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
  • Two studies have examined the internal consistency of the CAHAI and its shortened versions and reported excellent internal consistency using Cronbach’s alpha.
  • One study examined the test-retest reliability of the CAHAI and reported excellent test-retest reliability using using the Intraclass Correlation Coefficient (ICC).
  • No studies have examined the intra-rater reliability of the CAHAI.
  • 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 Validity:

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 Validity:

No studies have examined the predictive validity of the CAHAI.

Construct:

Convergent validity:

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

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