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post-stroke, which has also been reported by others
(26, 37). The floor effect in scales assessing pure motor
function and activity capacity (ARAT-2, ARAT and
FMA-UE without reflex items), can be expected in
the acute stage after stroke in a non-selected cohort at
stroke unit (6, 8). The ceiling effect for ARAT-2 was
reached at 10 days (22% of patients reached a full
score), and for the ARAT at 4 weeks (21%). These
results are comparable with previous studies that also
demonstrated a ceiling effect at 4 weeks post-stroke
in ARAT, but not in FMA-UE (26, 37).
In the current study, the ARAT-2 along with establis-
hed clinical scales of ARAT and FMA-UE were able to
detect changes in motor functions and activity capacity
between the selected early time-points. The ARAT-2
showed the lowest (0.31) effect size for detecting a
change between 10 days and 4 weeks post-stroke,
which might be connected to lower sensitivity to smal-
ler changes in ARAT-2 due to few grading categories of
the ARAT-2 compared with the ARAT. An advantage
of using a short assessment in the acute stage is that
it will facilitate a wider use of standardized testing in
clinical settings and be less demanding for the patient.
The ARAT and the FMA-UE should, however, be con-
sidered as better alternatives when the highest score
has been reached with the ARAT-2, and when smaller
specific improvements are important to capture, e.g. to
determine the effect of specific targeted interventions
to improve the upper limb function or activity capacity.
activity capacity and motor assessments included in
the present study is low. The strength of the current
study is that the cohort represents an ecologically
valid unselected sample of patients with a wide range
of motor deficits that are commonly seen in an acute
clinical stroke setting.
There is a clinical need for a short valid and reliable
assessment for upper extremity activity capacity in
the acute setting of stroke. The ARAT-2 offers several
benefits for assessing upper extremity activity capacity
early after stroke. First, it consists of 2 items that can
be administered quickly by a physiotherapist or oc-
cupational therapist. Thus, ARAT-2 can be an efficient
way to assess activity capacity in patients with low en-
durance without getting scores confounded by fatigue.
Secondly, the ARAT-2 does not rely on understanding
the language or any complex instructions. Thirdly, the
concurrent validity and responsiveness of the ARAT-2
were found to be satisfactory.
Conclusion
The results of the current study indicate that ARAT-2
is a valid and responsive tool for assessment of upper
extremity activity capacity in the acute stage after
stroke. However, when the highest score has been
reached in ARAT-2, the assessment needs to be com-
plemented with other assessments in order to evaluate
minor deficits or improvements in upper extremity
activity capacity.
Limitation
One limitation of this study was that the patients were
assessed with a battery of assessments, which may have
caused tiredness and subsequently affected the scoring
of the assessments. Tiredness is also one of the con-
sequences particularly evident in the acute stage after
stroke. On the other hand, there were only 4 patients
who had missing assessments due to tiredness 3 days
post-stroke. In addition, in the SALGOT protocol, the
order of assessments was predefined and ARAT was
always assessed first prior to FMA and before other
assessments. During the assessments, breaks were
also allowed at any time and the testing could also be
split into 2 parts. The test procedure was constructed
in order to minimize testing bias caused by tiredness.
The cognitive impairments are common after stroke
and may be particularly evident in the early stages
after stroke onset (38). In the present study the patients
were not excluded due to cognitive deficits, which
may have influenced the scoring due to communica-
tion problems. Cognitive deficit was also a reason for
missing assessment data in 2 participants. On the other
hand, the cognitive demand to perform the clinical
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ACKNOWLEDGEMENTS
The authors thank all participants and staff at Sahlgrenska
University Hospital who have contributed to the data collection.
This work was supported by the Local Research and Deve-
lopment Board for Gothenburg and Southern Bohuslän, the
Swedish Foundation for Neurological Disabilities (Neuroför-
bundet) and Swedish Stroke Association.
The authors declare no conflicts of interest.
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