Yi-Jing Huang

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 (Nu200a=u200a1180) 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 (nu200a=u200a41) 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 squareu200a=u200a0.57–1.40). 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 (ESu200a=u200a0.35–0.41, SRMu200a=u200a0.85–0.99), which was comparable to that of the STREAM (ESu200a=u200a0.43–0.44, SRMu200a=u200a1.00–1.13). 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.

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.

BACKGROUNDnThe 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.nnnAIMnWe aimed to examine the test-retest reliability and minimal detectable change (MDC) of the BBS-3P and PASS-3P in patients with stroke.nnnDESIGNnCross-sectional study.nnnSETTINGnThe rehabilitation departments of a medical center and a community hospital.nnnPOPULATIONnA total of 51 chronic stroke patients (64.7% male).nnnMETHODSnBoth 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.nnnRESULTSnThe 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.nnnCONCLUSIONSnOur 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.nnnCLINICAL REHABILITATION IMPACTnOur 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.

Comparison of the Responsiveness of the Long-Form and Simplified Stroke Rehabilitation Assessment of Movement: Group- and Individual-Level Analysis

Background The group-level responsiveness of the original, 30-item Stroke Rehabilitation Assessment of Movement measure (STREAM-30) is similar to that of the simplified STREAM (STREAM-15), even though the STREAM-30 has twice as many items as those of the STREAM-15. Objective The purpose of this study was to compare the responsiveness of the STREAM-30 and STREAM-15 at both group and individual levels in patients with stroke. For the latter level, the Rasch-calibrated 27-item STREAM (STREAM-27) was used because the individual-level indexes of the STREAM-30 could not be estimated. Design A repeated-measurements design was used. In total, 195 patients were assessed with the STREAM-30 at both admission and discharge. Methods The Rasch scores of the STREAM-27 and STREAM-15 were estimated from the participants responses on the STREAM-30. We calculated the paired t-test value, effect size, and standardized response mean as the indexes of group-level responsiveness. The significance of change for each participant was estimated as the individual-level responsiveness index, and the paired t test and test of marginal homogeneity were used for individual-level comparisons between the STREAM-27 and STREAM-15. Results At the group level, the STREAM-30, STREAM-27, and STREAM-15 showed sufficient and comparable responsiveness. At the individual level, the STREAM-27 detected significantly more participants with significant improvement and fewer participants with no change or deterioration compared with the STREAM-15. Limitations Few patients with subacute stroke showed deterioration at discharge, so the abilities of the 2 measures to detect deterioration remain inconclusive. Conclusions The STREAM-27 detected more participants with significant recovery compared with the STREAM-15, although the group-level responsiveness of the 2 measures was the same. The STREAM-27 is recommended as an outcome measure to demonstrate the treatment effects of movement and mobility for patients with stroke.

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.

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

ObjectivenThe 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.nnnMethodnEach 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).nnnResultsnForty-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).nnnConclusionsnThe 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.

Comparison of construct validity of two short forms of Stroke-Specific Quality of Life scale

Background No studies have compared the 2-factor structures of Wong’s and Post’s versions of the short-form Stroke-Specific Quality of Life (i.e., 12-item SSQOL) scale. This study compared the construct validity of 2 short-forms of the 12-item-SSQOL (not the 12-domain-SSQOL). Methods Data were obtained from a previous validation study of the original 49-item SSQOL in 263 patients. Construct validity was tested by confirmatory factor analysis (CFA) to examine whether the two-factor structure, including psychosocial and physical domains, was supported in both versions. The CFA tested the data-model fit by indices: chi-square χ2/df ratio, root mean square error of approximation (RMSEA), comparative fit index (CFI), nonnormative fit index (NNFI), standard root mean square residual (SRMR), and parsimony normed fit index (PNFI). Item factor loadings (cutoffs: .50) were examined. Model fit was compared using Akaike information criterion (AIC) and consistent AIC (i.e., CAIC) values. Results All model fit indices for Post’s version fell within expected ranges: χ2/df ratio = 2.02, RMSEA = 0.05, CFI = 0.97, NNFI = 0.97, SRMR = 0.06, and PNFI = 0.76. In the psychosocial domain, the item factor loadings ranged from 0.46 to 0.63. In the physical domain, all items (except the language and vision items) had acceptable factor loadings (0.68 to 0.88). However, in Wong’s version, none of the model indices met the criteria for good fit. In model fit comparisons, Post’s version had smaller AIC and CAIC values than did Wong’s version. Conclusions All fit indices supported Post’s version, but not Wong’s version. The construct validity of Post’s version with a 2-factor structure was confirmed, and this version of the 12-item SSQOL is recommended.

Development of a computerized adaptive testing system of the Functional Assessment of Stroke

OBJECTIVEnTo develop a computerized adaptive testing system of the Functional Assessment of Stroke (CAT-FAS) to assess upper- and lower-extremity (UE/LE) motor function, postural control, and basic activities of daily living with optimal efficiency and without sacrificing psychometric properties in patients with stroke.nnnDESIGNnSimulation study.nnnSETTINGnOne rehabilitation unit in a medical center.nnnPARTICIPANTSnPatients with subacute stroke (N=301; mean age, 67.3±10.9; intracranial infarction, 74.5%).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnThe UE and LE subscales of the Fugl-Meyer Assessment, Postural Assessment Scale for Stroke Patients, and Barthel Index.nnnRESULTSnThe CAT-FAS adopting the optimal stopping rule (limited reliability increase of <.010) had good Rasch reliability across the 4 domains (.88-.93) and needed few items for the whole administration (8.5 items on average). The concurrent validity (CAT-FAS vs original tests, Pearson r=.91-.95) and responsiveness (standardized response mean, .65-.76) of the CAT-FAS were good in patients with stroke.nnnCONCLUSIONSnWe developed the CAT-FAS, and our results support that the CAT-FAS has sufficient efficiency, reliability, concurrent validity, and responsiveness in patients with stroke. The CAT-FAS can be used to simultaneously assess patients functions of UE, LE, postural control, and basic activities of daily living using, on average, no more than 10 items; this efficiency is useful in reducing the assessment burdens for both clinicians and patients.

Development of a Social Functioning Assessment using Computerized Adaptive Testing for Patients with Stroke

OBJECTIVEnTo develop a computerized adaptive test of social functioning (Social-CAT) for patients with stroke.nnnDESIGNnThis study contained 2 phases. First, a unidimensional item bank was formed using social-related items with sufficient item fit (ie, infit and outfit mean square [MNSQ]). The social-related items were selected from 3 commonly used patient-reported quality-of-life measures. Items with differential item functioning (DIF) of sex were deleted. Second, we performed simulations to determine the best set of stopping rules with both high reliability and efficiency. The participants responses to the items were extracted from a previous study.nnnSETTINGnRehabilitation wards and departments of rehabilitation/neurology of 5 general hospitals.nnnPARTICIPANTSnPatients (N=263) with stroke (47.1% were inpatients).nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASUREnSocial-CAT.nnnRESULTSnThe unidimensionality of the 24 selected items was supported (infit and outfit MNSQs =0.8-1.2). One item had DIF of sex and was deleted. The item bank was composed of the remaining 23 items. With the best set of stopping rules (person reliability ≥.90 or limited reliability increased ≤.001), the Social-CAT used on average 10 items to achieve sufficient reliability (average person reliability =.88; 81.0% of the patients with reliability ≥.90).nnnCONCLUSIONSnThe Social-CAT appears to be a unidimensional measure with acceptable reliability and efficiency, and it could be useful for both clinicians and patients in time-pressed clinical settings.

Group- and Individual-Level Responsiveness of the 3-Point Berg Balance Scale and 3-Point Postural Assessment Scale for Stroke Patients

OBJECTIVESnTo examine both group- and individual-level responsiveness of the 3-point Berg Balance Scale (BBS-3P) and 3-point Postural Assessment Scale for Stroke Patients (PASS-3P) in patients with stroke, and to compare the responsiveness of both 3-point measures versus their original measures (Berg Balance Scale [BBS] and Postural Assessment Scale for Stroke Patients [PASS]) and their short forms (short-form Berg Balance Scale [SFBBS] and short-form Postural Assessment Scale for Stroke Patients [SFPASS]) and between the BBS-3P and PASS-3P.nnnDESIGNnData were retrieved from a previous study wherein 212 patients were assessed at 14 and 30 days after stroke with the BBS and PASS.nnnSETTINGnMedical center.nnnPARTICIPANTSnPatients (N=212) with first onset of stroke within 14 days before hospitalization.nnnINTERVENTIONSnNot applicable.nnnMAIN OUTCOME MEASURESnGroup-level responsiveness was examined by the standardized response mean (SRM), and individual-level responsiveness was examined by the proportion of patients whose change scores exceeded the minimal detectable change of each measure. The responsiveness was compared using the bootstrap approach.nnnRESULTSnThe BBS-3P and PASS-3P had good group-level (SRM, .60 and SRM, .56, respectively) and individual-level (48.1% and 44.8% of the patients with significant improvement, respectively) responsiveness. Bootstrap analyses showed that the BBS-3P generally had superior responsiveness to the BBS and SFBBS, and the PASS-3P had similar responsiveness to the PASS and SFPASS. The BBS-3P and PASS-3P were equally responsive to both group and individual change.nnnCONCLUSIONSnThe responsiveness of the BBS-3P and PASS-3P was comparable or superior to those of the original and short-form measures. We recommend the BBS-3P and PASS-3P as responsive outcome measures of balance for individuals with stroke.