What is the Challenge?

The Challenge is a performance measure that assesses 20 advanced gross motor skills that tap into a child's co-ordination, agility, balance, fitness and strength. It was designed for use with children with cerebral palsy who are age 6 years and up, and are in GMFCS Level I (i.e., able to run and jump independently but limited in speed and quality of movement) and higher ability children in GMFCS II.

As a pre-requisite for this test, the child should be able to consistently walk within the 0.45cm test pathway from start to finish, keep feet within the path for all steps, and follow test instructions for at least 45 minutes.

How was the Challenge developed?

The Challenge was developed at Holland Bloorview Kids Rehabilitation Hospital with assistance of graduate students from the Department of Physical Therapy, University of Toronto and with funding from Bloorview Research Institute and the Pediatric Division of the Canadian Physiotherapy Association. 

Our CIHR-funded research (2012 to 2016) (Drs Virginia Wright and Barbara Gibson, CoPIs) successfully linked the Challenge to the GMFM-66 via a Rasch-scaled scoring system, and resulted in a 20-item revised measure. The qualitative arm of this work provided in-depth information on the physical activity experiences and preferences of children in GMFCS Level I and allow us to produce Child Engagement guidelines PTs to use as a part of the Challenge administration.

We were pleased to be working in this research with the following participating Canadian centres: IWK Health Centre, Halifax, Nova Scotia; ErinoakKids Centre for Treatment and Development, Mississauga, Ontario; McMaster Children’s Hospital, Hamilton, Ontario; Rehabilitation Centre for Children, Winnipeg, Manitoba; Glenrose Rehabilitation Hospital, Edmonton, Alberta;  and Sunnyhill Health Centre for Children, Vancouver, BC

Our Co-investigators are: Dr Darcy Fehlings,  Dr Peter Rosenbaum, Dr Ellen Wood, Dr John Andersen, Dr. Cheryl Glazebrook, Dr Ronit Mesterman, Dr Marie Kim, and Ms Lori Roxborough.

How is the Challenge administered?

The Challenge is meant to be administered by a pediatric physical therapist who has experience with the GMFM, and requires 45 to 60 minutes to complete.

Testing is conducted on and around the Challenge assessment track following item-specific guidelines outlined in the Challenge manual. The 10 metre long track's outline can be taped to the floor in a hallway or large therapy gym. The equipment needed consists of basic gym skills items such as soccer/basketball/tennis/bouncy balls, skipping rope, pylons (cones), a plastic bowling pin, masking tape, and a stopwatch. All test equipment should be assembled in advance to make the test flow smoothly. For every item, assessor should do a demonstration of the task. The speed of the assessor’s performance can be kept fairly slow so child is not discouraged at the outset by tester’s super speed, but need to be 100% accurate. The child is given a chance to walk through all or part of the task before testing. Like the GMFM, the child is given the three chances to perform each item.

Explain that on the first trial of an item, the child should be as accurate as they possibly can, even if it takes a bit longer to do it. They will then be given two more chances to see: i) if they can be more accurate if they did not do perfectly, or ii) if they did it perfectly, to try to speed up while staying accurate. If a top score of ’4’ is achieved on the first try, a second and third trial are usually still done to determine the child;s consistency in high level performance. Throughout the test, the child is also given the chance to say ‘no’ to doing an item or to doing the repeat trials to keep the experience positive and engaging.

Some items can be discouraging for some children and it is important to keep going with testing all of the items rather than getting too frustrated with a single item. The child's test performance should be scored live (no need to videotape) using the Challenge worksheet. The therapist transfers the scores over to the summary score form and excel spread sheet after the assessment is done.

Training and certification on the Challenge

Certification training (consisting of a one day in-person Challenge course, independent review of training videos after the course, practice with several children, and finally completion of the Challenge criterion test) is required prior to use of the Challenge to  ensure sufficient familiarity with the items and response options, and to optimize scoring accuracy.

Cities where we have given our Challenge courses include: Toronto (May 2016), London (UK) in February 2016 and January 2017, Vela Luka (Croatia) in August 2016, Amsterdam in January 2016, Brisbane and Melbourne (Australia) in April/May 2016, Cork (Ireland) in May 2017, Adelaide in April 2017, Aarhus (Denmark) in June 2016 and Sept 2017, and Oslo (Norway) in Sept 2017.  .

Upcoming Training Dates

We now do Zoom based training with the training date organized for interested physiotherapists who are in a similar  time zone region, e.g., Canada/US/Mexico/South America; UK/Europe; Asia; Australia. If you are interested, please contact Virginia Wright to discuss the possibilities and have your name put onto the next Zoom training list for your region.

How are Challenge scores used and reported?

From a child and parent information and goal setting perspective, both the item scores and Challenge total score are of value. While there is a large range of scores among children (i.e., from 20 to 80% across children in GMFCS I),  we have early evidence of strong potential for score change within a child over time.

However, while helpful to use in the child's health record to monitor change over time, the total score can be somewhat discouraging to the child and parent. In contrast, the individual item scores tend to be information rich, encouraging as to the child's abilities and potential, and useful for strength and challenge identification and thus for goal setting. Thus we suggest focusing on the item scores and using these scores to determine areas of strengths and challenge (e.g., related to balance, agility, speed, co-ordination) that can be discussed with the child and parent after the assessment.

What do the Challenge items look like?

This is a sample item from the Challenge Module.

What attendees have said...

"The most useful parts were the discussion and observation/demo of challenge module being carried out and [seeing] how to adapt items/cue to different ages and abilities."

"Thank you so much for the Challenge and Quality FM courses. I have been waiting several years for someone to come up with these measures. That will help me no end clinically. The most useful training that I have attended in a very long while."

"I am quite excited to try out and administer in practice with patients and share with the team to ensure we use more standardised assessment criteria to improve development of goals with patients."

 "The course was presented very well, engaged participants and more importantly the children so well! Virginia was always open to thoughts that were offered."

"The Challenge looks very promising and looks like it will link well with GAS goal setting, next step would be to develop curves and I would be keen to contribute."

"I'm looking forward to trying out the Challenge in my clinical practice to inform goal setting which is relevant to the individual child and to evidence effective therapeutic interaction."

"Thank you for sharing your passion, knowledge and enthusiasm. So inspiring to see how working to improve children’s lives is being is vehemently put into practice.”