Functional recovery following stroke: capturing changes in upper-extremity function

Abstract

Background and purpose: Augmenting changes in recovery is core to the rehabilitation process following a stroke. Hence it is essential that outcome measures are able to detect change as it occurs, a property known as responsiveness. This article critically reviewed the responsiveness of functional outcome measures following stroke, specifically examining tools that captured upper-extremity (UE) functional recovery.

Methods: A systematic search of the literature was undertaken to identify articles providing responsiveness data for 3 types of change (observed, detectable, and important).

Results: Data from 68 articles for 14 UE functional outcome measures were retrieved. Larger percentage changes were required to be considered important when obtained through anchor-based methods (eg, based on patient opinion or comparative measure) compared with distribution methods (eg, statistical estimates). Larger percentage changes were required to surpass the measurement error for patient-perceived functional measures (eg, Motor Activity Log) compared with laboratory-based performance measures (eg, Action Research Arm Test). The majority of rehabilitation interventions have similar effect sizes on patient-perceived UE function and laboratory-based UE function.

Conclusions: The magnitude of important change or change that surpasses measurement error can vary substantially depending on the method of calculation. Rehabilitation treatments can affect patient perceptions of functional change as effectively as laboratory-based functional measures; however, larger sample sizes may be required to account for the larger measurement error associated with patient-perceived functional measures.

Figure 1

Graphic representation of observed, important and detectable change Abbreviations: MDC90: minimal detectable change (with 90% confidence interval); MDC95: minimal detectable change (with 95% confidence interval); LOA: limits of agreement; PES: population effect size; SRM: standardized response mean; MCID: minimally clinically important difference

Figure 2

Flow diagram of process to select final list of outcome measures Abbreviations: OM: outcome measure; AMAT: Arm Motor Activity Test; ARAT: Action Research Arm Test; CAHAI: Chedoke Arm and Hand Activity Inventory; Duruoz: Durouz Hand Index; Frenchay: Frenchay Arm Test; FTHUE: Functional Test for the Hemiplegic Upper Extremity; Jebsen: Jebsen Hand Function Test; MAL: Motor Activity Log; SIS: Stroke Impact Scale; TEMPA: Upper Extremity Performance Scale for the Elderly; Wolf: Wolf Motor Function Test

Figure 3

Effect sizes by measure calculated at <3 months and ≥ 3 months post stroke The bars on the graph represent the range of effect sizes calculated from studies that measured UE function across time. ^athe full range of the effect sizes for the Frenchay is 0.2–5. Abbreviations: Wolf: Wolf Motor Function Test; Duruoz: Duruoz Hand Index; TEMPA: Upper Extremity Performance Scale for the Elderly; FTHUE: Functional Test for the Hemiplegic Upper Extremity; Jebsen: Jebsen Hand Function Test; CAHAI: Chedoke Arm and Hand Inventory; SIS: Stroke Impact Scale (hand scale); ARAT: Action Research Arm Test; Frenchay: Frenchay Arm Test

Figure 4

Comparison of observed change captured by ‘lab-based’ versus ‘patient-perceived functional measures Points on the graph represent the effect sizes obtained from a single study. Lines on the graph represent a 1:1 relationship between the ‘lab-based’ vs ‘patient-perceived’ functional measures. Lab-based measures are located on the X-axes (ie. Wolf, ARAT). Patient-perceived functional measures are located on the Y axes (ie. MAL). Abbreviations: MAL: Motor Activity Log; AOU: amount of use scale; QOM: quality of movement scale; CIMT: ARAT: Action Research Arm Test; Wolf: Wolf Motor Function Test; FAS: functional ability scale

Figure 5

Comparison of detectable change (calculated at 95% confidence level) relative to the sample means and scale maximums The bars beside each measure represent the range of MDC₉₅%values extracted or calculated from different studies. *Two studies analysed different subsets of the same sample to obtain multiple estimates. ϯEstimates for the ARAT, Wolf (FAS) and SIS are missing from this graph as sample means were not provided in two studies.^, Abbreviations: MDC₉₅%: Minimally detectable change (with a 95% confidence interval) expressed as a percentage of A: the scale maximum score and B: the sample means; MAL: Motor Activity Log; AOU: amount of use scale; SIS: Stroke Impact Scale (hand); QOM: quality of movement scale; TEMPA: Upper Extremity Performance Scale for the Elderly; AMAT: Arm Motor Ability Test; FAS: functional