Abstract
BACKGROUND:
Although there is a myriad of unilateral assessments for stroke survivors, few address bilateral function, which is critical for many daily living tasks.
OBJECTIVE:
To develop an activities of daily living list of tasks requiring bilateral upper extremity function for use when assessing patients with stroke.
METHOD:
A list of 938 items was generated based on a literature review, opinions of occupational therapists and patients with stroke. A panel of professional experts then validated that the items were bilateral and functional. Similar items were then combined and duplicates eliminated.
RESULTS:
The list was reduced to 69 items and 40 items were selected based on the content validity index. Based on the bilateral function, importance, expansion, and deletion criteria, the expert panel selected 27 items that best represented bilateral activities of daily living.
CONCLUSIONS:
A final list of 27 activities of daily living requiring bilateral function was generated and validated. Future work will focus on development of a tool to assess bilateral upper extremity function of patients with stroke.
Introduction
Bilateral upper extremity function is important for performing in activities of daily living. Bilateral function is not only necessary for engaging in basic activities of daily living such as bathing, putting on a shirt, feeding, and using the bathroom, but it is also necessary for performing instrumental activities of daily living such as cooking, shopping and using the computer (Waller & Whitall, 2008). However, unilateral upper extremity motor problems with most stroke survivors lead to difficulty in bilateral upper limb functions such as buttoning a shirt, or being able to tie/untie shoelaces (Duncan & Badke, 1987). Therefore, assessment of bilateral upper limb functions is important for planning activities of daily living interventions.
Most assessment tools of upper extremity function for use with stroke survivors are designed to assess the upper extremity function of the affected limb. Such tools include the Wolf Motor Function Test, the Action Research Arm Test, Box and Block Test, Nine-Hole Peg Test, and the Purdue Peg Board Test (Brunner, Skouen, & Strand, 2012; Murphy, Resteghini, Feys, & Lamers, 2015; Stoykov & Corcos, 2009).
Evaluation of the functional level of the affected upper limb cannot provide sufficient information on bilateral function, or accurately measure the effects of unilateral interventions on bilateral function (Wolf et al., 2014). This is because assessment data collected from a tool focused on unilateral function does not provide direct information related to bilateral function, such as movement patterns or improvements in bilateral upper limb performance (Okkema & Culler, 1998). This suggests the need to develop and validate standardized assessment tool to measure stroke survivors’ bilateral upper extremity function by using items related to activities of daily living that require the use of both upper limbs.
Method
Item generation
Literature review
During the month of December 2014, we first conducted a literature search on upper extremity function assessment tools by screening the PubMed database. The search terms were: (“upper extremity”) AND (“motor activity” OR “activities of daily living”) AND (“assessment” OR “instrument” OR “disability evaluations”). From this search, we set up a list of all the items in the upper extremity function assessment tools.
Experts in upper extremity function
A survey was conducted with 48 occupational therapists during the month of January 2015 to identify bilateral upper limb tasks commonly assessed in clinical settings. The questionnaire consisted of items including respondents’ demographic characteristic such as age, sex, and clinical experience. In addition, the survey asked two questions: “Did you use bilateral upper limb training with your patients?” and “What tasks did you use for bilateral upper limb interventions?” The demographic characteristics of the experts are indicated in Table 1.
Demographic characteristics of experts interviewed for item generation (n = 48)
Demographic characteristics of experts interviewed for item generation (n = 48)
In addition to the literature review, and expert item generation, we administered a questionnaire to 20 stroke survivors at Wonju Rehabilitation Hospital during the month of February 2015. The inclusion criteria were: (a) having hemiplegia due to stroke, (b) no other conditions affecting upper extremity function, (c) cognitive ability to understand the questionnaire and verbal consent for participation in research. The questionnaire included demographic information such as age, gender, onset, side of hemiparesis, brunnstrom stages of arm and hand recovery, as well as multiple choice questions about activities such as buttoning or unbuttoning a shirt, screwing or unscrewing nuts onto bolts, etc., and a short answer question. The short answer question was: “What bilateral activities are difficult for you to perform?”
The demographic characteristics of the patients are summarized in Table 2. There were 7 (35%) with brunnstrom stage 3 and less, 5 (25%) with stages 4 and 5, and 8 (40%) with stages 6 of arm function recovery. Also, there were 5 (25%) with brunnstrom stage 3 and less, 8 (40%) with stages 4 and 5, and 7 (35%) with stages 6 of hand function recovery.
Characteristics of stroke patients interviewed for item generation (n = 20)
Characteristics of stroke patients interviewed for item generation (n = 20)
In order to select the initial set of assessment items, an expert panel consisting of a researcher, an occupational therapy professor, and an assessment tool developer reviewed the upper limb items during March and April of 2015.
Phase I: First panel review
The expert panel review was held online. The researcher and the occupational therapy professor deleted candidate items using item exclusion criteria, namely: (1) items including upper extremity movement but representing multiple activities, (2) items including functional upper limb task, but not based on activities of daily living. (3) duplicate items, and combined items that were similar in nature. The remaining items were then sent to the assessment tool developer via e-mail for her to apply the exclusion criteria.
Phase II: Second panel review
In order to select bilateral upper limb items from the upper limb items selected in the previous step, a second panel review was held in May and June 2015. The second panel meeting progressed in the same manner as the first panel meeting, however, a new exclusion criterion was used: items that could be performed using only one hand.
Phase III: Third panel review
In order to further refine the items selected in the previous step, a third panel review was held in July 2015. For this process, a panel consisting of two occupational therapy professors and two occupational therapists was newly created. In this panel review, the items were assessed for (1) fit of the bilateral upper extremity items, (2) importance of the items, (3) if items should be expanded, (4) if items should be deleted. Item fit, importance, and expansion were rated on a 4-point Likert scale: (4 = strongly agree, 3 = mostly agree, 2 = mostly disagree, and 1 = strongly disagree). And, items for deletion were rated on a score of 1 (strongly agree) to 4 (strongly disagree). We calculated the content validity index (CVI) to identify which items were perceived as bilateral, item importance, and need for expansion or deletion. Bilateral upper limb items with a CVI of less than 0.5 were eliminated first, followed by importance, expansion, and deletion.
The remaining items were reviewed again by the panel of four experts using the following exclusion criteria: (1) item cannot be performed at a table with an object placed on it (2) item cannot be defined in a standardized manner (3) item does not apply to activities of daily living performed by most people.
Data analysis
SPSS 21.0 was used for descriptive statistics regarding the subjects’ characteristics and for verification of the items’ content validity. The content validity index was calculated by using the 4-point scale questionnaire. The total number of items with a score of 3 or 4 was divided by the number of experts. If the resulting value was 0.75 or greater, the validity was verified (Polit & Beck, 2006).
Results
Item generation
Literature review
A total of 1358 articles were identified, 68 of which were selected after excluding 1290 articles (see Fig. 1). Articles were excluded if they did not address an upper extremity assessment tool, the assessment tools did not include subitems, were not in English, were not full text, were review or meta-analysis articles, posters or theses. There were 46 upper extremity function assessment tools addressed in the 68 articles, with a total of 854 items, excluding duplicated assessment tools.
Process of literature search.
Forty-eight occupational therapists generated 24 new items, excluding duplicate tasks.
Stakeholder item development
Sixty new bilateral upper limb tasks were generated by stroke survivors.
Thus, a total of 938 upper limb items were collected in the first step, including 854 assessment items listed in current assessment tools, 24 items generated from the survey of occupational therapists, and 60 items generated by stroke survivors.
Item selection
First panel review
Based on the first set of criteria, of the potential 938 assessment items, 679 items were eliminated to yield an initial item set of 259 upper limb items.
Second panel review
Based on the second set of criteria 190 more items were eliminated, yielding 69 bilateral upper limb items.
Third panel review
Based on the third set of criteria and the CVI analysis, of the 69 remaining items 21 items were eliminated because they had a bilateral CVI of 0.5 or less. Of the remaining 48 items, one item was eliminated because it had an importance CVI of 0.5 or less. Finally, of the remaining 47 items, 7 items were eliminated because they had an expansion CVI or deletion CVI of 0.5 or less. Following the third panel review 40 items remained (Table 3).
CVI according to fit, importance, expansion, deletion of bilateral upper limb items
CVI according to fit, importance, expansion, deletion of bilateral upper limb items
aItem that was difficult to perform on table. bItem that was difficult to operationally define. cItem that applied to specific people.
Of the 40 remaining items, 6 items did not render themselves suitable for an “object on the table top item,” 4 items were difficult to operationally define, and 5 items were too specific and too infrequently performed in daily life. Thus, these 15 items were eliminated, resulting in a selection of 25 bilateral upper limb items (Table 3). From the 25 selected items, some items were modified or separated by the four panel experts. As a result of the modifications, 27 bilateral activities of daily living items were deemed suitable to assess bilateral upper limb function (Table 4).
Preliminary items of the bilateral upper extremity activity inventory
Summary of study findings
The present study generated and validated activities of daily living tasks that require bilateral upper extremity use, in preparation for developing a bilateral upper extremity assessment for stroke survivors. To identify potential bilateral tasks relevant to stroke survivors, a literature review was conducted to ascertain tasks included in unilateral assessments. Then occupational therapists who assessed and treated stroke survivors were surveyed. Finally, the most relevant stakeholders, stroke survivors, were surveyed. This array of perspectives enabled a large pool of potential bilateral tasks relevant to stroke survivors (Barreca Gowland, Stratford, Huijbregts, Griffiths, Torresin & Masters, 2004). Using pre-established criteria, expert panels, and several iterations of review, as well as calculating content validity indexes, a final list of 27 bilateral activities of daily living were selected. This selection method is valid and reliable, and it is similar to the method used to develop the upper limb assessment tools containing items selected based on patient opinions (Baker, Cano, & Playford, 2011).
The 27 items selected were similar to bilateral upper extremity items of the TEMPA and CAHAI tools such as “open a jar and take a spoonful of coffee,” “deal a deck of playing cards,” “put toothpaste on toothbrush,” “draw a line with a ruler,” “cut putty,” “wring out a facecloth,” “clean eyeglasses,” “zip up zipper,” and “do up buttons on a shirt” (Desrosiers et al., 1993; Rowland, Turpin, Gustafsson, Henderson, & Read, 2011). These 27 items were well selected based on activities of daily living (e.g., put on a shirt, fasten a belt, and put toothpaste on toothbrush), instrumental activities of daily living (remove a pot, open/close a button on the wallet, and clean a pair of eyeglasses) as well as work (fasten/unfasten nuts onto bolts) and leisure (deal a deck of playing cards) (Roly et al., 2008). Also, the 27 items address all patterns of bilateral upper limb movement, including symmetrical and asymmetrical movement such as “wring out a washcloth,” and “zip up a jacket,” Thus, the items will be well suited for inclusion of an assessment of bilateral upper limb function for use with stroke survivors (Barreca et al., 2004).
Limitations and future studies
As with all studies, this study had limitations. Of the occupational therapists surveyed, the majority did not have experience using bilateral interventions with stroke survivors. Also, the occupational therapist and stroke survivor stakeholders were from South Korea, and the tasks identified may not always be relevant in another culture. Further study is needed in the bilateral assessment phase of the study to ensure that items are operationally defined so that patients perform the bilateral tasks under the same conditions – a pre-condition for a measurement tool.
Conclusions
Using acceptable methods of establishing content validity, 27 bilateral functional activities of daily living were identified that will be relevant for inclusion in a bilateral functional assessment for stroke survivors. The inclusion of stroke survivor stakeholders confirmed tasks identified in the literature and by occupational therapists, and also added new relevant items.
Conflict of interest
The authors declare they have no conflict of interest.