Journal of Rehabilitation Medicine 51-4inkOmslag | Page 24

258
T. Kristersson et al.
impairments and preferably provide useful information
on recovery prediction (20). A short version of the
ARAT, the ARAT-2 that contains 2 items from ARAT
(pour water from glass to glass and place hand on top
of the head), has been shown to predict well functional
outcome early after stroke (21). It does not require any
special equipment, is quick and easy to use and has
potential to contribute valuable predictive and clinical
information.
There is a need to investigate the psychometric pro-
perties of a short assessment, such as ARAT-2, in the
acute stage after stroke. Thus, the aim of this study was
to determine the concurrent validity, responsiveness,
floor and ceiling effect of the ARAT-2 in comparison
with the original ARAT and the FMA-UE in a non-
selected cohort of patients with stroke assessed at 3
days, 10 days and 4 weeks after stroke onset.
METHODS
Participants
Data for this study were extracted from the Stroke Arm Longi-
tudinal study at the University of Gothenburg (SALGOT-study,
ClinicalTrials.gov NCT01115348) (22), which aimed to investi-
gate upper extremity functioning, recovery and consequences
of stroke on activity and participation in a non-selected sample
during the first year after stroke. The SALGOT study com-
prised 117 patients who were included from a stroke unit at
the Sahlgrenska University Hospital in Gothenburg, Sweden
during a period of 18 months (2009–10). Inclusion criteria for
the SALGOT study were: (i) diagnosed first-ever clinical stroke
according to the World Health Organization (WHO) (23); (ii)
impaired upper extremity function, defined as < 57 points on
ARAT, at day 3 (± 1 day) after stroke onset; (iii) admitted to
the stroke unit within 3 days after stroke onset; (iv) 18 years or
older; (v) resident in Gothenburg urban area within 35 km of the
hospital. The exclusion criteria were: (i) injury or condition prior
to the stroke that limits the upper extremity function; (ii) short
life-expectancy, e.g. less than 12 months due to other illness
(cardiac disease, malignancy); (iii) non-Swedish speaking. The
flowchart of the inclusion process is shown in Fig. 1.
All participants received individually adjusted functional
task-specific rehabilitation from the first day at the stroke unit
according to the Swedish national guidelines. The participants
followed an individually adjusted standardized routine for re-
habilitation after the hospital discharge that commonly included
interventions at community care with a physiotherapist and/or
occupational therapists. In the SALGOT study the participants
were assessed with a battery of assessments at 8 occasions
during the first year post-stroke: 3 and 10 days, 3, 4 and 6 weeks,
3, 6 and 12 months post-stroke (22).
In the current study, data from the assessment time-points at
3 and 10 days, as well as 4 weeks post-stroke were used. All
assessments at these time-points were performed by 2 expe-
rienced physiotherapists, undergoing a training period for the
assessment battery prior to the study (24). Most of the assess-
ments were performed at the hospital. In case the patient was
discharged and unable to travel, the assessment was conducted
in the patients’ home or nursing home. Ethical approval for the
SALGOT study was approved by the Regional Ethics Commit-
www.medicaljournals.se/jrm
Fig. 1. Flowchart of the inclusion process in the Stroke Arm Longitudinal
study at University of Gothenburg (SALGOT study).
tee, Gothenburg (225-08) and informed, written consent was
received from all participants.
Clinical assessments
Stroke severity was determined by the National Institute of
Health Stroke Scale (NIHSS) (25) and the type and location
of stroke were collected from the patients’ medical charts. The
total score of the NIHSS varies from 0 to 42 points and a higher
score indicates a more severe stroke.
Upper extremity activity capacity was assessed by the ARAT
(16), which is a standardized observational rating scale construc-
ted to assess manual ability to grasp and handle different objects
after stroke. The assessment contains 19 items divided into 4
subscales: grasp, grip, pinch and gross movement. Each item
is scored on a 4-point ordinal scale (0 = unable to complete any
part of the task within 60 s, 1 = the task is partially performed
within 60 s, 2 = the task is completed, but with great difficulty
or takes an abnormally long time (6–60 s), 3 = the task is per-
formed normally within 5 s with a total score of 0–57 points.
The ARAT is valid and responsive to change of activity capacity
over time in patients with stroke, has good intra- and inter-rater
reliability (ICC = 0.99 and 0.95, respectively) (19, 26). The intra-
and inter-rater reliability at item level shows good agreement
(percentage agreement, PA ≥ 70%) although minor systematic
disagreements have been shown for few items (grasping a large
block, pinch grip of a 6-mm ball-bearing between 3rd finger
and thumb, hand to mouth) (24).
The ARAT-2 (17, 21, 24) comprises 2 items from the ARAT:
pour water from glass to glass (item 7) and place hand on top
of the head (item 18). Each item is scored in a similar way as
in the original ARAT and the total score of the 2 items ranges
between 0 to 6 points. The construction of ARAT-2 was based on
a standardized procedure (21): (i) the items that did not require
special standardized equipment were selected; (ii) principal
components analysis was used to identify the minimum number
of items needed to capture most of the variance in the ARAT;
and (iii) item difficulty established with Mokken analysis (27)
was used to guide the selection of items that would cover a wide
range of activity capacity limitation. The intra- and inter-rater
reliability evaluated by percentage of agreement for the pour
water item varied between 89% an 97%, and for the hand on top
of the head item between 77% and 91% (24). Neither systematic