B P O M: Rachial Lexus Utcome Easure

BRACHIAL
PLEXUS
OUTCOME
MEASURE
Copyright BPOM v2.0 © 2007, 2013 Emily S. Ho, BSc, OT, MEd, OT. Reg. (Ont.) Page 1 of 14
The Hospital for Sick Children, Toronto, Canada
BRACHIAL PLEXUS OUTCOME MEASURE
INTRODUCTION
The Brachial Plexus Outcome Measure (BPOM) is a disease specific functional evaluation for
school-aged children with obstetrical brachial plexus palsy. It has two components: Activity
Scale and Self-evaluation Scale. The BPOM Activity scale evaluates the key functional
movement patterns that are deficient in the affected limb of a child with obstetrical brachial
plexus palsy (OBPP). The child’s performance on these items is graded using a 5-point ordinal
scale according to the ability to complete the task, and the quality of movement pattern
executed. The BPOM Self-evaluation scale consists of 3 (100 mm) visual analog scales to
evaluate the perceived function of the arm and hand and the cosmetic appearance of the limb.
The BPOM was developed to provide information to assist with decision making regarding:
a) Secondary reconstructive procedures
b) Remedial rehabilitation interventions and,
c) Recommendations for adaptations and accommodations for daily living
The BPOM was developed on the theoretical framework of the World Health Organization,
International classification of function, disability and health (ICF).1 The BPOM is classified
within the ICF Activity and Participation domains of functioning. The BPOM measures function
in relation to the activity limitations resulting from the physical sequela of nerve injury to the
brachial plexus at birth.
The purpose of the BPOM Activity Scale is to measure the capacity of the affected limb.
The ICF defines ‘capacity’, as the individual’s ability to execute a task or action at their
maximal potential. In contrast, ‘performance’ is defined as what the individual actually does
within their respective environments.1
The BPOM self-evaluation scale is a screening tool to measure how a child’s perception of
their upper extremity function and appearance hinders or enhances his/her’s participation
in daily activities.
The BPOM is a discrimative outcome measure. It was developed by a team of experts and
has demonstrated good construct validity and internal consistency.2 Further studies are being
conducted to evaluate reliability and concurrent validity of the BPOM. In 2013, the BPOM was
revised to clarify the instructions and materials used to administer the test. The test items were
not changed in any format from the original BPOM. The titles and descriptors of some items
were edited to create a more uniform use of language.
MATERIALS
You will require the following materials to administer the BPOM Activity and Self-evaluation
Scales.
BPOM FORMS
! BPOM Activity Scale – General Guidelines for Scoring Page 9

! BPOM Activity Scale – Specific Guidelines for Scoring Page 10
! BPOM Assessment and Score Sheet Page 14
BPOM ACTIVITY SCALE ASSESSMENT TOYS
Standard Comb *5” Circular Container with Lid **Button/Snap Belt

Used for BPOM Activity Item: Used for BPOM Activity Items: Used for BPOM Activity Item:
Combs Back of Head Places Container Above Head Undo Button at Midline
Opens Large Container
Holds Plate with Palm Up
Computer Mouse ½” Round Beads with Holes Drum Sticks

Used for BPOM Activity Item: Used for BPOM Activity Items: Used for BPOM Activity Item:
Uses Computer Mouse Pretends to Eat Candy Plays the Drums
Strings Bead
* It is essential that the lid loosely fits
on the container and should not screw
on or require strength to remove
**The child’s pant button or snap is

typically used for this item. If not
available, a custom made adjustable
cumberband with a button and snap
sewn at midline is used. Contact us for
Theraputty (Soft/Medium soft) Shoelace instructions: [email protected]
Used for BPOM Activity Item: Used for BPOM Activity Item:
Pulls Apart Theraputty Strings Bead
ADMINISTRATION GUIDELINES
BPOM ACTIVITY SCALE

The BPOM Activity Scale is validated for children greater than 4 years of age with no
significant cognitive or developmental delays.
Organize the assessment materials in a bag for ease of access and administration. Store the
shoelace and beads in the large container. Use the following instructions as a guide. However,
the use of play and playfulness is essential when assessing children.
The purpose of the BPOM activity scale is to evaluate the capacity of the child’s affected limb.
The unilateral items are presented to the affected limb only. This is to observe the maximum
ability and quality of movement of this limb. The bilateral items are designed to evaluate the
quality of the movement of the affected limb as an assisting hand.
The following sequence of presenting the BPOM Activity Items is preferred for ease of
administration.
BPOM Activity Item Instructions
1 Combs Back of Head Place the comb in the child’s

- Uses affected hand to affected hand and ask them to
reach the back of head to comb the back of their head.
comb hair
2 Pulls Apart Theraputty Ask the child to pull apart the

- Uses power grasp to pull theraputty with both hands in
apart theraputty with active front of them. Cue the child to
wrist extension with both keep the theraputty in front of
hands their body.
3 Opens Large Container Ask the child to open the large

- Uses both hands to open container by removing the lid.
5” diameter container with The child should use the
snap on lid; abducts thumb affected hand to stabilize the
with affected hand container. Observe carefully if
the child abducts the thumb.
4 Holds Plate with Palm Up Once the container is opened,

- Holds plate with affected ask the child to pretend the lid
hand palm up is a plate. Ask the child to
hold the plate using their
affected hand with palm up.
5 Pretends to Eat Candy Ask the child to hold the plate

- Hold plate with with their unaffected hand.
unaffected hand, pick up Put the bead on the plate.
bead with affected hand Ask the child to pretend the
from plate and bring it up bead is a candy, and pick up
to mouth the bead with their affected
hand and pretend to eat it.
6 Strings Bead Ask the child to string one

- Uses both hands to string bead on the shoelace. The
bead; uses precision grasp child can use their unaffected
(pinch) with affected hand hand to string or place the
bead on the shoelace.
Carefully observe the child’s
pattern of pinch.
7 Plays Drums Place the container with lid

- Hits drumsticks on closed in front of the child.
container with both hands Give the child the drumsticks
and ask them to play the
drums on the container.
8 Places Container Above Pick up the container and ask

Head the child to hold the container
- Uses both hands to reach with both hands. Put your
forward to place a hand in front of the child,
container directly above palms up, at the height of the
their head child’s head. Ask the child to
keep both hands on the
container and place it on your
hand.
9 Uses Computer Mouse Place the computer mouse

- Uses affected hand on a desk in front of the
with isolated finger child’s affected hand. Ask the
flexion to click on mouse child to click on the computer
mouse with their affected
hand.
10 Undo Button at Midline Ask the child to stand up and

- Undo button or snap at undo the button or snap on
navel level with both their pants or shirt at navel
hands level. If the child is not
wearing any buttons, use the
custom made button belt.
11 Hand to Back Pant Ask the child to place their

Pocket affected hand into the back
- Puts affected fingers pocket of their pants.
into ipsilateral back pant
pocket
ADMINISTRATION GUIDELINES
BPOM SELF-EVALUATION SCALE
The BPOM Self-evaluation Scale is validated for children greater than 7 years of age with no
significant cognitive, developmental or learning delays. Each VAS line is 100 mm in length.
Prior to administering the BPOM Self-evaluation scale, it is important to tell the child that their
thoughts and feelings about their affected limb is a very important aspect of their medical care.
The BPOM Self-evaluation scale may be administered prior to the BPOM Activity Scale to
reinforce to the child and family that the child’s perspective is greatly valued.
First, show the child the BPOM Self-evaluation Scale. Use the following instructions as a
guide. However, tailor the language and instructions as required to facilitate the child’s
understanding of the visual analog scale.
Self-Evaluation Arm Function
My arm works . . .
" #
Very POORLY Very WELL
Say to the child, “I would like to know how well you think your arm works.” Point to the child’s
arm from the shoulder down to the hand to illustrate the whole limb.
Next, instruct the child: “Can you draw a mark on this line to tell me how you feel? If you mark
the line closer to the sad face, then you think your arm works very poorly. If you mark the line
closer to the happy face, then you think your arm works well. If you mark the line in the middle,
then you think that your arm works neither poor or well.”
“Where would you mark the line to show how well your arm works?”
Self-Evaluation Hand Function

My hand works . . .
" #
Say to the child, “I would like to know how well you think your hand works.” Point to the child’s
hand.
Next instruct the child: “Can you draw a mark on this line to tell me how you feel? If you mark
the line closer to the sad face, then you think your hand works very poorly. If you mark the line
closer to the happy face, then you think your hand works well. If you mark the line in the
middle, then you think that your hand works neither poor or well.”
“Where would you mark the line to show how well your hand works?”
Self-Evaluation Appearance
My arm and hand looks . . .
" #
Very BAD Very GOOD
Say to the child, “I would like to know what you think about the look of your arm and hand.”
Point to the child’s arm from the shoulder down to the hand to illustrate the whole limb.
Next, instruct the child: “Can you draw a mark on this line to tell me how you feel? If you mark
the line closer to the sad face, then you think your arm and hand looks very bad. If you mark
the line closer to the happy face, then you think your arm and hand looks very good. If you
mark the line in the middle, then you think that your arm and hand looks neither bad or good.”
“Where would you mark the line to show how what you think about the look of your arm and
hand?”
BPOM ACTIVITY SCALE
GENERAL GUIDELINES FOR SCORING

This scale was defined by: 1) the ability to complete the task and, 2) the quality and degree of
compensatory movements observed in the affected upper extremity during the task. The
Functional Movement Scale is an ordinal scale from 1 to 5. A lower score represents a greater
activity limitation. A child who cannot complete the BPOM Activity item is given a score of 1. A
child who scores 1 or 2 does not have functional movement in their affected limb.
A score of 3 on this scale is defined as functional movement in the affected upper extremity.
The child is able to complete the BPOM task at this level. However, the quality of movement in
the affected limb is still significantly impaired. In developing the scale, there was a specific
challenge of defining the difference between minor and major compensatory movements that
are observed between grades 3 and 4 in the scale. Absent or insufficient (defined as < ½ range
of AROM gravity eliminated) active movement in a primary mover(s) as defined in the
development of the tool was used to distinguish the quality of movement used to complete the
task. A child who scores a 3, may use passive range of motion in one or more joints of the
affected limb to complete the task. A child who scores 3 is functional, but may still require
surgical or non-surgical intervention to optimize the quality of the movement in the affected limb.
A child who completes the task with sufficient quality of movement scores a 4. At this level only
minor compensations are used to complete the task. A score of 5 is graded as movement that is
symmetrical to the unaffected side.
BPOM ACTIVITY SCALE: FUNCTIONAL MOVEMENT SCORE
General Guidelines
1 Cannot complete task
• Child is unable to complete task

• Ability to complete task may be impaired due to development or behavioural
factors
2 Completes task using only unaffected arm
• Child only uses unaffected arm to complete task
3 Completes task
Absent active movement in primary mover(s).
May use passive range of motion to complete movement pattern
• Quality of functional movement of whole limb is greatly impaired

• Child completes task using significant compensatory movements with the
affected arm
• May use passive range of motion to complete movement pattern when active
range of motion is absent or insufficient (defined as < ½ range of AROM gravity
eliminated; i.e. AMS score < 3) in one or more primary mover(s)
• May use unaffected arm to move affected arm to complete the task due to
absent or insufficient range of motion in one or more primary mover(s)
• Absent or insufficient shoulder external rotation defined by the presence of a
trumpet sign of greater than 90° shoulder abduction
4 Completes task
Initiates all movements actively
Compensatory techniques used to complete movement pattern
• Child completes the task, but uses minor compensatory movements

• Joint movements are initiated actively (> ½ range of AROM gravity eliminated),
but end range of motion may be completed passively using compensatory
movements; or position of primary mover(s) is sufficient for function (i.e. forearm
pronation and supination activity items)
• Quality of functional movement of entire upper limb is not symmetrical as
unaffected arm
5 Completes task
Completes movement pattern
• Child completes task

• Quality of functional movement of entire upper limb is symmetrical as unaffected
arm
BPOM ACTIVITY SCALE
SPECIFIC GUIDELINES FOR SCORING
Activity
Primary Mover(s)
SHOULDER 1 2 3 4 5
Combs Back of Head Unable to perform Uses unaffected Uses unaffected Actively brings Actively brings
task due to arm and hand hand to place hand to the level hand to back of
Shoulder External developmental only due to pain affected hand on of the ear using head using
Rotation age, behaviour or or restricted the back of the shoulder external shoulder
caregiver passive range of head to comb hair rotation, but may abduction,
dependence. motion in shoulder or uses use compensatory external rotation
abduction, table/body/back movements such with head in
external rotation extension and as the use of the neutral;
and/or poor hand momentum in fingers to (“climb”) symmetrical to
function on the affected limb to position the hand unaffected side.
affected side. comb back of at the back of
head due to head, trunk side
absent or flexion, swinging
insufficient (AMS affected arm with
< 3) active momentum, back
shoulder external extension and/or
rotation. neck flexion to
comb back of
head to complete
the movement.
Places Container Unable to perform Uses unaffected Unable to Actively maintains Actively maintains
Above Head task due to arm and hand maintain contact both hands on both hands on
developmental only to complete with container container and container and
Shoulder Flexion age, behaviour or task due to pain with affected hand places it using places it using full
Elbow Extension caregiver or restricted through out the active shoulder shoulder flexion;
dependence passive range of activity due to flexion on the elbow flexion;
motion in shoulder absent or affected side, but symmetrical to
flexion or due to insufficient (AMS may use unaffected side,
poor hand < 3) active compensatory including shoulder
function on the shoulder flexion. movements such external rotation.
affected side; may May use as back
try to use unaffected limb or extension; elbow
unaffected hand table to support flexion may be
to support affected limb to more pronounced
container, but get to end range compared to
unable to shoulder flexion to unaffected side.
complete place container.
movement pattern
with affected arm.
Undo Button at Unable to perform Uses unaffected Wrist flexed, and Actively brings Actively brings
Midline task due to arm and hand is only able to hand to midline hand to midline
developmental only due to pain complete task by using shoulder using shoulder
Shoulder Internal age, behaviour or or restricted using unaffected internal rotation. internal rotation;
Rotation caregiver passive range of limb to pull May use symmetrical to
dependence motion in shoulder clothing towards compensatory unaffected side.
internal rotation or affected hand or movements such
poor hand uses object/table/ as wrist flexion on
function on the unaffected hand the affected side
affected side. to push affected to assist.
hand toward navel
to complete task
due to absent or
insufficient (AMS
< 3) active
shoulder internal
rotation.
Activity
Primary Mover(s)
SHOULDER 1 2 3 4 5
Hand to Back Pant Unable to perform Uses unaffected Unable to reach Actively brings Actively brings
Pocket task due to arm and hand ipsilateral side affected hand to affected hand to
developmental only due to beyond trunk ipsilateral ipsilateral back
Shoulder Internal age, behaviour or restricted passive midpoint; may use waistline at or pocket;
Rotation caregiver range of motion in swinging and past trunk symmetrical to
dependence shoulder internal momentum or the midpoint, but may unaffected side.
rotation or poor unaffected limb to use compensatory
hand function on position affected movements such
the affected side. limb to reach the as using
ipsilateral back (“climbing”) the
pocket due to fingers to position
absent or hand towards the
insufficient (AMS back pocket.
< 3) active
shoulder internal
rotation.
ELBOW & FOREARM 1 2 3 4 5
Pretends to Eat Candy Unable to perform Uses unaffected Trumpet sign Trumpet sign Actively brings
task due to arm and hand >90°; or trumpet <90°, active elbow hand to mouth
Elbow Flexion developmental only due to pain sign <90° and flexion, forearm using elbow
Shoulder External age, behaviour or or restricted absent or neutral/ supination flexion with
Rotation caregiver passive range of insufficient (AMS but may use mild forearm neutral/
dependence. motion in shoulder < 3) active compensatory supinated, wrist
external rotation shoulder external movements such extended, neck
and/or elbow rotation and/or as neck flexion, neutral;
flexion or poor elbow flexion to trunk flexion and symmetrical with
hand function on reach mouth; may adaptive wrist and unaffected side
affected side. require object/ finger positions.
table or
unaffected hand
to move affected
hand passively to
complete task.
Uses Computer Mouse Unable to perform Uses unaffected Trumpet sign Trumpet sign Actively brings
task due to arm and hand >90°; or trumpet <90°, elbow forearm into 45-
Forearm Pronation developmental only due to pain sign < 90° and flexed, forearm 90° pronation with
Finger Flexion (isolated) age, behaviour or or restricted absent or actively pronates active individual
Finger Extension caregiver passive range of insufficient (AMS or position of finger movement;
dependence. motion in shoulder < 3) active forearm is fixed symmetrical with
external rotation pronation; may between neutral unaffected side.
or forearm use unaffected to 90° pronation;
pronation to hand or active wrist flexed or
position arm or wrist flexion of the extended; active
poor hand affected side to individual finger
function on passively move movement on
affected side. fingers to press affected side.
mouse due to
absent or
insufficient (AMS
< 3) active finger
flexion and
extension.
Activity
Primary Mover(s)
Plays Drums Unable to perform Uses unaffected Trumpet sign >90° Trumpet sign Actively pronates
task due to arm and hand to position <90°, elbow forearm to neutral
Forearm Pronation developmental only due to pain or forearm in neutral; flexed, forearm or greater,
Finger Flexion age, behaviour or restricted passive if forearm fixed in neutral or slightly extends wrist and
caregiver range of motion in >60° supination – pronated; uses uses good finger/
dependence. shoulder external may use adapted transpalmar or thumb grasp;
rotation or forearm (i.e. interdigital) radial digital grasp symmetrical with
pronation or poor grip on drumstick to complete task; unaffected side.
hand function on to complete task may use
affected side. with absent or compensatory
insufficient (AMS patterns for wrist
< 3) active and shoulder on
forearm pronation affected side.
and finger flexion.
Holds Plate with Unable to perform Uses unaffected Absent or Actively supinates Actively supinates
Palm up task due to arm and hand insufficient (AMS forearm to neutral forearm to end
developmental only due pain or < 3) active or beyond; or range and holds
Forearm Supination age, behaviour or restricted supination; or position of the plate with
caregiver supination or poor forearm fixed at > forearm is fixed palm up and
dependence. hand function on 60° pronation – between neutral to fingers extended;
affected side. may use adapted 90° of supination; symmetrical with
grip with forearm may hold the plate unaffected side.
in pronated with radial digital
position to hold grasp or palm ups
plate with affected with fingers
hand. extended;
may use
compensatory
patterns for
deficits in
shoulder, elbow,
and wrist on the
affected side.
WRIST, FINGER AND 1 2 3 4 5

THUMB
Opens large container Unable to perform Uses unaffected Wedges container Actively extends Actively extends
task due to arm and hand into affected hand thumb and wrist, fingers and
Thumb Extension developmental only due to pain or to passively fingers, but may thumb to encircle
(Abduction) age, behaviour or poor hand extend thumb and use passive container or lid;
Finger Extension caregiver function on fingers due to movement at end symmetrical with
dependence. affected side. absent or range to get unaffected side.
insufficient (AMS thumb and finger
< 3) active thumb around object;
or finger extension may use
or uses unaffected compensatory
hand or patterns for
body/table to help deficits in
hand around shoulder, elbow,
container. forearm, wrist and
finger joints on the
affected side.
Activity
Primary Mover(s)
Pulls Theraputty Unable to perform Uses unaffected Absent or Actively extends Actively extends
task due to arm and hand insufficient (AMS wrist or wrist fixed wrist, fingers and
Finger Flexion developmental only due to pain or < 3) active in extension; wrist thumb with
(Power Grasp) age, behaviour or poor hand extension of wrist, may fall into opposition to use
Wrist Extension caregiver function; or uses may use flexion after transpalmar
dependence other body part table/body or the activation of grasp;
(i.e.: shoulder direction of pull to power grasp; may symmetrical with
adduction or legs) hold wrist in wedge putty into unaffected side.
to stabilize putty extension to pull hand to
and pull with theraputty; compensate for
unaffected hand. may use deficits in fingers
compensatory and thumb
movements for extension; may
deficits in fingers use compensatory
and thumb on the patterns for
affected side. deficits in
shoulder, elbow
and forearm on
affected side.
Strings Beads Unable to perform Uses unaffected Absent or Actively extends Actively extends
task due to arm and hand insufficient (AMS thumb and wrist and thumb
Thumb Flexion developmental only due to pain or < 3) active thumb sustains lateral and sustains
(Adduction) age, behaviour or poor hand flexion and/or pinch or pincer lateral pinch or
Thumb Extension caregiver function; may extension on grasp on string or pincer grasp on
dependence bead on the table affected side; may bead; may use bead or string;
or on lap to string wedge the string compensatory symmetrical with
with unaffected or bead inbetween patterns for unaffected side
hand only. the thumb and deficits in
index finger or shoulder, elbow,
palm; may use an forearm, wrist and
interdigital or finger joints on the
transpalmar affected side.
grasp; may use
fisted or flaccid
affected hand or
arm to stabilize
string or bead
against table
REFERENCES
1. World Health Organization. International classification of functioning, disability, and

health (ICF). Geneva: World Health Organization; 2001.
2. Ho ES, Curtis CG, Clarke HM. The brachial plexus outcome measure: development,
internal consistency, and construct validity. J Hand Ther. Oct 2012;25(4):406-417.
BRACHIAL PLEXUS OUTCOME MEASURE
ACTIVITY SCALE Functional

SHOULDER Movement FUNCTIONAL MOVEMENT SCALE
Score
Combs Back of Head
- Uses affected hand to reach the back of head to 1. Cannot complete task
comb hair
Places Container Above Head
- Uses both hands to reach forward to place a 2. Completes task using only unaffected arm
container directly above their head
Undo Button at Midline 3. Completes task
- Undo button or snap at navel level with both hands Absent active movement in primary mover(s).
May use passive range of motion to complete
Hand to Back Pant Pocket movement pattern
- Puts affected fingers into ipsilateral back pant
pocket 4. Completes task
Initiates all movement actively or position of
ELBOW AND FOREARM
primary mover(s) is sufficient for function.
Pretends to Eat Candy Compensatory techniques used to complete
- Hold plate with unaffected hand, pick up bead with
movement pattern
affected hand from plate and bring it up to mouth
Uses Computer Mouse
- Uses affected hand with isolated finger flexion to 5. Completes task with normal movement
click on mouse pattern
Plays Drums
- Hits drumsticks on container with both hands
Holds Plate with Palm Up

- Holds plate with affected hand palm up
WRIST, FINGER, AND THUMB

Opens Large Container
- Uses both hands to open 5” diameter container
with snap on lid; abducts thumb with affected hand
Pulls Apart Theraputty
- Uses power grasp to pull apart theraputty with
active wrist extension with both hands
Strings Bead
- Uses both hands to string bead; uses precision
grasp (pinch) with affected hand
SELF-EVALUATION SCALE
My arm works . . .
" #
My hand works . . .
" #
My arm and hand looks . . .
" #
Very BAD Very GOOD

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BRACHIAL

! BPOM Activity Scale – General Guidelines for Scoring Page 9

BPOM ACTIVITY SCALE ASSESSMENT TOYS

Standard Comb *5” Circular Container with Lid **Button/Snap Belt

Computer Mouse ½” Round Beads with Holes Drum Sticks

**The child’s pant button or snap is

BPOM ACTIVITY SCALE

BPOM Activity Item Instructions

1 Combs Back of Head Place the comb in the child’s

2 Pulls Apart Theraputty Ask the child to pull apart the

3 Opens Large Container Ask the child to open the large

4 Holds Plate with Palm Up Once the container is opened,

5 Pretends to Eat Candy Ask the child to hold the plate

6 Strings Bead Ask the child to string one

7 Plays Drums Place the container with lid

8 Places Container Above Pick up the container and ask

9 Uses Computer Mouse Place the computer mouse

10 Undo Button at Midline Ask the child to stand up and

11 Hand to Back Pant Ask the child to place their

BPOM SELF-EVALUATION SCALE

Self-Evaluation Arm Function

Self-Evaluation Hand Function

BPOM ACTIVITY SCALE

GENERAL GUIDELINES FOR SCORING

1 Cannot complete task

• Child is unable to complete task

2 Completes task using only unaffected arm

• Child only uses unaffected arm to complete task

• Quality of functional movement of whole limb is greatly impaired

• Child completes the task, but uses minor compensatory movements

• Child completes task

SPECIFIC GUIDELINES FOR SCORING

ELBOW & FOREARM 1 2 3 4 5

ELBOW & FOREARM 1 2 3 4 5

WRIST, FINGER AND 1 2 3 4 5

ELBOW & FOREARM 1 2 3 4 5

1. World Health Organization. International classification of functioning, disability, and

ACTIVITY SCALE Functional

Holds Plate with Palm Up

WRIST, FINGER, AND THUMB

My arm and hand looks . . .

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