Journal of Rehabilitation Medicine 51-4inkOmslag | Page 25

Short assessment for upper extremity after stroke
nor random individual disagreements were detected for these
2 items (24). The 2 items in the ARAT-2 have been shown to
cover a broad range of activity limitations by explaining 95%
of the total variance in ARAT (21).
Upper extremity motor function was assessed by the FMA-
UE (18), which is a standardized observational rating scale
constructed to assess sensorimotor impairments after stroke. It
consists of 33 items, each scored on a scale of 0–2, and with a
total score of 66 points, which indicates high motor function.
In addition to pure motor items, the FMA-UE also includes 3
reflex activity items, measuring a different construct (28). In this
study, also a pure motor score of the FMA-UE, excluding the
3 reflex items was calculated. The FMA-UE without the reflex
items had a maximum score of 60 points. The FMA-UE has
shown excellent intra- and inter-rater reliability (ICC = 0.99 and
0.96, respectively) (26) and validity for individuals with stroke
(19, 29). The non-motor domains of the FMA-UE, assessing
sensory impairment and pain during passive joint motion, at 3
days post-stroke were used for background data.
Statistical analysis
Descriptive statistics were used to summarize demographics
and clinical characteristics. The ratings of the ARAT-2 were
retrieved from the ratings on the original 19-item ARAT. At 10
days assessment, the FMA-UE scores were missing from 20
patients due to administration problems. An estimated score
for each of these patients was calculated by using the mean
change from day 3 to day 10 of all patients (n = 97), as described
previously (21). This mean score was then added to the patients
(n = 20) day 3 FMA-UE score. The estimated score for day 10
could not exceed the FMA-UE score at day 3. The scores for
the FMA-UE without reflex items of these 20 patients at day 10
were only constructed when the scores of the reflex items were
unchanged from a previous and following test occasion. Data
analyses were performed in parallel with observed and imputed
data to ensure that the imputed data did not influence the results.
Concurrent validity of ARAT-2 was examined in comparison
with the original ARAT (0–57), FMA-UE (0–66) and the FMA-
UE without reflex items (0–60) separately at day 3, 10 and week
4. Correlation between the scales was examined visually using
scatterplots and by using the Spearman’s correlation coefficient
rho (r). The significance level p < 0.05 was used and the strength
of correlation was interpreted as follows: < 0.26 (little if any),
0.26–0.49 (low), 0.50–0.69 (moderate), 0.70–0.89 (high) and
≥ 0.90 (very high) (30).
The responsiveness of ARAT-2 was examined by using the
Wilcoxon signed-rank test to evaluate the change between each
time-point. Bonferroni correction of the p-value (p < 0.016) was
used to correct testing between 3 time-points (31). The effect
size for change scores was calculated by dividing the z value
obtained from the Wilcoxon signed-rank test with the square
root of number of observations. Effect size values < 0.30 indicate
small effect, 0.30–0.49 medium effect and ≥ 0.50 large effect
259
Table I. Characteristics of the included patients at 3 days post-stroke
Characteristic
Value
Number of patients, n (%)
117 (100)
Age, years, mean, (SD)
69 (13)
Sex, male/female, %
56/44
Location of stroke, %
Right
51
Left
44
Bilateral
3
Brain stem
1
Cerebellum
1
Ischaemic/haemorrhage, %
84/16
Stroke severity, NIHSS (0–42p), median (q1–q3)* n  = 115
7 (3–13)
Dominant hand, right/left, %
97/3
Affected arm, right/left, %
46/54
ARAT, median (q1–q3), n  = 112
5.5 (0–44)
FMA-UE (0–66), median (q1–q3), n  = 116
20 (4–56)
FMA-UE without reflex items (0–60), median (q1–q3), n  = 116 16.5 (0–52)
Sensory deficit (<12p FMA-UE Sensory), n (%), n  = 113
64 (57)
Pain (<24p FMA-UE Pain), n (%), n  = 115
21 (18)
*NIHSS at admission.
NIHSS: National Institutes of Health Stroke Scale; q1–q3: 1 st and 3 rd quartile
values; ARAT: Action Research Arm Test; FMA-UE: Fugl-Meyer Assessment of
Upper Extremity; SD: standard deviation.
(31). The percentage of patients with a positive, negative and
tie outcome was also investigated. The change between each
time-point was similarly calculated for the ARAT (0–57), FMA-
UE (0–66) and the FMA-UE without reflex items (0–60). The
floor and ceiling effect was considered when more than 20% of
the patients scored a minimum or maximum score of the scale,
respectively (32, 33). All statistical analyses were performed
with SPSS version 22.
RESULTS
The demographic and clinical characteristics of the
117 patients assessed at 3 days post-stroke are sum-
marized in Table I. The number of patients included
in the analysis at each time-point is reported in Table
II. The main reasons for missing data was being too
tired to perform an assessment (n = 4), difficulties to
cooperate or understand instructions needed to perform
the assessment (n = 2), moving away from the Goth-
enburg urban area (n = 1), did not want to come to the
assessment (n = 2), death (n = 2) or dismissed from the
study (n = 3). The ARAT-2 showed high correlation
(r = 0.92–0.97) with ARAT, FMA-UE and FMA-UE
without reflex items (Fig. 2).
All scales showed a medium to large effect to detect
changes during the first 4 weeks after stroke (p < 0.001,
effect size 0.49–0.53, Table III). The ARAT-2 showed
Table II. Ceiling and floor effects of the assessment scales at 3 and 10 days and 4 weeks after stroke onset
ARAT-2 (0–6)*
ARAT (0–57)
FMA-UE (0–66)
Time post-stroke Floor n (%) Ceiling Floor
3 days
10 days
4 weeks 43 (38.4) n  = 112
36 (31.0) n  = 116
26 (24.1) n  = 108 1 (0.9)
26 (22.4)
35 (32.4) 43 (38.4) n  = 112 0 (0)
35 (30.2) n  = 116 11 (9.5)
26 (24.1) n  = 108 23 (21.3)
n (%)
n (%)
Ceiling
n (%)
Floor
n (%)
FMA-UE without reflex items (0–60)
Ceiling
n (%)
13 (11.2) n  = 116
1 (0.9)
5 (4.3) n  = 117
3 (2.6)
3 (2.8) n  = 108 11 (10.2)
Floor
n (%)
Ceiling
n (%)
40 (34.5) n  = 116
1 (0.9)
29 (26.6) n  = 109
3 (2.8)
13 (12.1) n  = 108 11 (10.2)
*ARAT-2, short version of the ARAT with 2 items (pour water, hand to head); the number of subjects included in the analyses are shown separately for each scale
and time-point ARAT: Action Research Arm Test; FMA-UE: Fugl-Meyer Assessment for Upper Extremity.
J Rehabil Med 51, 2019