Action Research Arm Test (ARAT)

Purpose of the measure

The Action Research Arm Test (ARAT) is an evaluative measure to assess specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia (Lyle, 1981). It assesses a client’s ability to handle objects differing in size, weight and shape and therefore can be considered to be an arm-specific measure of activity limitation (Platz, Pinkowski, Kim, di Bella, & Johnson, 2005).

Available versions
The ARAT was developed by Ronald Lyle in 1981 by adapting the Upper Extremity Function Test (UEFT) (Carroll, 1965). The UEFT test administration and scoring was simplified, the time required to administer the test was shorted, and items were grouped based on the hierarchical scale (Guttman Scale) (Lang, Wagner, Dromerick, & Edwards, 2006). Due to the need for more specific and detailed instructions related to the client’s position, scoring and test administration, Yozbatiran, Der-Yeghiaian, and Cramer (2008) proposed a standardized approach to the ARAT.
Features of the measure

Items:
The ARAT consists of 19 items grouped into four subscales: grasp, grip, pinch, and gross movement. Each subscale constitutes a hierarchical Guttman scale, which means that all items are ordered according to ascending difficulty. In the ARAT, if the client succeeds in completing the most difficult item in a subscale, this suggests he/she will succeed in the easier items for that same subscale. Similarly, failure on an item suggests the client will be unable to complete the remaining more challenging items in the subscale.

According to the rules defined by Lyle (1981), the client must first try to perform the most difficult task in a subscale. If the maximum score (score = 3) is obtained for this task then the maximum score for this entire subscale should be assigned, and the evaluator should move to the next subscale to be administered. When the client is unable to complete the most difficult item (scoring between 0-2), then the easiest item in this specific subscale should be performed. If the client fails completely (score = 0) when performing the easiest task, then the other intermediate items must not be tested, the entire subscale should be scored as zero, and the evaluator should then move to the next subscale. However, if the client succeeds at the easiest task either partially (score = 1 or 2) or completely (score = 3), then all the other tasks in that same subscale should be tested before moving to the next subscale. Following these rules, the items administered will range from a minimum of 4 to a maximum of 19 (van der Lee, Roorda, & Lankhorst, 2002).

The ARAT must be administered in a formal setting, since a specially designed table and chair are required (see equipment section for more information). For the starting position, the client should be seated in a chair, with a firm back and no armrests. The client’s trunk should be in contact with the back of the chair at all times during the test performance. Instructions about the required seating posture should be provided to the client prior to initiating the test. Additionally, reminders about the maintenance of this position should be given to the client when this condition is not respected. The client’s feet should be in contact with the floor throughout testing (van der Lee, DeGroot, Beckerman, Wagenaar, Lankhorst, & Bouter, 2001a; Yozbatiran et al., 2008). Both hands should be tested, beginning with the non- or less-affected hand, in order to practice and register baseline scores. Should the client be unable to understand the instructions for the required task, the evaluator should demonstrate the task and allow the client to try it as a trial (Yozbatiran et al., 2008). To facilitate recording the time for each task, the client’s hands should start and finish the task with palms down on the table. However, for the gross movement tasks, the client’s hands should be placed pronated on their lap. (Lyle, 1981; Yozbatiran et al., 2008).

In the grasp and pinch subscales, testing materials are lifted 37 cm from the surface of the table to the top of the shelf. In the grip subscale, testing materials are moved from one side of the table to the other. Finally, in the gross movement subscale, the client is requested to place the hand being tested either behind his/her head, on top of his/her head, or to his/her mouth (Lyle, 1981; Hsieh, Hsueh, Chiang, & Lin, 1998; Hsueh, Lee, & Hsieh, 2002a). The proper sequence for testing is 1) grasp subscale, 2) grip subscale, 3) pinch subscale, 4) gross movement subscale (Lyle, 1981). The ARAT comes with simple instructions to guide the evaluator on scoring and administering the test (Lyle, 1981).

Scoring:
The ARAT is scored on a four-level ordinal scale (0-3) (Lyle, 1981).

  • 0 = can not perform any part of the test,
  • 1 = performs the test partially,
  • 2 = completes the test, but takes abnormally long, time
  • 3 = performs the test normally

In order to facilitate scoring, time limits have been suggested (Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers, & Rijswijk, 1990; Yozbatiran et al., 2008). Incorporating the time limits to Lyle’s scoring definition, the new scoring system would be:

  • 0 = cannot perform any part of the test;
  • 1 = performs the test partially;
  • 2 = completes the test, but takes an abnormally long time, varying from 5 to 60 seconds.

    If a client takes more than 60 seconds to perform an item, the evaluator should interrupt after 60 seconds and a score of 1 is given on that specific item.

  • 3 = performs the test normally in less than 5 seconds.

The subscale scores range according to the number of items on each subscale, as follows:

Subscales on the ARAT Number of items per subscale Score ranges per subscale
Grasp subscale 6 items Score 0-18
Grip subscale 4 items Score 0-12
Pinch subscale 6 items Score 0-18
Gross Movement subscale 3 items Score 0-9

The total score on the ARAT ranges from 0 to 57, with the lowest score indicating that no movements can be performed, and the upper score indicating normal performance. Thus, higher scores will indicate better performance (Lang et al., 2006; van der Lee et al., 2002). The ARAT scores is a continuous measure, with no categorical cutoff scores. Therefore the score obtained at the ARAT does not allow classifying the clients into categories such as normal, mild limited, or severely limited.

Time:
The time required to complete the ARAT will depend on the number of items administered. Based on its hierarchical design, the ARAT was constructed to save testing time. Thus, no more than 7-10 minutes should be required to assess a client with stroke (DeWeerdt, & Harrinson, 1985). However, if all 19 items are performed, the ARAT usually takes 20 minutes to administer (van der Lee et al., 2002). In one study by Hsieh and colleagues (1998), the ARAT took, on average, 8 minutes to administer to clients with stroke.

Subscales:
The ARAT is divided in four subscales: Grasp; Grip; Pinch and Gross movement.

The grasp and pinch subscales have 6 items each, the grip subscale has 4 items, and the gross movement has 3 items (Lyle, 1981).

Equipment:
Standardized equipment is required to administer the ARAT. It can be ordered only from Netherlands’ representatives. The average cost for this equipment is approximately 850 Euros ($1200 CAD) with an additional delivery fee of 179 Euros ($252 CAD).

The complete ARAT kit consists of:

  • A specially designed table of 92cm x 45cm x 83cm high, with a shelf of 93cm x 10cm, positioned 37cm above the main surface of the table (Lyle, 1981; Hsueh et al., 2002a).
  • A chair with back rest and no arm rests, that should be placed 44cm above floor level (Lyle, 1981; Hsueh et al., 2002a).
  • Woodblocks of 2.5, 5, 7.5 and 10cm³ (Lyle, 1981; Hsueh et al., 2002a).
  • A cricket ball 7.5cm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • Two alloy tubes: one 2.25cm in diameter x 11.5 cm long, the second one 1.0cm in diameter x 16cm long (Lyle, 1981; Hsueh et al., 2002a).
  • A washer and bolt; which is a type of screw with its anchor (Lyle, 1981; Hsueh et al., 2002a).
  • Two glasses (Lyle, 1981; Hsueh et al., 2002a).
  • A marble 1.5cm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • A ball bearing 6mm in diameter (Lyle, 1981; Hsueh et al., 2002a).
  • A stopwatch (Wagenaar et al., 1990; Yozbatiran et al., 2008)
  • Paper and pencil for the evaluator.

Training:
None typically reported.

Alternative forms of the Action Research Arm Test
None.
Client suitability

Can be used with:

  • The ARAT was constructed for assessing recovery of upper limb function following cortical damage (Lyle, 1981).
  • Clients with stroke.

Should not be used in:

  • When administering the ARAT for clients with finger amputation, pinch subscale should be scored as 0 as well all other tasks that require movement of an amputated body part (Yozbatiran et al., 2008).
In what languages is the measure available?

There are no official translations of the ARAT.

Nevertheless, some peer-reviewed publications from the Netherlands and Taiwan have used the ARAT as an outcome measure, which may indicate that instructions have been informally translated to other languages (Hsieh et al., 1998; Hsueh et al., 2002a; van der Lee et al., 2002).