Reducing the number of test items of the Action Research Arm Test post stroke: A decision tree analysis

Objective - The present study aimed to create a shorter version of the Action Research Arm Test (ARAT) without compromising its measurement properties. Design - Secondary analysis of stroke recovery cohorts that used the ARAT to measure upper-limb impairment. Setting - Rehabilitation centers. Participants - Patients with stroke from five different stroke recovery cohorts. Interventions - Not applicable. Main Outcome Measures - A decision tree version of the ARAT (ARAT-DT) was developed using Chi-squared Automated Interaction Detection (CHAID). In an independent validation subset, criterion validity, agreement of ARAT-DT with original ARAT scores and score categories, and construct validity with the Fugl-Meyer upper extremity (FM-UE) score were determined. Results - In total, 3738 ARAT measurements were available involving 1,425 subjects. CHAID analysis in the development subset (n=2803) revealed an optimized decision tree with a maximum of four consecutive items. In the validation dataset (n=935), the ARAT-DT differed by a mean of 0.19 points (0.3% of the total scale) from the original ARAT scores (limits of agreement: -5.67 to 6.05). The ARAT-DT demonstrated excellent criterion validity with the original ARAT scores (ICC=0.99 and ρ=0.99) and scoring categories (κ_w=0.97). The ARAT-DT showed very good construct validity with the FM-UE motor scale (ρ=0.92). Conclusion - A decision tree version of the ARAT was developed, reducing the maximum number of items necessary for ARAT administration from 19 to 4. The scores produced by the decision tree had excellent criterion validity with original ARAT scores.

Paretic and Nonparetic Step Tests Are Noninterchangeable in Stroke: A Prospective Cohort Study

OBJECTIVE

The step test (ST) is a common clinical assessment of dynamic balance among survivors of stroke. The ST assesses a person's ability to place their paretic (paretic ST) or nonparetic (nonparetic ST) foot rapidly and repeatedly on and off a standardized block while standing. No study has formally explored if the 2 tests are interchangeable. Our study aimed to: (1) differentiate the correlates of paretic and nonparetic ST, and (2) compare their associations with physical function and falls.

METHODS

Eighty-one survivors of stroke were consecutively recruited from inpatient rehabilitation units (n = 4) and were assessed within 1 week prior to discharge. In addition to the ST, a handheld dynamometer and computerized posturography were used to measure lower limb muscle strength and standing balance, respectively. Self-selected gait speed and Timed Up and Go test were also assessed as measures of physical function. Falls data were monitored for 12 months post discharge using monthly calendars. Multivariable regression analyses were used to differentiate (1) the correlates of paretic and nonparetic STs, and (2) their associations with physical function and falls.

RESULTS

The median score for the paretic and nonparetic STs were 8 and 9 steps, respectively. Paretic ankle plantar-flexor and dorsiflexor strength were the strongest correlates of nonparetic ST, whereas both paretic ankle and knee extensor strength were the strongest correlates of paretic ST. In multivariable analyses adjusting for each other, both STs were independently associated with gait speed and Timed Up and Go scores. Paretic ST (odds ratio = 0.37; 95% CI = 0.22 to 0.62) was a stronger predictor than nonparetic ST (odds ratio = 0.51; 95% CI = 0.34 to 0.78) in predicting future falls.

CONCLUSION

This study confirmed that the paretic and nonparetic STs are noninterchangeable. ST scores should be assessed separately to achieve a more complete interpretation.

IMPACT

To our knowledge, this study is the first to objectively evaluate the similarities and differences between paretic and nonparetic STs. This information may refine the use and interpretation of the 2 STs for survivors of stroke.

Test-Retest Reliability of the Mini-BESTest in People With Mild to Moderate Multiple Sclerosis

OBJECTIVE

The mini-Balance Evaluation Systems Test (BESTest) is a balance measure for assessment of the underlying physiological systems for balance control in adults. Evaluations of test-retest reliability of the mini-BESTest in larger samples of people with multiple sclerosis (MS) are lacking. The purpose of this study was to investigate test-retest reliability of the mini-BESTest total and section sum scores and individual items in people with mild to moderate overall MS disability.

METHODS

This study used a test-retest design in a movement laboratory setting. Fifty-four people with mild to moderate overall MS disability according to the Expanded Disability Status Scale (EDSS) were included, with 28 in the mild subgroup (EDSS 2.0-3.5) and 26 in the moderate subgroup (EDSS 4.0-5.5). Test-retest reliability of the mini-BESTest was evaluated by repeated measurements taken 1 week apart. Reliability and measurement error were analyzed.

RESULTS

Test-retest reliability for the total scores was considered good to excellent, with intraclass correlation coefficients of .88 for the whole sample, .83 for the mild MS subgroup, and .80 for the moderate MS subgroup. Measurement errors were small, with standard error of measurement and minimal detectable change of 1.3 and 3.5, respectively, in mild MS, and 1.7 and 4.7, respectively, in moderate MS. The limits of agreement were -3.4 and 4.6. Test-retest reliability for the section scores were fair to good or excellent; weighted kappa values ranged from .62 to .83. All items but 1 showed fair to good or excellent test-retest reliability, and percentage agreement ranged from 61% to 100%.

CONCLUSION

The mini-BESTest demonstrated good to excellent test-retest reliability and small measurement errors and is recommended for use in people with mild to moderate MS.

IMPACT

Knowledge of limits of agreement and minimal detectable change contribute to the interpretability of the mini-BESTest total score. The findings of this study enhance the clinical usefulness of the test for evaluation of balance control and for designing individually customized balance training with high precision and accuracy in people with MS.

Brain Injury Functional Outcome Measure (BI-FOM): A Single Instrument Capturing the Range of Recovery in Moderate-Severe Traumatic Brain Injury

OBJECTIVE

To develop a measure of global functioning after moderate-severe TBI with similar measurement precision but a longer measurement range than the FIM.

DESIGN

Phase 1: retrospective analysis of 5 data sets containing FIM, Disability Rating Scale, and other assessment items to identify candidate items for extending the measurement range of the FIM; Phase 2: prospective administration of 49 candidate items from phase 1, with Rasch analysis to identify a unidimensional scale with an extended range.

SETTING

Six TBI Model System rehabilitation hospitals.

PARTICIPANTS

Individuals (N=184) with moderate-severe injury recruited during inpatient rehabilitation or at 1-year telephone follow-up.

INTERVENTIONS

Participants were administered the 49 assessment items in person or via telephone.

MAIN OUTCOME MEASURES

Item response theory parameters: item monotonicity, infit/outfit statistics, and Factor 1 variance.

RESULTS

After collapsing misordered rating categories and removing misfitting items, we derived the Brain Injury Functional Outcome Measure (BI-FOM), a 31-item assessment instrument with high reliability, greatly extended measurement range, and improved unidimensionality compared with the FIM.

CONCLUSIONS

The BI-FOM improves global measurement of function after moderate-severe brain injury. Its high precision, relative lack of floor and ceiling effects, and feasibility for telephone follow-up, if replicated in an independent sample, are substantial advantages.

Measurement Properties of the SF-MPQ-2 Neuropathic Qualities Subscale in Persons with CRPS: Validity, Responsiveness, and Rasch Analysis

OBJECTIVES

The purpose of this study was to conduct classical psychometric evaluation and Rasch analysis on the Neuropathic Qualities subscale of the Short-Form McGill Pain Questionnaire-2 utilizing scores from persons with complex regional pain syndrome to consider reliability and person separation, validity (including unidimensionality), and responsiveness in this population.

METHODS

Secondary analysis of longitudinal data from persons with acute complex regional pain syndrome was utilized for analysis of the psychometric properties and fit to the Rasch model of the Neuropathic Qualities subscale. We followed an iterative process of Rasch analysis to evaluate and address data fitting challenges.

RESULTS

Repeated measures from 59 persons meeting the Budapest criteria were used for analysis. Both item-total correlations and unidimensionality analyses supported theoretical construct validity; all convergent construct validity hypotheses were also supported. Responsiveness was demonstrated comparing baseline and one-year data at d = 0.92, with a standardized response mean of 0.97. Data were able to fit the Rasch model, but all Neuropathic Qualities items had disordered thresholds that required rescoring. Additionally, local dependency and differential item function were addressed by "bundling," suggesting that no further item reduction would be possible.

CONCLUSIONS

This study provided preliminary support for the validity and responsiveness of the Neuropathic Qualities subscale in persons with complex regional pain syndrome. Rasch analysis further endorses use of the Neuropathic Qualities subscale as a "stand-alone" measure for neuropathic features, but with substantial background data transformations. Replication with larger samples is recommended to increase confidence in these findings.

Use of welfare outcome information in three types of dairy farm inspection reports

Objective

The aim of this study was to examine the use of outcome-based observations within Assured Dairy Farm scheme (ADF), Soil Association Organic Standards (SA), and cross compliance (CC) farm assessment reports.

Methods

A total of 449 ADF reports, 37 SA reports and 26 CC reports were analyzed and their objective comments categorized as either resource-based or outcome-based.

Results

A mean of 61.0% of ADF questions were responded to with comments, in comparison to 25.0% of SA and, 21.0% of CC report questions. The SA and CC reports had significantly more outcome-based comments than the ADF (p<0.001). The assessors’ tendency of choosing resource-based approach was revealed in the questionnaire results.

Conclusion

Generally, the comments were comprehensive and contained professional judgements. Large numbers of comments provided in the ADF reports were mostly compliant and resource-based evidence, which serves as proof of assessment rather than aiding the certifying process. The inclusion of specific welfare outcome measures in the SA inspection likely increased the use of outcome-based comments in the reports, irrespective of whether the farm achieved compliance with a given standards. The CC scheme, on the other hand, focused on providing outcome-based evidence to justify noncompliant decisions.

Feedback informed treatment: evidence-based practice meets social construction

This article explores the challenges presented by the mandate for evidence-based practice for family therapists who identify with the philosophical stance of social construction. The history of psychotherapy outcome research is reviewed, as are current findings that provide empirical evidence for an engaged, dialogic practice. The authors suggest that the binary between empiricism and social construction may be unhinged by understanding empiricism as a particular discursive frame (i.e., a particular way of talking, acting, and being in the world), one of many available as a way of understanding and talking about our work. Through a case vignette, the authors introduce the evidence-based practice of Feedback Informed Treatment as an elaboration of social construction, and as an example of bridging the gap between the discursive frames of empiricism and social construction.