ABILHAND

Evidence Reviewed as of before: 17-06-2012
Author(s)*: Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The ABILHAND is a semi-structured item-response questionnaire that measures manual ability according to an individual’s perceived difficulty performing daily bimanual tasks.

In-Depth Review

Purpose of the measure

The ABILHAND is an interview-based assessment tool that measures a patient’s perceived difficulty using his/her hands to perform manual activities in daily life. The ABILHAND assesses active function of the upper limbs. The tool measures an individual’s ability to perform bimanual tasks, regardless of strategies used to complete the task (Ashford et al., 2008; Penta et al., 1998)

Available versions

The ABILHAND was originally developed by Penta et al. (1998) as a 56-item, 4-level questionnaire of unimanual and bimanual ability for patients with rheumatoid arthritis. The original ABILHAND was intended to measure rehabilitation outcomes and to provide guidelines for goal setting in treatment planning (Gustafsson et al., 2004). Penta et al. (2001) found that patients with stroke were able to complete unimanual activities with the unaffected limb, regardless of hand dominance, whereas bimanual tasks were more difficult. Accordingly, a version was developed specifically for patients with stroke that only included bimanual items, as well as two alternate unimanual’ activities that require skillful use of the affected hand (cutting nails, filing nails). Penta et al. (2001) also reviewed the 4-level scoring criterion (impossible, very difficult, difficult, easy) and found that patients rarely used the very difficult’ score. This indicated that the two intermediate scoring criteria (very difficult, difficult) were not sufficiently differentially distinct. Accordingly, the stroke version of the ABILHAND was developed with a 3-level scoring criterion (impossible, any difficulty, easy).

Other impairment-specific versions were subsequently created with modified item sets and levels. Each version of the ABILHAND has its own Rasch-derived item difficulty calibrations that rely on computerized algorithms to obtain the patient’s overall measure from his/her responses (Simone et al., 2011).

Features of the measure

Items:

The ABILHAND is an inventory of 23 bimanual activities (from most difficulty to least difficult):

  1. Hammering a nail
  2. Threading a needle
  3. Peeling potatoes with a knife
  4. Cutting own nails
  5. Wrapping up gifts
  6. Filing own nails
  7. Cutting meat
  8. Peeling onions
  9. Shelling hazel nuts
  10. Opening a screw-topped jar
  11. Fastening zipper of jacket
  12. Tearing open pack of chips
  13. Buttoning up a shirt
  14. Sharpening a pencil
  15. Spreading butter on a slice of bread
  16. Fastening a snap
  17. Buttoning up trousers
  18. Taking the cap off a bottle
  19. Opening mail
  20. Squeezing toothpaste on a toothbrush
  21. Pulling up the zipper of trousers
  22. Unwrapping a chocolate bar
  23. Washing hands

Scoring:

The patient is asked to rate his/her perceived difficulty performing items without help, according to the following scoring criteria:

  • 0 = impossible
  • 1 = difficult
  • 2 = easy

Tasks that the patient has not performed in the past 3 months are not scored and are encoded as missing responses.

The ABILHAND was developed using the Rasch measurement model, which provides a method to convert the ordinal raw score into a linear measure on a unidimensional scale. Item scores are entered into the WINSTEPS computer program, and raw ordinal data is converted to linear measures expressed in logits (log-odds probability units). The total score is scaled along a unidimensional continuum with 0 at the centre of the scale, whereby the higher the logit number, the greater the patient’s perceived ability (Gustafsson et al., 2004).

What to consider before beginning:

Users should note that self-estimated measures (i.e. when scores are not based on clinician observation of performance) are subject to overestimation or underestimation of actual performance, depending on motivation and cognitive skills (Penta et al. 2001).

Clinicians should consider patient factors such as self-esteem, insight, vision, hearing, language and cognitive function prior to administering the ABILHAND (Gustafsson et al., 2004).

Mpofu & Oakland (2010) advise caution when using the ABILHAND to measure improvements in impairment of the affected upper limb after stroke rehabilitation. The ABILHAND does not take into consideration the arm used to perform a task or compensatory strategies employed to complete the task. Accordingly, improvement in scores may be based on use of compensatory strategies rather than on improvement in the affected arm.

Time:

The ABILHAND takes 10 to 30 minutes to administer (Ashford et al., 2008; Connell et al., 2012).

Training requirements:

No training requirements have been specified for the ABILHAND, although administration by a clinician is recommended (Ashford et al., 2008).

Equipment:

The ABILHAND is a semi-structured questionnaire that does not require specific equipment, however the WINSTEPS computer program is required to process raw scores.

Client suitability

Can be used with:

  • Individuals with chronic stroke
  • Individuals with rheumatoid arthritis
  • Individuals with systemic sclerosis

Should not be used with:

  • Due to the subjective nature of the patient’s reports, this measure should not be used with individuals with severe cognitive deficits (Penta et al., 2001).
  • The ABILHAND may not be suitable for use with patients with aphasia or apraxia (Gustafsson et al., 2004).

In what languages is the measure available?

  • French
  • English
  • Dutch
  • Italian
  • Swedish

Summary

What does the tool measure? Manual ability of the upper extremity.
What types of clients can the tool be used for? The ABILHAND can be used with, but is not limited to, patients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer 10-30 minutes
Versions
  • AH-RA for rheumatoid arthritis (46 items, 4 levels)
  • AH-RA revised version (27 items, 3 levels)
  • ABILHAND-ULA for upper limb amputees (22 items; 4 levels)
  • SSC-adapted ABILHAND for systemic sclerosis (26 items, 3 levels)
  • ABILHAND – neuromuscular age-independent version (22 items)
  • ABILHAND-Kids (21 items)
Other Languages French, English, Swedish, Dutch, Italian
Measurement Properties
Reliability Internal consistency:
– Order of difficulty of items has been confirmed by Rasch analysis.
– One study reported a high item Reliability index.
– One study reported high person separation Reliability.

Test-retest:
No studies have reported on the test-retest reliability of the ABILHAND.

Intra-rater:
No studies have reported on the intra-rater reliability of the ABILHAND.

Inter-rater:
No studies have reported on the inter-rater reliability of the ABILHAND.

Validity Content:
– One study reported that the 23 items of the ABILHAND define a common continuum of manual ability, and items are coherent with the overall questionnaire and contribute to the measurement of manual ability.
– One study examined stability of item difficulty of the ABILHAND and found that item hierarchy was substantially retained across different groupings (impairment, age, sex, ability).
– One study reported that scores explained 84% of observed variance. The main factor across the residuals explained only 11.4% of the residual variance (1.8% of the total variance).

Criterion:
Concurrent:
One study examined the concurrent validity of the ABILHAND among patients with chronic upper limb impairment resulting from conditions including stroke and reported adequate correlations with the Box and Block Test, Jamar handgrip and Purdue pegboard test, and an adequate negative correlation with the Nine Hole Peg Test.

Predictive:
No studies have reported on the predictive validity of the ABILHAND.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent/discriminant Validity of the ABILHAND.

Known Groups:
– One study reported highly significant differences in ABILHAND scores between patients with tetraparesis, hemiparesis, other neurological impairments (multiple sclerosis, Parkinson’s disease, ataxia) and healthy subjects.
– One study reported no correlation between ABILHAND scores and country, age, sex, time since stroke, affected side, lesion site or tactile sensitivity; poor correlation with grip strength and manual dexterity of the unaffected limb; poor negative correlation with depression; adequate correlation with grip strength and manual dexterity of the affected limb; and excellent correlation with upper limb motricity.

Floor/Ceiling Effects No studies have reported on the floor/ceiling effects of the ABILHAND.
Does the tool detect change in patients? – No studies have reported on the responsiveness of the ABILHAND.
– One study reported that the ABILHAND demonstrates 92% sensitivity and 80% specificity at a lower cutoff score of 80/100.
Acceptability The ABILHAND is non-invasive and quick to administer. The items are considered reflective of real-life activities (i.e. ecologically valid).
Feasibility The ABILHAND is portable and is suitable for administration in various settings. The assessment is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool? The ABILHAND is available in Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. stroke, 32, 1627-34

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the ABILHAND. While additional studies have been conducted on other ABILHAND versions, this review specifically addresses the psychometric properties of the 23-item stroke version of the ABILHAND, unless otherwise specified. Two studies were identified.

Floor/Ceiling Effects

No studies have reported on the floor or ceiling effects of the ABILHAND. However, given the hierarchical relationship of items, lower-level tasks of the ABILHAND may be susceptible to floor effects (Ashford et al., 2008).

Reliability

Internal consistency:
Penta et al. (2001) examined the Internal consistency of the original 56-item ABILHAND in a sample of 103 patients with chronic stroke using Rasch analysis and reported high reliability (Rasch separation reliability=0.90; person separation reliability=0.90). The authors examined the stability of the scale through differential item functioning (DIF) tests among 12 subgroups: sex (male/female); country (Belgium/Italy); age (< 60/≥ 60), affected side (dominant/nondominant); delay since stroke (< 2 years/≥ 2 years), level of depression, dexterity and manual ability of the unaffected limb, grip strength, dexterity and sensitivity of the affected limb, and motricity of the affected limb. The difficulty hierarchy of the ABILHAND was uniformly perceived by patients with chronic stroke.

Simone et al. (2011) examined the Internal consistency of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke (n=83), multiple sclerosis (n=17), peripheral or cerebellar ataxia (n=13), spinal cord lesion (n=10) or Parkinson’s disease (n=3), and 24 health subjects. The ABILHAND demonstrated high reliability (item reliability index=0.94; Cronbach’s alpha=0.99). All items of the ABILHAND fit the Rasch model satisfactorily. There were at least 4 strata of statistically different measures, indicating that variance across scores did not reflect randomness. The authors also examined stability of item difficulty through differential item functioning (DIF) by comparing 4 different groupings of the sample pool: impairment (hemiparesis vs. other); age (≤ 69 vs. > 69); sex (male vs. female); and ability (above median vs. below median). There was a very moderate DIF across the grouping criteria, whereby item hierarchy was substantially retained for all subgroups: impairment (1 outlier: buttoning a shirt); sex (6 outliers: fastening a snap, shelling hazel nuts, hammering a nail, wrapping up gifts, peeling potatoes, spreading butter); age (4 outliers: threading a needle, wrapping up gifts, spreading butter, fastening a snap); and ability (2 outliers: sharpening a pencil, cutting meat).

Test-retest:
No studies have reported on the test-retest reliability of the ABILHAND.

Intra-rater:
No studies have reported on the intra-rater reliability of the ABILHAND.

Inter-rater:
No studies have reported on the inter-rater reliability of the ABILHAND. Note, however that inter-rater reliability is less necessary because administration of the ABILHAND does not rely on clinician-observation of patient performance.

Validity

Content:

Penta et al. (2001) examined the measure of perceived difficulty of the ABILHAND in a sample of 103 patients with chronic stroke. Item distribution ranged from 1.72 to -2.18 logits. All items fit the Rasch model and the 23 items define a common continuum of manual ability. All point measure correlation coefficients (RPM) were positive, indicating that all items are coherent with the overall questionnaire and contribute to the measurement of manual ability. Although fit statistics indicated that most activities adequately measure recovery of manual ability in chronic stroke, 1 item obtained an outlier outfit value (buttoning up a shirt, mean square=1.64), and four items obtained outlier infit values (cutting meat, mnsq=0.69; shelling hazel nuts, mnsq=1.33; tearing open a packet of chips, mnsq=1.22; sharpening a pencil, mnsq=0.65).

Penta et al. (2001) examined the content validity of the ABILHAND by comparing the ranking of item difficulty with expert opinion of four occupational therapists regarding the involvement of the affected hand in each activity. The following classifications were used: (1) the item does not require the affected limb, if it is broken down into several unimanual sequences; (2) the task requires the affected upper limb to stabilize an object but does not involve any fingers; and (3) the task requires precision grip, grip strength, dexterity or any digital activity from the affected side. Findings indicate that more difficult items also tend to require a greater degree of use of the affected limb, whereas easier items do not require the use of the affected limb.

Simone et al. (2011) examined the validity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke (n=83), multiple sclerosis (n=17), peripheral or cerebellar ataxia (n=13), spinal cord lesion (n=10) or Parkinson’s disease (n=3), and 24 health subjects. Modeled scores explained 84% of observed variance. The main factor across the residuals explained only 11.4% of the residual variance (1.8% of the total variance).

Criterion:

Concurrent:
Simone et al. (2011) compared the concurrent validity of the ABILHAND, Jamar handgrip, Box and Block Test (BBT), Purdue pegboard test and Nine Hole Peg Test (NHPT) in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects, using Pearson’s r. Adequate correlations were found between the ABILHAND and the Jamar handgrip (r=0.377, p=0.001), BBT (r=0.481, p=0.000) and the Purdue pegboard test (r=0.493, p=0.000), and an adequate negative correlation was found between the ABILHAND and the NHPT (r=-0.370, r=0.007).

Predictive:
No studies have reported on the predictive validity of the ABILHAND.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the ABILHAND.

Known Group:
Penta et al. (2001) examined the relationship of the ABILHAND measures to other demographic and clinical variables in a sample of 103 patients with chronic stroke, using univariate ANOVA and correlation coefficients (Mann-Whitney U test, Kruskal-Wallis H tests, Spearman p, Pearson r). Tests revealed no significant differences in ABILHAND measures according to demographic indexes of country (Belgium/Italy), sex or age. Clinical variables such as time since stroke, affected side (dominant/nondominant), lesion site and tactile sensitivity of either limb (measured using the Semmes-Weinstein tactile sensation test) were not significantly related to ABILHAND measures. There was a poor correlation between ABILHAND measures and grip strength (Jamar handgrip, R=0.242, P<0.014) and manual dexterity (Box and Block Test, R=0.248, P=0.012) of the unaffected limb, and a poor negative correlation with depression (Geriatric depression Scale, p=-0.213, P=0.030). ABILHAND measures demonstrated an adequate correlation with grip strength (R=0.562, P<0.001) and manual dexterity (R=0.598, P<0.001) of the affected limb, and an excellent correlation with upper limb motricity (Brunnstrom upper limb motricity test, p=0.730, P<0.001). Results showed a direct relationship between ABILHAND measures of manual ability and impairment on the affected side, where more complex combinations of manual dexterity without/without grip strength and/or upper limb motricity impairment correlated with higher manual disability.

Simone et al. (2011) examined the known-group validity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects, using Kruskal-Wallis test. Highly significant differences (P<0.001) were found between patients with tetraparesis, hemiparesis, other neurological impairments (multiple sclerosis, Parkinson’s disease, ataxia) and control participants.

Responsiveness

Simone et al. (2011) reported a satisfactory match between the distribution of item difficulty levels and patients’ ability levels. The average ability of healthy controls vs. patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease was 89 (standard error=8) vs. 63 (standard error=17).

sensitivity & Specificity:
Simone et al. (2011) examined the sensitivity and Specificity of the ABILHAND in a sample of 126 patients with chronic upper limb impairment resulting from stroke, multiple sclerosis, sensory or cerebellar ataxia, spinal cord lesion or Parkinson’s disease, and 24 healthy subjects. An “impairment-normality” cut-off was computed through logistic regression and a lower cut-off score of 80/100 is proposed for healthy controls (area under ROC curve=0.9097, p<0.05). This allowed correct classification of patients vs. healthy controls with a 92% sensitivity rate and 80% Specificity rate, whereby 82% of the sample was correctly classified.

References

  • Ashford, S., Slade, M., Malaprade, F., & Turner-Stokes, L. (2008). Evaluation of functional outcome measures for the hemiparetic upper limb: a systematic review. Journal of Rehabilitation Medicine, 40, 787-95.
  • Connell, L.A. & Tyson, S.F. (2012). Clinical reality of measuring upper-limb ability in neurological conditions: a systematic review. Archives of Physical Medicine and Rehabilitation, 93, 221-8.
  • Gustafsson, S., Sunnerhagen, K.S, & Dahlin-Ivanoff, D. (2004). Occupational therapists’ and patients’ perceptions of ABILHAND, a new assessment tool for measuring manual ability. Scandinavian Journal of Occupational Therapy, 11, 107-17.
  • Mpofu, E. & Oakland, T. (2010). Rehabilitation and Health Assessment: Applying ICF Guidelines. New York: Springer Publishing Company.
  • Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. Stroke, 32, 1627-34.
  • Simone, A., Rota, V., Tesio, L., & Perucca, L. (2011). Generic ABILHAND questionnaire can measure manual ability across a variety of motor impairments. International Journal of Rehabilitation and Research, 34, 131-40.

See the measure

How to obtain the ABILHAND:

The ABILHAND is available in Penta, M., Tesio, L., Arnould, C., Zancan, A., & Thonnard, J-L. (2001). The ABILHAND questionnaire as a measure of manual ability in chronic stroke patients: Rasch-based validation and relationship to upper limb impairment. stroke, 32, 1627-34.

Table of contents

Action Research Arm Test (ARAT)

Evidence Reviewed as of before: 09-06-2011
Author(s)*: Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Action Research Arm Test (ARAT) is an evaluative measure to assess specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia (Lyle, 1981). It assesses a client’s ability to handle objects differing in size, weight and shape and therefore can be considered to be an arm-specific measure of activity limitation (Platz, Pinkowski, Kim, di Bella, & Johnson, 2005).

In-Depth Review

Purpose of the measure

The Action Research Arm Test (ARAT) is an evaluative measure to assess specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia (Lyle, 1981). It assesses a client’s ability to handle objects differing in size, weight and shape and therefore can be considered to be an arm-specific measure of activity limitation (Platz, Pinkowski, Kim, di Bella, & Johnson, 2005).

Available versions

The ARAT was developed by Ronald Lyle in 1981 by adapting the Upper Extremity Function Test (UEFT) (Carroll, 1965). The UEFT test administration and scoring was simplified, the time required to administer the test was shorted, and items were grouped based on the hierarchical scale (Guttman Scale) (Lang, Wagner, Dromerick, & Edwards, 2006). Due to the need for more specific and detailed instructions related to the client’s position, scoring and test administration, Yozbatiran, Der-Yeghiaian, and Cramer (2008) proposed a standardized approach to the ARAT.

Features of the measure

Items:

The ARAT consists of 19 items grouped into four subscales: grasp, grip, pinch, and gross movement. Each subscale constitutes a hierarchical Guttman scale, which means that all items are ordered according to ascending difficulty. In the ARAT, if the client succeeds in completing the most difficult item in a subscale, this suggests he/she will succeed in the easier items for that same subscale. Similarly, failure on an item suggests the client will be unable to complete the remaining more challenging items in the subscale.

According to the rules defained by Lyle (1981), the client must first try to perform the most difficult task in a subscale. If the maximum score (score = 3) is obtained for this task then the maximum score for this entire subscale should be assigned, and the evaluator should move to the next subscale to be administered. When the client is unable to complete the most difficult item (scoring between 0-2), then the easiest item in this specific subscale should be performed. If the client fails completely (score = 0) when performing the easiest task, then the other intermediate items must not be tested, the entire subscale should be scored as zero, and the evaluator should then move to the next subscale. However, if the client succeeds at the easiest task either partially (score = 1 or 2) or completely (score = 3), then all the other tasks in that same subscale should be tested before moving to the next subscale. Following these rules, the items administered will range from a minimum of 4 to a maximum of 19 (van der Lee, Roorda, & Lankhorst, 2002).

The ARAT must be administered in a formal setting, since a specially designed table and chair are required (see equipment section for more information). For the starting position, the client should be seated in a chair, with a firm back and no armrests. The client’s trunk should be in contact with the back of the chair at all times during the test performance. Instructions about the required seating posture should be provided to the client prior to initiating the test. Additionally, reminders about the maintenance of this position should be given to the client when this condition is not respected. The client’s feet should be in contact with the floor throughout testing (van der Lee, DeGroot, Beckerman, Wagenaar, Lankhorst, & Bouter, 2001a; Yozbatiran et al., 2008). Both hands should be tested, beginning with the non- or less-affected hand, in order to practice and register baseline scores. Should the client be unable to understand the instructions for the required task, the evaluator should demonstrate the task and allow the client to try it as a trial (Yozbatiran et al., 2008). To facilitate recording the time for each task, the client’s hands should start and finish the task with palms down on the table. However, for the gross movement tasks, the client’s hands should be placed pronated on their lap. (Lyle, 1981; Yozbatiran et al., 2008).

In the grasp and pinch subscales, testing materials are lifted 37 cm from the surface of the table to the top of the shelf. In the grip subscale, testing materials are moved from one side of the table to the other. Finally, in the gross movement subscale, the client is requested to place the hand being tested either behind his/her head, on top of his/her head, or to his/her mouth (Lyle, 1981; Hsieh, Hsueh, Chiang, & Lin, 1998; Hsueh, Lee, & Hsieh, 2002a). The proper sequence for testing is 1) grasp subscale, 2) grip subscale, 3) pinch subscale, 4) gross movement subscale (Lyle, 1981). The ARAT comes with simple instructions to guide the evaluator on scoring and administering the test (Lyle, 1981).

Scoring:

The ARAT is scored on a four-level ordinal scale (0-3) (Lyle, 1981).

  • 0 = can not perform any part of the test,
  • 1 = performs the test partially,
  • 2 = completes the test, but takes abnormally long, time
  • 3 = performs the test normally

In order to facilitate scoring, time limits have been suggested (Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers, & Rijswijk, 1990; Yozbatiran et al., 2008). Incorporating the time limits to Lyle’s scoring definition, the new scoring system would be:

  • 0 = cannot perform any part of the test;
  • 1 = performs the test partially;
  • 2 = completes the test, but takes an abnormally long time, varying from 5 to 60 seconds.

    If a client takes more than 60 seconds to perform an item, the evaluator should interrupt after 60 seconds and a score of 1 is given on that specific item.

  • 3 = performs the test normally in less than 5 seconds.

The subscale scores range according to the number of items on each subscale, as follows:

Subscales on the ARAT Number of items per subscale Score ranges per subscale
Grasp subscale 6 items Score 0-18
Grip subscale 4 items Score 0-12
Pinch subscale 6 items Score 0-18
Gross Movement subscale 3 items Score 0-9

The total score on the ARAT ranges from 0 to 57, with the lowest score indicating that no movements can be performed, and the upper score indicating normal performance. Thus, higher scores will indicate better performance (Lang et al., 2006; van der Lee et al., 2002). The ARAT scores is a continuous measure, with no categorical cutoff scores. Therefore the score obtained at the ARAT does not allow classifying the clients into categories such as normal, mild limited, or severely limited.

Time:

The time required to complete the ARAT will depend on the number of items administered. Based on its hierarchical design, the ARAT was constructed to save testing time. Thus, no more than 7-10 minutes should be required to assess a client with stroke (DeWeerdt, & Harrinson, 1985). However, if all 19 items are performed, the ARAT usually takes 20 minutes to administer (van der Lee et al., 2002). In one study by Hsieh and colleagues (1998), the ARAT took, on average, 8 minutes to administer to clients with stroke.

Subscales:

The ARAT is divided in four subscales: Grasp; Grip; Pinch and Gross movement.

The grasp and pinch subscales have 6 items each, the grip subscale has 4 items, and the gross movement has 3 items (Lyle, 1981).

Equipment:

Standardized equipment is required to administer the ARAT. It can be ordered only from Netherlands’ representatives. The average cost for this equipment is approximately 850 Euros ($1200 CAD) with an additional delivery fee of 179 Euros ($252 CAD).

The complete ARAT kit consists of:

  • A specially designed table of 92cm x 45cm x 83cm high, with a shelf of 93cm x 10cm, positioned 37cm above the main surface of the table (Lyle, 1981; Hsueh et al., 2002a).
  • A chair with back rest and no arm rests, that should be placed 44cm above floor level (Lyle, 1981; Hsueh et al., 2002a).
  • Woodblocks of 2.5, 5, 7.5 and 10cm³ (Lyle, 1981; Hsueh et al., 2002a).
  • A cricket ball 7.5cm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • Two alloy tubes: one 2.25cm in diameter x 11.5 cm long, the second one 1.0cm in diameter x 16cm long (Lyle, 1981; Hsueh et al., 2002a).
  • A washer and bolt; which is a type of screw with its anchor (Lyle, 1981; Hsueh et al., 2002a).
  • Two glasses (Lyle, 1981; Hsueh et al., 2002a).
  • A marble 1.5cm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • A ball bearing 6mm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • A stopwatch (Wagenaar et al., 1990; Yozbatiran et al., 2008)
  • Paper and pencil for the evaluator.

Training:

None typically reported.

Alternative forms of the Action Research Arm Test

None.

Client suitability

Can be used with:

  • The ARAT was constructed for assessing recovery of upper limb function following cortical damage (Lyle, 1981).
  • Clients with stroke.

Should not be used in:

  • When administering the ARAT for clients with finger amputation, pinch subscale should be scored as 0 as well all other tasks that require movement of an amputated body part (Yozbatiran et al., 2008).

In what languages is the measure available?

There are no official translations of the ARAT.

Nevertheless, some peer-reviewed publications from the Netherlands and Taiwan have used the ARAT as an outcome measure, which may indicate that instructions have been informally translated to other languages (Hsieh et al., 1998; Hsueh et al., 2002a; van der Lee et al., 2002).

Summary

What does the tool measure? The ARAT measures specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia.
What types of clients can the tool be used for? The ARAT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer An average of 7 to 10 minutes.
Versions There are no alternative versions.
Other Languages There are no official translations.
Measurement Properties
Reliability Internal consistency:
One study examined the Internal consistency of the ARAT and reported excellent Internal consistency using Cronbach’s alpha.

Test-retest:
Three studies have examined the test-retest reliability of the ARAT. All reported excellent test-retest reliability using ICCs.

Intra-rater:
Four studies have examined the intra-rater reliability of the ARAT and reported excellent intra-rater reliability using Spearman rho correlation, intraclass correlation coefficients (ICC) and weighted kappa.

Inter-rater:
Seven studies examined the inter-rater reliability of the ARAT and reported excellent inter-rater reliability using Spearman rho correlation, Intra ICC and weighted kappa.

Validity Criterion:
Concurrent:
One study has examined the concurrent validity of the ARAT and reported adequate to excellent correlations with the Box and Block Test (BBT) and the Nine-Hole Peg Test (NHPT) at pre and post-treatment.

Predictive:
No studies have examined the predictive validity of the ARAT.

Construct:
Convergent:
Seven studies examined convergent validity of the ARAT and reported excellent correlations between the ARAT and the Brunnstrom-Fugl-Meyer test; the upper extremity subscale of the Motor Assessment scale; the Motricity Index; the upper extremity movement of Modified Motor Assessment Chart; the BTT; the motor function subscore of the Fugl-Meyer test; the Hemispheric stroke Scale; upper extremity strength and grasp speed. Adequate correlations were reported between the ARAT and the passive joint motion/joint pain of the Fugl-Meyer test, the Functional Independence Measure and spasticity. Poor correlations were reported between the ARAT and the sensation score of the Fugl-Meyer test, the Ashworth scale, the Modified Barthel Index, the National Institutes of Health stroke Scale, the light touch sensation and pain.

Floor/Ceiling Effects – One study examined the floor/ceiling effects of the ARAT in clients with acute stroke and reported that at earlier phases of the stroke, floor effects were poor. At discharge from the acute rehabilitation ward, ceiling effects on the ARAT were adequate.
– One study examined the floor/ceiling effects of the ARAT in stroke clients with mild to moderate hemiparesis and reported adequate floor and ceiling effects.
Sensitivity/ Specificity No studies have examined the Specificity of the ARAT.
Does the tool detect change in patients? Six studies have examined the responsiveness of the ARAT and reported that the ARAT has a moderate to large Standardized Response Mean, moderate to large effect size and large responsiveness ratio, therefore, is able to detect change in clients with stroke.
Acceptability When administering the ARAT to clients with upper extremity amputations attention is required when scoring (i.e. – a score of 0 is given).
Feasibility The administration of the ARAT is quick and simple, but requires standardized equipment.
How to obtain the tool? Information on the ARAT can be obtained in the study by Lyle (1981), Hsieh et al. (1998), van der Lee et al. (2002), Rabadi & Rabadi (2006), and Yozbatiran et al. (2008) and at the website: http://www.aratest.eu/Index_english.htm Standardized equipment can be purchased from the following website: http://www.aratest.eu/ or from http://www.saliarehab.com/

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Action Research Arm Test (ARAT) in individuals with stroke. We identified twelve studies. The ARAT appears to be floor effects.

Floor/Ceiling Effects

Hsueh and Hsieh (2002b) examined floor and ceilings effects for the ARAT and the Upper Extremity Motor Assessment Scale (Carr, Shepherd, Nordholm, & Lynne, 1985) in 48 clients with acute stroke. Participants were assessed at admission and discharge from an acute rehabilitation ward. At admission, the ARAT total score demonstrated a poor floor effect, with 52.1% of participants scoring 0. Although all subscales were classified as having a poor floor effect, when comparing ARAT’s subscales among themselves, 72.9% of participants were unable to perform the pinch subscale, 70.8% were unable to perform both grasp and grip subscales and 52.1 % were unable to complete the gross movement subscale. At discharge, the ARAT total score demonstrated an adequate ceiling effect, with only 7% of participants scoring the maximal value. When analyzing ARAT’s subscales individually the gross movement subscale presented the poorest ceiling effect, with 29.2% of participants scoring the maximum score, followed by 27% of participants on the grasp subscale. The grip and pinch subscale had the best classification, with an adequate ceiling effect of 18.8% and 16.7%, respectively.

Compared to the ARAT, at admission the Upper Extremity Motor Assessment Scale had 58% of participants scoring the minimal value, indicating a poor floor effect. However, at discharge the Upper Extremity Motor Assessment Scale demonstrated a more adequate ceiling effect than the ARAT, with only 4.3 % of participants obtaining the maximum score.

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. The ARAT showed adequate floor and ceiling effects with only 12.5 to 17% of patients scoring the lowest or highest scores.

Reliability

Internal Consistency:
Nijland et al. (2010) investigated the Internal Consistency of the ARAT in 40 patients with stroke with mild to moderate hemiparesis. Internal Consistency of the ARAT, as calculated using Cronbach’s Coefficient Alpha was excellent (α = 0.98).

Test-retest:
Note: From the descriptions provided of the following studies it appears that some authors called the testing test-retest reliability while others called the same analysis intra-rater reliability.

Lyle (1981) examined test-retest reliability in 20 individuals who sustained cortical damage, either from stroke or traumatic brain lesion. The mean age was 53 years, ranging from 26 to 72 years. Participants were re-assessed with a 1-week interval by the same rater and under the same conditions. The test-retest reliability, as calculated using Pearson correlation, was excellent (r = 0.98).

Hsueh, Lee, and Hsieh (2002a) evaluated test-retest reliability performed using a regular table instead of the specially designed table for this test in 61 individuals with sub-acute stroke and a mean age of 63 years old. Participants were re-assessed after a two-day interval by the same rater. The test-retest reliability, as calculated using the Intraclass Correlation Coefficient (ICC), was excellent for the total score (ICC = 0.99) as well as for the grasp, grip, pinch and gross movement subscales (ICC = 0.99, 0.98, 0.96 and 0.95, respectively).

Platz, Pinkowski, van Wijck, Kim, di Bella, and Johnson (2005) estimated test-retest reliability for the ARAT, the Box and Block Test (Cromwell, 1965; Mathiowetz, Volland, Kashman, & Weber, 1985a), and the Fugl-Meyer Test upper extremity items (including items from the Motor function, Sensation and Passive Joint Motion/Joint pain subscores) (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) in 23 participants with upper extremity paresis either from stroke, multiple sclerosis, or traumatic brain injury. The participant’s most affected arm was re-assessed 1 week later by the same rater. The test-retest reliability of the ARAT total score, as calculated using ICC’s and Spearman rho correlation, was excellent (ICC = 0.96 and rho = 0.96). Furthermore, test-retest reliabilities for each subscale were all excellent: grasp (ICC = 0.94 and rho = 0.96), grip (ICC = 0.94 and rho = 0.95), pinch (ICC = 0.89 and rho = 0.89) and gross movement (ICC = 0.97 and rho = 0.97).
Note: These results applies only to the most affected upper limb.

Intra-rater:
Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers and Rijswijk (1990) evaluated intra-rater reliability in seven patients with acute stroke. The timeframe for assessments were not provided by the author. intra-rater reliability as calculated using Spearman rho correlation, was excellent (rho = 0.99).

Van der Lee, DeGroot, Beckerman, Wagenaar, Lankhorst, and Bouter (2001a) estimated intra-rater reliability in 20 patients with chronic stroke and a median age of 62 years. Participants were evaluated by the same rater at three points in time. At the baseline assessment participants were videotaped. The second assessment was 4-27 months following the first assessment, and the final assessment was 4-6 weeks after. Scoring the last two assessments was based on the videotaped recorded at baseline. intra-rater reliability results were analyzed between the two first assessments, where scoring sources were different (live vs. videotape) and between the two last assessments, were scoring sources were the same (videotape only). intra-rater reliability, as calculated using ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99), independent of scoring sources. intra-rater reliability, as calculated using weighted kappa was also excellent: scoring with the same information source resulted in a kappa = 1.00 versus only a slightly lower kappa when scoring from two different information sources (kappa = 0.94). The gross movement subscale showed the lowest weighted kappa value (kappa = 0.83), suggesting that this subscale had the lowest agreement level.

Yozbatiran, Der-Yeghiaian, and Cramer (2008) examined intra-rater reliability in 8 clients with chronic stroke. Participants were re-assessed by the same rater and under the same conditions with a 1-week interval. intra-rater reliability for the total score, as calculated using ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99). Additionally, the same excellent level of intra-rater reliability was found for the grasp, grip, pinch, and gross motor movement subscales (ICC = 0.98 and rho = 0.93; ICC = 0.97 and rho = 0.93; ICC = 0.99 and rho = 0.98; ICC = 0.93 and rho = 0.91, respectively).

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. 18 patients participated in the reproducibility testing of the ARAT and were assessed twice by the same observer approximately 10 days apart. intra-rater reliability, as analyzed using the ICC was found to be excellent (ICC = 0.97).

Inter-rater:
Lyle (1981) examined inter-rater reliability in 20 individuals who had sustained cortical damage, either from stroke or traumatic brain injury. The mean age was 53 years, ranging from 26 to 72 years. Participants were assessed independently by two different raters. Agreement between raters as calculated using Pearson correlation, was excellent (r = 0.99).

Hsieh, Hsueh, Chiang, and Lin (1998) assessed inter-rater reliability in 50 clients with stroke. Their mean age was 65 years old. Participants were evaluated independently, on three different days, by three raters. ICC for the total score showed excellent agreement (ICC = 0.98). Agreement between raters was also excellent for grasp, grip, pinch and gross movement subscales (ICC = 0.98; ICC = 0.96; ICC = 0.96; ICC = 0.95, respectively).

Van der Lee et al. (2001a) estimated inter-rater reliability in 20 patients with chronic stroke and a median age of 62 years old. Participants were videotaped and scored independently by two raters. inter-rater reliability, as calculated using ICC, weighted kappa, and Spearman rho correlation, was excellent (ICC = 0.98; kappa = 0.93; rho = 0.99). With respect to the individual subscales, the gross movement scale had the lowest weighted kappa value (kappa = 0.87), suggesting this subscale has the lowest agreement between raters.

Hsueh, Lee, and Hsieh (2002a) evaluated inter-rater reliability of the ARAT performed with a regular table instead of the specially designed table for this test in 61 individuals with sub-acute stroke and a mean age of 63 years old. Participants were re-assessed with a two-day interval by three different raters. ICC for the total score showed excellent agreement (ICC = 0.99) as well as for grasp, grip, pinch and gross movement subscales (ICC = 0.99; ICC = 0.98; ICC = 0.96; ICC = 0.94, respectively).

Platz et al. (2005) analyzed inter-rater reliability of the ARAT, the Box and Block Test and the Fugl-Meyer Test upper extremity items (including items from the Motor function, Sensation and Passive Joint Motion/Joint pain subscores) in 44 individuals with upper limb paresis either from stroke, multiple sclerosis, or traumatic brain injury. Participants had the most affected arm videotaped and scored independently by two raters. inter-rater reliability for the ARAT total score, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99). Additionally, the scores for each subscale were provided and inter-rater reliability for grasp (ICC = 0.99 and rho = 0.99), grip (ICC = 0.96 and rho = 0.95), pinch (ICC = 0.99 and rho = 0.99) and gross movement (ICC = 0.98 and rho = 0.98) subscales were all excellent.
Note: These results applies only to the most affected upper limb.

Yozbatiran et al. (2008) evaluated inter-rater reliability in 9 clients with chronic stroke. Participants were scored simultaneously and independently by two raters. inter-rater reliability for the total score, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.96). The same excellent level of inter-rater reliability was found for the grasp, grip, pinch and gross motor movement subscales (ICC = 0.99 and rho = 1; ICC = 0.99 and rho = 0.99; ICC = 0.99 and rho = 0.98; ICC = 0.97 and rho = 0.93, respectively).

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. 18 patients participated in the reproducibility testing of the ARAT and were assessed in random order by two observers, within one week. inter-rater reliability, as analyzed using the ICC was found to be excellent (ICC = 0.92).

Validity

Content:

Lyle, 1981 generated the 19 ARAT items from the 33 items of the Upper Extremity Function Test (UEFT – Caroll, 1965). Item reduction was based on a low inter-item correlation, on item redundancy, confirmed through a very high inter-item correlation (above r = 0.9) and on items that were extremely difficult to perform. Nevertheless, ARAT items were not based on a theoretical model (Finch, Brooks, Stratford, & Mayo, 2002).

Criterion:

Concurrent:
No gold standard exists against which to compare the ARAT.

Lin, Chuang, Wu, Hsieh and Chang (2010) compared the concurrent validity of the ARAT, Box and Block Test (BBT) and Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with stroke. The Fugl-Meyer Assessment of Sensorimotor Recovery After stroke (FMA), Motor Activity Log (MAL) and stroke Impact Scale (SIS) were also administered to assess the concurrent validity of the ARAT, BBT and NHPT. Using Spearman rank correlation coefficient, the ARAT, BBT and NHPT were found to have adequate to excellent correlations at pre-treatment (ranging from rho=-0.55 to -0.80) and post-treatment (ranging from rho=-0.57 to -0.71). In addition, the ARAT and BBT were found to have adequate correlations with the FMA, MAL and SIS (ranging from rho=0.31-59); however, the NHPT had only poor to adequate correlations with the FMA and MAL (ranging from rho=-0.16 to -0.33); and adequate to excellent correlations with the SIS (ranging from rho=-0.58 to -0.66). When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

Predictive:
No studies have examined the predictive validity of the ARAT.

Construct:

Convergent/Discriminant:
DeWeerdt and Harrison (1985) evaluated the convergent validity of the ARAT by comparing it to the Fugl-Meyer test (Fugl-Meyer et al., 1975) in 53 clients with acute stroke. Their mean age was 68 years. Correlations were calculated at two points in time after stroke onset using Spearman correlation coefficient. Excellent correlations were found between the ARAT and Fugl-Meyer test at 2 months (rho = 0.91) and at 8 months (rho = 0.94) post-stroke.

Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers and Rijswijk (1990) evaluated the convergent validity of the ARAT by comparing it to the Sollerman test (Jacobson-Sollerman & Sperling, 1977) in seven patients with acute stroke. An excellent correlation, as calculated using Spearman rho, was found (rho = 0.94).
Note: The Sollerman test measures hand grip function using 20 different daily life activities requiring hand movements.

Hsieh et al. (1998) assessed convergent validity of the ARAT by comparing it to the Upper Extremity portion of the Motor Assessment Scale (Carr et al., 1985), the arm subscale of the Motricity Index (Demeurisse, Demol, & obaye, 1980), and the upper extremity movements of the Modified Motor Assessment Chart (Lindmark & Hamrin, 1988) in 50 clients with stroke. The mean age of clients was 65 years old. Correlations were calculated using Pearson correlation Coefficients. Excellent correlations were found between the ARAT and the Upper Extremity part of the Motor Assessment Scale ((r = 0.96), Motricity Index (r = 0.87) and the upper extremity movements of the Modified Motor Assessment Chart (r = 0.94).

Platz et al. (2005) tested convergent validity of the ARAT by comparing it to the Box and Block Test (Cromwell, 1965; Mathiowetz et al., 1985a), the Fugl-Meyer Test upper extremity items (including items from the Motor Function, Sensation and Passive Joint Motion/Joint Pain subscores) (Fugl-Meyer et al., 1975), the Motricity Index (Demeurisse et al., 1980), the Ashworth Scale (Ashworth, 1964), the Hemispheric stroke Scale (Adams, Meador, Sethi, Grotta, & Thomson, 1986) and the Modified Barthel Index (Collin, Wade, Davies, & Horne, 1988) in 56 participants with upper extremity paresis either from stroke (n=37), multiple sclerosis (n=14), or traumatic brain injury (n=5). Correlations were calculated using the Spearman correlation Coefficient. Excellent correlations were found between the ARAT and the Box and Block Test (rho = 0.95), the Motor Function subscore of the Fugl-Meyer Test (rho = 0.92), the Motricity Index (rho = 0.81), and the Hemispheric stroke Scale (rho = -0.66). Adequate correlations were found between the ARAT and the Passive Joint Motion/Joint Pain subscore of Fugl Meyer Test (rho = 0.42). Poor correlations were found between the ARAT and the Sensation Subscore of the Fugl-Meyer Test (rho = 0.29), the Ashworth Scale (rho = -0.29) and the Modified Barthel Index (rho = 0.04).
Note: Negative correlations are observed because a high score on the ARAT indicates normal performance, whereas a low score on the Hemispheric stroke Scale and the Ashworth Scale indicates normal performance.

Lang, Wagner, Dromerick, and Edwards (2006) evaluated the convergent validity of the ARAT in 50 individuals with acute to sub acute stroke, mean age of 63 years old, attending an acute neurology stroke service at three points in time: admission (day 0); post intervention (day 14); and 90 days poststroke (day 90). The ARAT was compared to measures of sensorimotor impairment (e.g. light touch sensation, pain, elbow joint spasticity, upper extremity strength), to kinematic measures (e.g. reach and grasp), to the Functional Independence Measure (FIM) (Keith, Granger, Hamilton, & Sherwin, 1987), and to the National Institutes of Health stroke Scale (NIHSS) (Brott, Adams, Olinger, Marler, Barsan, Biller, et al., 1989). At day 0, excellent correlations were found between the ARAT and upper extremity strength (r = 0.60) and grasp speed (r = 0.60). Adequate correlations were found between the ARAT and grasp efficiency (r = 0.42), reach efficiency (r = -0.38) and reach speed (r = 0.40), and the FIM upper extremity score (r = 0.38). Poor correlations were found between the ARAT and NIHSS (r = -0.15); light touch sensation (r = 0.15), pain (r = 0.10), elbow joint spasticity (r = -0.28) and the FIM total score (r = 0.20). At day 14, excellent correlations were found between the ARAT and grasp efficiency (r = 0.60) and the FIM upper extremity scores (r = 0.62). Adequate correlations were found between the ARAT and elbow spasticity (r = 0.49), upper extremity strength (r = 0.42), reach efficiency (r = -0.58), grasp speed (r = 0.36) and the FIM total score (r = 0.52). Poor correlations were found between the ARAT and NIHSS (r = -0.24), light touch sensation (r = -0.20), and pain (r = -0.12). At day 90, excellent correlations were found between the ARAT and upper extremity strength (r = 0.60). Adequate correlations were found between the ARAT and elbow spasticity (r = -0.42), reach efficiency (r = -0.42), reach speed (r = 0.50), grasp efficiency (r = -0.48), grasp speed (r = 0.38) and the FIM upper extremity (r = 0.42) and total scores (r = 0.40). Poor correlations were found between the ARAT and the NIHSS (r = -0.29), light touch sensation (r = 0.00), and pain (r = 0.22). In summary, from this study’s findings it appears that the NIHSS, light touch sensation, and pain do not appear to relate to the ARAT. The relationship between the ARAT and FIM scores is stronger early on post-stroke and stabilizes by the ninetieth day.

Rabadi and Rabadi (2006) examined convergent validity of the ARAT by comparing it to the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) at admission and discharge from an acute stroke rehabilitation unit in 104 inpatients with acute stroke with a mean age of 72 years. The correlation between ARAT and the Fugl-Meyer Assessment was excellent both at admission (rho = 0.77) and discharge (rho = 0.87).

Yozbatiran et al. (2008) estimated the convergent validity of the ARAT by comparing it to the arm motor Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) score in 12 clients with chronic stroke at a mean age of 61 years. Excellent correlation (r = 0.94) was found between the ARAT and arm motor Fugl-Meyer score.

Known groups:
No studies have examined known groups validity of the ARAT.

Responsiveness

Van der Lee, Beckerman, Lankhorst, and Bouter (2001b) evaluated the responsiveness on the ARAT and Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) in 22 clients with chronic stroke, mean age of 58 years old, receiving intensive forced use treatment. Participants were assessed two weeks pre- and two weeks post- treatment. A responsiveness ratio was calculated. Compared to the Fugl-Meyer Assessment, the ARAT had a greater responsiveness ratio (2.03 for ARAT vs. 0.41 for Fugl-Meyer) suggesting that the ARAT is more sensitive to detecting change.
Note: The responsiveness ratio is a variant of effect size and higher values indicate better responsiveness.

Van der Lee, Roorda, Beckerman, and Lankhorst (2002) estimated the responsiveness of a modified version of the ARAT in 63 participants with chronic stroke. In this study, researchers did not follow Lyle’s standardized instructions. Instead, they administered all 19 ARAT items to verify any possible effect of this format on its psychometric properties. A responsiveness ratio was calculated. Compared to the hierarchical version proposed by Lyle, performing all 19 items was found to improve the measure’s responsiveness, with a responsiveness ratio of 1.7 compared to 1.2 with Lyle’s version.
Note: The responsiveness ratio can be considered an estimate of effect size normalized to the variability in a stable population and higher values indicate better responsiveness.

Hsueh et al. (2002b) analyzed the responsiveness of the ARAT and the upper extremity section of the Motor Assessment Scale (Carr et al., 1985) in 48 participants having acute stroke and a mean age of 62 years. Participants were assessed at two points in time: admission and discharge from the acute rehabilitation centre. The ARAT total score demonstrated a moderate effect size of 0.52, while the Motor Assessment Scale total score demonstrated a small effect size of 0.45.

Lang et al. (2006) examined the responsiveness of the ARAT in 50 participants with acute to subacute stroke, with a mean age of 63 years old, receiving constraint-induced movement therapy (CIMT). Assessments were performed at three points in time: baseline, immediately post-treatment, and 2.5 months post-treatment. Effects sizes and responsiveness ratios were calculated. ARAT total and subscale scores at the first follow-up evaluation were similar, with moderate to large effect sizes (ARAT total score = 1.01; grasp subscore = 1.04; pinch subscore = 0.85; grip subscore = 1.01; and gross movement subscore = 0.72). The second follow-up evaluation demonstrated large effect sizes, with individual higher values when compared to the first evaluation (ARAT total score = 1.39; grasp subscore = 1.22; pinch subscore = 1.49; grip subscore = 1.32 and gross movement subscore = 0.98). The responsiveness ratio for the ARAT total score at the first follow-up evaluation was 5.2 and at the second was 7.0. These two responsiveness estimations suggest that the ARAT is a sensitive tool for detecting change even months after stroke onset.
Note: responsiveness ratio is a variant of effect size and higher values indicate better responsiveness.

Rabadi and Rabadi (2008) assessed the responsiveness of the ARAT and the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) in 104 participants with acute stroke, with a mean age of 72 years, undergoing inpatient rehabilitation. Participants were evaluated at admission and discharge from acute care. The Standardized Response Mean (SRM) was used to calculate responsiveness. Amongst these upper extremity tests, the ARAT was less sensitive than the Fugl-Meyer Assessment (SRM = 0.68 and 0.74, respectively). However, since the difference between the SRMs for these two measures was minimal, these tests can be considered equally sensitive to change during inpatient acute rehabilitation. This result is contrary to the one presented by Van der Lee at al. (2002). The reason for this difference may be due to the difference in these studies population age and stroke severity.
Note: SRM is a variant of effect size and higher values indicate better responsiveness.

Lin, Chuang, Wu, Hsieh and Chang (2010) evaluated the responsiveness of the ARAT, Box and Block Test (BBT), the Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with subacute stroke (< 6-months) and Brunnstrom stage IV to VI for proximal and distal upper extremity function. Patients were randomly assigned to receive constraint-induced therapy, bilateral arm training or control treatment and received 2 hours of therapy, 5 days per week for 3 weeks. Assessments were performed at baseline and 3 weeks. Using Standardized Response Mean (SRM) to calculate responsiveness, the ARAT, BBT and NHPT were all found to have moderate SRM (0.79, 0.74, 0.64 respectively), indicating sensitivity for detecting change in hand dexterity. When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

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  • Van der Lee, J.H, Groot, V., Beckerman, H., Wagenaar, R.C., Lankhorst, G.J., Bouter, L.M. (2001b). The intra-rater and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke. Archives of Physical of Medicine Rehabilitation, 82, 14-19.
  • Van der Lee, J.H, Roorda, L.D., & Lankhorst, G.J. (2002). Improving the Action Research Arm Test: a unidimensional hierarchical scale. Clinical Rehabilitation, 16, 646-653.
  • Yozbatiran, N., Der-Yerghiaian, L., & Cramer, S.C. (2008). A standardized approach to performing the action research arm test. Neurorehabilitation & Neural Repair, 22(1), 78-90.
  • Wagenaar, R.C., Meijer, O.G., van Wieringen, P.C., Kuik, D.J., Hazenberg, G.J., Lindeboom, J., et al. (1990). The functional recovery of stroke: a comparison between neuro-developmental treatment and the Brunnstrom method. Scandinavian Journal of Rehabilitation and Medicine, 22, 1-8.

See the measure

How to obtain the Action Research Arm Test:

The ARAT can be obtained in the study by Lyle (1981), Hsieh et al. (1998), Van der Lee et al. (2002), Rabadi & Rabadi (2006), and Yozbatiran et al. (2008) and from the website: http://www.aratest.eu/Index_english.htm Standardized equipment can be purchased from the website: http://www.aratest.eu/ or from http://www.saliarehab.com/.

Table of contents

Box and Block Test (BBT)

Evidence Reviewed as of before: 09-06-2011
Author(s)*: Sabrina Figueiredo, BSc
Editor(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

Purpose

The Box and Block Test (BBT) measures unilateral gross manual dexterity. It is a quick, simple and inexpensive test. It can be used with a wide range of populations, including clients with stroke.

In-Depth Review

Purpose of the measure

The Box and Block Test (BBT) measures unilateral gross manual dexterity. It is a quick, simple and inexpensive test. It can be used with a wide range of populations, including clients with stroke.

Available versions

The original version of the BBT was developed, in 1957, by Jean Hyres and Patricia Buhler. This version was modified into the current one by E. Fuchs and P. Buhler (Cromwell, 1976). In 1985, normative data on the BBT was established by Mathiowetz, Volland, Kashman, and Weber.

Features of the measure

Items:

The BBT is composed of a wooden box divided in two compartments by a partition and 150 blocks. The BBT administration consists of asking the client to move, one by one, the maximum number of blocks from one compartment of a box to another of equal size, within 60 seconds. The box should be oriented lengthwise and placed at the client’s midline, with the compartment holding the blocks oriented towards the hand being tested. In order to practice and register baseline scores, the test should begin with the unaffected upper limb. Additionally, a 15-second trial period is permitted at the beginning of each side. Before the trial, after the standardized instructions are given to clients, they should be advised that their fingertips must cross the partition when transferring the blocks, and that they do not need to pick up the blocks that might fall outside of the box (Mathiowetz, Volland, Kashman, & Weber, 1985-1).

Scoring:

Clients are scored based on the number of blocks transferred from one compartment to the other compartment in 60 seconds (Mathiowetz et al., 1985-1). Higher scores are indicative of better manual dexterity. During the performance of the BBT, the evaluator should be aware of whether the client’s fingertips are crossing the partition. Blocks should be counted only when this condition is respected. Furthermore, if two blocks are transferred at once, only one block will be counted. Blocks that fall outside the box, after trespassing the partition, even if they don’t make it to the other compartment, should be counted.

Mathiowetz et al. (1985-1) reported that healthy male adults, aged 20 to 80 years, transfer an average of 77 blocks (SD ±11.6) with the right hand and 75 blocks (SD ±11.4) with the left hand within the 60 second limit. Scores for normal healthy men, aged 60 years old or more ranged from 61 to 70 blocks. Healthy female adults, aged 20 to 80 years, transfer an average of 78 blocks (SD ±10.4) with the right hand and 76 blocks (SD ±9.5) with the left hand. Scores for normal healthy women, aged 60 years old or more, ranged from 63 to 76 blocks. The score on the BBT and age are inversely correlated, meaning that average scores on the BBT decrease with older age.

Time:

The BBT requires 2 to 5 minutes to administer (Finch, Brooks, Stratford, & Mayo, 2002; Mathiowetz et al., 1985-1).

Subscales:

None.

Equipment:

The standardized equipment consists of:
A wooden box dimensioned in 53.7 cm x 25.4 cm x 8.5 cm. The partition should be placed at the middle of the box, dividing it in two containers of 25.4 cm each. (Mathiowetz et al., 1985-1).
150 wooden cubes – 2.5 cm in size (Mathiowetz et al., 1985-1). Stopwatch.

Training of administrator:

None typically reported.

Alternative forms of the Box and Block Test

None.

Client suitability

Can be used with:

  • Clients with stroke.

Should not be used in:

  • The BBT cannot be used with clients who have severe upper extremity impairment.
  • The BBT cannot be used with clients with severe cognitive impairment.

In what languages is the measure available?

There are no official translations of the BBT. The specific instructions provided to the client are in English. Clinicians and researchers may be using “home-grown” translations of the instructions as evidenced from peer-reviewed publication from Sweden, French Canada, Italy and Germany that have used the BBT as an outcome measure. (Broeren, Rydmark, Bjorkdahl, & Sunnerhagen, 2007; Dannenbaun, Michalsen, Desrosiers, & Levin, 2002; Mercier & Bourbonnais, 2004; Platz, Pinkowski, Kim, di Bella, & Johnson, 2005; Schneider, Schonle, Altenmuller, & Munte, 2007).

Summary

What does the tool measure? Unilateral gross manual dexterity.
What types of clients can the tool be used for? The BBT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer From 2 to 5 minutes.
Versions There are no alternative versions.
Other Languages There are no official translations.
Measurement Properties
Reliability Internal consistency:
No studies have examined the Internal consistency of the BBT.
Test-retest:
Two studies have examined the test-retest reliability of the BBT. Both reported excellent test-retest reliability using ICC’s.
Inter-rater:
Two studies have examined the inter-rater reliability of the BBT and reported excellent inter-rater reliability using correlation coefficients and ICC. One study used Pearson correlation and the other, ICC and Spearman rho correlation.
Validity Criterion:
Concurrent:
One study has examined the concurrent validity of the BBT and reported adequate to excellent correlations with the Action Research Arm Test (ARAT) and the Nine-Hole Peg Test (NHPT) at pre and post-treatment.
Predictive:
One study has examined predictive validity and reported that the BBT, compared to the NHPT, the Frenchay Arm Test, Grip Strength and the stroke Rehabilitation Assessment of Movement (STREAM) was the best predictor of upper limb function 5 weeks post-stroke.
Construct:
Convergent validity:
Three studies have examined Convergent validity of the BBT and reported excellent correlations between the BBT and the Minnesota Rate of Manipulation Test, the ARAT, the Hemispheric stroke Scale and the motor function score of the Fugl-Meyer Assessment (FMA). Adequate correlations were reported between the BBT and the SMAF, the Ashworth scale and the Passive Joint Motion/Joint Pain subscore of the FMA. Poor correlations were reported between the BBT and the Sensation subscore of the FMA and the Modified Barthel Index.
Floor/Ceiling Effects No studies have examined floor/ceiling effects of the BBT
Sensitivity/ Specificity No studies have examined Sensitivity/specificity of the BBT
Does the tool detect change in patients?

Two studies have examined the responsiveness of the BBT and reported that the BBT has moderate to large Standardized Response Mean, therefore, is able to detect change in clients with stroke.

Acceptability The BBT should not be used clients with severe upper extremity impairment and severe cognitive impairments.
Feasibility The administration of the BBT is quick and simple, however requires standardized equipment.
How to obtain the tool?

The BBT instructions can be obtained in the study by Mathiowetz et al. (1985)

Standardized equipment can be obtained at the website:
http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=7531

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Box and Block Test (BBT) in healthy individuals and individuals with stroke. We identified four studies. The BBT appears to be responsive in clients with stroke.

Floor/Ceiling Effects

No studies have examined floor/ceiling effects of the BBT.

Reliability

Test-retest:
Desrosiers, Bravo, Hebert, Dutil, and Mercier (1994) examined test-retest reliability of the BBT in 34 elderly with upper limb sensorimotor impairments from stroke (n=13) and other conditions. Participants were re-assessed with a 1-week interval by the same rater and under the same conditions. The test-retest reliability for the BBT was reported as excellent (ICC = 0.97; ICC = 0.96) for the right and left hand, respectively.

Platz, Pinkowski, van Wijck, Kim, di Bella, and Johnson (2005) estimated test-retest reliability of the BBT, the Action Research Arm Test (Lyle, 1981), and the Fugl-Meyer Assessment (FMA) upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores, (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) in 23 participants with upper extremity paresis either from stroke, multiple sclerosis, or traumatic brain injury. The participant’s most affected arm was re-assessed after a 1-week interval by the same rater. The test-retest reliability of the BBT, as calculated using ICC’s and Spearman rho correlation, was excellent (ICC = 0.96 and r = 0.97).
Note: This result applies only to the most affected upper limb.

Inter-rater:
Mathiowetz, Volland, Kashman, and Weber (1985-1) assessed the inter-rater reliability of the BBT in 26 healthy young females. Participants were evaluated simultaneously and independently by two raters. Pearson correlationcoefficients showed excellent agreement (r = 1.00; r = 0.99) for the right and left hand, respectively.
Note: Pearson correlation coefficient is not the statistical analysis of choice for assessing inter-rater reliability as it may artificially inflate agreement.

Platz et al. (2005) as described earlier also analyzed inter-rater reliability of the BBT, the Action Research Arm Test (Lyle, 1981), and the FMA upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores (Fugl-Meyer et al., 1975) in 44 individuals with upper limb paresis either from stroke, multiple sclerosis, or traumatic brain injury. Participants had the most affected arm videotaped and scored independently by two raters. inter-rater reliability for the BBT, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and r = 0.99).
Note: This result applies only to the most affected upper limb.

Validity

Content:

Not available.

Criterion:

Concurrent:
No gold standard exists against which to compare the BBT.

Lin, Chuang, Wu, Hsieh and Chang (2010) compared the concurrent validity of the BBT, Action Research Arm Test (ARAT) and Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with stroke. The Fugl-Meyer Assessment (FMA), Motor Activity Log (MAL) and stroke Impact Scale (SIS) were also administered to assess the concurrent validity of the BBT, ARAT and NHPT. Using Spearman rank correlation coefficient, the BBT, ARAT and NHPT were found to have adequate to excellent correlations at pre-treatment (ranging from rho=-0.55 to -0.80) and post-treatment (ranging from rho=-0.57 to -0.71). In addition, the BBT and ARAT were found to have adequate correlations with the FMA, MAL and SIS (ranging from rho=0.31-59); however, the NHPT had only poor to adequate correlations with the FMA and MAL (ranging from rho=-0.16 to -0.33); and adequate to excellent correlations with the SIS (ranging from rho=-0.58 to -0.66). When considering both the results of responsiveness and validation components of the study, the BBT and ARAT are believed to be more appropriate than the NHPT for evaluating dexterity.

Predictive:
Higgins, Mayo, Desrosiers, Salbach and Ahmed (2005) estimated wheter the BBT, Nine-Hole Peg Test (Kellor, Frost, Silberberg, Iversen, & Cummings, 1971; Mathiowetz, Weber, Kashman, & Volland, 1985-2), Frenchay Arm Test (Heller, Wade, Wood, Sunderland, Hewer, & Ward, 1987), Grip Strength (Mathiowetz, Kashman, Volland, Weber, Dowe, & Rogers, 1985-3), and stroke Rehabilitation Assessment of Movement (STREAM – Daley, Mayo, Wood-Dauphine, Danys, & Cabot, 1997) were able to predict upper limb function, measured by the BBT, at 5 weeks post-stroke. Predictive validity of the BBT was measured in 55 participants with acute stroke. Assessments were performed at two points in time: one and five weeks post-stroke. Compared to the other upper limb performance tests, the BBT when performed at one week post-stroke, was the best predictor of upper limb function at five months post-stroke, followed by the STREAM.

Construct:

Convergent/Discriminant:
Cromwell (1976) examined the convergent validity of the BBT by comparing it to the Minnesota Rate of Manipulation Test (American Guidance Service, 1969) in an unspecified population. The correlation between BBT and the Minnesota Rate of Manipulation Test was excellent (r = 0.91).

Desrosiers et al. (1994) assessed the convergent validity of the BBT by comparing it to the Functional Autonomy Measurement System – FAMS, known as the SMAF in French (Hebert, Carries, & Bilodeau, 1988), and to the Action Research Arm Test (ARAT – Lyle, 1981) in 104 elderly with upper limb impairments secondary to stroke (n=53) amongst other conditions. Excellent correlations (r = 0.80) were found between the BBT and the ARAT. Adequate pearson correlations were found between the BBT and the FAMS (r = 0.47; r = 0.51) for the right and left hand, respectively.

Platz et al. (2005) tested the convergent validity of the BBT by comparing it to the Action Research Arm Test (ARAT Lyle, 1981) and to the Fugl-Meyer Assessment (FMA)upper extremity items including items from the motor function, sensation and passive joint motion/joint pain sub-scores (Fugl-Meyer et al., 1975) using Spearman correlation, in 56 participants with upper extremity paresis either from stroke (n=37) or other conditions. Excellent correlations were found between the BBT and the ARAT (r = 0.95) and the Motor Function sub-score (r = 0.92) of the FMA. Furthermore, the BBT was correlated with more general measures of impairment and activity limitation, such as the Ashworth Scale (Ashworth, 1964), the Hemispheric stroke Scale (Adams, Meador, Sethi, Grotta, & Thomson, 1986) and the Modified Barthel Index (Collin, Wade, Davies, & Horne, 1988). Excellent correlation was found between the BBT and the Hemispheric stroke Scale (r = -0.67). Adequate correlations were found between the BBT and the passive joint motion/joint pain sub-score of the FMA (r = 0.43) and the Ashworth Scale (r = -0.38). Poor correlations were found between the BBT and the sensation sub-score of the FMA (r = 0.28) and the Modified Barthel Index (r = 0.04).
Note: Negative correlations are observed because a high score on the BBT indicates better performance, whereas a low score on the Hemispheric stroke Scale or the Ashworth Scale indicates better performance.

Known groups:
No studies have examined known groups validity of the BBT.

Responsiveness

Higgings et al. (2005) evaluated the responsiveness on the BBT, Frenchay Arm Test (Heller et al., 1987), Grip strength (Mathiowetz et al., 1985-3) and the stroke Rehabilitation Assessment of Movement (STREAM – Daley et al., 1997) in 50 participants with acute stroke. Participants were assessed one and four weeks post-stroke. The Standardized Response Mean (SRM) was used to calculate responsiveness. Amongst these upper extremity performance tests, the BBT was the most sensitive to detecting change, having a large SRM of 0.8.
Note: SRM is a variant of effect size and higher values indicate better responsiveness.

Lin, Chuang, Wu, Hsieh and Chang (2010) evaluated the responsiveness of the BBT, the Action Research Arm Test (ARAT) and the Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with subacute stroke (< 6-months) and Brunnstrom stage IV to VI for proximal and distal upper extremity function. Patients were randomly assigned to receive constraint-induced therapy, bilateral arm training or control treatment and received 2 hours of therapy, 5 days per week for 3 weeks. Assessments were performed at baseline and 3 weeks. Using Standardized Response Mean (SRM) to calculate responsiveness, the BBT, ARAT and NHPT were all found to have moderate SRM (0.74, 0.64, 0.79 respectively), indicating sensitivity for detecting change in hand dexterity. When considering both the results of responsiveness and validation components of the study, the BBT and ARAT are believed to be more appropriate than the NHPT for evaluating dexterity.

References

  • American Guidance Service. The Minnesota Rate Manipulative Tests. Examiner’s manual. Circle Pines, (MN): Author; 1969.
  • Adams, R.J., Meador, K.J., Sethi, K.D., Grotta, J.C., & Thomson, D.S. (1986). Graded neurologic scale for the use in acute hemispheric stroke treatment protocols. Stroke 18, 665-669.
  • Ashworth, B. (1964). Preliminary trial of carisoprodol in multiple sclerosis. Practitioner, 192, 540-542.
  • Broeren, J., Rydmark, M., Bjorkdahl, A., & Sunnerhagen, K.S. (2007). Assessment and training in a 3-dimensional virtual environment with haptics: a report on 5 cases of motor rehabilitation in the chronic stage after stroke. Neurorehabilitation & Neural Repair, 21(2), 180-189.
  • Collin, C., Wade, D.T., Davies, S., & Horne, V. (1988). The Barthel ADL Index: a reliability study. International Disability Study, 10, 61-63.
  • Cromwell, F.S (1965). Occupational therapists manual for basic skills assessment: primary prevocational evaluation. Pasadena, (CA): Fair Oaks Printing; 29-31.
  • Daley, K., Mayo, N.E., Wood-Dauphinee, S., Danys, I., & Cabot, R. (1997). Verification of the Stroke Rehabilitation Assessment of Movement (STREAM). Physiotherapy Canada, 49, 269-278.
  • Dannenbaum, R.M., Michaelsen, S.M., Desrosiers, J., & Levin, M.F. (2002). Development and validation of two new sensory tests of the hand for patients with stroke. Clinical Rehabilitation, 16(6), 630-639.
  • Desrosiers, J., Bravo, G., Hébert, R., Dutil, É., & Mercier, L. (1994). Validation of the box and block test as a measure of dexterity of elderly people: reliability, validity and norms studies. Archives of Physical Medicine and Rehabilitation, 75, 751-755.
  • Desrosiers, J., Rochette, A., Hebert, R., & Bravo, G. (1997). The Minnesota manual dexterity test: reliability, validity and reference values studies with healthy elderly People. Canadian Journal of Occupational Therapy, 64(5), 270-276.
  • Finch, E., Brooks, D., Stratford,P.W, & Mayo, N.E. (2002). Physical Outcome Measures: A guide to enhance physical outcome measures. Ontario, Canada: Lippincott, Williams & Wilkins.
  • Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
  • Hébert, R., Carrier, R., & Bilodeau, A. (1988). The functional autonomy measurement system (SMAF): description and validation of an instrument for the measurement of handicaps. Age Ageing, 17, 293-302.
  • Heller, A., Wade, D.T., Wood, V.A., Sunderland, A., Hewer, R., & Ward, E. (1987). Arm function after stroke: measurement and recovery over the first three months. Journal of Neurology, Neurosurgery & Psychiatry, 50(6), 714- 719.
  • Higgins, J., Mayo, N.E., Desrosiers, J., Salbach, N.M., & Ahmed, S. (2005). Upper-limb function and recovery in the acute phase poststroke. Journal of Rehabilitation Research & Development, 42(1), 65-76.
  • Jebsen, R.H., Taylor, N., Trieschmann, R.B., Trotter, M.J., & Howard, L.A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50, 311-319.
  • Kellor, M., Frost, J., Silberberg, N., Iversen, I., & Cummings R. (1971). Hand strength and dexterity. American Journal of Occupational Therapy, 25, 77-83.
  • Lin, K-C., Chuang, L-L., Wu, C-Y., Hseih, Y-W. & Chang, W-Y. (2010). Responsiveness and validity of three dexterous function measures in stroke rehabilitation. Journal of Rehabilitation Research and Development, 47(6), 563-572.
  • Lyle, R.C. (1981). A performance test for assessment of upper limb function in physical rehabilitation treatment and research. International Journal of Rehabilitation and Research, 4, 483-492.
  • Mathiowetz, V., Volland, G., Kashman, N., & Weber, K. (1985-1). Adult norms for the box and block test of manual dexterity. American Journal of Occupational Therapy, 39, 386-391.
  • Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985-2). Adult norms for the nine hole peg test of finger dexterity. Occupational Therapy Journal of Research, 5, 24 -33.
  • Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985-3). Grip and pinch strength: normative data for adults. Archives of Physical and Medicine and Rehabilitation, 66, 69-72.
  • Mercier, C. & Bourbonnais, D. (2004). Relative shoulder flexor and handgrip strength is related to upper limb function after stroke. Clinical Rehabilitation, 18(2), 215-221.
  • Platz, T., Pinkowski, C., van Wijck, F., Kim, I.H., di Bella, P., & Johnson, G. (2005). Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clinical Rehabilitation, 19(4), 404-411.
  • Schneider, S., Schonle, P.W., Altenmuller, E., & Munte, T.F. Using musical instruments to improve motor skill recovery following a stroke. Journal of Neurology, 254(10), 1339-1346.
  • Tiffin, J. (1968). Purdue Pegboard Examiner Manual. Chicago, USA: Science Research Associates.

See the measure

How to obtain the BBT

The BBT instructions can be obtained in the study by Mathiowetz et al. (1985)

Standardized equipment can be obtained at the website:
http://www.sammonspreston.com/Supply/Product.asp?Leaf_Id=7531

By clicking here, you can access a video showing how to administer the assessment.

Table of contents

Chedoke Arm and Hand Activity Inventory (CAHAI)

Evidence Reviewed as of before: 08-01-2009
Author(s)*: Sabrina Figueiredo, BSc
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc
Expert Reviewer: Susan Barreca,MSc, PT

Purpose

The Chedoke Arm and Hand Activity Inventory (CAHAI) is a functional assessment of the recovering arm and hand after stroke. The CAHAI compliments the Chedoke-McMaster stroke Assessment (Barreca, Stratford, Masters, Lambert, Griffiths, and McBay, 2006).

In-Depth Review

Purpose of the measure

The Chedoke Arm and Hand Activity Inventory (CAHAI) is a functional assessment of the recovering arm and hand after stroke. The CAHAI compliments the Chedoke-McMaster stroke Assessment (Barreca, Stratford, Masters, Lambert, Griffiths, and McBay, 2006).

Available versions

The CAHAI was developed by Barreca, Gowland, Stratford, Huijbregts, Griffiths, Torresin, Dunkley, Miller, and Masters in 2004 to address the need for a valid, clinically relevant, and responsive functional assessment of the recovering paretic upper limb.

Three shortened versions of the CAHAI were developed by Barreca, Stratford, Masters, Lambert, Griffiths, and McBay in 2006. The shortened versions have 7, 8 or 9 items and are identified as CAHAI-7, CAHAI-8, CAHAI-9, respectively.

Features of the measure

Items:

The original CAHAI consists of 13 functional items that are non-gender specific, involve both upper limbs, and incorporates a range of movements and grasps that reflect stages of motor recovery following stroke. The following items were generated from a review of the scientific literature on stroke, as well as from input from individuals with stroke and their families (Barreca et al., 2004):

  1. Open a jar of coffee
  2. Dial 911
  3. Draw a line with a ruler
  4. Pour a glass of water
  5. Wring out a washcloth
  6. Do up five buttons
  7. Dry back with a towel
  8. Put toothpaste on a toothbrush
  9. Cut medium consistency putty
  10. Clean eye glasses
  11. Zip up a zipper
  12. Place a container on a table
  13. Carry a bag up the stairs

The CAHAI-7 utilizes the first 7 items, CAHAI-8 the first 8 items, and CAHAI-9 the first 9 items. The 13 items together represent the original CAHAI (Barreca et al., 2006). On average, clients with stroke consider items 1, 2, 4 and 12 easy to perform; items 8, 10, 11, and 13 moderately difficult; and items 3, 6, 7, and 9 the most difficult (Barreca et al., 2004).

Detailed administration guidelines are in the development manual that can be obtained can be obtained by visiting the official website: http://www.cahai.ca

Scoring:

Each item of the CAHAI is scored on a 7-point quantitative scale, similar to the scale used in the Functional Independence Measure (FIM) (Keith, Granger, Hamilton, & Sherwin, 1987)

A score of

  • 1 = client needs total assistance and the weak upper limb performs less than 25% of the task;
  • 2 = client needs maximal assistance and the weak upper limb performs 25% to 49% of the task. There are no signs of arm or hand manipulation, only stabilization;
  • 3 = client needs moderate assistance and the weak upper limb performs 50% to 74% of the task. Begins to show signs of arm or hand manipulation;
  • 4 = client needs minimal assistance (light touch) and the weak upper limb performs more than 75% of the task;
  • 5 = client requires supervision, coaxing, or cueing;
  • 6 = client requires use of assistive devices or requires more than reasonable time, or there are safety concerns; and
  • 7 = total independence in completing the task.

The minimal possible score for the CAHAI is 13 and the maximum is 91, with higher scores indicating greater functional independence (Barreca et al., 2004; Barreca, Stratford, Lambert, Masters, & Streiner, 2005; Barreca, Stratford, Masters, Lambert, & Griffiths, 2006b).

The affected limb is also scored according to its positioning and functioning during test performance. The therapist should record the performance of the affected limb on each item by checking the appropriate box. The scoring table for the CAHAI is as follows: (Barreca et al., 2004):

Items Affected Limb
1) Open a jar of coffee Holds jar Holds lid
2) Call 911 Holds receiver Dials phone
3) Draw a line with ruler Holds ruler Holds pen
4) Put toothpaste on toothbrush Holds toothpaste Holds brush
5) Cut medium consistency putty Holds knife Holds fork
6) Pour a glass of water Holds glass Holds pitcher
7) Clean a pair of eyeglasses Holds glasses Wipes lenses
8) Zip up the zipper Holds zipper Holds zipper pull
9) Dry back with towel Reaches for towel Grasps towel end

Note: Standardized instructions on scoring can be obtained by visiting the official website: http://www.cahai.ca

Time:

The time to administer and score the CAHAI is approximately 25 minutes (Barreca et al., 2004; Barreca et al., 2006).

Subscales:

None

Equipment required:

CAHAI-7

Version (Items 1-7) requires all items in Equipment List A

Equipment List A

  • height adjustable table
  • chair/wheelchair without armrests
  • dycem
  • 200g jar of coffee
  • push-button telephone
  • 12″/30cm ruler
  • 8.5″ x 11″ paper
  • pencil
  • 2.3L plastic pitcher with lid filled with 1600 ml. Water
  • 250 ml plastic cup
  • wash cloth
  • wash basin (24.5 cm. in diameter, height 8 cm.)
  • Pull-on vest with 5 buttons (one side male & one side female), buttons (1.5 cm. In diameter, 7 cm. apart)
  • bath towel (65cm X 100cm)

CAHAI-8

Version (Items 1-8) requires all items in Equipment List A and B

Equipment List B

  • 75ml toothpaste with screw lid, >50% full
  • toothbrush

CAHAI-9

Version (Items 1-9) requires all items in Equipment List A, B, and C

Equipment List C

  • dinner plate (Melamine or heavy plastic, 25 cm. in diameter)
  • medium resistance putty
  • knife and fork
  • built up handles the length of the utensil handle

CAHAI-13

Version (Items 1-13) requires all items in Equipment List A, B, C, and D

Equipment List D

  • 27″/67cm metal zipper in polar fleece poncho
  • eyeglasses
  • handkerchief
  • Rubbermaid 38L container (50 x 37 x 27cm)
  • 4 standard size steps with rail
  • plastic grocery bag holding 4lb/2kg weight

Training:

Training may be provided by the authors as a half-day workshop. There is a training DVD available in English for a cost of $29.00 Canadian including shipping. Only cheque or money orders are processed.

Alternative forms of the CAHAI

CAHAI-7, CAHAI-8, CAHAI-9

Client suitability

Can be used with:

  • Clients with stroke.

Should not be used in:

  • To date, there is no information on restrictions of using the CAHAI.

In what languages is the measure available?

English, French, German, Hebrew, Italian

Summary

What does the tool measure? The CAHAI assess upper limb functional recovery.
What types of clients can the tool be used for? The CAHAI can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer An average of 20 to 25 minutes
Versions CAHAI, CAHAI-9, CAHAI-8, CAHAI-7.
Other Languages English, French, German, Hebrew and Italian.
Measurement Properties
Reliability Internal consistency:
Two studies have examined the Internal consistency of the CAHAI and its shortened versions and reported excellent Internal consistency using Cronbach’s alpha.

Test-retest:
One study examined the test-retest reliability of the CAHAI and reported excellent test-retest reliability using using the Intraclass Correlation Coefficient (ICC).

Intra-rater:
No studies have examined the intra-rater reliability of the CAHAI.

Inter-rater:
One study examined the inter-rater reliability of the CAHAI and reported excellent inter-rater reliability using ICC.

Validity Content:
One study examined the content validity of the CAHAI and reported that items were generated from a review of scientific literature and from input from clients with stroke, their family and caregivers. Items with poor frequency endorsement, difficulty to be standardized, and high inter-item correlation were eliminated.

Criterion:
Concurrent:
One study examined the concurrent validity of the CAHAI and the CAHAI-9 and reported that the CAHAI-9 was not able to predict individual scores and individual change scores of the CAHAI, using regression analysis.

Predictive:
No studies have examined the predictive validity of the CAHAI.

Construct:
Convergent:
Three studies examined convergent validity of the CAHAI and reported excellent correlations between all versions of the CAHAI and the Action Research Arm Test, and all versions of the CAHAI and the Chedoke-McMaster stroke Assessment (CMSA), and poor to moderate correlations between the CAHAI and the CMSA shoulder pain score, using Pearson correlation.

Known Groups:
Three studies examined longitudinal/known groups Validity of all versions of the CAHAI and reported that all versions are able to distinguish changes between subjects with acute and chronic stroke, and mild from severe impairments, using ROC curve (Receiver Operation Characteristic).

Floor/Ceiling Effects No studies have examined the floor/ceiling effects of the CAHAI.
Sensitivity/ Specificity No studies have examined the Sensitivity/specificity of the CAHAI.
Does the tool detect change in patients? One study examined the responsiveness of the CAHAI and reported that the minimal detectable change between two evaluations in stable patients was 6.3 points.
Acceptability The CAHAI is highly accepted by clients with stroke since is made up of real-life and non-gender specific items.
Feasibility The administration of the CAHAI is easy and quick to perform.
How to obtain the tool? The CAHAI can be obtained free of charge by visiting the official website: http://www.cahai.ca

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Chedoke Arm and Hand Activity Inventory (CAHAI) in individuals with stroke. We identified four studies. The CAHAI appears to be responsive in clients with stroke.

Floor/Ceiling Effects

No studies have examined floor/ceiling effects of the CAHAI.

Reliability

Internal Consistency:
Barreca, Gowland, Stratford, Huijbregts, Griffiths, Torresin, Dunkley, Miller, and Masters (2004) assessed the Internal Consistency of the CAHAI in 100 clients with stroke. Internal Consistency of the CAHAI, as calculated using Cronbach’s Coefficient Alpha was excellent (α = 0.98).

Barreca, Stratford, Masters, Lambert, Griffiths, and McBay (2006) examined the Internal Consistency of the CAHAI-7, CAHAI-8, and CAHAI-9 in 39 clients with stroke. Internal Consistency of all shortened versions of the CAHAI, as calculated using Cronbach’s Coefficient Alpha, was excellent (α = 0.97; α = 0.98; α = 0.98, respectively).

Test-retest:
Barreca et al. (2006) examined the test-retest reliability of the shortened version of the CAHAI in 39 clients with stroke. Participants were stratified into two different groups based on the amount of expected improvement. Participants were re-assessed following a 36 hour interval. The test-retest reliability as calculated using Intraclass Correlation Coefficient (ICC) was excellent for all shortened versions: CAHAI-7 (ICC = 0.96), CAHAI-8 (ICC = 0.97), and CAHAI 9 (ICC = 0.97).

Intra-rater:
No studies have examined the intra-rater reliability of the CAHAI.

Inter-rater:
Barreca, Stratford, Lambert, Masters, and Streiner (2005) assessed the inter-rater reliability of the CAHAI in 39 clients with stroke. Participants were stratified into two different groups based on the amount of expected improvement. Participants were re-assessed following a 36 hours interval. The inter-rater reliability as calculated using Intraclass Correlation Coefficient (ICC), was excellent (ICC = 0.98).

Validity

Content:

Barreca et al. (2004) performed a literature review to generate items for the CAHAI. From this review, 177 items were selected. Eighty-one clients with stroke, their families and caregivers were surveyed about important and relevant items regarding stroke recovery, which generated an additional 574 items. To reduce the 725 generated items to 26 items, only bilateral, gender-neutral items, that fell into the domains identified by the clients as important that were easy to obtain were kept. This version, with 26 items, was then tested in 20 participants with stroke. Items that were difficult to standardize or those with the potential for safety concerns were eliminated. Items with a high degree of difficulty were added in order to minimize possible ceiling effects. Inter-item correlation analyses of this new version (which contained 25 items), identified some redundant items (r > 0.90). Items with poor frequency endorsement, difficulty to standardize and high inter-item correlation were eliminated, resulting in the 13 finalized items.

Criterion:

Concurrent:
Barreca, Stratford, Masters, Lambert, & Griffiths (2006b) examined the ability of the CAHAI-9 to predict the scores and change scores of the original CAHAI in 105 clients with stroke. Mean scores and mean change scores of the CAHAI-9 accurately predicted means scores and mean change scores of the CAHAI. However, individual scores and individual change scores of the CAHAI-9 displayed moderate variability in predicting individual scores and change scores of CAHAI. The findings indicate that the CAHAI-9 should not be administered with the intent to predict the CAHAI.

Predictive:
No studies have examined the predictive validity of the CAHAI.

Construct:

Convergent/Discriminant:
Barreca et al. (2005) estimated convergent validity of the CAHAI by comparing it to Chedoke-McMaster stroke Assessment (CMSA – Gowland, Stratford, Ward, Moreland Torresin, VanHullenaar et al., 1993; Gowland, VanHullenaar, Torresin, et al., 1995) arm-hand sum score, and with the Action Research Arm Test (ARAT – Lyle, 1981) in 39 participants with stroke. Assessments were performed at baseline and 2 to 6 weeks later. Correlations, as calculated using Pearson correlation Coefficient were excellent between the CAHAI and the ARAT (r = 0.93) and between the CAHAI and the CMSA arm-hand at baseline (r = 0.81) and at follow up (r = 0.89). In the same study, the authors analyzed discriminant validity of the CAHAI by comparing it to the CMSA shoulder pain score in the same 39 participants with stroke. The correlation between the CAHAI and CMSA shoulder pain score as calculated using Pearson correlation, was adequate at baseline (r = 0.47) and at follow-up (r = 0.39).

Barreca et al. (2006) assessed the convergent validity of the CAHAI-7, CAHAI-8 and CAHAI-9 by comparing them to the Action Research Arm Test (ARAT), CAHAI and CMSA in 39 individuals with stroke. Pearson Correlations were used. Correlations between the ARAT and CAHAI-7 (r = 0.95), CAHAI-8 (r = 0.95) and CAHAI-9 (r = 0.94) were all excellent , as well as between the CAHAI and all the shortened versions (r = 0.99), and between the CMSA and CAHAI-7 (r = 0.85), CAHAI-8 (r = 0.84), and CAHAI-9 (r = 0.84).

Barreca et al., (2006b) determined the convergent validity of the CAHAI-9 and CAHAI by comparing them to the ARAT (Lyle, 1981) in 105 individuals with stroke. Re-assessments were performed with a 36 hours interval. Pearson correlation Coefficients were excellent between the CAHAI-9 and ARAT at baseline (r = 0.93), and at follow-up (r = 0.95), as well as between the CAHAI at baseline (r = 0.93), and at follow-up (r = 0.95).

Known groups:
Barreca et al. (2005) analyzed the longitudinal validity of the CAHAI in 39 clients with stroke by comparing change scores on the CAHAI with change scores on the arm-hand sum and on the shoulder pain dimensions of the Chedoke-McMaster stroke Assessment (CMSA – Gowland et al., 1995) and on the Action Research Arm Test (ARAT – Lyle, 1981). Change scores correlations, as calculated using Pearson correlation Coefficient, was excellent between the CAHAI and the ARAT (r = 0.86), adequate between the CAHAI and the CMSA arm-hand sum (r = 0.52) and poor between the CAHAI and the CMSA shoulder pain (r = -0.24). In a second analysis, Barreca et al. (2005) analyzed whether the CAHAI was more adept then the CMSA and the ARAT at distinguishing change in patients with mild/moderate impairments from patients with severe impairments in 39 clients with stroke. Longitudinal/known groups validity, as calculated using Receiver Operating Characteristic (ROC) demonstrated an excellent area under the curve for the CAHAI (ROC = 0.95). The ARAT and CMSA presented an adequate area under the curve (ROC = 0.88; ROC = 0.76), respectively.
Note: ROC curve analysis quantifies a measure’s ability to distinguish between groups as an area under the ROC curve. Greater areas indicate the measure is better at discriminating between individuals in the two groups.

Barreca et al. (2006) assessed the longitudinal validity of the CAHAI and its three shortened versions in 39 participants with stroke. Participants were divided according to stroke’s severity into acute and chronic groups. The CAHAI, CAHAI-7, CAHAI-8, and CAHAI-9 were administered at admission and discharge (2 to 6 weeks after admission) to verify which version was more adept to detecting changes in patients with acute stroke from patients with chronic stroke. Longitudinal/known groups validity, as calculated using Receiver Operating Characteristic (ROC) demonstrated an excellent area under the curve for all versions of the CAHAI as follows: CAHAI (ROC = 0.95); CAHAI -7 (ROC = 0.97); CAHAI-8 (ROC = 0.93), and CAHAI-9 (ROC = 0.94), meaning all versions of CAHAI are equally able to distinguish changes between different groups in stroke.

Barreca et al. (2006b) examined the longitudinal validity of the CAHAI, CAHAI-9 and the ARAT in 105 individuals with stroke. Participants were stratified between mild/moderate impairments and severe impairments, and those with mild/moderate impairments were expected to show greater changes across two repeated measures. The three outcome measures were administered at two points in time to verify which of them were more adept to detecting changes in clients with mild/moderate impairment from clients with severe impairment. Longitudinal/known groups validity, as calculated using Receiver Operating Characteristics, were adequate for the ARAT (ROC = 0.72), the CAHAI -9 (ROC = 0.82), and the CAHAI (ROC = 0.86). This ROC analysis indicated that the CAHAI was the best measure to detect change among patients with mild/moderate impairment from patients with severe impairment.

Responsiveness

Barreca et al. (2005) assessed the minimal detectable change of the CAHAI in 39 clients with stroke. Participants were assessed at two points in time: at admission, and after 2 to 6 weeks. For the CAHAI, the minimal detectable change was 6.3 points, meaning that stable patients displayed random fluctuations of 6.3 CAHAI points or less when assessed on two different occasions.

References

  • Barreca, S.R., Gowland, C.K., Stratford, P.W., et al. (2004). Development of the Chedoke Arm and Hand Activity Inventory: Theoretical constructs, item generation, and selection. Topics in Stroke Rehabilitation, 11(4), 31- 42.
  • Barreca, S.R., Stratford, P.W., Lambert, C.L., Masters, L.M., & Streiner, D.L. (2005). Test-retest reliability, validity, and sensitivity of the Chedoke Arm and Hand Activity Inventory: a new measure of upper-limb function for survivors of stroke. Archives of Physical Medicine and Rehabilitation, 86, 1616-1622.
  • Barreca, S.R., Stratford, P.W., Masters, L.M., Lambert, C.L., Griffiths, J., McBay, C. (2006). Validation of three shortened versions of the Chedoke Arm and Hand Activity Inventory. Physiotherapy Canada, 58, 148-156.
  • Barreca, S.R., Stratford, P.W., Masters, L.M., Lambert, C.L., Griffiths, J. (2006b). Comparing two versions of the Chedoke Arm and Hand Activity Inventory with the Action Research Arm Test. Physical Therapy, 86(2), 245-253.
  • Gowland, C., Stratford, P., Ward, M., Moreland, J., Torresin, W., VanHullenaar, S. et al.(1993). Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke, 24,58-63.
  • Gowland, C., VanHullenaar, S., Torresin, W., et al. (1995). Chedoke-McMaster Stroke Assessment: development, validation, and administration manual. Hamilton, ON, Canada: School of Rehabilitation Science, McMaster University.
  • Heller, A., Wade, D.T., Wood, V.A., Sunderland, A., Hewer, R., & Ward, E. (1987). Arm function after stroke: measurement and recovery over the first three months. Journal of Neurology, Neurosurgery & Psychiatry, 50(6), 714-719.
  • Keith, R.A, Granger, C.V., Hamilton, B.B., & Sherwin, F.S. (1987). The Functional Independence Measure: a new tool for rehabilitation. In: Eisenberg, M.G. & Grzesiak, R.C. (Ed.), Advances in clinical rehabilitation (pp. 6-18). New York: Springer Publishing Company.
  • Kellor, M., Frost, J., Silberberg, N., Iversen, I., & Cummings R. (1971). Hand strength and dexterity. American Journal of Occupational Therapy, 25, 77-83.
  • Lyle, R.C. (1981). A performance test for assessment of upper limb function in physical rehabilitation treatment and research. International Journal of Rehabilitation and Research, 4, 483-492.
  • Mathiowetz, V., Kashman, N., Volland, G., Weber, K., Dowe, M., & Rogers, S. (1985). Grip and pinch strength: normative data for adults. Archives of Physical and Medicine and Rehabilitation, 66, 69-72.
  • Mathiowetz, V., Weber, K., Kashman, N., & Volland, G. (1985b). Adult norms for the nine hole peg test of finger dexterity. Occupational Therapy Journal of Research, 5, 24 -33.

See the measure

How to obtain the CAHAI

The CAHAI can be obtained free of charge by visiting the official website: http://www.cahai.ca

Table of contents

Comprehensive Coordination Scale (CCS)

Evidence Reviewed as of before: 11-11-2021
Author(s)*: Sandra R. Alouche; Marika Demers; Roni Molad ; Mindy F. Levin

Purpose

The Comprehensive Coordination Scale (CCS) is a measure of coordination of multiple body segments at both motor performance (endpoint movement) and quality of movement (joint rotations and interjoint coordination) levels based on observational kinematics.

In-Depth Review

Purpose of the measure

 The Comprehensive Coordination Scale (CCS) is a measure of coordination of multiple body segments at both motor performance (endpoint movement) and quality of movement (joint rotations and interjoint coordination) levels based on observational kinematics. Coordinated movements are defined as movements of one or more limbs or body segments that occur together in identifiable temporal (i.e., timing) and spatial (i.e., positional/angular) patterns, concerning the desired action. It can be measured at a specific point in time during the movement or over the whole movement time.

The CCS can be used by healthcare professionals to assess coordination in older adults and individuals with various neurological conditions. The CCS is composed of six different tests: the Finger-to-Nose Test, the Arm-Trunk Coordination Test, the Finger Opposition Test, the Interlimb Coordination (synchronous anti-phase forearm rotations) Test, the Lower Extremity MOtor COordination Test (LEMOCOT) and the Four-limb Coordination (Upper and lower limb movements) Test.

Available versions

The CCS was developed by Alouche et al. (2021) from valid and reliable tests used in clinical practice and research to assess complementary aspects of motor coordination of the trunk, upper limb (UL), lower limb (LL) and combinations of them. Behavioral elements used to perform each test were identified and rating scales were developed to guide observational kinematic analysis by expert consensus (Alouche et al., 2021).

Features of the measure

 Items:
The CCS consists of 6 different tests used in either clinical practice or research to assess complementary aspects of motor coordination of the trunk, upper limb (UL), lower limb (LL) and combinations of them.

  1. Finger-to-Nose Test (FTN)
  2. Arm-Trunk Coordination Test (ATC)
  3. Finger Opposition Test (FOT)
  4. Interlimb Coordination Test (ILC-2)
  5. Lower Extremity MOtor COordination Test (LEMOCOT)
  6. Four-limb Coordination Test (ILC-4)
Parties du corps testées Type de test Test Éléments comportementaux notés
Membre supérieur Unilatéral Finger-to-Nose (FTN) Spatial : Stabilité, souplesse, précision
Temporel : Vitesse
Tronc et bras Unilatéral Arm-Trunk Coordination test (ATC) Spatial : Précision, coordination inter-articulations
Membre supérieur (dextérité fine) Unilatéral Finger Opposition (FOT) Spatial : Sélectivité
Temporel : Temps
Coordination inter-membres = les deux membres supérieurs Bilatéral Alternate movements of two upper limbs (ILC-2) Spatial : Compensation
Temporel : Synchronicité/temps
Membre inférieur Unilatéral Lower Extremity MOtor COordination Test (LEMOCOT) Spatial : Souplesse, précision
Temporel : Vitesse
Coordination des quatre membres = membres supérieurs et membres inférieurs Bilatéral Alternate movements of both hands and feet (ILC-4) Temporel : Temps/complexité

Scoring:
Multiple behavioral elements of each test are scored on separate rating scales ranging from 3 (normal coordination) to 0 (impaired coordination) to assess different elements of motor behavior needed to perform the action.
The CCS includes a total of 13 rating scales for the 6 tests.
The CCS score ranges from 0 to 69 points, with higher scores indicating better motor coordination. The CCS total score represents a coordination score for the whole body.
The CCS scores can be broken into 4 subscores: UL, LL, Unilateral, Bilateral.
UL: 54 points (includes FTN-24 points, ATC-12 points, FOT-12 points, and ILC2-6 points).
LL: 12 points (includes LEMOCOT-12 points).
Unilateral: 30 points (includes FTN-12 points, ATC-6 points, FOT-6 points, and LEMOCOT-6 points).
Bilateral: 9 points (includes ILC2-6 points and ILC4-3 points).
The manual describes the initial position, the instructions, and the detailed scoring.

What to consider before beginning:
The CCS is scored based on observational kinematics.

Time:
The CCS takes approximately 10-15 minutes to administer (Molad et al., 2021).

Training requirements:
The healthcare professional should read the CCS manual available on Open Science Framework:  Marika Demers, Mindy F Levin, Roni Molad, and Sandra Alouche. 2021. “Comprehensive Coordination Scale.” OSF. July 12. osf.io/8h7nm.

 Equipment:

  • Chair with back support and without armrests (suggested seat height: 46 cm)
  • Footstool, if needed
  • Targets:
    • One 2.54 cm-diameter sticker (FNT)
    • One target (sphere of 2.54 cm-diameter or a cube of similar dimensions) on an adjustable height support (ATC)
    • Two 5 cm-diameter stickers placed 30 cm (centre-to-centre) apart and attached to a cardboard (LEMOCOT test)
  • Stopwatch / timer
  • Table (optional, suggested height: 72 cm)
  • Pillow (optional)

Client suitability

Can be used with:

  • Individuals with neurological disorders

Should not be used with:

  • No information availble

In what languages is the measure available?

English

Summary

What does the tool measure? Temporal and spatial aspects of coordination.
What types of clients can the tool be used for? The CCS can be used with patients with neurological disorders.
Is this a screening or assessment tool? Assessment tool.
Time to administer 10-15 minutes.
ICF Domain Body function.
Other Languages French Canadian, Portuguese (both not published)
Measurement Properties
Reliability Internal consistency:
One study has reported high Internal consistency of the CCS in a stroke population (Molad et al., 2021).

Test-retest:
One study examined test-retest reliability of the CCS within a stroke population and reported excellent test-retest reliability (ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).

Intra-rater:
One study examined intra-rater reliability of the CCS within a stroke population and reported excellent intra-rater reliability (ICC = 0.97; 95% CI: 0.93-0.98; Molad et al., 2021).

Inter-rater:
One study examined intra-rater reliability of the CCS within a stroke population and reported excellent intra-rater reliability (ICC = 0.98, 95% CI: 0.95-0.99; Molad et al., 2021).

Validity Content:
One study has examined the content validity of the CCS. Using a Delphi Study done by a panel of experts. The CCS was found to have strong content validity (Alouch et al., 2021).

Criterion:
Concurrent:
Concurrent validity of the CCS has not been examined within a stroke population.
Predictive:
Predictive validity of the CCS has not been examined within a stroke population.

Construct:
Convergent/Discriminant:
One study has examined convergent validity of the CCS within a stroke population and reported: Adequate convergent validity with Fugl-Meyer-Total Score (ρ=0.602; p=0.001) and Fugl-Meyer-Motor Score (ρ=0.585; p<0.001) (Molad et al, 2021).
Known Groups:
One study has examined the known-group Validity of the upper-limb Interlimb Coordination Test (ICL2), a subscale of the CCS, within a stroke population and reported that the ICL2 is able to distinguish between aged-match healthy individiuals and chronic stroke survivors (Molad & Levin, 2021).

Floor/Ceiling Effects One study reported excellent floor and ceiling effects for the CCS (Molad et al., 2021).
Does the tool detect change in patients? No studies have reported on the responsiveness of the CCS within a stroke population.
Acceptability The CCS is non-invasive and quick to administer. The use of visual observation instead of complex and costly motion analysis equipment to analyze movement makes this scale clinically accessible and easy to use.
Feasibility The CCS is free and is suitable for administration in various settings. The assessment requires minimal specialist equipment or training. It takes 10-15 minutes to be completed.
How to obtain the tool? Alouche SR, Molad R, Demers M, Levin MF. Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase content validity Process. Neurorehabil Neural Repair. 2021 Feb;35(2):185-193. doi: 10.1177/1545968320981955. [Supplementary materials]
The CCS manual can be accessed on the Open Science Framework website: Marika Demers, Mindy F Levin, Roni Molad, and Sandra Alouche. 2021. “Comprehensive Coordination Scale.” OSF. July 12. osf.io/8h7nm.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Comprehensive Coordination Scale (CCS) in individuals with stroke. We identified two studies.

Floor/Ceiling Effects

Molad et al. (2021) examined floor/ceiling effects of the CCS in a sample of 30 participants with chronic stroke. There were no floor/ceiling effects for the total score of the CCS and CCS-Bilateral subscale. For the CCS-UL and CCS-LL subscales, 3.3% and 6.7% of participants reached the maximal score, respectively. Ten percent of participants scored 0 or 30 on the CCS-Unilateral subscale.

Reliability

Internal consistency:
Molad et al. (2021) assessed the Internal consistency of the CCS in a sample of 30 chronic stroke survivors, using principal component analysis and confirmatory factor analysis. The authors reported excellent Internal consistency (composite reliability = 0.938). Factor analysis of the entire CCS revealed two components explaining 99% of the variance: Factor 1: movement quality (8 items), Factor 2: endpoint performance (5 items).

Intra-rater:
Molad et al. (2021) assessed the intra-rater reliability of the CCS in 30 chronic stroke survivors. The intra-rater reliability was evaluated with intraclass correlation coefficients (ICC) with 95% confidence intervals (CI). The CCS has excellent intra-rater reliability (ICC = 0.97; 95%; CI: 0.93-0.98). All four subscales also have excellent intra-rater reliability: CCS-UL subscale (ICC = 0.96; 95%; CI: 0.92-0.98), CCS-LL subscale (ICC = 0.79; 95%; CI: 0.36-0.92), CCS-Unilateral (ICC = 0.98; 95%; CI: 0.96-0.99) and CCS-Bilateral scores (ICC = 0.95; 95%CI: 0.89-0.97).

Inter-rater:
Molad et al. (2021) assessed the inter-rater reliability of the CCS in 30 chronic stroke survivors. The inter-rater reliability was evaluated with intraclass correlation coefficients (ICC) with 95% confidence intervals (CI). The CCS has excellent inter-rater reliability (ICC = 0.98; 95%; CI: 0.95-0.99). All four subscales also have excellent inter-rater reliability: CCS-UL subscale (ICC = 0.96; 95%; CI: 0.91-0.98), CCS-LL subscale (ICC = 0.76; 95%; CI: 0.25-0.9), CCS-Unilateral scores (ICC = 0.99; 95%; CI: 0.97-0.99) and CCS-Bilateral (ICC = 0.95; 95%; CI: 0.89-0.98).

Validity

Content:
Alouche et al. (2021) conducted a 3-phase content validation supporting the importance, level of comprehension and feasibility of the CCS in identifying and quantifying coordination of movements made by individuals with neurological deficits in a clinical setting. First, a literature review was performed to generate unilateral and bilateral tests of UL, LL, and trunk coordination currently used in clinical practice or research studies for the CCS. From the 2761 studies reviewed, 5 tests were selected: FTN, ATC, LEMOCOT, ILC2, and ILC4. A Delphi study, using a structured questionnaire with open-ended questions, was done with 8 expert clinicians and researchers to identify the relative importance of each test, test element, and rating scales, the level of comprehension of the instructions, and the feasibility of each test. Then, a focus group meeting was held with 6 experts to refine the instructions and the rating scales. A consensus was reached to add the Finger Opposition Test (FOT) to the final version of the CCS to assess the selectivity and timing of finger movements.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the CCS.

Predictive:
No studies have reported on the predictive validity of the CCS.

Construct:
Convergent/Discriminant:
Molad et al. (2021) examined the convergent validity in a sample of 30 chronic stroke survivors. convergent validity of the total CCS was measured with the Fugl-Meyer Assessment (total score and motor score). Adequate convergent validity of the CCS with FMA-Total Score (ρ=0.602; p=0.001) and FMA-Motor Score (ρ=0.585; p<0.001) was obtained. The convergent validity of the subcales was measured with the Fugl-Meyer Assessment, prehension and pinch strength, Box and Blocks and 10-meter walk test. CCS-UL and CCS-Unilateral scores were moderate to strongly correlated with the Fugl-Meyer Assessment (total score and motor score), prehension and pinch strength, Box and Blocks and 10-meter walk test. The CCS-LL subscale was moderately correlated with the Fugl-Meyer Assessment (total score and motor score) and the Box and Blocks. The CCS-Bilateral subscale was moderately correlated with the Fugl-Meyer Assessment (total score and UL motor score) and the Box and Blocks.

Known Group:
Molad & Levin (2021) examined the known group validity of the ILC2 subscale in a sample of 13 stroke survivors and 13 healthy participants. They compared ILC2 scores with trunk and upper limb kinematics during synchronous bilateral anti-phase forearm rotations in 4 conditions: self-paced internally-paced, fast internally-paced, slow externally-paced, and fast externally-paced. Healthy participants had near maximal ILC2 scores and high temporal and spatial coordination indices. However, participants with stroke had lower ILC2 scores and used trunk and shoulder compensations to perform the task. ILC2 scores distinguished between healthy participants and participants with chronic stroke.

Responsiveness

 The responsiveness for the CCS has not been established.

Measurement error:
Molad et al. (2021) examined the measurement error in a sample of 30 chronic stroke survivors. The standard error of the measurement (SEM) was calculated based on the standard deviation (SD) of the sample and the reliability of measurement.  The minimal detectable change (MDC) at the 95% confidence level was computed. The CCS SEM was 1.80 points and the MDC95 was 4.98 points. The SEM and MDC values for the CCS, the CCS-UL, CCS-Unilateral and CCS-bilateral were less than 17%. Only the CCS-LL had an MDC greater than 17%.  For the CCS and all subscales, the SEM was smaller than the MDC.

References

Alouche, S.R., Molad, R., Demers, M., Levin, M.F. (2021) Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase Content Validity Process. Neurorehabil Neural Repair. 35(2):185-193. doi: 10.1177/1545968320981955. PMID: 33349134.

Molad, R., Alouche, S.R., Demers, M., Levin, M.F. (2021) Development of a Comprehensive Outcome Measure for Motor Coordination, Step 2: Reliability and Construct Validity in Chronic Stroke Patients. Neurorehabil Neural Repair. 35(2):194-203. doi: 10.1177/1545968320981943. PMID: 33410389.

Molad, R., & Levin, M. F. (2021) Construct validity of the upper-limb Interlimb Coordination Test (ILC2) in stroke. Neurorehabil Neural Repair [epub ahead of print]. doi: 10.1177/1545968321105809. PMID: 34715755

See the measure

The tool is available as supplementary material in:
Alouche SR, Molad R, Demers M, Levin MF. Development of a Comprehensive Outcome Measure for Motor Coordination; Step 1: Three-Phase content validity Process. Neurorehabil Neural Repair. 2021 Feb;35(2):185-193. doi: 10.1177/1545968320981955. [Supplementary materials]

The CCS manual can be accessed on the Open Science Framework website:
Marika Demers, Mindy F Levin, Roni Molad, and Sandra Alouche. 2021. “Comprehensive Coordination Scale.” OSF. July 12. osf.io/8h7nm.

Table of contents

Disabilities of the Arm, Shoulder and Hand (DASH)

Evidence Reviewed as of before: 19-06-2012
Author(s)*: Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Natasha Lannin (Associate Professor, OT)
Content consistency: Gabriel Plumier

Purpose

The Disabilities of the Arm, Shoulder and Hand (DASH) is a self-report questionnaire that measures disability and symptoms of upper limb musculoskeletal disorders.

In-Depth Review

Purpose of the measure

The Disabilities of the Arm, Shoulder and Hand (DASH) is a self-report questionnaire that measures physical function and symptoms of the upper limb. The DASH can be used for any joint and any musculoskeletal condition of the upper limb (Hudak et al., 1996; Veehof et al., 2002), which permits comparison across upper limb diagnoses (Atroshi et al., 2000). The DASH is intended for discriminative and evaluative purposes (Schmitt & Di Fabio, 2004).

The DASH demonstrates validity and responsiveness in proximal and distal upper limb disorders (Beaton et al., 2001). The DASH demonstrated better clinimetric properties than other shoulder disability questionnaires including the Simply Shoulder Test (SST), American Shoulder and Elbow Surgeons Standardised Shoulder assessment Form (ASES) and the Shoulder Pain and Disability Index (SPADI – Bot et al., 2004).

Available versions

The DASH was developed by the American Academy of Orthopedic Surgeons, the Council of the Musculoskeletal Specialty Societies, and the Institute for Work and Health as a region-specific instrument to measure patients’ perception of disability and symptoms associated with any joint or condition of the upper limb (Hudak et al., 1996; Veehof et al., 2002).

The third edition of the DASH has been recently published to incorporate the latest research and new information regarding cross-cultural use of the measure.

Features of the measure

Items:

The DASH consists of 30 items that measure: (a) physical function (21 items); (b) symptom severity (5 items); and (c) social or role function (4 items).

Ability to do the following activities:

  1. Open a tight or new jar
  2. Write
  3. Turn a key
  4. Prepare a meal
  5. Push open a heavy door
  6. Place an object on a shelf above your head
  7. Do heavy household chores (e.g. wash walls, wash floors)
  8. Garden or do yard work
  9. Make a bed
  10. Carry a shopping bag or briefcase
  11. Carry a heavy object (over 5kg)
  12. Change a light bulb overhead
  13. Wash or blow dry your hair
  14. Wash your back
  15. Put on a pullover sweater
  16. Use a knife to cut food
  17. Recreational activities that require little effort (e.g. card playing, knitting)
  18. Recreational activities that require taking some force or impact through the arm, shoulder or hand (e.g. golf, hammering, tennis)
  19. Recreational activities that require you to move the arm freely (Frisbee, badminton)
  20. Managing transportation needs (getting from one place to another0
  21. Sexual activities
  22. Extent to which arm, shoulder or hand problems interfered with normal social activities with family, friends, neighbours or groups
  23. Extent to which arm, shoulder or hand problems limited work or other regular daily activities

Severity of the following symptoms:

  1. Arm, shoulder or hand pain
  2. Arm, shoulder or hand pain when performing activities
  3. Tingling
  4. Weakness
  5. Stiffness
  6. Difficulty in sleeping
  7. Impact on self-image

The DASH also includes two optional modules regarding work and sports/performing arts that investigate the individual’s difficulty:

  1. Using the usual technique for the activity (work; sport/instrument)
  2. Performing the activity due to arm, shoulder or hand pain
  3. Performing the as well as he/she would like
  4. Spending the usual amount of time on the activity

Scoring:

The most recent version of the DASH uses a 5-point Likert scale that rates the individual’s difficulties the preceding week. Lower scores indicate no difficulty, limitations or symptoms whereas higher scores indicate inability to perform tasks or extreme difficulties or symptomatology.

Items 1 – 21
  • 1 = no difficulty
  • 2 = mild difficulty
  • 3 = moderate difficulty
  • 4 = severe difficulty
  • 5 = unable
Item 22
  • 1 = not at all
  • 2 = slightly
  • 3 = moderately
  • 4 = quite a bit
  • 5 = extremely
Item 23
  • 1 = not limited at all
  • 2 = slightly limited
  • 3 = moderately limited
  • 4 = very limited
  • 5 = unable
Items 24 – 28
  • 1 = none
  • 2 = mild
  • 3 = moderate
  • 4 = severe
  • 5 = extreme
Optional work and sports/performing arts modules:
  • 1 = no difficulty
  • 2 = mild difficulty
  • 3 = moderate difficulty
  • 4 = severe difficulty
  • 5 = unable

The DASH total score is calculated as a percentage (0=no disability to 100=maximal disability), using the following calculation:

[(Sum of completed responses ÷ number of completed responses) – 1] x 25

The final score for each optional module is calculated as follows:

[(Sum of completed responses ÷ 4) – 1] x 25

Note: A DASH total score cannot be calculated if more than 3 items have not been answered. Total scores for the additional modules cannot be calculated if there are any missing items.

Where 3 or fewer items have been missed, missing responses are replaced by the mean value of the responses to other items before summing.

Please note that earlier versions of the DASH use a different scoring system.

What to consider before beginning:

A study by Ring et al. (2006) showed a strong correlation between the DASH and measures of depression (Center for Epidemiologic Studies – depression) and anxiety (Pain Anxiety Symptoms Scale) in a sample of 235 patients with discrete hand problems (e.g. carpal tunnel syndrome, de Quervain tenosynovitis, lateral elbow pain, trigger finger, distal radial fracture). Subsequently, Lozano Calderon et al. (2010) conducted a study with 516 patients requiring hand surgery and adjusted DASH scores for the influence of depression. This resulted in a significant decrease in the mean and standard deviation of DASH scores, although the decrease in variation was small. There was a high correlation between DASH and depression-adjusted DASH scores, indicating no notable benefit to adjusting DASH scores for depression. Given the high incidence of depression among patients with stroke, consideration of the correlation between disability and depression should be considered when using the DASH.

Time:

The DASH takes approximately 5 minutes to administer with patients with musculoskeletal disorders (Bot et al., 2004). Administration with patients with stroke may require more time and support materials.

Training requirements:

No specific training requirements are specified.

Equipment:

No specific equipment is required.

Alternative Forms of the Measure

The QuickDASH is an 11-item questionnaire that was developed from the DASH using a concept-retention’ approach (Beaton et al., 2005). The QuickDASH is comprised of the following items:

  1. Open a tight or new jar
  2. Do heavy household chores (e.g. wash walls, wash floors)
  3. Carry a shopping bag or briefcase
  4. Wash your back
  5. Use a knife to cut food
  6. Recreational activities that require taking some force or impact through the arm, shoulder or hand (e.g. golf, hammering, tennis)
  7. Extent to which arm, shoulder or hand problems interfered with normal social activities with family, friends, neighbours or groups
  8. Extent to which arm, shoulder or hand problems limited work or other regular daily activities
  9. Arm, shoulder or hand pain
  10. Tingling
  11. Difficulty in sleeping

The QuickDASH also retains the optional work and sports/performing arts modules (Beaton et al., 2005).

Like the DASH, the QuickDASH uses a 5-point Likert rating scale and the total score is calculated as a percentage (0=no disability – 100=most severe disability). At least 10 of the 11 items must be completed for correct use. The QuickDASH demonstrates similar test-retest reliability, validity and responsiveness to the DASH and may demonstrate better precision in detecting different degrees of disability than the DASH. Although there is a high correlation between the QuickDASH and the DASH, an exact match between the numeric scores of the two assessments is not guaranteed (Beaton et al., 2005). Due to the smaller number of items, the QuickDASH is considered to be more efficient than the DASH (Beaton et al., 2005; Gummesson et al., 2006). However, the DASH is more suitable than the QuickDASH for use when monitoring arm pain and function over time in individual patients.

Client suitability

Can be used with:

  • Individuals with upper limb musculoskeletal impairment.
  • Due to limited research regarding patient acceptability, the DASH may be more suitable for patients with mild impairment.

Should not be used with:

  • N/A

Languages of the measure

Approved translations have been made in the following languages:

  • Afrikaans
  • Arabic
  • Armenian
  • Chinese (Hong Kong)
  • Chinese (Taiwan)
  • Czech
  • Danish
  • Dutch
  • English (Australia)
  • English (Hong Kong)
  • English (South Africa)
  • Finnish
  • French Canadian
  • French
  • German
  • Greek
  • Hebrew
  • Hungarian
  • Italian
  • Japanese
  • Korean
  • Lithuanian
  • Malay
  • Norwegian
  • Persian (Iran)
  • Polish
  • Portugese (Brazil)
  • Portugese (Portugal)
  • Romanian
  • Russian
  • Serbian
  • Sinhala (Sri Lanka)
  • Spanish (Argentina)
  • Spanish (Puerto Rico)
  • Spanish (Spain)
  • Swedish
  • Thai
  • Turkish

Translations are also in progress for the following languages:

  • Croatian
  • Estonian
  • Filipino
  • Isi-Xhosa
  • Latvian
  • Malayalam
  • Slovak
  • Spanish (Chile)
  • Spanish (Dominican Republic)
  • Ukrainian

Summary

What does the tool measure? Upper extremity disability and pain.
What types of clients can the tool be used for? Individuals with musculoskeletal disorders of the upper limb.
Is this a screening or assessment tool? Assessment
Time to administer Five minutes.
Versions
  • DASH
  • QuickDASH
Other Languages Afrikaans, Arabic, Armenian, Chinese (Hong Kong), Chinese (Taiwan), Czech, Danish, Dutch, English (Australia), English (Hong Kong), English (South Africa), Finnish, French Canadian, French, German, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Lithuanian, Malay, Norwegian, Persian (Iran), Polish, Portugese (Brazil), Portugese (Portugal), Romanian, Russian, Serbian, Sinhala (Sri Lanka), Spanish (Argentina), Spanish (Puerto Rico), Spanish (Spain), Swedish, Thai, Turkish.
Measurement Properties
Reliability Internal consistency:
No studies have reported on the Internal consistency of the DASH among patients with stroke.

Test-retest:
No studies have reported on the test-retest reliability of the DASH among patients with stroke.

Intra-rater:
No studies have reported on the intra-rater reliability of the DASH among patients with stroke.

Inter-rater:
No studies have reported on the inter-rater reliability of the DASH among patients with stroke.

Validity Content:
The DASH was developed by item generation (clinical expert input, literature review and patient focus groups) and item reduction (expert review, and psychometric and clinimetric analysis).

One study that examined the content validity of the DASH in a sample of patients with stroke suggested a disordered rating scale structure and item hierarchy that is not suitable for clinical use.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the DASH among patients with stroke.

Predictive:
No studies have reported on the predictive validity of the DASH among patients with stroke.

Construct:
Convergent/Discriminant:
One study reported moderate correlations between manual ability and pain.

Known Groups:
No studies have reported on the known-groups Validity of the DASH among patients with stroke.

Floor/Ceiling Effects No studies have reported on the floor/ceiling effects of the DASH among patients with stroke.
Does the tool detect change in patients? No studies have reported on the responsiveness among patients with stroke.
Acceptability The DASH is simple to comprehend, quick to complete and is comprised of real-life, non-gender specific items. Due to limited research regarding patient acceptance, this tool may be more suitable for patients with mild impairment.
Feasibility The DASH is a versatile measure that can be used for clinical or research purposes. However there is insufficient research regarding use of the DASH with patients with stroke and concerns that without testing, the clinical utility of the DASH remains unknown.
How to obtain the tool? Visit the DASH website for more information: https://dash.iwh.on.ca/

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the DASH. While numerous studies have been conducted with other patient groups, this review specifically addresses the psychometric properties relevant to patients with stroke. At the time of publication there was 1 conference paper but no published studies specific to patients with stroke.

Floor/Ceiling Effects

No studies have reported on the floor/ceiling effects of the DASH in a sample of patients with stroke. The DASH demonstrates no floor or ceiling effects in patients with shoulder and combined shoulder-upper limb problems (Bot et al., 2004).

Reliability

Internal consistency:
No studies have examined Internal consistency of the DASH in a sample of patients with stroke, although studies conducted among patient groups with other upper limb conditions indicate excellent reliability (see: Atroshi et al., 2000; Bot et al., 2004; Veehof et al., 2002). However, this may indicate item redundancy (Beaton et al., 2005).

Test-retest:
No studies have examined test-retest reliability of the DASH in a sample of patients with stroke, although studies conducted among patient groups with other upper limb conditions indicate excellent test-retest reliability (see: Atroshi et al., 2000; Bot et al., 2004; Beaton et al., 2001).

Intra-rater:
No studies have examined intra-rater reliability of the DASH in a sample of patients with stroke.

Inter-rater:
No studies have examined inter-rater reliability of the DASH in a sample of patients with stroke.

Validity

Content:

The DASH was developed in two stages of item generation and item reduction. The first stage of item generation involved clinical expert input, review of 13 relevant outcome measurement scales and patient focus groups to identify possible items. The second stage of item reduction involved preliminary item review by three content experts, secondary review by a panel of 15 experts for content/face validity and item importance, and subsequent pre-testing on 20 individuals with upper extremity difficulties. Further item reduction was conducted by psychometric and clinimetric analysis among patients with upper limb conditions, including (i) field-testing in a cross-sectional study of 407 patients with various upper limb problems, and (ii) importance- and difficulty- rating in a second sample of 76 patients. This resulted in the 30-item questionnaire (Hudak et al., 1996; Marx et al., 1999).

Lannin et al. (2010) examined the content validity of the DASH in a sample of 157 patients with stroke. Analysis of the original rating scale revealed a disordered structure; Rasch measurement modeling was used to transform ordinal ratings into a collapsed linear measure, which resulted in conformation to expectations of the model. The study also found that the hierarchy of the original 30 items is not appropriate for clinical use as there are few items suitable for the most disabled patient.

Franchignoni et al. (2010) investigated the dimensionality, rating scale diagnostics and model fit of the DASH (Italian version) on a sample of 238 patients with upper extremity disorders (excluding stroke). The authors noted that some items do not rely exclusively on upper limb function (e.g. item 9: Make a bed; item 20: manage transportation needs), and that items measure different ICF constructs (impairment, activity limitation and participation restriction). The authors found that patients were not able to reliably use the 5-level rating scale. Factor analysis revealed 3 underlying constructs of: (i) manual functioning (items 1-5, 7-11, 16-18, 20, 21); (ii) shoulder range of motion (items 6, 12-15, 19); and (iii) symptoms and consequences (items 22-30). Two items (Tingling, Sexual Activities) showed misfit by Rash Analysis. While results from this study identify issues to consider when using the DASH, it is important to note that patients with stroke were excluded from the sample population.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the DASH in a sample of patients with stroke.

Predictive:
No studies have reported on the predictive validity of the DASH in a sample of patients with stroke.

Construct:

Convergent/Discriminant :
Lannin et al. (2010) conducted a comparison of the DASH with a self-report questionnaire of upper limb function and an observation upper limb movement assessment in 90 patients with stroke. The authors reported moderate correlations between manual ability and pain (statistical data not provided).

While no other studies have examined construct validity of the DASH in a sample of patients with stroke, numerous studies conducted among patient groups with other upper limb conditions report adequate to excellent correlations with constructs of function and pain (see: Atroshi et al., 2000; Beaton et al., 2001; Bot et al., 2004; Kirkley et al., 1998; Schmitt & Di Fabio, 2004; SooHoo et al., 2002; Turchin et al., 1998).

Known Group:
No studies have examined known-group validity of the DASH in a sample of patients with stroke, although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

Responsiveness

No studies have examined responsiveness of the DASH in a sample of patients with stroke, although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001; Bot et al., 2004; MacDermid & Tottenham, 2004; Schmitt & Di Fabio, 2004).

Sensitivity & Specificity:
No studies have examined responsiveness of the DASH in a sample of patients with stroke, although studies have been conducted among patient groups with other upper limb conditions (see: Beaton et al., 2001).

References

  • Atroshi, I., Gummesson, C., Andersson, B., Dahlgren, E. & Johansson, A. (2000). The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: reliability and validity of the Swedish version evaluated in 176 patients. Acta Orthopaedica Scandinavica, 71(6), 613-8.
  • Beaton, D.E., Katz, J.N., Fossel, A.H., Wright, J.G., Tarasuk, V., & Bomardier, C. (2001). Measuring the whole or the parts? Validity, reliability, and responsiveness of the Disabilities of the Arm, Shoulder and Hand outcome measure in different regions of the upper extremity. Journal of Hand Therapy, 14, 128-46.
  • Beaton, D.E., Wright, J.G., Katz, J.N., and the Upper Extremity Collaborative Group. (2005). Development of the QuickDASH: comparison of three item-reduction approaches. The Journal of Bone and Joint Surgery, 87-A(5), 1038-46.
  • Bot, S.D.M., Terwee, C.B., van der Windt, D.A.W.M., Bouter, L.M., Dekker, J., & de Vet, H.C.W. (2004). Clinimetric evaluation of shoulder disability questionnaires: a systematic review of the literature. Annals of the Rheumatic Diseases, 63, 335-41.
  • Franchignoni, F., Biordano, A., Sartorio, F., Vercelli, S., Pascariello, B., & Ferriero, G. (2010). Suggestions for refinement of the Disabilities of the Arm, Shoulder and Hand outcome measure (DASH): a factor analysis and Rasch validation study. Archives of Physical Medicine and Rehabilitation, 91, 1370-7.
  • Gummesson, C., Ward, M.M., & Atroshi, I. (2006). The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskeletal Disorders, 7(44). doi:10.1186/1471-2474-7-44.
  • Hudak, P.L., Amadio, P.C., Bombardier, C., and the Upper Extremity Collaborative Group. (1996). Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Hand). American Journal of Industrial Medicine, 29, 602-8.
  • Kirkley, A., Griffin, S., McLintock, H., & Ng, L. The development and evaluation of a disease-specific quality of life measurement tool for shoulder instability: The Western Ontario Shoulder Instability Index (WOSI). The American Journal of Sports Medicine, 26(6), 764-72.
  • Lannin, N. McCluskey, A. Cusick, A. Ashford, S. Ross, L. (2010) Measuring function in everyday life: enhancing the Disabilities of the Arm Shoulder Hand questionnaire for use post-stroke. World Federation of Occupational Therapy, Santiago, Chile, May.
  • Lozano Calderon, S.A., Zurakowski, D., Davis, J.S., & Ring, D. (2010). Quantitative adjustment of the influence of depression on the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Hand, 5, 49-55.
  • MacDermid, J.C. & Tottenham, V. (2004). Responsiveness of the Disabilities of the Arm, Shoulder and Hand (DASH) and patient-rated wrist/hand evaluation (PRWHE) in evaluating change after hand therapy. Journal of Hand Therapy, 17, 18-23.
  • Marx, R.G., Bombardier, C., Hogg-Johnson, S., & Wright, J.G. (1999). Clinimetric and psychometric strategies for development of a health measurement scale. Journal of Clinical Epidemiology, 52(2) 105-11.
  • Ring, D., Kadzielski, J., Fabien, L., Zurakowski, D., Malhotra, L.R., & Jupiter, J.B. (2006) Self-reported upper extremity health status correlates with depression. The Journal of Bone and Joint Surgery, 88-A(9), 1983-8).
  • Schmitt, J.S. & Di Fabio, R. (2004). Reliable change and minimum important difference (MID) proportions facilitated group responsiveness comparisons using individual threshold criteria. Journal of Clinical Epidemiology, 57, 1008-18.
  • SooHoo, N.F., McDonald, A.P., Seiler, J.G., & McGillivrary, G.R. (2002). Evaluation of construct validity of the DASH questionnaire by correlation to the SF-36. Journal of Hand Surgery, 27A, 537-41.
  • Turchin, D.C., Beaton, D.E. & Richards, R.R. (1998). Validity of observer-based aggregate scoring systems as descriptors of elbow pain, function and disability. The Journal of Bone and Joint Surgery, 80A(2), 154-62.
  • Veehof, M.M., Sleegers, E.J.A., van Veldhoven, N.H.M.J., Schuurman, A.H., & van Meeteren, N.L.U. (2002). Psychometric qualities of the Dutch language version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-DLV). Journal of Hand Therapy, 15, 347-54.

See the measure

How to obtain the DASH?

You can obtain a copy of the DASH through https://dash.iwh.on.ca/

Table of contents

Frenchay Arm Test (FAT)

Evidence Reviewed as of before: 17-09-2012
Author(s)*: Katie Marvin, MPT
Editor(s): Annabel McDermott, OT

Purpose

The Frenchay Arm Test (FAT) is a measure of upper extremity proximal motor control and dexterity during ADL performance in patients with impairments resulting from neurological conditions. The FAT is an upper extremity specific measure of activity limitation.

In-Depth Review

Purpose of the measure

The Frenchay Arm Test (FAT) is a measure of upper extremity proximal motor control and dexterity during ADL performance in patients with impairments of the upper extremity resulting from neurological conditions. The FAT is an upper extremity specific measure of activity limitation.

Available versions

None typically reported.

Features of the measure

Description of tasks:

Clients sit comfortably at a table with hands on their lap; each test item starts from this position. Clients are then asked to use their affected arm to:

  • Stabilize a ruler, while drawing a line with a pencil held in the other hand. To pass, the ruler must be held firmly.
  • Grasp a cylinder (12 mm diameter, 5 cm long), set on its side approximately 15 cm from the table edge, lift it about 30 cm and replace it without dropping.
  • Pick up a glass, half full of water positioned about 15 to 30 cm from the edge of the table, drink some water and replace without spilling.
  • Remove and replace a sprung clothes peg from a 10mm diameter dowel, 15 cm long set in a 10 cm base, 15 to 30 cm from table edge. Not to drop peg or knock dowel over.
  • Comb hair (or imitate); must comb across top, down the back and down each side of head.

What to consider before beginning:

  • Before administering the FAT, the clinician should ensure that the client is able to comprehend either written or spoken language.
  • The FAT has been criticized for lacking assessment of quality of movement and performance (Kopp, 1997). In addition, clients were found to either pass or fail all or most subtests, indicating that the FAT may not be sensitive to change or subtleties in progress (Hsieh, Hsueh, Chiang & Lin, 1998), especially in clients performing in the upper range of arm function (Wade, et al., 1983).

Scoring and Score Interpretation:

Each item is scored as either pass (=1) or fail (=0). Total scores range from 0 to 5.

Time:

The FAT takes approximately 3 minutes to administer.

Training requirements:

None typically reported, however familiarity with the measure is recommended.

Equipment:

  • Ruler
  • Pencil
  • Paper
  • Cylinder (12mm diameter, 5 cm long)
  • Glass (Half filled with water)
  • Clothes peg
  • Dowel (15mm)
  • Hair comb

Alternative Forms of the FAT

None typically reported

Client suitability

Can be used with:

  • Clients with stroke

Should not be used in:

  • Clients with difficulty understanding written and spoken language

Languages of the measure

  • English
  • French
  • Dutch

Summary

What does the tool measure? The FAT measures upper extremity proximal control and dexterity during performance of functional tasks.
What types of clients can the tool be used for? The FAT can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer The FAT takes approximately 3 minutes to administer.
Versions There are no alternative versions of the FAT.
Other Languages French and Dutch
Measurement Properties
Reliability Intra-rater:
One study examined the intra-rater reliability of the FAT in clients with stroke and found adequate to excellent intra-rater reliability.

Inter-rater:
One study examined the inter-rater reliability of the FAT in clients with stroke and found excellent inter-rater reliability.

Validity Sensitivity/ Specificity:
Two studies compared the Sensitivity of the FAT with that of the Nine-Hole Peg Test (NHPT) and found the NHPT to be more sensitive than the FAT for detecting impaired upper extremity function in clients with stroke.
Floor/Ceiling Effects No studies have examined the floor/ceiling effects of the FAT in clients with stroke.
Does the tool detect change in patients? No studies have investigated the responsiveness of the FAT in clients with stroke.
Acceptability

The FAT has been criticized for lacking assessment of quality of movement and performance (Kopp, 1997). In addition, clients were found to either pass or fail all or most subtests, indicating that the FAT may not be sensitive to change (Hsieh, Hsueh, Chiang & Lin, 1998).

The FAT is quick to complete and should not produce any undue fatigue for patients.

Feasibility The FAT is short and easy to administer and score.
How to obtain the tool? For more information on the FAT, please visit the article by Parker, Wade & Langton Hewer (1986).

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Frenchay Arm Test (FAT) in clients with stroke. Two studies were found and have been reviewed in this module. More studies are required before definitive conclusions can be drawn regarding the reliability and validity of the FAT.

Floor/Ceiling Effects

No studies have examined the floor/ceiling effects of the FAT in clients with stroke.

Reliability

Internal constancy:
No studies have examined the internal consistency of the FAT in clients with stroke.

Intra-rater:
Heller, Wade, Wood, Sunderland, Hewer, and Ward (1987) examined the intra-rater reliability of the FAT, Nine-Hole Peg Test (NHPT), Finger Tapping Rate (Lezak, 1983), and Grip Strength (Mathiowetz, Kashman, Volland, Weber, Dowe, & Rogers, 1985) in 10 patients with subacute stroke. Participants were re-assessed with a 2-week interval by the same rater. In this study, results describe the range of reliability of the four measures mentioned above, and values for each individual measure were not provided. Spearman rho correlation coefficient was adequate to excellent (ranging for all four measures from r = 0.68 to 0.99).
Note: Although is not possible to discern the exact value for the FAT reliability, all values were considered adequate to excellent and statistically significant, suggesting that the FAT may be reliable with stable stroke clients.

Inter-rater:
Heller et al. (1987) examined the inter-rater reliability of the FAT, Nine-Hole Peg Test (NHPT), Finger Tapping Rate (Lezak, 1983), and Grip Strength (Mathiowetz et al., 1985) in 10 patients with subacute stroke. Participants were assessed twice within a week by two raters. Spearman rho correlation coefficients were excellent (ranging for all four measures from r = 0.75 to 0.99).
Note: In this study, individual values for each measure were not provided. Although is not possible to discern the exact value for the FAT reliability, all values were considered excellent.

Test-retest:
No studies have examined the test-retest reliability of the FAT in clients with stroke.

Validity

Content:

No studies have examined the content validity of the FAT in clients with stroke.

Criterion:

Concurrent:
No studies have examined the concurrent validity of the FAT in clients with stroke.

Predictive:
No studies have examined the predictive validity of the FAT in clients with stroke.

Construct:

Convergent/Discriminant:
No studies have examined the discriminant validity of the FAT in clients with stroke.

Known Groups:
No studies have examined the known groups validity of the FAT in clients with stroke.

Sensitivity/specificity:
Heller et al. (1987) investigated the specificity of the FAT and the Nine Hole Peg Test (NHPT) in 56 clients with chronic stroke. All of the clients that scored less than 5/5 on the FAT were correctly identified as having impaired dexterity, as identified by using the normal cut-off scores for the NHPT. However, 48 percent of patients that scored 5/5 on the FAT scored in the below normal range on the Nine Hole Peg Test. These results indicate that the NHPT is more sensitive than the FAT for detecting impaired upper extremity function in clients with stroke.

Parker, Wade & Hewer (1986) compared the specificity of the FAT and the Nine-Hole Peg Test (NHPT) in 187 clients with sub-acute stroke. Participants that were able to successfully place nine pegs in the pegboard were further categorized according to those who completed the NHPT in less than 19 seconds (n=37) and those who required over 19 seconds (n=69). For the FAT, 114 participants score 5/5, 33 participants scored in the middle range (1/5 – 4/5) and 36 participants scored 0/5. Researchers concluded that the NHPT is more sensitive than the FAT because 13 percent of participants who scored perfectly on the FAT placed less than 9 pegs on the NHPT and all participants who scored perfectly on the NHPT (9 pegs placed in less than 19 seconds) also scored 5/5 on the FAT.

Responsiveness

No studies have examined the responsiveness of the FAT in clients with stroke.

References

  • Heller, A., Wade, D.T., Wood, V.A., Sunderland, A., Langton Hewer, R., & Ward, E. (1987). Arm function after stroke: Measurement and recovery over the first three months. Journal of Neurology, Neurosurgery, and Psychiatry, 50, 714-719.
  • Hsieh, C-L., Hsueh, P. Chiang, F-M., & Lin, P-H. (1998). Inter-rater reliability and validity of the Action Research Arm Test in stroke patients. Age and Ageing, 27, 107-113.
  • Parker, V.M., Wade, D.T., & Langton Hewer, R. (1986). Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitative Medicine, 8, 69-73.
  • Wade, D.T., Langton-Hewer, R., Wood, V.A., Skilbeck, C.E., & Ismail, H.M. (1983). The hemiplegic arm after stroke: Measurement and recovery. Journal of Neurology, Neurosurgery and Psychiatry, 46, 521-524.

See the measure

For more information on the FAT, please review the article by Parker, Wade & Langton Hewer (1986).

Table of contents

Jebsen Hand Function Test (JHFT)

Evidence Reviewed as of before: 17-09-2012
Author(s)*: Jennifer Vissers
Editor(s): Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT

Purpose

The Jebsen Hand Function Test (JHFT) assesses fine motor skills, weighted and non-weighted hand function activities during performance of activities of daily living.

In-Depth Review

Purpose of the measure

The Jebsen Hand Function Test (JHFT) is a standardized evaluative measure of functional hand motor skills (Hummel et al., 2005).

Available versions

The JHFT was developed in 1969 by Jebsen, Taylor, Treischmann, Trotter, and Howard (Cook, McCluskey, & Bowman, 2006). The JHFT is also referred to as the Jebsen-Taylor Hand Function Test or the Jebsen-Taylor Test of Hand Function.

A 3-item version (Modified Jebsen Hand Function Test, MJT) was developed by Bovend’Erdt et al. (2004) to measure gross functional dexterity in patients with moderate unilateral or bilateral upper limb impairment.

An 8-item Australian version was developed by Agnew and Maas (1982). It consists of the original 7 items with the addition of a grip strength item, measured using the Jamar dynamometer (Cook, McCluskey, & Bowman, 2006).

Features of the measure

Items:

The JHFT consists of 7 items that measure: (a) fine motor skills; (b) weighted functional tasks; and (c) non-weighted functional tasks (Jebsen et al., 1969):

  • Writing a short sentence (24 letters, 3rd grade reading difficulty)
  • Turning over a 3×5 inch card
  • Picking up small common objects
  • Simulated feeding
  • Stacking checkers
  • Picking up large light cans
  • Picking up large heavy cans

Administration guidelines specify that testing begin with the non-dominant hand (Jebsen et al., 1969). Further details about the administration procedures of the JHFT can be found in the original article by Jebsen et al. (1969).

Items of the Modified Jebsen Hand Function Test (MJT) (Bovend’Erdt et al., 2004):

  • Turning over 5 cards
  • Stacking 4 cones
  • Spooning 5 kidney beans into a bowl (simulated feeding)

Scoring:

Each item is scored according to time taken to complete the task. Times are rounded to the nearest second (Spinal Cord Injury Rehabilitation Evidence, 2010). The scores for all 7 items are then summed for a total score. Jebsen et al. (1969) established norms with a sample of 300 healthy subjects of different age groups (20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-94 years). With the exception of writing, all items took under 10 seconds to perform. See Jebsen et al. (1969) for norms according to age, gender and hand use (dominant/non-dominant).

What to consider before beginning:

It is necessary to identify the patient’s dominant hand before beginning the JHFT. When working with patients with stroke it is recommended to take into consideration the area(s) of cortical insult, as damage to areas of the brain responsible for speech and language function may affect performance on the writing task (Celink et al., 2007). Prior to beginning the writing task, individuals should be reminded to use reading glasses if necessary (Jebsen et al., 1969).

Time:

The JHFT requires 15 – 45 minutes to complete.

Training requirements:

No specific training is required.

Equipment:

The JHFT does not require standardized equipment but the following equipment is used (Jebsen et al., 1969):

  • wooden board (41 1/2 inches long x 11 1/4 inches wide x 3/4 inch thick)
  • ball point pen
  • 8×11 inch sheets unruled paper
  • 5×8 inch index cards
  • 3×5 inch index cards
  • 1 pound coffee can
  • 1 inch paper clips
  • teaspoon
  • 5 kidney beans
  • standard size wooden checkers
  • 5 empty 303 cans
  • 5 full (1 pound) 303 cans.

Test equipment can be collated by the clinician or purchased as pre-packaged assessment kits from suppliers including:

Client suitability

Can be used with:

  • Clients with neurological or musculoskeletal conditions, e.g. stroke, spinal cord injury, arthritis (Cook, McCluskey, & Bowman, 2006).
  • This assessment has been administered in clients over 8 years of age (Cook, McCluskey, & Bowman, 2006).

Should not be used with:

  • Individuals with speech and language disorders may have difficulty understanding instructions.
  • The writing task can be excluded for individuals with speech and language difficulties due to dominant cerebral hemisphere stroke (Beebe & Lang, 2009, 2007; Hummel et al., 2005).

Languages of the measure

  • English
  • Portuguese (Ferreiro, dos Santos, & Conforto, 2010)

Summary

What does the tool measure? Hand function
What types of clients can the tool be used for? The JHFT can be use with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Assessment
Time to administer 15-45 minutes
Versions
  • JHFT
  • Modified Jebsen Hand Function Test (MJT)
  • JHFT Australian version, Portuguese version
Other Languages English, Portuguese
Measurement Properties
Reliability Internal consistency:
One study reported excellent Internal consistency of the JHFT (Portuguese version), and adequate to excellent Internal consistency of individual items.

Test-retest:
One study reported adequate to excellent test-retest reliability of JHFT individual items.

One study reported excellent test-retest reliability of the MJT.

Intra-rater:
One study reported excellent intra-rater reliability of the JHFT (Portuguese version).

Inter-rater:
One study reported excellent inter-rater reliability of the JHFT (Portuguese version) and individual items.

Validity Content:
No studies have examined the content validity of the JHFT.

Criterion:
Concurrent:
Two studies reported excellent correlation between the JHFT and grip strength, pinch strength, Action Research Arm Test, Nine Hole Peg Test, and stroke Impact Scale – Hand Domain.

One study reported an excellent correlation between the MJT and the Nine Hole Peg Test and an adequate correlation with grip strength.

Predictive:
No studies have examined the predictive validity of the JHFT.

Construct:
No studies have examined the construct validity of the JHFT.

One study reported no significant difference in scores on the JHFT (Portuguese version) according to education level or hand dominance.

Floor/Ceiling Effects No studies have examined the floor or ceiling effects of the JHFT.
Sensitivity/ Specificity No studies have reported on the Sensitivity or Specificity of the JHFT.
Does the tool detect change in patients?

One study reported moderate responsiveness of the JHFT from 1 to 3 months post-stroke, and from 3 to 6 months post-stroke.

Acceptability The JHFT is comprised of simple, familiar, and functional tasks. Consideration must be paid to individuals with speech and language difficulties, who may have difficulty understanding instructions and performing the writing task.
Feasibility The JHFT is easy to administer and does not require standardized equipment.
How to obtain the tool?

Information regarding test administration is provided in:

Jebsen, R.H., Taylor, N., Trieschmann, R.B., Trotter, M.J., & Howard, L.A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), 311 – 319.

Assessment kits can be purchased from:

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Jebsen Hand Function Test (JHFT). While studies have been conducted with other patient groups, this review specifically addresses the psychometric properties relevant to patients with stroke. At the time of publication five studies were identified: three relating to the JHFT, and one each for the JHFT (Portuguese version) and the Modified Jebsen Hand Function Test (MJT).

Floor/Ceiling Effects

No studies have examined the floor or ceiling effects of the JHFT.

Reliability

Internal consistency:
Ferreiro, dos Santos, & Conforto (2010) examined the Internal consistency of the JHFT (Portuguese version) with a sample of 40 patients with stroke using Cronbach’s alpha, and reported excellent internal consistency(α=0.924). Internal consistency of individual items, reported using Pearson’s correlation coefficient and Cronbach’s alpha , was adequate to excellent (writing: r=0.812, α=0.844; card turning r=0.857, α=0.632; small common objects r=0.657, α=0.651; simulated feeding r=0.813, α=0.646; checkers r=0.712, α=0.633; large light objects r=0.849, α=-0.681; large heavy objects r=0.898, α=0.687).

Test-retest:
Jebsen et al. (1969) examined test-retest reliability of the JHFT in a sample of 26 patients with a range of upper limb conditions including hemiparesis from cerebral vascular disease (n=5), using Pearson’s correlation coefficient. test-retest reliability of individual tasks was adequate to excellent (writing: r=0.67, 0.84; cards: r=0.91, 0.78; small objects: r=0.93, 0.85; simulated feeding: r=0.92, 0.60; checkers: r=0.99, 0.91; large light objects: r=0.89, 0.67; large heavy objects: r=0.89, 0.92, dominant and non-dominant hands respectively).

Bovend’Eerdt et al. (2004) examined the test-retest reliability of the Modified Jebsen Hand Function Test (MJT) in a sample of 26 individuals with neurological disorders including stroke (n=12), Multiple Sclerosis (n=7), head injury (n=4), and tumours (n=3). The mean time between retesting was 9.6 days. The study reported excellent test-retest reliability of the MJT (r = 0.95), using Pearson’s correlation coefficient.

Intra-rater:
Ferreiro, dos Santos, & Conforto (2010) examined intra-rater reliability of the JHFT (Portuguese version) with a sample of 40 patients with stroke and reported excellent intra-rater reliability (ICC=0.997), using intraclass correlation coefficient (ICC).

Inter-rater:
Ferreiro, dos Santos, & Conforto (2010) examined the inter-rater reliability of the JHFT (Portuguese version) with a sample of 40 patients with stroke using intraclass correlation coefficient (ICC), and reported excellent inter-rater reliability (ICC=1.0). inter-rater reliability for individual items was also excellent (writing, ICC=0.999; card turning, ICC=0.977; small common objects, ICC=0.998; simulated feeding, ICC=0.991; checkers, ICC=0.995; large light objects, ICC=0.988; large heavy objects, ICC=0.991).

Validity

Content:

No studies have examined the content validity of the JHFT

Criterion:

Concurrent:
Beebe & Lang (2009) examined the concurrent validity of the JHFT with grip and pinch strength (measured by dynamometer), the Action Research Arm Test (ARAT) , Nine Hole Peg Test (NHPT), and the stroke Impact Scale – Hand domain (SIS-Hand) in a sample of 33 patients with stroke, using Spearman’s correlation. Measures were administered at 1 month, 3 months and 6 months post-stroke. The JHFT demonstrated excellent correlations with grip strength (r=0.79-0.81), pinch strength (0.60-0.79), ARAT (r=0.87-0.95), NHPT (0.84-0.97) and SIS-Hand (0.61-0.83) at all time points.
Note: The study did not use the first task of the JHFT (writing a sentence) due to its dependence on hand dominance and education level.

Beebe & Lang (2007) examined concurrent validity of the JHFT with grip and pinch strength (measured by dynamometer), Action Research Arm Test (ARAT), 9-Hole Peg Test (NHPT), and stroke Impact Scale – Hand Function Subscale (SIS-Hand) in a sample of 32 participants with stroke, using Pearson’s product moment correlation. The JHFT demonstrated excellent correlations with ARAT (r=-0.89), grip strength (r=-0.76), pinch strength (r=-0.68), 9-HPT (r=-0.89), and SIS-Hand Function (r=-0.82).
Note: The study did not use the first task of the JHFT (writing a sentence) due to its dependence on hand dominance and education level.

Bovend’Eerdt et al. (2004) examined the concurrent validity of the Modified Jebsen Hand Function Test (MJT) with the University of Maryland Arm Questionnaire for stroke (UMAQS), Nine Hole Peg Test (NHPT), and grip strength (measured by dynamometer) in a sample of 26 individuals with neurological disorders including stroke (n=12), Multiple Sclerosis (n=7), head injury (n=4), and tumours (n=3). Measures were administered on two occasions (T1, T2) on average 9.6 days apart. The MJT showed excellent correlation with the NHPT (r=0.86 and 0.88 on T1 and T2 respectively) and adequate correlation with grip strength (r=0.44, significant on T2 only), using Pearson’s correlation coefficient. Correlations between the MJT and UMAQS were not significant at either time point.

Predictive:
No studies have examined the predictive validity of the JHFT.

Construct:

No studies have examined the construct validity of the JHFT.

Known Groups:
Ferreiro et al. (2010) reported no significant difference in scores on the JHFT (Portuguese version) according to education level or hand dominance in a sample of 40 patients with stroke.

Responsiveness

Beebe & Lang (2009) measured the responsiveness of the JHFT with a sample of 33 patients with stroke, using the single population effect size method. Measures were taken at 1, 3 and 6 months post-stroke, during which time participants received conventional stroke rehabilitation. The JHFT demonstrated moderate responsiveness from 1 to 3 months post-stroke (ES=0.69) and from 3 to 6 months post-stroke (ES=0.73).

Sensitivity & Specificity:
No studies have examined the Sensitivity and Specificity of the JHFT.

References

  • Beebe, J.A. & Lang, C.E. (2007). Relating movement control at 9 upper extremity segments to loss of hand function in people with chronic hemiparesis. Neurorehabilitation and Neural Repair, 21(3), 279 – 291.
  • Beebe, J.A. & Lang, C.E. (2009). Relationships and responsiveness of six upper extremity function tests during the first six months of recovery after stroke. Journal of Neurologic Physical Therapy, 33(2), 96-103.
  • Bovend’Erdt, T.J.H., Dawes, H., Johansen-Berg, H., & Wade, D.T. (2004). Evaluation of the Modified Jebsen Test of Hand Function and the University of Maryland Arm Questionnaire for Stroke. Clinical Rehabilitation, 18, 195-202
  • Celnik, P., Hummel, F., Harris-Love, M., Wolk, R., & Cohen, L. (2007). Somatosensory stimulation enhances the effects of training functional hand tasks in patients with chronic stroke. Archives of Physical Medicine and Rehabilitation, 88, 1369-76.
  • Cook, C., McCluskey, A., & Bowman, J. (2006). Jebsen Test of Hand Function. Penrith South, NSW: University of Western Sydney. Retrieved from http://www.maa.nsw.gov.au/default.aspx?MenuID=376
  • Duncan, P., Richards, L., Wallace, D., Stoker-Yates, J., Pohl, P., Luchies, C., Ogle, A., & Studenski, S. (1998). A randomized, controlled pilot study of a home-based exercise program for individuals with mild and moderate stroke. Stroke, 1998(29), 2055-2060.
  • Ferreiro, K.N., dos Santos, R.L., & Conforto, A.B. (2010). Pyschometric properties of the Portuguese version of the Jebsen-Taylor test for adults with mild hemiparesis. Revista Brasileira de Fisioterapia (Brazilian Journal of Physiotherapy), 14(5), 377-81.
  • Jebsen, R.H., Taylor, N., Trieschmann, R.B., Trotter, M.J., & Howard, L.A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), 311 – 319.
  • Hummel, F., Celnik, P., Giraux, P., Floel, A., Wu, W., Gerloff, C., & Cohen, L. (2005). Effects of non-invasive cortical stimulation on skilled motor function in chronic stroke. Brain, 2005(128), 490-9.
  • Poole, J. (2003). Measures of Adult Hand Function: Arthritis Hand Function Test (AHFT), Grip Ability Test (GAT), Jebsen Test of Hand Function, and The Rheumatoid Hand Functional Disability Scale (The Duruöz Hand Index [DHI]). Arthritis and Rhematism (Arthritis Care and Research), 49(5S), S59-66.
  • Spinal Cord Injury Rehabilitation Evidence. (2010). Jebsen Hand Function Test. Retrieved from http://www.scireproject.com/outcome-measures/jebsen-hand-function-test
  • Wu, C., Seo, H., & Cohen, L. (2006). Influence of electric somatosensory stimulation on paretic-hand function in chronic stroke. Archives of Physical Medicine and Rehabilitation, 87, 351-7.

See the measure

How to obtain the JHFT?

Administration instructions are published in Jebsen, R.H., Taylor, N., Trieschmann, R.B., Trotter, M.J., & Howard, L.A. (1969). An objective and standardized test of hand function. Archives of Physical Medicine and Rehabilitation, 50(6), 311 – 319.

While the JHFT does not require standardized equipment, assessment kits can be purchased from:

Table of contents

Leeds Adult Spasticity Impact Scale (LASIS)

Evidence Reviewed as of before: 13-06-2012
Author(s)*: Annabel McDermott, OT
Editor(s): Nicol Korner-Bitensky, PhD OT

Purpose

The Leeds Adult Spasticity Impact Scale (LASIS) is a measure of passive arm function, suitable for patients with Spasticity and little or no active movement of the upper extremity.

In-Depth Review

Purpose of the measure

The Leeds Adult Spasticity Impact Scale (LASIS) is a measure of passive arm function that is administered by semi-structured interview to the patient or carer. It consists of 12 items of low difficulty that evaluate performance of daily functional tasks in the individual’s normal environment. The LASIS is useful for patients with minimal or no active movement or function but with self-care issues of the upper extremity (Ashford et al., 2008).

Available versions

The LASIS was originally published as the Patient Disability and Carer Burden Scale by Bhakta et al. (1996), which included 8 patient items and 4 carer items (Bhakta et al., 2000). The four carer items have been excluded from the current version of the LASIS.

Features of the measure

Items:

The LASIS consists of 12 items that measure passive and low-level active function.

Passive function items:

  • Cleaning the palm (affected hand)*
  • Cutting fingernails (affected hand)*
  • Cleaning the affected elbow*
  • Cleaning the affected armpit*
  • Cleaning the unaffected elbow*
  • Putting arm through coat sleeve*
  • Difficulty putting on a glove
  • Difficulty rolling over in bed
  • Doing physiotherapy exercises to arm*

Active function items:

  • Difficulty balancing in standing*
  • Difficulty balancing when walking*
  • Hold object steady, use other hand (jar)

* Items originally included in the Patient Disability and Carer Burden Rating Scale (Bhakta et al., 2000).

Scoring:

Items are rated between 0 – 4 according to the following criteria:

  • 0 = No difficulty
  • 1 = Little difficulty
  • 2 = Moderate difficulty
  • 3 = A great deal of difficulty
  • 4 = Inability to perform the activity

The total score is calculated as the sum of individual scores, divided by the total number of questions answered. This results in a total score between 0 – 4 that represent disability or carer burden (Ashford et al., 2008).

Note: As the final score does not rely on responses to all 12 items, it may not reflect actual disability or function in the arm (Ashford et al., 2008).

Description of tasks:

The LASIS is administered through semi-structured interview with the patient or carer, with regard to the patient’s performance of tasks over the past 7 days.

Time:

The LASIS takes approximately 10 minutes to administer (Ashford et al., 2008).

Training requirements:

The LASIS should be administered by a clinician (Ashford et al., 2008).

Equipment:

Equipment such as a jar may be required to validate responses.

Alternative form of the Leeds Adult Spasticity Impact Scale (LASIS)

None reported.

Client suitability

Can be used with:

  • Patients with Spasticity, including patients with stroke.

Should not be used with:

  • None reported.

Languages of the measure

No translations reported.

Summary

What does the tool measure? Passive and low-level active function of the upper limb.
What types of clients can the tool be used for? Patients with upper limb spasticity, including patients who have experienced a stroke.
Is this a screening or assessment tool? Assessment tool
Time to administer 10 minutes
Versions The LASIS was originally published as the Patient Disability and Carer Burden Scale, which included four dressing and grooming items that have been excluded from the current version of the LASIS.
Other Languages None reported
Measurement Properties
Reliability Internal consistency:
No studies have reported on the Internal consistency of the LASIS.

Test-retest:
No studies have reported on the test-retest reliability of the LASIS.

Intra-rater:
No studies have reported on the intra-rater reliability of the LASIS.

Inter-rater:
No studies have reported on the inter-rater reliability of the LASIS.

Validity Content:
No studies have reported on the content validity of the LASIS.

Criterion:
Concurrent:
No studies have reported on the concurrent validity of the LASIS.

Predictive:
No studies have reported on the predictive validity of the LASIS.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent/discriminant Validity of the LASIS.

Known Groups:
No studies have reported on the known-groups Validity of the LASIS.

Floor/Ceiling Effects No studies have reported on the floor or ceiling effects of the LASIS.
Does the tool detect change in patients? No studies have reported on the sensitivity of the LASIS in patients with stroke.
Acceptability The LASIS is useful for patients with minimal or no active movement or function of the upper extremity.
Feasibility Administrative burden due to calculation of total score, but not complex.
How to obtain the tool? Further information can be found here.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Leeds Adult Spasticity Impact Scale (LASIS). At the time of publication no studies have reported on the psychometric properties of the LASIS in the stroke population.

Floor/Ceiling Effects

While no studies have investigated the floor or ceiling effects of the LASIS when used with a stroke population, it ca be anticipated that ceiling effects may exist when the LASIS is used with high-functioning patients, due to the hierarchical relationship of items (Ashford et al., 2008).

Reliability

Internal consistency:
No studies have reported on the Internal consistency of the LASIS.

Test-retest:
No studies have reported on the test-retest reliability of the LASIS.

Intra-rater:
No studies have reported on the intra-rater reliability of the LASIS.

Inter-rater:
No studies have reported on the inter-rater reliability of the LASIS.

Validity

Content:

No studies have reported on the content validity of the LASIS.

Criterion:

Concurrent:
No studies have reported on the concurrent validity of the LASIS.

Predictive:
No studies have reported on the predictive validity of the LASIS.

Construct:

Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the LASIS.

Known Group:
No studies have reported on the known-groups validity of the LASIS.

Responsiveness

No studies have reported on the responsiveness of the LASIS.

Sensitivity/Specificity:
No studies have reported on the Sensitivity or the specificity of the LASIS.

References

  • Ashford, S., Slade, M., Malaprade, F., & Turner-Stokes, L. (2008). Evaluation of functional outcome measures for the hemiparetic upper limb: A systematic review. Journal of Rehabilitation Medicine, 40, 787-95.
  • Bhakta, B.B., Cozens, J.A., Chamberlain, M.A., & Bamford, J.M. (2000). Impact of botulinum toxin type A on disability and carer burden due to arm spasticity after stroke: a randomised double blind placebo controlled trial. Journal of Neurological Neurosurgery and Psychiatry, 69, 217-21.

See the measure

How to obtain the LASIS?

Further information can be found here.

Table of contents

Motor Activity Log (MAL)

Evidence Reviewed as of before: 28-03-2019
Author(s)*: Annabel McDermott, OT
Content consistency: Gabriel Plumier

Purpose

The Motor Activity Log (MAL) is a subjective measure of an individual’s real life functional upper limb performance. The MAL is administered by semi-structured interview to determine (a) how much, and (b) how well the individual uses his upper limb in his own home (Ashford et al., 2008, Li et al., 2012; Simpson & Eng, 2013).

In-Depth Review

Purpose of the measure

The Motor Activity Log (MAL) was developed by Taub et al. (1993) as a subjective outcome measure of an individual’s real life functional upper limb performance. The MAL is administered by semi-structured interview to determine (a) how much (Amount of Use – AOU), and (b) how well the individual uses his upper limb (Quality of Movement – QOM) in his own home (Ashford et al., 2008, Li et al., 2012; Simpson & Eng, 2013).

Available versions

There are four versions of the original MAL-30, according to number of items.

  • MAL-14: Contains unilateral and simple items, to detect change in individuals with limited arm function.
  • MAL-26: Contains the same items as the MAL-14 as well as 11 additional items and 1 optional item chosen by the patient; this version includes some bilateral tasks.
  • MAL-28: Contains the same items as the MAL-14 and MAL-26, and additional items that challenge reach and strength.
  • MAL-12: A short version of the MAL-28 (Ashford et al., 2008).

Other adaptations of the MAL include:

  • Graded Motor Activity Log (Morera Silva et al., 2018)
  • Lower-Functioning Motor Activity Log (LF-MAL)
  • Lower-Extremity Motor Activity Log
  • Pediatric Motor Activity Log – Revised

Features of the measure

The MAL is comprised of two scales:

  • Amount of Use (AOU) scale – the amount the individual uses the paretic arm; and
  • Quality of Movement (QOM) scale – the patient’s perceived quality of movement while performing the functional activity (Ashford et al., 2008).

The MAL-QOM scale captures components of amount of arm use and has been shown to be more reliable than the MAL-AOU scale, and as such can be used independently (Uswatte & Taub, 2005).

Items:

Items the original MAL-30

  1. Turn on a light with a light switch
  2. Open drawer
  3. Remove an item from a drawer
  4. Pick up phone
  5. Wipe off a kitchen counter or other surface
  6. Get out of a car
  7. Open refrigerator
  8. Open a door by turning a door knob/handle
  9. Use a TV remote control
  10. Wash your hands
  11. Turning water on/off with knob/lever on faucet
  12. Dry your hands
  13. Put on your socks
  14. Take off your socks
  15. Put on your shoes
  16. Take off your shoes
  17. Get up from a chair with armrests
  18. Pull chair away from table before sitting down
  19. Pull chair toward table after sitting down
  20. Pick up a glass, bottle, drinking cup, or can
  21. Brush your teeth
  22. Put on makeup base, lotion, or shaving cream on face
  23. Use a key to unlock a door
  24. Write on paper
  25. Carry an object in your hand
  26. Use a fork or a spoon for eating
  27. Comb your hair
  28. Pick up a cup by a handle
  29. Button a shirt
  30. Eat half a sandwich or finger foods

Additional Items for the MAL-45

  • Removing bills from a wallet
  • Taking individual coins out of a pocket or purse
  • Removing keys out of a pocket or purse
  • Using a zipper pull
  • Pouring liquid from a bottle
  • Buckling a belt
  • Popping top of beverage can
  • Removing top from a medicine bottle
  • Keypad press
  • Use of keyboard/computer
  • Putting on or taking off watch band
  • Putting on glasses
  • Pumping a soap dispenser
  • Swiping a credit card or a card for an ATM
  • Adjusting a home or hotel air conditioner or heat

Items of the MAL-12:

  1. Pick up phone
  2. Open a door by turning a door knob
  3. Eat half a sandwich or finger food
  4. Turn water on/off with faucet
  5. Pick up a glass
  6. Pick up toothbrush and brush teeth
  7. Use a key to open a door
  8. Letter writing/typing
  9. Use removeable computer storage
  10. Pick up fork or spoon, use for eating
  11. Pick up cup by handle
  12. Carry an object from place to place

Items of the MAL-14:

  1. Putting arm through coat sleeve
  2. Steady myself while standing
  3. Carry an object from place to place
  4. Pick up fork or spoon, use for eating
  5. Comb hair
  6. Pick up cup by handle
  7. Hand craft/card playing
  8. Hold a book for reading
  9. Use towel to dry face or other body part
  10. Pick up a glass
  11. Pick up toothbrush and brush teeth
  12. Shaving/makeup
  13. Use a key to open a door
  14. Letter writing/typing

The MAL-26 includes the 14 items from the MAL-14 as well as the following items:

  1. Pour coffee/tea
  2. Peel fruit/potatoes
  3. Dial number on the phone
  4. Open/close a window
  5. Open an envelope
  6. Take money out of a wallet or purse
  7. Undo buttons on clothing
  8. Buttons on clothing
  9. Undo a zip
  10. Do up a zip
  11. Cut fingernails (affected hand)
  12. Other optional activity

Items of the MAL-28:

  1. Turn on a light with a light switch
  2. Open a drawer
  3. Remove item of clothing from drawer
  4. Pick up phone
  5. Wipe kitchen counter
  6. Get out of car
  7. Open refrigerator
  8. Open a door by turning a door knob
  9. Use a TV remote control
  10. Wash your hands
  11. Turn water on/off with faucet
  12. Dry your hands
  13. Put on your socks
  14. Take off your socks
  15. Put on your shoes
  16. Take off your shoes
  17. Get up from chair with armrests
  18. Pull chair away from table before sitting
  19. Pull chair toward table after sitting
  20. Pick up a glass
  21. Pick up toothbrush and brush teeth
  22. Use a key to unlock a door
  23. Steady self while standing
  24. Carry an object from place to place
  25. Comb hair
  26. Pick up cup by handle
  27. Buttons on clothing (shirt, trousers)
  28. Eat half a sandwich or finger food

For each item, the individual is asked whether he/she attempted the activity in the past 7 days, and the relevant score is assigned according to his/her response. The examiner can verify the response by paraphrasing it back to the individual (Uswatte & Taub, 2005). The MAL can also be used with caregivers.

Scoring:

The MAL is administered by semi-structured interview and items are scored by patients according to their performance of each task over the past 7 days; the MAL-28 can also be used to score performance over the past 3 days (Ashford et al., 2008; Uswatte & Taub, 2005).

The MAL adopts a 6-point ordinal scale, although patients can attribute a half-score, resulting in 11-point Likert scales with specified anchoring definitions at 6 points (Uswatte & Taub, 2005):

Amount of Use scale scoring:

  • 0: Never – The weaker arm was not used at all for that activity.
  • 1: Very rarely – Occasionally used the weaker arm, but only very rarely.
  • 2: Rarely – Sometimes used the weaker arm but did the activity most of the time with the stronger arm.
  • 3: Half pre-stroke – Used the weaker arm about half as much as before the stroke.
  • 4: Three quarters pre-stroke – Used the weaker arm almost as much as before the stroke.
  • 5: Same – Used the weaker arm as often as before the stroke.

Quality of Movement scale scoring:

  • 0: Never – The weaker arm was not used at all for that activity.
  • 1: Very rarely – The weaker arm was moved during the activity but was not very helpful.
  • 2: Rarely – The weaker arm was of some use during the activity but needed some help from the stronger arm but moved very slowly or with difficulty.
  • 3: Fair – The weaker arm was used for that activity, but the movements were slow or were made only with some effort.
  • 4: Almost normal – The movements made by the weaker arm for the activity were almost normal but not quite as fast or accurate as normal
  • 5: Normal – The ability to use the weaker arm for that activity was as good as before the stroke.

Scale total scores (summary scores) are the mean of the item scores.

What to consider before beginning:

The MAL is subject to experimenter bias and also the patient’s ability to accurately recall upper limb use (Page & Levine, 2003; Uswatte & Taub, 2005).

Ashford et al. (2008) noted an inadequate relationship between overall/item scores and the qualitative meaning, and an unclear Minimal clinically important difference.

Taub & Uswatte (2000) discuss the use of the MAL as an outcome measure in Constraint-Induced Movement Therapy (CIMT) research and recommend an upper cut-off score of 2.5 on the MAL-AOU, as the effect of stroke can impose an upper physiological limit on the amount of improvement that can be produced. The authors also note that individuals who score > 2.5 do not demonstrate learned non-use, which is the aim of CIMT.

Time:

All versions of the MAL are administered through structured interview with the patient and/or carer and require more than 10 minutes to administer. (Ashford et al., 2008).

Training requirements:

The MAL can be administered by health professionals who have reviewed the manual and literature.

Equipment:

Survey instrument and pencil.

Client suitability

Can be used with:

  • The MAL is suitable for use with adults and elderly adults following stroke and their caregivers. It is suitable for use in the subacute and chronic stages of stroke recovery.

Should not be used in:

Not specified.

  • The MAL is often used to measure outcomes following constraint induced movement therapy (Li et al., 2012; Page, 2003). The MAL is commonly used in research in conjunction wi with the Wolf Motor Function Test, Fugl-Meyer Assessment or the Action Research Arm Test (Santisteban et al., 2016; Simpson & Eng, 2013).

In what languages is the measure available?

  • Brazilian-Portuguese (Saliba et al., 2011)
  • English
  • German (Khan et al., 2013)
  • Portuguese (Pereira et al., 2011)
  • Turkish translation and cultural adaptation (Cakar et al., 2010).

Summary

What does the tool measure? Real life upper limb performance.
What types of clients can the tool be used for? Individuals following stroke and their caregivers.
Is this a screening or assessment tool? Assessment
What domain of the ICF does this measure? Activity/participation
Time to administer 20 minutes
Versions
  • MAL-30
  • MAL-28
  • MAL-26
  • MAL-14
  • MAL-12
  • Graded Motor Activity Log
  • Lower-Functioning Motor Activity Log (LF-MAL)
  • Lower-Extremity Motor Activity Log
  • Pediatric Motor Activity Log – Revised
Other Languages Brazilian-Portuguese, English, German, Portuguese, Turkish.
Measurement Properties
Reliability Internal consistency:
– MAL-14: Two studies reported excellent Internal consistency.
– MAL: One study reported excellent Internal consistency; one study reported excellent Internal consistency among patients with mild-moderate hemiparesis and adequate to excellent Internal consistency among patients with severe hemiparesis.
– MAL-28 (Turkish): One study reported excellent Internal consistency.
– MAL-30 (German): One study reported excellent Internal consistency.
– Grade 4/5 MAL: One study reported excellent Internal consistency.

Test-retest:
– MAL-14: One study reported excellent test-retest reliability; one study reported adequate to excellent test-retest reliability.
– MAL: One study reported excellent test-retest reliability; one study reported adequate to excellent test-retest reliability.
– MAL-28 (Turkish): One study reported excellent test-retest reliability.
– MAL-28 (Brazilian): One study reported excellent test-retest reliability.
– MAL-45: One study reported excellent test-retest reliability.
– Grade 4/5 MAL: One study reported excellent test-retest reliability.

Intra-rater:
No studies have reported on the intra-rater reliability of the MAL.

Inter-rater:
MAL-14: One study reported adequate inter-rater reliability.

Validity Content:
No studies have reported on content validity of the MAL.

Criterion:
Concurrent:
– MAL-14: One study reported excellent correlations with accelerometry.
– MAL: Three studies reported an excellent correlation with SIS – Hand function domain; adequate correlations with the BBT, ARAT, FAI; poor to adequate correlations with SIS, SS-QOL, NEADL; and poor correlations with the Nine Hole Peg Test.
– MAL-30 (German): One study reported excellent negative correlations with WMFT-PT; excellent correlations with WMFT-FA and Grip strength scores, CMSA – Arm and Hand scores, isometric strength.
– MAL-45: 1 study reported excellent correlations with the Abilhand.

Predictive:
No studies have reported on predictive validity of the MAL.

Construct:
– MAL-14: One study reported excellent correlations between QOM and AOU patient/carer change scores; one study reported an excellent correlation between AOU and QOM scales.
– MAL: One study reported an excellent correlation between AOU and QOM scales; one study reported an adequate correlation between AOU and QOM scales; one study conducted item analysis and removed two items due to low item-total correlations and Reliability coefficients; one study conducted item fit analysis and principal component analysis.
– MAL (Brazilian): One study reported an excellent correlation between AOU and QOM scales.
– MAL-30 (German): One study reported excellent correlations between AOU and QOM scales.
– MAL-28 (Turkish): One study reported an excellent correlation between AOU and QOM scales.
– LF-MAL: One study reported an adequate correlation between the AOU and QOM scales.

Convergent/Discriminant:
– MAL-14: Three studies reported excellent correlations with ARAT, accelerometry, Simple Test for Evaluating Hand Function (STEF).
– MAL: Seven studies reported excellent correlations with Actual Amount of Use Test, WMFT; adequate to excellent correlations with accelerometry ratios, SIS 2.0 – Hand function scale, FMA-UE; adequate correlations with ARAT, Motor Assessment Scale – Upper Extremity, 16 Hole Peg Test, grip strength; SF-36 – Physical domain; poor to adequate correlations with accelerometry ratios of the less affected arm; poor correlations with the SIS 2.0 – Mobility scale.
– MAL-28 (Turkish): One study reported excellent correlations with WMFT-FA; adequate negative correlations with the WMFT-PT.
– MAL (Brazilian): One study reported adequate correlations with grip strength of the more affected arm.

Known Group:
MAL: One study reported correlations with accelerometry was stronger among patients with paresis of the dominant arm vs. the non-dominant arm.

Floor/Ceiling Effects – Floor effects are evident when detecting change in lower level and passive functional tasks.
– One study found modest floor effects when the MAL-28 was administered to patients with upper extremity motor recovery at Brunnstrom stage III and higher; and modest floor effects when the LF-MAL was administered to patients with upper extremity motor recovery at Brunnstrom stage III and lower.
Does the tool detect change in patients? The MAL can be used to detect change
Acceptability The MAL reflects real life functional performance. It is simple and non-invasive to administer.
Feasibility The MAL is a free tool that requires no additional equipment. It can be administered in the clinical setting or the patient’s home. No additional training is required.
How to obtain the tool?

Click here to see the Motor Activity Log manual.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the MAL. Twenty-six studies were identified, most of which included patients in the chronic phase of stroke recovery. This review includes different versions of the MAL – the original MAL-30, MAL-28, MAL-14, MAL-45, LF-MAL, Grade 4/5 MAL and Turkish, Brazilian and German versions.

Floor/Ceiling Effects

Chuang et al. (2017) examined floor/ceiling effects of the 30-item MAL in a sample of 403 patients with chronic stroke. The MAL was administered to patients with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and higher. Results showed modest floor effects within this cohort, whereby 17.3% of participants received minimum scores on the MAL.

Chuang et al. (2017) examined floor/ceiling effects of the LF-MAL in a sample of 134 patients with chronic stroke. The LF-MAL was administered to patients with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and lower. Results showed modest floor effects within this cohort, whereby 16.4% of participants received minimum scores on the LF-MAL.

Reliability

Internal consistency:
van der Lee et al. (2004) examined Internal consistency of the MAL-14 in a sample of 56 patients with chronic stroke, using Cronbach’s alpha. Correlation among items was excellent for the MAL-AOU (a = 0.87) and the MAL-QOM (a = 0.90). Limits of agreement ranged from -0.70 to 0.85 for the MAL-AOU and from -0.61 to 0.71 for the MAL-QOM, indicating reproducibility sufficient to detect an individual change of approximately 12-15% of the range of the scale.

Uswatte et al. (2005b) examined Internal consistency of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers, using Cronbach’s alpha. Correlation among items was excellent for patients’ MAL-QOM (a = 0.87) and caregivers’ MAL-AOU and MAL-QOM (a > 0.83). The authors also examined Internal consistency of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke. Correlation among items was excellent for the MAL-QOM (a = 0.81).

Uswatte et al. (2006b) examined Internal consistency of the MAL-28 in a sample of 222 patients with subacute/chronic stroke and their caregivers, using Cronbach’s alpha. Responses from both patient and caregiver groups showed excellent Correlation among items for the MAL-AOU (patients a = 0.94; caregivers a = 0.95) and the MAL-QOM (patients a = 0.94; caregivers a = 0.95).

Huseyinsinoglu et al. (2011) examined Internal consistency of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using Cronbach’s alpha. Internal consistency was excellent for the MAL-AOU (a = 0.96) and MAL-QOM (a = 0.96).

Khan et al. (2013) examined Internal consistency of the MAL-30 (German version) in a sample of 42 patients with acute to chronic stroke, using Cronbach’s alpha. Measures were taken at baseline, discharge from rehabilitation and at 6-month follow-up. Internal consistency for the MAL-AOU and MAL-QOM were excellent at all timepoints (a = 0.98-0.995). The authors also calculated Internal consistency based on an elimination procedure of items that scored “N/A” down to 26 items and reported that Internal consistency remained high at all timepoints (a = 0.94-0.98).

Taub et al. (2013) reported on Internal consistency of the Grade 4/5 MAL, referencing unpublished data from Morris (2009) that used a sample of 30 individuals with stroke, using Cronbach’s alpha. Internal consistency for the Grade 4/5 MAL was excellent (a = 0.95).

Chuang et al. (2017) examined the 6-point rating system of the MAL and found rater difficulty discriminating among the 6 levels of functional ability. Results showed that 15 items of the MAL-AOU and MAL-QOM displayed disordering of step difficulty. Accordingly, the 6 levels were collapsed into 4 levels to restore reversed threshold (0 = 0; 1-2 = 1; 3-4 = 2; 5 = 3); using the 4-point system 9 items still showed disordered ordering, so the levels were further collapsed into 2 categories (0 = 0; 1 to 3 = 1), at which point all items exhibited ordering. The authors examined unidimensionality of the 30-item MAL in a sample of 403 patients with chronic stroke, using the revised scoring system. Item fit analysis of the MAL revealed that 7 items* of the MAL-AOU and MAL-QOM were a poor fit and were removed. Principal component analysis (PCA) of the remaining 23 items showed that Rasch measures accounted for 76% of the variance for both the MAL-AOU and MAL-QOM, with an eigenvalue of the first residual factor of 2.7. This indicates that the 23 items constitute unidimensional constructs. The authors examined reliability of the revised MAL (23 items, 4-point rating system), using Rasch analysis. With Pearson separation values of 2.4 and 2.6 for the MAL-AOU and MAL-QOM respectively, the revised version was sensitive to distinguish among 3 strata of upper limb performance. Pearson reliability coefficients were 0.85 and 0.87 (respectively), suggesting good reliability. Results showed no Differential Item Functioning (DIF) items across age, gender or hand dominance. Item difficulty hierarchy was consistent with clinical expectation, however items were more difficult than individuals’ ability, suggesting unsuitable targeting for the participants of this sample.

* Misfit items: (6) Get out of car; (12) Dry your hands; (18) Pull a chair away from the table before sitting down; (19) Pull chair toward table after sitting down; (21) Brush your teeth; (24) Write on paper; (29) Button a shirt.

Chuang et al. (2017) examined the 6-point rating system of the LF-MAL and found disordered thresholds; accordingly, the 6 levels were collapsed into 3 levels to restore reversed threshold (0 = 0; 1-3 = 1; 4-5 = 2); this 3-point rating system achieved step ordering. The authors examined unidimensionality of the LF-MAL in a sample of 134 patients with chronic stroke, using the revised 3-point scoring system. Item fit analysis of the LF-MAL-AOU revealed that 6 items were out of the acceptable range; PCA of the remaining 24 items showed that the Rasch dimension explained 70.5% of the variance, with an eigenvalue of 2.6 of the first residual factor. Item fit analysis of the LF-MAL-QOM revealed that 7 items were out of the acceptable range; PCA of the remaining 23 items showed that the Rasch dimension explained 71.0% of the variance, with an eigenvalue of the first residual factor of 2.5. The authors examined reliability of the revised LF-MAL (25 items, 3-point rating system), using Rasch analysis. With Pearson separation values of 1.9 for both the LF-MAL-AOU and LF-MAL-QOM, the revised version was sensitive to distinguish 2 strata of upper limb performance. Pearson reliability coefficients were 0.79 for both the LF-MAL-AOU and LF-MAL-QOM, indicating acceptable reliability. Results showed no DIF items across age, gender or hand dominance. Item difficulty hierarchy was consistent with clinical expectation, however items were more difficult than individuals’ ability, suggesting unsuitable targeting for the participants of this sample.

* Misfit items: (5) Wipe off a kitchen counter or another surface; (6) Get out of a car; (7) Open a refrigerator; (19) Apply soap to your body while bathing (LF-MAL-QOM only); (21) Brush your teeth; (23) Steady yourself while standing; (24) Carry an object in your hand.

Moreira Silva et al. (2018) examined Internal consistency of the MAL-30 in a sample of 66 individuals with chronic stroke, using Cronbach’s alpha. Participants were classified according to upper extremity motor function using the Fugl-Meyer Assessment – Upper Extremity (FMA-UE): mild to moderate hemiparesis (FMA-UE ≥ 32, n = 49) or severe hemiparesis (FMA-UE ≤31, n = 17). Internal consistency of the MAL-AOU and MAL-QOM was excellent among participants with mild-moderate hemiparesis (a = 0.95), and adequate to excellent among participants with severe hemiparesis (MAL-AOU: a = 0.79; MAL-QOM: a = 0.89). Rasch analysis was used to further evaluate reliability of the MAL-30. Item calibration of the MAL-AOU and MAL-QOM revealed one misfit (#19: Pull a chair toward table after sitting down). Item separation index of the MAL-AOU and MAL-QOM was 2.92 and 2.59 (respectively) suggesting 5 levels of difficulty for the MAL-AOU and 4 levels of difficulty for the MAL-QOM. Pearson separation index of the MAL-AOU and MAL-QOM was 2.62 and 2.58 (respectively), suggesting 4 ability levels for both the MAL-AOU and the MAL-QOM.

Test-retest:
Miltner et al. (1999) examined test-retest reliability of the MAL in a sample of 15 patients with chronic stroke. Measures were taken within a 2-week interval before participants began constraint-induced movement therapy. test-retest reliability was excellent (r = 0.98).

Johnson et al. (2003) examined test-retest reliability of the MAL-45 in a sample of 12 patients with chronic stroke, using Pearson’s Correlation coefficient. Measures were taken within a 3-week interval. test-retest reliability was excellent for the MAL-AOU (r=0.96) and MAL-QOM (r = 0.99).

van der Lee et al. (2004) examined test-retest reliability of the MAL-14 in a sample of 56 patients with chronic stroke, using the Bland and Altman method. Measures were taken within a 2-week interval before participants commenced an intervention program. test-retest reliability was excellent for the for MAL-AOU (r = 0.70 to 0.85) and the MAL-QOM (r = 0.61 to 0.71).

Uswatte et al. (2005b) examined test-retest reliability of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers, using Pearson Correlation coefficients. test-retest reliability was excellent for patient MAL-QOM scores (r = 0.91), and adequate for patient MAL-AOU scores (r = 0.44), and caregiver MAL-AOU and MAL-QOM scores (r = 0.61, r = 0.50 respectively).

Uswatte et al. (2006b) examined 2-week test-retest reliability of the MAL-30 in a sample of 116 patients with subacute/chronic stroke and their caregivers, using Intra Class Coefficients (ICC). test-retest reliability for the MAL-AOU and MAL-QOM was excellent among patients (ICC = 0.79, ICC = 0.82, respectively), and adequate among caregivers (ICC = 0.66, ICC = 0.72, respectively). There was a trend toward an increase from test 1 to test 2 among both patients and caregivers (patient MAL-AOU: 0.3 ± 0.6, p = 0.04; patient MAL-QOM: 0.3 ± 0.5, p = 0.02; caregiver MAL-AOU: 0.4 ± 0.7, p = 0.05; caregiver MAL-QOM: 0.4 ± 0.7, p = 0.02), although increases were less than the minimal clinically important difference (< 0.5 points).

Huseyinsinoglu et al. (2011) examined 3-day test-retest reliability of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using intraclass coefficients (ICC) and Spearman Correlation coefficients. test-retest reliability was excellent for the MAL-AOU (ICC = 0.97, r = 0.94) and the MAL-QOM (ICC = 0.96, r = 0.93).

Saliba et al. (2011) examined test-retest reliability of the MAL (Brazilian version), using intra-class Correlation coefficients (ICC). test-retest reliability for the MAL-AOU and MAL-QOM was excellent (ICC = 0.98).

Taub et al. (2013) reported on test-retest reliability of the Grade 4/5 MAL, referencing unpublished data from Morris (2009) that used a sample of 10 individuals with stroke. test-retest reliability for the Grade 4/5 MAL was excellent (r = 0.95).

Intra-rater:
No studies have reported on the intra-rater reliability of the MAL.

Inter-rater:
Uswatte et al. (2005b) examined inter-rater reliability of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers using Intra Class Coefficients (ICC). Participants received Constraint-Induced Movement Therapy (CIMT) or time-matched general fitness rehabilitation for two weeks. reliability between patient and carer pre-treatment scores was adequate (ICC = 0.52, p < 0.01); reliability between patient and carer change scores following treatment was adequate (ICC = 0.7, p < 0.0001).

Validity

Content:

No studies have reported on content validity of the MAL.

Criterion:

Concurrent:
Johnson et al. (2003) examined concurrent validity of the MAL-45 in a sample of 12 patients with chronic stroke by comparison with the Abilhand, using Pearson Correlation coefficients. Correlations with the Abilhand were excellent for the MAL-AOU (r = 0.71, p < 0.05) and MAL-QOM (r = 0.88, p < 0.05).

Uswatte et al. (2005b) examined concurrent validity of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke by comparison with accelerometry of the affected arm, using Pearson Correlation coefficients. Correlations between the MAL-QOM and accelerometer recordings at pre-treatment (r = 0.70, p < 0.05) were excellent. Correlations between MAL-QOM change scores from pre-treatment to post-treatment and corresponding change scores on accelerometer readings were also excellent (r = 0.91, p < 0.01).

Lin et al. (2010a) examined concurrent validity of the MAL-30 by comparison with the Nine Hole Peg Test (9HPT), the Box and Block Test (BBT) and the Action Research Arm Test (ARAT), using Spearman rank Correlation coefficients. Patients with chronic stroke (n=59) were randomized to receive distributed constraint-induced movement therapy, bilateral arm training or neurodevelopmental therapy, and measures were taken at baseline and post-treatment (3 weeks). Correlations at baseline and post-treatment were significant and adequate with the BBT (MAL-AOU: r = 0.37, r = 0.49; MAL-QOM: r = 0.52, r = 0.52) and the ARAT (MAL-AOU: r = 0.31, r = 0.32; MAL-QOM: r = 0.39, r = 0.35). Correlations with the 9HPT were significant for the MAL-QOM only (r = -0.26, r = -0.33).

Lin et al. (2010b) examined concurrent validity of the MAL-30 by comparison with the stroke Impact Scale 3.0 (SIS) and the Stroke-Specific Quality of Life Scale (SS-QOL), using Spearman rank Correlation coefficients. Patients with chronic stroke (n = 74) were randomized to receive distributed constraint-induced movement therapy, bilateral arm training or neurodevelopmental therapy, and measures were taken at baseline and post-treatment (3 weeks). There were significant poor to adequate correlations between the MAL-AOU and most SIS domains at baseline (r = 0.24-0.58) and post-treatment (r = 0.24-0.59). There were significant excellent correlations between the MAL-QOM and the SIS – Hand function domain at baseline (r = 0.65) and post-treatment (r = 0.68), and significant poor to adequate correlations between the MAL-QOM and most other SIS domains at baseline (r = 0.26-0.52) and post-treatment (r = 0.28-0.51). There were significant correlations between the MAL-AOU and some SS-QOL domains at baseline (r = 0.25-0.37) and post-treatment (r = 0.24-0.35), and between the MAL-QOM and some SS-QOL domains at baseline (r = 0.28-0.38) and post-treatment (r = 0.26-0.39).

Wu et al. (2011) examined concurrent validity of the MAL-30 in a sample of 77 patients with chronic stroke by comparison with a modified version of the Nottingham Extended ADL Scale (NEADL) and the Frenchay Activities Index (FAI), using Spearman rank Correlation coefficients. Measures were taken at pre-treatment and 3 weeks later at post-treatment. Correlations with the NEADL were poor to adequate (MAL-AOU: r = 0.3; MAL-QOM: r = 0.2-0.3). Correlations with the FAI were adequate (MAL-AOU: r = 0.3-0.4); MAL-QOM: r = 0.3).

Khan et al. (2013) examined cross-sectional concurrent validity of the MAL-30 (German version) by comparison with the Wolf Motor Function Test (WMFT) – Time and Functional ability subtests, the Chedoke McMaster stroke Assessment (CMSA) – Arm and Hand subtests, the grip strength scale, and isometric strength measured by handheld dynamometer (mean of shoulder and elbow flexion and extension), using Spearman’s rank Correlation coefficients. Patients with acute to chronic stroke (n = 42) received inpatient rehabilitation and measures were taken at baseline; discharge from hospital and at 6-month follow-up. Significant negative correlations were seen with the WMFT – Time scores (MAL-AOU r = -0.747 – -0.878; MAL-QOM r = -0.770 – -0.901). Correlations were excellent at all time points with the WMFT – Functional ability (MAL-AOU r = 0.769 – 0.808, MAL-QOM r = 0.789 – 0.837), the CSMA – Arm (MAL-AOU r = 0.680 – 0.765; MAL-QOM r = 0.691 – 0.798) and CSMA – Hand (MAL-AOU r = 0.692 – 0.801; MAL-QOM r = 0.717 – 0.803), grip strength (MAL-AOU r = 0.698 – 0.716; MAL-QOM r = 0.659-.0733) and isometric strength (MAL-AOU r = 0.643-0.719; MAL-QOM r = 0.714-0.726).

Predictive:
No studies have examined predictive validity of the MAL.

Construct:

Uswatte et al. (2006b) conducted item analysis of the original MAL-30 using item-total correlations, reliability and proportion of missing data (with an a priori cut-off of 20%) in a sample of 222 patients with subacute/chronic stroke and their caregivers. Of the 30 items, 25 items were completed by > 80% of caregivers and 28 items were completed by > 80% of patients; analysis of these 28 items indicated item-total correlations > 0.5 for 92% of items, and reliability coefficients > 0.5 for 89% of items. The remaining 2 items (write on paper: 48% missing data; put makeup/shaving cream on face: 20% missing data) showed lower item-total correlations and reliability coefficients and were dropped accordingly.

van der Lee et al. (2004) examined construct validity of the MAL-14 in a sample of 56 patients with chronic stroke, using Spearman’s Correlation coefficient. There was an excellent Correlation between the MAL-AOU and MAL-QOM (r = 0.95, p < 0.001).

Uswatte et al. (2005b) examined construct validity of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke by comparison with patient/caregiver MAL-AOU scores, using Pearson Correlation coefficients. Correlations were excellent between MAL-QOM change scores from pre-treatment to post-treatment and corresponding change scores in patient MAL-AOU (r = 0.80, p < 0.01), carer MAL-AOU (r = 0.73, p < 0.01) and carer MAL-QOM (r = 0.70, p < 0.01).

Uswatte et al. (2006a) examined construct validity of the MAL-30 in a sample of 169 individuals with subacute/chronic stroke, using Pearson Correlation coefficient. There was an excellent Correlation between the MAL-AOU and MAL-QOM (r = 0.92, p < 0.001).

Huseyinsinoglu et al. (2011) examined construct validity of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using Spearman’s Correlation coefficient. The Correlation between the MAL-AOU and the MAL-QOM was excellent (r = 0.95).

Saliba et al. (2011) examined construct validity of the MAL (Brazilian version) in a sample of 77 individuals with chronic stroke, using Rasch analysis. There was an excellent Correlation between the MAL-AOU and the MAL-QOM (r = 0.97, p < 0.0001).

Khan et al. (2013) examined construct validity of the MAL-30 (German version), using Spearman’s rank Correlation coefficients. Patients with acute to chronic stroke (n = 42) received inpatient rehabilitation and measures were taken at baseline, discharge from hospital and at 6-month follow-up. There was an excellent Correlation between the MAL-AOU and MAL-QOM at all timepoints (r = 0.994, 0.982, 0.980).

Chuang et al. (2017) examined construct validity of the MAL-30 in a sample of 403 patients with chronic stroke with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and higher, using Rasch analysis. Correlation between the MAL-AOU and MAL-QOM was adequate (r = 0.603), indicating that the subscales are not highly correlated and can be perceived as different concepts.

Chuang et al. (2017) examined construct validity of the LF-MAL in a sample of 134 patients with chronic stroke with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and lower, using Rasch analysis. Correlation between the LF-MAL-AOU and LF-MAL-QOM was adequate (r = 0.607), indicating that the subscales are not highly correlated and can be perceived as different concepts.

Convergent/Discriminant:
van der Lee et al. (2004) examined cross-sectional convergent validity of the MAL-14 by comparison with the Action Research Arm Test (ARAT) in a sample of 56 patients with chronic stroke, using Spearman’s Correlation coefficient. There were excellent correlations between the MAL-AOU and the ARAT (r = 0.63, p < 0.001) and between the MAL-QOM and the ARAT (r = 0.63, p < 0.001).

Uswatte et al. (2005a) examined convergent validity of the MAL-14 in a sample of 20 patients with chronic stroke by comparison with accelerometry of the affected arm, using Spearman rank correlations. There was an excellent Correlation between the MAL-14 and accelerometry (r = 0.74, p < 0.001).

Uswatte et al. (2006a) examined convergent validity of the MAL-30 (QOM scale only) in a sample of 169 patients with subacute/chronic stroke by comparison with accelerometry of the affected arm and the Actual Amount of Use Test (AAUT), using Pearson Correlation coefficients. Correlations between the MAL-QOM and accelerometry ratios (ratio summary variable, impaired arm summary variable) were adequate (r = 0.52, r = 0.41 respectively, p < 0.001). The Correlation between the MAL-QOM and AAUT was excellent (r = 0.94, p < 0.001).

Uswatte et al. (2006b) examined convergent validity of the MAL-30 in a sample of 222 patients with subacute/chronic stroke and their caregivers by comparison with accelerometry of the affected arm, and the SIS 2.0 – Hand function scale, using Pearson Correlation coefficients. Comparison of the MAL with accelerometry ratios showed adequate to excellent correlations for patient scores (MAL-AOU: r = 0.47; MAL-QOM: r = 0.52, p < 0.01), and adequate correlations for caregiver scores (MAL-AOU: r = 0.57; MAL-QOM, r = 0.61, p < 0.01). Comparison of the MAL and SIS – Hand function scores showed excellent correlations for patient scores (MAL-AOU: r = 0.68; MAL-QOM: r = 0.72, p < 0.01), and adequate correlations for caregiver scores (MAL-AOU: r = 0.35, MAL-QOM: r = 0.40, p < 0.01).

Uswatte et al. (2006b) examined divergent validity of the MAL-30 in a sample of 222 patients with subacute/chronic stroke and their caregivers by comparison with accelerometry of the less affected arm, and the SIS 2.0 – Mobility scale, using Pearson Correlation coefficients. Comparison of the MAL with accelerometry ratios of the less affected arm showed poor correlations for patient scores (MAL-AOU: r = 0.14; MAL-QOM: r = 0.14, p > 0.05), and poor to adequate correlations for caregiver scores (MAL-AOU: r = 0.25; MAL-QOM, r = 0.23, p < 0.001). Comparison of the MAL and SIS – Mobility scores showed poor correlations for patient scores (MAL-AOU: r = 0.14; MAL-QOM: r = 0.14, p > 0.05), and poor correlations for caregiver scores (MAL-AOU: r = 0.10, MAL-QOM: r = 0.07, p > 0.05).

Hammer and Lindmark (2010) examined cross-sectional convergent validity of the MAL-30 by comparison with the FMA-UE, ARAT, Motor Assessment Scale – Upper Extremity score (MAS-UE), 16-hole peg test (16HPT) and the Grippit ratio of isometric grip strength, using Spearman’s Correlation coefficient. Patients with subacute stroke (n = 30) were randomized to receive forced use therapy or standard upper limb rehabilitation, and measures were taken at baseline, post-treatment (2 weeks) and follow-up (3 months). Correlations were significant and adequate with all measures: FMA-UE (r = 0.43-0.52); ARAT (r = 0.31-0.51); MAS-UE (r = 0.41-0.54); 16HPT (r = -0.41 – -0.67); Grippit (r = 0.41-0.53).

Huseyinsinoglu et al. (2011) examined convergent validity of the MAL-28 (Turkish version) by comparison with the WMFT – Performance Time (WMFT-PT) and – Functional Ability (WMFT-FA) scores in a sample of 30 patients with stroke. There were excellent correlations with the WMFT-FA (MAL-AOU, r=0.63; MAL-QOM: r = 0.63), and adequate negative correlations with the WMFT-PT (MAL-AOU: r = -0.56; MAL-QOM: r = -0.55).

Saliba et al. (2011) examined convergent validity of the MAL (Brazilian version) by comparison with grip strength of the more severely affected upper limb in a sample of 77 individuals with chronic stroke, using Rasch analysis. There were adequate correlations between grip strength and the MAL-AOU (r = 0.51, p < 0.0001) and the MAL-QOM (r =0 .57, p < 0.0001).

Sterr et al. (2014) examined divergent validity of the MAL in a sample of 65 patients with chronic stroke by comparison with the Short Form 36 (SF-36), stroke Impact Scale (SIS), Hospital Anxiety and Depression Scale (HADS) and Visual Analog Mood Score (VAMS), using regression analysis. Participants received four different Constraint-Induced Movement Therapy (CIMT) treatment protocols that differed in intensity and use of a constraint. Following treatment there was a significant positive association between the MAL-AOU and the SF-36 Physical domain (r = 0.38m p = 0.025) and a trend towards a moderate association with the SIS Total score (r = 0.43, p = 0.061).

Shindo et al. (2015) examined convergent validity of the MAL-14 in a sample of 34 patients with acute/subacute stroke by comparison with the Simple Test for Evaluating Hand Function (STEF), using Spearman’s Correlation coefficient. There was a significant and excellent Correlation between the assessments (MAL-AOU: r = 0.805; MAL-QOM: r = 0.768).

Simpson, Conroy & Beaver (2015) examined convergent validity of the MAL-28 in a sample of 9 patients with stroke, by comparison with the FMA, Wolf Motor Function Test and stroke Impact Scale, using Spearman’s Correlation coefficient. There were excellent correlations between baseline MAL-AOU and FMA (ρ = 0.6889, p < 0.0132) and MAL-QOM and FMA (ρ = 0.7276, p < 0.0073).

Moreira Silva et al. (2018) examined convergent validity of the MAL-30 in a sample of 66 individuals with chronic stroke by comparison with the FMA-UE, using Spearman’s Correlation coefficient. There was a significant and excellent Correlation with the FMA-UE (MAL-AOU: r = 0.87; MAL-QOM: r = 0.87).

Chen et al. (2018) examined convergent validity of the MAL in a sample of 82 patients with stroke by comparison with accelerometry of the affected arm, using Pearson’s Correlation coefficient. There was an adequate Correlation with accelerometry (MAL-AOU: r = 0.47; MAL-QOM: r = 0.57).

Known Group:
Uswatte et al. (2006b) examined known-group