Gong-Hong Lin

Improving the utility of the Brunnstrom recovery stages in patients with stroke: Validation and quantification

Abstract The Brunnstrom recovery stages (the BRS) consists of 2 items assessing the poststroke motor function of the upper extremities and 1 assessing the lower extremities. The 3 items together represent overall motor function. Although the BRS efficiently assesses poststroke motor functions, a lack of rigorous examination of the psychometric properties restricts its utility. We aimed to examine the unidimensionality, Rasch reliability, and responsiveness of the BRS, and transform the raw sum scores of the BRS into Rasch logit scores once the 3 items fitted the assumptions of the Rasch model. We retrieved medical records of the BRS (N = 1180) from a medical center. We used Rasch analysis to examine the unidimensionality and Rasch reliability of both upper-extremity items and the 3 overall motor items of the BRS. In addition, to compare their responsiveness for patients (n = 41) assessed with the BRS and the Stroke Rehabilitation Assessment of Movement (STREAM) on admission and at discharge, we calculated the effect size (ES) and standardized response mean (SRM). The upper-extremity items and overall motor items fitted the assumptions of the Rasch model (infit/outfit mean square = 0.57–1.40). The Rasch reliabilities of the upper-extremity items and overall motor items were high (0.91–0.92). The upper-extremity items and overall motor items had adequate responsiveness (ES = 0.35–0.41, SRM = 0.85–0.99), which was comparable to that of the STREAM (ES = 0.43–0.44, SRM = 1.00–1.13). The results of our study support the unidimensionality, Rasch reliability, and responsiveness of the BRS. Moreover, the BRS can be transformed into an interval-level measure, which would be useful to quantify the extent of poststroke motor function, the changes of motor function, and the differences of motor functions in patients with stroke.

Psychometric properties of the Five-Digit Test in patients with stroke

Abstract Purpose: To examine the ecological validity, predictive validity, and responsiveness of the Five Digit Test (FDT) in patients with stroke. Methods: We included inpatients with stroke (n = 144, 114 and 105 in the ecological validity, predictive validity, and responsiveness analysis, respectively) in the study. At admission, the FDT and Barthel Index (BI) were assessed; at discharge, the FDT, BI, Postural Assessment Scale for Stroke Patients (PASS), and Mobility Subscale of the Stroke Rehabilitation Assessment of Movement (MO-STREAM) were assessed. Results: In the ecological validity analysis, the scores of the selective and alternating attention indices of the FDT were moderately correlated with those of the BI at admission and discharge (Spearman ρ = –0.38 to –0.45). In the predictive validity analysis, the scores of the two attention indices of the FDT at admission were moderately correlated with the scores of the BI, PASS, and MO-STREAM at discharge (ρ = –0.33 to –0.45). In the responsiveness analysis, the two attention indices of the FDT between admission and discharge had large differences (success rate difference = 0.56–0.67, Wilcoxon Z = –5.90 to –6.60). Conclusion: Our results indicate that the selective and alternating attention indices of the FDT have acceptable ecological validity, predictive validity, and good responsiveness in patients with stroke. Implications for Rehabilitation The Five Digit Test (FDT), an efficient and culture-free assessment tool, has been used to assess selective attention and alternating attention The selective index and alternating attention index of the FDT showed acceptable ecological validity, predictive validity, and good responsiveness in patients with stroke.

DEVELOPMENT OF A COMPUTERIZED DIGIT VIGILANCE TEST AND VALIDATION IN PATIENTS WITH STROKE

OBJECTIVES To develop a computerized Digit Vigilance Test (C-DVT) with lower random measurement error than that of the DVT and to examine the concurrent validity, ecological validity, and test-retest reliability of the C-DVT in patients with stroke. DESIGN A cross-sectional study. PATIENTS Forty-four patients with stroke. METHODS We developed and tested the C-DVT. To examine the psychometric properties, the participants completed both the C-DVT and DVT twice with a 14-day interval. RESULTS We developed the C-DVT on the basis of expert input and examinee feedback. C-DVT scores were highly correlated with DVT scores (ρ = 0.75), supporting the concurrent validity. The C-DVT scores were moderately correlated with the scores of the Barthel Index and the Activities of Daily Living Computerized Adaptive Testing system (ρ = -0.60~-0.57), supporting the ecological validity. The test-retest agreement of the C-DVT was excellent (intra-class correlation coefficient = 0.92). The random measurement error of the C-DVT (minimal detectable change percent change (MDC%) = 15.4%) was acceptable and lower than that of the DVT (33.0%). The practice effects of the C-DVT were statistically significant, but the effect size d was small (0.15). CONCLUSION A C-DVT with a limited amount of random measurement error was developed. These preliminary findings show that the C-DVT demonstrates satisfactory concurrent validity, ecological validity, and test-retest reliability in patients with stroke.

Refining 3 Measures to Construct an Efficient Functional Assessment of Stroke

Background and Purpose— The Fugl-Meyer Assessment motor scale, Postural Assessment Scale for Stroke patients, and Barthel Index are widely used to assess patients’ upper extremity and lower extremity motor function, balance, and basic activities of daily living after stroke, respectively. However, these 3 measures (72 items) require a great amount of time for assessment. Therefore, we aimed to develop an efficient test, the Functional Assessment of Stroke (FAS). Methods— The FAS was constructed from 4 short-form tests of the Fugl-Meyer Assessment-upper extremity, Fugl-Meyer Assessment-lower extremity, Postural Assessment Scale for Stroke patients, and Barthel Index based on the results of Rasch analyses and the items’ content. We examined the psychometric properties of the FAS, including Rasch reliability, concurrent validity, convergent validity, known-group validity, and responsiveness. Results— The FAS contained 29 items (10, 6, 8, and 5 items for the 4 short-form tests, respectively). The FAS demonstrated high Rasch reliability (0.92–0.94), concurrent validity (r=0.90–0.97 with the original tests), convergent validity (r=0.62–0.94 with the 5-scale Fugl-Meyer Assessment), and known-group validity (significant difference in the FAS scores among 3 groups of disability levels; P<0.001). In addition, the responsiveness of the FAS (standardized response mean=0.55–1.93) was similar or significantly superior to those of the original tests (standardized response mean=0.46–1.39). Conclusions— The FAS contains 29 items and has sufficient Rasch reliability, validities, and responsiveness. These findings support that the FAS is efficient for reliably and validly assessing upper extremity/lower extremity motor function, balance, and basic activities of daily living and for sensitively detecting change in those functions in patients with stroke.

Test-retest reliabilities and minimal detectable change of two simplified 3-level balance measures in patients with stroke.

BACKGROUND The 3-point Berg Balance Scale (BBS-3P) and 3-point Postural Assessment Scale for Stroke Patients (PASS-3P) were simplified from the BBS and PASS to overcome the complex scoring systems. The BBS-3P and PASS-3P were more feasible in busy clinical practice and showed similarly sound validity and responsiveness to the original measures. However, the reliability of the BBS-3P and PASS-3P is unknown limiting their utility and the interpretability of scores. AIM We aimed to examine the test-retest reliability and minimal detectable change (MDC) of the BBS-3P and PASS-3P in patients with stroke. DESIGN Cross-sectional study. SETTING The rehabilitation departments of a medical center and a community hospital. POPULATION A total of 51 chronic stroke patients (64.7% male). METHODS Both balance measures were administered twice 7 days apart. The test-retest reliability of both the BBS-3P and PASS-3P were examined by intraclass correlation coefficients (ICC). The MDC and its percentage over the total score (MDC%) of each measure was calculated for examining the random measurement errors. RESULTS The ICC values of the BBS-3P and PASS-3P were 0.99 and 0.97, respectively. The MDC% (MDC) of the BBS-3P and PASS-3P were 9.1% (5.1 points) and 8.4% (3.0 points), respectively, indicating that both measures had small and acceptable random measurement errors. CONCLUSIONS Our results showed that both the BBS-3P and the PASS-3P had good test-retest reliability, with small and acceptable random measurement error. These two simplified 3-level balance measures can provide reliable results over time. CLINICAL REHABILITATION IMPACT Our findings support the repeated administration of the BBS-3P and PASS-3P to monitor the balance of patients with stroke. The MDC values can help clinicians and researchers interpret the change scores more precisely.

Development of a Tablet-based symbol digit modalities test for reliably assessing information processing speed in patients with stroke.

Abstract Purpose: To develop a Tablet-based Symbol Digit Modalities Test (T-SDMT) and to examine the test–retest reliability and concurrent validity of the T-SDMT in patients with stroke. Methods: The study had two phases. In the first phase, six experts, nine college students and five outpatients participated in the development and testing of the T-SDMT. In the second phase, 52 outpatients were evaluated twice (2 weeks apart) with the T-SDMT and SDMT to examine the test–retest reliability and concurrent validity of the T-SDMT. Results: The T-SDMT was developed via expert input and college student/patient feedback. Regarding test–retest reliability, the practise effects of the T-SDMT and SDMT were both trivial (d=0.12) but significant (p≦0.015). The improvement in the T-SDMT (4.7%) was smaller than that in the SDMT (5.6%). The minimal detectable changes (MDC%) of the T-SDMT and SDMT were 6.7 (22.8%) and 10.3 (32.8%), respectively. The T-SDMT and SDMT were highly correlated with each other at the two time points (Pearson’s r=0.90–0.91). Conclusions: The T-SDMT demonstrated good concurrent validity with the SDMT. Because the T-SDMT had a smaller practise effect and less random measurement error (superior test–retest reliability), it is recommended over the SDMT for assessing information processing speed in patients with stroke. Implications for Rehabilitation The Symbol Digit Modalities Test (SDMT), a common measure of information processing speed, showed a substantial practise effect and considerable random measurement error in patients with stroke. The Tablet-based SDMT (T-SDMT) has been developed to reduce the practise effect and random measurement error of the SDMT in patients with stroke. The T-SDMT had smaller practise effect and random measurement error than the SDMT, which can provide more reliable assessments of information processing speed.

Validation of the Integrated Model of Health Literacy in Patients With Breast Cancer

Background Health literacy (HL) enables patients with breast cancer to actively participate in health decisions and promote positive health outcomes. The Integrated Model of Health Literacy (IMHL), defined as the personal, situational, and societal/environmental factors that predict the level of HL that can influence health outcomes, incorporates the concepts, determinants, and consequences of HL. Objective The aim of this study was to examine the mechanisms and completeness of the IMHL in patients with breast cancer. Methods Five hundred eleven Taiwanese patients were prospectively recruited. We conducted structural equation modeling to confirm and modify the predictive pathways linking the HL-related factors in the IMHL. Results Results on a total of 511 breast cancer patients showed good model-data fit. An alternative model revealed better fit with 2 pathways added from cancer stage to self-rated health and from cancer duration to shared decision making. Both the original model and alternative model modification revealed that only personal determinants (age, education, cancer stage, and duration) and not situational determinants (marital status) or social/environmental determinants (residence and occupation) could significantly predict the 3 domains of HL. Theorized consequences of HL were significantly influenced by HL in both models. Conclusions Our results partially support the relationships proposed in the IMHL for patients with breast cancer as only personal determinants significantly predicted HL. Implications for Practice Understanding the predictive pathways of the integrated HL model could help clinicians to tailor HL interventions using a patient’s personal determinants to facilitate participation in decision making and promote health for breast cancer patients.

Reducing the time needed to administer a sustained attention test in patients with stroke

Administering a sustained attention test often takes a lengthy time, which can hamper routine assessments in clinical settings. Therefore, we first proposed a method to reduce the time needed for administering a sustained attention test (the Computerized Digit Vigilance Test, C-DVT). The method was to retrieve 5 segments from different trial positions of the original C-DVT testing. Then we compared the concurrent validity, convergent validity, and random measurement error of the examinees’ performance on these segments to find the segment with better psychometric properties. The 5 segments were as follows: the first 50% of testing, the 21st~50th percentile of testing, the first 60% of testing, the 31st~60th percentile of testing, and the 36th~65th percentile of testing. Then we compared the validities and random measurement error of the examinees’ performance on these segments. Ninety patients with stroke participated in the validity study, and 44 of them participated in the random measurement error study. The patients’ scores on the 5 segments were highly correlated with those of the C-DVT (Pearson’s r ≥ 0.98), indicating excellent concurrent validity. The patients’ scores on the 5 segments were moderately correlated with those of the Tablet-based Symbol Digit Modalities Test (Pearson’s r = -0.51~-0.48), indicating sufficient convergent validity. The amounts of random measurement error (percent standard error of measurement) were all limited: 5.1% for the C-DVT, 6.6% for the first 50% of testing, 6.0% for the 21st~50th percentile of testing, 6.1% for the first 60% of testing, 6.0% for the 31st~60th percentile of testing, and 6.1% for the 36th~65th percentile of testing. The patients needed on average 3~4 minutes to complete all the aforementioned testing. The patients’ scores on the 5 segments showed excellent concurrent validity, sufficient convergent validity, and limited amounts of random measurement error in patients with stroke. We suggest the 31st~60th percentile of testing segment for users because it had the lowest amount of random measurement error and can reduce the time needed for formal testing by about 40%.

Responsiveness and predictive validity of the computerized digit vigilance test in patients with stroke

Abstract Purpose: To investigate the responsiveness and predictive validity of the computerized digit vigilance test (C-DVT) in inpatients receiving rehabilitation following stroke. Methods: Forty-nine patients completed the C-DVT and the Barthel Index (BI) after admission to and before discharge from the rehabilitation ward. The standardized response mean (SRM) was used to examine the responsiveness of the C-DVT. We used a paired t-test to determine the statistical significance of the changes in scores on the C-DVT. We estimated the predictive validity of the C-DVT with the Pearson correlation coefficient (r) to investigate the association between the scores of the C-DVT at admission and the scores of the BI at discharge. Results: Our data showed a small SRM (−0.31) and a significant difference (paired t-test, p = 0.034) between the C-DVT scores at admission and discharge. These findings indicate that the C-DVT can appropriately detect changes in sustained attention. In addition, we found a moderate association (r = 0.48) between the scores of the C-DVT at admission and the scores of the BI at discharge, suggesting the sufficient predictive validity of the C-DVT. Conclusions: Our results showed that the C-DVT had adequate responsiveness and sufficient predictive validity in inpatients receiving rehabilitation following stroke. Implications for rehabilitation The computerized digit vigilance test (C-DVT) had adequate responsiveness to be an outcome measure for assessing the sustained attention in inpatients receiving rehabilitation after stroke. The C-DVT had sufficient predictive validity to predict daily function in inpatients receiving rehabilitation after stroke.

A Reliable and Valid Assessment of Sustained Attention for Patients With Schizophrenia: The Computerized Digit Vigilance Test

Objective The purposes of this study were to examine the test-retest reliability, concurrent validity, and ecological validity of the Computerized Digit Vigilance Test (C-DVT) in patients with schizophrenia. Method Each participant was assessed four times, with 1-week intervals. In each assessment, the participants completed both the C-DVT and the original DVT. The participants were also assessed using the Lawton Instrumental Activities of Daily Living Scale (LIADL) and the Personal and Social Performance Scale (PSP). Results Forty-nine participants were recruited in this study. The results showed that the test-retest agreement of the C-DVT was good-to-excellent (intraclass correlation coefficient = 0.71-0.89). The random measurement errors of the C-DVT were acceptable (percentages of minimal detectable change = 12.9%-24.1%). The practice effect of the C-DVT reached a plateau after three assessments (effect size <0.20). The concurrent validity of the C-DVT was good (r = .75-.79 with DVT) when we controlled for the randomized administration order of the two tests. The ecological validity of the C-DVT was good (r = -.44 with the LIADL; r = -.45 with the PSP). Conclusions The C-DVT had acceptable test-retest reliability, sound concurrent validity, and sound ecological validity in patients with schizophrenia. These findings indicate that the C-DVT has the potential to be a reliable and valid test of sustained attention in patients with schizophrenia.