Action Research Arm Test (ARAT)

Overview


We conducted a literature search to identify all relevant publications on the psychometric properties of the Action Research Arm Test (ARAT) in individuals with stroke. We identified twelve studies. The ARAT appears to be floor effects.

Floor/Ceiling Effects

Hsueh and Hsieh (2002b) examined floor and ceilings effects for the ARAT and the Upper Extremity Motor Assessment Scale (Carr, Shepherd, Nordholm, & Lynne, 1985) in 48 clients with acute stroke. Participants were assessed at admission and discharge from an acute rehabilitation ward. At admission, the ARAT total score demonstrated a poor floor effect, with 52.1% of participants scoring 0. Although all subscales were classified as having a poor floor effect, when comparing ARAT’s subscales among themselves, 72.9% of participants were unable to perform the pinch subscale, 70.8% were unable to perform both grasp and grip subscales and 52.1 % were unable to complete the gross movement subscale. At discharge, the ARAT total score demonstrated an adequate ceiling effect, with only 7% of participants scoring the maximal value. When analyzing ARAT’s subscales individually the gross movement subscale presented the poorest ceiling effect, with 29.2% of participants scoring the maximum score, followed by 27% of participants on the grasp subscale. The grip and pinch subscale had the best classification, with an adequate ceiling effect of 18.8% and 16.7%, respectively.

Compared to the ARAT, at admission the Upper Extremity Motor Assessment Scale had 58% of participants scoring the minimal value, indicating a poor floor effect. However, at discharge the Upper Extremity Motor Assessment Scale demonstrated a more adequate ceiling effect than the ARAT, with only 4.3 % of participants obtaining the maximum score.

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. The ARAT showed adequate floor and ceiling effects with only 12.5 to 17% of patients scoring the lowest or highest scores.

Reliability

Internal Consistency:
Nijland et al. (2010) investigated the internal consistency of the ARAT in 40 patients with stroke with mild to moderate hemiparesis. Internal consistency of the ARAT, as calculated using Cronbach’s Coefficient Alpha was excellent (α = 0.98).

Test-retest:
Note: From the descriptions provided of the following studies it appears that some authors called the testing test-retest reliability while others called the same analysis intra-rater reliability.

Lyle (1981) examined test-retest reliability in 20 individuals who sustained cortical damage, either from stroke or traumatic brain lesion. The mean age was 53 years, ranging from 26 to 72 years. Participants were re-assessed with a 1-week interval by the same rater and under the same conditions. The test-retest reliability, as calculated using Pearson correlation, was excellent (r = 0.98).

Hsueh, Lee, and Hsieh (2002a) evaluated test-retest reliability performed using a regular table instead of the specially designed table for this test in 61 individuals with sub-acute stroke and a mean age of 63 years old. Participants were re-assessed after a two-day interval by the same rater. The test-retest reliability, as calculated using the Intraclass Correlation Coefficient (ICC), was excellent for the total score (ICC = 0.99) as well as for the grasp, grip, pinch and gross movement subscales (ICC = 0.99, 0.98, 0.96 and 0.95, respectively).

Platz, Pinkowski, van Wijck, Kim, di Bella, and Johnson (2005) estimated test-retest reliability for the ARAT, the Box and Block Test (Cromwell, 1965; Mathiowetz, Volland, Kashman, & Weber, 1985a), and the Fugl-Meyer Test upper extremity items (including items from the Motor function, Sensation and Passive Joint Motion/Joint pain subscores) (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) in 23 participants with upper extremity paresis either from stroke, multiple sclerosis, or traumatic brain injury. The participant’s most affected arm was re-assessed 1 week later by the same rater. The test-retest reliability of the ARAT total score, as calculated using ICC’s and Spearman rho correlation, was excellent (ICC = 0.96 and rho = 0.96). Furthermore, test-retest reliabilities for each subscale were all excellent: grasp (ICC = 0.94 and rho = 0.96), grip (ICC = 0.94 and rho = 0.95), pinch (ICC = 0.89 and rho = 0.89) and gross movement (ICC = 0.97 and rho = 0.97).
Note: These results applies only to the most affected upper limb.

Intra-rater:
Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers and Rijswijk (1990) evaluated intra-rater reliability in seven patients with acute stroke. The timeframe for assessments were not provided by the author. Intra-rater reliability as calculated using Spearman rho correlation, was excellent (rho = 0.99).

Van der Lee, DeGroot, Beckerman, Wagenaar, Lankhorst, and Bouter (2001a) estimated intra-rater reliability in 20 patients with chronic stroke and a median age of 62 years. Participants were evaluated by the same rater at three points in time. At the baseline assessment participants were videotaped. The second assessment was 4-27 months following the first assessment, and the final assessment was 4-6 weeks after. Scoring the last two assessments was based on the videotaped recorded at baseline. Intra-rater reliability results were analyzed between the two first assessments, where scoring sources were different (live vs. videotape) and between the two last assessments, were scoring sources were the same (videotape only). Intra-rater reliability, as calculated using ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99), independent of scoring sources. Intra-rater reliability, as calculated using weighted kappa was also excellent: scoring with the same information source resulted in a kappa = 1.00 versus only a slightly lower kappa when scoring from two different information sources (kappa = 0.94). The gross movement subscale showed the lowest weighted kappa value (kappa = 0.83), suggesting that this subscale had the lowest agreement level.

Yozbatiran, Der-Yeghiaian, and Cramer (2008) examined intra-rater reliability in 8 clients with chronic stroke. Participants were re-assessed by the same rater and under the same conditions with a 1-week interval. Intra-rater reliability for the total score, as calculated using ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99). Additionally, the same excellent level of intra-rater reliability was found for the grasp, grip, pinch, and gross motor movement subscales (ICC = 0.98 and rho = 0.93; ICC = 0.97 and rho = 0.93; ICC = 0.99 and rho = 0.98; ICC = 0.93 and rho = 0.91, respectively).

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. 18 patients participated in the reproducibility testing of the ARAT and were assessed twice by the same observer approximately 10 days apart. Intra-rater reliability, as analyzed using the ICC was found to be excellent (ICC = 0.97).

Inter-rater:
Lyle (1981) examined inter-rater reliability in 20 individuals who had sustained cortical damage, either from stroke or traumatic brain injury. The mean age was 53 years, ranging from 26 to 72 years. Participants were assessed independently by two different raters. Agreement between raters as calculated using Pearson correlation, was excellent (r = 0.99).

Hsieh, Hsueh, Chiang, and Lin (1998) assessed inter-rater reliability in 50 clients with stroke. Their mean age was 65 years old. Participants were evaluated independently, on three different days, by three raters. ICC for the total score showed excellent agreement (ICC = 0.98). Agreement between raters was also excellent for grasp, grip, pinch and gross movement subscales (ICC = 0.98; ICC = 0.96; ICC = 0.96; ICC = 0.95, respectively).

Van der Lee et al. (2001a) estimated inter-rater reliability in 20 patients with chronic stroke and a median age of 62 years old. Participants were videotaped and scored independently by two raters. Inter-rater reliability, as calculated using ICC, weighted kappa, and Spearman rho correlation, was excellent (ICC = 0.98; kappa = 0.93; rho = 0.99). With respect to the individual subscales, the gross movement scale had the lowest weighted kappa value (kappa = 0.87), suggesting this subscale has the lowest agreement between raters.

Hsueh, Lee, and Hsieh (2002a) evaluated inter-rater reliability of the ARAT performed with a regular table instead of the specially designed table for this test in 61 individuals with sub-acute stroke and a mean age of 63 years old. Participants were re-assessed with a two-day interval by three different raters. ICC for the total score showed excellent agreement (ICC = 0.99) as well as for grasp, grip, pinch and gross movement subscales (ICC = 0.99; ICC = 0.98; ICC = 0.96; ICC = 0.94, respectively).

Platz et al. (2005) analyzed inter-rater reliability of the ARAT, the Box and Block Test and the Fugl-Meyer Test upper extremity items (including items from the Motor function, Sensation and Passive Joint Motion/Joint pain subscores) in 44 individuals with upper limb paresis either from stroke, multiple sclerosis, or traumatic brain injury. Participants had the most affected arm videotaped and scored independently by two raters. Inter-rater reliability for the ARAT total score, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.99). Additionally, the scores for each subscale were provided and inter-rater reliability for grasp (ICC = 0.99 and rho = 0.99), grip (ICC = 0.96 and rho = 0.95), pinch (ICC = 0.99 and rho = 0.99) and gross movement (ICC = 0.98 and rho = 0.98) subscales were all excellent.
Note: These results applies only to the most affected upper limb.

Yozbatiran et al. (2008) evaluated inter-rater reliability in 9 clients with chronic stroke. Participants were scored simultaneously and independently by two raters. Inter-rater reliability for the total score, as calculated using the ICC and Spearman rho correlation, was excellent (ICC = 0.99 and rho = 0.96). The same excellent level of inter-rater reliability was found for the grasp, grip, pinch and gross motor movement subscales (ICC = 0.99 and rho = 1; ICC = 0.99 and rho = 0.99; ICC = 0.99 and rho = 0.98; ICC = 0.97 and rho = 0.93, respectively).

Nijland et al. (2010) investigated the psychometric properties of the ARAT and Wolf Motor Function Test in 40 patients with stroke with mild to moderate hemiparesis. 18 patients participated in the reproducibility testing of the ARAT and were assessed in random order by two observers, within one week. Inter-rater reliability, as analyzed using the ICC was found to be excellent (ICC = 0.92).

Validity

Content
Lyle, 1981 generated the 19 ARAT items from the 33 items of the Upper Extremity Function Test (UEFT – Caroll, 1965). Item reduction was based on a low inter-item correlation, on item redundancy, confirmed through a very high inter-item correlation (above r = 0.9) and on items that were extremely difficult to perform. Nevertheless, ARAT items were not based on a theoretical model (Finch, Brooks, Stratford, & Mayo, 2002).

Criterion
Concurrent:
No gold standard exists against which to compare the ARAT.

Lin, Chuang, Wu, Hsieh and Chang (2010) compared the concurrent validity of the ARAT, Box and Block Test (BBT) and Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with stroke. The Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA), Motor Activity Log (MAL) and Stroke Impact Scale (SIS) were also administered to assess the concurrent validity of the ARAT, BBT and NHPT. Using Spearman rank correlation coefficient, the ARAT, BBT and NHPT were found to have adequate to excellent correlations at pre-treatment (ranging from rho=-0.55 to -0.80) and post-treatment (ranging from rho=-0.57 to -0.71). In addition, the ARAT and BBT were found to have adequate correlations with the FMA, MAL and SIS (ranging from rho=0.31-59); however, the NHPT had only poor to adequate correlations with the FMA and MAL (ranging from rho=-0.16 to -0.33); and adequate to excellent correlations with the SIS (ranging from rho=-0.58 to -0.66). When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

Predictive:
No studies have examined the predictive validity of the ARAT.

Construct
Convergent/Discriminant:
DeWeerdt and Harrison (1985) evaluated the convergent validity of the ARAT by comparing it to the Fugl-Meyer test (Fugl-Meyer et al., 1975) in 53 clients with acute stroke. Their mean age was 68 years. Correlations were calculated at two points in time after stroke onset using Spearman correlation coefficient. Excellent correlations were found between the ARAT and Fugl-Meyer test at 2 months (rho = 0.91) and at 8 months (rho = 0.94) post-stroke.

Wagenaar, Meijer, van Wierinen, Kuik, Hazenberg, Lindeboom, Wichers and Rijswijk (1990) evaluated the convergent validity of the ARAT by comparing it to the Sollerman test (Jacobson-Sollerman & Sperling, 1977) in seven patients with acute stroke. An excellent correlation, as calculated using Spearman rho, was found (rho = 0.94).
Note: The Sollerman test measures hand grip function using 20 different daily life activities requiring hand movements.

Hsieh et al. (1998) assessed convergent validity of the ARAT by comparing it to the Upper Extremity portion of the Motor Assessment Scale (Carr et al., 1985), the arm subscale of the Motricity Index (Demeurisse, Demol, & obaye, 1980), and the upper extremity movements of the Modified Motor Assessment Chart (Lindmark & Hamrin, 1988) in 50 clients with stroke. The mean age of clients was 65 years old. Correlations were calculated using Pearson Correlation Coefficients. Excellent correlations were found between the ARAT and the Upper Extremity part of the Motor Assessment Scale ((r = 0.96), Motricity Index (r = 0.87) and the upper extremity movements of the Modified Motor Assessment Chart (r = 0.94).

Platz et al. (2005) tested convergent validity of the ARAT by comparing it to the Box and Block Test (Cromwell, 1965; Mathiowetz et al., 1985a), the Fugl-Meyer Test upper extremity items (including items from the Motor Function, Sensation and Passive Joint Motion/Joint Pain subscores) (Fugl-Meyer et al., 1975), the Motricity Index (Demeurisse et al., 1980), the Ashworth Scale (Ashworth, 1964), the Hemispheric Stroke Scale (Adams, Meador, Sethi, Grotta, & Thomson, 1986) and the Modified Barthel Index (Collin, Wade, Davies, & Horne, 1988) in 56 participants with upper extremity paresis either from stroke (n=37), multiple sclerosis (n=14), or traumatic brain injury (n=5). Correlations were calculated using the Spearman Correlation Coefficient. Excellent correlations were found between the ARAT and the Box and Block Test (rho = 0.95), the Motor Function subscore of the Fugl-Meyer Test (rho = 0.92), the Motricity Index (rho = 0.81), and the Hemispheric Stroke Scale (rho = -0.66). Adequate correlations were found between the ARAT and the Passive Joint Motion/Joint Pain subscore of Fugl Meyer Test (rho = 0.42). Poor correlations were found between the ARAT and the Sensation Subscore of the Fugl-Meyer Test (rho = 0.29), the Ashworth Scale (rho = -0.29) and the Modified Barthel Index (rho = 0.04).
Note: Negative correlations are observed because a high score on the ARAT indicates normal performance, whereas a low score on the Hemispheric Stroke Scale and the Ashworth Scale indicates normal performance.

Lang, Wagner, Dromerick, and Edwards (2006) evaluated the convergent validity of the ARAT in 50 individuals with acute to sub acute stroke, mean age of 63 years old, attending an acute neurology stroke service at three points in time: admission (day 0); post intervention (day 14); and 90 days poststroke (day 90). The ARAT was compared to measures of sensorimotor impairment (e.g. light touch sensation, pain, elbow joint spasticity, upper extremity strength), to kinematic measures (e.g. reach and grasp), to the Functional Independence Measure (FIM) (Keith, Granger, Hamilton, & Sherwin, 1987), and to the National Institutes of Health Stroke Scale (NIHSS) (Brott, Adams, Olinger, Marler, Barsan, Biller, et al., 1989). At day 0, excellent correlations were found between the ARAT and upper extremity strength (r = 0.60) and grasp speed (r = 0.60). Adequate correlations were found between the ARAT and grasp efficiency (r = 0.42), reach efficiency (r = -0.38) and reach speed (r = 0.40), and the FIM upper extremity score (r = 0.38). Poor correlations were found between the ARAT and NIHSS (r = -0.15); light touch sensation (r = 0.15), pain (r = 0.10), elbow joint spasticity (r = -0.28) and the FIM total score (r = 0.20). At day 14, excellent correlations were found between the ARAT and grasp efficiency (r = 0.60) and the FIM upper extremity scores (r = 0.62). Adequate correlations were found between the ARAT and elbow spasticity (r = 0.49), upper extremity strength (r = 0.42), reach efficiency (r = -0.58), grasp speed (r = 0.36) and the FIM total score (r = 0.52). Poor correlations were found between the ARAT and NIHSS (r = -0.24), light touch sensation (r = -0.20), and pain (r = -0.12). At day 90, excellent correlations were found between the ARAT and upper extremity strength (r = 0.60). Adequate correlations were found between the ARAT and elbow spasticity (r = -0.42), reach efficiency (r = -0.42), reach speed (r = 0.50), grasp efficiency (r = -0.48), grasp speed (r = 0.38) and the FIM upper extremity (r = 0.42) and total scores (r = 0.40). Poor correlations were found between the ARAT and the NIHSS (r = -0.29), light touch sensation (r = 0.00), and pain (r = 0.22). In summary, from this study’s findings it appears that the NIHSS, light touch sensation, and pain do not appear to relate to the ARAT. The relationship between the ARAT and FIM scores is stronger early on post-stroke and stabilizes by the ninetieth day.

Rabadi and Rabadi (2006) examined convergent validity of the ARAT by comparing it to the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) at admission and discharge from an acute stroke rehabilitation unit in 104 inpatients with acute stroke with a mean age of 72 years. The correlation between ARAT and the Fugl-Meyer Assessment was excellent both at admission (rho = 0.77) and discharge (rho = 0.87).

Yozbatiran et al. (2008) estimated the convergent validity of the ARAT by comparing it to the arm motor Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) score in 12 clients with chronic stroke at a mean age of 61 years. Excellent correlation (r = 0.94) was found between the ARAT and arm motor Fugl-Meyer score.

Known groups:
No studies have examined known groups validity of the ARAT.

Responsiveness

Van der Lee, Beckerman, Lankhorst, and Bouter (2001b) evaluated the responsiveness on the ARAT and Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) in 22 clients with chronic stroke, mean age of 58 years old, receiving intensive forced use treatment. Participants were assessed two weeks pre- and two weeks post- treatment. A responsiveness ratio was calculated. Compared to the Fugl-Meyer Assessment, the ARAT had a greater responsiveness ratio (2.03 for ARAT vs. 0.41 for Fugl-Meyer) suggesting that the ARAT is more sensitive to detecting change.
Note: The responsiveness ratio is a variant of effect size and higher values indicate better responsiveness.

Van der Lee, Roorda, Beckerman, and Lankhorst (2002) estimated the responsiveness of a modified version of the ARAT in 63 participants with chronic stroke. In this study, researchers did not follow Lyle’s standardized instructions. Instead, they administered all 19 ARAT items to verify any possible effect of this format on its psychometric properties. A responsiveness ratio was calculated. Compared to the hierarchical version proposed by Lyle, performing all 19 items was found to improve the measure’s responsiveness, with a responsiveness ratio of 1.7 compared to 1.2 with Lyle’s version.
Note: The responsiveness ratio can be considered an estimate of effect size normalized to the variability in a stable population and higher values indicate better responsiveness.

Hsueh et al. (2002b) analyzed the responsiveness of the ARAT and the upper extremity section of the Motor Assessment Scale (Carr et al., 1985) in 48 participants having acute stroke and a mean age of 62 years. Participants were assessed at two points in time: admission and discharge from the acute rehabilitation centre. The ARAT total score demonstrated a moderate effect size of 0.52, while the Motor Assessment Scale total score demonstrated a small effect size of 0.45.

Lang et al. (2006) examined the responsiveness of the ARAT in 50 participants with acute to subacute stroke, with a mean age of 63 years old, receiving constraint-induced movement therapy (CIMT). Assessments were performed at three points in time: baseline, immediately post-treatment, and 2.5 months post-treatment. Effects sizes and responsiveness ratios were calculated. ARAT total and subscale scores at the first follow-up evaluation were similar, with moderate to large effect sizes (ARAT total score = 1.01; grasp subscore = 1.04; pinch subscore = 0.85; grip subscore = 1.01; and gross movement subscore = 0.72). The second follow-up evaluation demonstrated large effect sizes, with individual higher values when compared to the first evaluation (ARAT total score = 1.39; grasp subscore = 1.22; pinch subscore = 1.49; grip subscore = 1.32 and gross movement subscore = 0.98). The responsiveness ratio for the ARAT total score at the first follow-up evaluation was 5.2 and at the second was 7.0. These two responsiveness estimations suggest that the ARAT is a sensitive tool for detecting change even months after stroke onset.
Note: Responsiveness ratio is a variant of effect size and higher values indicate better responsiveness.

Rabadi and Rabadi (2008) assessed the responsiveness of the ARAT and the Fugl-Meyer Assessment (Fugl-Meyer et al., 1975) in 104 participants with acute stroke, with a mean age of 72 years, undergoing inpatient rehabilitation. Participants were evaluated at admission and discharge from acute care. The Standardized Response Mean (SRM) was used to calculate responsiveness. Amongst these upper extremity tests, the ARAT was less sensitive than the Fugl-Meyer Assessment (SRM = 0.68 and 0.74, respectively). However, since the difference between the SRMs for these two measures was minimal, these tests can be considered equally sensitive to change during inpatient acute rehabilitation. This result is contrary to the one presented by Van der Lee at al. (2002). The reason for this difference may be due to the difference in these studies population age and stroke severity.
Note: SRM is a variant of effect size and higher values indicate better responsiveness.

Lin, Chuang, Wu, Hsieh and Chang (2010) evaluated the responsiveness of the ARAT, Box and Block Test (BBT), the Nine-Hole Peg Test (NHPT) for evaluating hand dexterity in 59 patients with subacute stroke (< 6-months) and Brunnstrom stage IV to VI for proximal and distal upper extremity function. Patients were randomly assigned to receive constraint-induced therapy, bilateral arm training or control treatment and received 2 hours of therapy, 5 days per week for 3 weeks. Assessments were performed at baseline and 3 weeks. Using Standardized Response Mean (SRM) to calculate responsiveness, the ARAT, BBT and NHPT were all found to have moderate SRM (0.79, 0.74, 0.64 respectively), indicating sensitivity for detecting change in hand dexterity. When considering both the results of responsiveness and validation components of the study, the ARAT and BBT are believed to be more appropriate than the NHPT for evaluating dexterity.

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