Original research| Volume 99, ISSUE 4, P736-742, April 2018

Preliminary Psychometric Evaluation of the Brachial Assessment Tool Part 2: Construct Validity and Responsiveness

Published:December 13, 2017DOI:



      To evaluate construct validity and responsiveness of the Brachial Assessment Tool (BrAT), a new patient-reported outcome measure for people with traumatic brachial plexus injury (BPI), and to compare it to the Disabilities of the Arm, Shoulder and Hand (DASH) and the Upper Extremity Functional Index (UEFI).


      Cross-sectional study.


      Outpatient clinics.


      Adults (N=29; age range, 20–69y) with confirmed traumatic BPI.


      Participants completed the BrAT 3 times over an 18-month period together with 16 DASH activity items and the UEFI. Evaluations were undertaken of construct validity, known-groups validity, 1-way repeated analysis of variance, and effect size.

      Main Outcome Measures

      BrAT, DASH, and UEFI.


      The BrAT demonstrated a moderate to low correlation with the DASH activity items (<0.7) and a large correlation with the UEFI (>0.7). According to known-groups validity, only the BrAT was able to discriminate between people who stated they could use their hand versus those who were unable to use their hand to perform activities. All measures indicated a significant effect for time with the exception of BrAT subscale 1. The effect size was highest for the BrAT but lower than expected (BrAT, .52–.40; DASH, .15; UEFI, .36).


      These preliminary findings support the BrAT as a valid and responsive patient-reported outcome measure for adults with traumatic BPI. The BrAT activity items appear to be more targeted than the DASH or UEFI particularly for people with more severe BPI. The BrAT also appears to be measuring a different activity construct than the DASH and the UEFI. Further work is required to confirm these results with larger sample sizes.


      List of abbreviations:

      BPI (brachial plexus injury), BrAT (Brachial Assessment Tool), DASH (Disabilities of the Arm, Shoulder and Hand), GPUS (Global Perceived Use Scale), ICF (International Classification of Functioning, Disability and Health), UEFI (Upper Extremity Functional Index)
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        • Dodakundi C.
        • Doi K.
        • Hattori Y.
        • et al.
        Outcome of surgical reconstruction after traumatic total brachial plexus palsy.
        J Bone Joint Surg Am. 2013; 95: 1505-1512
        • Seal A.
        • Stevanovic M.
        Free functional muscle transfer for the upper extremity.
        Clin Plast Surg. 2011; 38: 561-575
        • Ahmed-Labib M.
        • Golan J.D.
        • Jacques L.
        Functional outcome of brachial plexus reconstruction after trauma.
        Neurosurgery. 2007; 61: 1016-1022
        • Mancuso C.A.
        • Lee S.K.
        • Dy C.J.
        • Landers Z.A.
        • Model Z.
        • Wolfe S.W.
        Expectations and limitations due to brachial plexus injury: a qualitative study.
        Hand (N Y). 2015; 10: 741-749
        • Rolfson O.
        • Eresian Chenok K.
        • Bohm E.
        • et al.
        Patient-reported outcome measures in arthroplasty registries: report of the Patient-Reported Outcome Measures Working Group of the International Society of Arthroplasty Registries: part I. Overview and rationale for patient-reported outcome measures.
        Acta Orthop. 2016; 87: 3-8
        • Black N.
        Patient reported outcome measures could help transform healthcare.
        BMJ. 2013; 346: f167
        • Hill B.
        • Williams G.
        • Bialocerkowski A.
        Clinimetric evaluation of questionnaires used to assess activity after traumatic brachial plexus injury in adults: a systematic review.
        Arch Phys Med Rehabil. 2011; 92: 2082-2089
        • Hill B.
        • Williams G.
        • Olver J.
        • Bialocerkowski A.
        Do existing patient-report activity outcome measures accurately reflect day-to-day arm use following adult traumatic brachial plexus injury?.
        J Rehabil Med. 2015; 47: 438-444
        • Bengtson K.A.
        • Spinner R.J.
        • Bishop A.T.
        • et al.
        Measuring outcomes in adult brachial plexus reconstruction.
        Hand Clin. 2008; 24: 401-415
        • Dy C.J.
        • Garg R.
        • Lee S.K.
        • Tow P.
        • Mancuso C.A.
        • Wolfe S.W.
        A systematic review of outcomes reporting for brachial plexus reconstruction.
        J Hand Surg Am. 2015; 40: 308-313
        • World Health Organization
        International Classification of Functioning, Disability and Health.
        World Health Organization, Geneva2001
        • Hill B.
        • Pallant J.
        • Williams G.
        • Olver J.
        • Ferris S.
        • Bialocerkowski A.
        Evaluation of internal construct validity and unidimensionality of the Brachial Assessment Tool, a patient-reported outcome measure for brachial plexus injury.
        Arch Phys Med Rehabil. 2016; 97: 2146-2156
        • De Vet H.C.
        • Terwee C.B.
        • Mokkink L.B.
        • Knol D.L.
        Measurement in medicine: a practical guide.
        Cambridge University Pr, Cambridge2011
        • Stratford P.W.
        • Binkley J.M.
        • Stratford D.M.
        Development and initial validation of Upper Extremity Functional Index.
        Physiother Can. 2001; 53: 259-267
        • Hudak P.L.
        • Amadio P.C.
        • Bombardier C.
        Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Head).
        Am J Ind Med. 1996; 29: 602-608
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research: applications to practice.
        3rd ed. Pearson Prentice Hall, Upper Saddle River, NJ2009
        • Mokkink L.B.
        • Terwee C.B.
        • Patrick D.L.
        • et al.
        The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health-related patient-reported outcomes.
        J Clin Epidemiol. 2010; 63: 737-745
        • Polit D.F.
        Getting serious about test-retest reliability: a critique of retest research and some recommendations.
        Qual Life Res. 2014; 23: 1713-1720
        • Franchignoni F.
        • Giordano A.
        • Ferriero G.
        On dimensionality of the DASH.
        Mult Scler. 2011; 17: 891-892
        • Lehman L.A.
        • Woodbury M.
        • Velozo C.A.
        Examination of the factor structure of the Disabilities of the Arm, Shoulder, and Hand questionnaire.
        Am J Occup Ther. 2011; 65: 169-178
        • Drummond A.S.
        • Sampaio R.F.
        • Mancini M.C.
        • Kirkwood R.N.
        • Stamm T.A.
        Linking the Disabilities of Arm, Shoulder, and Hand to the International Classification of Functioning, Disability, and Health.
        J Hand Ther. 2007; 20: 336-344
        • Mancuso C.A.
        • Lee S.K.
        • Dy C.J.
        • Landers Z.A.
        • Model Z.
        • Wolfe F.
        Compensation by the injured arm after brachial plexus injury.
        Hand (N Y). 2016; 4: 410-416
        • Kachooei A.R.
        • Moradi A.
        • Janssen S.J.
        • Ring D.
        The influence of dominant limb involvement on DASH and QuickDASH.
        Hand (N Y). 2015; 10: 512-515
        • Forget N.J.
        • Higgins J.
        Comparison of generic patient-reported outcome measures used with upper extremity musculoskeletal disorders: linking process using the International Classification of Functioning, Disability, and Health (ICF).
        J Rehabil Med. 2014; 46: 327-334
        • Mokkink L.B.
        • Terwee C.B.
        • Patrick D.L.
        • et al.
        The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study.
        Qual Life Res. 2010; 19: 539-549
        • Cleland J.A.
        • Childs J.D.
        • Whitman J.M.
        Psychometric properties of the Neck Disability Index and Numeric Pain Rating Scale in patients with mechanical neck pain.
        Arch Phys Med Rehabil. 2008; 89: 69-74
        • Munro B.
        Statistical methods for health care research.
        JB Lippincott, Philadelphia2000
        • Terwee C.B.
        • Bot S.D.M.
        • de Boer M.R.
        • et al.
        Quality criteria were proposed for measurement properties of health status questionnaires.
        J Clin Epidemiol. 2007; 60: 34-42
        • Cohen J.
        Statistical power analysis for the behavioral sciences.
        2nd ed. Lawrence Erlbaum, Hillsdale1988
        • Wellington B.
        Quality of life issues for patients following traumatic brachial plexus injury—part 2 research project.
        Int J Orthop Trau Nurs. 2010; 14: 5-11
        • Gray B.
        Quality of life following traumatic brachial plexus injury: a questionnaire study.
        Int J Orthop Trauma Nurs. 2016; 22: 29-35
        • Wilson T.J.
        • Chang K.W.
        • Yang L.J.
        Depression and anxiety in traumatic brachial plexus injury patients are associated with reduced motor outcome after surgical intervention for restoration of elbow flexion.
        Neurosurgery. 2016; 78: 844-849
        • Franzblau L.
        • Chung K.C.
        Psychosocial outcomes and coping after complete avulsion traumatic brachial plexus injury.
        Disabil Rehabil. 2015; 37: 135-143
        • Franzblau L.
        • Shauver M.J.
        • Chung K.C.
        Patient satisfaction and self-reported outcomes after complete brachial plexus avulsion injury.
        J Hand Surg Am. 2014; 39: 948-955.e4
        • Ashford S.
        • Slade M.
        • Turner-Stokes L.
        Conceptualisation and development of the Arm Activity Measure (ArmA) for assessment of activity in the hemiparetic arm.
        Disabil Rehabil. 2013; 35: 1513-1518
        • Ashford S.
        • Turner-Stokes L.
        • Siegert R.
        • Slade M.
        Initial psychometric evaluation of the Arm Activity Measure (ArmA): a measure of activity in the hemiparetic arm.
        Clin Rehabil. 2013; 27: 728-740