Conceptualisation and development of the arm activity measure (ArmA) for assessment of activity in the hemiparetic arm.

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by  Ashford, Stephen

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ISSN0963-8288print/ISSN1464-5165online
DisabilRehabil,2013;35(18):1513–1518
!2013InformaUKLtd.DOI:10.3109/09638288.2012.743602
RESEARCH ARTICLE
Conceptualisation and development of the arm activity measure (ArmA)
for assessment of activity in the hemiparetic arm
Stephen Ashford1,2, Mike Slade3, and Lynne Turner-Stokes1,2
1RegionalRehabilitationUnit,NorthwickParkHospital,London,UK,2DepartmentofPalliativeCare,PolicyandRehabilitation,SchoolofMedicine,
King’sCollegeLondon,London,UK,and3DepartmentofHealthServiceandPopulationResearch,InstituteofPsychiatry,King’sCollegeLondon,
London,UK
Abstract Keywords
Purpose:Todevelopapatientreportedoutcomemeasureofactiveandpassivefunctioninthe ArmA,function,outcomemeasure,rehabili-
hemiparetic upper limb. Methods: Potential items for inclusion were identified through (a) tation,upperlimb
systematic review and analysis of existing measures and (b) analysis of the primary goals for
treatment in a spasticity service. Item reduction was achieved through consultation with a
History
small,purposivelyselectedmulti-disciplinarygroupofexperiencedrehabilitationprofessionals
Received22February2012
(n¼10) in a three-round Delphi process. This was followed by a confirmatory survey with a
Revised8August2012
largergroupofclinicians(n¼36)andpatientsandcarers(n¼13pairs).Results:Fromaninitial
shortlistof75items,23itemswereinitiallyidentifiedforinclusioninthearmactivitymeasure Accepted22October2012
(ArmA),andsubsequentlyrefinedtoa20-iteminstrumentcomprising7passiveand13active Publishedonline7January2013
function. In common with the six measures identified in the systematic review, a five-point
ordinalscalingstructurewaschosen,withratingsbasedonactivityoverthepreceding7days.
Conclusions: The ArmA is designed to measure passive and active function following focal
interventions for the hemiparetic upper limb. Content and face validity have initially been
addressed within the development process. The next phase of development has involved
formalevaluationofpsychometricproperties.
(cid:2)ImplicationsforRehabilitation
(cid:2) Inclinicalpracticeorresearch,outcomemeasuresinrehabilitationneedtohavefaceand
contentvalidity.
(cid:2) Followingstrokeorbraininjury,goalsforrehabilitationofthehemipareticupperlimbmay
be:torestoreactivefunction,ifthereisreturnofmotorcontrolortoimprovepassivefunction
makingiteasiertocareforthelimb(e.g.maintainhygiene)ifnomotorreturnispossible,
measurementofbothconstructsshouldbeconsidered.
(cid:2) ThisstudydescribesthesystematicdevelopmentoftheArmA,ameasureofactiveand
passivefunctioninthehemipareticupperlimb.
Introduction practice, they needtobefeasible for usein busyclinical settings
and reflect performance in the real-life context as closely as
Outcome measurement is applied in rehabilitation to determine
possible.
the effectiveness of interventions. Whether in clinical practice or
Followingstrokeorbraininjury,goalsforrehabilitationofthe
forresearch,measuresneedtobevalid,reliableandresponsiveto
hemipareticupperlimbmaybe:torestoreactivefunction,ifthere
clinically relevant change. Global measures of function in daily
isreturnofmotorcontrolortoimprovepassivefunctionmakingit
activities, such as the Barthel Index [1], provide a general
easier to care for the limb (e.g. maintain hygiene) if no motor
assessment of independence but are often unresponsive to focal
returnispossible[3].Acomprehensiveoutcomemeasureneedsto
interventions in the upper limb (such as management of focal
assess both constructs of active and passive function to fully
spasticity or constraint induced movement therapy – CIMT).
reflect the changes seen post-intervention [4]. Although active
Small changes, which may be extremely important to the patient
and passive function are different concepts, they represent two
and/or their carers are easily lost among the larger number of
different aspects of function important to patients following
unchanging items [2]. For tools to be used in clinical
acquiredbraininjuryandinparticularspasticitymanagement[3].
The ArmA measure development described, treats these con-
structs as separate entities from the outset and sub-scale
Address for correspondence: Stephen Ashford, Regional Rehabilitation
Unit, Northwick Park Hospital, WatfordRoad, Harrow,Middlesex HA1 development is undertaken on this basis.
3UJ, UK. Tel: þ44 20 88692800. Fax: þ44 20 88692803. E-mail:
[email protected]
1514 S. Ashford et al. DisabilRehabil,2013;35(18):1513–1518
As a starting point for this development, Ashford et al. [5] ArmA development. A sub-scale was developed for both active
published a systematic reviewof measures that had been used in and passive function.
the literature to evaluate real-life function or actual performance
in the hemiparetic upper limb. Six measures were identified; the Participants
Leeds AdultSpasticity Impact Scale [6], the MotorActivity Log
(MAL – four different versions) and the ABILHAND [7–11]. In Stage 1, participating clinicians worked in two regional
These appeared to fall broadly into a hierarchy of increasing rehabilitation units, two district rehabilitation services and a
difficulty. community rehabilitation team within the London Region. The
(cid:2) The LASIS was designed to assess passive functionwith an multi-professional panel of clinicians included four physiothera-
active function item, using the affected hand to hold and pists, four occupational therapists (all at clinical specialist or
stabilise objects [6]. senior level) and two consultant physicians in rehabilitation
(cid:2) The MAL and ABILHAND contained more difficult items medicine.
for active function, evaluating a wide range of activities, In Stage 2, the clinicians consisted of specialist physiothera-
including unilateral and bimanual function. pists, occupational therapists and rehabilitation nurses, none of
However, none of these tools provided a comprehensive whom have been involved in earlier stages of development or
assessmentofbothactiveandpassivefunctionreflectiveof‘‘real- evaluation. The consultation document was initially sent to all
life’’,andallhadlimitationsinrespectofpsychometricevaluation members of the UK physiotherapy Adult Spasticity Forum
[5], the arm activity measure (shortly ArmA) was therefore (n¼58). The 25 responding physiotherapists between them
developed to address these deficiencies. identified six occupational therapists with an interest in the
In this article, we report the development of the ArmA. The area. Rehabilitation nurses (n¼5) were identified from local
specific context of this development was the evaluation of rehabilitation services, all of whom had experience of working
interventions for focal spasticity, such as botulinum toxin and withpatientsfollowingstrokeandbraininjury.The totalnumber
physicalmanagement.However,suchameasuremightequallybe of participating clinicians was 36.
appliedintheevaluationofotherfocalinterventionssuchasCIMT. Patients and carers were identified from those receiving
inpatient, outpatient or outreach input through a regional
Aims rehabilitation service.
The aims were:
Procedure
(a) to develop the ArmA – a self-report measure for the
assessment of both active and passive function in the Delphi consultation round 1
hemipareticupperlimbfollowingrehabilitationinterventions
Theshortlistof75itemswaspresentedtotheexpertcliniciansby
and
post or electronic mail. Respondents were asked to identify:
(b) to confirm face and content validity by investigating item
(a) the items from the list which they considered important to
relevance for professionals, patients and carers.
include in a measure ofactive and passive arm function;
(b) items which should be excluded, along with the reason for
Method
exclusion;
Development of the ArmA comprised a multi-stage process of (c) any items that were not on the list whichtheyconsidered to
item selection followed by item reduction and confirmation. be of particular importance, explaining their reasons for
Ethicalapprovalfor theresearchprogramwasreceived(COREC inclusion.
number 05/Q1604/110). After the comments had been returned, and participants
Potentialitemsforinclusionwereselectedfrom(a)analysisof contacted if necessary to clarify any points, the initial list of
thetoolsidentifiedinthesystematicreview[5],selectingallitems items was revised and a short list of 23 items was produced for
identifiedforinclusioninArmAdevelopmentand(b)analysisof round 2.
goals commonly identified by patients as priority goals for
treatmentusingGoalAttainmentScaling[2],inthecontextofour Delphi consultation round 2
routine spasticity management service. The goals analysis had
Theselected23-itemshortlist(togetherwiththeoriginal75-item
threeaimsinsupplementingthefindingsofthesystematicreview:
list for reference) was then returned to the same 10 experts for
(1) identification of new items by patients and carers, (2) con-
their further comment and verification, again asking them to
firmation of passive function items identified in the systematic
identify items for inclusion and exclusion with stated reasons.
reviewand(3)ensuringthatitemsrelevanttotheproximalupper
A further six items were excluded.
limb are considered for inclusion. Goals for focal spasticity
intervention, from 16 patients, were used to identify five
Delphi consultation round 3
categories:passivefunction,activefunction,symptoms,cosmesis
and impairment. Two passive function items not previously Inthethirdround,thesamerespondentswereonceagainsentthe
identified were generated. These were used to draw up an initial original list with the 17-item short list from round 2. One item
shortlist of 75 possible constituent items; 11 items related to was added back in.
passive function and 64 to active function. Following consultation round 3, a draft measure was
Item reduction was conducted in a three-round Delphi constructed using the 18 items identified by the group – 7
consultation process with a small group of purposively chosen relating to passive and 11 to active function.
experienced clinicians (n¼10), based on being senior clinicians Based on the findings of the systematic review (which
(physiotherapist,occupationaltherapistorrehabilitationmedicine identified the same method of scoring for the final six measures
physician) in neurorehabilitation settings – highly specialist, included), the method of scoring items was adopted from these
clinicalspecialistorconsultantlevel(Stage1).Thiswasfollowed final six measures. The method comprised completion based on
by item confirmation through consultationwith awidergroup of activityover the preceding 7daysand was scaled on a five-point
other clinicians (n¼36) in addition to patients and their ordinal scale. This method of scaling responses was adopted as
carers (n¼13 pairs) (Stage 2). See Figure 1 for the stages of the method for the draft ArmA.
DOI:10.3109/09638288.2012.743602 Development of the arm activity measure 1515
Item Systematic review: 73 Items Goal Analysis: 2 Items
selection (9 Passive function) (2 Passive function)
(64 Active function)
Candidate items: 75 Items
(64 Active function) (11 Passive function)
Item Delphi Consultation 1 Items excluded
Reduction Consultation with clinicians Not prioritised by
n = 10 clinicians
(7 Passive function) (48 Active function)
(16 Active function) (4 Passive function)
Delphi Consultation 2
Consultation with clinicians
Items excluded
n = 10
(6 Active function)
(7 Passive function)
(10 Active function)
Additional Delphi Consultation 3
item Consultation with clinicians
Identified by n = 10
clinicians: (7 Passive function)
(1 Active) (11 Active function)
Item Additional Item confirmation Items excluded:
Confirmation items (1 Active function)
Identified by Clinicians Patients & carers
clinicians: n = 36 n = 13 n = 13
(3 Active)
ArmA (version 2)
(7 Passive function)
(13 Active function)
Figure1. SummaryofitemreductionfortheArmA.
Item confirmation Turner-Stokes andconsensus was found.This processresulted in
the version of ArmA for psychometric testing.
Consultation was then extended to the larger group of 36
clinicians, in order to confirm content validity among a wider
representationofclinicians,whichonthisoccasionalsoincluded Results
members of the nursing profession.
The results for reduction of items using modified Delphi
The consultation document circulated by e-mail or post
technique at Stage 1 and the confirmation and pilot testing of
consisted of the draft ArmA and the original list of 75 items.
ArmA at Stage 2 are presented.
Respondentswereaskedtoidentifywithreasonsitemswhichthey
believed should be included or excluded from the draft ArmA.
Stage 1 – Delphi consultation
Theywerealsoaskedtocommentonthewayinwhichitemswere
scaled. Atthis stage, 13 patients and their respective carers were All 10 clinicians initially approached returned the round one
also invited to respond to the same consultation document and consultation document. Following round 1, 48 active function
were also asked to complete the ArmA. items were excluded and four passive function items from the
The responses were then compared with the modified Delphi initial total of 75 items. Consensus for exclusion was between
consultation results. If new items were presented for inclusion 60%and100%(6–10clinicians).Table1presentstheinitialshort
thesewereconsidered,providedtheywereidentifiedbymorethan list of items following round 1.
one respondent, clinician, patient or carer. Stephen Ashford The table also shows the measures from which the items
reviewedallcommentsand madedecisions on changestoArmA originateoridentifiesthattheywerepatientselectedandthebroad
based on (1) issues raised by multiple respondents or (2) issues anatomicalregionofthearmaddressedbyeachitem.Duringround
corresponding to findings from the systematic review. 1, a passive function item, ‘‘Cleaning around the elbow’’ was
Decisions about item inclusion were then discussed with Lynne removed.Thisitemwasremovedontherecommendationofeight
1516 S. Ashford et al. DisabilRehabil,2013;35(18):1513–1518
Table1. Initialshortlistofpassiveandactivefunctionitems(round1),mappedbackontothesystematicreviewmeasureswhy?
Patient Proximal,distal
Functionalitems identified LASIS MAL-14 MAL-26 MAL-28 MAL-12 ABILHAND andwholearm
Splintapplication * Wholearm
Positioningthearmcomfortably * Wholearm
Puttingonaglove * Distal
Cuttingfingernails * Distal
Cleaningthearmpit * Proximal
Cleaningthepalm * * Distal
Puttingarmthroughcoat * * * Wholearm
sleeveordressingthearm
Eatwithaknifeandfork * * * * Wholearm
Pickupaglass,bottle,orcan * * * * * Wholearm
Brushteeth * * * * * Wholearm
Useakeytounlockthedoorþ * * * Wholearm
Combhair * * * * * Wholearm
Pickupacupbythehandle * * * Distal
Writeonpaper * * Distal
Carryanobjectinthehand * * Wholearm
Dialanumberonthephone * * * Distal
Openajar * * Distal
Pickupphone * Wholearm
PutonT-shirt * Wholearm
Doorundobuttonsonclothing * * Distal
Door undoazip * * Distal
Drinkfromcup/mug * Wholearm
Washyourback * Wholearm
Itemsinboldindicatethoseretainedattheendofround3ofitemreduction–modifiedDelphiconsensus.Itemmarkedwithaþwasinitiallyexcluded.
Asterisksindicatethattheitemisincludedinthemeasure.
Table 2. Demographic information of patients (n¼13) and carers
membersoftheconsultationgroup(80%),becauseitwasidentified (n¼13).
asnotbeingrelevantformanypatients.
All 10 clinicians again returned the round 2 consultation Characteristics Patients Carers
document. A further six active function items were removed
Ageofpatients(years) Median(range) 48.5(30–64) –
following round 2. Consensus was between 60% and 80% (6–8
Gender Male 8(62%) –
clinicians) for the removal of these items. Items not in bold in
Female 5(38%) –
Table 1 were removed. Ethnicity White 10(77%) –
All 10 clinicians returned the final round three-consultation Black 1(8%) –
document.Nofurtheritemswereexcludedandtherewasbetween Asian 2(15%) –
80%and100%(8–10clinicians)consensusfortheinclusionofthe Primarypathology Haemorrhagicstroke 5(38%) –
Ischaemicstroke 8(62%) –
itemschosen.Oneitemwhichhadinitiallybeenremoved;‘‘usea
Questionnaire Facetoface 8(62%) 3(23%)
key to unlock the door’’ was re-inserted with the agreement of
completionmethod Postalreturn 4(31%) 7(54%)
80% (8/10 of clinicians (see Table 1, item marked with ‘‘þ’’). Telephone 1(8%) 3(23%)
Stage 2 – item confirmation Carers:spouseorfamily(notprofessionalcarers).
Atotalof58questionnairesweresenttocliniciansand36(62%)
(1) The active function item ‘‘Wash your back’’ was removed
werereturned.Respondentscomprised25(69%)physiotherapists,
and replaced by ‘‘Tucking in a shirt’’, since five of the
six (17%) occupational therapists and five (14%) nurses.
respondents identified that washing your back is done by
Thirty-twoquestionnaireswerepostedordirectlypresentedto
manyablebodiedpeopleusinganaid,whichconcurredwith
16 patients and 16 carers; 13 questionnaires were completed in
views expressed byclinicians during item reduction.
each group (81%). Table 2 presents the characteristics of the
(2) Two additional items were added.
patients and carers returning questionnaires.
(a) The ‘‘Effect of the affected arm on balance when
Recommendations by clinicians, patients and carers (respon-
walking’’ was added following comment by six
dents) for the exclusion and inclusion of items were considered.
respondents. Two clinicians considered this item to
The majority of items (n¼12) were not recommended by potentiallyfitineitherpassiveoractivefunction,since
respondents for removal. Of the remaining six items, only one
although walking is active; the effect of the arm is
had more than two recommendations for removal. Five items
passive. However, the other four respondents felt it
from the original list (taken from the systematic review and
should be in the active function sub-scale.
goals) also provided to respondents were recommended for
(b) The task ‘‘Hold an object still while using the
inclusion. The specific modifications and the items changed are
unaffectedhand’’wasalsoaddedtotheactivefunction
detailed below.
sub-scale following support from seven respondents.
Somewordingadjustmentswerealsorecommended.Theterm
Modifications
‘‘Within the last week’’ was replaced with ‘‘In the last seven
Several modifications resulted from the wider consultation with days’’. The instructions for completion of the two main sections
clinicians, patients and carers. were further refined.
DOI:10.3109/09638288.2012.743602 Development of the arm activity measure 1517
The measure for psychometric testing consisted of two the management of spasticity in the UK, the approach takenwas
domains, active and passive function. Passive function contains adequate and produced comprehensive comments.
sevenitems.Activefunctioncontains13items.Asummaryofthe Thepatientandcarergrouppilottestingthequestionnairewas
changestoitemsthroughthedifferentstagesofdevelopmentcan relatively small but it is unclear if increasing this would make a
be observed in Figure 1. significant difference to achieve feedback that is more informa-
tive. A more representative sample could, however, have been
considered. However, this limitation, while an important con-
Discussion
sideration, does not invalidate the pilot testing applied for the
The development of the ArmA included the modified Delphi ArmA, which was sufficient to enable subsequent psychometric
consultation and further confirmation of items taken from a testing.
systematic review and goal setting in clinical practice. The Following psychometric evaluation of the ArmA after Delphi
resulting 20-item (two sub-scales) tool consists of seven passive consultation, one previously excluded passive function item has
function sub-scale items and 13 active function sub-scale items. been identified which merits further consideration regarding its
ThemodifiedDelphiconsultationensuredcontentvalidity,dueto place in the measure. During item reduction, ‘‘cleaning around
the experience of the clinicians in this area of practice, and theaffectedelbow’’wasremovedduringthefirstroundofDelphi
therefore appropriate reduction of items. Item confirmation with consultation. This item was removed on the recommendation of
wider consultation of clinicians in spasticity management eight members of the consultation group. However, from a
confirmed the selection of items, and also enabled some clinicalperspective‘‘Easeofelbowcreasehygiene’’continuedto
modification to take place. besetasagoalforparticipantsinthepsychometricevaluationand
ModifiedDelphiconsultationwasselectedbecauseitprovides associated cohort study (n¼6). This item has been added to the
anonymity to participants and reduces personality based influ- currentversionoftheArmAandevaluatingthescalingproperties
ences such as the impact of socially dominant individuals on the of the modified measure will be required in future work
consensus process [12,13]. Finger et al. [13] consider the Delphi (Table A1).
method to have four key characteristics: anonymity for those The ArmA is a measure of difficulty in passive and active
participating; iteration of concepts; statistical group response function for application following focal therapy intervention and
based on frequencyof selections (in this instance item selection) in particular for spasticity (botulinum toxin and physical)
and informed input from expert participants. The literature interventions. The active and passive sub-scales of the tool are
provides no definitive recommendation on panel size, which treated as separate constructs, which nevertheless have a
haverangedgreatlyindifferentstudiesbetween10and1685[14] relationship and are both important to the achievement of
andintherehabilitationliteraturefrom15[15]to263[13].Raine clinically relevant goals. The ArmA is therefore likely to have
[15] suggests that good results can be obtained with between 10 utility in practice for the evaluation of spasticity intervention
and 15 panel participants where the group is homogenous, and (oftenforpassivefunction)andpossiblyotherfocalinterventions
that smaller groups such as this are also more likely to retain such as task practice training for active function improvement.
group members. In conclusion, (1) a test for real arm activity was developed
A possible limitation of prioritising the items generatedusing and(2)theDelphimethodconfirmedthecontentandfacevalidity
the Delphi process and wider consultation is that a set of oftheArmA.TheuseofDelphiconsultationwiththeadditionof
homogeneous items will be produced, which risks losing the further clinician and patient involvement has resulted in a
uniqueness of the broader range of items important for measure for psychometric testing, which should provide impor-
hierarchical scaling [16]. Homogeneity may be a strength in tant clinical information and be feasible in practice. The process
supportingunidimensionality(inasingleormultipledimensions), ofitemselection,reductionandconfirmationwascomprehensive
butagroupofverysimilaritemsmayalsoleadtoasetofitemsof and while limitations to the methodologyare present, the overall
similar difficulty [17,18]. However, in practice, it may be less process had a high degree of rigour ensuring confidence in
significant because items selected were focused on lower level content validity of the ArmA measure produced. The psycho-
active function more likely to change in a patient group metric properties (construct validity, internal consistency, uni-
undergoing spasticity intervention, which was the focus of the dimensionality,reproducibilityandfeasibility)oftheArmAhave
measure developed. In addition, confirmation of item selection undergonepreliminaryevaluationandaredescribedinaseparate
alsoincludedtheanatomicalregion(proximal,middleanddistal) paper.
ofthearminvolvedinperformingeachitem.Boththepassiveand
active function sub-scales therefore contain a range of items Acknowledgements
addressingeachoftheseanatomicalregions.Unidimensionalityis
The authors thank patients, carers and colleagues who helped with this
furtherevaluatedusingprincipalcomponentanalysisandMokken
developmentwork.
analysis [19] in the psychometric testing of the ArmA.
Selection of all clinical groups could have been enlarged to
Declarations of interest
ensure a true national survey for the item confirmation by
approaching the respective professional bodiesor special interest Theauthorsreportnospecificdeclarationsofinterest.
groups[20].Breadthofexperienceamongthecliniciansmayalso
have been improved by selection through a professional References
organisation. This approach would have given more support to
1. WadeDT,CollinC.TheBarthelADLIndex:astandardmeasureof
the content validity of the measure and may have led to a larger physicaldisability?IntDisabilStud1988;10:64–7.
consultation with a more consistent national focus. The group 2. AshfordS,Turner-StokesL.Goalattainmentforspasticitymanage-
selected was also biased towards physiotherapists and although mentusingbotulinumtoxin.PhysiotherResInt2006;11:24–34.
this professional group undertake much upper limb assessment, 3. SheeanGL.Botulinumtreatmentofspasticity:whyisitdifficultto
showafunctionalbenefit?CurrOpinNeurol2001;14:771–6.
they are certainly not the only profession involved. A more
4. Shaw L, Rodgers H, Price C, et al. BoTULS: a multicentre
representative sample should include more balance between the
randomised-controlledtrialtoevaluatetheclinicaleffectivenessand
differentprofessionsandensuringanationalsurveyisundertaken. cost-effectivenessoftreatingupperlimbspasticityduetostrokewith
However, given that physiotherapists are commonly involved in botulinumtoxinA.HealthTechnolAssess2010;14:iii–iv.
1518 S. Ashford et al. DisabilRehabil,2013;35(18):1513–1518
5. Ashford S, Slade M, Malaprade F, et al. Evaluation of functional 13. Finger M, Cieza A, Stoll J, et al. Identification of intervention
outcome measures for the hemiparetic upper limb: a systematic categoriesforphysicaltherapy,basedontheinternationalclassifica-
review.JRehabilMed2008;40:787–95. tion of functioning, disability and health: a Delphi exercise. Phys
6. Bhakta BB, Cozens J, Chamberlain M, et al. Impact of botulinum Ther2006;86:1203–20.
toxin type A on disability and carer burden due to arm spasticity 14. ReidN.TheDelphitechnique:itscontributiontotheevaluationof
after stroke: a randomised double-blind placebo-controlled trial. professional practice. In: Ellis R, ed. Professional competence and
JNeurolNeurosurgPsychiatry2000;69:217–21. qualityassuranceinthecaringprofessions.London:ChapmanHall;
7. Uswatte G, Taub E, Morris D, et al. The Motor Activity Log-28 1988:230–63.
assessing daily use of the hemiparetic arm after stroke. Neurology 15. Raine S. Defining the Bobath concept using the Delphi technique.
2006;67:1189–94. PhysiotherResInt2006;11:4–11.
8. UswatteG,TaubE,MorrisD,etal.Reliabilityandvalidityofthe 16. MassofRW.Applicationofstochasticmeasurementmodelstovisual
upper-extremity Motor Activity Log-14 for measuring real world function rating scale questionnaires. Ophthalmic Epidemiol
armuse.Stroke2005;36:2493–6. 2005;12:103–24.
9. van der Lee JH, Beckerman H, Knol DL, et al. Clinimetric 17. LinacreJM.Samplesizeanditemcalibrationstability.RaschMeas
propertiesoftheMotorActivityLogfortheassessmentofarmuse Trans1994;7:328.
inhemipareticpatients.Stroke2004;35:1–5. 18. MartinM,LiuH,SpritzeK,etal.Itemresponsetheorymethodscan
10. PentaM,TesioL,ArnouldC,etal.TheABILHANDquestionnaire improve the measurement of physical function by combining the
as a measure of manual ability in chronicstrokepatients – Rasch- modified health assessment questionnaire and the SF-36 physical
basedvalidationandrelationshiptoupperlimbimpairment.Stroke functionscale.QualLifeRes2007;16:647–60.
2001;32:1627–34. 19. Wismeijer AAJ, Sijtsma K, van Assen MA, et al. A comparative
11. Penta M, Thonnard J-L, Tesio L. ABILHAND: a Rasch- study of the dimensionality of the self-concealment scale using
built measure of manual ability. Arch Phys Med Rehabil 1998; principal component analysis and Mokken scale analysis. J Pers
79:1038–42. Assess2008;90:323–34.
12. BurnsSP,RivaraFP,JohansenJM,etal.Rehabilitationoftraumatic 20. DeaneKHO,Ellis-HillC,DekkerK,etal.ADelphisurveyofbest
injuries: use of the Delphi method to identify topics for evidence- practiceoccupational therapyforParkinson’sdisease intheUnited
basedreview.AmJPhysMedRehabil2003;82:410–14. Kingdom.BrJOccupTher2003;66:247–54.
Appendix
TableA1. ArmAitems.
Difficultyforeachitemisscoredovertheproceeding7dasfollows
0¼Nodifficulty
1¼Mild
2¼Moderate
3¼Severedifficulty
4¼Unabletodoactivity
SectionA:Caringforyouraffectedarm(notusingitintasksoractivities)
1.Cleaningthepalmofthehand
2.Cuttingfingernails
3.Cleaningthearmpit
4.Cleaningtheelbowcrease*
5.Positioningarmonacushionorsupportinsitting(ifneverdonecircle0)
6.Puttingarmthroughagarmentsleeve
7.Puttingonaglove(ifneverdonecircle0)
8.Puttingonasplint(ifneverdonecircle0)
SectionB:Independentlycompletingtasksoractivitiesusingyouraffectedarm
1.Doupbuttonsonclothing
2.Pickupaglass,bottle,orcan
3.Useakeytounlockthedoor
4.Writeonpaper
5.Openapreviouslyopenedjar
6.Eatwithaknifeandfork
7.Holdanobjectstillwhileusingunaffectedhand
8.Difficultywithbalancewhenwalkingduetoyourarm
9.Dialanumberonhomephone
10.Tuckinyourshirt
11.Comborbrushyourhair
12.Brushyour teeth
13.Drinkfromacupormug
*Iteminsertedfollowingpreliminarypsychometrictestingreportedinasubsequentpaper.
TheArmAisfreelyavailabletouseandcanbeobtainedfromtheKing’sCollegeLondon,Departmentof
PalliativeCare,PolicyandRehabilitation,website(http://www.csi.kcl.ac.uk/arma.html).