Zancolli Classification Research Articles

The effects of hand deformity on upper-limb function and health-related quality of life in children with spastic hemiplegic cerebral palsy

The aim of this study was to investigate the effect of hand deformity on upper-limb function and health-related quality of life (HRQOL) in children with hemiplegic cerebral palsy (CP). The study included 44 children with hemiplegic CP between the ages of 6 and 14 years (mean age, 10.04 years; SD, 3.1; 23 males, 21 females). The Manual Ability Classification System (MACS) and Gross Motor Function Classification System (GMFCS) were used, with the Zancolli classification to characterize hand deformities on the more affected side. Upper-limb function was assessed in terms of unilateral capacity (Quality of Upper Extremity Skills Test: QUEST) and bimanual performance (Children’s Hand-use Experience Questionnaire: CHEQ), while HRQOL was evaluated on the KIDSCREEN-27 questionnaire. Comparison of bimanual performance and unilateral capacity in children with Zancolli level 1 and 2a hemiplegic CP found statistically significant differences (p < 0.01). There was also a significant difference on the HRQOL ‘physical activities and health’ subdomain, in favor of Zancolli level I deformity (p = 0.003), but not on the other HRQOL domains (p > 0.05). Upper-limb function and the HRQOL physical health domain were poorer with greater hand deformity in children with hemiplegic CP.

The Dynamic Thumb-in-Palm Pattern in Children with Spastic Cerebral Palsy and Its Effects on Upper Limb Function.

The thumb-in-palm (TIP) pattern is one of the most common upper limb deformities in cerebral palsy (CP). This study was designed to investigate the effect of the dynamic TIP pattern on upper limb function in children with spastic CP. This prospective observational study included a total of 106 children with CP with dynamic TIP. The House TIP classification while grasping small or large objects, Melbourne Assessment of Unilateral Upper Limb Function (MUUL), Shriners Hospital Upper Extremity Evaluation (SHUEE), Zancolli classification for wrist–finger flexor deformity, and degree of swan neck deformity were assessed. Type I was the most common and highest functioning House TIP classification type. However, there were no significant differences in upper arm function between types II, III, and IV. The three components of the SHUEE showed stronger association with MUUL than House TIP and Zancolli classifications. After multivariable analysis, functional use of the wrist–finger and the thumb played a more significant role than the dynamic alignment of the thumb. In conclusion, the House TIP classification is useful to describe the TIP pattern. The SHUEE thumb assessment is a useful tool for reflecting upper arm function. The upper arm function was related more with the associated wrist flexor deformity than dynamic TIP.

P 107 – Do Kinesio-tape change upper extremity position, functional status and family satisfaction of children with Unilateral Cerebral Palsy in short term?

The aim of this study was to investigate if Kinesio-tape (KT) changed upper extremity position, functional status and family satisfaction of children with Unilateral Cerebral Palsy (CP) in short term. KT was used on affected upper extremities of 14 children with hemiplegic CP. Zancolli Classification, Manual Ability Classification System (MACS), Upper Limb Rating Scale (ULRS), Quality of Upper extremity skills test (QUEST), Box and Block Test (BBT) were applied for functional status before and after three days. Family satisfaction was assessed with ten-point numeric scale. There were significant differences in Zancolli Classification (p = 0.01), UPRS (p = 0.037) and OUEST dissociated movement sub-dimension (p=0.002) and family satisfaction (p = 0.001) after the KT application but there was no significant difference about performance. KT is a promising additional approach to increase upper extremity status and families were satisfied the images of upper extremity with KT.

Effects of a service dog on social participation of a C5 complete spinal cord injury patient: A case report

Patients with complete high cervical spinal cord injury have significantly restricted social participation even with the use of various prosthetic devices. We describe a patient with a C5 complete injury who showed remarkable improvements in social participation after obtaining a service dog. During March X-8, a 48-year-old man experienced a C5 complete spinal cord injury and underwent anterior cervical fusion. In January X-7, he underwent cystostomy. He discharged from the hospital in September with Zancolli classification: C5A and American Spinal Injury Association Classification: A. Since living with his service dog, he has been giving lectures about his experiences and opinions regarding physical disabilities and barrier-free-concepts at medical institutions and schools. In October X-2, he successfully flew from Ishikawa Prefecture to Tokyo with his service dog. He received the Ishikawa Prefectural Barrier-free Governor Prize. In July X, a semi-structured interview was conducted using the International Classification of Functioning, Disability, and Health (ICF) Rehabilitation Set. The interview and analysis were performed after obtaining written consent. The ethics committee of our institution permitted this study. There are no conflicts of interest. Using a service dog positively changed the man's health condition as defined by ICF. The following outcomes were observed: ability to take initiative and focus on actions, increased motivation, clearer planning for specific care needs, physical improvement, increased resilience, increased physical movements, emergence of new roles, better ability to resolve emotional conflict, improved autonomous health management, locomotion with a service dog, communication facilitation, acquisition of stress coping measures, living with consideration of other people, acquiring a job, employment, experiencing positive emotions, reduction of psychological barrier, increased social support and empathy due to visualization of disability, assistance from public service providers ( Fig. 1 ). Service dogs can encourage social participation, even for those with a complete high cervical spinal cord injury.

Flexion Deformities of the Wrist and Fingers in Spastic Cerebral Palsy: A Protocol of Management.

Background:Literature is confusing regarding grading and treatment of flexion deformities of wrist and fingers in spastic cerebral palsy (CP). The most established classification is that described by Zancolli; unfortunately, it has its shortcomings which we experienced in the beginning of our approach to manage this rather difficult deformity. We thus modified Zancolli's classification and developed a classification system and treatment protocol.Materials and Methods:Thirty patients with spastic CP were operated upon due to flexion deformity of the wrist and fingers and were included in this study. Age ranged from 4 to 14 years, average 7 years. There were twenty boys and ten girls.Results:The average followup was 18 months (range 9 months - 3 years). The power of wrist dorsiflexion, the “House's classification of upper extremity functional use” and the clinical assessment of hand function were used for evaluation; they improved in all patients and this improvement was statistically significant. In all patients, cosmetic appearance improved without any residual flexion deformity.Conclusion:This study introduces a new grading system for flexion deformity of wrist and fingers in spastic CP that correlates with severity of the condition and allows a treatment protocol to be established.

Effects of Neuromuscular Electrical Stimulation on the Wrist and Finger Flexor Spasticity and Hand Functions in Cerebral Palsy

PurposeTo evaluate the effects of neuromuscular electrical stimulation on wrist range of motion, wrist and finger flexor spasticity, and hand functions in patients with unilateral cerebral palsy. MethodTwenty-four children with unilateral spastic cerebral palsy (14 boys and 10 girls) between the ages of 5 and 14 years were randomized into neuromuscular electrical stimulation and control groups. Conventional exercises were applied, and static volar wrist-hand orthosis was administered to all patients 5 days a week for 6 weeks. Additionally, 30-minute neuromuscular electrical stimulation sessions were applied to the wrist extensor muscles in the neuromuscular electrical stimulation group. Patients were evaluated by Zancolli Classification System, Manual Ability Classification System, and Abilhand-Kids Test. ResultsCompared with baseline, a significant increase was evident in active wrist extension angle at the fourth and sixth weeks in both groups (all P < 0.001), more prominent in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.015 and P = 0.006, respectively). A decrease was observed in the spasticity values in the neuromuscular electrical stimulation group at the fourth and sixth weeks (P = 0.002 and P = 0.001, respectively) and in the control group only at the sixth week (P = 0.008). Abilhand-Kids values improved only in the neuromuscular electrical stimulation group (P < 0.001). ConclusionNeuromuscular electrical stimulation application in addition to conventional treatments is effective in improving active wrist range of motion, spasticity, and hand functions in cerebral palsy.

Bimanuality is improved by hand surgery in children with brain lesions

The present study was performed to investigate if, in a short term perspective, bimanual hand function in children with brain damage improves as an effect of hand surgery. Assisting Hand Assessment (AHA), Goal Achievement Scale, consolidated House Functional Classification, Zancolli Classification, and the active range of motion were measured before surgery and 5-14 months after surgery in 18 children, aged 6-16 years, mean of 11 years. AHA improved from 44.5 AHA units (range 20-66) to 52.5 AHA units (range 25-69) (P<0.005) on a 0-100 AHA unit scale. Active motion improved (P<0.005). Rating of selected goals improved from 2.6 to 6.4, on a 10-grade scale. On a short term, hand surgery improved not only the grip, but also the ability to use the hemiplegic hand in bimanual activities.

Effect of upper limb deformities on gross motor and upper limb functions in children with spastic cerebral palsy

The aims of this study were to investigate the nature and extent of upper limb deformities via the use of various classifications, and to analyze the relationship between upper limb deformities and gross motor or upper limb functionality levels. Upper extremity data were collected from 234 children with spastic cerebral palsy (CP) who were admitted to the university hospital for intensive rehabilitation. Upper limb deformities were classified according to the Zancolli classification for finger and wrist extension ability, the Gshwind and Tonkin classification for supination ability, and the House classification for thumb-in-palm deformity. Digital deformity was also classified. Upper limb function was assessed using the Upper Extremity Rating Scale (UERS) and the Upper Limb Physician's Rating Scale (ULPRS). Gross motor function was assessed using the Gross Motor Functional Classification System (GMFCS). Among the 234 children observed, 70.5% had a limitation in forearm supination, and 62.8% had problems with wrist and finger extension in at least one limb. Thumb-in-palm deformity of at least one hand was found in 47.0% of patients. Swan neck deformity was the most common finger deformity. Upper limb functional measures, the ULPRS and the UERS, significantly correlated with the degree of upper limb deformity, as assessed by the Gschwind and Tonkin, Zancolli, and House classifications. Further, the degree of upper limb deformity was significantly related to the GMFCS level in children with bilateral CP, but not in children with unilateral CP. Limitation of forearm supination was the most common upper limb deformity in children with spastic CP. The degree of upper limb deformity significantly affected upper limb function in these children.

Upper limb motor and sensory impairments in children with hemiplegic cerebral palsy. Can they be measured reliably?

Purpose. To establish interrater and test–retest reliability of a clinical assessment of motor and sensory upper limb impairments in children with hemiplegic cerebral palsy aged 5–15 years.Method. The assessments included passive range of motion (PROM), Modified Ashworth Scale (MAS), manual muscle testing (MMT), grip strength, the House thumb and Zancolli classification and sensory function. Interrater reliability was investigated in 30 children, test–retest reliability in 23 children.Results. For PROM, interrater reliability varied from moderate to moderately high (correlation coefficients 0.48–0.73) and test–retest reliability was very high (>0.81). For the MAS and MMT, total score and subscores for shoulder, elbow, and wrist showed a moderately high to very high interrater reliability (0.60–0.91) and coefficients of >0.78 for test–retest reliability. The reliability for the individual muscles varied from moderate to high. The Jamar dynamometer was found to be highly reliable. The House thumb classification showed a substantial reliability and the Zancolli classification an almost perfect reliability. All sensory modalities had a good agreement.Conclusions. For all motor and sensory assessments, interrater and test–retest reliability was moderate to very high. Test–retest reliability was clearly higher than interrater reliability. To improve interrater reliability, it was recommended to strictly standardize the test procedure, refine the scoring criteria and provide intensive rater trainings.

Surgical management of windblown hand: Results and literature review

Windblown hand is a congenital anomaly characterized by multiple hand deformities. The condition is extremely rare as shown by the paucity of cases reported in the literature. The deformities, which can result in a cosmetically unsatisfactory appearance and, if left untreated, maladaptive behavior, are progressive in nature. Consequently early treatment is necessary. We operated upon 23 hands in 18 patients (age range at surgery 6 months to 16 years) at a tertiary care center over a period of 7 years. The patients were followed for an average period of 7 years. The surgical approach was chosen based on the severity of the condition according to Zancolli and Zancolli's classification [Hand Clin 1:443-456 (1985)]. According to the criteria of Wood and Biondi [J Hand Surg 15A:431-438 (1990)], of the 23 hands operated upon, 17 had excellent cosmetic results, and 15 had excellent functional results. The results were better in patients undergoing early surgery-before the age of 2 years. Relapse of the deformity to a lesser extent than the original condition was seen in two hands at the last follow up. Definitive conclusions on this condition cannot be drawn due to limited experience in the surgical management of this rare condition. We believe that early surgical management is probably the best option available for the patient based on the results obtained. Early surgery and good post-operative compliance from patients can facilitate successful management of this rare condition with predictable results.

Hand Function in Cerebral Palsy. Report of 367 Children in a Population-Based Longitudinal Health Care Program

To describe aspects of hand function in a total population of children with cerebral palsy (CP). Upper extremity data were collected for 367 children who were born between 1992 and 2001 and were registered in a population-based health care program for children with CP. Hand function was classified according to the Manual Ability Classification System (MACS), the House functional classification, and the Zancolli classification. The type of spastic thumb-in-palm deformity was evaluated according to House. In the total population of children with CP aged 4 to 14 years, 60% had more than minor problems with hand function (>MACS I). Independence in age-relevant, daily manual activities (MACS I-II) was noted in 87% of children with spastic unilateral CP and in 63% of children with spastic bilateral CP, but in only 20% of children with dyskinetic CP. According to the House functional classification, both hands were spontaneously and independently used in 55% of children (House 7-8), whereas 5% did not use either of their hands (House 0). Minor increase of flexor muscle tone (Zancolli level 1) was found in 69% of all children. Only 2% were in level 3 in both hands. Spastic thumb-in-palm deformity in 1 hand was found in 25% and in both hands in another 15%. Limitations in hand function are common in all types of CP, but characteristics of the disability vary considerably between different CP subtypes. The MACS classification is useful to evaluate how well children can handle objects in daily activities. The House functional classification describes grip function in each hand separately; the Zancolli classification of finger and wrist extension and the classification of thumb-in-palm deformity according to House give an estimate of dynamic spasticity. All these classifications were shown to be useful in a population-based health care program, but further studies of the psychometric properties are required.

Comparison of the Effect of Neuromuscular Electrical Stimulation and Cryotherapy on Spasticity and Hand Function in Patients with Spastic Cerebral Palsy

Children with cerebral palsy (CP) often demonstrate poor hand function due to spasticity. Thus spasticity in the wrist and finger flexors poses a great deal of functional limitations. This study was therefore designed to compare the effectiveness of Cryotherapy and Neuromuscular Electrical Stimulation (NMES) on spasticity and hand function in patients with spastic CP. Thirty eight subjects aged 4 to 15 years with diagnosis of mild to moderate spastic CP participated in the study. Twenty of the subjects met the inclusion criteria of the study and were randomly assigned to two groups (A & B) with equal subjects number in each group. Group A were treated with cryotherapy and passive stretching and Group B, treated with NMES and passive stretching. The subjects were treated 3 times a week for 6 weeks. Spasticity and hand function were assessed pre-treatment and post-treatment using the Modified Ashworth Scale (MAS) and the Zancolli classification respectively. The results showed that 7 and 3 subjects in group A respectively and B had a significant reduction in spasticity respectively; while 7 and 8 subjects in group A and B respectively had a significant improvement in hand function. Cryotherapy and NMES were found to be effective and generally well tolerated by the patients. The study revealed that cryotherapy was not superior to NEMS and vice versa in the treatment of patients with spastic CP. Keywords: Spasticity, Cerebral Palsy, Neuromuscular stimulation, Cryotherapy. The Nigerian Medical Practitioner Vol. 51 (6) 2007: pp. 128-132

Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy

A prospective study was designed to determine whether the combined use of neuromuscular electrical stimulation (NMES) and dynamic bracing was more effective than use of either alone in reducing upper-extremity spasticity in children with spastic hemiplegic cerebral palsy. Twenty-four patients (12 males, 12 females; mean age 8y 7mo [SD 4y 2mo]; age range 3–18y) diagnosed with spastic hemiplegic CP were randomly allocated to three groups: group 1 had two 30-minute sessions of NMES a day applied on the antagonist extensors without bracing; group 2 had two 30-minute sessions of dynamic bracing per day; and group 3 had two 30-minute sessions of NMES and dynamic bracing every day. Treatment was continued for 6 months in all groups and applied only to the affected extremity. Patients were evaluated before therapy, at monthly intervals during the therapy, and 3 months after completion of the therapy. Three measures of outcome were taken: the Melbourne Assessment, grip strength, and posture evaluation with Zancolli's classification. The therapist performing the outcome assessments was blinded as to groups. Statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing. However, this significant effect lasted for only 2 months after discontinuation of the treatment. We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application.

Prevalencia de la disfunción de la mano en la parálisis cerebral tras la toxina botulínica

To examine the level of dependence, the functional class, the most frequent type of compromise and the proprioception of the hand in spastic cerebral palsy following the application of botulinum toxin, as well as to determine the sociodemographic characteristics of the individuals involved. We conducted a cross-sectional study of 21 spastic patients with extrinsic muscle involvement, of both sexes and a mean age of 15.4 +/- 5.6 years, who attended the neuro-rehabilitation outpatients department and were treated with botulinum toxin in the muscles responsible for the functional movements in the hand; they were evaluated after a mean period of 2.1 years. Patients were subjected to procedures such as a semi-structured interview, the FIM (Functional Independence Measurement) scale, Hausen's functional characterisation, Zancolli classification and a proprioception test. There was a predominance of females (57% of patients) and of a basic level of schooling. On the FIM scale, 38% of the patients presented modified independence, without help; 23.8% belonged to Hausen grade 3 (grasping and holding an object steady with the help of the other hand). On the Zancolli classification, 54% belonged to type III (the fingers can only be extended if the fist is bent more than 70 masculine); perception of movement is absent (76.2%) and the sense of position of the movement is altered (54.2%). Findings confirmed the existence of a high rate of modified independence, grade 3 (Hausen), together with type III involvement (Zancolli) and alterations affecting proprioception. Data from the study show the importance of occupational therapy as part of the care received by patients with cerebral palsy following the administration of botulinum toxin type A.

Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy

A prospective study was designed to determine whether the combined use of neuromuscular electrical stimulation (NMES) and dynamic bracing was more effective than use of either alone in reducing upper-extremity spasticity in children with spastic hemiplegic cerebral palsy. Twenty-four patients (12 males, 12 females; mean age 8y 7mo [SD 4y 2mo]; age range 3-18y) diagnosed with spastic hemiplegic CP were randomly allocated to three groups: group 1 had two 30-minute sessions of NMES a day applied on the antagonist extensors without bracing; group 2 had two 30-minute sessions of dynamic bracing per day; and group 3 had two 30-minute sessions of NMES and dynamic bracing every day. Treatment was continued for 6 months in all groups and applied only to the affected extremity. Patients were evaluated before therapy, at monthly intervals during the therapy, and 3 months after completion of the therapy. Three measures of outcome were taken: the Melbourne Assessment, grip strength, and posture evaluation with Zancolli's classification. The therapist performing the outcome assessments was blinded as to groups. Statistically significant differences were found in all three measures for only those treated with combined NMES and dynamic bracing. However, this significant effect lasted for only 2 months after discontinuation of the treatment. We conclude that the combined use of NMES and bracing is more effective than either alone but requires continuous application.

Electrostimulation at sensory level improves function of the upper extremities in children with cerebral palsy: a pilot study

The aim of this study was to evaluate the effect of electrical stimulation (ES) on the function of the upper extremities in children with cerebral palsy (CP). The participants were 12 children (seven females and five males) with spastic hemiplegia (mean age 5 years 7 months, SD 3 years 9 months). Indications were weak wrist dorsiflexion and elbow extension. The ES was given at sensory level (20–40 minutes) on the infraspinatus muscle and on the wrist dorsiflexors during 12 regularly scheduled physical and occupational therapy sessions (during 4–5 weeks). The Goal Attainment Scale, the Zancolli classification of hand function, muscle testing according to Daniels and Worthington, and King hypertonicity scale were used for evaluation. Assessments were made twice before (between 4 weeks) and twice after (between 12 weeks) the stimulation period except the King hypertonicity scale, which was used once before and 3 months after the stimulation period. Active elbow extension, wrist dorsiflexion, and forearm supination with the elbow flexed and extended improved when the results of assessments before ES were compared with those made immediately before (p &lt; 0.001) and three months after (p &lt; 0.01) this treatment. Results of this pilot uncontrolled study suggest that ES at sensory level can be used as an adjunct to physiotherapy and/or occupational therapy in children with spastic hemiplegia. These results will be used as basis for further research.

Car-driving abilities of people with tetraplegia

Kiyono Y, Hashizume C, Matsui N, Ohtsuka K, Takaoka K. Car-driving abilities of people with tetraplegia. Arch Phys Med Rehabil 2001;82:1389-92. Objectives: To examine the relationship between the spinal cord injury (SCI) level, age, and car-driving ability in people with tetraplegia and to explore the association between car-driving ability and social activity. Design: Retrospective clinical survey. Setting: Rehabilitation center in Japan. Patients: Sixty-two subjects with traumatic complete tetraplegia. Interventions: Driving evaluation; comprehensive driver's training (muscle strengthening, transfer training, adjustment of equipment, on-road training); and questionnaire (car-driving status, employment, participation in sports). Main Outcome Measures: The SCI level (Zancolli's classification), age, functional status of activities of daily living (ADLs), and driving ability were obtained from the medical records. Vocational status and engagement in sports activities were investigated by questionnaire. Results: The SCI level and age strongly influenced the patients' ability to drive a car independently. The highest neurologic level in which independent driving was achievable was C6A. Toilet transfer ability almost paralleled the ability to drive a car. Eighty-four percent of the people with tetraplegia who had a defined job could drive independently and 70% of the driving-independent individuals held a job. Half of driving-independent individuals participated in some sports activities. Conclusions: Toilet transfer ability is a reliable indicator for driver's training. Driving ability is an important factor that allows individuals with tetraplegia to participate in work and sports-related activities. © 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation.

NEUROMUSCULAR ELECTRICAL STIMULATION AND DYNAMIC BRACING AS A TREATMENT FOR UPPER-EXTREMITY SPASTICITY IN CHILDREN WITH CEREBRAL PALSY

We have investigated a therapeutic regimen using neuromuscular electrical stimulation (NMES) and dynamic bracing to assess their effectiveness in reducing upper-extremity spasticity in children with cerebral palsy. Nineteen patients between 4 and 21 years of age with documented diagnoses of spastic cerebral palsy were treated. The patients included in the study followed a regimen of two 30-minute sessions of NMES of the antagonist extensors combined with dynamic orthotic traction during the day. A static brace was used at night. Spasticity of the wrist and fingers was assessed periodically using the Zancolli classification. Treatment ranged from 3 to 43 months. After treatment with electrical stimulation and dynamic bracing, all the patients moved up 1 to 3 levels in the Zancolli classification and showed a marked improvement in upper-extremity function. These results show that combining NMES and dynamic orthotic traction dramatically decreases spasticity of the upper extremity in young patients with cerebral palsy.

Assessment of hand after brain damage with the aim of functional surgery

The semiology of the hand after brain damage is really rich. Its clinical evaluation remains quite difficult and must be integrated in the neuro-orthopedic and cognitive context. Deficiency, neuropsychological, analytic and functional status, must be assessed before any surgical decision aiming the improvement of prehension. Neuropsychological evaluation precise the hemispheric specialization: right hemisphere lesions conduct to unilateral spatial neglect while left hemispherical lesions determine language troubles and gesture impairment (apraxia). The analytical evaluation describes motor and sensitive function and assesses spasticity and pain. Concerning the functional assessment, the Enjalbert's score seems to be the most adapted to the upper limb. The assessment of hand deficiency and its origin is necessary to orientate the surgical decision and includes the Zancolli classification for the fingers and wrist and the House classification for the thumb. These classification used for cerebral palsy seems to be insufficient for all the different situations occurring after brain damage. A new classification is proposed based on 3 parameters: fingers extension, thumb abduction and supination. Surgical decision should be examined only after an adapted rehabilitation program.

Relationship between functional levels and movement in tetraplegic patients. A retrospective study

The aim of the present study was to set targets for each spinal lesion level after determining the relationship between the spinal lesion level and movement abilities in patients with tetraplegia following injury to the cervical cord. A total of 109 patients, 96 men and 13 women were included in the study. We mainly examined locomotion and transfer capabilities according to Zancolli's classification. The results of this study showed that 50% of the patients classified as C6A, 75% of C6B1 and 96% of the patients classified C6B2 accomplished bed transfer. The number of patients who could manage toilet transfer was 53% in the group classified as C6B1 and 85% in group C6B2. These results suggest that achievement of those classified as C6B2 is a clue to the assumption that the patient will achieve toilet transfer capability and can perform ADL independently.