Concurrent validity of the Upper Limb Assessment Tool (ULAT) for acute neurological patients.
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.
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.
A small-scale validity study undertaken to examine the concurrent validity of the ULAT.
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).
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.
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.
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.
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).
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).
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.
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.
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.
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.
* 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.
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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Sharon Downie (BOT, MPH)
Senior Clinician (OT)--Neurosciences
Acute Occupational Therapy Service
Monash Medical Centre
246 Clayton Road
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|
|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Oct 1, 2012|
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