Reliability,validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke

Purpose:?The upper limb items of the Motor Assessment Scale (MAS) have been shown to be a sensitive, valid and reliable measure of upper limb function for adults following stroke, however the validity and reliability of summing these items into an independent subscale has not yet been evaluated. The stability, internal consistency and construct validity of the upper limb MAS subscale (UL-MAS) was assessed in this study.

Method:?Twenty-seven inpatients following stroke (mean age?=?67 years, range?=?40?–?80) were sampled from an acute, inpatient rehabilitation setting. Patients were evaluated with ‘Upper Arm Function’, ‘Hand Movements’, and ‘Advanced Hand Activities’ items of the MAS by masked physiotherapists who had received standardized training in administration of the MAS.

Results:?All items were explained by one factor on confirmatory factor analysis and correlated significantly with one another and with the composite (summed total) score. Internal consistency analysis produced a Cronbach's alpha of 0.83 which did not benefit from removal of any items.

Conclusions:?The acceptable internal consistency score obtained verifies the validity and reliability of using the UL-MAS as an independent scale. This study has also verified the construct validity of the UL-MAS subscale and provides a valuable extension of previous work, which together demonstrates the value of the UL-MAS as a responsive, valid and reliable measure of upper limb function in adults following stroke. The UL-MAS produced a single, composite score that could be interpreted as a total score for upper limb function in this population.     

Comparison of clinical test and questionnaires for the evaluation of upper limb prosthetic use in children

Purpose: The aim of the present study was to find out if there was a correlation between an observational clinical test and a questionnaire for the evaluation of upper limb prosthetic use in children and to determine which one was better and easier to use in clinical practice.

Method: Twenty children who were patients of the children's prosthetic clinic at the Rehabilitation Institute in Ljubljana, Slovenia, and had a functional prosthesis were included in the study. The age appropriate subtest of the University of New Brunswick Test of Prosthetic Function (the UNB test) was assessed by an occupational therapist. Parents completed either the Child Amputee Prosthetics Project-Functional Status Inventory for Preschool children (CAPP-FSIP) or the Child Amputee Prosthetics Project-Functional Status Inventory (CAPP-FSI), depending on which was appropriate for the child's age. Information was limited to the upper extremity items.

Results: We found a significant correlation between UNB spontaneity and skill score (r = 0.956, p = 0.000) and also between the parental CAPP score and UNB test (UNB spontaneity—CAPP activities r = 0.634, p = 0.003; UNB spontaneity—CAPP prosthetic use r = 0.542, p = 0.014, UNB skill—CAPP activities r = 0.559, p = 0.010, UNB skill—CAPP prosthetic use r = 0.597, p = 0.005).

Conclusions: We concluded that both instruments can be used for assessing upper limb prosthetic use in children but neither is an optimal choice.     

Dimensionality and scalability of the Motor Assessment Scale (MAS)

Purpose. The Motor Assessment Scale (MAS) has shown to be a reliable and valid instrument for measuring motor functioning for stroke patients. The purpose of this paper was to study dimensionality and scalability of the instrument.

Method. A total number of 137 patients were evaluated at admission and on discharge. To study dimensionality and scalability, Partial Credit Models (PCM) were applied for the eight items in the instrument and also for the upper limb and lower limb activities separately. Studies were performed to compare subgroups such as young/old, men/women and diagnosis to examine if the items had the same meaning for the subgroups.

Results. The items showed the same ordering for admission and discharge. Infit and outfit values varied between 0.5 and 1.9 at admission and 0.5 and 1.7 on discharge.

Conclusions. We conclude that the scalability of the different items is not optimal. For some items, the top and/or bottom levels are overrepresented and for other items the middle levels tend to cluster. There seems to be a single construct except for one of the items. The instrument also showed the same meaning for the different subgroups.     

Psychometric validation of a subjective well-being measure for people with spinal cord injuries

Purpose: The researchers examined the factorial validity and the concurrent validity of the Sense of Well-Being Inventory (SWBI) based on a sample of Canadians with spinal cord injuries (SCI) in the community.

Method: One hundred thirty-two participants were recruited from the Alberta, Saskatchewan, Nova Scotia, and Manitoba chapters of the Canadian Paraplegic Association. Mean age of participants was 45.82 years (SD = 15.67), and 77% were men. The participants were asked to complete a research packet containing a demographic questionnaire, the SWBI, and the brief version of the World Health Organization Quality of Life questionnaire (WHOQOL-BREF).

Results: Factor analysis yield four factors (Psychological Well-Being, Financial Well-Being, Social and Family Well-Being, and Physical Well-Being) similar to the original SWBI. In addition, the SWBI factors in the present study correlated moderately well with the corresponding factors in the WHOQOL-BREF and with demographic variables appropriate to the respective subscale.

Conclusions: The factorial validity and the concurrent validity of the SWBI were generally supported. The SWBI, as a subjective well-being measure developed specifically to relate to disability and rehabilitation, appears useful for use with people with SCI in the community.     

Prosthetic socket fit comfort score

Purpose: To validate a simple numerical scale to record the socket comfort of an artificial limb.

Method: This study has adapted the numerical rating scale for pain (Downie et al.¹) to form a 11 point scale to record the socket comfort score (SCS). Patients were asked to rate the comfort of their socket on a 0 - 10 scale where 0 and 10 represented the most uncomfortable and the most comfortable socket imaginable. Ratings of clinical evidence of poor fit were recorded independently by the physician and the prosthetist. Patients gave new numerical ratings of comfort after any necessary intervention to the socket. Repeatability, criterion related validity, sensitivity to change and use in clinical practice was studied on 44 consecutive patients in the prosthetic rehabilitation clinic.

Results: The study showed the reported SCS was consistent and reliable, high correlations being found between three scores obtained from patients by independent recorders. A strong relationship existed between the reported SCS and clinical evidence of poor fit judged by the physician and by the prosthetists' ratings. Significant positive changes in SCS were found after intervention to improve the fit.

Conclusion: SCS has shown repeatability, criterion related validity and sensitivity to change. It has clinical utility and wider use is recommended.     

A comparison of upper limb amputees and patients with upper limb injuries using the Disability of the Arm, Shoulder and Hand (DASH)

Purpose: To use the Disability of the Arm Shoulder and Hand (DASH) scale to measure the disability of patients with upper limb amputation(s) and to compare these to other upper limb injuries.

Method: All 274 patients over the age of 18 years presenting to Prince Henry Hospital in Sydney over a 4-year time frame were given the DASH assessment tool and asked to complete it under supervision of the Occupational Therapist.

Results: Patients with brachial plexus injuries, Complex Regional Pain Syndrome and bilateral upper limb amputations demonstrated significantly higher levels of disability to patients with unilateral upper limb amputations. Partial hand amputees reported a higher level of disability than major unilateral upper limb amputees. For the 48 patients who completed pre- and post-treatment assessments, there was a significant improvement in their health status.

Conclusions: Further research is required to understand the factors that affect a patient's perceptions of their disability. Perhaps the definitive nature of an amputation and the immediate involvement of highly skilled health professionals serve to assist patients to accept their injury and therefore minimizes the level of disability.     

Using the theory of planned behaviour to develop an assessment of attitudes and beliefs towards prosthetic use in amputees

Purpose: To develop a questionnaire based on the theory of planned behaviour (TPB) to predict prosthetic use.

Method: In part one, 31 amputees over 50 years of age with peripheral arterial disease completed attitude items containing 27 bipolar adjectives and open-ended questions on behavioural, normative and control beliefs relating to using the prosthesis. Academic, clinical and patient experts (n = 12) identified bipolar adjectives with best face validity. In part two, 15 amputees completed three behavioural format questions relating to prosthetic use and were asked to indicate the easiest to answer.

Results: Following the completion of the attitude items by the amputees and the expert panel review, 5 items remained (Cronbach's alpha = 0.87) with corrected item-total correlations ranging from 0.43 to 0.83. Modal behavioural beliefs concerned mobility (46.5%), independence (25.6%) and participation restrictions (16.3%), normative beliefs concerned family (33.3%), NHS staff (31.7%), friends (19.1%) and other patients (15.9%) and control beliefs concerned stairs (21.1%), slippery/rough surfaces (28.9%), disabled facilities (54.8%) and people helping (22.6%). In relation to part 2, an exact numerical report of hours and days of prosthetic use was found easiest to answer (73%).

Conclusions: Based on this qualitative and quantitative development work, the questionnaire contains five attitude items, six behavioural, eight normative, eight control belief items and two self-report questions of the behaviour.     

Upper limb recovery after stroke: the stroke survivors' perspective

Purpose. This study investigated stroke survivors' perspective of upper limb recovery after stroke. The aim was to determine factors other than medical diagnosis and co-morbidities that contribute to recovery. The objectives were to explore how stroke survivors define recovery, identify factors they believe influence recovery and determine strategies used to maximize upper limb recovery.

Method. A qualitative study consisting of three focus groups and two in-depth interviews was conducted with stroke survivors (n = 19) and spouses (n = 9) in metropolitan, regional and rural Queensland, Australia. Data were analysed using principles of grounded theory.

Results. Stroke survivors maximize upper limb recovery by 'keeping the door open' a process of continuing to hope for and work towards improvement amidst adjusting to life with stroke. They achieve this by 'hanging in there', 'drawing on support from others', 'getting going and keeping going with exercise', and 'finding out how to keep moving ahead'.

Conclusions. This study provides valuable insight into the personal experience of upper limb recovery after stroke. It highlights the need to develop training strategies that match the needs and aspirations of stroke survivors and that place no time limits on recovery. It reinforces the benefits of stroke support groups and advocates their incorporation into stroke recovery services. These findings can be used to guide both the development and evaluation of stroke survivor centred upper limb training programmes.     

The value of the Rehabilitation Activities Profile (RAP) as a quality sub-system in rehabilitation medicine

Purpose: To determine whether interdisciplinary team care, using the Rehabilitation Activities Profile (RAP) as a team tool, results in a better rehabilitation outcome.

Method: A multilevel prospective cohort study, with a controlled before and after design. Eighteen rehabilitation teams in eight rehabilitation centres in the Netherlands and Belgium participated. Based on the level of implementation of the RAP, we compared three study groups. Consecutive adult patients (n = 933) with stroke, amputation of the lower limb, spinal cord injury, multiple sclerosis, or other neuromuscular disorders, were followed during inpatient or outpatient rehabilitation. Main outcome measures were Barthel Index, RAP-CPM (sum score of the domains communication, personal care and mobility), Nottingham Health Profile (NHP), length of rehabilitation (LOR) and discharge destination (home vs elsewhere).

Results: Overall results show that scores on the Barthel Index, the RAP-CPM and the NHP improved, on average, by 18.4%, 12.7%, and 6.7%, respectively. However, treatment from a rehabilitation team that uses the RAP was associated with a significantly lower Barthel score, and small, non-significant effects on the RAP-CPM and the NHP. Partial use of the RAP resulted in non-significant, lower scores on these measures. With respect to discharge destination and LOR, there were also no significant differences between the three study groups, with the exception of a shorter outpatient rehabilitation period for the group in which partial use was made of the RAP.

Conclusion: The RAP, at the current level of implementation, does not improve rehabilitation outcome.     

Issues for selection of outcome measures in stroke rehabilitation: ICF Body Functions

Purpose: To evaluate the psychometric and administrative properties of outcome measures assigned to the ICF Body Functions category, and commonly used in stroke rehabilitation research.

Method: Critical review and synthesis of measurement properties for five commonly reported instruments in the stroke rehabilitation literature. Each instrument was rated using the eight evaluation criteria proposed by the UK Health Technology Assessment (HTA) programme. The instruments were also assessed for the rigour with which their reliability, validity and responsiveness were reported in the published literature.

Results: The reporting of specific measurement qualities for outcome instruments was relatively consistent across measures located within the same general ICF category. Far less information was available on the responsiveness of measures, compared with reliability and validity. The best available instruments were associated with the following body functions: cognitive impairment, depression and motor recovery.

Conclusions: The reader is encouraged to examine carefully the nature and scope of outcome measurement used in reporting the strength of evidence for improved body functions in stroke rehabilitation since there is significant diversity. However there appears to be good consensus about what are the most important indicators of successful rehabilitation outcome in each domain of body function.     

Evaluation of prosthetic usage in upper limb amputees

Purpose: Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method: The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results: Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion: No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.     

Mirror treatment of lower limb phantom pain: A case study

Purpose: Phantom limb pain (PLP) can be an enduring and distressing experience for people with amputations. Previous research has shown that 'mirror treatment' can reduce PLP for some people who have an upper limb amputation, and that it can increase a sense of motor control over the phantom in people with lower limb amputations who are not reporting PLP. There has been no previous report of therapeutic 'mirror treatment' for lower-limb phantom pain.

Method: We present the first case study of the use of 'mirror treatment' in a person with a lower limb amputation who was reporting PLP at the time of treatment.

Results: During the intervention there was a significant reduction in his PLP, an increase in sense of motor control over the phantom and a change in aspects of the phantom limb that was experienced.

Conclusion: This case study, conducted in a conventional clinical setting, supports the potential of 'mirror treatment' for PLP in people with a lower limb amputation.     

The efficacy of a work-station intervention programme to improve functional ability and flexibility in ageing clients with Cerebral Palsy: a pilot study

Purpose: Health care workers associated with the long-term care of ageing clients with Cerebral Palsy have reported on the adverse effects of less active daily activity programmes with resultant decreased functional mobility. While the negative effects of ageing have been reported in these clients, programmes have not been implemented to determine whether these adverse changes can be reversed or prevented. The efficacy of a work-station intervention programme to improve functional ability and flexibility in ageing clients with cerebral palsy was investigated.

Method: A clinical intervention study using repeated measures (pre/post-intervention and at follow-up) to evaluate efficacy was undertaken. Twenty-two clients with Cerebral Palsy participated in a twice-weekly work-station programme delivered over 8 weeks. The Physical Mobility Scale items, two upper limb function measures, range limitation of hip and knee extension and gleno-humeral movement were assessed.

Results: Results showed a significant improvement that was retained at follow-up in functional but not flexibility measures.

Conclusion: The efficacy of a work-station exercise programme for ageing clients with Cerebral Palsy was demonstrated. Evidence was provided that the PMS is effective in showing level of dependency for these clients.     

Development and validation of AIMFREE: Accessibility Instruments Measuring Fitness and Recreation Environments

Purpose: The purpose of this study was to develop and validate a series of 16 survey instruments measuring fitness and recreation accessibility, collectively referred to as AIMFREE (Accessibility Instruments Measuring Fitness and Recreation Environments). General domains of assessment included the built environment, equipment, programmes, policies, and training and behaviour.

Methods: Fitness and recreation professionals (n = 35) assessed fitness centres/swimming pools (n = 35) in nine regions across the US. Rasch analysis was used to assess the psychometric properties of the instrument.

Results: The AIMFREE evidenced adequate to good fit to the Rasch model and adequate to good internal consistency (r = 0.70 - 0.90). Test-retest reliability ranged from 0.70 (entrance areas) to 0.97 (swimming pools). Analysis of differential item functioning indicated that item calibrations generally did not differ significantly between urban and suburban environments.

Conclusion: The AIMFREE instruments demonstrated adequate to good fit to the Rasch model with several of the subscales demonstrating well to excellent separation of facility accessibility.     

Effects of surface electrical stimulation on the muscle-tendon junction of spastic gastrocnemius in stroke patients

Purpose: The purpose of this study was to explore the effects of spasticity suppression by surface electrical stimulation (ES) on the muscle-tendon junction of spastic gastrocnemius muscles in stroke.

Methods: Twenty-four neurologically stable stroke patients (aged 41 - 69 years, 12 - 35 months post-stroke), with spasticity graded 2 or 3 on the modified Ashworth scale, were recruited and divided into two groups. In the ES group, each patient received 20 min of surface ES once daily, 6 days per week for 1 month. In the control group, ES was used with stimulation intensity kept at zero. To evaluate the therapeutic effect, the modified Ashworth scale, Fmax/Mmax ratio, H-reflex latency, H-reflex recovery curve, and the 10-m walking time were tested before and after the 1-month treatment.

Results: In the ES group, the modified Ashworth Scale showed a trend toward reduced spasticity after 1 month of treatment. The Fmax/Mmax ratio decreased from 8.10% ± 4.84% to 4.00% ± 1.36%; the H-reflex latency increased from 28.87 ± 2.45 ms to 29.40 ± 2.57 ms; the H-reflex recovery curves indicated a downward shift; and the 10-metre walking time significantly decreased after ES. In the control group, none of the measures showed a statistically significant change.

Conclusions: In the study, we demonstrated a way to suppress spasticity at a metameric site and to increase walking speed effectively by applying surface ES on the muscle-tendon junction of spastic gastrocnemius muscles.     

Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature

Purpose: The objective of our study was to identify prognostic social factors in the subacute phase after stroke for the discharge destination from the hospital stroke-unit.

Methods: A systematic literature search was performed, designed in accordance with the Cochrane Collaboration criteria. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria.

Results: Characteristics of the social situation that proved to be important for prediction of the discharge destination are marital status and social support. Quantity and methodological quality of the research studies were insufficient, and the number of possible social prognostic factors investigated was limited by the absence of a conceptual framework of social subdomains in the studies, including an unambiguous definition of the prognostic social factors within these subdomains.

Conclusions: A great need exists for research into the prognostic qualities of the following social factors: the ability to provide support, presence, and readiness of the homefront; the availability of professional care, personal financial means, membership of societies and clubs, frequency of contacts with close relatives and friends; the quality of the patient's residence with regard to the adaptation to the needs and abilities of the patient. A commitment about the aforementioned conceptual framework is mandatory.     

Factors contributing to upper limb recovery after stroke: a survey of stroke survivors in Queensland Australia

Purpose. To identify factors which contribute to upper limb recovery, from the perspective of stroke survivors.

Method. A retrospective cross-sectional survey was administered by post to 220 stroke survivors with upper limb impairment who were more than 3 months post-stroke. The content and language for the questionnaire were drawn from a series of focus groups and in-depth interviews with stroke survivors (n = 29). Where possible items or composite scales were replicated or adapted from existing surveys.

Results. Many factors regarding the stroke survivors' commitment to recovery, the type and amount of exercise undertaken and their knowledge of how to progress were associated with self-reported upper limb recovery. The single most important factor was 'use of the arm in everyday tasks', which was independently responsible for more than 12% of the variance in recovery. 'Not enough movement to work with' was the second most important factor, representing the greatest barrier to recovery.

Conclusions. The findings of this survey highlight many practical day to day factors that may contribute to a stroke survivor's ability to advance the recovery of their upper limb. Stroke recovery services can use this information to tailor their services to ensure these practical concerns are addressed.     

Characteristics of the Frenchay Activities Index one year after a stroke: a population-based study

Purpose. To further describe the properties of Frenchay Activities Index (FAI) with special emphasis on relationships with stroke severity and cognition.

Methods. Survivors from a population-based first-ever stroke cohort (n = 246) were assessed with FAI one year post-stroke. At the same time patients were asked about their status pre-stroke. Stroke severity was assessed at baseline with the NIH stroke scale (NIHSS). Cognition was assessed at one year with the Mini Mental State Examination (MMSE).

Results. Pre-stroke and post-stroke FAI averaged at 40.1 and 32.4, respectively. There was a floor effect post-stroke, where 17% had the lowest possible score. The sum score was related to age, but not to gender. Individual items, however, were gender-related. NIHSS was clearly related to the difference FAI pre-stroke - post-stroke, but individual variations were large. Individual NIHSS items differed regarding their impact on post-stroke FAI. MMSE post-stroke also has a clear relationship with FAI, but there are large individual variations.

Conclusions. This study establishes a population-based standard for FAI scores one year after a stroke. The effects of stroke severity and cognition have been demonstrated. FAI gives useful information that is not obtained from basic ADL scales, such as the Barthel Index.     

The development of the Stroke Physiotherapy Intervention Recording Tool (SPIRIT)

Purpose: To develop a recording system that describes physiotherapy interventions for the rehabilitation of postural control post-stroke.

Methods: Design: A draft recording tool was developed using the method described by Edwards et al,¹² involving literature searches and collaboration with senior clinicians. It was piloted with stroke physiotherapists using a cross-sectional survey design to assess validity, utility and completeness. Participants used the recording tool to record five treatment sessions. Feedback regarding the utility and completeness of the system was obtained via short semi-structured interviews. Setting: 11 NHS Trusts. Participants: 35 stroke physiotherapists working in acute and rehabilitation settings recorded the treatment of 120 patients in 590 treatment sessions.

Results: A double-sided A4 form with a checklist of 79 physiotherapy interventions in 9 categories was produced: the Stroke Physiotherapy Intervention Recording Tool (SPIRIT). The participants found it quick and easy to use and reflective of clinical practice. There were a few missing interventions and some confusion regarding definition of terms. Revisions were to include the omitted interventions and to produce a user's booklet defining the categories and interventions.

Conclusions: SPIRIT provides a system for recording physiotherapy treatment for stroke patients which reflects current clinical practice in acute and rehabilitation settings.     

Adapting the Canadian Occupational Performance Measure for use in a paediatric clinical trial

Background. The Canadian Occupational Performance Measure (COPM) is a commonly used outcome measure in rehabilitation. In this study it was adapted for very young children by deleting paid/unpaid work and household management categories and having parents act as proxies to rate child performance and their own satisfaction.

Purpose. To assess the internal consistency reliability, content and construct validity, responsiveness, and impact of half scores (20 not 10-point scale) of the adapted COPM.

Method. Parent proxies of subjects aged 2 - 8 (mean 3.9) years with spastic hemiplegic cerebral palsy (n = 41) participating in a clinical trial. There was a total of 214 occupational performance problems for analysis and an additional 56 which had used half score ratings. Internal consistency reliability and construct validity were evaluated using Cronbach alpha statistic. Proxy views explored content validity. Responsiveness was evaluated using pre-post intervention scores and a comparison with Goal Attainment Scaling scores which were assumed to be a suitable benchmark measure. The effect of half scores was assessed by two-sample t-tests.

Results. The COPM adaptations did not have a negative impact on internal consistency reliability as this was acceptable for performance (0.73) and satisfaction (0.83). The high Cronbach alpha scores indicated good construct validity. Content of occupations and rating approach was considered valid by proxies. Use of half scores did not result in significantly different performance ratings, but mean satisfaction ratings were significantly higher when half scores were used (p = 0.0001). This suggests that half scores may provide more precise proxy satisfaction ratings, but at the cost of rigour as internal consistency with satisfaction half scores was lower (0.63 vs. 0.82). Responsiveness to change in clinical status was demonstrated by significant pre-post scores and moderate correlations with goal attainment scores.

Conclusion. The adapted COPM is a psychometrically robust tool and the use of half scores is not recommended.