Stroke Arm Ladder

Evidence Reviewed as of before: 15-02-2012
Author(s): Katie Marvin, MSc. PT (Candidate)
Editor(s): Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Expert Reviewer: Johanne Higgins, PhD

Purpose

The Stroke Arm Ladder was developed from an existing bank of test items used to evaluate upper extremity function in patients with stroke. The Stroke Arm Ladder incorporates observable tests of capacity or performance and questions aimed at identifying activity and participation components of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). The measure includes items that cover a wide range of difficulty levels.

In-Depth Review

Purpose of the measure

The Stroke Arm Ladder was developed from an existing bank of test items used to evaluate upper extremity function in patients with stroke. The measure incorporates observable tests of capacity or performance and questions aimed at identifying activity and participation components of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF). The measure includes items that cover a wide range of difficulty levels.

Clinicians and researchers need to use a variety of evaluation measures to assess interventions and constructs related to upper extremity function in patients following stroke. Administration of a variety of tests can be lengthy, time-consuming and burdensome on clients. The Stroke Arm Ladder was developed to address this issue by providing a more comprehensive, all-encompassing interval scale measure for evaluation and monitoring of upper extremity.

Available versions

None yet reported

Features of the measure

Items:

The Stroke Arm Ladder is comprised of 34 items selected from an existing bank of 49 test items used to evaluate upper extremity function in patients with stroke. The existing bank of items reflect the domains of the World Health Organization’s International Classification of Functioning, Disability and Health (ICF) (body functions; and activity and participation), and was derived from commonly used outcome measures, such as the Chedoke McMaster Stroke Assessment, Barthel Index and the Stroke Rehabilitation Assessment of Movement.

Description of tasks:

Staring item: pistol grip, pull trigger then return.

  • If patient is unable to perform starting item – then proceed to EASY subtest, start with number 7.
  • If patient is able to perform starting item – then proceed to DIFFICULT subtest, start with number 36.

EASY subtest items:

Item Score/100
1.Tie a scarf around one’s neck (bilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 3
2.Open a jar and remove a spoonful of coffee (bilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 4
3.Unlock a lock and open a pill container (bilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 5
4.Feeding independently. The patient needs some assistance to feed him- or herself a meal from a tray or table when someone places the food within reach. The patient needs assistance to put on an assistive device if required, cut up food, use salt and pepper, spread butter, etc. The patient needs assistance to be able to accomplish this in a reasonable time. 23
5.Write on an envelope and stick a stamp on it (bilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 29
6.Dressing and undressing. The patient needs some assistance: to put on, remove and fasten all clothing and tie shoelaces (unless it is necessary to use adaptive aids for this). This includes putting on, removing and fastening corsets or braces when they are prescribed. 33
7.Shuffle and deal playing cards (bilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable.

Able to perform item number 7: Move down until patient is unable to meet the criteria for the specific task.

Unable to perform item number 7: Move up until patient is able to meet the specific criteria for the specific task.

34
8.Elbow at side 90 flexion: supination then pronation. 44
9.Finger flexion then extension. 45
10.Extends elbow in supine (starting with elbow fully flexed). Able to complete the movement in a manner that is comparable to the unaffected side. 46
11.Protract scapula in supine. Able to complete the movement in a manner that is comparable to the unaffected side. 48
12. Can the patient prepare their own meals? Cook meals independently?. 49
13. Feeding independently: The patient can feed him- or herself a meal from a tray or table when someone places the food within reach. The patient is able to put on an assistive device if required, cut up food, use salt and pepper, spread butter, etc. The patient must be able to accomplish this in a reasonable time. 51
14. Hand unsupported: opposition of thumb to little finger. 51
15. Handle coins (unilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 52
16. Place hand on sacrum. Able to complete the movement in a manner that is comparable to the unaffected side. 53
17. Shrug shoulders (scapular elevation). Able to complete the movement in a manner that is comparable to the unaffected side. 55
18. Can patient perform housework? Without help? 56
19. Dressing and undressing independently. Patient is able to put on, remove and fasten all clothing and tie shoelaces (unless it is necessary to use adaptive aids for this). This includes putting on, removing and fastening corsets or braces when they are prescribed. 56
20. Pick up and move small objects (unilateral task). The task is partially executed (more than 25%) or certain steps are executed with major difficulties necessitating repeated efforts. Part of the task may have had to be modified or needed assistance to make it achievable. 57
21. Write on an envelope and stick a stamp on it (bilateral task). The task is successfully completed without hesitation or difficulty, as instructed or demonstrated. 57

Difficult subtest items:

Item Score/100
22.In the past two weeks, were you able to cut your food with a knife and fork? 58
23.In the past two weeks, were you able to use your hand that was more affected by your stroke to turn a doorknob? 59
24.Pick up and move a jar (unilateral task). The task is successfully completed without hesitation or difficulty, as instructed or demonstrated. 59
25.Unlock a lock and open a pill container (bilateral task). The task is successfully completed without hesitation or difficulty, as instructed or demonstrated. 60
26.In the past two weeks, were you able to do light household tasks/chores (e.g. dust, make a bed, take out garbage, do the dishes)? Just a little or not difficult at all. 61
27.Bathing independently. The patient must be able to use a bathtub, a shower or take a complete sponge bath. The patient must be able to perform all the steps involved in any one of these tasks without another person being present. 63
28.Tie a scarf around one’s neck (bilateral task). The task is successfully completed without hesitation or difficulty, as instructed or demonstrated. 63
29.Hand from knee to forehead 5x in 5 seconds. 64
30.Arm resting at side of body: raise arm overhead with full supination. 64
31.Pronation: tap index finger 10x in 5 seconds 65
32.In the past two weeks, were you able to use your hand that was most affected by your stroke to carry heavy objects (e.g. bag of groceries)? (Men) 66
33.Open a jar and remove a spoonful of coffee (bilateral task). The task is successfully completed without hesitation or difficulty, as instructed or demonstrated. 71
34.In the past two weeks, were you able to clip your toenails? 73
35.In the past two weeks, were you able to use your hand that was most affected by your stroke to carry heavy objects (e.g. bag of groceries)? (women) Just a little or not difficult at all. 73
36.Elbow at side, 90 degrees flexion: resisted shoulder external rotation.

Able to perform item number 36: Move down until patient is unable to meet the criteria for the specific task.

Unable to perform test item number 36: Move up until patient is able to meet the criteria for the specific task.

76
37.Thumb to finger tips, then reverse 3x in 12 seconds. 78
38.Number of blocks transferred in 60 seconds > 30 82
39.Clap hands overhead then behind back 3x in 5 seconds. 82
40.Bounce ball 4 times in succession then catch. 93
41.Number of blocks transferred in 60 seconds >60 100

Scoring and Score Interpretation:

The Stroke Arm Ladder is scored out of 100 and is based on completion of test items. For example, if the patient is able to perform the starting test item (pistol grip, pull trigger), they automatically start at item number 36 in the ‘DIFFICULT items subtest’; items are tested in a sequential order (36, 37, 38, 39…etc); if the patient successfully completes the next three items but is unable to complete item 40 then they receive a score of 82 out of 100 (as indicated in the right hand column beside item 39).

Information on score interpretation is not yet available.

Time:

Not reported.

Training requirements:

None reported.

Equipment:

  • Scarf
  • Jar with lid
  • Coffee
  • Pill container
  • Manual lock
  • Feeding utensils
  • Plate, bowl, glass, mug
  • Salt and pepper shakers
  • Envelope
  • Stamp
  • Clothing (shirt and pants with buttons)
  • Deck of cards
  • Coins
  • Pen or pencil
  • Access to a kitchen and bathroom if observation of tasks is required

Alternative forms of the assessment

None yet reported

Client suitability

Can be used with:

Clients with stroke (mild, moderate and severe) in the acute and sub-acute phase.

Should not be used with:

Patients greater than 7 months post-stroke until further validation testing is completed.

In what languages is the measure available?

English

Summary

What does the tool measure? Upper extremity function following stroke.
What types of clients can the tool be used for? Can be used with clients with stroke.
Is this a screening or assessment tool? Assessment tool
Time to administer Not yet reported.
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 Stroke Arm Ladder and found internal consistency to be excellent.

Validity

Content:

One study examined the content validity of the Stroke Arm Ladder and confirmed the hierarchial sequencing of the items using Rasch analysis.

Construct:

Convergent/Divergent:

One study examined convergent validity of the Stroke Arm Ladder and reported excellent correlations between the Stroke Arm Ladder and the Stroke Rehabilitation Assessment of Movement; and poor correlation between the Stroke Arm Ladder and the mental and emotional health subsets of the Medical Outcomes Study Short Form 36.

Known Groups:

One study examined known groups validity and found that the Stroke Arm Ladder could differentiate between the two extremes of stroke severity: mild and severe.

Floor/Ceiling Effects

One study examined the floor and ceiling effects and found no floor or ceiling effects in a sample population of patients with stroke ranging from mild to severe.

Note: The Stroke Arm Ladder has only been tested on patients up to 7 months post-stroke.

Does the tool detect change in patients? Not yet assessed.
Acceptability Results support preliminary validation of the psychometric properties, however further research is needed before the tool is ready for use clinically.
Feasibility The administration of the Stroke Arm Ladder is easy and simple to administer. The Stroke Arm Ladder provides a more comprehensive all-encompassing evaluation tool for evaluation and monitoring of upper extremity function.
How to obtain the tool? Information on the Stroke Arm Ladder can be obtained from the Higgins, Finch, Kopec & Mayo (2011) study.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Stroke Arm Ladder and revealed only the initial validation study. Results support preliminary validation of the psychometric properties, however further research is needed before the tool is ready for use clinically.

Floor/Ceiling Effects

Higgins, Finch, Kopec and Mayo (2011) examined the floor and ceiling effects of the Stroke Arm Ladder in patients with stroke and found no floor or ceiling effects, as no patients scored below or above the easiest and hardest items (respectively).

Note: This sample only included patients up to 7 months post-stroke and thus, the Stroke Arm Ladder should not be used for patients past 7 months post-stroke until further validation testing is completed.

Reliability

Internal consistency:
Higgins, Finch, Kopec and Mayo (2011) investigated the internal consistency of the Stroke Arm Ladder and found excellent internal consistency (Cronbach’s alpha = 0.97).

Test-retest:
Test-retest reliability has not been examined.

Intra-rater:
Intra-rater reliability has not been examined.

Inter-rater:
Inter-rater reliability has not been examined.

Validity

Content:

Higgins, Finch, Kopec and Mayo (2011) investigated the content validity of the Stroke Arm Ladder in clients with stroke. In the development of the Stroke Arm Ladder, 49 items from validated tests and indices used to assess upper extremity function and movement, such as the Box and Block Tests, were selected. Fifteen items were deleted for reasons such as redundancy and lack of fit to the model. When validating the 34 items selected for the final version of the measure, all patients with stroke had fit residuals between -2.0 and +2.0. The hierarchical sequencing of the items was confirmed using Rasch analysis. The results from this study suggest that all 34 items in the Stroke and Arm Ladder reflect the same construct.

Criterion:

Concurrent:
Concurrent validity has not been examined.

Predictive:
Predictive validity has not been examined.

Construct:

Convergent/Discriminant:
Higgins, Finch, Kopec and Mayo (2011) investigated the convergent validity of the Stroke Arm Ladder by comparing it to the index of global functional recovery (total score on the Stroke Rehabilitation Assessment of Movement). Excellent correlation was found between the two measures (r=0.6, P<0.0001). The authors also reviewed the correlation between the Stroke Arm Ladder and the mental and emotional subsets of the Medical Outcomes Study Short Form 36 (SF-36), and found poor correlation (r=0.2, P<0.0001). Results from this study indicate that the Stroke Arm Ladder adequately measures the construct of upper extremity function, with limited ability to assess mental and emotional status following stroke, as intended by the developers.

Known Groups:
Higgins, Finch, Koppec and Mayo (2011) examined known groups validity of the Stroke Arm Ladder in patients with stroke. Patients with stroke were classified as having mild, mild-moderate, moderate or severe stroke using the Canadian Neurological Scale (CNS). Results revealed that the Stroke Arm Ladder was able to differentiate two out of four different levels of stroke severity: mild and severe Patients classified as having either moderate or severe stroke scored similarly on the measure, as did patients classified as having mild and mild-moderate stroke. Patients classified as having moderate or severe stroke differed significantly from those classified as having mild or mild-moderate stroke, indicating the ability of the Stroke Arm Ladder to differentiate between the two extremes (mild versus severe).

Sensitivity/ Specificity

Sensititive or specificity has not been examined.

Responsiveness

Responsiveness has not been examined.

References

  • Higgins, J., Finch, L.E., Kopec, J. & Mayo, N.E. (2011). Development and initial psychometric evaluation of the Stroke Arm Ladder: A measure of upper extremity function post stroke. Clinical Rehabilitation, 25(8), 740-759.

See The Measure

How to obtain the Stroke Arm Ladder?

The Stroke Arm Ladder is available in the following article:

Higgins, J., Finch, L.E., Kopec, J. & Mayo, N.E. (2011). Development and initial psychometric evaluation of the Stroke Arm Ladder: A measure of upper extremity function post stroke. Clinical Rehabilitation, 25(8), 740-759.

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