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Comparison of Three Tools to Measure Improvements in Upper-Limb Function With Poststroke Therapy Angelica G. Thompson-Butel, Gaven Lin, Christine T. Shiner and Penelope A. McNulty Neurorehabil Neural Repair published online 9 September 2014 DOI: 10.1177/1545968314547766 The online version of this article can be found at: http://nnr.sagepub.com/content/early/2014/09/06/1545968314547766

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NNRXXX10.1177/1545968314547766Neurorehabilitation and Neural RepairThompson-Butel et al

Original Article

Comparison of Three Tools to Measure Improvements in Upper-Limb Function With Poststroke Therapy

Neurorehabilitation and Neural Repair 1­–8 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1545968314547766 nnr.sagepub.com

Angelica G. Thompson-Butel, PhD1,2, Gaven Lin1, Christine T. Shiner1,2, and Penelope A. McNulty, PhD1,2

Abstract Background. Functional ability is regularly monitored poststroke to assess improvement and the efficacy of clinical trials. The balance between implementation times and sensitivity has led to multidomain tools that aim to assess upper-limb function comprehensively. Objective. This study implemented 3 common multidomain tools to investigate their suitability across a broad spectrum of movement ability after stroke. Methods. Forty-nine hemiparetic patients (18 females), aged 22 to 83 years and 24.7 ± 39.2 months poststroke, were assessed before and after a 14-day upper-limb rehabilitation program of Wii-based Movement Therapy. Assessments included the upper-limb motor subscale of the Fugl-Meyer Assessment (F-M), the Wolf Motor Function Test (WMFT), and the Motor Assessment Scale (MAS) upper-limb sections 6 to 8. The MAS was analyzed both with and without the hierarchical system. Patients were stratified with low, moderate, or high motor-function. Results. Upper-limb function improved significantly for the pooled cohort for all assessments (P < .001), although ceiling effects were evident for the F-M, floor effects for the WMFT, and both floor and ceiling effects for MAS. When analyzed by stratified subgroup these improvements were significant for all groups with the F-M, for the moderate and high motor-function groups with both the WMFT and the MAS scored without hierarchical system, but only for the high motor-function group with the hierarchically scored MAS. Conclusion. These results suggest that no single test is suitable for measuring function and improvement across the spectrum of poststroke upper-limb dysfunction and that assessment tool selection should be based on the level of residual motor-function of individual patients. Keywords stroke, functional assessments, Wolf Motor Function Test, Fugl-Meyer Assessment, Motor Assessment Scale, upper-limb motor function

Introduction Upper-limb motor dysfunction is a significant contributor to the loss of independence in activities of daily living after stroke. Movement may be impaired by a single aspect of motor control such as reduced speed, coordination, range of motion or strength, or by a combination of these components and this is reflected in different strategies to measure motor function.1 Many tools address a single aspect of function, such as hand-held dynamometry, which measures only handgrip strength,2 or the modified Ashworth Scale, which categorizes muscle resistance to passive movement.3 Although such tests provide an indicator of the level of motor dysfunction, the results cannot be generalized to functional movement ability or the capacity for rehabilitation. More comprehensive assessments of upper-limb functional ability can be made using tests that examine multiple aspects of upper-limb motor function, several of which have been specifically developed for use after stroke. This

study investigated 3 such multidomain assessments: the upper-limb motor subscale of the Fugl-Meyer Assessment (F-M), the Wolf Motor Function Test timed-tasks (WMFT), and the upper-limb sections of the Motor Assessment Scale (MAS). The F-M,4 and particularly the upper-limb motor subscale, is among the most frequently used tools internationally to assess stroke impairment.5,6 International use of the WMFT7 is growing, and in Australia, the upper-limb sections of the MAS8 is the most commonly used multidomain tool.9,10 Ceiling and floor effects have been reported for the 1

Neuroscience Research Australia, Sydney, New South Wales, Australia University of New South Wales, Sydney, New South Wales, Australia

2

Corresponding Author: Penelope A McNulty, Neuroscience Research Australia, Barker Street, Sydney, New South Wales 2031, Australia. Email: [email protected]

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Neurorehabilitation and Neural Repair 

F-M and WMFT, respectively,11,12 and both floor and ceiling effects have been reported for the MAS.9,13-16 There is some debate about the MAS scoring system and the accuracy of the rank order of items within each section that were designed to reflect the hierarchical structure of the assessment.9,17-19 More recent Rasch analyses confirmed the rank order of section 6, upper arm function,15,20,21 while that of section 7, hand movements, was confirmed in 1 study20 but rejected in 2 others.15,21 The rank order of section 8, advanced hand activities, was rejected by all 3 studies.15,20,21 When section 8 of the MAS was assessed without the hierarchical scoring system (ie, patients attempted all items), patient scores were higher than when the hierarchy was employed.19 There is a growing international consensus regarding the need for a harmonized core set of clinical outcome measures for trials involving stroke survivors.22,23 This will not only enable more direct comparison between trials but will also enhance the utility and generalizability of meta-analyses.24,25 Up to 129 different tools were identified in recent surveys of upper-limb stroke rehabilitation trials emphasizing the absence of a harmonized set of assessments.22,26 While there is little consensus regarding the optimal assessment set, there is agreement that no single assessment tool adequately measures upper-limb function across the spectrum of poststroke dysfunction.1,27 Rather than select assessment tools a priori, it may be more efficient to compare multiple tests in the same patients to identify the most robust tools.28,29 The choice of assessment tool is influenced by many factors that may include the level of impairment; measurement sensitivity, validity, and reliability of a given tool; the time and cost required for implementation; or assessor preferences and familiarity.1,30-33 The nature and extent of motor impairment must be accurately established for each patient not only to enable intertrial comparisons and to prevent treatment arm bias in clinical trials34 but more importantly to provide a basis on which to design rehabilitation programs and set achievable patient-centered goals. This study investigated 3 stroke specific multidomain assessment tools used to quantify different aspects of upperlimb motor ability and improvement with therapy in a heterogeneous cohort of community-dwelling stroke survivors. This study is the first to implement an upper-limb stratification scheme to provide a novel approach to maximize the utility of these tests. We hypothesized that the WMFT would be the most sensitive across a broad spectrum of stroke patients. Each patient was tested with the F-M, WMFT, and MAS before and after a novel upper-limb therapy program. All items of each of the upper-limb MAS sections were assessed and then analyzed both with and without the hierarchical scoring system. The results of this study confirm that no single tool provides adequate sensitivity to cover a broad spectrum of poststroke dysfunction and that

the assessment tool of choice should be based on the level of each patient’s residual upper-limb motor function.

Methods Participants Fifty-nine patients were consecutively recruited and screened from St Vincent’s and Prince of Wales’ Hospitals, Sydney, Australia. Of these 10 were excluded from the study (8 did not meet criteria, 2 declined). The remaining 31 male and 18 female patients were aged 22 to 83 years (62.6 ± 12.8 years, mean and standard deviation) and were between 1 month and 21 years poststroke (24.7 ± 39.2 months). All had suffered a unilateral stroke in the territory of the middle cerebral artery and were hemiparetic with an upper-limb involvement. Inclusion criteria were the following: (a) ≥14 years; (b) ≥10° of voluntary movement in the more-affected hand or wrist; (c) the ability to communicate in English; and (d) cognitively competent with a MiniMental State Examination score ≥24. Cognitive competency was confirmed by treating clinicians for patients with expressive aphasia, dyspraxia, dysarthria or English as a second language who were unable to complete the MiniMental State Examination. Exclusion criteria were the following: (a) unstable blood pressure and (b) peripheral comorbidities affecting sensorimotor function. Patients gave informed written consent, and the study was approved by St Vincent’s Hospital Human Research Ethics Committee and was conducted in accordance with the Declaration of Helsinki. Some data included in this novel analysis have been reported previously.35-37

Stratification Classification into upper-limb motor-function groups was achieved using our novel stratification system37 based on the ability to perform the Box and Block Test (BBT)38 of gross manual dexterity and the grooved pegboard test39 of fine manual dexterity. Briefly, patients who could move ≤1 block on the BBT and could not complete the grooved pegboard test were classified with low motor-function, those who could move >1 block on the BBT but were unable to complete the grooved pegboard test were classified with moderate motor-function, and those able to complete both tests were classified with high motor-function. Patients with poor eyesight were encouraged to wear prescription glasses during all assessments, and those with hemianopia and neglect were reminded to scan the test area.

Functional Assessments Motor ability was assessed using 3 multidomain, hierarchically structured upper-limb tools: the upper-limb motor

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Thompson-Butel et al subscale of the F-M,40 the WMFT timed-tasks,12 and the upper-limb MAS.41,42 The 33 items of the F-M are scored on a 3-point scale where 0 represents an inability to complete the test item, 1 represents a partial ability, and 2 represents full completion. Test items assess reflexes; the capacity to move in and out of synergy; to isolate movement to the shoulder, elbow, and wrist; and to grasp different objects. The WMFT consists of 15 timed-tasks and 2 strength-based tasks. The timed-tasks simulate functional activities that range from basic movements such as placing the forearm onto a table, to complex fine motor skills such as stacking checkers. A faster mean time represents better motor performance.43 Strength-based tasks are tested by a progressive submaximal weight-lifting task and maximal grip-strength measured with hand-held dynamometry. The upper-limb MAS sections contain 6 items scored on a 2-point scale where 1 indicates an ability to complete the task and 0 an inability to complete the task. We examined section 6, upper arm function (for logistical reasons the first 3 items were not included); 7, hand movements; and 8, advanced hand activities. When using the hierarchical scoring system patients must successfully complete each item before proceeding to the next item.41,42 In this study, all items were tested regardless of performance and data were analyzed both with and without the hierarchical structure. Assessments were conducted as part of a larger suite of tests immediately before and after therapy by the second and third authors following a standardized protocol. The order of tests was determined on an individual basis to account for fatigue and available resources.

any item, and in this study the maximum score for the MAS was 15. Wilcoxon signed rank tests were used to compare pre- and posttherapy assessments. To facilitate comparisons with previous studies data are illustrated as mean, range, and 95% confidence intervals. Differences were considered significant when P < .05.

Results Patients were stratified as low (n = 16), moderate (n = 14), or high (n = 19) motor-function (see Methods). Assessment scores are presented first as pooled data (n = 49) and then for each motor-function subgroup. The MAS analysis is presented first with and then without hierarchical scoring.

Fugl-Meyer Assessment The rank ordered pretherapy F-M scores described an almost continuous distribution with a ceiling effect for 2 patients with high motor-function (Figure 1A). A further 7 patients scored ≥60. A ceiling effect was evident for 4 patients after therapy with another 13 patients scoring ≥60. There was no floor effect although the 3 patients with the lowest scores received points only due to the presence of reflexes, and this did not change after therapy. Although 9 patients (including those scoring maximal points) showed no improvements there was a significant improvement in F-M scores after therapy both for the pooled data and for each of the functional subgroups (Figure 2A).

Wolf Motor Function Test—Timed Tasks

Intervention All patients received a standardized 14-day protocol of Wiibased Movement Therapy35,36,44 predominantly implemented by the first author who was unaware of assessment results. In brief, this protocol consisted of 60-minute formal therapy sessions with a trained therapist on 10 consecutive weekdays, augmented by progressively increasing home practice. Therapy and home practice sessions use the Wii and Wii Sports (Nintendo, Japan) games of golf, baseball, bowling, tennis, and boxing. The Wii controller was held in the more-affected hand only, and therapy was structured, targeted, and individualized to the needs of each patient. For those with poor grip strength a self-adhesive wrap was used to secure the Wii controller in the more-affected hand and the extent of wrapping was reduced over the 14-day therapy period as strength and ability progressed.

Data Analysis The maximum score for the upper-limb motor F-M is 66, the maximum mean time for WMFT timed-tasks is 120 seconds with 121 seconds denoting an inability to complete

The distribution of WMFT mean times highlighted the floor effect for 5 patients with low motor-function who were unable to complete any task in the allotted 120 seconds (see Figure 1B). The long “toe” at shorter times includes data for patients with high motor-function, there was no ceiling effect. Posttherapy scores showed a reduction in the floor effect with 2 of the above 5 patients scoring