The SARAH motor-functional evaluation scale for children and adolescents with cerebral palsy

The SARAH Network of Rehabilitation Hospitals provides specialized care for individuals with various motor disorders, including ataxia, hypotonia, chorea, athetosis, dystonia, and more. They offer comprehensive evaluations, treatment options, and support for associated disorders. The evaluation assesses motor acquisitions, motor function, and activities of daily living.

The SARAH Network of Rehabilitation Hospitals
The SARAH motor-functional evaluation scale
for children and adolescents with cerebral palsy
ASSESSMENT FORM………….......................... 1
HOW TO FILL THE FORM……………………… 7
Patient Profile................................................ 7
Neurological State......................................... 7
Orthosis/Prosthesis........................................ 9
Special Conditions.......................................... 9
Handedness.................................................... 9
Evaluation Start................................................ 10
Motor Acquisitions.......................................... 10
Locomotion..................................................... 15
Gross Motor Skills.......................................... 19
Upper Limb Function....................................... 20
Activities of Daily Living................................... 21
HOW TO COMPUTE SCORES……………………. 27
Scores Description…….……........................... 27
Form with Scores …….……........................... 28
Expected Score by Age Group …………........ 33
Four-level Conversion …………….................. 34

1
ASSESSMENT FORM
The SARAH motor-functional evaluation scale for children and adolescents with
cerebral palsy
PATIENT PROFILE
Neurological State
Motor impairment:
□ Spasticity
□ Ataxia
□ Hypotonia
Involuntary movement: □ Chorea □ Athetosis □ Choreoathetosis
□ Dystonia
Distribution:
□ Quadriplegia □ Right hemiplegia □ Left hemiplegia □ Diplegia □ Triplegia □ Monoplegia
Associated disorders:
□ Seizures □ Hearing impairment
□ Dysphagia □ Cognitive impairment
□ Gastroesophageal reflux □ Behavioral disorders
□ Visual impairment □ Neuropsychological disorders
Reflexes:
□ Asymmetric tonic neck reflex
□ Symmetric tonic neck reflex
□ Moro reflex
□ Extensor thrust
□ Neck-righting reflex
Reactions:
□ Placing
□ Parachute reaction
Orthosis/Prosthesis
□ Bilateral □ Unilateral □ No
Special Conditions
□ Post-surgery
□ Treatment with botulin toxin or alcohol
□ Treatment with serial casting
Handedness
□ Right □ Left □ Not defined
EVALUATION START
Uses independent gait as a means of locomotion outside the home, without the need of mobility aids.
□ No □ Yes (if yes, skip to question 57)
Uses independent gait as a means of locomotion at home or outside, with limitations.
□ No □ Yes (if yes, skip to question 25)
Gait with support of cane.
□ No □ Yes (if yes, skip to question 24)

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MOTOR ACQUISITIONS
Head balance:
1. Prone position □ Absent □ Precarious □ Regular □ Good
2. Supine position □ Absent □ Precarious □ Regular □ Good
3. Sitting position □ Absent □ Precarious □ Regular □ Good
Rolling:
4. Supine/prone □ Complete □ Partial □ No
5. Prone/supine □ Complete □ Partial □ No
Creeping:
6. Pivots (prone or supine) □ Yes □ No
7. Creeps □ Prone position □ Sitting position □ Supine position □ No
8. Overcomes obstacles □ Yes □ No
Trunk balance:
9. Sitting position □ Absent □ Precarious □ Regular □ Good
10. Moves from supine to sitting position □ Yes □ No
11. Moves from prone to sitting position □ Yes □ No
Four point position balance:
12. □ Absent □ Precarious □ Regular □ Good
Crawling:
13. □ Homologous □ Reciprocal □ No
14. Climbs down from sofa/bed to floor □ Yes □ No
15. Climbs up from floor to sofa/bed □ Yes □ No
Kneeling balance:
16. □ Absent □ Precarious □ Regular □ Good
17. Moves to kneeling position: □ Without support □ With support □ No
Standing position balance:
18. □ Absent □ Precarious □ Regular □ Good
19. Moves to standing position: □ Without support □ With support □ No
Displacement standing up:
20. Cruising □ Yes □ No
21. Pushes a mobile support □ Yes □ No
22. Performs gait as exercise □ Yes □ No
23. Early stepping □ Yes □ No
LOCOMOTION
Usual form of locomotion
24. Most usual form of locomotion, without assistance from others:
□ Absent (carried, transported in baby stroller or wheelchair)
□ Crawling or creeping in sitting position
□ Wheelchair
□ Gait with walker
□ Gait with crutches
25. Functional capacity in most frequent form of locomotion (without assistance from others):
□ Absent □ Home □ Outside home □ No limitations outside home

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Mobility aids
26. Wheelchair: □ Does not use □ Not age-appropriate or lacking physical/cognitive capacity
27. Able to follow a straight path □ Yes □ With assistance from others □ No
28. Performs maneuvers □ Yes □ With assistance from others □ No
29. Goes up/down ramp □ Yes □ With assistance from others □ No
30. Goes up/down sidewalk □ Yes □ With assistance from others □ No
Moves (from/to):
31. Wheelchair – bed □ Yes □ With assistance from others □ No
32. Bed – wheelchair □ Yes □ With assistance from others □ No
33. Wheelchair – floor □ Yes □ With assistance from others □ No
34. Floor – wheelchair □ Yes □ With assistance from others □ No
35. Wheelchair – car □ Yes □ With assistance from others □ No
36. Car – wheelchair □ Yes □ With assistance from others □ No
37. Wheelchair – toilet seat □ Yes □ With assistance from others □ No
38. Toilet seat – wheelchair □ Yes □ With assistance from others □ No
39. Walker: □ Does not use □ Not age-appropriate or lacking physical/cognitive capacity
40. Able to follow a straight path □ Yes □ With assistance from others □ No
41. Performs maneuvers □ Yes □ With assistance from others □ No
42. Goes up/down ramp □ Yes □ With assistance from others □ No
43. Goes up/down sidewalk □ Yes □ With assistance from others □ No
Moves (from/to):
44. Walker – bed □ Yes □ With assistance from others □ No
45. Bed – walker □ Yes □ With assistance from others □ No
46. Walker – floor □ Yes □ With assistance from others □ No
47. Floor – walker □ Yes □ With assistance from others □ No
48. Walker – car □ Yes □ With assistance from others □ No
49. Car – walker □ Yes □ With assistance from others □ No
50. Walker – toilet seat □ Yes □ With assistance from others □ No
51. Toilet seat – walker □ Yes □ With assistance from others □ No
52. Canes/Crutches: □ Does not use □ Not age-appropriate or lacking physical/cognitive capacity
53. □ Unilateral □ Bilateral
54. Able to follow a straight path □ Yes □ With assistance from others □ No
55. Goes up/down ramp □ Yes □ With assistance from others □ No
56. Goes up/down sidewalk □ Yes □ With assistance from others □ No
Locomotion capacity
57. Locomotion distance, without assistance from others 57.1. Conditions of evaluation:
□ Under 20 meters □ Habitual
□ 20 – 50 meters □ Gait training
□ 50 – 100 meters □ Crutches training
□ 100 – 200 meters □ Walker training
□ 200 – 300 meters □ Wheelchair training
 300 – 500 meters
 500 – 1000 meters
 Over 1000 meters
□ Not age-appropriate or lacking physical/cognitive capacity

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GROSS MOTOR SKILLS
58. Climbs up/down stairs □ Yes □ No
59. Kicks a ball □ Yes □ No
60. Spins around body axis □ Yes □ No
61. Starts running (accelerated gait) □ Yes □ No
62. Runs □ Yes □ No
63. Jumps, both feet simultaneously □ Yes □ No
UPPER LIMB FUNCTION
Right upper Limb:
64. Reaches objects □ Yes □ No
65. Uses limb as support □ Yes □ No
66. Voluntary prehension □ Yes □ No
67. Palmar prehension □ Yes □ No
68. Digital □ Yes □ No
69. Pincer grasp □ Yes □ No
70. Supination until midline □ Yes □ No
71. Complete supination □ Yes □ No
Left upper Limb:
72. Reaches objects □ Yes □ No
73. Uses limb as support □ Yes □ No
74. Voluntary prehension □ Yes □ No
75. Palmar prehension □ Yes □ No
76. Digital □ Yes □ No
77. Pincer grasp □ Yes □ No
78. Supination until midline □ Yes □ No
79. Complete supination □ Yes □ No
Manual function:
80. Transfers objects from one hand to the other □ Yes □ No
81. Performs wide insertions □ Yes □ No
82. Performs fine insertion □ Yes □ No
83. Piles objects on top of each other □ Yes □ No
84. Tears paper □ Yes □ No
85. Turns pages of a book □ Yes □ No
86. Puts a paper inside an envelope □ Yes □ No
87. Scribbles on paper and erases it afterwards □ Yes □ No
88. Cuts paper in half with scissors □ Yes □ No
89. Sharpens pencils □ Yes □ No
90. Can draw more than one recognizable form □ Yes □ No
91. Writes recognizable letters and numbers □ Yes □ No
92. Uses computer with interface □ Yes □ No
93. Uses computer with regular keyboard □ Yes □ No

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ACTIVITIES OF DAILY LIVING
6 to 12 months
Feeding:
94. Holds bottle □ Yes □ No
95. Eats food with hands □ Yes □ No
Dressing:
96. Takes off socks □ Yes □ No
97. Takes off shoes □ Yes □ No
1 to 2 years
Feeding:
98. Brings utensils to mouth (spoon/fork) □ Yes □ No
Dressing:
99. Unties shoelaces □ Yes □ No
100. Handles Velcro on shoes/clothing □ Yes □ No
2 to 3 years
Feeding:
101. Uses eating utensils without help □ Yes □ No
102. Drinks from glass without help □ Yes □ No
103. Opens/closes containers □ Yes □ No
104. Unscrews lids □ Yes □ No
Dressing:
105. Takes off T-shirt □ Yes □ No
106. Takes off underwear □ Yes □ No
107. Takes off shorts □ Yes □ No
108. Takes off pants □ Yes □ No
109. Opens zipper □ Yes □ No
110. Closes zipper □ Yes □ No
Sphincter control:
111. Controls bowel □ Yes □ No
112. Controls bladder □ Yes □ No
3 to 4 years
Feeding:
113. Transfers liquid from one container to another □ Yes □ No
114. Spreads butter/jam on bread/toast □ Yes □ No
115. Cuts food □ Yes □ No
116. Gets food from the refrigerator □ Yes □ No
Dressing:
117. Takes off open shirts □ Yes □ No
118. Puts on open shirts (short/long sleeves) □ Yes □ No
119. Puts on T-shirts (short/long sleeves) □ Yes □ No
120. Puts on underwear □ Yes □ No
121. Puts on shorts □ Yes □ No
122. Puts on pants □ Yes □ No
123. Puts on socks □ Yes □ No
124. Fastens and unfastens buckle □ Yes □ No
125. Buttons /unbuttons □ Yes □ No
Hygiene:
126. Washes and dries hands □ Yes □ No

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127. Puts toothpaste on toothbrush □ Yes □ No
128. Combs hair □ Yes □ No
129. Uses the toilet without help □ Yes □ No
130. Blows nose □ Yes □ No
131. Upper body hygiene □ Yes □ No
132. Upper-limb hygiene □ Yes □ No
133. Lower-limb hygiene □ Yes □ No
134. Rinses hair □ Yes □ No
Other abilities:
135. Opens/closes taps □ Yes □ No
136. Opens/closes doors □ Yes □ No
137. Turns lights on/off □ Yes □ No
138. Turns TV/radio on/off □ Yes □ No
4 to 5 years
Dressing:
139. Puts on shoes □ Yes □ No
Hygiene:
140. Brushes teeth □ Yes □ No
141. Washes face □ Yes □ No
5 to 6 years
Feeding:
142. Chooses and serves own food □ Yes □ No
Hygiene:
143. Washes private parts □ Yes □ No
Dressing:
144. Laces up own shoes □ Yes □ No
6 to 7 years
Dressing:
145. Ties and laces shoes □ Yes □ No
7 to 8 years
Dressing:
146. Chooses own clothes □ Yes □ No
147. Takes out clothes from drawers/closet □ Yes □ No
> 8 years
Hygiene:
148. Cuts own fingernails □ Yes □ No

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HOW TO FILL THE FORM
PATIENT PROFILE
This section collects information about the child being evaluated, including:
neurological state, orthosis and prosthesis, special conditions and handedness.
The items evaluated in this profile are not scored.
NEUROLOGICAL STATE
Motor impairment
Mark the types(s) of motor impairment the child presents (if inexistent, leave
blank).
• Spasticity: characterized by the muscle’s increased sensitivity to stretching,
causing contraction from the recruitment of muscle fibers. This can be defined
as speed-dependent resistance to movement, associated with exaggerated
deep-tendon reflexes.
• Ataxia: characterized by uncoordinated gait, wide support base and balance
disorders. Other clinical signs are: dysdiadochokinesia, dysmetria,
decomposition of movements, nystagmus, and dysarthria.
• Hypotonia: decreased muscle tone, often resulting in loose, floppy limbs.
Involuntary movement (if inexistent, leave blank)
• Chorea: movements that are gross, fast, arrhythmic and of sudden onset.
• Athetosis: continuous, uniform, slow movements.
• Choreoathetosis: combination of chorea and athetosis.
• Dystonia: intermittent twisting movements secondary to the simultaneous
contraction of agonist and antagonist muscles involving extremities, neck and
trunk.
Distribution
• Quadriplegia: involvement of all four limbs, with abnormal
posturing/movements of the trunk, head and neck.
• Right hemiplegia: involvement of the upper and lower limbs on the right side
of the body.
• Left hemiplegia: involvement of the upper and lower limbs on the left side of
the body.
• Diplegia: the lower limbs are more affected than the upper limbs.

8
• Triplegia: predominant involvement of 3 limbs, normally the lower limbs and
one of the upper limbs.
• Monoplegia: involvement of only one limb.
Associated disorders (if inexistent, leave blank)
• Seizures
• Dysphagia
• Gastroesophageal reflux
• Visual impairment
• Hearing deficits
• Cognitive impairment
• Behavioral disorders
• Neuropsychological disorders.
Reflexes
Should be tested in children up to 2 years of age; or in cases of tetraplegia
and/or involuntary movements up to 7 years of age (if inexistent, leave blank)
• Asymmetric tonic neck reflex: flexion of the upper and lower limbs on the
skull side and extension on the facing side in supine position. In some children
with cerebral palsy, only one of the upper limbs may manifest an obvious reflex,
together with a milder postural change in one of the lower limb.
• Symmetric tonic neck reflex: the child is placed in the crawling position.
When the head in flexed ventrally, flexion of the forelimbs and extension of the
lower limbs results; extension of the head and neck causes extension of the
upper limbs and flexion of the lower limbs.
• Moro reflex: is a sudden abduction and extension of the upper limbs with
spreading of the fingers followed by an embrace.
• Extensor thrust: the child is lifted by the axilla and suspended and then
lowered so that the feet touch the floor. A positive response consists in
extension of the lower limbs progressing upward into the trunk.
• Neck-righting reflex: positive if the shoulder girdle and trunk turn
simultaneously when the head is turned.

9
Reactions (if inexistent leave blank)
• Placing: Should be tested in children between 3 months and 2 years of age.
Hold the child by the chest and axilla, bring the dorsal surface of the feet
upward against the edge of a table. Automatic foot placement on the tabletop
surface occurs either symmetrically or asymmetrically.
• Parachute reaction: Should be tested in children between 7 months and 2
years of age. Place the child in a prone position. Lift horizontally from the table
and then quickly lower to tabletop or similar surface. This movement should
yield an automatic protective extension of the upper limbs and hands. If the
child has severe impairment of an upper limb, the protective placement of the
upper limbs may be unilateral.
ORTHOSIS/PROSTHESIS
• Yes: wears orthosis/prosthesis. Specify if it is unilateral or bilateral and the
reason for its use.
• No: does not wear orthosis/prosthesis.
SPECIAL CONDITIONS
• Post-surgery: fill out this item in cases up to 1 year post-surgery.
• Treatment with botulin toxin or alcohol: fill out this item in cases up to 6
months post-procedure.
• Treatment with serial casting: fill out this item in cases up to 6 months post-
procedure.
HANDEDNESS
• Mark the manual dominance (right or left). This information can be obtained
from the family and should be confirmed by observing the child’s performance
during the evaluation. In case the manual dominance is not defined, mark “not
defined”.

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EVALUATION START
I. Uses independent gait as a means of locomotion outside the home.
Yes: walks without assistance (no reliance on hand-held mobility devices
or a caregiver). The minimal distance that the child should be able to
walk is 300 meters. If marking this item “yes”, skip to item 57. Full credit
will be given for items 1-56).
No: incapable of unassisted gait outside. Proceed to the next item (II).
II. Uses independent gait as a means of locomotion at home or outside, with
limitations.
Yes: walks without assistance (no reliance on hand-held mobility devices
or a caregiver) at home or outside. The maximum distance that the child
is able to walk is 100 meters. If marking “yes”, skip to item 25. Full credit
will be given for items 1-24).
No: incapable of unassisted gait at home or outside. Proceed to the next
item (III).
III. Gait with support of cane
Yes: walks with cane but without caregiver’s assistance (at home or
outside). If marking “yes”, skip to item 24. Full credit will be given for
items 1-23).
No: unable to walk with canes or without caregiver’s assistance. Proceed
to item 1.
MOTOR ACQUISITIONS
Head balance:
1. Prone position
Absent: the child does not lift head.
Precarious: cervical extension up to 45° with head oscillations, then head
drops back down.
Regular: cervical extension > or equal 45° and maintains this position for
at least 10 seconds. Has difficulties rotating head or there are head
oscillations during movement.
Good: extends head 90°,maintains this position and is capable of cervical
rotation without oscillations.

11
2. Supine position
Absent: hyperextension of head when pulled by the arms to sitting
position.
Precarious: when first being pulled into the sitting position, there are
attempts at maintaining head and trunk alignment, but then head
oscillates and drops back down during the second half of movement arc.
Regular: head drops back down only during the final part of the
maneuver, or partial flexion of the head sustained during entire
movement arc.
Good: flexes head at beginning of maneuver (chin-tuck) and maintains it
aligned with the trunk or in maximal flexion entire movement arc
3. Sitting position
Absent: does not extend the head.
Precarious: does not maintain head and trunk alignment, but tries to
extend head. Head oscillations are observed.
Regular: head and trunk alignment maintained for at least 10 seconds,
but unable to rotate head or does so with head oscillations.
Good: head and trunk alignment maintained, head rotation without
oscillations.
Rolling:
4. Supine/prone
Complete: rolls from supine to prone.
Partial: rolls from supine to lateral decubitus. Mark this item if the child
rolling from supine to prone is "accidental" (this is caused by an
imbalance and not by a controlled action).
No: does not roll from supine to lateral decubitus or to prone, despite
intention to do so.
5. Prone/supine
Complete: voluntarily rolls from prone to supine.
Partial: rolls from prone to lateral decubitus. Full score if the rolling from
prone is “accidental”.
No: does not roll from prone to lateral decubitus or to supine, despite
intention to do so.

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Creeping:
6. Pivots
Yes: makes circular movements (precedes creeping), at least 90° to the
right or left. Full score for pivoting in prone or/and in supine position.
No: does not pivot or does so less than 90°.
7. Creeps
Mark how the child creeps (prone, seated or supine).
No: does not creep.
8. Overcomes obstacles
Yes: overcomes obstacles during creeping (prone, seated or supine).
Some examples of obstacles are pillows and toys. This item can be
tested using a pillow or a 10 cm-high cushion.
No: does not overcome obstacles during creeping.
Trunk balance:
9. Sitting position
Absent: does not maintain this position without support of caregiver or
devices.
Precarious: can sit with upper limb support for at least 10 seconds. May
try to use an arm to reach objects, but trunk flexion intensifies with this
motion.
Regular: sits with unilateral upper limb support for at least 10 seconds.
Maintaining the trunk completely erect is not necessary, but note if too
much anterior trunk flexion is required to remain seated with the support
of only one arm. The child may be able to sit without upper limb support
during a few seconds, but is unable to rotate the trunk.
Good: sits without upper limb support, rotates trunk and has functional
use of the hands.
10. Moves from supine to sitting position
Yes: moves from supine to sitting position without assistance or use of
devices. Uses upper limbs for support.
No: does not move from supine to sitting position.
11. Moves from prone to sitting position
Yes: moves from prone to sitting position without assistance or use of
devices.
No: does not move from prone to sitting position.

13
12. Four point position balance
Absent: cannot attain this position.
Precarious: attains this position for at least 10 seconds, but shoulder and
pelvic girdle are not aligned.
Regular: attains this position for at least 10 seconds with shoulder and
pelvic girdle aligned. Is able to free one arm.
Good: attains position for at least 10 seconds with shoulder and pelvic
girdle aligned. Is able to free one of the upper limbs and flex the arm up
to the shoulder line.
13. Crawling:
Homologous: crawls without dissociation of the lower limbs.
Reciprocal: crawls with dissociation of the lower limbs.
No: incapable of crawling.
14. Climbs down from sofa/bed to floor:
Yes: climbs down from the sofa/bed without assistance. Height of
sofa/bed must allow the child to support arms/forearms on its surface
with feet on the floor.
No: does not climb from the sofa/bed.
15. Climbs up from floor to sofa/bed:
Yes: climbs up to sofa/bed without assistance. Height of sofa/bed must
allow the child to support arms/forearms on its surface with feet on the
floor.
No: does not climb to sofa/bed.
16. Kneeling balance:
Absent: is unable to attain in this position.
Precarious: remains in the kneeling position using upper limb support.
Unable to free one arm and use it functionally.
Regular: remains in the kneeling position using upper limb support. Able
to free one arm from support.
Good: remains in kneeling position without upper limb support for at least
10 seconds. Able to reach arms out with trunk rotation and no assistance
or support from devices.

14
17. Moves to kneeling position:
With support: kneels holding onto device or furniture.
Without support: kneels without support.
No: unable to kneel.
18. Standing position balance:
Absent: unable to remain standing even with support (devices/furniture).
Precarious: remains standing with upper limb support, but cannot free
either arm and use it functionally. Supports lower trunk against
devices/furniture to maintain balance.
Regular: remains standing using one arm for support and the other for
functional use. Does not use devices/furniture for lower trunk support.
Good: remains standing without upper limb support for at least 10
seconds. Does not need devices/furniture for lower trunk support .
19. Moves to standing position:
With support: moves to standing position with upper limb support on
devices/furniture. Able to move to standing position from a semi-kneeling
position or by using the arms to push from sitting (without dissociation of
the lower limbs).
Without support: moves to standing position without upper limb support
on devices/furniture. Able to use arms to push up from the floor.
No: does not move to standing position.
Displacement standing up
20. Cruising
Yes: cruises by supporting upper limbs on furniture.
No: unable to cruise.
21. Pushes mobile support
Yes: walks pushing mobile support. (ex: chair, doll stroller).
No: does not walk/push mobile support.
22. Performs gait training exercises
Yes: begins gait training exercises with support using equipment such
as parallel bars or hand-held mobility devices. Unable to perform
maneuvers or control movement speed without assistance (non-
functional gait).
No: Unable to perform gait training exercises.

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23. Early stepping
Yes: walks a few steps without support. Must be able to walk at least 3
steps without support in order to score on this item.
No: unable to walk 3 steps without support.
LOCOMOTION
24. Most usual form of locomotion, without assistance from others: mark the
child’s most habitual form of locomotion, which on this scale is understood as
the one most often used throughout the day without any assistance.
Absent: no form of locomotion without assistance. In this case, child is
carried or transported in baby stroller or wheelchair most of the time.
Children that roll or creep for short distances should score on this item,
because they normally depend on assistance for moving about inside the
house.
Crawling or creeping in seated position: the child moves about indoors by
crawling or creeping in a seated position. To score on this item, the child
has to be capable of moving about the home, most of the time
unassisted. No score is given if movement is only for very short
distances (2 meters or less).
Wheelchair: the wheelchair is the main form of locomotion without
assistance. Children that use hand-held mobility devices for short
distances and for a short period of time should score on this item.
Gait with walker: use of a walker without assistance is the most habitual
form of locomotion.
Gait with crutches: use of crutches without assistance is the most
habitual form of locomotion.
Note: if the child moves about with walker and/or on crutches for most of the
day, even if only indoors (they need the wheelchair for outdoor locomotion),
walking with walker or crutches should be considered the main form of
locomotion.
25. ‘Functional capacity’ in the child’s most frequent form of locomotion (without
assistance from others) refers to endurance (item 24).
Absent: Does not walk or does not use wheelchair without assistance.
Home: walks or uses a wheelchair as the most habitual form of getting
around in the home, with a maximum distance of 100 meters.
Outside the home: walks or uses a wheelchair as the most habitual form
of getting around, with distances between 100 and 300 meters.
No limitations outside the home: walks or uses a wheelchair as the most
habitual form of getting around, with distances greater than 300 meters

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(ex., a walker is the most habitual form of getting around (item 24)
outside home).
Mobility aids
26. Wheelchair
Does not use: wheelchair not needed, capable of walking without
restrictions/limitations. Skip to item 39.
Not age-appropriate or lacking physical/cognitive capacity: no wheelchair
yet; instead, is still carried or pushed in a baby stroller; or, no wheelchair
is needed because the amount of distance normally walked daily is
compatible with gait endurance; or uses wheelchair but is completely
dependent on others to push it. Skip to item 39.
If neither of the above 2 options apply, e.g., independent wheelchair use or with
minimal assistance, skip to item 27.
27-30: Mark "yes" if the child accomplishes the task independently. Mark
"assistance from others" if the child accomplishes at least 50% of the task. Mark
"no" if the child is incapable of performing the task or is able to do less than 50%
of it independently.
27. Able to follow a straight path: moves the wheelchair forward in a straight
line.
28. Performs maneuvers: deviates from obstacles, and can turn at least 90°.
29. Goes up/down ramp: goes up and down a standard-size ramp.
30. Goes up/down sidewalk: goes up and down a standard-size sidewalk.
31-38: Mark "yes" if the child independently performs transfers. Mark
"assistance from others" if the child accomplishes at least 50% of the task (for
example, to transfer from wheelchair to car, the child stands up with support
and needs help to enter the car). Mark "no" if the child is incapable of
performing the task or is able to do less than 50% of it independently (ex: to
transfer from wheelchair to car, the child flexes the upper limbs but needs
assistance to stand up and is completely dependent on someone for help
entering the car.
31. Transfers from wheelchair to bed.
32. Transfers from bed to wheelchair.
33. Transfers from wheelchair to floor.
34. Transfers from floor to wheelchair.
35. Transfers from wheelchair to car.
36. Transfers from car to wheelchair.
37. Transfers from wheelchair to toilet seat.

17
38. Transfers from toilet seat to wheelchair.
39. Walker
Does not need: walker is not required for moving about. Skip to item 52.
Not age-appropriate or lacking physical/cognitive capacity: walker not
used for age-related lack of motor and/or cognitive abilities. Skip to item
52.
If neither of the above 2 options apply, e.g., child uses a walker, skip to item 40.
40-43: Mark "yes" if the child performs the task independently. Mark "with
assistance of others" if the child accomplishes at least 50% of the task. Mark
"no" if incapable of performing task or needs assistance for more than 50% of it.
40. Able to follow a straight path: able to follow a straight line on flat surfaces
using a walker.
41. Performs maneuvers: deviates from obstacles with walker, and can turn at
least 90°.
42. Goes up/down ramp: goes up and down a standard-size ramp using a
walker.
43. Goes up/down sidewalk: goes up and down a standard-size sidewalk with a
walker.
44-51: Mark "yes" if the child performs transfers independently. Mark
"assistance from others" if the child accomplishes at least 50% of the task (ex:
to transfer from the floor to the walker, pulls to standing position by holding onto
walker and only needs help to keep the walker stable during this transfer). Mark
"no" if the child is incapable of performing the task or is able to do less than 50%
of it independently (ex: to transfer from the floor to the walker, requires
assistance to stand up).
44. Transfers from walker to bed.
45. Transfers from bed to walker.
46. Transfer from walker to floor.
47. Transfers from floor to walker.
48. Transfers from walker to car.
49. Transfers from car to walker.
50. Transfers from walker to toilet seat.
51. Transfers toilet seat to walker.

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52. Canes/Crutches
Does not use: walks without hand-held mobility aids. Skip to item 57.
Not age-appropriate or lacking physical/cognitive capacity: does not use
crutches for age-related lack of motor and/or cognitive abilities. Skip to
item 57.
If neither of the above 2 options apply, e.g., the child uses crutches, skip to item
53.
53. Unilateral/bilateral: specify if the child uses unilateral or bilateral crutches.
54-56: Mark “yes” if the child performs the task independently. Mark "with
assistance of others" if the child accomplishes at least 50% of the task. Mark
"no" if the child is incapable of performing the task or is able to do less than 50%
of it independently.
54. Able to follow a straight path: is able to follow a straight line on flat surfaces
with crutches.
55. Goes up/down ramp: can go up and down a standard size ramp with
crutches.
56. Goes up/down sidewalk: can go up and down a standard size sidewalk with
crutches.
Locomotion capacity
57. Locomotion distance, without assistance from others.
The locomotion capacity (wheelchair or gait, with or without hand-held mobility
devices) is classified in meters: up to 20, 20-50, 50-100, 00-200, 200-300, 300-
500, 500-1000, more than 1000 meters.
Mark “not age-appropriate or lacking physical/cognitive capacity” in absence of
any locomotion capacity.
In case the distance corresponds to a “transition” number (ex: 300 meters),
choose the “inferior band” (ex: 200-300 meters) if the child has difficulties
reaching the measured distance, and the “superior band” (ex: 300-500 meters)
if the child appears to be able to walk further than the distance measured.
This item refers to the locomotion capacity without assistance from others.
Normally the distance is measured in a clinic is up to 300 meters. For greater
distances, the information should be obtained from the patient/family. In the
event that distance cannot be measured in the clinic, take the family’s input into
account.

19
57.1. Conditions of evaluation: no score is given for this item. Its purpose is
simply to establish the conditions under which locomotion capacity was
assessed.
Habitual: the child is not training independent gait or gait with hand-held
mobility aids; nor training the use of wheelchair.
Gait training: exercising independent gait.
Crutches training: exercising gait with crutches.
Walker training: exercising gait with walker.
Wheelchair training: exercising with wheelchair.
GROSS MOTOR SKILLS
58. Climbs up/down stairs:
Yes: able to climb up/down stairs, at least 5 steps, in a standing position.
Full score even if done holding onto railing and without alternating feet,
as long as most of the support is on lower limbs.
No: incapable of climbing up/down 5 steps in a standing position.
59. Kicks a ball:
Yes: able to kick a ball. Can hold onto walker or crutches and kick the
ball with right or left foot.
No: unable to kick a ball.
60. Spins around body axis:
Yes: spins around body axis at least 180, even if with hand-held
locomotion aid (except wheelchair)
No: unable to spin around body axis at least 180°.
61. Starts running (accelerated gait):
Yes: walks fast, even if with hand-held mobility devices.
No: unable to walk fast.
62. “Runs”:
Yes: walks fast enough (“run”) in such a way that at some point both feet
are off the ground.
No: unable to “run”.

20
63. Jumps with both feet simultaneously:
Yes: jumps upward with both feet without falling and without any support.
Must be able to jump 5 cm off the floor to score on this item.
No: unable to jump 5 cm high.
UPPER LIMB FUNCTION
64-79: Mark “yes” if the child is able to perform the tasks without assistance
from others.
Reaches for objects (64 and 72): scores if able to reach for objects from
any position (seated, supine, prone).
Uses upper limbs as support (65 and 73): arms are used during
bimanual function to hold or to stabilize an object.
Voluntary prehension (66 and 74): grasps an object with voluntary
movements of the hand. Scores if able to grasp object with any kind of
prehension.
Palmar grasp (67 and 75): grasps an object with palmar prehension,
which is characterized by flexion of all fingers around the object.
Digital (68 and 76): grasps small objects between the radial fingers and
the thumb.
Pincer grasp (69 and 77): grasps an object between the thumb and tip of
forefinger.
Supination up to midline (70 and 78): with the forearm completely
pronated, supinates with a movement arc of 90° (to midline).
Complete supination (71 and 79): with the forearm completely pronated,
supinates with a movement arc of 180° (complete).
Manual function
80-93: Mark “yes” if the child performs the task without assistance from others,
with the exception of items 80 and 84, in which the use of both hands is
obligatory. Scores on the other items even if task is performed with only one
upper limb or with use of other body parts (ex: lower limbs). The aim is to
evaluate functionality.
80. Transfers objects from one hand to the other: moves the object from one
hand to the other.
81. Performs wide insertions: puts objects, such as cups, inside each other.
82. Performs fine insertion : inserts small objects, such as pins, into holes. The
ability to cap a pen also scores on this item.

21
83. Piles objects on top of each other: piles at least 3 objects (such as blocks)
on top of each other.
84. Tears paper: tears a sheet of paper using both hands. To score, it is not
enough to simply be able to tear the paper by pushing the sheet; must be able
to perform the opposing movements with the upper limbs)
85. Turns pages of a book: turns pages of a book, one at a time. The pages
should be thin.
86. Puts a paper inside an envelope: folds a sheet of paper and put it inside an
envelope,
87. Scribbles on paper and then erases it: doodles on paper and erase it
completely.
88. Cuts paper in half with scissors: cuts a sheet of paper (minimum size 10
centimeters) with scissors in a straight line.
89. Sharpens pencils: sharpens a pencil into a fine tip.
90. Can draw more than one recognizable form: draws at least 2 recognizable
forms (ex: circle, cross). The child can copy a drawing produced by the
evaluator.
91. Writes recognizable letters and numbers: writes at least 2 recognizable
letters or numbers. The child can copy the letters/numbers written by the
evaluator.
92. Uses a computer with adaptations: uses the computer with adaptations (on
the keyboard, mouse, etc.).
93. Uses a computer without adaptations: uses a regular computer (including
laptop) without any adaptations. A score on this item implies in a score on item
92 as well, since the child is also able to use computer with adaptations.
ACTIVITIES OF DAILY LIVING
The following items are organized into age groups to make it easier to identify a
child’s developmental level. The evaluator should give a score to all items.
Those that are classified into age groups older than the child’s age (ex: items in
the 3-4 age group but the child being evaluated is 2 years old), the evaluator
should ask the parents if their child is able to perform them; in some instances,
a child may be able to accomplish tasks in a higher age group. The parents can
also be asked about the items within the child’s age group if it is not possible to
evaluate them in clinical setting.
To receive the score (marking "yes"), the child must be able to perform the
tasks without assistance from others, but may use adaptations. If the child
performs the task with help, the evaluator should mark the item with a "no".
Sometimes the motor capacity is there but not the necessary
cognitive/neuropsychological abilities.

22
The aim is to evaluate capacity. Therefore, the child receives a positive score if
the task is completed during the evaluation, even if it is not normally performed
at home (e.g., the parents may be doing it for the child).
6 to 12 months
Feeding:
94. Holds a bottle: holds a bottle with one or both upper limbs without
assistance.
95. Eats food with hands: eats solid food (ex: piece of fruit, cookies) without
assistance.
Dressing:
96. Takes off socks: intentionally takes off socks without assistance. May use
strategies such as sitting with support of the trunk to accomplish the task.
97. Takes off shoes: intentionally takes off shoes without assistance - any type
of shoe (trainers, sandals), except flip-flops. This item does not address the
ability to deal with shoelaces and buckles.
1 to 2 years
Feeding:
98. Brings utensils to mouth (spoon/fork): takes some food from the plate with a
spoon or fork and bring it to mouth. Scores even if large amounts of food drop
during task.
Dressing:
99. Unties shoelaces: unties shoelaces without assistance.
100. Handles Velcro on shoes/clothing: intentionally opens and closes Velcro
on shoelaces and clothing without assistance.
2 to 3 years
Feeding:
101. Uses eating utensils: eats with spoon/fork without assistance. This item
does not address cutting up food. To score, may not drop more than a very
small amount of food.
102. Drinks from glass: holds a glass with one or both hands without
assistance. Scores even if the glass is adapted (ex: glass with handle).
103. Opens/closes containers: opens and closes containers without help.
104. Unscrews lids: unscrews lid without assistance (ex: toothpaste cap).

23
Dressing:
105. Takes off T-shirt: takes off T-shirt without assistance.
106. Takes off underwear: takes off underwear without assistance.
107. Takes off shorts: takes off the shorts with elastic waist (this item does not
address the ability to deal with buttons or zippers).
108. Takes off pants: takes off pants with elastic waist (this item does not
address the ability to deal with buttons or zippers).
109. Opens zipper: opens zipper. To score on this item, does not need to be
able to unclasp insertion pin from retainer box.
110. Closes zipper: closes zipper. To score on this item, does not need to be
able to put the insertion pin into the retainer box (the evaluator can do this part
of the task for the child).
Sphincter control:
111. Controls bowel: has bowel control. To score on this item, child must have
enough control to not soil underpants.
112. Controls bladder: has bladder control. To score on this item, child must
have enough control to not wet underpants (controls bladder during the day).
3 to 4 years
Feeding:
113. Transfers liquid from one container to another: transfers liquid from one
container to another. The first container must be bigger than the second one (ex:
jar and glass/cup). To score on this item, none or very little liquid is spilled.
114. Spreads butter/jam on bread/toast: spreads butter/jam on the bread/toast
with a knife.
115. Cuts food: cuts food using a knife. Scores on this item even if able to cut
only soft food (ex: cake, bread).
116. Gets food from the refrigerator: opens refrigerator and retrieves food
without assistance. May receive verbal instructions about which food to get.
Dressing:
117. Takes off open shirts: takes off open shirts without assistance. This item
does not address the ability to deal with buttons/zippers.
118. Puts on open shirts (short/long sleeves): puts on open shirts without
assistance. This item does not address the ability to deal with buttons/zippers.
119. Puts on T-shirts: puts on T-shirt without assistance.
120. Puts on underwear: puts on underwear without assistance.

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121. Puts on shorts: puts on shorts with elastic waist unassisted. This item does
not address the ability to deal with buttons/zippers.
122. Puts on pants: puts on pants with elastic waist unassisted. This item does
not address the ability to deal with buttons/zippers.
123. Puts on socks: puts on socks without assistance. May use strategies such
as sitting with support of the trunk to accomplish the task.
124. Fastens and unfastens buckle: fastens and unfastens buckle without
assistance.
125. Buttons /unbuttons: buttons and unbuttons without assistance.
Hygiene:
126. Washes and dries hands: uses soap to wash and then adequately dries
both hands. May be helped by an adult to reach the sink.
127. Puts toothpaste on toothbrush: opens the toothpaste and puts an adequate
amount of paste on toothbrush. It is not obligatory to use both hands.
128. Combs hair: combs own hair.
129. Uses the toilet without help: transfers to the toilet and lowers/lifts clothing
to be able to use it. This item does not address intimate hygiene.
130. Blows nose: blows nose using a handkerchief without assistance.
131. Upper body hygiene: washes trunk. Scores even if unable to wash the
parts of the trunk unreachable with the hands.
132. Upper-limb hygiene: washes the upper limbs without assistance.
133. Lower-limb hygiene: washes the lower limbs without assistance. May sit in
a chair to accomplish this task.
134. Rinses hair: rinses own hair with a towel without assistance. This item
does not address the ability to wash the hair.
Other abilities:
135. Opens/closes faucets: opens and closes faucets without assistance.
136. Opens/closes doors: opens and closes doors without assistance. This item
address the ability to deal with door handles.
137. Turns lights on/off: reaches and turns the lights on/off without assistance.
138. Turns TV/radio on/off: turns the TV/radio on/off. May use the remote
control.

25
4 to 5 years
Dressing:
139. Puts on shoes: puts on shoes. This item does not address the ability to
deal with shoelaces, Velcro or buckles. To score, must put shoe on the correct
foot.
Hygiene:
140. Brushes teeth: brushes teeth completely.
141. Washes face: washes and dries face without assistance.
5 to 6 years
Feeding:
142. Chooses and serves own food: puts food on plate. May receive verbal
instructions to help choose food
Hygiene:
143. Washes private parts: performs hygiene of private parts without assistance
after using the toilet.
Dressing:
144. Laces up own shoes: laces up shoes without assistance.
6 to 7 years
Dressing:
145. Laces and ties shoes: laces and ties shoes without assistance.
7 to 8 years
Dressing:
146. Chooses own clothes: chooses own clothes, which should be appropriate
for the occasion (setting- and weather-appropriate).
147. Takes out clothes from drawers/closet: opens drawers/closet and retrieves
clothes without assistance. To score, must perform this task with the aim of
actually changing clothes (taking them out just to play does not count).
8 years and older
Hygiene:
148. Cuts own fingernails: able to use a nail cutter to trim fingernails without
assistance.

26
References:
Bleck, E.E. Horstman, M. H. Orthopaedic Management in Cerebral Palsy, 2nd
ediyion, 2007, Mac Keith Press
Duthie, R. Bentley, G. Mercer`s Orthopaedic Surgery. 9Th Edition. Hodder &
Stoughton, England, 1991.
Henderson, A. Pehoski, C. (org). Hand Function in the Child – Foundations for
Remediation. Second Edition, Mosby, 2006.
Piper MC, Darrah J. Motor assessment of the developing infant. Philadelphia:
WB Saunders; 1994.
Russell DJ, Rosenbaum PL, Gowland C, Lane M. Gross Motor Function
Measure (GMFM-66 & GMFM-88): user's manual. London: Mac Keith Press;
2002.
Mancini MC. Inventario de Avaliacao Pediatrica de Incapacidade (PEDI):
manual da versao brasileira adaptada. Belo Horizonte: Ed. UFMG; 2005.

27
HOW TO COMPUTE SCORES
SCORES DESCRIPTION
The punctuation for the domains and dimensions of the scale, as well as the
scale's overall score, each one of them separately, can range from 0 to 100
points.
The score for the motor dimension of the Sarah scale is calculated as the
arithmetic mean of the points obtained for the following domains: “motor
acquisition”, “locomotion”, “gross motor skills”, and “upper limb function”. The
score for the functional dimension consists of the points obtained in its single
domain, the domain of "activities of daily living”. The overall score on the scale
is the arithmetic mean of the points obtained in the two dimensions, “motor” and
“functional”.
Within the domains, the maximum punctuation for each item is equivalent to
100 divided by the number of items in the domain, e.g., each of the 23 items in
the motor acquisition domain has a maximum score of 100 divided by 23 points
(100/23).
The locomotion domain, because of the inherent complexity of its assessment,
is an exception to the punctuation criteria described for the scale domains. For
the locomotion domain: the single item referring to the “most usual form of
locomotion, without assistance from others” is scored out of a maximum of
100/5 points; the single item referring to the “functional capacity in the most
frequent form of locomotion” out of a maximum of 100/5 points; the set of items
relating to the “need for and skill in the use of mobility aids” is scored out of a
maximum of (100/5)*2 points; and the single item referring to the “locomotion
distance, without assistance from others” is scored out of a maximum of 100/5
points. The final score for the locomotion domain is the sum of the punctuation
for all items in this domain and ranges, as for the other domains, from 0 to 100
points.
In the locomotion domain, the items related to the “need and skill in the use of
mobility aids” were divided into three types of aids: wheelchair ((100/5)*2*(1/3)
points), walker ((100/5)*2*(1/3)), and canes/crutches ((100/5)*2*(1/3)). If a child
or adolescent being assessed does not need that specific mobility aid, he/she
receives full points for that aid; however, if he/she is too young to use that aid or
is physically or cognitively unable to do so, than he/she is given a zero for that
aid. If the child or adolescent uses more than one mobility aid, his/her
locomotion performance is evaluated for each aid independently. Four items
related to control of mobility aid concern patients who use wheelchairs or
walkers, each scoring a maximum of (100/5)*1/12 points. There are also eight
items on transfers, each scoring a maximum of (100/5)*1/24 points. Use of
canes/crutches is classified as either unilateral, (100/5)*1/6 points, or bilateral,
(100/5)*1/12 points); there are also three items related to control of mobility aids,
each scoring a maximum of (100/5)*1/6 points.

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At the beginning of the assessment, if the child or adolescent has “community
ambulation without the need of mobility aids”, then the assessment skips to
“locomotion capacity”, with the kid receiving the highest score for the skipped
items. If the child or adolescent has “limited home or community ambulation
without assistance”, then the assessment skips to “functional capacity of
locomotion”, with the kid receiving the highest score for the skipped items. If the
kid’s gait is aided by a cane or crutch, then the assessment skips to “most
frequent form of locomotion”, and the highest score is given to the previous
items.
FORM WITH SCORES
Sarah motor-functional evaluation scale: 148 evaluation items
EVALUATION START
Uses independent gait as a means of locomotion outside the home, without the need of mobility aids.
□ No (0) □ Yes (Motor Acquisitions = 100; Locomotion + 60) (if yes, skip to question 57)
Uses independent gait as a means of locomotion at home or outside, with limitations.
□ No (0) □ Yes (Motor Acquisitions = 100; Locomotion + 20) (if yes, skip to question 25)
Gait with support of cane. □ No (0) □ Yes (Motor Acquisitions = 100) (if yes, skip to question 24)
MOTOR ACQUISITIONS
Head balance:
1. Prone position □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
2. Supine position □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
3. Sitting position □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
Rolling:
4. Supine/prone □ Complete (100/23) □ Partial (100/23)*1/2 □ No (0)
5. Prone/supine □ Complete (100/23) □ Partial (100/23)*1/2 □ No (0)
Creeping:
6. Pivots (prone or supine) □ Yes (100/23) □ No (0)
7. Creeps □ Prone position (100/23) □ Sitting position (100/23)*2/3 □ Supine position (100/23)*1/3 □ No (0)
8. Overcomes obstacles □ Yes (100/23) □ No (0)
Trunk balance:
9. Sitting position □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
10. Moves from supine to sitting position □ Yes (100/23) □ No (0)
11. Moves from prone to sitting position □ Yes (100/23) □ No (0)
Four point position balance:
12. □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
Crawling:
13. □ Homologous (100/23) □ Reciprocal (100/23)*1/2 □ No (0)
14. Climbs down from sofa/bed to floor □ Yes (100/23) □ No (0)
15. Climbs up from floor to sofa/bed □ Yes (100/23) □ No (0)
Kneeling balance:
16. □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
17. Moves to kneeling position: □ Without support (100/23) □ With support (100/23)*1/2 □ No (0)
Standing position balance:
18. □ Absent (0) □ Precarious (100/23)*1/3 □ Regular (100/23)*2/3 □ Good (100/23)
19. Moves to standing position: □ Without support (100/23) □ With support (100/23)*1/2 □ No (0)

29
Displacement standing up:
20. Cruising □ Yes (100/23) □ No (0)
21. Pushes a mobile support □ Yes (100/23) □ No (0)
22. Performs gait as exercise □ Yes (100/23) □ No (0)
23. Early stepping □ Yes (100/23) □ No (0)
LOCOMOTION
Usual form of locomotion
24. Most usual form of locomotion, without assistance from others:
□ Absent (carried, transported in baby stroller or wheelchair) (0)
□ Crawling or creeping in sitting position (100/5)*1/4
□ Wheelchair (100/5)*2/4
□ Gait with walker (100/5)*3/4
□ Gait with crutches (100/5)
25. Functional capacity in most frequent form of locomotion (without assistance from others):
□ Absent (0) □ Home (100/5)*1/3 □ Outside home (100/5)*2/3 □ No limitations outside home (100/5)
Mobility aids
26. Wheelchair: □ Does not use (100/5)*2/3 □ Not age-appropriate or lacking physical/cognitive capacity (0)
27. Able to follow a straight path □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
28. Performs maneuvers □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
29. Goes up/down ramp □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
30. Goes up/down sidewalk □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
Moves (from/to):
31. Wheelchair – bed □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
32. Bed – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
33. Wheelchair – floor □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
34. Floor – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
35. Wheelchair – car □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
36. Car – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
37. Wheelchair – toilet seat □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
38. Toilet seat – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
39. Walker: □ Does not use (100/5)*2/3 □ Not age-appropriate or lacking physical/cognitive capacity (0)
40. Able to follow a straight path □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
41. Performs maneuvers □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
42. Goes up/down ramp □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
43. Goes up/down sidewalk □ Yes (100/5)*1/12 □ With assistance from others (100/5)*1/24 □ No (0)
Moves (from/to):
44. Wheelchair – bed □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
45. Bed – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
46. Wheelchair – floor □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
47. Floor – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
48. Wheelchair – car □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
49. Car – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
50. Wheelchair – toilet seat □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
51. Toilet seat – wheelchair □ Yes (100/5)*1/24 □ With assistance from others (100/5)*1/48 □ No (0)
52. Canes/Crutches: □ Does not use (100/5)*2/3 □ Not age-appropriate or lacking physical/cognitive capacity (0)
53. □ Unilateral (100/5)*1/6 □ Bilateral (100/5)*1/12
54. Able to follow a straight path □ Yes (100/5)*1/6 □ With assistance from others (100/5)*1/12 □ No (0)
55. Goes up/down ramp □ Yes (100/5)*1/6 □ With assistance from others (100/5)*1/12 □ No (0)
56. Goes up/down sidewalk □ Yes (100/5)*1/6 □ With assistance from others (100/5)*1/12 □ No (0)

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Locomotion capacity
57. Locomotion distance, without assistance from others 57.1. Conditions of evaluation:
□ Under 20 meters (100/5)*1/8 □ Habitual
□ 20 – 50 meters (100/5)*2/8 □ Gait training
□ 50 – 100 meters (100/5)*3/8 □ Crutches training
□ 100 – 200 meters (100/5)*4/8 □ Walker training
□ 200 – 300 meters (100/5)*5/8 □ Wheelchair training
 300 – 500 meters (100/5)*6/8
 500 – 1000 meters (100/5)*7/8
 Over 1000 meters (100/5)
□ Not age-appropriate or lacking physical/cognitive capacity (0)
GROSS MOTOR SKILLS
58. Climbs up/down stairs □ Yes (100/6) □ No (0)
59. Kicks a ball □ Yes (100/6) □ No (0)
60. Spins around body axis □ Yes (100/6) □ No (0)
61. Starts running (accelerated gait) □ Yes (100/6) □ No (0)
62. Runs □ Yes (100/6) □ No (0)
63. Jumps, both feet simultaneously □ Yes (100/6) □ No (0)
UPPER LIMB FUNCTION
Right upper Limb:
64. Reaches objects □ Yes (100/30) □ No (0)
65. Uses limb as support □ Yes (100/30) □ No (0)
66. Voluntary prehension □ Yes (100/30) □ No (0)
67. Palmar prehension □ Yes (100/30) □ No (0)
68. Digital □ Yes (100/30) □ No (0)
69. Pincer grasp □ Yes (100/30) □ No (0)
70. Supination until midline □ Yes (100/30) □ No (0)
71. Complete supination □ Yes (100/30) □ No (0)
Left upper Limb:
72. Reaches objects □ Yes (100/30) □ No (0)
73. Uses limb as support □ Yes (100/30) □ No (0)
74. Voluntary prehension □ Yes (100/30) □ No (0)
75. Palmar prehension □ Yes (100/30) □ No (0)
76. Digital □ Yes (100/30) □ No (0)
77. Pincer grasp □ Yes (100/30) □ No (0)
78. Supination until midline □ Yes (100/30) □ No (0)
79. Complete supination □ Yes (100/30) □ No (0)
Manual function:
80. Transfers objects from one hand to the other □ Yes (100/30) □ No (0)
81. Performs wide insertions □ Yes (100/30) □ No (0)
82. Performs fine insertion □ Yes (100/30) □ No (0)
83. Piles objects on top of each other □ Yes (100/30) □ No (0)
84. Tears paper □ Yes (100/30) □ No (0)
85. Turns pages of a book □ Yes (100/30) □ No (0)
86. Puts a paper inside an envelope □ Yes (100/30) □ No (0)
87. Scribbles in paper and erases it afterwards □ Yes (100/30) □ No (0)

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88. Cuts paper in half with scissors □ Yes (100/30) □ No (0)
89. Sharpens pencils □ Yes (100/30) □ No (0)
90. Can draw more than one recognizable form □ Yes (100/30) □ No (0)
91. Writes recognizable letters and numbers □ Yes (100/30) □ No (0)
92. Uses computer with interface □ Yes (100/30) □ No (0)
93. Uses computer with regular keyboard □ Yes (100/30) □ No (0)
DAILY LIVING ACTIVITIES
6 to 12 months
Feeding:
94. Holds bottle □ Yes (100/55) □ No (0)
95. Eats food with hands □ Yes (100/55) □ No (0)
Dressing:
96. Takes off socks □ Yes (100/55) □ No (0)
97. Takes off shoes □ Yes (100/55) □ No (0)
1 to 2 years
Feeding:
98. Brings utensils to mouth (spoon/fork) □ Yes (100/55) □ No (0)
Dressing:
99. Unties shoelaces □ Yes (100/55) □ No (0)
100. Handles Velcro on shoes/clothing □ Yes (100/55) □ No (0)
2 to 3 years
Feeding:
101. Uses eating utensils without help □ Yes (100/55) □ No (0)
102. Drinks from glass without help □ Yes (100/55) □ No (0)
103. Opens/closes containers □ Yes (100/55) □ No (0)
104. Unscrews lids □ Yes (100/55) □ No (0)
Dressing:
105. Takes off T-shirt □ Yes (100/55) □ No (0)
106. Takes off underwear □ Yes (100/55) □ No (0)
107. Takes off shorts □ Yes (100/55) □ No (0)
108. Takes off pants □ Yes (100/55) □ No (0)
109. Opens zipper □ Yes (100/55) □ No (0)
110. Closes zipper □ Yes (100/55) □ No (0)
Sphincter control:
111. Controls bowel □ Yes (100/55) □ No (0)
112. Controls bladder □ Yes (100/55) □ No (0)
3 to 4 years
Feeding:
113. Transfers liquid from one container to another □ Yes (100/55) □ No (0)
114. Spreads butter/jam on bread/toast □ Yes (100/55) □ No (0)
115. Cuts food □ Yes (100/55) □ No (0)
116. Gets food from the refrigerator □ Yes (100/55) □ No (0)
Dressing:
117. Takes off open shirts □ Yes (100/55) □ No (0)
118. Puts on open shirts (short/long sleeves) □ Yes (100/55) □ No (0)
119. Puts on T-shirts (short/long sleeves) □ Yes (100/55) □ No (0)
120. Puts on underwear □ Yes (100/55) □ No (0)

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121. Puts on shorts □ Yes (100/55) □ No (0)
122. Puts on pants □ Yes (100/55) □ No (0)
123. Puts on socks □ Yes (100/55) □ No (0)
124. Fastens and unfastens buckle □ Yes (100/55) □ No (0)
125. Buttons /unbuttons □ Yes (100/55) □ No (0)
Hygiene:
126. Washes and dries hands □ Yes (100/55) □ No (0)
127. Puts toothpaste on toothbrush □ Yes (100/55) □ No (0)
128. Combs hair □ Yes (100/55) □ No (0)
129. Uses the toilet without help □ Yes (100/55) □ No (0)
130. Blows nose □ Yes (100/55) □ No (0)
131. Upper body hygiene □ Yes (100/55) □ No (0)
132. Upper-limb hygiene □ Yes (100/55) □ No (0)
133. Lower-limb hygiene □ Yes (100/55) □ No (0)
134. Rinses hair □ Yes (100/55) □ No (0)
Other abilities:
135. Opens/closes taps □ Yes (100/55) □ No (0)
136. Opens/closes doors □ Yes (100/55) □ No (0)
137. Turns lights on/off □ Yes (100/55) □ No (0)
138. Turns TV/radio on/off □ Yes (100/55) □ No (0)
4 to 5 years
Dressing:
139. Puts on shoes □ Yes (100/55) □ No (0)
Hygiene:
140. Brushes teeth □ Yes (100/55) □ No (0)
141. Washes face □ Yes (100/55) □ No (0)
5 to 6 years
Feeding:
142. Chooses and serves own food □ Yes (100/55) □ No (0)
Hygiene:
143. Washes private parts □ Yes (100/55) □ No (0)
Dressing:
144. Laces up own shoes □ Yes (100/55) □ No (0)
6 to 7 years
Dressing:
145. Ties and laces shoes □ Yes (100/55) □ No (0)
7 to 8 years
Dressing:
146. Chooses own clothes □ Yes (100/55) □ No (0)
147. Takes out clothes from drawers/closet □ Yes (100/55) □ No (0)
> 8 years
Hygiene:
148. Cuts own fingernails □ Yes (100/55) □ No (0)

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EXPECTED SCORE BY AGE GROUP
One cause of variation in the scores obtained on the Sarah scale is the range of
ages of the children and adolescents to whom it is applied. In order to
encompass the effect of age on the score, five developmental pediatricians who
were members of the Sarah network’s rehabilitation team (with three to 20
years’ experience in pediatric service) independently assessed the scale items
and then established a consensus as to the minimum age at which a child or
adolescent without any functional or motor impairment could attain the top score
for each item of the scale. Based on these evaluations, an “expected” score for
each age group was established for each domain of the scale. Comparison of
the actual with the expected score allows analysis of the proportional degree of
deviation from the age group.
Table 1 shows the details of the expected score for each age group for each
domain and dimension of the scale. For example, a child aged between 3 and 4
years with no motor or functional disability is expected to achieve scores of
approximately 100 points for the domains of “motor acquisition” and “gross
motor skills,” a score of approximately 84 for the “locomotion” domain, a score
of approximately 77 for the “upper limb function” domain, total scores of
approximately 90 points for the motor dimension and 62 points for the functional
dimension (the latter of which is equivalent to the “activities of daily living”
domain), and an overall motor/functional score of approximately 76 points.
Table 1 – Expected Sarah scale scores for age groupa.
Age group
Domain Dimension General
(Motor/
Functional)
Motor
acquisition
Locomotion
gains
Gross motor
skills
Upper limb
function Motor Functional
<6 months 26.1 0.0 0.0 30.0 14.0 0.0 7.0
6 months – 1 yr 78.3 11.0 0.0 60.0 37.3 3.6 20.5
1–2 years 100.0 72.0 66.7 70.0 77.2 12.7 44.9
2–3 years 100.0 81.7 100.0 73.3 88.8 34.5 61.6
3–4 years 100.0 84.0 100.0 76.7 90.2 61.8 76.0
4–5 years 100.0 100.0 100.0 90.0 97.5 78.2 87.8
5–6 years 100.0 100.0 100.0 96.7 99.2 89.1 94.1
6–7 years 100.0 100.0 100.0 100.0 100.0 98.2 99.1
7–8 years 100.0 100.0 100.0 100.0 100.0 98.2 99.1
>8 years 100.0 100.0 100.0 100.0 100.0 100.0 100.0
(a) Expected scores for age group for children without any functional or motor impairment, established by
developmental pediatricians associated with the Sarah Network of Rehabilitation Hospitals.

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FOUR-LEVEL CONVERSION
The Sarah scale covers a wide range of domains, from motor skills and
locomotion to gross motor skills, upper limb function, and activities of daily living.
The raw scores of the Sarah scale domains range from 0 to 100 points. In order
to validate the specific domains of the scale and with the aim of creating an
option to reduce the score range for each domain from 100 points to a four-level
classification (which can sometimes be more practical for clinical or scientific
use), Sarah's professional team was consulted again. The members of the team
of physical therapists, occupational therapists, and developmental pediatricians
(with three to 22 years’ experience in the treatment of patients with CP) were
asked to assess, independently, each of the 76 children and adolescents who
participated in the study for scale’s validation, in each one of the scale domains
using a four-level classification. In performing the four-level classification, the
professionals were asked to observe, for each domain, the following criteria:
• no relevant impairment: performs 100% of tasks expected for age, exercises
skills and performs tasks without help from others, within a reasonable time,
with full functional performance, and without any safety concerns;
• mild impairment: performs most tasks (above 70% of those expected for
age), exercises skills and performs tasks without help, but may require
supervision from others, and/or requires more than a reasonable amount of
time, and/or has partial functional performance, and/or elicits safety
concerns;
• moderate impairment: partially performs tasks (30–70% of those expected
for age), only partially possesses the skill(s) and/or partially performs the
movement(s), needs help from others;
• severe impairment: does not perform the tasks (performs below 30% of
those expected for age), does not possess the skill(s) and/or does not
perform the expected movement(s), needs help from others.
The tasks and aspects to be considered for the classification of each domain
are as follows: “motor acquisition” comprises head balance, rolling, creeping,
trunk balance, four-point position balance, crawling, kneeling balance, standing
point balance, and displacement standing up; “locomotion comprises functional
capacity in the most frequent form of locomotion, use of assistive devices for
mobility, and dexterity in the use of any assistive device; “gross motor skills”
comprise kicking a ball, climbing stairs, running, jumping, and spinning around
the body axis; “upper limb function” comprises reaching for objects, using the
limbs for support, voluntarily performing prehension, pincer grasping,
transferring objects from one hand to the other, performing adjustment of
objects, inserting sheets into an envelope, writing letters, and drawing
recognizable forms; “activities of daily living” comprise feeding, dressing, toilet
training, and hygiene.
The four-level classification for each individual was determined according to the
consensus of the evaluation team. These results were used to establish a
conversion from the Sarah scale score to a four-level classification.

35
Table 2 shows the limits for converting the Sarah scale (in terms of the
deviation of the raw score from the expected score for age group) into a four-
level classification. The limits were chosen on the basis of analysis of the 76
evaluations; adjustments were made as needed to improve the concordance
between the converted Sarah scale four-level classification and the four-level
classification performed by the rehabilitation professionals.
Table 2 also shows the exact proportion of agreement between the converted
Sarah scale four-level classification and the examiners’ classification, as well as
the quadratic weighted Kappa coefficient between the two classifications, for
each domain. The exact proportion of agreement between the Sarah scale and
the examiners’ classification ranged from 63% to 87% and the quadratic
weighted Kappa coefficient from 0.84 to 0.95.
Table 2 – Conversion of the Sarah scale (in terms of the deviation of the continuous
score from the expected score for age group) into a four-level classification and
comparison of the converted scale with the four-level classification performed by staff
members of the Sarah Network of Hospitals.
Deviation from expected score Four-level conversion
Value greater than -1% 0 – No relevant impairment
Value less than or equal to -1% down to -20% 1 – Mild impairment
Value less than or equal to -20% down to -70% 2 – Moderate impairment
Value less than or equal to -70% 3 – Severe impairment
Sarah scale (n = 76)
Proportion of agreementa Kappab (CI)
Motor dimension 75% 0.91 (0.87; 0.95)
Motor acquisition 83% 0.95 (0.92; 0.98)
Locomotion 76% 0.92 (0.88; 0.96)
Gross motor skills 76% 0.90 (0.86; 0.95)
Upper limb function 63% 0.84 (0.78; 0.90)
Functional dimension 80% 0.88 (0.81; 0.95)
Overall motor/functional 87% 0.92 (0.88; 0.97)
CI – 95% confidence interval; n – number of participants.
(a) Exact concordance between “the Sarah scale converted to a four-level classification” and “the four-
level classification performed by the Sarah network staff”.
(b) Quadratic weighted Kappa coefficient.