Of the almost 600,000 newly diagnosed strokes per year in the United States,1 nearly 80% of these individuals have acute paresis affecting the upper extremity.2 Research suggests that most recovery occurs within the first few months after stroke2–7 and not coincidentally rehabilitation begins as early as possible, often within the first week. To evaluate changes in upper extremity function early after stroke, clinicians can choose from a number of standardized clinical tests. Recent research from our laboratory has shown that many of these tests measure the same underlying construct of upper extremity function.8,9 Using principal components analysis, we found, in two separate samples, that six standardized clinical tests all loaded onto a single principal component. This suggests that each of these tests was measuring the same thing and that standardized upper extremity function tests are interchangeable, ie, one is as good as another. Knowing how these same six tests are related to each other and whether the relationships change over time would be of great benefit to clinicians because they choose tests to assess upper extremity function of individuals with acute hemiparesis and throughout the first few months of recovery.
The starting point for selecting upper extremity tests is to identify the ones with established reliability and validity.10 Beyond the typical types of validity, clinicians and researchers need to know the responsiveness of the test, ie, can it accurately detect change over time?11–13 The responsiveness of a test, as with other psychometric properties, needs to be assessed for each population in which the test is to be used.14 For people with stroke, a few upper extremity function tests have been examined for responsiveness. The Action Research Arm Test (ARAT),15–17 the Motor Assessment Scale,15 Fugl-Meyer Assessment,16 the Stroke Impact Scale (SIS),18 and the Chedoke Arm and Hand Activity Inventory19 have been shown to be responsive to change early after stroke. Initial testing in all these studies was conducted within one month of stroke onset. Two of these studies involving the ARAT17 and the SIS18 examined responsiveness over a longer period with follow-up testing at three months17,18 or six months.18 In rehabilitation settings, other upper extremity function tests are often administered poststroke, such as the Nine-Hole Peg Test (9HPT), the Jebsen Taylor Test of hand function, and grip and pinch strength. Grip and pinch strength, although impairment level measures, have been to be proposed to be surrogate measures of upper extremity functional outcomes20 and will be treated as such in this manuscript. The responsiveness of these other tests has not been examined in people during the first few weeks and months after stroke.
The purpose of this investigation was twofold: (1) to determine how six clinical tests of upper extremity function were related to each other in the first weeks and months after stroke and (2) to determine how responsive the tests were to change over the first six months after stroke. This information is needed by clinicians and researchers because it is critical for evidence-based practice and sound research.
Thirty-three subjects with hemiparesis due to stroke participated in this study. Subjects were recruited from the Cognitive Rehabilitation Research Group Stroke Registry based on the presence of hemiparesis. Subjects were included if they had (1) a diagnosis of ischemic or hemorrhagic stroke by a stroke neurologist within one month of onset of symptoms, (2) computed tomography or magnetic resonance imaging data consistent with clinical presentation, (3) persistent hemiparesis with a score of 1 to 4 on the Motor Arm item of the National Institutes of Health Stroke Scale (NIHSS), (4) evidence of preserved cognition as indicated by a score of 0 or 1 on the Consciousness and Communication item of the NIHSS, and (5) the ability to follow two-step commands. Individuals were excluded from the study if they had (1) orthopaedic or other medical conditions that limited the more affected upper extremity before the stroke, (2) a history of hemiparesis or stroke, (3) hemispatial neglect as evidenced by a score of 2 on the Extinction and Inattention item of the NIHSS, (4) severe aphasia as evidenced by a score of 2 or 3 on the Language item of the NIHSS, or (5) complete hemianopsia as evidenced by a score of 2 or 3 on the Visual item of the NIHSS or (6) the subject was unable to give informed consent. Characteristics of the group are provided in Table 1. Subjects were recruited from a tertiary care center where a large portion of the people with stroke either lived too far away for follow-up research testing, had multiple comorbidities that excluded them from our study, or were discharged to a skilled nursing facility where we did not have access to continue testing them. The 33 subjects that were tested accounted for ∼10% of the total subjects screened for this study. This study was approved by the Washington University Human Research Protection Office, and all participants provided informed consent before participation.
Over the duration of the study, subjects received standard stroke rehabilitation services as directed by their neurology and rehabilitation physicians. At the first visit, most subjects were in inpatient rehabilitation and were therefore receiving daily occupational and physical therapy services. The subjects that were living at home at the time of the first visit typically had outpatient services a few days per week. By the three-month and six-month visits, subjects had progressively decreasing services or no services at all as determined by their progress and by their rehabilitation team. We did not record subject-specific information on the type and duration of therapy received.
Subjects were tested for their ability to use their upper extremity for functional activities at three time points: within one, three, and six months after stroke. At each time point, testing was completed during a single session lasting approximately one hour. The tests were administered randomly with the SIS questionnaire always being administered last. The authors, both physical therapists, administered all the tests. The least affected side was tested first. Physical fatigue did not seem to be a concern because subjects were permitted rest time as needed between tests.
Measurement of Upper Extremity Function
All subjects underwent a battery of six standardized clinical tests of upper extremity function. The battery of tests were evaluative measures used to measure upper extremity function in multiple ways such as criterion rated, timed performance, and self-report. We were careful as to the number of tests administered so as not to place too great a testing burden on our subjects, particularly at the one-month time point. The tests in this study were selected based on published data at the time of study initiation regarding reliability, validity, normative values, and appropriateness for use with people with stroke. Several tests were excluded for the following reasons. The Motor Assessment Scale was not included because it contains items examining other body segments and is not specific to the more affected upper extremity. The Fugl-Meyer was not included because it has already been shown to be highly correlated with the ARAT (r = 0.91–0.94).21 The Chedoke Arm and Hand Activity Inventory was not included because information about it was not available at the time of study initiation. It has since been shown to be highly correlated with the ARAT (r = 0.93).19 Two of the tests, grip and pinch strength, were included because they are quick and easy to administer and are common in most clinics. All clinical tests were performed bilaterally, such that the less affected upper extremity served as the matched control for the more affected side. The following tests were used.
Grip strength22 is a dynamometer measurement of the maximum amount of force produced during a five-finger grip. Test-retest reliability (intraclass correlation coefficients [ICCs] = 0.91) has been reported for the more affected side of subjects with chronic stroke.20 Three trials were performed on each side with the subject sitting, arm at his or her side, the elbow at 90 degrees, the forearm neutral, and the wrist in slight extension. If subjects were not able to hold the test position, the dynamometer was supported; however, care was taken to ensure that the support did not influence force production. The average of three trials23 was computed, and scores were expressed in kilograms. Normal grip strength for similarly aged individuals has been reported to be 32.9 (8.5) kg24 as mean (standard deviation [SD]).
Pinch strength24 is a dynamometer measurement of the maximum amount of force produced during a three-fingered key pinch. Test-retest reliability of an average between left and right hands (r = 0.85) has been reported for young, healthy subjects.25 Three trials were performed on each side with the subject sitting, arm at their side, the elbow at 90 degrees, forearm neutral, and the wrist in slight extension. If subjects were not able to hold the test position, the dynamometer was supported; however, extreme care was taken to ensure that the support did not influence force production. The average of three trials23 was computed, and scores were expressed in kilograms. Normal pinch strength for similarly aged individuals has been reported to be 8.8 (1.5) kg.24
ARAT17,26–30 is a test for upper extremity function with four subscales: grasping, gripping, pinching, and gross movement. It uses ordinal scoring on 19 items, where 0 indicates no movement and 3 indicates normal movement. Items in each subscale are summed for grasping (18-point maximum), gripping (12-point maximum), pinching (18-point maximum), and gross movement (9-point maximum), with a total scale score of 57, indicating normal. Test-retest reliability has been reported (ICC = 0.97) for the more affected side of individuals with stroke of varying duration.31
Jebsen-Taylor Test of Hand Function
Jebsen-Taylor Test of Hand Function32,33 is a functional assessment scored by the summed times to complete seven common tasks. The tasks are writing a sentence, simulated page turning, picking up small objects, simulated feeding, stacking checkers, picking up large light objects, and picking up large heavy objects. The first task, writing a sentence, was not used because it is dependent on hand dominance and education level.33 The maximal amount of time allotted for each subtest was 120 seconds.34 Test-retest reliability has been reported (r = 0.92) for individuals with stable hand disorders resulting from stroke, brain injury, or rheumatoid arthritis.32 Normal time to complete the Jebsen for similarly aged individuals has been reported to be 30.4 (1.11) seconds.35,36
9HPT37 is a finger coordination measure involving timed performance to insert and remove nine pegs from a wooden block. Test-retest reliability has been reported (r = 0.98) for individuals with acquired neurological disorders resulting from stroke, multiple sclerosis, brain injury, or tumor.38 Scores were expressed in seconds, with the maximal amount of time allotted being 120 seconds. Normal time to complete the 9HPT for similarly aged individuals has been reported to be 19.4 (2.68) seconds.37
SIS18,39,40 is a self-report questionnaire to measure the impact of stroke in multiple domains. Test-retest reliability has been reported (ICC = 0.92) for the hand function domain in individuals with stroke of varying duration.40 The subject answers the questions based on a five-point Likert scale, and the scores are computed to obtain a number between 0 and 100, where 100 indicates normal.39 Data on all domains of the SIS were collected, but only the hand function domain (asking about the most affected upper extremity) was part of our upper extremity function battery. Questions in the hand function domain pertain to carrying heavy objects, turning a doorknob, opening a can or jar, tying a shoelace, and picking up a dime.
Additional tests were conducted to provide a more thorough description of the sample (Table 1). This testing occurred randomly during each testing session. To quantify upper extremity strength, a hand-held dynamometer was used to assess both flexion and extension of the shoulder, elbow, wrist, and index finger using standard manual muscle test positions.41 Both more affected and less affected upper extremities were tested. The values obtained were highly correlated within each arm and thus, the values were combined into one variable and were expressed as a percentage of less affected side (Table 1, composite strength).42 More affected side shoulder pain was assessed using a standard 11-point numeric rating scale, where 0 = no pain (Table 1, shoulder pain). Joint position sense was evaluated on both sides at the index finger using standard clinical techniques where normal = correct on ≥3/5 trials (Table 1, index finger joint position sense). Last, spasticity was evaluated on the more affected side using the Modified Ashworth Scale43 for flexion/extension movements at four joints: metacarpophalangeal joints of the hand, wrist, elbow, and shoulder (Table 1, Modified Ashworth Scale).
SPSS version 13 (SPSS Inc., Chicago, IL) was used for analyses. Spearman correlations were used to evaluate the relationships between test scores at each time point. For ease of interpretation, all correlations were expressed as absolute values. This was done because lower times reflect better performance on timed tests (ie, Jebsen-Taylor and 9HPT), and higher scores reflect better performance on the other tests (ie, grip, pinch, ARAT, and SIS-Hand). Bonferroni correction for statistical significance was set to P < 0.0033 to allow for 15 comparisons within each time point. Interpretation of the magnitude of the correlation coefficients were as follows: r > 0.25 were considered fair; r > 0.50 were considered moderate; and r > 0.75 were considered excellent/strong.44
For each test, we calculated responsiveness between testing at one and three months and one and six months, using the single population effect size method.11,12 The effect size from one to three months was calculated as the mean absolute value change from one to three months divided by the SD at one month. The effect size from one to six months was calculated as the mean absolute value change from one to six months divided by the SD at one month. Similar to the interpretation of the correlation coefficients, responsiveness values >0.20 were considered fair; values >0.50 were considered moderate; and values >0.80 were considered highly responsive to change.45 It is possible for values to exceed 1.0; however, for values <1.0, those closer to 1.0 indicate better responsiveness.
Thirty-three subjects with acute hemiparesis were included in the study. By the three- and six-month follow-up visits, 28 and 19 subjects remained, respectively. Subject attrition by the three-month time point was attributed to one deceased, two with additional medical complications that prohibited them from continuing, and two who could not be reached for follow-up. Subject attrition by the six-month time point was attributed to four with additional medical complications that prohibited them from continuing, four whose original testing paradigm only included one- and three-month visits and did not include a six-month follow-up visit, and one who could not be reached for follow-up.
Subject demographic information is included in Table 1. The average mean (SD) age of the individuals was 56.9 (10.2) years, and the average (SD) time since stroke was 18.6 (5.6) days for the first visit, 98.3 (14.9) days for the second visit, and 186.7 (12.3) days for the third visit. Within this sample, there were varying degrees of hemiparesis from nearly complete plegia to just barely detectable paresis as indicated by the range of values for composite strength (Table 1). The subjects had minimal shoulder pain and minimal spasticity throughout their upper extremity. Only 6 subjects had impaired joint position sense at the index finger and/or wrist. The type of lesion was ischemic in 97% of the subjects, with the dominant hand affected 52% of the time. Paired t tests were conducted to determine whether differences existed between the subjects who were lost to attrition and those that remained in the study between one and three months, and between three and six months. These analyses did not show any differences between the subjects who were lost and those who remained on any of the six clinical tests at either time point.
Clinical Test Scores
The clinical tests of upper extremity function were administered to each subject within one month and at three and six months poststroke. The group mean, SD, and range for each time point are shown in Table 2. Results of the tests show that the sample had decreased upper extremity function early after stroke, which generally improved over time, as expected. For example, grip strength values represented ∼30%, 45%, and 47% of the less affected side for each time point, respectively. Subjects improved on all other tests with time with the exception of the SIS-Hand, which showed a decrease in perceived function between the three- and six-month time points. By and large, however, the scores indicate an overall improvement in upper extremity function, most notably during the first three months poststroke.
Clinical Test Correlations
To determine how the tests were related to each other, we conducted correlational analyses at each time point. Our results showed that the clinical tests were moderately to strongly correlated with each other at each time point (Table 3). At the one-month time point, all correlations were significant at the P < 0.0033 level. The highest correlation was between grip and pinch (0.92) and the lowest correlation between pinch and the SIS-Hand (0.54). At the three-month time point, all correlations were again significant at the P < 0.0033 level. The highest correlation at the three-month time point was between the Jebsen and the 9HPT (0.97), and the lowest between the ARAT and the SIS-Hand (0.57). At the six-month time point, nine correlations were significant at the P < 0.0033 level; three correlations had a P value <0.01 level, one had a P value <0.05, and one had a P value >0.05 (see Table 3, footnotes). The highest correlation at six months continued to be between the Jebsen and the 9HPT (0.97), and the lowest was between pinch and the SIS-Hand (0.41). Overall, the correlation coefficients between pairs of tests were generally similar at each time point, indicating that the relationships between tests remain stable over the first six months poststroke.
To determine how responsive the tests were to change over time, we used the single population effect size method. A higher effect size (closer to 1.0) is considered more responsive to change. Values for responsiveness between the one- and three-month time points are shown in Table 4 (first column), with the highest being the SIS-Hand (1.02), and the lowest being grip (0.50). Values for responsiveness between the one- and six-month time points are shown in Table 4 (second column), with the highest being the SIS-Hand (0.86), and the lowest being pinch (0.56). The values between each time point are similar indicating that these upper extremity function tests are at least moderately responsive to change in this sample.
Correlations Between Clinical Tests
We found that the tests were correlated with each other at each time point. Based on the interpretation of a strong correlation being r > 0.75, all correlations except that between the Jebsen and pinch, and most of the pairs which included the SIS-Hand were considered strong or excellent at the time of initial testing. The correlation between the Jebsen and pinch, and those that included the SIS-Hand was considered to be fair to moderate. At the three-month time point, all the tests were considered at least moderately related to each other. At six months, the relationships became somewhat more variable with pinch strength and SIS-Hand having weaker relationships with the other tests. These data extend the available information regarding relationships between upper extremity function tests by investigating how six commonly used measures are related to each other early after stroke and during the first six months of recovery. Later, we discuss how our results relate to previously published data.
Some of our correlational data were similar to those published by others. The relationship between grip strength and the 9HPT has been reported to be 0.71 and 0.79 at one and six months, respectively.46 Relationships between a modified version of the Jebsen test with the 9HPT have been reported to be between 0.86 and 0.88.38 Finally, in previously published data from our laboratory with a sample of individuals with chronic hemiparesis, using the same tests, we reported similar correlations between all tests except for the SIS-Hand.8 Despite differences in samples and time elapsed since stroke, the converging evidence of our data with other published results confirms that we are getting closer to the true correlational values.
Our correlational data were different from that of Bovend'Eerdt et al.38 They reported the relationships between grip strength and the 9HPT to be between 0.39 and 0.43, and the modified Jebsen and grip strength to be between 0.53 and 0.44. Also the values reported by Lang and Beebe8 were somewhat higher between the SIS-Hand and all the other clinical tests. A few methodological differences exist between our study8 and those listed above which may account for some of the discrepancies. One obvious difference is that we used six Jebsen subtests, whereas Bovend'Eerdt et al38 used three: flipping index cards, stacking checkers, and simulated feeding. Another difference is the populations studied. Our sample included people with hemiparesis early after stroke. The sample of Bovend'Eerdt et al38 included various neurological disorders ranging from stroke to multiple sclerosis to head injury to tumor, and our other study was done with people with chronic (more than six months) stroke.8 Also, it is interesting to note in this study that the SIS-Hand was the only one of the test battery to show a decline in the average scores from three to six months. We speculate that a longer period post-stroke without full return led to lower scores on the self-report SIS-Hand, whereas the more objective measures showed improvements. This may account for the lower correlations between tests in our study. These substantial differences between studies could possibly account for the variations in the strength of the relationships.
Our finding that the correlations fluctuate only slightly at each time point suggests that the relationships between tests are relatively stable over the first six months of recovery. Although other studies have investigated relationships between one or two tests over time,46 our results show that the relationships between a larger number of standardized upper extremity tests is stable over the course of recovery. Our data suggest that if a person with stroke attains a high score/better times for one test, he or she could expect to also attain high scores/better times on the other tests.
Responsiveness of the Clinical Tests
We found that all tests were responsive to change during the first six months after stroke. Between one and three months, the SIS-Hand was considered highly responsive to change and all the other tests were moderately responsive to change. Although the values changed a little, this same pattern existed between one and six months. As mentioned in the Introduction, the investigation of the responsiveness of these tests is in its infancy, especially in this population. Our data add to this literature by examining multiple tests simultaneously and permitting comparison of test responsiveness within the same sample.
Of the six clinical tests examined in this study, responsiveness values for people poststroke have been published for only the ARAT and the SIS-Hand.15–17,29 For the ARAT, published responsiveness values ranged from 0.5129 to 1.02.17 The results from this study are within this range, and differences between values may arise from differences in time points of testing. For the SIS-Hand, the previously published data for responsiveness used different statistical methodologies but was determined to be responsive to change.18 Unfortunately, because of the methodological differences no direct comparison of values with this study is possible. We found it particularly interesting that the SIS-Hand was the most responsive to change in our sample. This five-question instrument was more sensitive to change than other, longer tests that required performance of upper extremity movements. Because it is a patient-focused functional assessment, quick to administer, and sensitive to change, the SIS-Hand is an excellent tool for evaluating upper extremity clinical outcomes.19,47
Grip and pinch strengths were the least responsive to change at each time point, respectively. This may be because, despite our choice to consider these tests as surrogate measures for functional outcomes,20 these are impairment level measures versus activity level measures. Responsiveness of these tests, however, was not largely different from the other more time consuming, and/or better constructed measures of upper extremity activity. Thus, they continue to have high clinical utility.
Limitations of Our Study
There are two primary limitations of our study. First, our sample size was small (n = 33) for the one-month time point and decreased at the three-month (n = 28), and six-month (n = 19) time points. Although we determined that the lost subjects did not differ statistically from the ones who remained, we cannot rule out the possibility that results could have been different had we been able to maintain the original sample size. The reduced sample size also reduced statistical power in the correlational analyses. Despite this, most of the correlations continued to be significant even after strict Bonferroni corrections for multiple comparisons. Still, further investigation with a larger sample size is needed to confirm these results. Second, our inclusion/exclusion criteria restricted our sample to those primarily with motor deficits. Like most other studies of motor function after stroke, we did not recruit individuals who had aphasia, neglect, or could not give informed consent. Thus, our results should be interpreted with caution with regard to individuals with deficits in multiple nonmotor domains.
Our results are important for clinicians and researchers working with individuals with a recent onset of stroke. Our data can be used to help make decisions about which tests to choose when measuring upper extremity function in groups or in individual patients. Studying six tests with published reliability and validity values, we have shown that these tests yield scores that are highly correlated and that the tests are moderately to strongly responsive to change over the course of recovery. Because of these findings, we suggest that when selecting upper extremity function tests for individual patients, the circumstances can dictate the test choice, instead of any one test being considered the gold standard. In other words, the choice of which test to use could be made based on the individual patient and what is available in the therapist's practice setting.
Later we discuss some potential situations and/or limitations that we have identified for using each test. If there is a need to make frequent assessments, choosing grip or pinch strength may be a good option. There is no need to perform both tests because of strong relationships between them (r = 0.83–0.92). From our experience, most clinics have grip or pinch dynamometers available for use. These tests are quick and easy to administer. The limitation to using grip or pinch strength is that they are impairment level measures, which may be useful for more severely affected individuals, but can only provide indirect information on the broader range of upper extremity movement capabilities.
If the goal is to obtain a more comprehensive assessment of upper extremity movement capabilities, then choosing the ARAT or Jebsen test may be a preferred option. Both of these tests evaluate multiple tasks of varying complexity and require controlled movement of the entire upper extremity. Some potential drawbacks about the ARAT and the Jebsen are that they take more time to administer and require specific testing equipment that may not be available in a particular clinic. The Jebsen test is available commercially, but the ARAT must be created/manufactured. Building an ARAT is feasible as the specifications have recently been published.48 There is no need to perform both tests because of strong relationships between them (r = 0.87–0.95).
Finally, the 9HPT and SIS-Hand are good choices because they do not take much time to administer and are easy to obtain. The SIS-Hand can be procured from the Internet18 and could be given to a patient to complete while he or she sits in the waiting room.40 It is useful to note that this test is valid as an interview, completed independently, and from a caregiver report.49 The 9HPT does not take long to administer, can be purchased as a kit, and can be a good choice for use with a patient where additional information about fine motor dexterity is needed. Whichever test the clinician or researcher decides to use, it is important that the same measure is used at each follow-up time point because only through consistent use of the same test, within the same patient, can change be measured over time.
This study provides data to assist clinicians and researchers in making decisions to use specific tests for measuring upper extremity function in people with hemiparesis in the first six months of recovery. Our data establish the relationships between tests and their responsiveness to change when used in people with hemiparesis early after stroke. From this information, choices can be made based on individual patient, clinic, or laboratory specific needs.
The authors thank Lucy Morris, MD, MPH, for her assistance with lesion data analysis, and Dustin Hardwick, DPT, for his assistance with data collection. Subject recruitment was facilitated by the Stroke Registry supported by the James S. McDonnell Foundation 21002032.
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