Development of an Item List to Assess Bilateral Upper-Extremity Function of Stroke Patients With Hemiplegia

PURPOSE: The purpose of the study is to develop items for a bilateral upper-extremity (UE) assessment for stroke survivors.

RATIONALE: Bilateral UE function is important for performing in activities of daily living, but the motor problems encountered by stroke survivors lead to difficulty in bilateral upper-limb function activities such as buttoning a shirt. Assessment and intervention for these activities is important for improvement of performance; however, most UE assessment tools focus on unilateral items. Thus, there is a need for assessment items that focus on bilateral UE function.

PARTICIPANTS: Experts in UE function (48 occupational therapists) who generated bilateral activity items, as well as 20 stroke survivors.

METHOD: The current study to generate potential item content for the Assessment of Bilateral Upper Extremity Function (ABUEF) during activities of daily living consisted of five phases.

In Phase 1, we conducted a literature search on UE function assessment tools. For Phase 2, experts in UE function were asked to nominate bilateral items relevant to stroke survivors. In Phase 3, we administered a questionnaire to 20 stroke survivors. The questionnaire included demographic information and a short-answer question: “What bilateral activities are difficult for you to perform?”

For Phase 4, the item list was refined, duplicate items were deleted, and similar items were combined. For Phase 5, the refined item list was sent to an expert panel and patients for a final evaluation. Items were assessed for (1) bilateral task, (2) importance of the task, (3) understanding of the wording, (4) if item should be expanded, and (5) if the item should be deleted. Difficulty level of the 70 items was assessed by 20 stroke survivors.

ANALYSIS: Descriptive statistics were generated for participant demographic characteristics. A content validity index (CVI) was calculated to identify which tasks were perceived as bilateral, and descriptive statistics were used to generate rater scores for importance, understanding, expansion, and deletion.

RESULTS: In Phase I, a total of 1,358 articles were identified, 68 of which met final inclusion criteria. The 68 studies addressed 46 assessment tools, with a total of 854 items. Of the 854 items, items not related to UE function were deleted, yielding 199 items. In Phase II, experts generated 24 new items, and in Phase III, 60 bilateral UE items were generated by stroke survivors. The most frequent items identified by stroke survivors were the following: Thread a needle (85%), tie/untie shoelaces (80%), drive a nail (80%), do knitting (75%), and cut food with a knife (75%).

In Phase IV, the 259 items were reduced to a total of 70 items for expert rater review. In Phase V, items with CVI ≤ 0.5 and average scores for expansion < 3 and deletion > 2 were deleted. After these results, 21 items with CVI2 were dropped. This resulted in 37 items remaining on the list. Of the 37 items, items that were difficult to perform on a table, did not consist of permanent materials, or applied only to specific people were eliminated. Thus, the content for the ABUEF consisted of 25 items.

DISCUSSION: The items generated for a bilateral UE function assessment tool will greatly assist clinicians who assess and treat stroke survivors. Next, we will need to define the measurement parameters and conduct test–retest and interrater reliability as well as construct and concurrent validity. This tool is unique because it was developed with input from the stakeholders who will use it: stroke survivors and experienced clinicians.

IMPACT STATEMENT: By selecting bilateral UE items for assessing stroke survivors, therapists will be able to help patients identify meaningful bilateral activities that they need to do, want to do, or are expected to do. This will facilitate collaborative treatment planning.