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Comparison of Responsiveness of the Fugl-Meyer Assessment and the Wolf Motor Function Test

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Title: Comparison of Responsiveness of the Fugl-Meyer Assessment and the Wolf Motor Function Test
Physical Description: 1 online resource (29 p.)
Language: english
Creator: Wen, Pey-Shan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: cimt, fugl, outcome, responsiveness, stroke, wolf
Occupational Therapy -- Dissertations, Academic -- UF
Genre: Occupational Therapy thesis, M.H.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

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Abstract: To determine the effectiveness of a clinical intervention, an important property for outcome measurement is to capture change over time. Responsiveness, defined as the ability to detect change over time, is becoming a new standard for establishing the soundness of outcome instruments. The Fugl-Meyer Assessment (FMA) has been reported as a reliable and valid measurement for stroke population; however, little evidence has been reported to support its sensitivity in measuring change. The Wolf Motor Function Test (WMFT) has been commonly used in the constraint-induced movement therapy (CIMT) studies; however, no study reports its ability in detecting change. The purpose of the study is to compare responsiveness of the FMA and the WMFT. The data were collected from three studies related to the CIMT. Eighty-seven participants were assessed by the FMA and the WMFT before and after intervention. For detecting responsiveness three methods were used: 1) the paired t-test; 2) the standard response mean; 3) the effect size. This study was approved by the Institutional Review Board of the University of Florida. The paired t-test results for the WMFT and the FMA were 5.76 and 5.13 respectively. The standard response means for the WMFT and the FMA were 0.73 and 0.65 respectively. The effect sizes for the WMFT and the FMA were 0.17 and 0.32 respectively. In conclusion, while the results are mixed, the WMFT had a tendency to show better responsiveness than the FMA, especially with the more sophisticated responsiveness designs. Future studies will be necessary to determine the replicability of these findings.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Pey-Shan Wen.
Thesis: Thesis (M.H.S.)--University of Florida, 2007.
Local: Adviser: Velozo, Craig A.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2009-12-31

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Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021799:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021799/00001

Material Information

Title: Comparison of Responsiveness of the Fugl-Meyer Assessment and the Wolf Motor Function Test
Physical Description: 1 online resource (29 p.)
Language: english
Creator: Wen, Pey-Shan
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: cimt, fugl, outcome, responsiveness, stroke, wolf
Occupational Therapy -- Dissertations, Academic -- UF
Genre: Occupational Therapy thesis, M.H.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: To determine the effectiveness of a clinical intervention, an important property for outcome measurement is to capture change over time. Responsiveness, defined as the ability to detect change over time, is becoming a new standard for establishing the soundness of outcome instruments. The Fugl-Meyer Assessment (FMA) has been reported as a reliable and valid measurement for stroke population; however, little evidence has been reported to support its sensitivity in measuring change. The Wolf Motor Function Test (WMFT) has been commonly used in the constraint-induced movement therapy (CIMT) studies; however, no study reports its ability in detecting change. The purpose of the study is to compare responsiveness of the FMA and the WMFT. The data were collected from three studies related to the CIMT. Eighty-seven participants were assessed by the FMA and the WMFT before and after intervention. For detecting responsiveness three methods were used: 1) the paired t-test; 2) the standard response mean; 3) the effect size. This study was approved by the Institutional Review Board of the University of Florida. The paired t-test results for the WMFT and the FMA were 5.76 and 5.13 respectively. The standard response means for the WMFT and the FMA were 0.73 and 0.65 respectively. The effect sizes for the WMFT and the FMA were 0.17 and 0.32 respectively. In conclusion, while the results are mixed, the WMFT had a tendency to show better responsiveness than the FMA, especially with the more sophisticated responsiveness designs. Future studies will be necessary to determine the replicability of these findings.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Pey-Shan Wen.
Thesis: Thesis (M.H.S.)--University of Florida, 2007.
Local: Adviser: Velozo, Craig A.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2009-12-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021799:00001


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COMPARISON OF RESPONSIVENESS OF THE FUGL-MEYER ASSESSMENT AND THE WOLF MOTOR FUNCTION TEST By PEY-SHAN WEN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF HEALTH SCIENCE UNIVERSITY OF FLORIDA 2007 1

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2007 PEY-SHAN WEN 2

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To my family and friends 3

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ACKNOWLEDGMENTS This material is the result of work supported with resources and the use of facilities at the North Florida/South Georgia Veterans Health System. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS ...............................................................................................................4 LIST OF TABLES ...........................................................................................................................6 ABSTRACT .....................................................................................................................................7 CHAPTER 1 INTRODUCTION................................................................................................................. ...9 2 METHOD....................................................................................................................... ........12 Participants .............................................................................................................................12 Instruments .............................................................................................................................12 Responsiveness Measure ........................................................................................................13 3 RESULTS...................................................................................................................... .........16 4 DISCUSSION................................................................................................................... ......20 APPENDIX A FUGL-MEYER ASSESSMENT OF UPPER EXTREMITY FUNCTION...........................23 B WOLF MOTOR FUNCTION TEST......................................................................................24 C STROKE IMPACT SCALE...................................................................................................25 LIST OF REFERENCES ...............................................................................................................26 BIOGRAPHICAL SKETCH .........................................................................................................29 5

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LIST OF TABLES Table page 3-1 The characteristics of 62 participants included in re sponsiveness analysis based on single-population category. ................................................................................................18 3-2 The means and standard deviations of pr etest and post test for stable and improved group ..................................................................................................................................18 3-3 Responsiveness comparisons for single-population category ............................................19 3-4 Responsiveness comparison fo r two-population category (N=57). ...................................19 6

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Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Health Science COMPARISON OF RESPONSIVENESS OF THE FUGL-MEYER ASSESSMENT AND THE WOLF MOTOR FUNCTION TEST By Pey-Shan Wen December, 2007 Chair: Craig Velozo Major: Occupational Therapy To determine the effectiveness of a clini cal intervention, an important property for outcome measurement is to capture change over ti me. Responsiveness, defined as the ability to detect change over time, is becoming a new st andard for establishing the soundness of outcome instruments. The Fugl-Meyer Assessment (FMA ) has been reported as a reliable and valid measurement for stroke population; however, little evidence has been reported to support its sensitivity in measuring change. The Wolf Mo tor Function Test (WMFT) has been commonly used in the constraint-induced movement therapy (CIMT) studies; however, no study reports its ability in detecting change. The purpose of the study is to co mpare responsiveness of the FMA and the WMFT. The data were collected from three studies re lated to the CIMT. Eighty-seven participants were assessed by the FMA and the WMFT before and after intervention. For detecting responsiveness three methods were used: 1) the pa ired t-test; 2) the sta ndard response mean; 3) the effect size. This study was approved by the Institutional Review Board of the University of Florida. 7

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The paired t-test results for the WMFT and the FMA were 5.76 and 5.13 respectively. The standard response means for the WMFT a nd the FMA were 0.73 and 0.65 respectively. The effect sizes for the WMFT and the FMA were 0.17 and 0.32 respectively. In conclusion, while the results are mixe d, the WMFT had a tendency to show better responsiveness than the FMA, es pecially with the more sophis ticated responsiveness designs. Future studies will be necessary to determine the replicability of these findings. 8

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CHAPTER 1 INTRODUCTION Stroke, which affects four out of five American families, is one of the leading causes of disability in the United States (www.stroke.org). Two-thirds of the four million stroke survivors continue to have moderate or severe disabilities at the e nd of treatment (www.stroke.org). Several studies demonstrate that only 5% to 20 % of the patients with stroke regain completely functional recovery (Heller et al., 1987; Moskowitz, Light body, & Freitag, 1972; Nakayama, Jorgensen, Raaschou, & Olsen, 1994; Parker, Wade, & Langton Hewer, 1986). Approximately half of the stroke survivors cannot functionally use their aff ected upper extremity (Broeks, Lankhorst, Rumping, & Prevo, 1999). In addition, 67% of participants with stroke claimed that loss of the arm function is their major problem ev en four years after th eir first stroke onset (Broeks et al., 1999). The persistence of functional loss and the limit functional re covery have made selecting treatments for chronic stroke survivors extrem ely challenging. Historically, the recovery of function in stroke patients has been thought to ta ke place only in the first six months following stroke onset (Langton Hewer, 1990) Furthermore, upper extremity recovery may be limited to the first four months after stroke onset (Broeks et al., 1999; Nakayama et al., 1994). Conventional interventions such as proprioce ptive neuromuscular f acilitation (PNF) and neurodevelopmental therapy (NDT) have been wi dely used in rehabili tation; however, limited evidence supports their efficacy (de Pedro-Cu esta, Widen-Holmqvist, & Bach-y-Rita, 1992; Duncan, 1997). In contrast to c onventional interventions, novel tr eatments such as constraintinduced movement therapy (CIMT) and robot treatment have dem onstrated the treatment effect for stroke population (Bonifer & Anderson, 2003; Kopp et al., 1999; Kunkel et al., 1999; Liepert et al., 2000; Liepert et al., 1998; Miltner, Bauder, Sommer, Dettmers, & Taub, 1999; Tarkka, 9

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Pitkanen, & Sivenius, 2005; Ta ub et al., 1993; van der Lee, Beckerman, Lankhorst, & Bouter, 1999; van der Lee, Wagenaar et al., 1999; Wolf Lecraw, Barton, & Jann, 1989). While more and more novel treatments are proposed, to determine the most effective treat ment outcome measure has to be sensitive to change overtime. A number of outcome measurements are ava ilable for monitoring upper extremity recovery in stroke. One of the most widely used instru ments is the Fugl Meyer Assessment (FMA). The FMA, which is based on Brunstroms six stages of recovery, is considered the gold standard for assessing stroke patients. The FMA consists of 33 upper-extremity items and 17 lower-extremity items. This instrument includes five domains: mo tor, sensory, balance, joint range of motion, and joint pain(Fugl-Meyer, Jaasko, & Norlin, 1975). D uncan (1983) reported the total motor score of the FMA has excellent intrarater and interrate r reliability ( 0.98 and 0.98)(Duncan, Propst, & Nelson, 1983). Studies also suggest the FMA is a valid measurement for stroke (De Weerdt & Harrison, 1985; Wood-Dauphinee, Williams, & Shapiro, 1990). While the FMA shows good psychometric properties, little evidence supports its ability of measuring change over time. Gladstone and colleagues (2002) reported the FMA might fail to detect subtle changes in mild motor impaired stroke patients due to the ce iling effect (Gladstone, Danells, & Black, 2002). Moreover Wolf and colleagues (2001) stated that the FMA is not useful for evaluating full range of function in patients with mild to moderate im pairment (Wolf et al., 2001). These studies imply that although the FMA has good psychometric properties, it might not be sensitive in monitoring clinical improvement. In an attempt to more precisely measure the ab ilities of participants who enrolled in CIMT studies, Wolf and colleagues developed the Emor y Motor Test, later called Wolf Motor Function Test (WMFT) (Wolf et al., 1989) The WMFT was specifically designed for assessing the upper 10

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extremity ability of people receivi ng CIMT. The WMFT consists of three parts: (1) time score, recording how long the examinee completes a sta ndardized task; (2) ratin g scale, assessing the quality of movement while performing the task; (3 ) strength. This assessment contains 17 tasks: 15 timed/rating tasks and two strength tasks. These tasks were sequenced according to complexity of upper extremity movement (from single joint to multiple joint movement, and from gross motor to fine motor movements).T he WMFT shows good reliab ility of both the time score and rating scale, ranging fr om .86 to .97 (Morris, Uswatte, Crago, Cook, & Taub, 2001). In addition, the WMFT time score shows good construct and criterion validity (Wolf et al., 2001). While reliability and validity are importa nt foundational psychometric elements for measurement, reliability and validity provide littl e information of an instruments ability to measure change over time(Guyatt, Walter, & No rman, 1987). Responsiveness, defined as the ability to detect subtle change over time, is becoming a new standard test to determine the soundness of an instrument (Kirshner & Guya tt, 1985). While the FMA and the WMFT are broadly used as outcome measures in stroke pop ulation, the comparison of their capabilities to detect the subtle change within the participants over time has not been investigated. Responsiveness may be an important means to further validate the FMA and the WMFT as outcome measures for determining treatment effect. This study compared responsiveness of the FMA and the WMFT using four di fferent responsiveness indices. 11

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CHAPTER 2 METHOD Participants The existing data were provided by three CIMT related studies. Study 1 (N=48): The participants only received the constraint i nduced movement therapy (CIMT-alone). Study 2 (N=19): The participants received transcranial magnetic stimulation (TMS) on their brain and the CIMT (CIMT-TMS). Study 3 (N=20): The particip ants received Donepezil 10mg/day and the CIMT (CIMT-Donepezil). Total 87 participants enro lled in these three studies. All Participants received CIMT 6 hours a day, 5 days a week for two weeks. The partic ipants were assessed before interventions and immediately after 10 days CIMT training. These three studies were approved by the institution review board. The inclusion and exclusion of thes e studies are described as follow: The inclusion criteria: (1) the diagnosis of at least one stroke and no more than 3 strokes on the same side of the brain; (2) ability to understand and follow in structions; (3) the ability to sit independently without back or arm support for 5 minutes; (4) the ab ility to stand with suppor t of a straight cane, quad cane or hemiwalker for 2 minutes; (5) the ability to actively partic ipate 6 hours of therapy without long rest or nap periods ; (6) passive range of motion of all upper extremity motions of at least half the normal range. (7) onset at least 6 months prior to part icipation. The exclusion criteria: (1) Mini-Mental score less than 24; (2 ) health problems judged by the screen physician to put the client at significant risk of harm during the study; (3) other ne urological conditions; (4) pain that is scored greater th an 5 on the McGill Pain Scale. Instruments A series of outcome measurements were used in these CIMT related studies. The upper extremity portion of the FMA and the rating sc ale portion of the WMFT were used in the 12

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responsiveness analyses. The FMA consists of 33 items measuring upper extremity movements rated by 3-point scales (0-2) with the maximum score of 66. Items of the upper extremity portion of the FMA were listed in Appendix A. The WMFT consists of 15 items measuring quality of upper extremity movement rated by 6 point scales (0-5) with the maximum score of 75. Items of the WMFT were listed in Appendix B. The Stroke Impact Scale (SIS) was developed from patient and caregivers perspective. The SIS consists of eight domains: m obility, ADL, memory, communication, emotion, participation, physical and hand function. It was rated by 5 point scales (1-5) with converting score from 0 to 100 (Duncan et al., 1999). Hand function domain contains five items. See Appendix C. Although recent studies suggest th at measuring responsiveness is important, there is no general consensus on the methods to assess respon siveness. Several different methods have been proposed to assess responsiveness. These methods can be generally divided into two categories: assessing change in a single population and asse ssing change in two popul ations (the population with change and the population without change) (Wallace, Duncan, & Lai, 2002). Since there is no consensus on which method is the best, methods designed for single population and two populations were be compared in this study. Responsiveness Measure Three indices were used for evaluating responsiveness in single-population category : the paired t-test, the standardized effect size (SES), and the standardized response mean (SRM). The paired t-test is commonly used in test statistics for two-time-point measurements in a single population. The paired t-test compares the dependent sample mean of differences in terms of the number of standard errors. Comparing the values of statistic test across instruments over 13

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the same time period, the largest test statistic represents the most responsive instrument. However, the paired t-test has been challe nged due to its influence by sample size. Effect size statistics, quantifying the change sc ores in terms of certain variations (Cohen, 1977), are independent on sample size, Because of its sample size independency, effect size statistics might be preferred statistics to evaluate responsiveness. Several effect size indices have been proposed. Among these effect size indices, th e differences often are the formula of the denominators. The SES and SRM are two common forms of effect size statistics used in evaluating responsiveness. The SES is defined as the mean change score divided by the standard deviation of the baseline score (Kazis, Anderson, & Meenan, 1989). The SRM is defined as the mean change score divided by the standard deviation of the change (Liang, 1995). Another effect size index the Guyatt effect size (GES), was conducted for evaluating responsiveness in two-population category (Guyatt et al., 19 87). The GES is defined as the minimal meaningful clinical Diffe rence (MMCD) divided by the sta ndard deviation of change in the stable group. In this study desi gn, participants need to be di vided into two populations (stable population and improved population) based on an external criteri on and then the values of MMCD of instruments to be determined. The exte rnal criterion in this study is the SIS hand function score. The improved group was defined as individuals showing a change in the SIS hand function score greater or equal to two points and the stable group was defined as individuals showing a change of less than two points or a negativ e change of two points (Duncan et al., 1999). Individuals SIS hand function score decreased more than two points were excluded from this analysis. The methods of determining MMCD values ar e controversial through out the literature. In this study, two methods were used to obtain the MMCD for the FMA and the WMFT; when the amount of change in the FMA or WMFT reached: (1) 0.8 specificity compared 14

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to the level of no change in SI S (Wallace et al., 2002) and (2) 10% of the to tal score of the FMA or WMFT (Gladstone et al., 2002; va n der Lee, Wagenaar et al., 1999). 15

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CHAPTER 3 RESULTS The first responsiveness comparisons for si ngle-population category were based on 62 out of 87 participants from combining dataset. Twen ty-five participants were not analyzed because of the missing values on either FMA or WMFT. The characteristics of 62 part icipants included in responsiveness analysis based on single-population category pres ented in Table 3-1. Moreover, the responsiveness comparisons for two-populati on category (Guyatt effect size) were based on 57 participants. Five additional participants were excluded because of either missing scores on SIS hand function score (external criterion) or decreasing more than 2 points on their SIS hand function scores. Finally, since it is unusual to combine multiple treatment studies in a single analysis, the responsive comparisons for singlepopulation category from the above analyses were also calculated based on only 37 partic ipants from Study 1. The means and standard deviations of pretest and pos t test for stable and improved group presented in Table 3-2. Using the combined dataset (N=62), in singl e population category, pa ired t-tests were significant; with the t values fo r the FMA and the WMFT were almost identical at 5.13 and 5.16, respectively. The SES analysis showed the FM A to be more responsive than the WMFT (0.32 and 0.17, respectively) while the SRM analysis s howed the WMFT to be more responsive than the FMA (0.73 and 0.65, respectively). See Table 3. Using the data from Study 1 (N=37) only, again, both the FMA and the WMFT showed significant t-tests, though the t-value for the WMFT was larger than that of the FMA (4.91 and 2.19, respectively). For Study 1, the SES values fo r the FMA and WMFT were almost identical (0.16 and 0.17, respectively), while the SRM valu es was greater for the WMFT than the FMA (0.36 and 0.81, respectively). See Table 3. 16

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In two-population category, when MMCD values we re established by the definition as the amount of change in the FMA or the WMFT reaching 0.8 specificity, the MMCD for the FMA and the WMFT were 7 and 3 respectively. The GES test for the WMFT was greater than that for the FMA (1.35 and 1.54, respectively). Again, when the MMCD values were established by the definition of MMCD as 10% of the total score of the FMA or the WMFT, the MMCD for the WMFT was greater than that of the FMA (6.6 a nd 7.5, respectively). Furthermore, the GES tests again showed the WMFT to be more responsive than the FMA (2.88 and 1.11, .88 respectively). See Table 4. 17

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Table 3-1. The characteristics of 62 participants included in responsiveness analysis based on single-population category. Demography Information (N=62) Mean Age SD 64.1.6 Mean Time after Stroke SD 3.8 3.5 Gender Female/Male 29 (46%) / 34 (54%) Hemiparesis Side Left/Right 37 (58.7%) / 26 (41.3%) Concordance Yes/No 34 (54%) / 29 (46%) Table 3-2. The means and standard deviations of pretest and post test for stable and improved group Instrument All (N=62) Stable (N=19) Improved (N=38) Study1 (N=37) FMA Pre 36.53 11.49 31.68 11.54 39.26 10.90 34.35 12.46 Post 40.16 11.58 35.00 10.72 43.24 11.51 36.29 11.84 Change 3.63 5.57 3.32 5.94 3.97 5.60 1.95 5.4 WMFT Pre 34.66 11.54 27.37 8.96 38.16 11.47 30.97 12.38 Post 36.65 11.18 29.63 9.71 40.24 10.8 33.11 12.11 Change 1.98 2.71 2.26 2.60 2.08 2.78 2.14 2.65 18

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Table 3-3. Responsiveness comparisons for single-population category Responsiveness Measure Participants FMA WMFT Pair t-test All (N=62) **5.13 **5.76 Study 1 (N=37) **2.19 **4.91 Standardize Effect Size All (N=62) 0.32 0.17 Study 1 (N=37) 0.16 0.17 Standardize Response Mean All (N=62) 0.65 0.73 Study 1 (N=37) 0.36 0.81 ** represent statistically significant. Table 3-4. Responsiveness comparison for two-population category (N=57). Minimal Meaningful Clinical Difference Guyatt Effect Size FMA WMFT FMA WMFT 0.8 Specificity 8 4 8/5.94=1.35 4/2.6=1.54 10% total score range 6.6 7. 5 6.6/5.94=1.11 7.5/2.6=2.88 19

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CHAPTER 4 DISCUSSION Using the combined dataset, inconsistent ranki ng of the instruments ex ists across different responsiveness indices. T-tests indicated that both the FMA and WMFT showed significant responsiveness. The standardized effect size (SES) showed the FM A to be more responsive than the WMFT, while the standard ize response mean (SRM) and the Guyatt effect size (GES) showed the WMFT is more responsive than the FMA. These conflicting results are not surprising. Stratford (1996) demonstrated the disagreement by using the SES and SRM to compar e responsiveness of two instruments, the Jan Van Breemen Function Questionnaire (JVBF) a nd Raland-Marris Questionnaire (RMQ). While the SES showed the JVBF is more responsiv e than the RMQ, the SRM showed the opposite result. This confirms that the study design a nd the responsiveness indices strongly impact responsiveness results(Stratford, Binkley, & Ridd le, 1996). In contrast to the inconsistent ranking from analyzing the combining dataset, analyzing all three responsiveness indices of single-population category using the data from Study 1 showed the WMFT is more responsive than the FMA. Van der Lee and colleague compared responsiv eness of the Action Research Arm Test and the FMA. Data were from pretest and post test of 22 chronic stroke part icipants underwent the CIMT. (van der Lee, Beckerman, Lankhorst, & Bouter, 2001) By applying the means and standard deviations obtained from this study to the SES and the SRM indices, the SES and the SRM of the FMA (0.15 and 0.36 respectively) are almo st identical to what we obtained from the Study 1 dataset: CIMT with chronic stroke ( 0.16 and 0.36 respectively). However, the SES and the SRM recalculated from Van der Lees study do not equal to what we obtained from combining dataset: CIMT and other treatments w ith chronic stroke (0.32 and 0.65 respectively). 20

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This finding suggests that the SES and the SRM ar e treatment sensitive. This finding is in accordance with Husteds statement: The inte rnal responsiveness of a measure will depend on both the particular treatment and the particular outcomes used to determine treatment effect (Husted, Cook, Farewell, & Gladman, 2000). There are several limitations to this study. The pair-t test, the SES and the SRM for singlepopulation category assume participants have homogeneous change. The homogeneous change assumption is unlike to hold since the the three st udies in the present analysis employed different treatments. Moreover, under the assumption of homogeneous change, these responsiveness indices are considered a weak design since they cannot account for different amounts of change (Husted et al., 2000; Stratford et al., 1996; Stratford & Riddle, 2005). While combining the data from similar intervention studies increased the sample size, it is unclear how differences in study interventions affected our results. In GES study design, the decision of selecting cu t-off point for dividi ng participants into two groups (stable vs. improved) was arbitrary. Duncan and colleagues (1999) proposed that 10 to 15 points change in Stroke Impact Scale (SIS ) represent clinical meaningful change (Duncan et al., 1999). According to this st atement, the clinically meaningful change for the hand domain of the SIS was established proportionally as two points. However, applying two points as cut-off point to distinguish participants as stable or improved is not empirical based. The decision of cutoff point could potentially affect the results of the GES (Stratford et al., 1996). In addition, although the SIS is a reliable, valid and respons ive measurement (Duncan et al., 1999), whether hand function domain of the SIS is a valid external criterion is uncertain. Minimal meaningful clinical difference ( MMCD) was arbitrarily set by two different criteria: the amount of change in the instruments reached certain specificit y in external criterion 21

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(Wallace et al., 2002) and at 10% of the total rang e of the scale (Gladstone et al., 2002; van der Lee, Wagenaar et al., 1999). However, the minima l meaningful clinical ch ange is population and instrument dependent. Whether appl ying these criteria to obtain the MMCD is adequate needs to be further evaluated. Empirical evidence to es tablishing MMCD prior to further investigate responsiveness analysis is required for future study. Due to the limitation of available data from the existing dataset, the stronger study designs were not feasible in this study. Future studies should employ stronger designs. In conclusion, while the results are mixe d, the WMFT had a tendency to show better responsiveness than the FMA, es pecially with the more sophis ticated responsiveness designs. Future studies, will be necessary to determin e the replicability of these findings. With responsiveness designs a nd statistics being relatively new to healthcare outcomes research, studies are needed to determine the relative strengths and weakness of these designs. Furthermore, item response theory models whic h determine the item-level psychometrics of instruments may be useful in determining why one instrument is more responsive than another. 22

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APPENDIX A FUGL-MEYER ASSESSMENT OF UPPER EXTREMITY FUNCTION Item number and label Description of items Reflex Activity Item 1: Biceps Reflex Biceps reflex elicited with reflex hammer Item 2: Triceps Reflex Triceps reflex elicited with reflex hammer Flex Synergy Item 3: Flexor Synergy 1 Scapular elevation Item 4: Flexor Synergy 2 Scapular retraction Item 5: Flexor Synergy 3 Shoulder abduction Item 6: Flexor Synergy 4 Shoulder external rotation Item 7: Flexor Synergy 5 Elbow flexion Item 8: Flexor Synergy 6 Forearm supination Extensor Synergy Item 9: Extensor Synergy 1 Shoulder adduction with in ternal rotation Item 10: Extensor Synergy 2 Elbow extension Item 11: Extensor Synergy 3 Forearm pronation Combination of Synergy Item 12: Combo of Synergy 1 Hand to lumbar spine Item 13: Combo of Synergy 2 Shoulder fl exion to 90 degrees with elbow extended Item 14: Combo of Synergy 3 Pronation supination of forearm with elbow extended Movements out of Synergy Item 12: Out of Synergy 1 Shoulder abduction to 90 with elbow extended Item 13: Out of Synergy 2 Shoulder flexion to 90-180 with elbow extended Item 14: Out of Synergy 3 Pronation-supination of forearm with elbow extended Item 18: Normal Reflex Activity Normal reflex activity Wrist Item 19: Wrist 1 Wrist stable with elbow at 90 Item 20: Wrist 2 Wrist flexion with elbow at 90 Item 21: Wrist 3 Wrist stable with elbow extended and shoulder at 30 Item 22: Wrist 4 Wrist flexion with elbow extended and shoulder at 30 Item 23: Wrist 5 Wrist circumduction Hand Item 24: Hand 1 Finger mass flexion Item 25: Hand 2 Finger mass extension Item 26: Hand 3 Hook grasp Item 27: Hand 4 Lateral prehension Item 28: Hand 5 Palmar pinch Item 29: Hand 6 Cylindrical grasp Item 30: Hand 7 Spherical grasp Coordination Item 31: Coordination 1 Tremor Item 32: Coordination 2 Dysmetria Item 33: Coordination 3 Speed 23

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APPENDIX B WOLF MOTOR FUNCTION TEST 1. Forearm to table (side) 2. Forearm from table to 25.4-cm box (side) 3. Extend elbow 28cm on table top (side) 4. Extend elbow 28cm on table top (1-lb weight) 5. Hand to table (front) 6. Hand to box (front) 7. Retrieve .45-kg weight from 28-cm line on table top by elbow flexion 8. Lift can to mouth 9. Lift pencil from table 10. Lift pencil clip from table 11. Stack 3 checkers 12. Flip 3 cards 13. Turn key in lock: clockwise to 180 degree, counterclockwise to 180 degree, and back to the starting position 14. Fold face towel 15. Lift basket with 1.35-kg weight from desk (29 high) to bedside table that placed on the desk Rating scale 0-did not attempt 1-unable to perform 2-performed very slowly or with difficulty, needed greater than 2 attempts, needed assistance from stronger ar m, or task modified 3-performed slowly or with synergy 4-almost normal, just not as fast or accurate 5-appeared normal 24

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APPENDIX C STROKE IMPACT SCALE The purpose of this questionnaire is to evaluate how stroke has impacted your health and life. We want to know from your point of view how stroke has affected you. We will ask you questions about impairments and disabilities caused by your stroke as well as how stroke has affected your quality of life. Finally, we w ill ask you to rate how much you think you have recovered from your stroke. The following questions are about your ability to use your hand that was MOST AFFECTED by your stroke. 7. In the past 2 weeks, how difficult was it to use your hand that was most affected by your stroke to Not difficult at all A little difficult Somewhat difficult Very difficult Extremely difficult a. Carry heavy objects (e.g. bag of groceries)? 5 4 3 2 1 b. Turn a doorknob? 5 4 3 2 1 c. Open a can or jar? 5 4 3 2 1 d. Tie a shoe lace? 5 4 3 2 1 e. Pick up a dime? 5 4 3 2 1 25

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LIST OF REFERENCES Bonifer, N., & Anderson, K. M. (2003). A pplication of constraint-induced movement therapy for an individual with severe chronic upper-extremity hemiplegia. Physical Therapy, 83(4), 384-398. Broeks, J. G., Lankhorst, G. J., Rumping, K., & Prevo, A. J. (1999). The long-term outcome of arm function after stro ke: Results of a follow-up study. Disability and Rehabilitation, 21 (8), 357-364. Cohen, J. (1977). Statistical power analysis for behavior science New York: Acdemic Press. de Pedro-Cuesta, J., Widen-Holmqvist, L., & Ba ch-y-Rita, P. (1992). Evaluation of stroke rehabilitation by randomized controlled studies: A review. Acta Neurological Scandinavica, 86 (5), 433-439. De Weerdt, W., & Harrison, M. A. (1985). Me asuring recovery of arm hand function in stroke patients: A comparison of th e Brunnstrom-Fugl-Meyer test and Action Research Arm test. Physiotherapy Canada, 37 65-70. Duncan, P. W. (1997). Evidence based medicine. Physiotherapy Research International, 2 (4), 271-272. Duncan, P. W., Propst, M., & Nelson, S. G. (1983). Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident. Physical Therapy, 63(10), 1606-1610. Duncan, P. W., Wallace, D., Lai, S. M., Johnson D., Embretson, S., & Laster, L. J. (1999). The stroke impact scale version 2.0. Evaluati on of reliability, va lidity, and sensitivity to change. Stroke, 30(10), 2131-2140. Fugl-Meyer, A. R., Jaasko, L., & Norlin, V. (19 75). The post-stroke hemi plegic patient. II. Incidence, mortality, and vocational return in Goteborg, Sweden with a review of the literature. Scandinavian Journal of Rehabilitation Medicine, 7 (2), 73-83. Gladstone, D. J., Danells, C. J., & Black, S. E. (2002). The Fugl-Meyer assessment of motor recovery after stroke: A critical revi ew of its measurement properties. Neurorehabilitation and Neural Repair, 16 (3), 232-240. Guyatt, G., Walter, S., & Norman, G. (1987). Measuring change over time: Assessing the usefulness of evaluative instruments. Journal of Chronic Diseases, 40 (2), 171-178. Heller, A., Wade, D. T., Wood, V. A., Sunderla nd, A., Hewer, R. L., & Ward, E. (1987). Arm function after stroke: Measurement an d recovery over the first three months. Journal of Neurology, Neuros urgery and Psychiatry, 50(6), 714-719. 26

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Husted, J. A., Cook, R. J., Farewell, V. T., & Gladman, D. D. (2000). Methods for assessing responsiveness: A critical review and recommendations. Journal of Clinical Epidemiology, 53 (5), 459-468. Kazis, L. E., Anderson, J. J., & Meenan, R. F. (1989). Effect sizes fo r interpreting changes in health status. Medical Care, 27 (3 Suppl), S178-189. Kirshner, B., & Guyatt, G. (1985). A method ological framework for assessing health indices. Journal of Chronic Diseases, 38 (1), 27-36. Kopp, B., Kunkel, A., Muhlnickel W., Villringer, K., Taub, E., & Flor, H. (1999). Plasticity in the motor system related to therapy-induced improvement of movement after stroke. Neuroreport, 10 (4), 807-810. Kunkel, A., Kopp, B., Muller, G., Villringer, K., Villringer, A., Taub, E., et al. (1999). Constraint-induced movement therapy for motor recovery in chronic stroke patients. Archives of Physical Medicine and Rehabilitation, 80 (6), 624-628. Langton Hewer, R. (1990). Rehabilitation after stroke. The Quarterly Journal of Medicine, 76(279), 659-674. Liang, M. H. (1995). Evaluating measurement responsiveness. The Journal of Rheumatology, 22 (6), 1191-1192. Liepert, J., Bauder, H., Wolfgang, H. R., Miltn er, W. H., Taub, E., & Weiller, C. (2000). Treatment-induced cortical reorganiz ation after stroke in humans. Stroke, 31(6), 1210-1216. Liepert, J., Miltner, W. H., Bauder, H., Sommer, M., Dettmers, C., Taub, E., et al. (1998). Motor cortex plasticity during constrai nt-induced movement therapy in stroke patients. Neuroscience Letters, 250 (1), 5-8. Miltner, W. H., Bauder, H., Sommer, M., Dettmers, C., & Taub, E. (1999). Effects of constraint-induced movement therapy on pati ents with chronic motor deficits after stroke: A replication. Stroke, 30(3), 586-592. Morris, D. M., Uswatte, G., Crago, J. E., Cook, E. W., 3rd, & Taub, E. (2001). The reliability of the wolf motor function test for assessing upper extremity function after stroke. Archives of Physical Medicine and Rehabilitation, 82 (6), 750-755. Moskowitz, E., Lightbody, F. E., & Freit ag, N. S. (1972). Long-term follow-up of the poststroke patient. Archives of Physical Medicine and Rehabilitation, 53 (4), 167-172. Nakayama, H., Jorgensen, H. S., Raaschou, H. O ., & Olsen, T. S. (1994). Recovery of upper extremity function in stroke pati ents: The Copenhagen Stroke Study. Archives of Physical Medicine and Rehabilitation, 75 (4), 394-398. 27

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Parker, V. M., Wade, D. T., & Langton Hewe r, R. (1986). Loss of arm function after stroke: Measurement, frequency, and recovery. International Rehabilitation Medicine, 8 (2), 69-73. Stratford, P. W., Binkley, F. M., & Riddle, D. L. (1996). Health status measures: Strategies and analytic methods for assessing change scores. Physical Therapy, 76 (10), 11091123. Stratford, P. W., & Riddle, D. L. (2005). Asse ssing sensitivity to change: Choosing the appropriate change coefficient. Health and Quality of Life Outcomes, 3 23. Tarkka, I. M., Pitkanen, K., & Sivenius, J. (2005). Paretic hand rehabilitation with constraint-induced movement therapy after stroke. American Journal of Physical Medicine and Rehabilitation, 84(7), 501-505. Taub, E., Miller, N. E., Novack, T. A., C ook, E. W., III, Fleming, W. C., Nepomuceno, C. S., et al. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74 (4), 347-354. van der Lee, J. H., Beckerman, H., Lankhorst, G. J., & Bouter, L. M. (1999). Constraintinduced movement therapy. Archives of Physical Medicine and Rehabilitation, 80(12), 1606-1607. van der Lee, J. H., Beckerman, H., Lankhorst, G. J., & Bouter, L. M. (2001). The responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients. Journal of Rehabilitation Medicine, 33 (3), 110-113. van der Lee, J. H., Wagenaar, R. C., Lankhorst, G. J., Vogelaar, T. W., Deville, W. L., & Bouter, L. M. (1999). Forced use of the upper extremity in chronic stroke patients: Results from a single-blind randomized clinical trial. Stroke, 30(11), 2369-2375. Wallace, D., Duncan, P. W., & Lai, S. M. (2002). Comparison of the responsiveness of the Barthel Index and the motor component of the Functional Independence Measure in stroke: the impact of using different methods for measuring responsiveness. Journal of Clinical Epidemiology, 55 (9), 922-928. Wolf, S. L., Catlin, P. A., Ellis, M., Archer, A. L., Morgan, B., & Piacentino, A. (2001). Assessing Wolf Motor Function Test as ou tcome measure for research in patients after stroke. Stroke, 32(7), 1635-1639. Wolf, S. L., Lecraw, D. E., Barton, L. A., & Jann, B. B. (1989). Forced use of hemiplegic upper extremities to reverse the effect of learned nonuse among chronic stroke and head-injured patients. Experimental Neurology, 104(2), 125-132. Wood-Dauphinee, S. L., Williams, J. I., & Shapiro, S. H. (1990). Examining outcome measures in a clinical study of stroke. Stroke, 21(5), 731-739. 28

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BIOGRAPHICAL SKETCH Pey-Shan Wen was born on June 22, 1974 in Ka ohsiung, Taiwan. She is the middle child with an older brother and a younger sister. She graduated from Kaohsiung Municipal Girls Senior High School in 1992. She was awarded B.S. degree in occupational therapy in National Cheng Kung University in Tainan, Taiwan in 1996. She enrolled in the advanced masters program in the Occupational Therapy department of the University of Florida in 2003. In 2004, she started the rehabilitation science docto ral program in University of Florida. Pey-Shan Wen had worked as a licensed occupa tional therapist for five years before she came to the United States for her masters degr ee. She worked in Taipei Medical University Hospital from 1996 to 1998. Between 1999 and 2002, she worked as a chief occupational therapist in hospital and worked part-time as a school-occupationa l therapist in school system. In the fall 2003, Pey-Shan Wen worked as teaching assistant in Occupational Therapy department. Since 2004, she has worked as a research assistant for Dr. Craig Velozo. 29