in Japanese.)

Test-retest validity with a 21 to 25 day interval between assessments:

Domain

Test-retest Reliability

Chart-SF Total Score

Excellent r=0.78***

Physical

Adequate r=0.53***

Mobility

Excellent r=0.96***

Occupation

Excellent r=0.86***

Economic self sufficiency

Excellent r=1.00***

Social Integration

Excellent r=0.78***

  • *P<0.05, **p<0.01,***p<0.001
  • Adequate total score test-retest validity = 0.78 (p < 0.001)

Various Diagnosis's: (Walker et al, 2003)

  • 2 week interval for test-retest reliability

Test Re-test reliability Interclass Correlations (ICC):

SCI

TBI

MS

Stroke

Amputation

Burn

Physical Idependence

0.71

0.77

0.77

0.86

0.99

0.82

Cognitive Idependence

0.70

0.83

0.79

0.91

0.95

0.95

Mobility

0.89

0.82

0.89

0.89

0.86

0.93

Occupation

0.72

0.77

0.83

0.74

0.84

0.88

Social Integration

0.73

0.78

0.80

0.75

0.86

0.93

Economic Self-sufficiency

0.81

0.82

0.75

0.80

0.84

0.94

Total

0.87

0.92

0.92

0.95

0.90

0.95

Interrater/Intrarater Reliability

Chronic SCI: (proxy inter-rater reliability, reviewed in Noonan et al, 2009, from Whiteneck 1992 and Cusick 2001, agreement between participant and a proxy (i.e. family member, caregiver), SCI n=224.)

1week (proxy)

Whiteneck 1992

2 weeks (proxy)

Cusick 2001

Overall

Excellent r=0.83

Excellent r=0.84

Physical

Excellent r=0.80

Adequate r=0.69

Mobility

Excellent r=0.84

Excellent r=0.86

Occupation

Excellent r=0.81

Adequate r=0.60

Economic self sufficiency

Adequate r=0.69

Adequate r=0.59

Social Integration

Poor r=0.28

Adequate r=0.57

Cognitive

Poor r=0.34

  • Consistently lower compared with test-retest reliability

Internal Consistency

Not Established

Criterion Validity (Predictive/Concurrent)

Chronic SCI: (Gontkovsky et al, 2009) 
  • Adequate to Excellent correlation between the CIQ and CHART total scores (see table below)
  • Poor to Adequate correlation between CIQ and CHART domains
 
CHART-SF and CIQ Correlations:
CIQ
Home Integration
Social Integration
Productive Activity
Total
CHART-SF
Physical Independence
0.55**
0.01
0.14
0.33
Cognitive Independence
0.57**
0.43*
0.07
0.53**
Mobility
0.52**
0.68**
0.39*
0.73**
Occupation
0.56**
0.46*
0.41*
0.64**
Social Integration
0.47*
0.77**
0.34
0.73**
Economic Self-Sufficiency
0.25
0.01

0.37

0.24
Total

0.74**

0.57**

0.42*

0.79**

*p <0.05
**p <0.01
CIQ = Community Integration Questionnaire

 
Amputation or Spinal Cord Injury: (Masedo et al, 2005; n = 84 with spinal cord injury, n  = 38 with amputation; For SCI mean time since injury = 13.96 (9.36) years)
 
CHART and FIM Correlations for SCI and Amputee Participants:

CHART Sub-scales

Physical

Mobility

Total Score

FIM-SR
SCI
AMP
SCI
AMP
SCI
AMP
Self-care
0.52*
-0.08
0.32*
-0.12
0.27**
0.20
Sphincter
0.52*
--
0.32*
--
0.30*
--
Mobility
0.46*

0.21

0.26**
-0.10
0.24**
-0.04
Locomotion
0.13
0.17
0.26**
0.13
0.23**
0.13
Motor

0.51*

0.09

0.33**

0.18

0.29**

0.39**

Total score

0.49*

0.02

0.30*

0.37*

0.26*

0.54*

p < 0.01
p < 0.05
 

TBI: (Resnik, et al, 2011; n = 68; mean age = 27.1 (5.6) years; mean time post injury = 397.6 (270.6) days)

  • No CRIS subscale was correlated with the CHART Occupational Function subscale
  • CRIS Satisfaction with Participation subscale was correlated with the CHART Social Integration subscale (r = 0.26)

Concurrent and Discriminant Validity of Community Reintegration of Servicemember Subscales:  Pearson Product Moment Correlations
 
Extend of Participation Perceived Limitations Satisfaction with Participation
Measure (CHART)
r
p-value
r
p-value
r
p-value
Occupational Function
-.04
0.721
-.12
0.314
-.12
0.310
Social Integration
0.17
0.150
0.22
0.064
0.26
0.025

Construct Validity (Convergent/Discriminant)

Chronic SCI: (Tozato et al, 2005). Discriminant validity evidence established with employed versus unemployed Japanese SCI patients.
  • Employed respondents demonstrated significantly higher subscores than unemployed respondents in all CHART subscales except social integration
 
Discriminant Validity:
Domain
employment status
mean (SD)
t-value
p
Physical Independence
employed
95.5 (8.9)
4.795***
0.0001
unemployed 84.2 (23.9)
Mobility
employed
89.7 (16.9)
11.092***
0.0001
unemployed 58.5 (27.8)
Occupation
employed
79.5 (28.3)
15.030***
0.0001
 
unemployed 23.4 (31.8)
Social integration
employed
66.0 (33.5)
0.997
0.319
unemployed 62.2 (29.6)
Economy
employed
81.4 (24.8)
3.799***
0.0001
unemployed 67.7 (32.0)
Chart-J Total Score
employed
424.7 (54.1)
11.39***
0.0001
unemployed
305.4 (84.5)
*p < 0.05
**p < 0.01
***p < 0.001

Traumatic Brain Injury: (Hall et al, 2001; n=48; mean age=37; gender, male=77%; average of 5 years post-injury; CHART long form)

  • The strongest relations were between the CHART cognition subscale (.84) and the Neurobehavioral Functioning Inventory memory/attention subscale (-.83).

Content Validity

Not statistically assessed

Face Validity

Not statistically assessed

Floor/Ceiling Effects

Chronic TBI: (Hall et al, 2001, n = 48, all participants received rehabilitation 2 to 9 (mean = 5) years previously)
 
For Chronic TBI patients, the CHART demonstrated pronounced ceiling effects that effected between 25 to 81% of participants.
 
CHART Ceiling Effects:

Cases

No. Cases

% at Ceiling

Ceiling Score

Physical independence
39
48
81
95-100
Cognition
12
48
25
95-100
Mobility
27
48
56
95-100
Occupation
17
48
35
95-100
Social integration
33
48
69
95-100
 
SCI: (Hall et al, 1998)
  • Lower and incomplete injury (e.g. less severe) demonstrated substantial ceiling effects on all CHART sub-scales

Responsiveness

Not Established

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

R

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

NR

NR

NR

LS

LS

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

R

R

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

No

Yes

Yes

Not reported

TBI EDGE

No

Yes

Yes

Not reported

Considerations

  • Proxy responder (caregivers) tended to rate a patient's impairment as more severe
  • Proxy / patient agreement tends to be lowest for the social integrations domain
  • CHART long form discriminates between people with TBI who report lower scores than those with other disabilities (Walker et al, 2003)
  • CHART-SF was developed using regression analysis and related statistical methods to select items from the CHART. Rescoring was completed so the CHART-SF has the same 0-100 ranges as the CHART. Its metric properties and equivalence to the CHART have not yet been evaluated.
  • CHART-SF sub-scales closely approximate the scores of the subscales gathered by the Original CHART
  • CHART-SF takes less time to administer than the Original CHART
  • CHART –SF may decreased the precision for smaller groups, however, use in larger groups can obviate the lack of precision by the change in confidence intervals.
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Cusick, C. P., Brooks, C., et al. (2001). "The use of proxies in community integration research." Archives of physical medicine and rehabilitation 82(8): 1018.

Gontkovsky, S. T., Russum, P., et al. (2009). "Comparison of the CIQ and CHART Short Form in assessing community integration in individuals with chronic spinal cord injury: a pilot study." NeuroRehabilitation 24(2): 185-192. Find it on PubMed

Hall, K. M., Bushnik, T., et al. (2001). "Assessing traumatic brain injury outcome measures for long-term follow-up of community-based individuals." Arch Phys Med Rehabil 82(3): 367-374. Find it on PubMed

Masedo, A. I., Hanley, M., et al. (2005). "Reliability and validity of a self-report FIM (FIM-SR) in persons with amputation or spinal cord injury and chronic pain." Am J Phys Med Rehabil 84(15725790): 167-176.

Noonan, V. K., Miller, W. C., et al. (2009). "A review of instruments assessing participation in persons with spinal cord injury." Spinal Cord 47(6): 435-446. Find it on PubMed

Resnik, L., Gray, M., et al. (2011). "Measurement of community reintegration in sample of severely wounded servicemembers." Journal of Rehabilitation Research and Development 48(2): 89-102. Find it on PubMed

Srinivasan, L., Roberts, B., et al. (2009). "The impact of hypopituitarism on function and performance in subjects with recent history of traumatic brain injury and aneurysmal subarachnoid haemorrhage." Brain Injury 23(7): 639-648. Find it on PubMed

Tozato, F., Tobimatsu, Y., et al. (2005). "Reliability and validity of the Craig Handicap Assessment and Reporting Technique for Japanese individuals with spinal cord injury." Tohoku J Exp Med 205(4): 357-366. Find it on PubMed

Tyler, E. J., Jensen, M. P., et al. (2002). "The reliability and validity of pain interference measures in persons with cerebral palsy." Archives of Physical Medicine and Rehabilitation 83(2): 236-239. Find it on PubMed

Walker N, M. D., Brooks CA, Whiteneck GG. (2003). "Measuring participation across impairment groups using the Craig Handicap Assessment Reporting Technique." American Journal of Physical Medicine and Rehabilitation 82(12): 936-941. Find it on PubMed

Whiteneck, G., Charlifue, S., et al. (1992). "Guide for use of the CHART: Craig handicap assessment and reporting technique." Englewood (CO): Craig Hospital.

Wilde, E. A., Whiteneck, G. G., et al. (2010). "Recommendations for the use of common outcome measures in traumatic brain injury research." Archives of physical medicine and rehabilitation 91(11): 1650-1660. e1617.

Year published

 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
CHART Manual1.pdf    
Craigs Hospital Inventory.pdf    
Created at 2/19/2011 3:08 PM  by Jason Raad 
Last modified at 5/8/2015 10:30 AM  by Jason Raad