Development and Preliminary Reliability of the Functional Upper Extremity Levels (FUEL)

Upper-extremity (UE) hemiplegia is a common condition after stroke that can have a significant impact on UE function (Kelly-Hayes et al., 2003). Within the past decade, substantial advances have been made in rehabilitation options at the impairment, activity, and participation levels for stroke survivors with UE hemiplegia (Nilsen et al., 2015). Although these newer UE treatment options continue to be explored and scientifically examined, the selection of tools and techniques to promote functional recovery varies among clinicians (Doucet, 2012), and the rehabilitation community continues to lack a common nomenclature or classification tools to measure and describe recovery of the UE after stroke. New assessment tools are required not only to examine the effectiveness of these new UE strategies, but also to describe the recovery of the UE in a meaningful and functional way and provide a common nomenclature for the rehabilitation community. This article discusses the development, content validity, and interrater reliability of the Functional Upper Extremity Levels (FUEL) tool to assess, describe, and assist with treatment planning for poststroke UE function.

Much debate remains in the rehabilitation profession as to whether the bottom-up or top-down approach to assessment is more optimal. A bottom-up approach, grounded in the medical model, considers impairment-level factors first to obtain an understanding of the client’s limitations and strengths and how they affect performance. Conversely, a top-down approach focuses on the client’s actual performance and considers impairment factors later in the process (Weinstock-Zlotnick & Hinojosa, 2004). Because both approaches are valuable in the assessment of clients with UE hemiplegia (Doucet, 2012), development of an assessment tool that supports both approaches is needed. The FUEL tool is rooted in both approaches.

Although several poststroke UE recovery outcome assessments are available to clinicians and researchers, many are outdated, have limitations, and do not classify UE function in a useful way. According to the American Occupational Therapy Association (2010), practitioners should avoid using outdated and obsolete assessment measures and use evidence-based interventions. For example, the Fugl-Meyer Assessment (FMA; Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) is the gold-standard assessment for measuring motor recovery after stroke. The FMA was created from Brunnstrom’s (1966) seven-stage classification system of UE recovery that had a small description of movement correlated to each stage. It is widely used despite the fact that no research has found that stroke survivors pass through the predictable Brunnstrom stages or supported the effectiveness of Brunnstrom’s movement therapy on people living with disabilities secondary to a neurological event (Fleming-Castaldy & Gillen, 2013). Moreover, the FMA does not address performance in activities of daily living (ADLs) in a functional or meaningful manner but is still used to categorize a patient’s general arm function (Sabari, Capasso, & Feld-Glazman, 2014).

The FMA and other objective outcome measures for UE motor recovery after stroke, such as the Nine-Hole Peg Test (Grice, Vogel, Le, & Mitchell, 2003), Box and Block Test (Mathiowetz, Volland, Kashman, & Weber, 1985), Action Research Arm Test (Lyle, 1981), and Wolf Motor Function Test (Wolf, Thompson, & Winstein, 2010), have their place in research and the clinic because they are valid and responsive to change (Hsieh et al., 2009; Lin, Chuang, Wu, Hsieh, & Chang, 2010). However, we believe the FUEL classification tool is unique because it provides an assessment of UE use after stroke during real daily activities, whereas these other assessments do not. The FUEL provides information about how the UE is used during daily activities that can be shared and understood by clinicians, rather than a numerical score that may or may not correlate with real and meaningful functional use or gains for the person. It can be administered in real-life situations, such as people getting dressed, brushing their teeth, and transferring to a wheelchair, rather than in artificial environments. In addition, unlike other assessments, the FUEL does not require any additional equipment for administration other than daily objects, such as clothes and grooming items. Finally, the FUEL can be used during any functional activity that provides the clinician the opportunity to evaluate the patient during every session, in the context of ADLs, and thus monitor progress and further challenge the patient for optimal recovery.

With the body of research continuing to grow in support of performance-based interventions and with shortened lengths of stay for physical rehabilitation, clinicians frequently cite the need for assessments that are time efficient as well as reliable and valid outcome measures (Rowe, 2013). The need to create and research new classification and assessment tools is essential to provide the best care for patients, improve communication between rehabilitation professionals, demonstrate successful progression of treatment, and provide measureable and meaningful outcomes for third-party payers. The FUEL meets these needs because it is time efficient, can describe and classify the progress of a person’s UE use during functional tasks, can be used across disciplines, and integrates both a top-down and a bottom-up approach to UE assessment. Moreover, it also provides a template for treatment and progression of the UE after stroke.

As shown in Table 1, the FUEL includes seven levels of UE use ranging from nonfunctional to fully functional. Each level in the table includes a general description of how to classify the use of the affected UE during a task. Below each description, in italics, is an example of how one would describe the use of the affected hand during the activity of brushing one’s teeth. Brushing teeth is just one activity example; the FUEL can be used during any functional activity that requires arm use as long as the levels and definitions are adhered to. Therefore, one can classify UE function for different activities, thus taking into account the person, environment, and difficulty of the task. For instance, an occupational therapist may observe a patient using the affected hand as a gross assist for meal preparation but using the affected arm as a semifunctional assist when brushing the teeth. This classification should be based on how the affected UE is used the majority of the time for a given activity.

The tool also includes the external qualifiers of either spontaneous movement or movement that requires minimal, moderate, or maximal verbal, tactile, or demonstrative cues as a result of nonmotor impairments that could affect UE use, such as visual, cognitive, or perceptual difficulties. For instance, if a patient had mild left inattention and gross grasp and release of the hand, one could describe the patient’s level as being able to use the affected UE as a semifunctional assist while brushing teeth, with moderate verbal cues to attend to the left side to find the toothbrush. The FUEL not only captures the unique UE skills involved in the performance of different functional activities but can also provide a template for individual goal setting, treatment planning, and progression of UE use after stroke.