Spanish consensus of occupational therapists on upper limb assessment tools in stroke

Abstract

Introduction:

There is a lack of explicit tool recommendations for upper limb (UL) assessment in stroke, occupational therapists are frequently underrepresented in consensus studies, and the frequency of use of tools is highly variable between countries. The objective was to generate national occupational therapy consensus recommendations on UL assessment tools in stroke, and to classify the tools that achieve consensus according to the International Classification of Functioning, Disability and Health (ICF) components.

Methods:

Three-round e-Delphi study of national scope. Occupational therapists working in Spain with training and experience in neurorehabilitation were recruited. Rounds were based on the completion of questionnaires on UL stroke assessment tools. Consensus was reached when ⩾75% of experts gave a ⩾7 rating on a nine-point Likert scale.

Results:

A total of 29 occupational therapists comprised the expert panel. Twenty-three (17.8%) assessment tools achieved consensus and were classified according to the ICF components of body functions and structures (7), activities (11), participation (3) and other (2).

Conclusion:

The expert panel recommended 23 outcome measures for UL recovery in stroke, representing all ICF components. The consensus recommendations are intended to assist occupational therapists in their clinical decision-making process, and to reduce the heterogeneity of research tools.

Keywords

Delphi Technique stroke patient outcome assessment upper extremity occupational therapy

Introduction

Stroke is one of the leading causes of disability in the world (Feigin et al., 2021). In Spain, it constitutes a major economic burden for the National Health System (Alvarez-Sabín et al., 2017), and this burden is expected to increase due to the ageing of the population (Feigin et al., 2017).

Stroke survivors face a complex range of physical, psychosocial and cognitive impairments (Olver et al., 2021). Among these deficits, impairment of upper limb (UL) function is present in 33–77% of individuals (Kwakkel et al., 2003; Lawrence et al., 2001) and is associated with limitations in daily living activities, participation restrictions and a poorer health-related quality of life (Franceschini et al., 2010; Morris et al., 2013). Improving UL functionality is an imperative therapeutic goal in stroke rehabilitation, not only for healthcare professionals but also for patients and their caregivers (Bayley et al., 2007; Pollock et al., 2014).

Assessment of UL function and performance after stroke is paramount in both clinical and research settings (Lemmens et al., 2012). Standardised and valid assessment tools should be used to evaluate stroke-related impairments, including activity limitations and participation restrictions (Hebert et al., 2016). The International Classification of Functioning, Disability and Health (ICF) can be used to classify UL assessment tools into three areas: body functions and structures, activities and participation. By using tools pertaining to the various ICF components, it is possible to measure complex and multidimensional deficits in a holistic manner and to better understand the impact they have on patients’ daily lives (Metcalf et al., 2007; Velstra et al., 2011).

Currently, there is a lack of consensus in clinical practice guidelines on which tools should be used for UL assessment after stroke, even when using the ICF components as reference (Burridge et al., 2019). The current lack of explicit tool recommendations can slow down the understanding of UL recovery mechanisms, the efficacy of treatments, and the consolidation of research-derived knowledge (Ali et al., 2013; Burridge et al., 2019). Likewise, the use of UL assessment tools in the stroke population is highly variable and heterogeneous between countries, even in those that are geographically close or that share the same language. Therefore, geographical preferences need to be thoroughly explored (Santisteban et al., 2016). In addition, there is great diversity regarding the choice of UL assessment tools in stroke clinical trials, as exemplified by a Cochrane review that identified 208 unique assessment tools in 243 trials (Pollock et al., 2014).

The Delphi technique is a well-established approach for generating reliable consensus opinion among experts (Barrett and Heale, 2020). A common application of this technique in the healthcare field is to select assessment tools for a particular population (Humphrey-Murto and de Wit, 2019). In recent Delphi studies about assessment tools for the stroke population, occupational therapists were underrepresented compared with other health professions (Kwakkel et al., 2017; Pohl et al., 2020). Cuesta-García et al. (2021) explored the UL assessment process of Spanish occupational therapists in adults with acquired brain injury (ABI). They identified 110 assessment tools and found that most occupational therapists mainly assessed the body functions and structures component of the ICF (Cuesta-García et al., 2021).

The aforementioned findings illustrate the need to reach a national consensus in the field of occupational therapy on UL assessment tools for patients with stroke.

The principal objective of this study was to generate national consensus recommendations in the field of Occupational Therapy on the assessment tools needed in the UL recovery of patients with stroke. The secondary objective was to classify the tools that achieved consensus according to the ICF components.

Methods

Study design

A three-round modified electronic Delphi study of national scope was performed. The study was conducted between February and July 2022. Each expert participated individually, unaware of the composition of the rest of the panel, and its anonymity was maintained at all times.

The Research ethics heading already contains this information. Therefore, it can be eliminated from this section.

The present manuscript was reported according to the Guidance on Conducting and Reporting Delphi Studies (CREDES) (Jünger et al., 2017). However, CREDES is only validated in the palliative care field (Nasa et al., 2021).

Participants

Inclusion and elimination criteria

In Delphi studies, there are no standardised criteria for being considered an expert (Diamond et al., 2014; Keeney et al., 2006). The inclusion criteria in the present research were the following: (a) occupational therapists working in Spain; (b) with postgraduate qualifications in neurological pathology; (c) working as clinicians, teachers and/or researchers; and (d) with ⩾10 years of experience in ABI. Failure to participate in one of the consensus rounds was considered an elimination criterion.

Selection and recruitment

Non-probabilistic convenience sampling was performed between February and March, 2022. Recruitment was carried out through various means, and an attempt was made to ensure representation from all the autonomous communities of Spain: (1) social networks (Twitter, LinkedIn, Facebook and ResearchGate); (2) Spanish professional associations of occupational therapists; (3) faculty directories of Spanish universities in which the occupational therapy degree is taught; and (4) database searching to identify publications on stroke by Spanish occupational therapists. Snowball sampling was also used.

Sample size

There are no clear guidelines on the number of participants that should be included in Delphi studies (Keeney et al., 2006, 2011). De Villiers et al. (2009) defined the sample size according to its homogeneity. The expert panel should consist of 15–30 participants if they share the same profession and, if they do not, 5–10 participants from each discipline should be included (de Villiers et al., 2009). Therefore, the present study aspired to recruit 30 experts, taking into consideration potential losses over the three rounds.

Questionnaires

Personal data questionnaire

An ad hoc online questionnaire was developed that collected the following data: demographic (age and sex); academic (postgraduate qualifications in neurological pathology); and work-related (employment sector, primary work area, type of worker, type of professional activity, years of work experience in ABI and ABI phase of the treated patients).

Assessment tools questionnaire

An ad hoc online questionnaire was developed after conducting a literature review on UL assessment tools in stroke. The following exclusion criteria were established: (a) instruments developed for the paediatric population; (b) aimed only at lower limb assessment; (c) focused on cognitive and/or behavioural status assessment; (d) non-standardised; and (e) medical tests. Two researchers conducted a separate search in three databases: Google Scholar, EBSCO and MEDLINE. Several keywords were used: upper limb, upper extremity, stroke, stroke recovery, stroke rehabilitation, outcome measures, assessment tools and measurement tools. Assessment tools were also identified using citation searching. Subsequently, their results were compared and combined into a single list of assessment tools that constituted the first-round questionnaire.

Each tool of the questionnaire was accompanied by a nine-point Likert scale so that each expert could rate its importance in stroke UL recovery. Scores of 1–3 indicated ‘low importance’, scores of 4–6 indicated ‘uncertain importance’, and scores of 7–9 indicated ‘high importance’. Likert-type scales are commonly used in Delphi studies to help the expert panel move towards consensus (Keeney et al., 2011).

Consensus

There is no universal agreement on what is considered ‘consensus’ in Delphi studies (Keeney et al., 2006, 2011). One of the most common metrics is the percentage of agreement between experts (Hall et al., 2018), which can range from 51 to 100% (Keeney et al., 2011), and is often arbitrarily selected. The systematic review by Diamond et al. (2014) determined that the most frequent threshold for consensus agreement was 75% (Diamond et al., 2014). Thus, 75% was used in the present study.

If ⩾75% of the experts rated a tool with a score of 7–9 on the Likert scale, consensus was reached, meaning that that it was necessary to include that assessment tool in stroke UL recovery. If a tool did not reach consensus (⩽75% of agreement), two situations could occur: (1) If the median score was ⩾7, the tool was included in the next-round questionnaire; (2) If the median score was ⩽6, the tool was eliminated. Murphy et al. (1998) recommended using the median versus the mean in Delphi studies because the median is more robust (Murphy et al., 1998).

Procedure

An email was sent to potential experts containing information on the nature of the study, its procedure, objectives and expected benefits. The e-mail also included a link to a Microsoft Forms survey with two sections (informed consent and personal data questionnaire). The personal data section was used to check whether the candidates met the inclusion criteria. Subsequently, three consecutive consensus rounds were performed.

Round 1 of consensus

The first round of surveys began on 30 March 2022. An email was sent to the participants who met the inclusion criteria. The email detailed the functioning of round 1: which assessment tools were included in the questionnaire, how experts should rate their agreement or disagreement with said tools, the possibility of suggesting additional tools, the duration of the round, and how the following round questionnaire would be generated. It also included a link to a Cognito Forms survey. This survey contained the assessment tools questionnaire. Each expert was asked to rate the importance of each assessment tool in stroke UL recovery using a nine-point Likert scale. At the end of the questionnaire there was a textbox that offered the experts the possibility of adding additional assessment tools. Following the recommendations of Hall et al. (2018), experts had 1 month to answer the questionnaire and received a reminder email 15 days after the start of the round (Hall et al., 2018).

At the end of the round, questionnaire responses were analysed to determine which tools had reached consensus, which were included in the next round questionnaire, and which were eliminated, in order to build the second-round questionnaire.

Round 2 of consensus

The second round of consensus began on 10 May 2022. An email was sent to the experts who had completed round 1. The email contained the following information: (1) Detailed functioning of round 2; (2) A list of the assessment tools that had reached consensus in round 1; (3) Individualised feedback on round 1 scores so that each expert could confidentially compare and contrast their personal opinion with the overall opinion of the panel and reconsider, if deemed appropriate, their scores (feedback example in Figure 1); (4) An ad hoc document containing relevant information about each assessment tool that made up the second-round questionnaire, with the intention of allowing each expert to reflect on the first-round scores; and (5) A link to a Cognito Forms survey containing the second-round assessment tools questionnaire. Each expert was asked to rate the importance of each assessment tool in stroke UL recovery using a nine-point Likert scale.

Figure 1.

Example of the individualised feedback provided to experts in rounds 2 and 3.

As in the first round, participants had 1 month to respond to the questionnaire and received a reminder email 15 days after the start of the round. At the end of the round, questionnaire responses were analysed to determine which tools had reached consensus, which were included in the next round questionnaire, and which were eliminated, in order to build the third-round questionnaire.

Round 3 of consensus

The third round of consensus began on 20 June 2022. An email was sent to the experts who had completed round 2. The email contained the following information: (1) Detailed functioning of round 3; (2) A list of the assessment tools that had reached consensus in round 2; (3) Individualised feedback on round 2 scores; (4) An ad hoc document containing relevant information about each assessment tool that made up the third-round questionnaire; and (5) A link to a Cognito Forms survey containing the third-round assessment tools questionnaire. Once again, each expert was asked to rate the importance of each assessment tool in stroke UL recovery using a nine-point Likert scale. In addition, four questions related to the assessment process were added to the questionnaire: (1) time spent on assessment and frequency of assessment during the treatment plan; (2) importance of UL assessment; (3) disadvantages or limitations of the tools that had reached consensus; and (4) comments on the assessment process.

As in previous rounds, participants had 1 month to respond to the questionnaire and received a reminder email 15 days after the start of the round. At the end of the round, questionnaire responses were analysed to determine which tools had reached consensus.

ICF classification

All the tools that reached consensus throughout the three rounds were classified according to the ICF components (body functions and structures, activities and participation). A fourth category (other) was created for tools that could not be classified into a single component. The principal investigator decided to classify a tool in a particular ICF category using his expertise and up-to-date evidence.

Statistical analysis

An analysis of the results was performed using SPSS v. 25.0 software (SPSS Inc., Chicago, IL, USA). A descriptive analysis was performed for the variables of the personal data questionnaire and the evaluation tools questionnaires.

In relation to the personal data questionnaire, quantitative variables were presented as mean ± standard deviation, and categorical variables as absolute value and percentage (n (%)). Regarding the assessment tools questionnaires, the percentage of agreement for each tool was calculated to establish whether it had reached consensus. If a tool had not reached consensus, the median score was calculated to determine whether it was included in the next round of consensus or was eliminated.

Results

Expert panel

Twenty-nine occupational therapists made up the expert panel. Most of the panel (n = 18; 62%) had between 10 and 14 years of work experience in ABI, followed by 15–19 years (n = 7; 24%), 20–24 years (n = 2; 7%) and 25 or more years (n = 2; 7%). Round 1 was completed by 93.1% of the experts (n = 27), round 2 by 72.4% (n = 21), and round 3 by 69% (n = 20). The overall dropout rate was 31% (see Supplemental Material).

The demographic, academic and work-related data of the experts who completed the three rounds is provided in Table 1. With respect to the autonomous community where the experts worked, the geographic distribution for each consensus round is shown in the Supplemental Material.

Table 1.

Demographic, academic and work-related characteristics of the final expert panel.

Sample characteristics	N = 20 (%)
Age* (years)	38.95 ± 4.21
Sex
Men	9 (45)
Women	11 (55)
Postgraduate qualifications in neurological pathology
Expert course	2 (10)
Master’s degree	10 (50)
Doctoral candidate	4 (20)
Doctorate	4 (20)
Employment sector
Public	5 (25)
Private	14 (70)
State assisted	1 (5)
Primary work area
Academic	3 (15)
Rehabilitation centre	10 (50)
Domiciliary	0
Hospital	7 (35)
Research	0
Type of worker
Employee	16 (80)
Self-employed	4 (20)
Type of professional activity
Assistance	9 (45)
Teaching	2 (10)
Assistance and teaching	3 (15)
Assistance, teaching and research	5 (25)
Assistance and research	1 (5)
Years of work experience in ABI (years)
⩾10	14 (65)
⩾15	4 (20)
⩾20	1 (5)
⩾25	2 (10)
ABI phase of the treated patients
Acute	2 (10)
Subacute	11 (55)
Chronic	7 (35)

ABI: acquired brain injury.

Mean ± standard deviation.

Assessment tools

A total of 129 assessment tools that met the established criteria were identified through a literature review and made up the first-round questionnaire. No additional tools were proposed by the experts in round 1. After three consensus rounds, 23 (17.8%) assessment tools reached consensus. The consensus process is presented in the Supplemental Material. The percentage of agreement of the tools that reached consensus is presented in Figure 2.

Figure 2.

Percentage of agreement of the assessment tools that reached consensus.

ICF classification

Of the 23 tools that reached consensus, 7 were categorised as body functions and structures, 11 as activities, 3 as participation and 2 as other (Figure 3).

Figure 3.

Categorisation of the assessment tools that reached consensus according to the ICF components.

Assessment process

Regarding the results of the questions related to the evaluation process, the experts unanimously considered that the evaluation process is essential for setting therapeutic objectives and demonstrating treatment results. Eighty percent of the experts reported that they assess patients at least three times during treatment: at admission, after 1–3 months, and at discharge. With respect to the time dedicated to evaluation, most of them spent approximately 1 hour. Regarding the limitations of the tools that reached consensus, the most frequent answers were: (1) the need to use several tools, given that there is no tool that integrates all dimensions; (2) the economic cost and the amount of time involved in some of them (e.g. electromyography); and (3) the need for training in some of them.

Discussion

The main objective of the study was to generate national consensus recommendations in the field of Occupational Therapy on the assessment tools needed in UL stroke recovery. The expert panel identified a total of 23 tools that represented all components of ICF: 7 body function and structure tools (3D movement analysis; Chedoke-McMaster Stroke Assessment – Arm and Hand Impairment Inventory; dynamometry; surface electromyography; Erasmus-Modified Nottingham Sensory Assessment – Upper Extremity Sections; Fugl-Meyer Assessment – Upper Extremity; and Nottingham Sensory Assessment); 11 activity tools (Action Research Arm Test; Box and Blocks Test; original and reduced version of the Chedoke Arm and Hand Activity Inventory; ABILHAND questionnaire; Jebsen-Taylor Hand Function Test; Motor Activity Log-30, -28 and -14; Nine-Hole Peg Test; and Wolf Motor Function Test), and three participation tools (Assessment of Motor and Process Skills; Canadian Occupational Performance Measure [COPM]; and Stroke Impact Scale [SIS]-16 – Hand Function Domain), as well as two tools that were classified as ‘other’ (Disabilities of the Arm, Shoulder and Hand; and Goal Attainment Scale).

The results of the present investigation are consistent with the European evidence-based recommendations for clinical assessment of the UL in neurorehabilitation (CAULIN). Multiple tools that belonged to the body functions and structures and activities components of the ICF were recommended using several criteria (psychometric properties and clinical utility of assessment tools, their frequency of use in clinical practice guidelines, and the consensus of European experts). The basic set of tools consisted of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE) and the Action Research Arm Test (ARAT), and the extended set consisted of movement analysis, the Box and Blocks Test (BBT), the Chedoke Arm and Hand Activity Inventory (CAHAI), the Wolf Motor Function Test (WMFT), the Nine-Hole Peg Test (NHPT) and the ABILHAND questionnaire. In addition, in the supplementary set, both studies agreed on the use of the Chedoke-McMaster Stroke Assessment (CMSA) (Prange-Lasonder et al., 2021).

Along the same lines, the American Physical Therapy Association Neurology Section conducted a consensus study to generate recommendations for clinical practice, research and university education regarding assessment tools in the stroke population. Coinciding with the findings of the present study, multiple UL assessment tools reached consensus, and they belonged to the body function and structure (CMSA, dynamometry, FMA-UE and Nottingham Sensory Assessment), activity (ARAT, BBT, CAHAI, Jebsen-Taylor Hand Function Test, Motor Activity Log, NHPT and WMFT) and participation (COPM, Goal Attainment Scale and SIS) components of the ICF (Sullivan et al., 2013).

The consensus recommendations of the present study are also supported by the systematic review of Alt Murphy et al. (2015). They concluded that the motor section of the Fugl-Meyer Assessment, the ARAT, BBT, CAHAI, WMFT and the ABILHAND questionnaire were the most appropriate tools for UL assessment after stroke because they obtained the highest level of measurement quality and clinical utility, in terms of administration, scoring, interpretation, cost and portability (Alt Murphy et al., 2015).

Other relevant investigations also agree on the use of several tools that reached consensus in the present study. Bushnell et al. (2015) conducted an expert panel to make recommendations about which assessment tools to employ in chronic stroke clinical trials. In relation to the UL, the FMA-UE was the main recommendation because it had the best psychometric properties (reliability, responsiveness, validity and minimal clinically important difference). To a lesser extent, the WMFT, ARAT and SIS were also recommended (Bushnell et al., 2015). Connell and Tyson (2012) reviewed the psychometric properties and clinical utility of UL assessment tools in neurological conditions. They concluded that BBT and ARAT produce robust data, and their use in clinical practice is feasible (attending to validity criteria, intra- and inter-rater reliability and ability to detect change) (Connell and Tyson, 2012). Furthermore, it has been observed that the FMA-UE and ARAT are the most frequently used tools in clinical trials on UL stroke rehabilitation (Millar et al., 2019).

However, there is a greater discrepancy between the results of the present investigation and a recent international consensus on UL stroke assessment tools in clinical trials. Regarding the body functions and structures component, consensus was reached on the visual analogue scale, the pain rating scale and dynamometry, the latter being the only common recommendation between both studies. Regarding the activity component, there was greater consensus, with 5 out of 10 tools in accordance: BBT, Motor Activity Log (MAL), NHPT, ARAT and WMFT. Finally, the only tool in the participation component was the COPM (Millar et al., 2021).

Body functions and structures component

Motion analysis is included in the CAULIN recommendations to quantify the quality and execution of UL motion, although its clinical applicability is not yet well established (Prange-Lasonder et al., 2021). Recent technological advances have aided the design of more accessible and portable motion capture systems for out-of-laboratory assessment (Abdollahi et al., 2022). However, one of the current limitations is the lack of standardised assessment procedures (Schwarz et al., 2019). Nevertheless, the Second Stroke Recovery and Rehabilitation Roundtable recommended that protocols to assess UL quality movement should consist of four performance tests (two-dimensional reaching, finger individualisation, grip strength and precision grip) and 1 functional task (three-dimensional drinking task) (Kwakkel et al., 2019).

Measurement of grip strength can be used to monitor motor recovery and estimate current and future UL capacity and functional performance in the stroke population (Bertrand et al., 2015). Shoulder abduction and finger extension strength can also predict functional recovery within 72 hours after stroke onset (Nijland et al., 2010). Along the same lines, surface electromyography is a noninvasive tool that can help assess neuromuscular changes during stroke rehabilitation, guiding the design of individualised intervention protocols (Steele et al., 2020; Zhu et al., 2020).

The Nottingham Sensory Assessment (NSA) was developed to identify sensory deficits as well as to monitor the recovery process in cerebrovascular disease (Lincoln et al., 1998). However, it is not frequently used in clinical practice to assess somatosensory impairment after stroke (Pumpa et al., 2015). In 2006, Stolk-Hornsveld et al. (2006) improved the inter-rater reliability of the NSA through the Erasmus MC modifications (EmNSA). Recently, validation studies of the EmNSA for the UL have been published in various countries (Villepinte et al., 2019; Zamarro-Rodríguez et al., 2021); thus, its use is increasing compared with the original version. The systematic review by Connell and Tyson (2011) studied the psychometric properties and clinical utility (in terms of administration, cost and portability) of sensory assessment tools in neurological conditions. They concluded that the EmNSA and the FMA sensation section showed the best balance between clinical utility and psychometric properties (Connell and Tyson, 2011).

Activities component

In general, the tools that reached consensus on this ICF component have good psychometric properties and are correlated with each other and with the WMFT in the stroke population. ARAT is strongly correlated with WMFT at 14 days, at 1, 3 and 6 months after stroke (Lin et al., 2009), and with CAHAI (Barreca et al., 2005). ARAT, dynamometry and NHPT have moderate to strong correlations at 1, 3 and 6 months after stroke (Beebe and Lang, 2009). ARAT and BBT have excellent concurrent validity and are highly sensitive to change (Chanubol et al., 2012). BBT, ARAT and FMA-UE have excellent inter-rater and test-retest reliability, and correlations among said tools are high in patients with hemiparesis due to stroke (Platz et al., 2005). WMFT is an instrument with high inter-rater and test-retest reliability, high internal consistency and adequate stability (Morris et al., 2001). Also, WMFT and FMA scores can predict clinically relevant improvements in quality of movement and quantity of use according to the MAL (Li et al., 2020). The ABILHAND questionnaire can also predict UL function and participation in daily activities in patients with stroke (Wang et al., 2011).

Participation component

CAULIN recommendations did not take into account the ICF participation component, given that the experts considered that tools assessing participation are not strongly related to UL functioning (Prange-Lasonder et al., 2021). Although the inclusion of participation measures in stroke clinical trials is rare (Salter et al., 2007), there is a need to explore participation to determine whether interventions produce changes that are important in people’s lives (Lang et al., 2013). The Stroke Recovery and Rehabilitation Roundtable on the measurement of sensorimotor recovery in stroke trials could not reach consensus on a participation measure, arguing that all exhibited generally inadequate measurement properties (Kwakkel et al., 2017). The fact that fewer tools are generally identified in the ICF participation component could indicate that it is an area with potential for the development of new assessment tools (Sullivan et al., 2013).

The measurement of a complex and multidimensional construct such as participation presents challenges due to the lack of consensus regarding its conceptualisation and operationalisation for its evaluation and intervention (Chang et al., 2013). Two dimensions are usually distinguished to understand participation: (1) objective, which reflects observable behaviour and can be quantifiable in frequency, intensity, duration and variety of activities performed; and (2) subjective, which is self-reported and addresses the internal experience of the individual. In our findings, there has been a gap in relation to the objective dimension (Bueby, 2021). The SIS was the only specific stroke tool for subjective participation that reached consensus. Other consensus studies also recommend the use of SIS for assessing stroke participation, both in clinical practice and research (Bushnell et al., 2015; Hughes et al., 2016). The SIS has eight domains, three of which are related to UL (hand function, activities of daily living and strength) (Duncan et al., 1999). However, controversy exists regarding its frequency of use. Although Lang et al. (2013) reported that it is one of the most commonly employed self-report measures in UL stroke assessment (Lang et al., 2013), Millar et al. (2019) found that it was only used in 18 of 243 clinical trials (Millar et al., 2019).

The systematic review by Yang et al. (2017) concluded that COPM is an appropriate tool to help patients with stroke identify meaningful occupational performance goals (Yang et al., 2017). Occupational therapists can also use COPM to design occupation-based, patient-centred intervention programmes (Phipps and Richardson, 2007).

Regarding the Assessment of Motor and Process Skills tool, it measures the quality of an individual’s performance in daily living activities through the observation of meaningful tasks in a natural environment (Fisher, 1993). Because it must be administered by an occupational therapist who has completed specialised training (Fisher and Jones, 2012), it is less accessible for widespread use (Poulin et al., 2013) in comparison to other mentioned tools.

Assessment process

The panel’s responses regarding the timing of assessment coincide with the recommendations of other studies, although they were not answered according to each ICF component. Pohl et al. (2020) recommended assessing body functions and structures on days 1 and 7, and at weeks 2, 4, 12, 26 and onwards; activities on day 7 and the same weeks as the previous component; and participation at weeks 2, 26 and onwards (Pohl et al., 2020).

Toglia et al. (2019) considered that participation outcomes could be optimised by monitoring and evaluating post-stroke participation with follow-up questionnaires after 6 months. They also proposed the combination of two tools: SIS and Community Participation Indicators (Toglia et al., 2019).

The Canadian Stroke Best Practice Recommendations state that ‘all patients admitted to hospital with acute stroke should have an initial assessment, conducted by rehabilitation professionals, as soon as possible after admission (evidence level A)’ in order to develop an individualised rehabilitation care plan. Also, assessment of functional impairments, activity limitations, role participation restrictions and environmental factors should be performed using standardised and validated assessment tools (Teasell et al., 2020).

Experts noted the lack of a single test that assesses all the dimensions affected in stroke. Designing such a tool would be very complex due to the large number of functions and activities that the UL can perform. However, Ingram et al. (2019) developed a physiological UL profile assessment in asymptomatic adults to quantify important domains for proper UL functioning. The included tests evaluated muscle strength, unilateral movement and dexterity, position sense, skin sensation, bimanual coordination and arm stability. The tests were sufficiently reliable to detect motor impairments in people with compromised UL function (Ingram et al., 2019).

Limitations

Because no systematic search was conducted to identify the assessment tools submitted for consensus, there could be other instruments relevant to occupational therapy practice that were not included in the first questionnaire. In addition, tools related to the environmental and personal components of the ICF were not taken into consideration. Another source of bias could have been the choice to begin the first consensus round with predefined items rather than open-ended questions. Nevertheless, experts were allowed to propose additional assessment tools to be included in the second-round questionnaire.

The experts’ familiarity with the assessment tools was unknown, a factor that might have influenced the study’s results. In addition, not all panel members had the same level of training or experience, so their assessments might not be equally well-founded, and they were not given the opportunity to clarify their scores. Another limitation inherent to the Delphi methodology lies in the subjective nature of the opinions offered by the experts, given that they might not be representative of current clinical practice or even of their own practice.

A potential bias could have been introduced by using non-probability sampling methods, limiting the representativeness of the sample. Also, there could have been a self-selection bias of the experts based on their interest in the study’s results. Although an effort was made to obtain representatives from all Spanish autonomous communities and cities, 8 out of 19 were not represented in any round (Canary Islands, Cantabria, Extremadura, La Rioja, Murcia, Basque Country, Ceuta and Melilla). Thus, geographical bias is present, and the study’s results could present limitations in terms of generalisability. Another limitation that might have influenced the validity of the results was the loss of participants in the second round of consensus. This fact could be related to the amount of time it took to complete the first-round questionnaire or to the wait time between rounds.

Implications and future research

The consensus recommendations of the present study are intended to assist occupational therapists in the decision-making process on which assessment tools to choose in the UL recovery of patients with stroke, improving the quality of clinical practice at the national level. Hohmann et al. (2018) believe that properly designed Delphi studies can be a valuable tool for clinical practice, regardless of the level of evidence assigned to expert’s opinion (Hohmann et al., 2018). The recommendations also have the potential to reduce the heterogeneity of the tools used in research, favouring the use of meta-analyses, which are essential to advance the understanding of stroke recovery.

In the future, new assessment tools that meet the inclusion criteria of this study will be designed. Therefore, consensus recommendations might have to be updated periodically.

In occupational therapy, the evaluation of the quality of occupational performance is a critical component in the top-down approach. This approach proposes performance observation and analysis while the patient is performing their occupations in their natural environment (Bueby, 2021). In this framework, UL function and participation are connected. This should be a future line of research to reinforce participation programmes in domestic and social settings.

Conclusion

This study provides consensus recommendations for occupational therapy on assessment tools for UL recovery in patients with stroke. The expert panel recommends 23 tools that cover the body functions and structures, activities and participation components of the International Classification of Functioning, Disability and Health. This consensus opinion could be useful for standardising UL stroke, both in clinical and research settings. The selected tools should be reviewed and updated to reflect advances in the diagnosis of UL dysfunction.

Key Findings

The experts unanimously considered that the evaluation process is essential for setting therapeutic objectives and demonstrating treatment results.

Eighty per cent of the experts reported that they assess patients at least three times during treatment (at admission, after 1–3 months, and at discharge), and they spend approximately 1 hour to the evaluation.

The most important limitations for the experts were the need to use several tools, the economic cost and the amount of time involved in some of them, and the need for training in some of them.

What the study has added

The consensus recommendations are intended to assist occupational therapists in their clinical decision-making process, and to reduce the heterogeneity of research tools.

Supplemental Material

sj-docx-1-bjo-10.1177_03080226231175574 – Supplemental material for Spanish consensus of occupational therapists on upper limb assessment tools in stroke

Supplemental material, sj-docx-1-bjo-10.1177_03080226231175574 for Spanish consensus of occupational therapists on upper limb assessment tools in stroke by Beatriz Madroñero-Miguel and César Cuesta-García in British Journal of Occupational Therapy

Footnotes

Acknowledgements

The authors would like to thank the experts for their effort in participating in the study. Supplementary material associated with the composition of the expert panel can be requested.

Research ethics

The study was approved by the Bioethics Committee of Centro Superior de Estudios Universitarios La Salle (Madrid, Spain) [registration number: CSEULS-PI-004/2022].

Consent

Informed consent to participate was obtained from participants at the beginning of the Microsoft Forms survey as a clickable option.

Patient and public involvement data

During the development, progress, and reporting of the submitted research, Patient and Public Involvement in the research was not included at any stage of the research.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) declared no financial support for the research, authorship, and/or publication of this article.

Contributorship

BMM and CCG conceived the study and included the different instruments. BMM designed the procedure and questionnaires of the different phases, analyzed the data of each round, and elaborated on the manuscript. BMM and CCG reviewed and edited the manuscript and approved the final version of the manuscript.

ORCID iDs

Beatriz Madroñero-Miguel

César Cuesta-García

Supplemental material

Supplemental material for this article is available online.

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