Measurement Tools of Stroke

Patients in Rehabilitation
Review of existing scales and tests and their psychometric properties

Professional assignment of Hogeschool van Amsterdam

School of physiotherapy
Amsterdam 26/01/2007
Yaara Levi
Zohar Raveh

Table of contents
1. Acknowledgments
2. Introduction
1.1 The client
1.2 Measurements in rehabilitation
3. Stroke
3.1 Definitions
3.2 Epidemiology and impact
3.3 Stroke manifestation
4. Quality of a measuring instrument
4.1 Reliability
4.2 Validity
4.3 Responsiveness
5. Method
5.1 The search process
5.2 Criteria list
5.3 The analysis
5.4 The product
6. Scale analysis
6.1 Function and structures
6.1.1 Motor
6.1.2 Tone
6.1.3 Trunk stability
6.1.4 Balance
6.1.5 Pain
6.1.6 Sensation
6.1.7 All in one
6.2 Activity
6.2.1 Mobility
6.2.2 Arm and hand mobility
6.2.3 Activity of daily living
6.2.4 Disability
6.3 Participation
6.3.1 Quality of life
7. Conclusion
8. References

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*Appendix 1 : All Scales Seperate booklet

1. Acknowledgments
We would like to thank our client Nitza Kaner for giving us the apportunity to work
on such a fascinating project and the learning process it brought with it. We would
also like to thank Jaap Bakker and Jesse Aarden for helping us along in the progress
and giving us great advice and guidance. Last but not least, we thank Avihay Haim
for helping us with the design of the computer program.

2. Introduction
This end project of our third year of study is aimed to release us into the world ready
to work as physiotherapists. We were approached by a client Nitza Kaner who is a
physiotherapist in a rehabilitation center in Afula Israel, and her request was to make
a digital catalogue of assessment scales and tests for stroke patients.
This paper is aimed to describe the process towards the end product and to explain
our decisions during our course of action.
In the introduction we will describe shortly the rehabilitation center and their need
for assessment tool box and measurements in rehabilitation medicine.
The scales and tests we put in the tool box could be used for all neurological
patients; however we decided to focus on stroke patients since in the rehabilitation
clinic they are most prevalent.

2.1 The client

The rehabilitation center Sav-Yom located in Afula, Israel, is an out patient clinic,
has many patients ages 18 and above and deals with all spectrums of neurological
and orthopedic patients, however it specializes in stroke rehabilitation. It is a
multidisciplinary clinic consisting of physiotherapists, occupational and speech
therapists, social worker and doctors. Until today, the assessment of stroke patients
in the clinic was performed using observation and subjective measurements and not
by quantifying data using assessment scales and tests. The need for this tool box
arises from a movement, which is occurring in the physiotherapy field of using a
more scientific and accurate measurements and assessment in practice.

2.2 Measurement in rehabilitation

Rehabilitation medicine focuses on the impact of disease rather than on the disease
itself, therefore disability and handicap assessment is a key element in the process of
rehabilitation (van Bennekom et al. 1995). Wade (1992) in his book Measurement
in neurological rehabilitation starts off by stressing the importance of having a model
of rehabilitation when discussing assessment. He discusses the ICIDH model of
World Health Organization (WHO) but since the book was written a newer model has
been accepted. This model is the ICF and it has been published and accepted by 191

countries since 2001. It is a classification of health and health related domains that
describe body functions and structures, activities and participation. The domains are
classified from body, individual and societal perspectives. ICF is useful to understand
and measure health outcomes. It can be used in clinical settings, health services, or
surveys at the individual or population level (World Health Organization 2001).

The terms measurement and assessment are often used interchangeably especially
when referring to the tools used to collect information (Wade 2004). In rehabilitation
assessment refers to the process of evaluating a patient problem including
recognition and measurement of the problem and determining the cost and the
extent. Measurement is to quantify and to determine the extent of something by
comparison with a standard unit (Wade 1992).
According to Wade there are several reasons why a patient should be assessed:
Diagnosis refers to understanding of whether a specific item is present or absent
but also to the structures, activities and participation, which are impaired.
Prognostics determining who is likely to recover well and the extent of help the
patient will need.
Measurement determining the severity of the problem and the changes that
occur through time.
Process Keeping a record of the treatments given to the patients.
Others administration and legal reasons.
The importance of using quantified measurements as part of the whole assessment
is to detect change, quantify input and outcome and to evaluate effectiveness of our
intervention. We also believe that by using quantified measurements we could show
the patients their improvements therefore motivating them.

3. Stroke
3.1 Definitions
The term stroke is used synonymously with cerebrovascular accident (CVA). The
World Health Organization defines stroke as a condition characterized by rapid
developing symptoms and signs of a focal brain lesion, with symptoms lasting for
more than 24 hours or leading to death, with no apparent cause other than that of
vascular origin (Stokes 2004).

3.2 Epidemiology and impact

The WHO estimated that 16.7 million people around the globe die of cardiovascular
disease (CVD) each year. This is over 29 percent of all deaths globally. Of the 16.6
million deaths from CVDs every year, 7.2 million are due to ischaemic heart disease,
5.5 million to cerebrovascular disease, and an additional 3.9 million hypertensive and
other heart conditions. As well, at least 20 million people survive heart attacks and
strokes every year, a significant proportion of them requiring costly clinical care,
which puts a huge burden on long-term care resources. CVD affects people in their
mid-life years, undermining the socioeconomic development, not only of affected
individuals, but families and nations (World Health organization 2003).
3.3 Stroke manifestation
Stroke can have effects on the patients body structures and functions, activities and
participation in society. Some example of these that are related to the field of
physiotherapy can be:

Impairments in Structures and functions:

- Motor:

Paralysis/paresis

Spasticity

Instability

Lack of coordination

Imbalance
- Sensation

Proprioception disturbances

Pain


Hypoesthesia /anaesthesia
- Visual

Hemionopia

Diplopia
- Other Organs abnormalities

Bowel/bladder dysfunction

Orofacial dysfunction like Dysphagia
- Higher cortical functions

Neglect

Amnesia

Personality changes

Apraxia/ Dyspraxia

Aphasia

Agnosia

Activity limitations in the sphere of:

Mobility

ADL/I-ADL

Participation restriction in the sphere of:

Work

Hobbies

Social interaction

Lead a wholesome, fulfilling life.
(Stokes 2004).

Because we recognize this method of classifying the patients problems as an

important concept to have for the assessing and treating the patient, our scales will
be organized according to this classification.

4. Quality of a measuring instrument

The usefulness of measurements in clinical research and decision-making depends
on the extent to which clinicians can rely on data as accurate and meaningful
indicators of a behavior or attribute (Portney and Watkins 2000). This is dependent
on the psychometric properties of the instrument, which are reliability; intra, inter
and internal consistency, validity; content, construct predictive and concurrent and
responsiveness. There are more properties of measurement tools, but we focused
only on the above mentioned because we found they are the most common and
believe they are more important. The definitions of these terms are as followed:

4.1 Reliability
Reliability concern the degree to which a measuring tool accounts for random error
and therefore repeatability and consistency (Gaubert and Mockett 2000).
-

Intrarater reliability refers to the stability of data recorded by one

individual across two or more trials

Interrater reliability - Concerns variation between two or more raters

who measure the same group of subjects

Internal consistency - the extent to which items measure various

aspects of the same characteristics and nothing else (Portney and
Watkins 2000).

4.2 Validity
Validity Places an emphasis on the objectives of a test and the ability to make
inferences from test scores or measurements.
-

Content validity refers to the extent to which the content of an

instrument reflects the domain of content of the attribute being
measured (Fujiwara et al. 2004). For example a scale that measures
muscle strength should not contain items that assess sensitivity.

Construct validity Reflects the ability of an instrument an abstract

concept, or construct.

Predictive validity attempts to establish that a measure will be a

valid predictor of some future criterion score. An example for this

might be that a low score on the Barthel index after a stroke

indicates poor chances of recovery.
-

Concurrent validity is usually established by demonstrating a high

correlation between the scale and a gold standard. For example when
a new scale is developed it is correlated with an already proven to be
valid scale that measures the same construct (Portney and Watkins
2000).

4.3 Responsiveness

Responsiveness - The ability to detect changes that are meaningful or clinically

important (Pickard et al. 2005).

When assessing the stroke scales and tests we will check whether all these
psychometric properties have been scientifically assessed. This is important to the
quality and usefulness of the scales and tests.

5. Method
In the next section we will describe the process we went through to reach our end
product.

5.1 The search process

Firstly we read the Dutch stroke guidelines and the book measurement in
Neurological rehabilitation by Wade to formulate a list of all scales that were
relevant to the rehabilitation phase of a stroke patient. For example the NIH stroke
scale is used in the acute phase of the stroke therefore was excluded from the list.
When we had the list, we divided our scales and tests into the impairments in
structures and functions, activity and participation categories. We then started our
search for each scales psychometric properties. We used the well-known databases
of Pubmed, Google Scholar, Scirus, and Pedro.
To search for specific articles we used the following key words: the name of each
scale, validity/reliability/responsiveness/psychometric properties together with stroke.
Only full articles in the English language were reviewed. We decided that the
published year is not important in our case because some of the most used scales
have been around since the 50s and were already proven to be reliable and valid at
that time. We used articles that we could find in the database and those are usually
from the year 95 and above.
During our search we found more scales and tests, which have been more recently
developed and added them to our list and performed a search of articles for them as
well. We read each article and got the information we needed about the same
subject.

5.2 Criteria list

We went on to develop a criteria list to check each measurement tool. We divided
the scale into six items; four are related to the psychometric properties of the scale
based on literature and is awarded eight points, two items are related to the practical
use of the scale and is awarded four points. The scale ranges from 4 to 12 points.

Grading Criteria

1. Validity

Points

Reference

of the scale :
Content validity proven: 1 point
Concurrent validity proven: 1 point
Predictive validity proven: 0.5 point
Construct validity proven: 0.5 point
No validity has been proven: 0 point
The scale has been proven to be not
valid: -2 point2

/3

2. Reliability of the scale :

Intrarater reliability proven: 1 point
Interrater reliability proven: 1 point
Internal consistency proven: 1 point
No reliability has been proven: 0 point
The scale has been proven to be not
reliable: -2 point

/3

3. There have been articles that proven

responsiveness of the scale: 1 point

/1

4. The scale have been used as a golden standard to

proven a new scale validity: 1 point

/1

5. Takes 15 minutes or less to complete: 2 point

/2

6. Does not require special equipment specific for the

test: 2 point

/2

Total

/12
Range: -4 points to 12 points

1. If only a part of the scale has been proven for one of the categories it will get a score of 0.5 point.
2. Minus points are awarded to a scale if there is evidence proving that the scale is not valid or
unreliable.

10

5.3 The analysis

After having completed the criteria list, we applied the list on each of the 28 scales
that were chosen, and gave the references. We also formed a short description for
each scale using the literature.
Now that we had all the scales scored, we made an average of the scores, which is
6.125. We decided that in our tool box we would use the scales that received a
score that is higher than six. If the scale is the only one in the category we will use it
as well even though the score is not high enough like the Nottingham Sensory
Assessment. If in a specific category none of the scales have a score of six, the scale
with the highest score will be used.

5.4 The product

The computerized catalogue will consist of all the scales that made the final
selection. The program will be divided according to the WHO classification; structure
and function, activity and participation and our subdivision mentioned in paragraph
3.3. A short description of each scale will also be included as well as any instructions
or guidelines on how to perform or score the tests.
This paper will also be included in the catalogue, so the examiners can follow our
rationale and use the references for further information.

11

6. Scales analysis
6.1. Functions and structures
6.1.1 Motor

A. Rivermead motor assessment scale

It is a 38 items scale divided into 3 categories: gross function, leg and trunk, and
arm with total score of 37. It assesses motor functions but also activities therefore it
is not exclusively a motor scale.

Criteria

Point

References

1. Validity

0/3

Wade (1992) mentions reasonable validity and reliability but offers no

references to support this comment.

2. Reliability

0/3

3. Responsiveness

0/1

4. Golden standard 1/1

The test has been used to validate the Motricity index and Trunk
control test (Collin and Wade 1990).

5. Brief

0/2

This scale is too long for routine use (Collen et al. 1990).

6. No special

2/2

The scale requires equipment that is normally available in a

equipment
Total

rehabilitation clinic like balls and silver wear.

3/12

12

B. Motor assessment scale

The motor assessment scale was designed to measure the functional capacity of
stroke patients. The scale consists of 8 hierarchical items related to motor function
and one item related to muscle tone. Each item is scored on a scale of 0 to 6. The
criteria for each score on the scale corresponds to a description of the activity to be
performed (Hsueh et al. 2002).

Criteria

Point

References

1. Validity

1/3

Concurrent validity has been proven (Poole and Whitney 1988).

2. Reliability

1/3

Interrater reliability has been proven (Poole and Whitney 1988, Carr
et al. 1985).
The test is well studies with good support for validity and reliability
except for the tone item, which is unreliable (wade 1992).

3. Responsiveness

0.5/1

Responsiveness of only the upper extremity part of the scale has been
tested and was found moderate. Change at the level of disability is
closely related to change at the level of impairment in relation to arm
function (Hsueh et al. 2002).

4. Golden standard 1/1

Action Research Arm Test was validated by the motor assessment

scale (Hsieh et al. 1998).

5. Brief

2/2

The scale is brief and easily administered (Carr et al. 1985).

6. No special

2/2

The scale requires many items such as a stool, stopwatch etc, which

equipment

are easily found in a rehab clinic and do not need to be bought

especially for the test.

Total

7.5/12

13

C. Motricity Index
The Motricity Index is a brief means of assessing motor impairment by examining
one movement at three joints or portions of the upper extremity (pinch grip, elbow
flexion, shoulder abduction) and one movement at three joints of the lower extremity
(Kopp et al. 1997). The movement is given a score according to the strength. The
Scores are between 0 for no movement and 33 for normal movement. Than the arm
score is added to the leg score and divided by two.

Criteria

Point

References

1. Validity

1/3

Concurrent validity has been proven (Collin and Wade 1990). Also
the concurrent validity of the leg portion of the index has been
proven when it was correlated with the strengths of the muscle
groups measured by a hand held dynamometry (Cameron et al.
2000).

2. Reliability

1/3

Interrater reliability and internal consistency of the lower limb

portion found to be good (Collin and Wade 1990, Cameron et al.
2000) awarded 0.5 for each.

3. Responsiveness

0/1

4. Golden standard 0.5/1

The arm portion of the index has been used as a golden standard
to correlate with a newly formed test (Kopp et al. 1997).

5. Brief

2/2

6. No special

2/2

equipment
Total

6.5/12

14

6.1.2 Tone

A. Modified Ashworth scale

It is assessed by given a score to the resistance to a passive movement of one joint
(usually the elbow or knee joint). The scale ranges from 0 (no increase in muscle
tone) to 4 (rigid in flexion or extension). It is a fast and easy test to perform.

Criteria

Point

References

1. Validity

-2/3

It has been proven that the scale is not valid for measuring spasticity
however it may be valid for measuring resistance to passive
movement (Pandyan et al. 2003). Validity is questioned due to lack of
interrater reliability (Blackburn et al. 2002, Ansari et al. 2006).

2. Reliability

2/3

Both Intrarater and interrater reliability has been proven (Gregson et

al. 1999, Gregson et al. 2000, Bohannon et al 1987). In addition the
reliability of the scale has been proven in the lower extremity
(Blackburn et al. 2002).

-2/3

Intrarater reliability has been found to be poor (Blackburn et al. 2002,

Ansari et al. 2006). Ansari used untrained raters.

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/1

6. No special

2/1

equipment
Total

2/12

15

6.1.3 Trunk stability

A. Trunk Control Test

The test evaluates three movements and one posture. The total score ranges from 0
to 100 points; a higher score indicates a better trunk performance. A limitation to the
test is that it does not take the quality of movement into account (Verheyden et al.
2006).

Criteria

Point

References

1. Validity

2/3

Concurrent validity has been proven by correlating the test with the
Rivermead motor assessment (Collin and Wade 1990).
Construct and predictive validity were proven. The individual items
were correlated with the FIM and the TCT scores were shown to
predict the recovery of more complex motor function (Frenchignoni et
al. 1997).

2. Reliability

1/3

3. Responsiveness

0/1

4. Golden standard

1/1

Interrater reliability has been proven (Collin and Wade 1990).

The newly developed Trunk Impairment Scale was correlated with the
TCT as a proof of its validity (Verheyden et al. 2004).

5. Brief

2/2

6. No special

2/2

equipment
Total

8/12

16

B. Trunk Impairment Scale (TIS)

The TIS consists of three subscales; static sitting balance, dynamic sitting balance
and coordination. Each subscale contains between three and ten items. The TIS
score ranges from a minimum of 0 to a maximum of 23 (Verheyden et al. 2004).

Criteria

Point

References

1. Validity

2/3

Construct, concurrent and predictive validity were proven (Fujiwara et

al. 2004).
Correlating the test with the Trunk control test proved concurrent
validity. Predictive validity was analyzed by how the TIS total scores
contributed to the prediction of discharge functional status (Fujiwara
et al. 2004).

2. Reliability

2/3

The internal consistency and Interrater reliability of the Trunk control

test has been proven to be sufficient for use in clinical practice and
stroke research (Verheyden et al. 2004).

3. Responsiveness

1/1

The responsiveness of the TIS was satisfactory and comparable with

that of the Trunk Control Test (Fujiwara et al. 2004).

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

9/12

17

6.1.4 Balance

A. Berg balance scale

The Berg balance scale (BBS) evaluates a persons performance on 14 items (one
sitting and 13 standing items) related to balance function that are frequently
encountered in everyday life. The scoring method is based on a five point ordinal
scale of 0-4, with a total score ranging from 0-56 (Mao et al. 2006). The scale
requires the subject to maintain a static position and change the orientation.

Criteria

Point

References

1. Validity

1.5/3

Concurrent validity has been proven to be high by correlating the BBS

with two balance measurements: Postural assessment Scale for Stroke
and the balance portion of the Fugl Meyer (Mao et al. 2002). In
addition, concurrent validity was tested by correlating the BBS with
laboratory measures of balance (Stevenson and Garland 1996). The
scale estimates the length of stay in the hospital, which indicate
predictive validity (Wee et al. 2003).

2. Reliability

3/3

Interater reliability and internal consistency has been found to be high

(Mao et al. 2002). The agreement between raters was excellent (ICC
= 0.98) as was the consistency within the same rater at two points in
time (ICC = 0.97) (Berg et al. 1995).

3. Responsiveness

1/1

The BBS had fair to good levels of responsiveness before 90 days of

recovery (Mao et al. 2002)

4. Golden standard

1/1

The BBS has been used as a golden standard to validate a new

balance scale the Balance Master (Liston and Brouwer 1996). In
addition, in order to contribute the criterion-related validity of a
serious of functional balance test the BBS was compared (Tyson and
Desouza 2004).

5. Brief

0/2

It applied within 20 minute (Stevenson and Garland 1996).

6. No special

2/2

Require minimum of readily available equipment (step, stopwatch,

equipment
Total

roller and a chair) (Stevenson and Garland 1996).

8.5/12

18

B. Postural assessment for stroke scale (PASS)

The scale is designed to assess and monitor postural control after stroke (Benaim et
al. 1999). It contains twelve four-point items that grade performance for situations
of varying difficulty in maintaining or changing a given lying, sitting or standing
posture. Its total score ranges from 0-36. The score of 0 is given if the subjects
cannot perform the activity and 3 if they can perform the activity without help (Wang
et al. 2005).

Criteria

Point

References

1. Validity

2.5/3

Concurrent validity has been proven to be high at each stage of

stroke. It has been proven by correlating the scale with 2 other
balance scales; BBS and balance portion of Fugl-Meyer (Mao et al.
2002).
Predictive validity has been proven by correlating it with the total FIM
score and making the conclusion that it is an early relevant indicator
for long-term functional prognosis (Benaim et al. 1999).
Content validity has been also proven (Benaim et al.1999).

2. Reliability

2/3

Interater reliability and internal consistency has been found to be high

(Mao et al. 2002). High interrater and test retest reliabilities has
been found (Benaim et al. 1999).

3. Responsiveness

1/1

The Pass had fair to good levels of responsiveness before 90 days of

recovery (Mao et al. 2002).

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

9.5/12

19

6.1.5 Pain

A. Visual analogue scale

The Visual Analogue Scale (VAS) consists of a 10 cm line anchored by 2 extremes of

pain. The extremes are no pain and pain as bad it could be. Patients are asked to
make a mark on the line, which represents their level of perceived pain intensity, and
the scale is scored by measuring the distance from the no pain end to the patients
mark (Jensen et al. 1986).
Criteria

Point

References

1. Validity

0/3

We found articles referring to the reliability and validity of this test but
could not find articles using stroke patients (Jensen et al. 1986). We
found one article that questions the ability of stroke patients to use
the scale because of cognitive impairments and neglect (Price et al.
1999).

2. Reliability

0/3

3. Responsiveness

0/1

4. Golden standard

1/1

Used to validate the faces pain scale for stroke patients (Benaim et al.
2006).

5. Brief

2/2

6. No special

2/2

equipment
Total

5/12

20

B. Numeric pain rating scale (NPRS)

One type of NPRS has a range from O to 10 with the patients being asked to select a
number that best represents their intensity of pain. The O represents no pain. The
10, however, has been used to represent pain as bad as it can be (Mawdsley et al.
2002).
Criteria

Point

References

1. Validity

0/3

We found articles referring to the reliability and validity in elderly

patients but not for stroke patients (Mawdsley et al. 2002).

2. Reliability

0/3

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

4/12

C. Faces pain scale (FPC)

The FPS is a horizontal seven-point scale that displays varying levels of discomfort by
means of schematic face depictions. Face 0 represents no pain, and face 6
represents the worst possible pain. Patients select the face that best describes
their present state of pain. The FPS does not require speaking ability, but may be
biased in the case of unilateral spatial neglect because of the horizontal disposition of
the faces (Benaim et al. 2006).

Criteria

Point

References

1. Validity

0.5/3

The content validity has been proven but only for left hemispheric
stroke patients but not for the right (Benaim et al. 2006)

2. Reliability

1/3

Inter and intrarater reliability has been found to be good but only for
left hemispheric stroke patients (Benaim et al. 2006).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

5.5/12

21

6.1.6 Sensation

A. Nottingham Sensory Assessment Scale

The Nottingham Sensory Assessment Scale was developed as a sensory assessment
tool for physiotherapists. The assessment incorporates separate tests for different
somatosensory modalities, i.e. light touch, pressure, pinprick, temperature, tactile
localization, bilateral simultaneous touch, appreciation of joint movement, two-point
discrimination, joint position sense, and stereognosis (Gaubert and Mockett 2000).
The scoring is 0,1&2, which is absent, impaired and normal.
There are also modification and revisions to this scale, which make it quicker to
perform (Lincoln et al. 1998, Stolk-Hornsveld et al. 2006).

Criteria

Point

1. Validity

0/3

2. Reliability

0.5/3

References

We could find articles that referred to the reliability of the scale but
could not find the article itself The unreliability of sensory
assessment by Lincoln (Lincoln et al. 1998, Gaubert and Mockett
2000).
The stereognosis part of the scale has found to have high interrater
reliability (Gaubert and Mockett 2000).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

0/2

6. No special

2/2

equipment
Total

The scale requires such equipment as a pen, coins, blindfolds, cotton

ball etc. This is readily available in any clinic.

2.5/12

22

6.1.7. All in one

A. Stroke impairment assessment set (SIAS)

The SIAS was developed to assess various aspects of impairments in patients with
stroke in daily clinical setting. It consists of the nine categories of motor function:
tone, sensory function, ROM, pain, trunk function, visuospatial function, speech,
sound-side function, which are further divided into twenty two items. Each subscale
is scored differently and the score ranges from 0-3 or 5 points (Liu et al. 2002).

Criteria

Point

References

1. Validity

0.5/3

Stroke outcome is successfully predicted using SIAS correlated with

the FIM proving predictive validity (Sonoda et al. 1995, Tsuji et al.
2000).
Concurrent validity and responsiveness has also been proven but the
articles are in the Japanese language.

2. Reliability

1/3

Interrater reliability has been found to be satisfactory (Chino et al.

1995).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

0/2

6. No special

2/2

equipment
Total

3.5/12

23

6.2 Activity
6.2.1. Mobility

A. Rivermead Mobility Index

The Rivermead Mobility Index was developed to measure mobility in-patient with
head injury or stroke. It comprises of 14 questions and one direct observation it
covers a range of high hierarchical activity from turning over in bed to running. It is
short, simple, and clinically relevant, and can be used in hospital or at home.

Criteria

Point

1. Validity

2/3

References
Construct, predictive and concurrent validity has been proven
(Antonucci et al. 2002, Collen et al. 1991, Rossier et al. 2001, Hsieh et
al. 2000).
The construct validity has been proven by comparing results of the
RMI with those of the Berg balance scale (BBS) and the Barthel index
(BI). The predictive validity has been asses by comparing the result of
the RMI at admission with those of the BI at discharge (Hsieh et al.
2000).

2. Reliability

1/3

Interrater reliability has been proven (Rossier et al. 2001).

5. Responsiveness

1/1

The responsiveness of the scale has been proven (Hsieh et al. 2000,
Hsueh et al. 2003).

6. Golden standard

0/1

7. Brief

2/2

18. No special

2/2

equipment
Total

8/12

24

B. Timed walking tests (2,6, and 12 minutes walking tests)

The timed walking tests are used by clinicians to measure cardiovascular endurance.
The simplicity of these tests has lead to their use in the assessment of patients with
functional disability due to neurological disorder (Kosak and Smith 2005). Most of the
literature describes the 6-minute walk test.
The patient is asked to walk as far as they can in the given time, and the distance is
measured. The patient should not be encouraged to walk faster and should wear
comfortable footwear. Walking aids can be used if the patient uses them normally.

Criteria

Point

1. Validity

0/3

2. Reliability

2/3

References

2,6,and 12 minutes walk test showed acceptable inter and intrarater

reliability (Kosak and Smith 2005). The 6 minutes walk test has the
best reliability compared to other gait performance tests like the
Timed up and go test (Flansbjer et al. 2005).

3. Responsiveness

1/1

All has been found to be responsive, however the 6-minute walk test
has been found to be the most responsive (Kosak and Smith 2005).

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

7/12

25

C. Timed up and go test (TUG)

The timed up and go test is a simple and quick functional mobility test that requires
the subject to stand up, walk three meters, turn, walk back and sit down (Shamay et
al. 2005).

Criteria

Point

1. Validity

0/3

2. Reliability

1/3

References

Intrarater reliability has been proven to be of high degree (Shamay et

al. 2005, Flansbjer et al. 2005).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

5/12

D. 5-and 10-meter walking tests

The 5-and 10-meter walking tests are quick simple tests that can be done easily in
the clinic or at home (Green et al. 2002). It measures short distance gait speed.
The patient is asked to walk at his or her own preferred speed, using whatever aid
needed (including personal support if wanted) (Wade 1992).

Criteria

Point

References

1. Validity

0/3

2. Reliability

1/3

Intrarater reliability has been proven to be high (Flansjber et al. 2005)

3. Responsiveness

1/1

5-meter walk at a comfortable test has been found to be most

responsive when compared to other tests as the berg balance and
Barthel Index (Salbach et al. 2001).

4. Golden standard

1/1

10-meter was used as a golden standard to validate the Emory

Functional Ambulation Profile (Wolf et al. 1999).

5. Brief

2/2

6. No special

2/2

equipment
Total

6/12

26

E. Functional ambulation category

The FAC instrument is designed to provide information on the level of physical
support needed by subjects in order to ambulate safely (Kollen et al. 2006). It is
most useful in active rehabilitation rather than a measure of disability (Wade 1992).
It is a six-point scale ranging from 0-5 totally dependent to totally independent

Criteria

Point

References

1. Validity

0/3

We found articles that mentioned the scale was valid and reliable but
we were not able to find the actual articles that proved this fact
(Kollen et al. 2006).

2. Reliability

1/3

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

Interrater reliability has been proven (Collen et al. 1990).

equipment
Total

5/12

27

6.2.2. Arm and hand mobility

A. Action Research Arm Test

It is a test that measures upper extremity function. It contains four subscales; grasp,
grip, pinch and gross movement comprising of 19 items in total.
The items are ordered in a way that is if the patient can complete the last and
hardest item in the subscale the other items can be assumed (Hsieh et al. 1998).

Criteria

Point

References

1. Validity

1/3

Correlating the scale with the upper extremity part of the motor
assessment scale has proved concurrent validity (Hsieh et al. 1998).

2. Reliability

2/3

Interrater reliability has shown to be very high (Hsieh et al. 1998,

Platz et al. 2005). Internal consistency has been found to be very high
(van der Lee et al. 2002).

3. Responsiveness

1/1

Responsiveness has been proven in two articles, one in the

rehabilitation phase and the other in the acute phase (Van der Lee et
al. 2001, Hsueh et al. 2002, Rabadi et al. 2006).

4. Golden standard

0/1

5. Brief

2/2

It takes no more than 10 minutes to examine the patient with the

ARAT (Hsieh et al. 1998).

6. No special

0/2

equipment

The scale requires many different types of equipment like specially

constructed table, a sharpening stone, and a ball bearing (Hsieh et al.
1998).

Total

6/12

28

B. Nine-hole peg test

The nine-Hole Peg Test is a simple, timed test of fine motor coordination. The test
involves the subject placing nine dowels in nine holes. Subjects are scored on the
amount of time it takes to place and remove all nine pegs.
Criteria

Point

References

1. Validity

0/3

We found many articles referring to the reliability and validity of this

test but could not find the actual articles that were referenced to due
to age of these articles (Croarkin et al. 2004).

2. Reliability

2/3

Interrater reliability has been found to be high and intrarater

moderate (Oxford et al. 2003, Heller et al. 1987).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

It is a simple and quick test for finger dexterity (Oxford et al. 2003).

6. No special

0/2

The scale requires a nine-hole board and nine wooden pegs that have

equipment
Total

to be bought especially for this test.

4/12

C. Frenchay Arm Test (FAT)

The Frenchay Arm Test a test of upper limb function, consisting of five pass/fail
tasks; the subject scores 1 for each task that is completed successfully. Only the
affected upper limb is evaluated (Higgins et al. 2005).
Criteria

Point

References

1. Validity

0/3

We found many articles referring to the reliability and validity of this

test but could not find the actual articles that were referenced to due
to age of these articles (Wade 1992, Higgins et al. 2005).

2. Reliability

2/3

Interrater and intrarater reliability have been found to be good (Heller

et al. 1987).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

It is a simple and quick test (wade 1992).

6. No special

0/2

The scale requires some equipment like cylinder, rod, clothes pins,

equipment
Total

hair brush etc, therefore it is not portable (wade 1992)

4/12

29

6.2.3. Activities of daily living (ADL)

A. Barthel index (BI)

The BI is a 10-item instrument measuring disability in terms of a persons level of
functional independence in personal activity of daily living. It is rated from
observation and has two items on a 2-point scale, six items on a 3-point scale, and
two items on a 4-point scale. Items scores are summed to generate a total score
from 0=minimum independence to 100=total independence (Van der Putten et al.
1999). It is recommended to use this scale not because it is much better than the
other ADL scales but primarily because it is now the best known and we must start
to standardize measurement (Wade 1992).

Criteria

Point

References

1. Validity

1.5/3

Construct and face validity have been found to be strong (Gosman

Hedstrom and Svensson 2000).
Concurrent validity has been found to be high by correlating the index
with the FIM (Hsueh et al. 2002).

2. Reliability

2/3

Interrater reliability has been found to be excellent (Wolfe et al.

1991).
Internal consistency has been found to be acceptable (Hsueh et al.
2002).

3. Responsiveness

1/1

Has been found to be highly responsive (Huseh et al. 2002).

4. Golden standard

1/1

The BI has been used as a golden standard in a number of articles to

validate different scales. For example: Rivermead mobility index
(Hsieh et al. 2000), Stroke rehabilitation assessment of movement
measure-STREAM (Hsueh at el. 2003).

5. Brief

2/2

The BI is reasonably easy and requires short amount of time to be

administered (Wallace at el. 2002).

6. No special

2/2

equipment
Total

9.5/12

30

B. Frenchay activities index (FAI)

The FAI is a short questionnaire designed to measure lifestyle after stroke. The index
of 15 items records how frequently the subject engages in social activity and more
complex activities of daily living such as cooking and shopping. Ten items refer to
everyday activities, which the subject has engaged in during the past three months.
The remaining five items refer to more seasonal activities carried out over the
previous six months (Piercy et al. 2000).

Criteria

Point

References

1. Validity

1/3

Construct validity has been proven by correlating the index with the
Barthel Index and the Sickness Impact Profile (Schuling et al. 1993).

2. Reliability

0.5/3

Interrater reliability has been proven to be good for 9 of the 15 items

but 6 items showed only moderate or fair agreement (Piercy et al.
2000).
The reliability of the instrument could be improved by deleting two
items: Reading books and gainful work (Schuling et al. 1993).

3. Responsiveness

0/1

4. Golden standard

1/1

The scale was used to validate the London Handicap Scale (Jenkinson
et al. 2000).

5. Brief

2/2

The FAI can be completed within a few minutes by means of direct

interview and as a mailed questionnaire, which enriches its value for
research (Schuling et al. 1993).

6. No special

2/2

equipment
Total

6.5/12

31

C. Rivermead Extended ADL index (READL)

The READL comprises of 12 items divided into two domains: domestic activities (6
items) and community activities (6 items). For each item there are four possible
answers:
3 points able to do it alone
2 points with minor physical support
1 point with major physical assistance
0 point unable to do it.
The score is summed give a value of 0=inactive to 36=active (Rossier et al. 2001).

Criteria

Point

1. Validity

0/3

2. Reliability

1/3

References

Intrarater reliability has been found to be reasonable (Rossier et al.

2001).

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

5/12

32

6.2.4 Disability
A. Functional Independent measurement (FIM)
The FIM is a functional assessment scale that evaluates the patients abilities in selfcare, sphincter control, mobility, locomotion, communication, and social cognition.
The conceptual basis of the FIM is to determine the burden of care for a disabled
individual to perform basic life activities effectively.
The FIM was designed to be collected by trained clinicians, but to be discipline free.
FIM item scores range from 1 to 7: a FIM item score of 1 is total assist (performs
less than 25% of task), while a score of 7 is categorized as complete
independence. Scores falling below six require another person for supervision or
assistance (Cohen and Marino 2000).

Criteria

Point

References

1. Validity

1.5/3

The correlations (rs > 0.92) and agreement (ICC > 0.83) between the
FIM motor and 10 item BI were high at admission and discharge,
indicating high concurrent validity (Hsueh et al. 2002).
Another article has been proven the concurrent and construct validity
of this scale (Hobart et al. 2001).

2. Reliability

3/3

All scales satisfy recommended criteria for internal consistency

reliability and intrarater reproducibility (Hobart et al. 2001). In
addition another article shown that FIM has high internal consistency
(Dodds et al. 1993).

3. Responsiveness

1/1

Responsiveness has been proven (Hobart et al. 2001).

4. Golden standard

1/1

The Hooper Visual Organization Test was validated with comparing it

to the FIM scale (Greve et al. 2000).

5. Brief

2/2

6. No special

2/2

equipment
Total

10.5/12

33

6.3. Participation
6.3.1.Quality of life

A. Stroke Impact Scale (SIS)

The SIS is a new comprehensive and psychometrically robust stroke specific outcome
measure, which was developed to extend to range of function measured by the
Barthel Index and the physical domain of the short form 36. The scale was
developed from the perspective of patients, caregivers, and health professionals with
stroke expertise and consists of items measuring eight domains (strength, hand
function, ADL/I-ADL, mobility, communication, memory and thinking, and
participation) (Duncan et al. 1999).
The scale consists of 64 questions with answers ranging from 1-5 meaning different
answers in different domains. The scale is scored for each domain ranging from 0100 using this algorithm:
Transformed Scale=[(Actual raw score-lowest possible raw score)]

x100

Possible raw score range

(Landon M Theo and Alfred Center On aging).

Criteria

Point

References

1. Validity

1.5/3

Convergent and discriminate validity (a part of construct validity) have

been found to be good (Edwards and OConnell 2003, Duncan et al.
1999).
Concurrent validity has been found to be good (Duncan et al. 1999).

2. Reliability

2/3

Interrater reliability is high except for one domain-emotion (Duncan et

al. 1999).
Internal consistency was acceptable except for emotional domain
(Edwards and OConnell 2003)

3. Responsiveness

0/1

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

7.5/12

34

B. Stroke Specific Quality of Life Scale (SS-QOL)

The scale was designed to assess the health related quality of life specific for stroke
patients. The 12 domains (energy, family roles, language, mobility, mood,
personality, self-care, social roles, thinking, upper extremity function, vision,
work/productivity) and 49 items included in this measure were initially obtained from
interviews with stroke survivors. These items were then reviewed and modified by
experts in neurology, physical medicine, rehabilitation, and by additional stroke
survivors (Saladin et al. 2000). The scale consists of 49 statements with answers
ranging from 1-5 meaning different answers in different domains. Total Score ranges
from 49 (poor QoL) to 245 (excellent QoL).

Criteria

Point

References

1. Validity

0.5/3

Construct validity has been shown to be reasonable for the individual

domains (Williams et al. 1999). Further investigation on the reliability,
validity, and sensitivity of the SS-QOL is also necessary with larger
numbers of subjects. (Williams et al. 1999).

2. Reliability

1/3

The interrater reliability of the domains has been found to be quite

high > 0.73 in all domains (Williams et al. 1999).

3. Responsiveness

1/1

Most of the domains demonstrated moderate responsiveness

(Williams et al. 1999).

4. Golden standard

0/1

5. Brief

2/2

6. No special

2/2

equipment
Total

6.5/12

35

7. Conclusion
Making this project provided us with broader understanding of how scales should be
formed and tested and which aspects are important when reviewing and choosing
which scales would be best to use.

In an overview of our work, we discovered that even though some of the scales have
received a low score when graded with our criteria list, we cannot state that they are
not good quality scales. Some of these scales were developed many years ago and
therefore we could not find literature about their psychometric properties. In
contrast, we found recently developed scales that are not widely used (yet) however
they are well tested for their psychometric properties and are good quality tests (i.e.
PASS). For example; the Rivermead Motor Assessment Scale (developed before
1992) received a score of three by us because of lack of evidence of its psychometric
properties and yet it is used as a golden standard. This emphasizes the limitation in
our research process, which resulted from the limited access to articles, especially to
the ones who were published before 1995.

Another limitation of our study is the fact that we are not statisticians and therefore
could not go deep into the methods of how to analyze the psychometric properties of
scales. We took the results as stated in the articles and could not be critical readers
regard the statistics tests and analysis.

We found some of the areas, especially in measuring structures and functions, as

being problematic. The Modified Ashworth Scale is most commonly used
measurement tool measures the spasticity of the patients. Spasticity is a caused by a
two main factors; one is the biomechanical change in the muscles and joints, and the
other is neural activity. The MAS scale according to our findings is not valid as
measurement of spasticity because it can only be used if the increase in the
resistance to passive movement is exclusively associated with the increase in stretch
reflex mediated neural activity (Pandyan et al. 2003). This should be taken into
account when measuring a patient. Other measurement tools that take into account
all factors of spasticity still need to be developed. However, this scale is so well
known and used in the physiotherapy field, maybe it is not so valid and reliable for
research purposes but it is enough for the practice.

36

The pain scales also received lower than average scores according to our criteria list.
These scales in our opinions are hard to validate because they measure a very
subjective feeling that is influenced by multidimensional factors (such as culture,
education etc).

The Nottingham sensory scale also received a low score according to our criteria list.
Firstly, the scale is not well tested for the psychometric properties (we found only
one article). This could also be due to the fact it is a very long and cumbersome
scale that examines many aspects of sensory abnormalities and takes much time to
perform. We believe that in the physiotherapy field, a tester can just quickly make a
few specific tests and get the information that they need about the sensation.
On the other hand the most commonly used scales like the Barthel Index, Berg
Balance Scale and the FIM got a high score according to our criteria lists. These
scales have many articles about their psychometric properties and are used in many
scientific research and therefore it is not surprising that they are highly scored.

The process of researching, writing and making the catalogue has been a challenging
and interesting one. We believe that this product will benefit the quality of work in
the rehabilitation clinic, providing a more accurate assessment and as a consequence
a better treatment. It will also give the patients a better insight into their
rehabilitation process and will motivate and inspire them.

We found this learning process very interesting and enjoyed working together on this
project. We are excited about the results and are enthusiastic to see our work being
used soon by the clinic and the results it could bring. The next stage for us as future
physiotherapists is to apply a more scientific approach to our work, using these
assessment tools.

37

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39

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