Ching-Lin Hsieh

Analysis and Comparison of the Psychometric Properties of Three Balance Measures for Stroke Patients

Background and Purpose— This study compared the psychometric properties of 3 clinical balance measures, the Berg Balance Scale (BBS), the Balance subscale of the Fugl-Meyer test (FM-B), and the Postural Assessment Scale for Stroke Patients (PASS), in stroke patients with a broad range of neurological and functional impairment from the acute stage up to 180 days after onset. Methods— One hundred twenty-three stroke patients were followed up prospectively with the 3 balance measures 14, 30, 90, and 180 days after stroke onset (DAS). Reliability (interrater reliability and internal consistency) and validity (concurrent validity, convergent validity, and predictive validity) of each measure were examined. A comparison of the responsiveness of each of the 3 measures was made on the basis of the entire group of patients and 3 separate groups classified by degree of neurological severity. Results— The FM-B and BBS showed a significant floor or ceiling effect at some DAS points, whereas the PASS did not show these effects. The BBS, FM-B, and PASS all had good reliability and validity for patients at different recovery stages after stroke. The results of effect size demonstrated fair to good responsiveness of all 3 measures within the first 90 DAS but, as expected, only a low level of responsiveness at 90 to 180 DAS. The PASS was more responsive to changes in severe stroke patients at the earliest period after stroke onset, 14 to 30 DAS. Conclusions— All 3 measures tested showed very acceptable levels of reliability, validity, and responsiveness for both clinicians and researchers. The PASS showed slightly better psychometric characteristics than the other 2 measures.

Comparison of the psychometric characteristics of the functional independence measure, 5 item Barthel index, and 10 item Barthel index in patients with stroke

Objectives: To compare the reliability, validity, and responsiveness of the motor subscale of the functional independence measure (FIM), the original 10 item Barthel index (BI), and the 5 item short form BI (BI-5) in inpatients with stroke receiving rehabilitation. Methods: 118 inpatients with stroke at a rehabilitation unit participated in the study. The patients were tested with the FIM motor subscale and original BI at admission to the rehabilitation ward and before discharge from the hospital. The distribution, internal consistency, concurrent validity, and responsiveness of each measure were examined. Results: The BI and FIM motor subscale showed acceptable distribution, high internal consistency (α coefficient ≥ 0.84), high concurrent validity (Spearmans correlation coefficient, rs ≥ 0.92, intraclass correlation coefficient (ICC) ≥ 0.83), and high responsiveness (standardised response mean ≥ 1.2, p < 0.001). The BI-5 exhibited a notable floor effect at admission but this was not found at discharge. The BI-5 showed acceptable internal consistency at admission and discharge (α coefficient ≥ 0.71). The concurrent validity of the BI-5 was poor to fair at admission (rs = 0.74, ICC ≤ 0.55) but was good at discharge (rs ≥ 0.92, ICC ≥ 0.74). It is noted that the responsiveness of the BI-5 was as high as that of the BI and the FIM motor subscale. Conclusions: The results showed that the BI and FIM motor subscale had very acceptable and similar psychometric characteristics. The BI-5 appeared to have limited discriminative ability at admission, particularly for patients with severe disability; otherwise the BI-5 had very adequate psychometric properties. These results may provide information useful in the selection of activities of daily living measures for both clinicians and researchers.

Trunk Control as an Early Predictor of Comprehensive Activities of Daily Living Function in Stroke Patients

Background and Purpose— Prediction of activities of daily living (ADL) functions at an early stage after a stroke is critical because it enables clinicians to set treatment programs and goals. The objective of this study was to assess the relationship between trunk control at an early stage and comprehensive ADL function (as assessed by combining basic ADL and instrumental ADL [IADL]) in patients at 6 months after stroke. Methods— A total of 169 stroke patients participated in this prospective study. Trunk control was measured with the use of the trunk control items of the Postural Assessment Scale for Stroke Patients (PASS-TC). In addition to the PASS-TC score, age, sex, type of stroke, side of hemiparesis, urinary incontinence, limb paresis (measured by the Fugl-Meyer motor test), balance (measured by the Fugl-Meyer balance test), and basic ADL (measured by the Barthel Index) were also selected as predictor variables. These variables were assessed at 14 days after stroke or earlier. The Barthel Index and Frenchay Activities Index (measuring IADL) were administered at 6 months after stroke. The sum of the standardized Barthel Index and standardized Frenchay Activities Index scores was used to assess comprehensive ADL function. Results— Multivariable stepwise linear regression analysis showed that PASS-TC score, age, Fugl-Meyer motor test score, and Barthel Index score (listed by the order of forward selection) were the strongest predictors of comprehensive ADL function. These results were internally validated with the use of the bootstrap resampling technique. The PASS-TC score alone accounted for 45% of the variance in predicting comprehensive ADL function. Results also indicated that the PASS-TC score had slightly more power in predicting comprehensive ADL function than either the Fugl-Meyer motor test score or Barthel Index score. Conclusions— The findings of this study provide strong evidence of the predictive value of trunk control on comprehensive ADL function in stroke patients. The results imply that early assessment and management of trunk control after stroke should be emphasized.

Test-Retest Reproducibility and Smallest Real Difference of 5 Hand Function Tests in Patients With Stroke

Objective. To investigate the test-retest reproducibility and smallest real difference (SRD) of 3 hand strength tests (grip, palmar pinch, and lateral pinch) and 2 dexterity tests (the Box and Block test [BBT] and the Nine Hole Peg test [NHPT]) in patients with stroke. Methods. The 5 tests were administered on 62 stroke patients in 2 sessions, 3 to 7 days apart. The intraclass correlation coefficient (ICC) was used to determine the level of reproducibility between measurements on 2 sessions. The SRD was used to determine the extent of measurement error because of chance variation in individual patients. SRD percentage (SRD relative to mean score) was used to compare test-retest reliability across tests. We analyzed the group as a whole, then in 2 subgroups (hand spasticity vs none). Results. The test-retest reproducibility of all 5 tests was high for all the patients, with ICCs ranging from 0.85 to 0.98. The SRDs for the more/less affected hand were: 2.9/4.7 kg for the grip test; 1.2/1.3 kg for the palmar pinch test; 1.4/1.0 kg for the lateral pinch test; 5.5/7.8 blocks/minute for the BBT; and 32.8/6.2 seconds for the NHPT. Unacceptably high SRD percentages (>30%) were found for the affected hand using the NHPT (54%), palmar pinch (35%), and lateral pinch (34%). When comparing these indices for participants with spasticity versus none for all 5 tests, the ICCs were lower and the SRD and SRD percentage were higher for the spasticity group. Conclusions. All 5 tests demonstrated satisfactory test-retest reproducibility for a diverse group of patients with stroke. However, all tests showed higher levels of measurement error when performed with the more affected hand and in patients with hypertonicity of that hand. Thus, baseline and postrehabilitation change scores using these common tests of strength and dexterity must be interpreted with some caution, especially in poorly controlled clinical trials. Repeated measures ought to be incorporated to examine reliability within a trial that includes participants with a hypertonic hand.

Minimal Detectable Change of the Timed “Up & Go” Test and the Dynamic Gait Index in People With Parkinson Disease

Background The minimal detectable change (MDC) is the smallest amount of difference in individual scores that represents true change (beyond random measurement error). The MDCs of the Timed “Up & Go” Test (TUG) and the Dynamic Gait Index (DGI) in people with Parkinson disease (PD) are largely unknown, limiting the interpretability of the change scores of both measures. Objective The purpose of this study was to estimate the MDCs of the TUG and the DGI in people with PD. Design This investigation was a prospective cohort study. Methods Seventy-two participants were recruited from special clinics for movement disorders at a university hospital. Their mean age was 67.5 years, and 61% were men. All participants completed the TUG and the DGI assessments twice, about 14 days apart. The MDC was calculated from the standard error of measurement. The percentage MDC (MDC%) was calculated as the MDC divided by the mean of all scores for the sample. Furthermore, the intraclass correlation coefficient was used to examine the reproducibility between testing sessions (test-retest reliability). Results The respective MDC and MDC% of the TUG were 3.5 seconds and 29.8, and those of the DGI were 2.9 points and 13.3. The test-retest reliability values for the TUG and the DGI were high; the intraclass correlation coefficients were .80 and .84, respectively. Limitations The study sample was a convenience sample, and the participants had mild to moderately severe PD. Conclusions The results showed that the TUG and the DGI have generally acceptable random measurement error and test-retest reliability. These findings should help clinicians and researchers determine whether a change in an individual patient with PD is a true change.

Psychometric Comparisons of 4 Measures for Assessing Upper-Extremity Function in People With Stroke

Background: Functional limitation of the upper extremities is common in patients with stroke. An upper-extremity measure with sound psychometric properties is indispensable for clinical and research use. Objective: The purpose of this study was to compare the psychometric properties of 4 clinical measures for assessing upper-extremity motor function in people with stroke: the upper-extremity subscale of the Fugl-Meyer Motor Test (UE-FM), the upper-extremity subscale of the Stroke Rehabilitation Assessment of Movement, the Action Research Arm Test (ARAT), and the Wolf Motor Function Test. Design: This was a prospective, longitudinal study. Methods: Fifty-three people with stroke were evaluated with the 4 measures at 4 time points (14, 30, 90, and 180 days after stroke). Thirty-five participants completed all of the assessments. The ceiling and floor effects, validity (concurrent validity and predictive validity), and responsiveness of each measure were examined. Interrater reliability and test-retest reliability also were examined. Results: All measures, except for the UE-FM, had significant floor effects or ceiling effects at one or more time points. The Spearman ρ correlation coefficient for each pair of the 4 measures was ≥.81, indicating high concurrent validity. The predictive validity of the 4 measures was satisfactory (Spearman ρ, ≥.51). The responsiveness of the 4 measures at 14 to 180 days after stroke was moderate (.52 ≤ effect size ≤ .79). The 4 measures had good interrater reliability (intraclass correlation coefficient [ICC], ≥.92) and test-retest reliability (ICC, ≥.97). Only the minimal detectable changes of the UE-FM (8% of the highest possible score) and the ARAT (6%) were satisfactory. Limitations: The sample size was too small to conduct data analysis according to type or severity of stroke. In addition, the timed component of the Wolf Motor Function Test was not used in this study. Conclusions: All 4 measures showed sufficient validity, responsiveness, and reliability in participants with stroke. The UE-FM for assessing impairment and the ARAT for assessing disability had satisfactory minimal detectable changes, supporting their utility in clinical settings.

Reliability, Sensitivity to Change, and Responsiveness of the Peabody Developmental Motor Scales–Second Edition for Children With Cerebral Palsy

Background and Purpose. The psychometric properties of the Peabody Developmental Motor Scales–Second Edition (PDMS-2), a revised motor test to assess both gross motor and fine motor composites in children with cerebral palsy (CP), are largely unknown. The purpose of this study was to examine the test-retest reliability and the responsiveness of the PDMS-2 for children with CP. Subjects. A sample of 32 children who had CP (age=27–64 months) and who received intervention participated in this study. Methods. The PDMS-2 was administered to each child 3 times (at the beginning of the study, at 1 week, and at 3 months later) by a physical therapist. The agreement between the first 2 measurements was used to examine the reliability. The change between the first and the third measurements was used to examine the responsiveness. Results. The composite scores on the PDMS-2 had good test-retest reliability (intraclass correlation coefficient=.88–1.00). The sensitivity-to-change coefficients ranged from 1.6 to 2.1, and the responsiveness coefficients ranged from 1.7 to 2.3. Discussion and Conclusion. Our results provide strong evidence that the 3 composites of the PDMS-2 had high test-retest reliability and acceptable responsiveness. The PDMS-2 can be used as an evaluative motor measure for children with CP and aged 2 to 5 years.

Psychometric Comparisons of 3 Functional Ambulation Measures for Patients With Stroke

Background and Purpose— We compared the test-retest reliability, validity, and responsiveness of the Dynamic Gait Index, the 4-item Dynamic Gait Index, and the Functional Gait Assessment for assessment of walking in patients with stroke. Methods— Forty-five outpatients participating in the validity and responsiveness study were tested using the 3 walking measures as well as the 10-m walk test, Barthel Index, and Postural Assessment Scale for Stroke Patients. We tested them during the first week, then again after 2 months and 5 months of therapy. Another 48 chronic patients completed the 3 measures twice, 1 week apart, in the test-retest reliability study. Results— Thirty-five participants completed 3 time-point assessments. The Functional Gait Assessment showed the least floor and ceiling effects, indicating it has the best discriminative ability for patients with stroke with high walking function. We found the 3 measures were highly correlated with each other, indicating excellent concurrent validity, and all measures at the first week of therapy were moderately to highly correlated with the Barthel Index scores at 5 months, indicating good predictive validity. Responsiveness of the 3 measures was moderate during a 5-month period, and all showed good test-retest reliability. The minimal detectable changes between tests indicate acceptable random error. Conclusions— All 3 measures showed sufficient validity, responsiveness, and reliability for assessment of walking function in patients with stroke undergoing rehabilitation, but the Functional Gait Assessment is recommended for its psychometric properties.

The relative and absolute reliability of two balance performance measures in chronic stroke patients

Purpose. To examine the relative reliability and absolute reliability of the Berg Balance Scale (BBS) and the Postural Assessment Scale for Stroke Patients (PASS) in chronic stroke patients. Method. A total of 52 mild to moderate stroke patients, who had a stroke more than 6 months previously, participated in the study. Both balance measures were administered twice, seven days apart, to the patients. A relative reliability index (intra-class correlation coefficient, ICC2,1) was used to examine the level of agreement between test and retest. Absolute reliability indices, including the Bland and Altman method, the standard error of measurement (SEM), and the smallest real differences (SRD), were used to define the extent to which a balance score varies on test-retest measurements. Results. Test-retest agreements were high (ICC2,1: BBS = 0.98; PASS = 0.97), indicating excellent agreement from a relative perspective. The SEM of the BBS and PASS, representing the smallest change threshold that indicates a real improvement for a group of individuals, were 2.4 and 1.1, respectively. The SRD of the BBS and PASS were 6.7 and 3.2, respectively, exhibiting the smallest change threshold that indicates a real improvement for a single individual. Conclusions. The test-retest agreements of the BBS and PASS were high in mild to moderate chronic stroke patients. The thresholds of both measures to detect real change are acceptable in research and clinical settings.

Responsiveness of two upper extremity function instruments for stroke inpatients receiving rehabilitation

Objective: To compare the responsiveness of the Action Research Arm test (ARAT) and the upper extremity section of the Motor Assessment Scale (UE-MAS) in assessing the recovery of upper extremity function in stroke inpatients receiving rehabilitation. Subjects: Forty-eight stroke inpatients. Setting: The physical medicine and rehabilitation department of a medical centre. Design: The patients were tested at admission and at discharge from the department. Methods: Various indices, including effect size d, Wilcoxon test and Spearmans rho, were used to assess responsiveness. The change in score of the upper extremity subscale of the Fugl-Meyer scale was used as the external criterion. Results: The responsiveness indices of both total scores of the ARAT and UE-MAS are generally moderate and similar (d = 0.52, Wilcoxon Z = 5.03, p < 0.001 and rho = 0.66 for the ARAT; d = 0.45, Z = 4.54, p < 0.001 and rho = 0.7 for the UE-MAS). Responsiveness indices are small to moderate and similar in each of the subscales of both instruments. Conclusion: The results of this study support the value of the ARAT and UE-MAS for measuring recovery of upper extremity function in stroke patients.