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Concurrent validity of the Upper Limb Assessment Tool (ULAT) for acute neurological patients.

Within healthcare settings, patients typically receive discrete acute and subacute episodes of care following serious neurological injury and/or neurological-based disease progression. The term 'acute care' is used to refer to immediate, short-term inpatient treatment for severe illness, disease or trauma, such as acute stroke, cerebral haemorrhage or aneurysm. Confirmation of diagnosis and the provision of urgent medical/ surgical interventions are central aims of acute care, which is usually provided within a designated hospital/medical unit over a brief time period of days to weeks (Levenson, 2000; Poulos & Eagar, 2007). In contrast, subacute care is characterised by a multidisciplinary focus on functional needs and therapy goals, reflecting moderate to low patient acuity (Eagar & Innes cited in Poulos & Eagar, 2007). Subacute care provides time-limited rehabilitation and restoration, and is viewed as a precursor to either a return to independent community living or residential supported placement (nursing home care) (Levenson cited in Gray, 2002; Poulos & Eagar, 2007).

Occupational therapists practicing within acute neurosciences face many clinical challenges unique to the demands of their work environment. High patient acuity, short length of stay and constant patient throughput, all greatly impact upon occupational therapy practice. In the context of the acute neurological patient, Corben, Downie and Fielding (2011) identified that acute occupational therapists typically employ a range of non-standardised clinical techniques in their assessment of the neurological upper-limb. Significant criticisms of this subjective assessment approach have been well documented within the literature (Stapleton & Galvin, 2005; Stapleton & McBrearty, 2009). Nonetheless, a reliance on non-standardised evaluation techniques appears to have been driven in part by the perceived limitations of existing, standardised upper-limb assessments for the acute patient population, and the acute work environment. Therefore the study reported in this article explored the validity of selected upper limb assessments in acute neurological settings.

Literature review

Most standardised, neurological upper-limb assessments used by occupational therapists and physiotherapists primarily focus upon motor performance, and target the subacute stages of neurological recovery (Corben et al., 2011; Downie, 2011). Examples of these assessments include the Action Research Arm Test (Lyle, 1981), Chedoke McMaster Stroke Assessment (Barreca, Gowland, Stratford, Huijbregts, Griffiths, & Torresin,et al., 2004), Dynanometry (Bohannon, 2004), Functional Test for the Hemiplegic Upper Extremity (Fong, Ng, Chan, Chan, Ma, & Au, et al., 2004), Fugl-Meyer Upper Limb (Fugl-Meyer, Jaasko, Leyman, Olsson, & Steglind, 1975), Modified Ashworth Scale (Bohannon & Smith, 1987), Motor Assessment Scale (Carr, Shepherd, Nordholm, & Lynne, 1985), Motor Club Assessment (Ashburn, 1982), Motricity Index (Demeurisse, Demol & Robaye, 1980), Nine Hole Peg Test (Mathiowetz, Weber, Vollaqnd & Kashman, 1984), Rivermead Motor Assessment (Lincoln & Leadbitter, 1979), Trunk Control Test (Collins & Wade, 1990) and Wolf Motor Function Test (Wolf, Catlin, Ellis, Archer, Morgan, & Piacentino, 2001). With regard to service provision for acute neurological patients, a variety of impairment-level assessment criteria are also of clinical significance, such as shoulder integrity, spasticity, sensation and coordination (National Stroke Foundation, 2010). However, these aspects of the neurological upper-limb are not adequately addressed in totality by any of the above listed assessments. Rather, the reported validity of assessments varies greatly, with limited research undertaken as to their concurrent validity (refer to Table 1).

Validity refers to the degree to which an assessment measures what it purports to measure (Polgar & Thomas, 2008), and is central to an assessment's accuracy in detecting change in defined characteristics of patient function, and the subsequent correct interpretation of test results (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 1999). Concurrent validity specifically measures the degree to which a particular test correlates with a previously validated test of the same phenomenon or construct (Rust & Golombok, 1989), that is, the evidence of construct validity based upon a relationship with other variables (American Educational Research Association, American Psychological Association, & National Council on Measurement in Education, 1999).

Thus, there is a clear need for a reliable and valid neurological upper-limb assessment specific to the demands of the acute practice setting, to facilitate the integration of evidence to practice and to aid goal planning, intervention provision and program evaluation (Stapleton & Galvin, 2005; Stapleton & McBrearty, 2009). The ULAT is proposed as potentially being one such assessment, which therapists can apply to acute clinical practice. Initially developed in Australia in 2007 by the Monash Medical Centre - occupational therapy neurosciences team (Corben et al., 2011; Downie, 2011), the ULAT is a performance-based, upper extremity assessment specific to acute neurological diagnostic groups. The ULAT incorporates several existing standardised assessments (the Motor Assessment Scale [Carr et al., 1985], the Modified Ashworth Scale [Bohannon & Smith, 1987], and the Australian Therapy Outcome Measures for Occupational Therapy [AusTOMS] upper-limb subsection [Unsworth & Duncombe, 2004]), together with several qualitative neurological domains assigned a quantitative score (refer to Figure 1).

Thirty individual test items are grouped into eight assessment domains or subscales which are reflective of the impairment-based focus of the ULAT; shoulder integrity, passive range of movement (PROM), tone, spasticity, active range of movement (AROM), sensation, coordination, and the AusTOMS. For each of the qualitative assessment domains (ie. shoulder integrity, PROM, spasticity, sensation, and coordination) evidence-based assessment protocols have been developed outlining the features of each impairment along with a uniform basis for patient instruction and 'hands-on' assessment by the therapist. A binary scoring system of '0' = intact or '1' = impaired was selected to enable the standardised assessments with discrete scoring methodologies and the assessment domains to be integrated into a single assessment tool and scoring system, as well as to provide a 'starting point' for a study of the composite assessment's psychometric properties.

From a clinical utility perspective, the ULAT is suitable for use with patients with both central and peripheral neurological pathologies, affecting either unilateral or bilateral upper-limb/s, and for all stages of neurological recovery, from severe to more subtle deficits (Corben et al., 2011). It can be quickly administered on the hospital ward or at the patient's bedside, requiring approximately 10 to 30 minutes administration time dependent upon patient presentation. Negligible financial expenditure on test materials is required, with the Motor Assessment Scale subtests and sensation assessment domain requiring the use of common and easily obtained everyday objects, such as pens/ paper, cups, cutlery and a ball (Corben et al., 2011).

The ULAT focuses on body functions and structures impairment criteria (occupational performance components) as framed by the World Health Organization's International Classification of Functioning, Disability and Health framework (2001). These are the 'building blocks' to recovery of upper-limb functional use in daily occupations and ultimately, engagement in roles (Downie, 2011). This sensitivity at an impairment level enables the ULAT to quantify even slight improvements in upper-limb recovery, which is essential when advocating for patient access to finite sub-acute/rehabilitation resources.

The purpose of this study is to compare the ULAT's concurrent validity with an alternate measure of upper-limb function that has previously established validity properties. This article details the review process undertaken to select an appropriate assessment and presents the results of correlation analyses between the two assessments. The implications for use of the ULAT in acute clinical settings are also addressed.

Methods

A small-scale validity study undertaken to examine the concurrent validity of the ULAT.

Participants

A convenience sample of eligible participants was drawn from the acute neuroscience inpatient unit at Monash Medical Centre, a large, acute tertiary hospital. All participants had a confirmed primary neurological diagnosis requiring acute medical care, and met all study inclusion criteria; [greater than or equal to]18 years, patient/next of kin consent, and an ability to tolerate the completion of the full upper-limb assessment. Specific exclusions to the study were concurrent medical diagnoses which may have presented as pseudo limb weakness (i.e. Todd's paresis) and/or potentially have impacted upon a participant's cognitive ability to complete the assessment (i.e. dementia, receptive dysphasia, significant intellectual disability and/or reduced alertness as determined by medical past history and multidisciplinary assessment upon ward admission).

Instrumentation

This study involved administration of both the ULAT (as outlined above) and a comparative upper-limb assessment with known psychometric properties, for a cohort of acute neurological patients. Although it is acknowledged that no 'gold standard' assessment currently exists against which to compare the validity of acute-focused assessments such as the ULAT, review of the literature identified three upper-limb assessments as being a potentially suitable for comparison; the Fugl Meyer Assessment of Sensorimotor Recovery after Stroke (FMA) (Fugl-Meyer et al., 1975), the Action Arm Research Tool (Lyle, 1981) and the Disabilities of Arm Shoulder and Hand (DASH) (Solway, Beaton, McConnell, & Bombardier, 2002).

The upper limb subsection of the FMA is strongly correlated with several other common upper-limb assessments (DeWeerdt & Harrison, 1985; Fong et al., 2004; Gowland, Stratford, Ward, Moreland, Torresin, & Van Hullenaar, et al., 1993; Malouin, Pichard, Bonneau, Durand, & Corriveau, 1994; Poole & Whitney, 1988). However, these collective results only support the use of the FMA with stroke patients, and do not ensure its' appropriateness across all neurological diagnoses, which is a primary aim of the ULAT. In comparison, the Action Arm Research Tool does have demonstrated validity for a mixed neurological population of stroke, traumatic brain injury and multiple sclerosis patients (Platz, Pinkowski, van Wijck, Kim, di Bella, & Johnson, 2005), but suffers from the limitation of only having proven convergent validity as opposed to concurrent validity. Lastly, the DASH is suitable for use with various clinical groups with upper-limb pathologies including neurosciences (MacDermid & Tottenham, 2004), and has well-established construct, discriminate and convergent validity in numerous clinical populations and settings (Bot, Terwee, van der Windt, Bouter, Dekker, & de Vet, 2004).

The use of the DASH for patients with central neurological pathologies, such as stroke, guillian barre syndrome, chronic inflammatory demylienating polyneuropathy and myasthenia gravis, is emerging rather than established (Hijmans, Hale, Satherley, McMillan & King, 2011; Lannin, Cusick, McCluskey & Herbert, 2007; Padua, 2004). However, it was selected as the comparison tool for this study on the basis that it achieved the best balance between established validity, suitability for mixed neurological diagnoses and inclusion of several upper-limb impairment criteria relevant to acute neurological populations.

The DASH is a 30 item self-report questionnaire of upper-limb impairments/symptoms and functional performance designed to measure disability over time (MacDermid & Tottenham, 2004; Solway et al., 2002). Each test item is scored on a 5-point likert scale (i.e. 1 = no difficulty, 2 = mild difficulty, 3 = moderate difficulty, 4 = severe difficulty, 5 = unable), with minimum completion of 27 tests items required for calculation of an overall score. The overall score is transformed and expressed out of 100, with an increased score reflective of greater patient disability. An optional assessment module of four test items is also included for individuals whose occupations or professions require high levels of upper-limb function and hand dexterity, such as musicians, surgeons and athletes.

Following review of content and test items for both the ULAT and DASH assessment tools, significant overlap in constructs between the DASH and ULAT was noted. Specifically, the ULAT and DASH both contain test items relating to shoulder pain, sensation change, muscle weakness, resistance to joint range and functional use. Given these similarities, it was therefore hypothesised that a correlation may exist between the individual ULAT assessment domains and DASH score.

Procedure

This research study was granted formal ethics approval by Southern Health's Human Research Ethics Committee B (Certificate of Approval: Project No. 09061B). Informed consent for participant involvement and medical records access was also obtained from individual patients and/or their next of kin. Eligible participants were recruited for the study by an independent clinician not aligned to the research team, to limit perceived or potential coercion. Basic demographic data from the participant's medical record (i.e. age, sex, neurological diagnosis, hand dominance and affected upper-limb) was subsequently collected by the principle investigator.

As part of standard clinical practice, the ULAT was administered by the primary treating occupational therapist to each study participant on either one or several occasions. For the purpose of statistical analysis of concurrent validity, data collection was limited to the first administration of the ULAT. Participant completion of the DASH questionnaire was overseen by an independent clinician not aligned to the research team, at the point of study recruitment. Completion of the ULAT and DASH questionnaire occurred within close time proximity (i.e. 24 hours maximum) for all study participants.

Data analysis

All data collected was de-identified, coded and entered onto Excel spreadsheets. Complete data-sets were then analysed using the Statistical Package for the Social Sciences (SPSS)--Version 17 (SPSS Inc., Chicago IL). Descriptive statistics were calculated and non-parametric statistical analyses conducted to assess the ULAT's concurrent validity in relation to the DASH; intra-class correlation coefficients for the relationship between variables were measured on an ordinal scale (Spearman-Rho coefficients). Reference ranges for the effect size of correlations were based on Cohen's (1988) classification system;

* Strong degree of association between variables (r = 1.0 to 0.5)

* Moderate degree of association between variables (r= 0.3 to 0.5)

* Weak degree of association between variables (r = 0.1 to 0.3)

* Very weak to negligible degree of association between variables (r < 0.1)

A simple analysis was first completed to examine the relationship between ULAT domains/total score and DASH score by left and right sides, not accounting for differences in affected side, hand dominance and severity of presentation within the patient group.

In patients with known neurological deficits, discrimination of the left versus right affected side was considered to be especially important owing to the potential impact of left perceptual deficits (such as neglect) on upper-limb performance. It was hypothesised that analysis by affected sides would be more sensitive and reflective of the true relationship between the two measures rather than a simple analysis of left and right sides. This scrutiny was necessary to control the likelihood that an uneven proportion of affected to non-affected upper limb scores may skew the results. A second analysis was completed to investigate the relationship between ULAT and DASH scores by affected limb only.

Results

Participant demographics

A total of 29 acute inpatients (male = 20, female = 9) presenting with a neurological diagnoses met the eligibility criteria for the study. The mean participant age of the total study cohort was 63 years (SD = 14.15, range = 58), with the most common primary neurological diagnosis being one of stroke (N = 20). Whilst 93% of participants were right hand dominant (N = 27), the left upper-limb was more commonly affected post neurological event (58%). In comparison, right upper-limb or bilateral upper-limb involvement accounted for 25% and 17% of participants respectively.

Participants were assessed at varying points in their acute-care inpatient stay, from day one of admission through to the day of discharge. Twelve days was the average length of stay for all study participants (M = 11.55, SD = 18.24, range = 102).

Concurrent validity

To review the degree of association between the two assessments, the study participants were assessed using both the ULAT and the DASH. Spearman-Rho correlation coefficients were calculated using SPSS.

Data analysis by left and right upper-limbs

Relationships between left sided ULAT domains and total DASH score were all weak and statistically non-significant (range = .21). Scores for right sided ULAT domains and the DASH were also consistently very weak and non-significant (range = .20), with the exception of tone (r = .50, p = .006), spasticity (r = .41, p = .03) and coordination (r = .46, p = .01) which exhibited weak to moderate concurrent validity with the DASH (refer to Table 3). Similarly, analysis of total left and right sided ULAT scores and total DASH score demonstrated weak to very weak levels of concurrent validity, however only the relationship between right upper-limb scores was weak at a significance level (r = .37, p = 0.05).

Data analysis by left affected and right affected upper-limbs

Analysis of the data by the side of the affected upper-limb produced two comparison groups; left affected (N = 22) and right affected (N = 12). Patients with bilateral upper-limb involvement (N = 5) were included within both groups which is reflected by the increase in total sample size across the two groups.

All left affected assessment domains and the total DASH score were weakly correlated at a non-significant level (range = .27). Moderate, statistically significant correlations for right affected tone (r = .71, p = .009), spasticity (r = .70, p = .01) and sensation (r = .69, p = .01) were obtained, however the relationship between all other right affected domains and DASH score were weak (range = .62), (refer to Table 4). Correlations between total ULAT and DASH scores by affected upper-limb, were moderate at a statistically significant level for the right affected side only (r = .56, p = .06).

Discussion

Given the apparent overlap in constructs between five of the eight ULAT assessment domains (i.e. shoulder integrity, tone, AROM, sensation and functional use) and the DASH, it was initially hypothesised that a correlation should exist between the two assessments. However, these study findings collectively indicate varying levels of statistical association between the ULAT assessment domains and total DASH score.

Significant correlations were only achieved for the 'right side' ULAT assessment domains of tone, spasticity and coordination, and 'right side affected' domains of tone, spasticity and sensation. Whilst a relationship between tone and sensation assessment domains was not unexpected given the overlap in constructs between the two assessments, the DASH was not considered to include test items specifically related spasticity and coordination. This infers that DASH may contain test items that are indirectly associated with the impact of spasticity and coordination on upper-limb function.

The absence of statistically significant relationships by 'left side' analyses is also an important point to consider. In analysing the data by left and right upper limbs, the greater proportion of unaffected upper limbs within the left side group was thought to strengthen the correlation between the two assessments, as their would seem to be less variability in 'normal' upper limb performance. Interestingly, when a second analysis was completed by 'affected side', thus increasing the variability of performance within the left group, this trend remained evident. It is difficult to explain the seemingly stronger correlations obtained for the 'right side' and right affected side other than to suggest that other non-neurological conditions (i.e. osteoarthritis, not controlled for in this study) may impact on upper limb function. Equally, it may be a result of inadequate statistical power.

Overall, these results infer that the ULAT and DASH assessments measure differing aspects of neurological upper-limb function, thus the constructs being measured by the two individual assessments are similar but not associated with each other. This lack of a truly comparative assessment by which to measure the concurrent validity of the ULAT, again highlights the place of ULAT in fulfilling an unmet clinical need for the assessment of acute neurological upper-limb function.

Study limitations

This small-scale research study has several limitations. Slower than anticipated participant recruitment coupled with project time constraints necessitated revision of the project scope, which had initially proposed a study of the ULAT's discriminant validity against an age and sex matched cardiothoracic control group. This is particularly regrettable as the ability of an assessment to distinguish between two groups of participants with known differences (referred to as discriminant validity) is central to its clinical usefulness (Eysenck, 2004). Although, the minimum sample size for adequate statistical power (N = 25) was achieved, it is reasonable to suggest that study may have been under-powered when analysis by subgroups (i.e. affected versus non-affected upper-limb) is considered. Owing to resource limitations, it was beyond the scope of this project to consider the use of more than one comparison assessment, which would undoubtedly have strengthened the conclusions which can be drawn from this study regarding the ULAT's validity.

Future research

In the future, it is recommended that larger research trials be undertaken to examine the psychometric properties of the ULAT in more detail. Research evidence of the ULAT's content validity and construct validity, along with data suggesting good to excellent intra-rater reliability and good to very good inter-rater reliability (Downie, 2011), suggest its potential clinical usefulness for patients with various acute neurological diagnoses and associated left, right or bilateral upper-limb dysfunction. Although inherently difficult, further study of the ULAT's concurrent validity should also be considered, with the inclusion of an alternate performance-based upper extremity assessment scale if and when available.

Conclusion

This small-scale study examined the concurrent validity of the newly developed, ULAT, to support its further clinical trial with acute neurological patients. In comparing ULAT total assessment scores against the DASH self-report questionnaire, concurrent validity was generally deemed to be poor. Partial support of the ULAT's concurrent validity is provided by the moderate but statistically significant correlation obtained between the right upper-limb ULAT domains of tone, spasticity, sensation and coordination and the DASH assessment scores. Ultimately, these results suggest that the ULAT and DASH assessments measure similar aspects of neurological upper-limb function as opposed to the same constructs.

Partial evidence of the ULAT's concurrent validity, coupled with the lack of a 'gold standard' for acute neurological upperlimb assessment, should support its ongoing trial and refinement within the clinical setting. Further research trials with larger sample sizes are strongly recommended to further examine the ULAT's global validity.

Key points

* Within an acute neurological population, the study results collectively indicate insignificant to moderate levels of statistical association between the ULAT assessment domains and total DASH score.

* The results suggest that the ULAT and DASH assessments measure similar aspects of neurological upper-limb function as opposed to the same constructs, and in doing so highlight the place of ULAT in fulfilling an unmet clinical need for the assessment of acute neurological upper-limb function.

Acknowledgements

This research study was funded by the Southern Health Emerging Researcher Fellowship (under the auspices of the Southern Health Research Directorate) and the in-kind support of the Acute OT Service - Monash Medical Centre. The Principle Researcher would like to thank Dr Ted Brown (Research Supervisor, Monash University and Monash Medical Centre, Victoria, Australia), Annette Leong (Acute OT Service Manager, Monash Medical Centre, Victoria, Australia) and Louise Corben (Senior Clinician OT--Neurosciences, Monash Medical Centre, Victoria, Australia) for their ongoing support with this project. The significant contribution and commitment of the members of the OT Neurosciences Team--Monash Medical Centre (Janice McKeever, Maria Mathieson, Tameeka Robertson, Emma Hughson, Jennifer Cameron, Tess Uhi and Robyn McDonald) are also acknowledged. Without them, this research would not have been possible.

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Whitall, J., Savin, D., Harris-Love, M., & Waller, S. (2006). Psychometric properties of a modified Wolf Motor Function Test for people with mild and moderate upper extremity hemiparesis. Archives of Physical Medicine & Rehabilitation, 82, 750-755.

Wolf, S., Catlin, P., Ellis, M., Archer, A., Morgan, B., & Piacentino, A. (2001). Assessing Wolf Motor Function Test as outcome measure for research in patients after stroke. Stroke, 32, 1635-1639.

Wood-Dauphinee, S. L., Williams, J. I., & Shapiro, S. H. (1990). Examining outcome measures in a clinical study of stroke. Stroke, 21, 731-739.

World Health Organisation. (2001). International Classification of Functioning, Disability and Health (ICF). Geneva, Switzerland: Author.

Corresponding author:

Sharon Downie (BOT, MPH)

Senior Clinician (OT)--Neurosciences

Acute Occupational Therapy Service

Monash Medical Centre

246 Clayton Road

CLAYTON, 3168

Victoria

Email: sharon.downie@southernhealth.org.au
Table 1: Documented Concurrent and Convergent Validity for Common
Neurological Upper-Limb Assessments

 Study
Test Population Documented Validity

Chedoke McMaster Stroke Concurrent Validity
Stroke Assessment CMSA strongly correlated to
(CMSA) Fugl-Meyer Sensorimotor
 Assessment total score
 (Pearson Rho = .95) and
 Functional Independence
 Measure total score (Pearson
 Rho = .79) (Gowland et al.,
 1993).

Disabilities of Arm Mixed Concurrent Validity
Shoulder and Hand Diagnostic
(DASH) Construct, discriminate and
 convergent validity have been
 evaluated in numerous clinical
 populations and settings (Bot
 et al., 2004).

 DASH strongly correlated with
 the Neck Disability Index in
 neck/shoulder pain patients
 (r = .75) (Mehta, MacDermid,
 Carlesso & McPhee, 2010) and
 the Health Assessment
 Questionnaire Disability Index
 in a rheumatoid arthritis
 population (r = .80, p <
 0.001) (Bilberg, Bremmell &
 Mannerkorpi, 2012).

Dynamometer Mixed Concurrent Validity
 Diagnostic
 Hand held dynamometer versus
 stationary dynamometer scores
 strongly correlated (Pearson
 Rho = .81) (Roy, MacDermid,
 Orton, Tran, Faber &
 Drosdowech, et al., 2009).

 Significant correlations (p <
 .001) recorded for 22 of 24
 tests of hand held dynamometry
 versus manual muscle testing
 in spinal cord injury
 population at various time
 intervals (Schwarz, Cohen,
 Herbison & Shah, 1992).

Functional Test for Stroke Concurrent Validity
the Hemiplegic Upper
Extremity--Hong Kong FTHUE-HK strongly correlated
(FTHUE--HK) in stroke populations with the
 Fugl-Meyer Sensorimotor
 Assessment, upper extremity
 (r = .88, p < 0.01) and hand
 subscores (r = .88, p < .01)
 (Fong et al., 2004), Action
 Research Arm Test (Spearman-
 Rho = .92, p < .01) (Ng,
 Leung, & Fong, 2008) and Wolf
 Motor Function Test (Spearman-
 Rho = .92, p < .01) (Ng, et
 al., 2008).

 Moderated correlation between
 the FTHUE-HK and Functional
 Independence Measure self-
 care subscore (r = .46, p <
 .01) (Fong et al., 2004).

Fugl-Meyer Upper- Stroke Concurrent Validity
Limb (FMUL)
 Fugl-Meyer Sensorimotor
 Assessment total score
 strongly correlated to Motor
 Assessment Scale; r = .88
 (Poole & Whitney, 1988) and
 r = .96 (Malouin et al., 1994).
 Excellent relationship also
 demonstrated between
 corresponding test items; r =
 64-92 (Poolf & Whitney 1988)
 and r = 65-93 (Malouin et al
 1994)

 Strong correlation between
 FMUL and Barthel Index score
 during acute recovery and 5
 weeks post stroke (Pearson Rho
 = .75 & = .82) (Wood-
 Dauphinee, Williams & Shapiro,
 1990), Action Research Arm
 Test at 2 and 8 weeks post
 stroke (r = .91 & r = .94)
 (DeWeerdt & Harrison, 1985),
 Chedoke-McMaster Stroke
 Assessment Scale total
 impairment score (r = .95)
 (Gowland et al., 1993), and
 FTHUE-HK (r = .88, p < 0.01)
 (Fong et al., 2004)

 Conflicting relationship
 demonstrated between motor
 recovery as measured by FMUL
 score and sensory evoked
 potentials; high correlation
 (Kusoffsky, Wadell & Nilsson,
 1982) vs. low correlation
 (Feys, Van Hees, Bruyninck,
 Mercelis & deWeerdt, 2000).

Modified Ashworth Stroke Concurrent Validity
Scale
 Modified Ashworth Scale score
 poorly correlated with surface
 electromyography (Spearman-
 Rho = .21), as the gold
 standard for spasticity
 assessment (Cooper, Musa, van
 Deursen, & Wiles, 2005).

Motor Assessment Stroke Concurrent Validity
Scale
 Motor Assessment Scale total
 score strongly correlated to
 Fugl Meyer total score;
 Spearman-Rho = .88 (Malouin et
 al., 2004) and Spearman-Rho =
 .96 (Poole & Whitney, 1988).
 Excellent relationship also
 demonstrated between
 corresponding test items with
 the exception of balance test
 scores; r = .65-.93 (Malouin
 et al., 2004) and r = .64 -.92
 (Poole & Whitney, 1988).

Motor Club Stroke Concurrent Validity
Assessment (MCA)
 Comparison between MCA and
 Frenchay Arm Test demonstrated
 97% correct classification at
 6 months post stroke
 (Sunderland, Trinson, Bradley,
 & Hewer, 1989).

Motricity Index (MI) Stroke Concurrent Validity

 Linear correlation established
 between MI and Nine Hole Peg
 Test r = .82 (Parker, Wade &
 Hewer, 1986).

Nine Hole Peg Test Stroke Concurrent Validity
(NHPT)
 NHPT weakly correlated to
 Frenchay Arm Test in
 comparison the Motor Club
 Assessment and Motricity Index
 (Sunderland et al., 1989).

Rivermead Motor Stroke Concurrent Validity
Assessment (RMA)
 RMA strongly correlated to
 Barthel Index at admission (r
 = .84), 1 month post stroke (r
 = .78), and 1 year post stroke
 (r = .63) (Endres, Nyary,
 Banhidi, & Deak, 1990).

Trunk Control Test Stroke Concurrent Validity
(TCT)
 TCT strongly correlated with
 Trunk Impairment Scale scores
 (r = .83) (Verheyden,
 Nieuwboer, Mertin, Kiekens &
 deWeerdt, 2004).

Wolf Motor Function Stroke Concurrent Validity
Test (WMFT)
 WMFT total score moderately
 correlated to the Fugl-Meyer
 Upper Limb (FMUL) in stroke
 population (r = -.57) (Wolf et
 al., 2001), however the
 functional ability subtest of
 the WMFT and FMUL reported to
 be more strongly correlated
 (r = -.88) (Whitall, Savin,
 Harris-Love & Waller , 2006).

 WMFT strongly correlated to
 ARAT in stroke diagnostic
 group with hemiplegia,
 specifically WMFT functional
 ability subtest (r = .86),
 WMFT median time score (r = -
 .89) and WMFT strength
 subtests (r = .70) (Nijland,
 van Wegen, Verbunt, van Wijk,
 van Kordelaar, & Kwakkel,
 2010).

Table 2: Participant demographics

 Age Gender Diagnosis UL Hand Length of
 Affected Dominance Stay (Days)

P1 30 Female Other Neurological Bilateral Right 103
P2 75 Female Cerebral Tumour Left Right 15
P3 55 Female Other Neurological Bilateral Right 2
P4 77 Male Stroke Left Right 7
P5 65 Male Stroke Left Right 20
P6 42 Male Other Neurological Bilateral Right 9
P7 54 Male Stroke Right Left 8
P8 68 Male Cerebral Tumour Right Left 10
P9 59 Female Other Neurological Bilateral Right 5
P10 80 Female Stroke Left Right 5
P11 82 Male Stroke Right Right 5
P12 77 Female Stroke Left Right 9
P13 55 Male Other Neurological Bilateral Right 22
P14 75 Male Stroke Left Right 11
P15 47 Female Stroke Left Right 15
P16 62 Male Other Neurological Left Right 11
P17 68 Male Stroke Right Right 10
P18 71 Male Stroke Left Right 7
P19 72 Male Stroke Left Right 6
P20 52 Male Stroke Left Right 4
P21 88 Male Stroke Right Right 5
P22 63 Male Stroke Left Right 4
P23 53 Male Stroke Right Right 4
P24 51 Male Stroke Left Right 10
P25 76 Male Stroke Right Right 1
P26 64 Male Cerebral Tumour Left Right 7
P27 45 Female Stroke Left Right 7
P28 83 Male Stroke Left Right 5
P29 58 Female Stroke Left Right 8

Table 3: Spearman-Rho Correlations for DASH Score and Left
& Right Upper-limb Domains (N = 29)

ULAT Assessment Domain Left Right

Shoulder r = .05 p = .81 r = .05 p = .80
PROM r = .18 p = .34 r = .12 p = .56
Tone r = .08 p = .69 r = .50 p = .006*
Spasticity r = .10 p = .59 r = .41 p = .03*
AROM r = -.08 p = .69 r = .18 p = .36
Sensation r = .17 p = .38 r = .25 p = .20
Coordination r = .03 p = .87 r = .46 p = .01*
AusTOMS r = .16 p = .42 r = .16 p = .42

Note: * indicates significant p value [less than or equal to]< .05

Table 4: Spearman-Rho Correlations for DASH Score and Left
Affected & Right Affected Upper-limb Domains (N = 29; Left
N = 22 and Right N = 12 including 5 bilaterally affected)

ULAT Assessment Domain Left Affected Right Affected

Shoulder r = .08 p = .74 r = .27 p = .41
PROM r = .33 p = .14 r = -.07 p = .84
Tone r = .14 p = .42 r = .71 p = .009 *
Spasticity r = .18 p = .68 r = .70 p = .01 *
AROM r = .09 p = .69 r = .26 p = .41
Sensation r = .10 p = .67 r = .69 p = .01 *
Coordination r = .18 p = .42 r = .55 p = .07
AusTOMS r = .33 p = .14 r = .30 p = .34

Note: * indicates significant p value < .05

Figure 1: Upper Limb Assessment Tool -ULAT (Corben, Downie & Fielding,
2011)

Ax Domain Score Conversion Admission R. UL

Dominance Right Left
Shoulder Pain Yes = 1 1 0
 No = 0
Shoulder Yes = 1 1 0
Subluxation No = 0
Passive Range Impaired = 1 Scapula
 Intact = 0 1 0
 Shoulder
 1 0
 Elbow
 1 0
 Wrist
 1 0
 Digits/Thumb
 1 0
Tone Impaired = 1 Flaccidity/Hypotonicity
 Intact = 0 1 0
 Modified Ashworth Modified Ashworth
 Score Shoulder Flexion
 Score > 0 = Impaired 1 1 0
 Score 0 = Intact 0 Shoulder Abduction
 1 0
 Elbow Flexion
 1 0
 Elbow Extension
 1 0
 Wrist Flexion
 1 0
 Wrist Extension
 1 0
 Digit Flexion
 1 0
 Digit Extension
 1 0

Spasticity Yes = 1 Elbow
(Quick Stretch) No = 0 1 0
 Wrist
 1 0
Active Range MAS Score MAS
 Score < 6 = Impaired Upper Arm Function
 1 1 0
 Score 6 = Intact 0 Hand Movements
 1 0
 Adv. Hand Activities
 1 0
Sensation Impaired = 1 Light Touch
 Intact = 0 1 0
 Temperature
 1 0
 Proprioception
 1 0
Coordination Impaired = 1 Finger Nose
 Intact = 0 1 0
 Rapid Alternating
 1 0
AusTOMS AusTOM Impairment
(Upper-Limb) Score < 5 = Impaired 1 0
 1 Activity Limitation
 Score 5 = Intact 0 1 0
 Participation
 Restriction
 1 0
 Well-Being (Client)
 1 0
Total (Max 30) /30

Ax Domain Score Conversion Admission L. UL

Dominance Right Left
Shoulder Pain Yes = 1 1 0
 No = 0
Shoulder Yes = 1 1 0
Subluxation No = 0
Passive Range Impaired = 1 Scapula
 Intact = 0 1 0
 Shoulder
 1 0
 Elbow
 1 0
 Wrist
 1 0
 Digits/Thumb
 1 0
Tone Impaired = 1 Flaccidity/Hypotonicity
 Intact = 0 1 0
 Modified Ashworth Modified Ashworth
 Score Shoulder Flexion
 Score > 0 = Impaired 1 1 0
 Score 0 = Intact 0 Shoulder Abduction
 1 0
 Elbow Flexion
 1 0
 Elbow Extension
 1 0
 Wrist Flexion
 1 0
 Wrist Extension
 1 0
 Digit Flexion
 1 0
 Digit Extension
 1 0

Spasticity Yes = 1 Elbow
(Quick Stretch) No = 0 1 0
 Wrist
 1 0
Active Range MAS Score MAS
 Score < 6 = Impaired Upper Arm Function
 1 1 0
 Score 6 = Intact 0 Hand Movements
 1 0
 Adv. Hand Activities
 1 0
Sensation Impaired = 1 Light Touch
 Intact = 0 1 0
 Temperature
 1 0
 Proprioception
 1 0
Coordination Impaired = 1 Finger Nose
 Intact = 0 1 0
 Rapid Alternating
 1 0
AusTOMS AusTOM Impairment
(Upper-Limb) Score < 5 = Impaired 1 0
 1 Activity Limitation
 Score 5 = Intact 0 1 0
 Participation
 Restriction
 1 0
 Well-Being (Client)
 1 0
Total (Max 30) /30

Ax Domain Score Conversion Discharge R. UL

Dominance Right Left
Shoulder Pain Yes = 1 1 0
 No = 0
Shoulder Yes = 1 1 0
Subluxation No = 0
Passive Range Impaired = 1 Scapula
 Intact = 0 1 0
 Shoulder
 1 0
 Elbow
 1 0
 Wrist
 1 0
 Digits/Thumb
 1 0
Tone Impaired = 1 Flaccidity/Hypotonicity
 Intact = 0 1 0
 Modified Ashworth Modified Ashworth
 Score Shoulder Flexion
 Score > 0 = Impaired 1 1 0
 Score 0 = Intact 0 Shoulder Abduction
 1 0
 Elbow Flexion
 1 0
 Elbow Extension
 1 0
 Wrist Flexion
 1 0
 Wrist Extension
 1 0
 Digit Flexion
 1 0
 Digit Extension
 1 0

Spasticity Yes = 1 Elbow
(Quick Stretch) No = 0 1 0
 Wrist
 1 0
Active Range MAS Score MAS
 Score < 6 = Impaired Upper Arm Function
 1 1 0
 Score 6 = Intact 0 Hand Movements
 1 0
 Adv. Hand Activities
 1 0
Sensation Impaired = 1 Light Touch
 Intact = 0 1 0
 Temperature
 1 0
 Proprioception
 1 0
Coordination Impaired = 1 Finger Nose
 Intact = 0 1 0
 Rapid Alternating
 1 0
AusTOMS AusTOM Impairment
(Upper-Limb) Score < 5 = Impaired 1 0
 1 Activity Limitation
 Score 5 = Intact 0 1 0
 Participation
 Restriction
 1 0
 Well-Being (Client)
 1 0
Total (Max 30) /30

Ax Domain Score Conversion Discharge L.UL

Dominance Right Left
Shoulder Pain Yes = 1 1 0
 No = 0
Shoulder Yes = 1 1 0
Subluxation No = 0
Passive Range Impaired = 1 Scapula
 Intact = 0 1 0
 Shoulder
 1 0
 Elbow
 1 0
 Wrist
 1 0
 Digits/Thumb
 1 0
Tone Impaired = 1 Flaccidity/Hypotonicity
 Intact = 0 1 0
 Modified Ashworth Modified Ashworth
 Score Shoulder Flexion
 Score > 0 = Impaired 1 1 0
 Score 0 = Intact 0 Shoulder Abduction
 1 0
 Elbow Flexion
 1 0
 Elbow Extension
 1 0
 Wrist Flexion
 1 0
 Wrist Extension
 1 0
 Digit Flexion
 1 0
 Digit Extension
 1 0

Spasticity Yes = 1 Elbow
(Quick Stretch) No = 0 1 0
 Wrist
 1 0
Active Range MAS Score MAS
 Score < 6 = Impaired Upper Arm Function
 1 1 0
 Score 6 = Intact 0 Hand Movements
 1 0
 Adv. Hand Activities
 1 0
Sensation Impaired = 1 Light Touch
 Intact = 0 1 0
 Temperature
 1 0
 Proprioception
 1 0
Coordination Impaired = 1 Finger Nose
 Intact = 0 1 0
 Rapid Alternating
 1 0
AusTOMS AusTOM Impairment
(Upper-Limb) Score < 5 = Impaired 1 0
 1 Activity Limitation
 Score 5 = Intact 0 1 0
 Participation Restriction
 1 0
 Well-Being (Client)
 1 0

Total (Max 30) /30
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Title Annotation:RESEARCH ARTICLE
Author:Downie, Sharon
Publication:New Zealand Journal of Occupational Therapy
Article Type:Report
Geographic Code:8AUST
Date:Oct 1, 2012
Words:7201
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