| | Measurement of Upper-Extremity Function Early After Stroke: Properties of the Action Research Arm TestPresented in part to the American Heart Association and American Stroke Association, February 16–18, 2006, Kissimmee, FL. Abstract Lang CE, Wagner JM, Dromerick AW, Edwards DF. Measurement of upper-extremity function early after stroke: properties of the Action Research Arm Test. ObjectiveTo examine the responsiveness and validity of the Action Research Arm Test (ARAT) in a population of subjects with mild-to-moderate hemiparesis within the first few months after stroke. DesignData were collected as part of the Very Early Constraint-Induced Therapy for Recovery from Stroke trial, an acute, single-blind randomized controlled trial of constraint-induced movement therapy. Subjects were studied at baseline (day 0), after treatment (day 14), and after 90 days (day 90) poststroke. SettingInpatient rehabilitation hospital; follow-up 3 months poststroke. ParticipantsFifty hemiparetic subjects. InterventionsNot applicable. Main Outcome MeasuresAt each time point, subjects were tested on: (1) the ARAT, (2) clinical measures of sensorimotor impairments, (3) in the kinematics laboratory where they performed reach and grasp movements, and (4) clinical measures of disability. Blinded raters performed all evaluations. Analyses at each time point included calculating effect size as indicators of responsiveness, and correlation and regression analyses to examine relationships between ARAT scores and other measures. ResultsThe ARAT is responsive to change, with effect sizes greater than 1.0 and responsiveness ratios of 7.0 at 3 months poststroke. ARAT scores were related to sensorimotor impairment measures, 3-dimensional kinematic measures of movement performance, and disability measures at all 3 time points. ConclusionsThe ARAT is a responsive and valid measure of upper-extremity functional limitation and therefore may be an appropriate measure for use in acute upper-extremity rehabilitation trials. THE ACTION RESEARCH ARM TEST (ARAT) is a tool with which to assess upper-extremity functional limitations in people with cerebral cortical injury.1 A functional limitation is a restriction or lack of ability to perform an action.2 An example of a functional limitation of the upper extremity is an inability to dress oneself. Starting with the upper-extremity function test described by Carroll,3 Lyle1 reorganized that test by using a Guttman scale to create the ARAT. In the process, he simplified test administration and scoring and shortened the time required to administer the test, thereby enhancing the ARAT’s clinical utility. Since then, interrater reliability (.98) and test-retest reliability (.99) have been established for its use with people with hemiparesis poststroke.4, 5 Likewise, concurrent validity of the ARAT and the Fugl-Meyer Assessment6, 7 (r range, .91–.94): the ARAT and the Motor Assessment Scale,4 upper-extremity part (r=.96); and the ARAT and the Motricity Index arm subscale4 (r=.87) has also been established in people with chronic hemiparesis. More recent work has examined its hierarchical rating scale and its division into subscales.8 The ARAT and other similar tests are often used to evaluate the efficacy of treatment for 1 patient or for a study population. There is, however, little information about how responsive the ARAT is to change9 and how ARAT scores relate to clinical impairment and disability measurements. Furthermore, previous studies of the psychometric properties of the ARAT used samples of people with chronic hemiparesis, or mixed samples that included people with acute, subacute, and chronic hemiparesis. Because the majority of rehabilitation efforts and monies are concentrated in the first few weeks and months after stroke, it is crucial to establish the ARAT’s psychometric properties in the acute patient population. This is the patient population in which the test may be most often used, particularly in pharmacologic or motor intervention trials. Our purpose in this report, therefore, was to examine the responsiveness and validity of the ARAT in a population of hemiparetic subjects within the first weeks and months after stroke. We examined: (1) how ARAT scores relate to sensorimotor impairment measures typically measured by rehabilitation professionals, (2) how ARAT scores relate to more objective and sensitive measures of movement quality obtained via kinematic analyses, and (3) how ARAT scores relate to disability scores. Additionally, we looked at the relation between age and ARAT scores, and initial stroke severity (as measured by the National Institutes of Health Stroke Scale [NIHSS]). We examined potential relationships with age because age could be a modifier of ARAT performance and we examined potential relationships with NIHSS scores because those scores are often used as outcome measures in clinical trials of new pharmacologic agents. Methods  Participants All subjects in this study were enrolled in the Very Early Constraint Treatment for Recovery from Stroke (VECTORS) trial. VECTORS is a single-center, pilot clinical trial of the early application of constraint-induced movement therapy (CIMT); its purpose is to gather the information necessary to design a definitive multicenter trial of CIMT administered in the immediate poststroke period. Study and treatment procedures are similar to those described elsewhere.10 VECTORS has a single-blind, randomized controlled design. Subjects are randomized to 1 of 3 groups: (1) 2 hours a day of conventional treatment, (2) 2 hours a day of shaping treatment plus 6 hours of constraint, or (3) 3 hours a day of shaping plus constraint 90% of waking hours. The Human Studies Committee at Washington University (St. Louis) approved the study protocol and all subjects provided informed consent before participating. At the time this report was written, the study was ongoing and the blind had not been broken. Patients admitted to the acute neurology stroke service at Barnes–Jewish Hospital in St. Louis were screened for study eligibility. Subjects were included if they had: (1) an ischemic or hemorrhagic stroke (with confirmatory neuroimaging) within 28 days of admission to inpatient rehabilitation; (2) persistent hemiparesis, generally as indicated by a score of 1 or 2 on the motor arm item of the NIHSS; (3) some upper-extremity voluntary activity as indicated by the ability to move proximal and/or distal joints against gravity; (4) evidence of preserved cognitive function; (5) the ability to follow 2-step commands; and (6) no upper-extremity injury or conditions that limited use before the stroke. Subjects were excluded if they: (1) could not give informed consent; (2) had clinically significant fluctuations in mental status in the 72 hours before enrollment; (3) were not independent before the first stroke, as measured by scores less than 95 on the Barthel Index or greater than 1 on the Modified Rankin Scale; (4) had hemispatial neglect; and/or (5) were not expected to survive 1 year because of other illnesses (eg, cardiac disease, malignancy). Fifty subjects with hemiparesis poststroke are included in this report. Procedures Trained study personnel blinded to the treatment type performed all evaluations. Clinical rating scales were administered by one set of blinded raters while a different rater (blind to the clinical rating scale data also) evaluated the sensorimotor impairments and performed the kinematic testing. The data in this study include the evaluations performed before randomization (day 0), after treatment (day 14), and 90 days after stroke onset (day 90). Note that the time point labels of day 0 and day 14 refer to time of enrollment in the study and not to time poststroke. The day 90 time point is the primary study endpoint because most acute stroke intervention trials assess efficacy at 90 days after onset, when the majority of stroke patients are at or near their clinical plateau.11 Clinical Scale Evaluations Action Research Arm Test The ARAT assesses function of the upper extremity. It uses ordinal scoring on 19 items, where 0 indicates no movement and 3 indicates normal movement.1 Item scores are summed to create 4 subscale scores: gross motor (9-point maximum), grasp (18-point maximum), grip (12-point maximum), and pinch (18-point maximum), and a total scale score with a maximum score of 57, indicating normal performance. FIM instrument The FIM assesses global disability with 18 items that assess performance of functional activities such as mobility, bowel and bladder control, language and communication, and cognition.12 In this study, the FIM was scored through telephone interviews; therefore, it was considered a measure of self-perceived disability. The 15 items requiring motor function were summed to create a FIM motor score, while a subset of 5 items relating to upper extremity use was summed to create a FIM upper-extremity score. National Institutes of Health Stroke Scale The NIHSS assesses overall stroke severity.13 Its 13 items measure impairments in consciousness, motor, sensory, language, and attention domains. Scores can range from 0 (indicating no deficit) to 46 (indicating severe deficit). Subjects with scores between 6 and 22 are considered to have sustained strokes of moderate severity. This measure was assessed only on admission to the acute stroke service. Sensorimotor Impairment Evaluations Various sensorimotor impairments are evaluated by physical and occupational therapists, and impairment findings are used to guide rehabilitation treatments. Here, we evaluated 4 impairment commonly assessed by rehabilitation team members. Light touch sensation was measured at 4 locations on the upper extremity with Semmes-Weinstein monofilaments.a Monofilament values were converted to an ordinal scale and averaged across the 4 locations to create a composite light touch score.14, 15 Elbow joint spasticity was measured using the Modified Ashworth Scale.16 Pain in the affected shoulder was measured using a visual analog scale (range, 0−10). Strength of the flexors and extensors of the upper extremity were measured using a hand-held dynamometerb using the protocol of Andrews et al,17 except that subjects were seated during testing. Strength values were expressed as a ratio of the affected to the nonaffected side. A composite upper-extremity strength score was determined by averaging the strength of the antigravity muscles used during a reaching task: shoulder flexors, elbow flexors, and wrist extensors.15 Kinematic Measurement of Upper-Extremity Movements The purpose of the kinematic testing was to obtain objective and sensitive quantification of upper-extremity movement. We tested each subject’s ability to perform reach and reach-to-grasp movements of the affected upper extremity, using previously described methodology.15, 18 In this study, we focused on the reach and on the grasp component of the reach-to-grasp movement. These movements were chosen because they are important for functional use of the upper extremity. Briefly, 3-dimensional movements were recorded by using a 6-camera video systemc while seated subjects reached and reached to grasp objects. Offline, EVaRT and KinTrak softwarec was used to extract position, velocity, and angular data for the upper extremity from video images. Variables of interest for the reach were: (1) speed (quantified as peak wrist velocity), (2) efficiency (quantified as reach path ratio), and (3) accuracy (quantified as endpoint error).18 Variables of interest for the grasp component of the reach-to-grasp movement were: (1) speed (quantified as peak aperture rate), (2) efficiency (quantified as aperture path ratio), and (3) peak aperture.18 Because of the acute status of our subjects, especially at the day 0 visit, our analyses were structured to capture the range of behaviors (and attempts) recorded, such that our variables of interest quantified performance whether or not the subjects could touch or grasp the target. Analyses Statistical analyses were conducted using SPSSd for Windows. Distributions of variables were tested for normality using Kolmogorov-Smirnov tests. Four variables from the kinematic testing were not normally distributed and were transformed for further statistical analyses. The type of transformation done on a variable was chosen by examining the raw distribution and then selecting the transformation that would best minimize skewness. The 4 variables were transformed as follows: reach efficiency (reach path ratio) using percentile ranks, reach accuracy (endpoint error) using the natural log function, grasp speed (peak aperture rate) using the square root function, and grasp efficiency (aperture path ratio) using percentile ranks. All statistical analyses on these 4 variables were done using the transformed data. Responsiveness of the ARAT from day 0 to day 14 and from day 0 to day 90 was determined in 2 ways. First, it was determined by use of the single population effect size method,19 where the effect size within the first weeks of stroke was calculated as the mean change from day 0 to day 14 divided by the standard deviation (SD) at day 0; the effect size within the first months of stroke was calculated as the mean change from day 0 to day 90 divided by the SD at day 0. Second, responsiveness was determined using the responsiveness ratio method,20 which can be considered an effect size that is normalized to the variability in a stable population. The responsiveness ratio within the first weeks of stroke was calculated as the mean change from day 0 to day 14 divided by the SD of mean change in a stable population. The value for SD of mean change was 3.0 points, based on an earlier report of people with chronic hemiparesis.9 The responsiveness ratio within the first months of stroke was calculated as the mean change from day 0 to day 90 divided by this same standard deviation of mean change in a stable population. We examined the construct validity of the ARAT using bivariate correlational analyses. We used Pearson product-moment correlations to examine the relation between ARAT scores and sensorimotor impairments, kinematic, and disability measures. Analyses were done separately at each of the 3 time points. Analyses were performed on 50 subjects at day 0 and day 14 time points, and 40 subjects at the day 90 time point (5 subjects did not return for their day 90 evaluation, 5 subjects were not evaluated in the kinematic laboratory at day 90). Based on our sample sizes, correlation coefficients with an absolute value greater than .40 were statistically significant at P less than .01 and correlation coefficients with an absolute value greater than .30 were statistically significant at P less than .05. The following criteria were used to interpret the magnitude of the correlation coefficients. Coefficients of .25 or below were considered low, coefficients ranging from .26 to .50 were considered fair, coefficients from .51 to .75 were considered good, and those greater than .75 were considered excellent.21 Results Table 1 lists the characteristics of the 50 subjects. Enrollment was based on the presence of hemiparesis and the absence of severe sensory or cognitive impairments. Using these criteria, participants displayed a surprisingly wide range of upper-extremity dysfunction, as measured by the ARAT, in their affected arms (contralateral to the lesion) at all 3 time points. Pearson correlation coefficients between age and ARAT total score were −.16 at day 0, −.44 at day 14, and −.29 at day 90. Initial stroke severity, as measured by the NIHSS on admission to the acute hospital, was minimally related to ARAT total scores at day 0 (r=−.15), day 14 (r=−.24), and day 90 (r=−.29). | | |  | Variable | Mean ± SD | |
|---|
| Age (y) | 63.7±13.6 | | | Admission NIHSS score | 5.28±1.76 | | | Time to day 0 evaluation (days since stroke) | 9.5±4.5 | | | Time to day 14 evaluation (days since stroke) | 25.9±10.6 | | | Time to day 90 evaluation (days since stroke) | 110.8±20.7 | | | Premorbid Barthel Index score | 99.6±2.2 | | | Premorbid Modified Rankin Index score | 0.30±0.60 | | | Day 0 ARAT total score | 22.5±15.2 | | | Day 14 ARAT total score | 38.1±16.5 | | | Day 90 ARAT total score | 43.7±14.9 | | | | n (%) | | | Sex | | | | Male | 21(42) | | | Female | 29(58) | | | Race | | | | White | 21(42) | | | African American | 28(56) | | | Other | 1(2) | | | Stroke type | | | | Ischemic | 39(78) | | | Hemorrhagic | 11(22) | | | Affected side | | | | Dominant | 21(42) | | | Nondominant | 29(58) | | | | |
We assessed responsiveness of the ARAT (table 2) with the single population effect size method and the responsive ratio method. A test may be considered responsive to change with effect size values approaching 1.0.19, 22 The effect size of the ARAT total score was large in the first weeks after stroke (day 0 to day 14 time points) and first months after stroke (day 0 to day 90 time points). Effect sizes of the ARAT subscales were similar, except for the gross motor subscale, which was slightly smaller. The responsiveness ratio, a method to normalize effect size to the variability in a stable population, was extremely large for the total ARAT score in both the first few weeks and the first few months after stroke. Figure 1 shows the relationships between the ARAT total scores and 4 sensorimotor impairments frequently measured by occupational and physical therapists. Upper-extremity strength correlated with ARAT total scores across all 3 time points, such that the greater the strength the higher the ARAT score. Spasticity was inversely related to ARAT total scores, such that greater spasticity was associated with lower ARAT total scores. Light touch sensation was unrelated to ARAT total score. Pain scores showed a trend toward increasingly negative correlations at the 90-day time point, with more pain in the affected shoulder being somewhat associated with lower ARAT total scores. Figure 2 shows relationships between ARAT total scores and kinematic measures of movement. Kinematic measures of reach (see fig 2A) were related to ARAT total score in that faster, more efficient, and more accurate reaching performance were associated with better ARAT total scores. Kinematic measures of grasp (see fig 2B) were similarly related to ARAT total scores; with faster and more efficient grasping performance and a greater ability to open the fingers were associated with better ARAT total scores. Figure 3 shows the relationships between ARAT total scores and disability measures. The strength of the relation between the ARAT and motor disability, as measured by the FIM motor score, increased from day 0 to day 14 and remained stable at day 90. Likewise, the relation between the ARAT and focal disability of the upper extremity, as measured by the FIM upper extremity score, increased from day 0 to day 14 and remained stable at day 90. Discussion Psychometric properties of many clinical scales used to evaluate upper-extremity function after stroke have not been thoroughly investigated.23 We examined the responsiveness and the construct validity of the ARAT, a measure of upper-extremity function, in a cohort of subjects participating in the VECTORS trial. Previous studies24 at our institution have demonstrated the reliability and internal consistency of the ARAT in an inpatient rehabilitation setting. Our data show that the ARAT was responsive to change in the first weeks and months after stroke. It was related to impairment level measurements of strength and spasticity, to kinematic measures of movement performance, and to disability level measurements, thus providing additional evidence of its construct validity at these early time points. Given the proliferation of randomized controlled trials in rehabilitation, it is crucial to select outcome measures that are sensitive to change as well as being reliable and valid. Our results may also be useful for researchers who are considering clinical trials of drugs to enhance recovery. Currently, there is no consensus on the appropriate outcome measures for upper-extremity motor intervention trials, and this is particularly true regarding the inpatient rehabilitation phase of care.25 Our subjects were recruited based on whether they had hemiparesis poststroke and had been evaluated during their inpatient rehabilitation stay. They represent a limited but ecologically valid sample of subjects with relatively pure motor hemiparesis who are most likely to participate in future upper-extremity motor intervention trials. Our data are important for the development of future trials and indicate that the ARAT would be an appropriate tool with which to assess upper-extremity function in this population. The ARAT offers several advantages for the study of upper-extremity function in patients at both the acute and later stages of stroke recovery. The scale is easily administered, does not rely heavily on language and complex instructions, nor does it require much in the way of equipment and test supplies. The use of Guttman scaling to derive subtest and total scores also enhances the clinical utility of the ARAT for assessment of patients at all levels of recovery. This is particularly true for studies undertaken in acute stroke care settings, where patient capacity is often limited. In the acute care setting, the ability to quickly discontinue testing after failure of the least demanding items without sacrificing a valid score is particularly important. The use of the Guttman scale also decreases the likelihood that ARAT scores will be confounded by the effects of fatigue, a major problem in many assessments of stroke-related functional impairments early after stroke. Sensitivity to change is an important factor in selecting measures for rehabilitation trials.26 Effect sizes for the total ARAT scores were similar in the first few weeks and months after stroke (values of 1.0 and 1.3) (see table 2). We consider these effect sizes to be large, given that conventional “large” effect sizes are usually around 0.8.21 Responsiveness ratios for the total ARAT score were 5.2 and 7.0 in the first few weeks and months after stroke. For comparison, responsiveness ratios in people with chronic hemiparesis were found to be 2.03 for the total ARAT score, 0.41 for the upper extremity portion of the Fugl-Meyer Assessment, and 1.9 (amount of use score) and 2.0 (quality of movement score) for the Motor Activity Log.9, 27 Our high responsiveness ratios indicate that the ARAT is a sensitive tool for detecting the changes in upper-extremity function in this early recovery period after stroke. The responsiveness ratio can be considered an estimate of effect size that has been normalized to the variability in a stable population.20 The finding that our responsiveness ratios were about 5 times larger than our effect sizes is due to the fact that the variability between our acute subjects was much greater than the variability within subjects at a more stable time period.9 For researchers, the responsiveness of the ARAT shown here suggests that researchers can comfortably choose this relatively simple scale without compromising the statistical power of their acute treatment trial.28 For clinicians, the responsiveness of the ARAT shown here means that it is sufficiently sensitive to detect true changes in a patient’s ability to use the upper extremity for functional activities in the first few weeks and months after stroke. The minimal clinically important difference (MCID) for a change in ARAT score has been defined as a change of 10%, or about 6 points on the 57-point scale.29 This 6-point MCID matches the limits of agreement or error thresholds of about ±6 points,9 indicating that the ARAT is capable of detecting the smallest clinically meaningful change. We found mean changes in ARAT scores of 15.6 from day 0 to day 14 and 21.2 from day 0 to day 90 (see table 1). Clinicians measuring changes in individual patients over the first few weeks and months after stroke can be confident that an improvement of 6 points or more on the ARAT represents a real and important change. Our results provide new data that support the construct validity of the ARAT with impairment level measures, with objective measures of movement performance, and with disability measures during this early period after stroke. The finding that upper-extremity strength measures have the strongest relation with the ARAT is in agreement with the contemporary viewpoint that compromised motor function after stroke is a direct result of muscle weakness.15, 30, 31 The lack of a relation to light touch sensation and pain was expected, given that our subjects had only minimal levels of somatosensory loss and pain.15 The relation between ARAT scores and movement performance was moderate. This may be because the reach and grasp movements studied are only 2 movements in the enormous repertoire of possible upper-extremity movements, albeit they are 2 of the most functional movements. The magnitude of the correlations between the ARAT scores and disability measures was also moderate and likely reflects the fact that upper-extremity functional limitations are an important, but not the only, component that determines disability poststroke.32 Given that perfect or near-perfect performance on the ARAT or other upper-extremity functional limitation measures do not equate to the absence of disability,25 stroke and rehabilitation researchers might consider using the ARAT in conjunction with disability measures. We consider the correlation coefficients in our sample to be estimates of the correlations that exist in a larger population. It is expected that, as estimates, they fluctuate to some degree, even if the true value in the population remains constant. For example, correlations between the ARAT and strength range from .42 to .60 and those between the ARAT and spasticity range from −.28 to −.49 (see fig 1). These ranges are not unexpected if we assume that the true relationships between the ARAT and other measures are constant. It is also possible that such relationships are not constant in this early time period after stroke. Given that improvements in function lag improvements in neurologic impairments by 1 to 2 weeks,11 the small fluctuations in correlation coefficients reported here may reflect a slight shifting in the magnitude of the relationships over the first few weeks and months poststroke. A much larger sample size, in which narrow confidence intervals for the correlation coefficients could be calculated, would be required to distinguish between these 2 possibilities. Conclusions The ARAT is a responsive and valid instrument to measure upper-extremity functional limitation and recovery during the first weeks and months poststroke. It would be an appropriate measure for use in acute upper-extremity rehabilitation trials. Suppliers Acknowledgment We thank the VECTORS research team for its assistance with this project. References 1. 1Lyle RC. A performance test for assessment of upper limb function in physical rehabilitation treatment and research. Int J Rehabil Res. 1981;4:483–492. MEDLINE 2. 2Research plan for the national center for medical rehabilitation research. Bethesda: National Institute of Child Health and Human Development, National Institutes of Health; 1993;. 3. 3Carroll D. A quantitative test of upper extremity function. J Chronic Dis. 1965;18:479–491. MEDLINE |
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a Program in Physical Therapy, Washington University, St. Louis MO b Program in Occupational Therapy, Washington University, St. Louis MO c Department of Neurology, Washington University, St. Louis MO d National Rehabilitation Hospital, Washington, DC.  Reprint requests to Catherine E. Lang, PT, PhD, Program in Physical Therapy, Washington University, 4444 Forest Park Blvd, Campus Box 8502, St. Louis, MO 63108.
Supported by the National Institutes of Health (grant nos. NS41261, HD047669), the James S. McDonnell Foundation (grant no. 21002032), and the Foundation for Physical Therapy. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(06)01333-5 doi:10.1016/j.apmr.2006.09.003 © 2006 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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