Craig Handicap Assessment and Reporting Technique

Last Updated

January 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CHART: Based on the now outdated World Health Organization ICIDH framework, the Craig Handicap Assessment and Reporting Technique (CHART) was originally based on 5 domains, but was then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

Link to Instrument

Instrument Details

Acronym CHART / CHART-SF

Area of Assessment

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

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Brain Injury Recovery
Multiple Sclerosis
Spinal Cord Injury
Stroke Recovery

Spinal Injuries

Mixed Populations

Brain Injury

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

Number of Items

32
Short: 19

15 minutes

Varies with form used

Required Training

Reading an Article/Manual

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

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.

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

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 (Vestibular EDGE) 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

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

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!

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

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;

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***

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

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

Construct Validity

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

Content Validity

Not statistically assessed

Face Validity

Not statistically assessed

Floor/Ceiling Effects

SCI: (Hall et al, 1998)

Lower and incomplete injury (e.g. less severe) demonstrated substantial ceiling effects on all CHART sub-scales

Normative Data

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)

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

Criterion Validity (Predictive/Concurrent)

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

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).

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

Normative Data

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	Ampu-tation	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.

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)

Test/Retest Reliability

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	Ampu-tation	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

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.

Last Updated

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Standard Error of Measurement (SEM)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Face Validity

Floor/Ceiling Effects

Normative Data

Criterion Validity (Predictive/Concurrent)

Construct Validity

Floor/Ceiling Effects

Normative Data

Test/Retest Reliability

Bibliography

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