Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as Measures of Upper-Extremity Motor Weakness After Stroke

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ORIGINAL ARTICLE

Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as Measures of Upper-Extremity Motor Weakness After Stroke Meheroz H. Rabadi, MD, MRCPI, Freny M. Rabadi, BSc ABSTRACT. Rabadi MH, Rabadi FM. Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as measures of upper-extremity motor weakness after stroke. Arch Phys Med Rehabil 2006;87:962-6. Objective: To assess the relative responsiveness of 2 commonly used upper-extremity motor scales, the Action Research Arm Test (ARAT) and the Fugl-Meyer Assessment (FMA), in evaluating recovery of upper-extremity function after an acute stroke in patients undergoing inpatient rehabilitation. Design: Prospective. Setting: An acute stroke rehabilitation unit. Participants: One hundred four consecutive admissions (43 men, 61 women; mean age ⫾ standard deviation, 72⫾13y) to a rehabilitation unit 16⫾9 days after acute stroke. Interventions: Not applicable. Main Outcome Measures: The following assessments were completed within 72 hours of admission and 24 hours before discharge: ARAT, upper-extremity motor domain of the FMA, National Institutes of Health Stroke Scale, FIM instrument total score, and FIM activities of daily living (FIM-ADL) subscore. Results: The Spearman rank correlation statistic indicated that the 2 upper-limb motor scales (ARAT, FMA) correlated highly with one another, both on admission (␳⫽.77, P⬍.001) and on discharge (␳⫽.87, P⬍.001). The mean change in score from admission to discharge was 10⫾15 for the ARAT and 10⫾13 for the FMA motor score. The responsiveness to change as measured by the standard response mean was .68 for the ARAT and .74 for the FMA motor score. The Spearman rank correlation of each upper-limb motor scale with the FIMADL at the time of admission was as follows: ARAT, ␳ equal to .32 (P⬍.001) and FMA motor score, ␳ equal to .54 (P⬍.001). Conclusions: Both the FMA motor score and the ARAT were equally sensitive to change during inpatient acute rehabilitation and could be routinely used to measure recovery of upper-extremity motor function. Key Words: Rehabilitation; Stroke; Upper extremity. © 2006 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation UNCTIONAL RECOVERY AFTER STROKE may occur by improvement in underlying neurologic impairments, by F teaching compensatory techniques, by providing assistive de-

From the Weill Medical College of Cornell University, Burke Rehabilitation Hospital, White Plains, NY. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Meheroz H. Rabadi, MD, MRCPI, Burke Rehabilitation Hospital, 785 Mamaroneck Ave, White Plains, NY 10605, e-mail: [email protected]. 0003-9993/06/8707-10590$32.00/0 doi:10.1016/j.apmr.2006.02.036

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vices, or by a combination of the above. Critical evaluation of the effects of rehabilitation treatment strategies such as constraint-induced therapy,1,2 robotic sensorimotor training,3,4 biofeedback, and functional electric stimulation5,6 increasingly require assessments that are sensitive measures of change in motor impairment and in self-care function. There is no consensus concerning which standardized upperextremity motor scale is best suited for routinely assessing recovery of motor function in the upper extremity poststroke. The Fugl-Meyer Assessment (FMA) scale is a well-designed, comprehensive, and efficient clinical examination method that has been widely used by therapists to evaluate stroke-related motor impairment.7 The FMA was developed to measure sensorimotor stroke recovery based on Twitchell and Brunnstrom’s concept of sequential stages of motor return in patients with hemiplegic stroke. The domains assessed by the FMA include upper-extremity and lower-extremity movements, sensation, and balance. The whole FMA takes approximately 30 to 40 minutes to administer; however, the motor domain of the upper-extremity FMA can be administered within 10 minutes (appendix 1). The FMA motor score includes 33 items related to movements of the proximal and distal parts of the upper extremity. The total score ranges from 0 to 66. It is best administered to each patient on a one-on-one basis by a therapist trained in FMA evaluation. Both the motor and other subsections of the FMA have high reliability8,9 and validity.10,11 The main limitation of the FMA has been the ceiling effect in mild motor impairment. The Action Research Arm Test (ARAT) is a standardized ordinal scale that measures upper-extremity (arm and hand) function.12 The ARAT is based on the assumption that complex upper-extremity movements used in daily life could be explained and assessed by 4 basic movements: grasp, grip, pinch, and gross movements of extension and flexion at the elbow and shoulder (appendix 2). This test assesses the ability to lift variously sized objects to a height of 37.5cm (14.75in), move cylindrically shaped objects a distance of 37.5cm, use pinch grasp to lift variously sized objects (eg, a ball bearing, a marble) between the thumb and the third finger, and perform 3 gross upper-extremity movements. Each upper extremity is evaluated individually.13 The ARAT is graded on a 4-point scale (57 points maximum for each upper extremity): 3 points if the task is performed normally; 2 points if the task is completed but takes an abnormally long time, is performed with great difficulty, or is performed with poorly coordinated movements; 1 point if the task is only partially completed; and 0 points if the task is not performed at all. The ARAT has high reliability and validity13,14 and can be completed in 8 to 10 minutes.15 Its main advantage is its ability to assess a wide range of upper-extremity functions after stroke. Its main limitations are (1) that dexterity (manipulative task) is not addressed and (2) the need for standardized equipment to complete the evaluation. Three previous trials have compared the ARAT and FMA motor score. De Weerdt and Harrison15 found a mean change

MEASURES OF UPPER-EXTREMITY MOTOR WEAKNESS AFTER STROKE, Rabadi

in ARAT and FMA motor scores of 9.6 and 8.4, respectively, when measuring arm-hand motor function in 53 hemiplegic stroke patients admitted to an acute inpatient rehabilitation unit 2 weeks after the insult. Despite similar degrees of improvement in the mean score in both scales, they recommended the ARAT because of less time needed to administer that test in their study. In their study of 22 chronic stroke patients who were undergoing constraint-induced treatment, van der Lee et al16 found that the number of patients who improved more than the upper limit of agreement were 12 (54.5%) for the ARAT and 2 (9.1%) for the FMA motor score and that the responsiveness ratios (defined as the sensitivity of an instrument to real change) were 2.03 and 0.41 for the ARAT and FMA motor score, respectively. van der Lee suggested that the ARAT was more responsive to improvement in upper-extremity function than the FMA motor score in these chronic stroke patients. Kondziolka et al17 used the European Stroke Scale, ARAT, and FMA motor score to assess the benefit of neurotransplantation. In this randomized, observer-blinded trial of 18 chronic stroke patients undergoing neuronal implantation, it was found that wrist movement and hand movement scores recorded on the FMA did not improve compared with baseline (P⫽.06), and only the gross hand-movement and the grasp subset scores of the ARAT improved compared with control (P⫽.017) and baseline (P⫽.001) values. Kondziolka concluded that the total scores for each of the outcome scales failed to reflect any significant motor functional improvement. We, therefore, decided to assess 2 commonly used upperextremity scales, the ARAT and FMA motor score, in acute stroke patients undergoing inpatient rehabilitation, for their intertest correlation, responsiveness to change over time, and correlation with upper-extremity self-care function as measured by the FIM instrument total score and FIM activities of daily living (FIM-ADL) subscore. METHODS Participants Participants were recruited at 1 of the 5 academic neurorehabilitation centers that make up the Burke Stroke Recovery Consortium Investigator Group. One hundred four patients consecutively admitted to an acute stroke rehabilitation unit within 2 weeks of stroke onset were included in the study. Stroke diagnosis was based on clinical history, neurologic examination, and confirmatory computed tomography and magnetic resonance imaging studies. The inclusion criteria were independence in ADLs and mobility function before the index stroke, moderate to severe upper-limb impairment based on the National Institutes of Health Stroke Scale (NIHSS) score (ⱖ5),18 and ability to follow verbal and gestural cues. Data collected included age, sex, lesion type as defined by the International Classification of Disease, 9th Revision (thrombotic, embolic, carotid occlusion, or acute but ill-defined stroke), stroke severity based on the admission neurologic examination, rehabilitation hospital admission and discharge total FIM scores, and length of stay (LOS). The study physician (NIHSS certified) recorded both the admission and discharge NIHSS scores. The NIHSS was completed as a part of the initial rehabilitation hospital neurologic examination. The NIHSS is a standardized ordinal stroke impairment scale, with scores ranging from 0 to 42. The examination can be reliably performed in 8 to 10 minutes after appropriate training.19 The scale has a high reliability.20,21 The ARAT was administered as described in a standardized training video that accompanied the standardized test equipment. The tester initially showed each patient how each of the 4 basic

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movements was to be performed before asking the patient to perform these movements. The study physician placed the ARAT test items in the patient’s intact visual field. ARAT scoring was undertaken as per instructions (see appendix 2). Admission and discharge upper-extremity FMA motor scores were recorded by each patient’s assigned occupational therapist, who had been trained, met our institution’s training standards, and had used this scale in previous research studies.22 Assessors of both the ARAT and FMA motor score were blinded to each other’s findings. All measures were administered within 72 hours of patient admission to the rehabilitation unit and within 24 hours before discharge. Outcome The FIM instrument was used to measure both the degree of disability and the functional improvements during the medical rehabilitation program.23 The FIM is an 18-item ordinal scale scored from 1 to 7. A FIM item score of 7 is categorized as “complete independence,” and a score of 1 is “total assist.” The total FIM scores range from 18 (maximum level of assistance needed) to 126 (highest level of independence). The FIM scale is a reliable24 and valid functional independence measure.25,26 The FIM has become the standard functional assessment measure of self-care and mobility in the United States.27-29 The FIM-ADL subscore assesses the following 8 FIM items: feeding, grooming, bathing, toileting, upper- and lower-extremity dressing, and bowel and bladder management, with scores ranging from 8 to 56. Stroke rehabilitation team members who are FIM-certified scored the admission and discharge total FIM and FIM-ADL scores unaware of the study hypothesis. Statistics The Spearman rank correlation coefficient (␳) was used to compare admission and discharge ARAT and FMA motor scores with one another and with admission and discharge FIM total and FIM-ADL subsection scores. The Spearman rank correlation coefficient was also used to compare admission ARAT and FMA motor scores with stroke severity as measured by the NIHSS. Responsiveness to change in ARAT and FMA motor scores over time was assessed by computing the standard response mean (SRM) for each assessment. The SRM was defined as mean change in score divided by the standard deviation (SD) of the change score. The SRM is meant to assess clinically meaningful change relevant for a diagnostic test being performed. However, at present there is no consensus concerning how best to assess responsiveness to change.30 Cohen’s rule of thumb for interpreting the effect size index can be applied to the SRM: a value of 0.2 is small, 0.5 is moderate, and 0.8 or greater is large.31,32 RESULTS The demographic features of our study population (N⫽104) are summarized in table 1. The mean age ⫾ SD of our patients was 72⫾13 years. There were 43 men and 61 women. The study sample included patients with moderate stroke severity as assessed by their admission neurologic impairment (NIHSS score, 10⫾5.5) and disability (FIM total score, 59⫾19) scores. Based on the Spearman rank correlation statistic, the 2 upper-limb motor scales (ARAT, FMA motor score) correlated highly with one another, both on admission (␳⫽.77, P⬍.001) and on discharge (␳⫽.87, P⬍.001). Similarly, when compared with admission NIHSS score, the FMA motor score was similar to the ARAT score (␳⫽⫺.71, P⬍.001 vs ␳⫽⫺.48, P⬍.001). Changes in motor scores compared with LOS were similar between the ARAT (␳⫽.21, P⫽.07) and FMA motor score (␳⫽.14, P⫽.24). Arch Phys Med Rehabil Vol 87, July 2006

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MEASURES OF UPPER-EXTREMITY MOTOR WEAKNESS AFTER STROKE, Rabadi Table 1: Demographic Features of Our Study Population Value

Age (y) Sex (male/female) Race (white/black/others) Time of stroke onset to admission (d) Stroke type, n (%) Ischemic Hemorrhagic Comorbidity, n (%) Hypertension Diabetes mellitus Cardiac diseases* Other diseases FIM total score Admission (N⫽104) Discharge (n⫽85) FIM-ADL score Admission (N⫽104) Discharge (n⫽85) NIHSS score Admission (N⫽104) Discharge (n⫽76) Total ARAT score Admission (N⫽104) Discharge (n⫽77) Total FMA motor score Admission (N⫽104) Discharge (n⫽74) LOS (d) (N⫽104)

72⫾13 43/61 86/14/4 16⫾9 91 (87.5) 13 (12.5) 72 (69) 27 (26) 47 (45) 40 (38) 59⫾19 88⫾18 27⫾9.7 40⫾8.9

60 50 40 30 20 10 0 -10 -10

20 30 40 50 Change ARAT Change FMA=2.91+.701 Change ARAT, R2=.568 0

10

60

Fig 1. Linear regression plot for change in ARAT versus change in FMA motor scores (P<.001).

10.2⫾5.5 4.2⫾4 23⫾24 36⫾23 30⫾24 43⫾22 34⫾15

NOTE. Values are mean ⫾ SD unless otherwise indicated. *Atrial fibrillation and congestive cardiac failure.

The mean changes in scores from admission to discharge were as follows: ARAT, 10⫾15; and FMA motor score, 10⫾13. (There was a 17.8% change in the ARAT score and a 15% change in the FMA motor score during the 6-wk study period.) Scores for both scales improved and correlated positively with one another. Individual patient scores, however, showed occasional inconsistencies: FMA motor scores showed no change in 9 patients and ARAT scores showed no change in 29 patients. Similarly, deterioration was noted in FMA motor scores for 6 patients, whereas ARAT scores declined in only 1 patient. Thus the ARAT had a strong floor and ceiling effect compared with the FMA motor score. The SD exceeded the mean change for both the ARAT and FMA motor scores; this was due to deterioration in scale scores in some patients whereas in other patients there was improvement, resulting in a wide spread in the change of both scale scores. Sensitivity to change as measured by SRM was .68 for the ARAT and .74 for the FMA motor score. The change in ARAT score correlated well with the change in FMA motor score (R2⫽.56, P⬍.001) (fig 1). All Spearman rank correlations were similar for both admission and discharge ARAT and FMA motor scores when compared with admission and discharge FIM total and FIM-ADL subsection scores (table 2). This was true for both admission and discharge functional assessments. Both scales (ARAT, FMA motor score) showed a stronger correlation with FIM total and FIM-ADL subscores for admission scores than for discharge scores. DISCUSSION The principal findings of this study are that (1) both the ARAT and FMA motor score are highly correlated upperArch Phys Med Rehabil Vol 87, July 2006

Bivariate Scattergram with Regression 70

FMA Change

Characteristic

extremity measures after an acute stroke; (2) both scales are sensitive to change during the 6-week time period when these patients were studied: the mean ⫾ SD change was 10⫾14 points for the ARAT (range, ⫺1 to 57) and 10⫾13 points for the FMA motor score (range, ⫺3 to 61); and (3) the degree of responsiveness to change was similar for both scales, making them useful outcome measures in intervention studies. De Weerdt and Harrison,15 in their study of 53 hemiplegic stroke patients admitted 2 weeks poststroke to an acute inpatient rehabilitation unit, found a mean change in ARAT and FMA motor scores of 9.6 and 8.4, respectively, when measuring arm-hand motor function. Our study showed, in addition to the mean change in ARAT and FMA motor scores, that the FMA motor score and ARAT also correlated well with ADL performance as assessed by the FIM total and FIM-ADL scores. De Weerdt and Harrison,15 in their study, did not address how responsive these scales were to upper-extremity motor function performance. They recommended the ARAT over the FMA motor score, because the ARAT took less time to administer (8min) than the FMA motor score (11min). We did not measure test administration time in our study. In our study of acute stroke patients, the sensitivity to change as measured by SRM was .68 for the ARAT and .74 for the FMA motor score. This result is quite the opposite of the findings of van der Lee et al.16 In that study of 22 chronic stroke patients undergoing intensive forced-use treatment to improve upper-extremity function, researchers found a responTable 2: Spearman Rank Correlations (␳) Comparing Admission ARAT and FMA Motor Scores With Admission and Discharge FIM and FIM-ADL Subsection Scores Scale

FIM total Admission Discharge FIM-ADL Admission Discharge *P⬍.01. † P⬍.001.

ARAT

FMA Motor Score

.33† .21*

.54† .29*

.32† .32*

.54† .39†

MEASURES OF UPPER-EXTREMITY MOTOR WEAKNESS AFTER STROKE, Rabadi

siveness rate of 2.03 and 0.41 for the ARAT and FMA motor score, respectively. This responsiveness rate was based on the number of patients whose upper-extremity function improved above the set upper limit: 12 (54.5%) for the ARAT and 2 (9.1%) for the FMA motor score. This differential responsiveness rate between our 2 studies is mainly due to the following 3 reasons. First, patients in the acute recovery phase (within 2wk of stroke onset) were studied versus chronic patients in their study (3.6y of stroke onset). One expects most improvement in impairment and disability to occur in the initial few weeks after stroke. Chronic stroke patients, however, might be expected to show less improvement in impairment for the same degree of functional improvement.33 Second, their population had moderate stroke severity with higher median baseline ARAT and FMA motor scores of 31 and 49, respectively, compared with our baseline ARAT and FMA motor scores of 23 and 30, respectively. In view of their lower ARAT scores and a higher FMA motor score, there was a ceiling effect limiting the degree of change attainable in FMA motor scores compared with ARAT scores in their study. Third, it is also possible that functional improvement can be achieved without obvious change in motor impairment (FMA motor score being more impairment based vs ARAT being more function based). Both scales in our study appeared to have similar ceiling and floor effects without observable differences for patients with either high or low upper-extremity motor impairment scores. These floor and ceiling effects affected the ability of the responsiveness index to detect change in their scale scores. A similar floor effect was found by Hsueh and Hsieh34 in their comparison of the ARAT and the upper-extremity section of the Motor Assessment Scale in 48 acute stroke patients undergoing inpatient rehabilitation. Both these studies show that these scales would ideally assess functional motor recovery in moderate-stroke patients but would be less ideal in mild- or severe-stroke patients. Study Limitations First, our study is a single-center assessment, administered by clinicians who are also providing therapy. This raises the possibility of bias. It would be preferable to have blinded evaluators doing admission and discharge assessments to overcome this bias. However, such a setup would be self-defeating given that we are looking at 2 scales that can be routinely used in everyday practice. Second, despite correlation of admission, discharge, and change in the ARAT and FMA motor score with the FIM-ADL subscore, it is possible for patients to achieve a high level of independence based on FIM total and FIM-ADL evaluations without significant motor improvement. Using the unaffected upper extremity and/or using assistive devices could achieve the same functional improvement in FIM score. Third, patients were evaluated over a short time period (average, 6wk) while they were undergoing inpatient rehabilitation. They were still improving both neurologically and functionally. This, however, is the most relevant time interval for measuring responsiveness to treatment intervention and further strengthens the clinical applicability of our observations. CONCLUSIONS Our study shows that the FMA motor score and the ARAT are sensitive to change during inpatient acute rehabilitation, and both correlated similarly with FIM total and FIM-ADL function. Because the FMA motor score requires no equipment, it is potentially more convenient to administer.

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APPENDIX 1: FMA UPPER-EXTREMITY MOTOR DOMAIN Shoulder retraction Hip flexion Shoulder elevation Hip extension (supine) Shoulder abduction Hip adduction (supine) Shoulder abduction to 90° Knee flexion (supine) Shoulder adduction/internal rotation Knee flexion (sitting) Shoulder external rotation Knee flexion (standing) Shoulder flexion 0°–90° Knee extension (supine) Shoulder flexion 90°–180° Ankle dorsiflexion (supine) Elbow flexion Ankle dorsiflexion (sitting) Elbow extension Ankle dorsiflexion (standing) Forearm supination Ankle plantarflexion (supine) Forearm pronation Heel-shin speed Forearm supination/pronation (elbow at 0°) Heel-shin tremor Forearm supination/pronation (elbow at 90°, shoulder at 0°) Heel-shin dysmetria Hand to lumbar spine Knee reflex Wrist flexion/extension (elbow at 0°) Hamstring reflex Wrist flexion/extension (elbow at 90°) Ankle reflex Wrist extension against resistance (elbow at 0°) Wrist extension against resistance (elbow at 90°) Wrist circumduction Finger flexion Finger extension Extension of MCP joints, flexion of PIPs/DIPs Thumb adduction Thumb opposition Grasp cylinder Grasp tennis ball Finger-nose speed Finger-nose tremor Finger-nose dysmetria Finger flexion reflex Biceps reflex Triceps reflex Upper Extremity (66 points) Abbreviations: DIPs, distal interphalangeals; MCP, metacarpophalangeal: PIPs, proximal interphalangeals.

APPENDIX 2: ARAT Activity

Grasp 1. Block, wood, 10 cm cube (If score ⫽ 3, total ⫽ 18 and go to Grip) Pick up a 10 cm block 2. Block, wood, 2.5 cm cube (If score ⫽ 0, total ⫽ 0 and go to Grip) Pick up 2.5 cm block 3. Block, wood, 5 cm cube 4. Block, wood, 7.5 cm cube 5. Ball (Cricket), 7.5 cm diameter 6. Stone 10 ⫻ 2.5 ⫻ 1 cm Coefficient of reproducibility ⫽ 0.98 Coefficient of scalability ⫽ 0.94

Score

_______

_______ _______ _______ _______ _______

Grip 1. Pour water from glass to glass (If score ⫽ 3, total ⫽ 12, and go to Pinch) _______ 2. Tube 2.25 cm (If score ⫽ 0, total ⫽ 0 and go to Pinch) _______ 3. Tube 1 ⫻ 16 cm _______

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APPENDIX 2: ARAT (cont’d) Activity

4. Washer (3.5 cm diameter) over bolt Coefficient of reproducibility ⫽ 0.99 Coefficient of scalability ⫽ 0.98 Pinch 1. Ball bearing, 6 mm, 3rd finger and thumb (If score ⫽ 3, total ⫽ 18 and go to Grossmt) 2. Marble, 1.5 cm, index finger and thumb (If score ⫽ 0, total ⫽ 0 and go to Grossmt) 3. Ball bearing 2nd finger and thumb 4. Ball bearing 1st finger and thumb 5. Marble 2nd finger and thumb 6. Marble 1st finger and thumb Coefficient of reproducibility ⫽ 0.99 Coefficient of scalability ⫽ 0.98 Grossmt (Gross Movement) 1. Place hand behind head (If score ⫽ 3, total ⫽ 9 and finish) 2. (If score ⫽ 0, total ⫽ 0 and finish) 3. Place hand on top of head 4. Hand to mouth Coefficient of reproducibility ⫽ 0.98 Coefficient of scalability ⫽ 0.97

Score

_______

_______ _______ _______ _______ _______ _______

_______ _______ _______ _______

Instructions: There are four subtests: Grasp, Grip, Pinch, Gross Movement (Grossmt). Items in each are ordered so that: ● if the subject passes the first, no more need to be administered and he scores top marks for that subtest; ● if the subject fails the first and fails the second, he scores zero, and again no more tests need to be performed in that subtest; ● otherwise he needs to complete all tasks within the subtest.

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