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Dimensionality and Item-Difficulty Hierarchy of the Lower Extremity Fugl-Meyer Assessment in Individuals With Subacute and Chronic Stroke

Published:December 28, 2015DOI:https://doi.org/10.1016/j.apmr.2015.12.012

      Highlights

      • The lower extremity Fugl-Meyer Assessment represents a multidimensional construct.
      • Our results challenge use of the total score to predict lower extremity motor recovery.
      • The abnormal synergy items of the lower extremity Fugl-Meyer Assessment are unidimensional.
      • The abnormal synergy items deviate from the originally proposed hierarchical order.

      Abstract

      Objective

      To investigate the dimensionality and item-difficulty hierarchy of the Fugl-Meyer Assessment of the lower extremity (FMA-LE).

      Design

      Secondary analyses of data pooled from 4 existing datasets: a phase III randomized controlled trial investigating the effectiveness of body weight support and a treadmill for rehabilitation of walking poststroke, and 3 cross-sectional studies investigating the link between impaired motor performance poststroke and walking.

      Setting

      University research centers and rehabilitation centers.

      Participants

      A pooled sample of individuals with a stroke (N=535, men=313; mean age ± SD, 61.91±12.42y).

      Interventions

      Not applicable.

      Main Outcome Measures

      Confirmatory factor analyses (CFA) and Rasch residual principal component analysis (PCA) investigated the dimensionality of the FMA-LE. The Rasch analysis rating scale model investigated item-difficulty hierarchy of the FMA-LE.

      Results

      The CFA showed adequate fit of a 3-factor model, with 2 out of 3 indices (CFA=.95; Tucker-Lewis Index=.94; root mean square error of approximation=.124) showing good model fit. Rasch PCA showed that removal of the reflex and coordination items explained 90.8% of variance in the data, suggesting that the abnormal synergy items contributed to the measurement of a unidimensional construct. However, rating scale model results revealed deviations in the item-difficulty hierarchy of the unidimensional abnormal synergy items from the originally proposed stepwise sequence of motor recovery.

      Conclusions

      Our findings suggest that the FMA-LE might represent a multidimensional construct, challenging the use of a total score of the FMA-LE to predict lower extremity motor recovery. Removal of the misfit items resulted in creation of a unidimensional scale composed of the abnormal synergy items. However, this unidimensional scale deviates from the originally proposed hierarchical ordering.

      Keywords

      List of abbreviations:

      CFA (confirmatory factor analysis), CFI (comparative fit index), FMA (Fugl-Meyer Assessment), FMA-LE (Fugl-Meyer Assessment of the lower extremity), MNSQ (mean square), PCA (principal component analysis), RMSEA (root mean square error of approximation), TLI (Tucker-Lewis Index)
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