Wednesday, March 02, 2016

A New Hand Evaluation for Stroke Survivors

Rebecca Dutton
Home After a Stroke
February 25, 2016

Van Lew and associates (1) studied the reliability of a hand evaluation called Functional Upper Extremity Levels (FUEL).

What They Got Right

To prove the efficacy of treatment approaches, researchers need tests that are sensitive enough to detect both emerging movement and small improvements.  Hand tests traditionally begin by asking clients to reach out, pick up an object sitting on a table, and release the object by placing it back on the table.  Many stroke survivors cannot do this.  The FUEL provides sensitivity by describing 3 levels of skill below the starting level of traditional tests.

      Level 1 = Dependent Stabilizer.  The sound hand places the affected hand on an object.  The weight of the hand stabilizes the object so the sound can manipulate the object.  Level 2 = Independent Stabilizer.  The affected hand places itself on the object (e.g. hand holding down wad of toilet paper so other hand can tear paper).  Level 3 = Gross Assist.  Affected hand holds an object with a gross grasp.  No functional release is present.

What They Missed

One task did not have good inter-rater reliability.  When scoring a grooming task, 70% of OTs scored the subject as Level 3 while 30% of OTs scored the subject as Level 4.  The authors attributed this finding to a video that "did not have the clarity of other videos."  However, when a subject does not exhibit ALL the skills of a level it can be difficult for raters to agree.

     An alternative explanation may be that reach, grasp, and release do not emerge together - a combination Level 4 requires to give full credit.  Before reaching, a hand-to-hand transfer can be done close to the body.  The affected hand has to open a few inches to accept a small object from the sound hand and relax to release the object so the sound hand does not have to tug on the object. Ignoring hand-to-hand transfers is not a small omission on a test of hand function.
  1. Van Lew S, Geller D, Feld-Glasman R, et al. Development and preliminary reliability of the Functional Upper Extremity Levels (FUEL). American Journal of Occupational Therapy, 690650010p1-6906350010p.5 (online only).

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