I-Ping Hsueh

The Brunnstrom recovery stages (the BRS) consists of 2 items assessing the poststroke motor function of the upper extremities and 1 assessing the lower extremities. The 3 items together represent overall motor function. Although the BRS efficiently assesses poststroke motor functions, a lack of rigorous examination of the psychometric properties restricts its utility. We aimed to examine the unidimensionality, Rasch reliability, and responsiveness of the BRS, and transform the raw sum scores of the BRS into Rasch logit scores once the 3 items fitted the assumptions of the Rasch model.We retrieved medical records of the BRS (N = 1180) from a medical center. We used Rasch analysis to examine the unidimensionality and Rasch reliability of both upper-extremity items and the 3 overall motor items of the BRS. In addition, to compare their responsiveness for patients (n = 41) assessed with the BRS and the Stroke Rehabilitation Assessment of Movement (STREAM) on admission and at discharge, we calculated the effect size (ES) and standardized response mean (SRM).The upper-extremity items and overall motor items fitted the assumptions of the Rasch model (infit/outfit mean square = 0.57-1.40). The Rasch reliabilities of the upper-extremity items and overall motor items were high (0.91-0.92). The upper-extremity items and overall motor items had adequate responsiveness (ES = 0.35-0.41, SRM = 0.85-0.99), which was comparable to that of the STREAM (ES = 0.43-0.44, SRM = 1.00-1.13).The results of our study support the unidimensionality, Rasch reliability, and responsiveness of the BRS. Moreover, the BRS can be transformed into an interval-level measure, which would be useful to quantify the extent of poststroke motor function, the changes of motor function, and the differences of motor functions in patients with stroke.

The aims of this study were: (1) to validate the psychometric properties of the Balance Assessment in Sitting and Standing Positions (BASS), including validity (unidimensionality and concurrent validity), reliability (Rasch reliability), and responsiveness (compared with the Postural Assessment Scale for Stroke Patients, PASS), and (2) to transform the BASS from an ordinal-level measure into an interval-level measure. Medical records from a medical center. Retrospective cross-sectional study. Patients with stroke. Not Applicable. The 4-item Balance Assessment in Sitting and Standing Positions (BASS) was used, assessing static sitting balance, dynamic sitting balance, static standing balance, and dynamic standing balance. Data of 1,193 patients with stroke were included for Rasch analysis. The 4 items of the BASS constituted a unidimensional construct (infit/outfit mean square = 0.75 - 1.05), had good concurrent validity (r = 0.70- 0.90), and had sufficient Rasch reliability (0.93). ...

A performance-based measure for assessing executive functions (EF) is useful to understand patients' real life performance of EF. This study aimed to develop a performance-based measure of executive functions (PEF) based on the Lezak model and to examine psychometric properties (i.e., unidimensionality and reliability) of the PEF using Rasch analysis in patients with schizophrenia. We developed the PEF in three phases: (1) designing the preliminary version of PEF; (2) consultation with experts, cognitive interviews with patients, and pilot tests on patients to revise the preliminary PEF; (3) establishment of the final version of the PEF and examination of unidimensionality and Rasch reliability. Two hundred patients were assessed using the revised PEF. After deleting items which did not satisfy the Rasch model's expectations, the final version of the PEF contained 1 practice item and 13 test items for assessing the four domains of EF (i.e., volition, planning, purposive acti...

To examine the ecological validity, predictive validity, and responsiveness of the Five Digit Test (FDT) in patients with stroke. We included inpatients with stroke (n = 144, 114 and 105 in the ecological validity, predictive validity, and responsiveness analysis, respectively) in the study. At admission, the FDT and Barthel Index (BI) were assessed; at discharge, the FDT, BI, Postural Assessment Scale for Stroke Patients (PASS), and Mobility Subscale of the Stroke Rehabilitation Assessment of Movement (MO-STREAM) were assessed. In the ecological validity analysis, the scores of the selective and alternating attention indices of the FDT were moderately correlated with those of the BI at admission and discharge (Spearman ρ = -0.38 to -0.45). In the predictive validity analysis, the scores of the two attention indices of the FDT at admission were moderately correlated with the scores of the BI, PASS, and MO-STREAM at discharge (ρ = -0.33 to -0.45). In the responsiveness analysis, the ...

The group-level responsiveness of the Stroke Rehabilitation Assessment of Movement measure (STREAM-30) is similar to that of the simplified STREAM (STREAM-15), even though the STREAM-30 has twice as many items as those of the STREAM-15. To compare the responsiveness of the STREAM-30 and STREAM-15 at both group and individual levels in patients with stroke. For the latter level, the Rasch-calibrated 27-item STREAM (STREAM-27) was used because the individual-level indices of the STREAM-30 could not be estimated. Repeated-measurements design. In total, 195 patients were assessed with the STREAM-30 at both admission and discharge. The Rasch scores of the STREAM-27 and STREAM-15 were estimated from the patients' responses on the STREAM-30. We calculated the paired t test, effect size, and standardized response mean as the indices of group-level responsiveness. The significance of change for each patient was estimated as the individual-level responsiveness index, and the paired t test...

To improve the utility of the Berg Balance Scale (BBS), the aim of this study was to develop a short form of the BBS (SFBBS) that was psychometrically similar (including test reliability, validity, and responsiveness) to the original BBS for people with stroke. A total of 226 subjects with stroke participated in this prospective study at 14 days after their stroke; 167 of these subjects also were examined at 90 days after their stroke. The BBS, Barthel Index, and Fugl-Meyer Motor Test were administered at these 2 time points. By reducing the number of tested items by more than half the number of items in the original BBS (ie, making 4-, 5-, 6-, and 7-item tests) and simplifying the scoring system of the original BBS (ie, collapsing the 5-level scale into a 3-level scale [BBS-3P]), we generated a total of 8 SFBBSs. The distributions of scores for all 8 SFBBSs were acceptable but featured notable floor effects. The 4-item BBS, 5-item BBS, 5-item BBS-3P, and 7-item BBS-3P demonstrated ...

To examine the intrarater reliability, interrater reliability, and responsiveness of the Activities of Daily Living Computerized Adaptive Testing system (ADL CAT) in patients with stroke. One repeated-measures design (at an interval of 7d) was used to examine the intrarater reliability and interrater reliability of the ADL CAT. For the responsiveness study, participants were assessed with the ADL CAT at admission to the rehabilitation ward and at discharge from the hospital. Eight rehabilitation units. Three different (nonoverlapping) groups of patients (N=157) were recruited. Fifty-five and 42 outpatients with chronic stroke participated in the intrarater and interrater reliability studies, respectively; 60 inpatients who had recently had a stroke participated in the responsiveness study. Not applicable. The intraclass correlation coefficient values were .94 and .80 for the ADL CAT in the intrarater reliability and interrater reliability studies, respectively. The classical test theory-based minimal detectable change values were 6.5 and 9.5 for the ADL CAT in the intrarater reliability and interrater reliability studies, respectively. The Kazis' effect size and standardized response mean of the ADL CAT were moderate (.62-.73). The ADL CAT has good intrarater reliability and interrater reliability in outpatients with chronic stroke, and sufficient responsiveness in inpatients with stroke undergoing inpatient rehabilitation. Further investigations on the responsiveness of the ADL CAT in outpatients are needed to obtain more evidence on the utility of the ADL CAT.

Health-related quality of life (HRQOL) is considered an important outcome indicator in substances abuse studies. However, psychometric properties of HRQOL measures are largely unknown in people who abuse heroin. Therefore, the present study aimed to examine data quality, scaling properties, reliability, and construct validity of the 36-Item Short Form healthy survey (SF-36) in people who abuse heroin. A total of 469 people who abuse heroin participated in the study. Data quality was determined by data completeness. Scaling properties were evaluated by item frequency distribution, equivalence of item means and standard deviations, item-internal consistency, and item-discriminant validity (calculating scaling success). Internal consistency was examined using Cronbach's α. Construct validity was examined by investigating convergent validity and divergent validity among the eight scales of the SF-36. The results of data quality showed low missing rates (0.0-3.8%) and high completion rates in the scales (91.9-98.7%). The results of scaling assumptions showed good item frequency distribution on each item, roughly equivalent item means and standard deviations within a scale, good item-internal consistency (>0.4) and good scaling success rates (77.5-100%), except on the two scales of bodily pain (BP) and social functioning (SF). Three scales showed ceiling and/or floor effects [i.e., physical functioning (PF), role limitations due to physical problems (RP), and role limitations due to emotional problems (RE)]. Cronbach's α was acceptable (>0.7), except for the BP and SF scales. Construct validity was partially supported by the results of convergent validity and divergent validity. The results confirmed good data quality; satisfactory scaling assumptions and internal consistency (except for the BP and SF scales); and generally acceptable construct validity. However, the PF, RP, and RE scales showed ceiling and/or floor effects. Therefore, the BP, SF, PF, RP, and RE scales should be used with cautions in measuring HRQOL in people who abuse heroin.

To validate the unidimensionality of the Action Research Arm Test (ARAT) using Mokken analysis and to examine whether scores of the ARAT can be transformed into interval scores using Rasch analysis. A total of 351 patients with stroke were recruited from 5 rehabilitation departments located in 4 regions of Taiwan. The 19-item Action ARAT was administered to all the subjects by a physical therapist. The data were analysed using item response theory by non-parametric Mokken analysis followed by Rasch analysis. The results supported a unidimensional scale of the 19-item ARAT by Mokken analysis, with the scalability coefficient H = 0.95. Except for the item "pinch ball bearing 3rd finger and thumb", the remaining 18 items have a consistently hierarchical order along the upper extremity function's continuum. In contrast, the Rasch analysis, with a stepwise deletion of misfit items, showed that only 4 items ("grasp ball", "grasp block 5 cm(3)", "grasp block 2.5 cm(3)", and "grip tube 1 cm(3)") fit the Rasch rating scale model's expectations. Our findings indicated that the 19-item ARAT constituted a unidimensional construct measuring upper-extremity function in stroke patients. However, the results did not support the premise that the raw sum scores of the ARAT can be transformed into interval Rasch scores. Thus, the raw sum scores of the ARAT can provide information only about order of patients on their upper extremity functional abilities, but not represent each patient's exact functioning.

To examine the psychometric properties of the sensory scale of the Fugl-Meyer Assessment (FMA-S) in stroke patients with a broad range of neurological and functional impairment at times from 14 to 180 days after stroke. A total of 176 first stroke patients consecutively admitted to a university-based medical centre. This prospective, longitudinal investigation was based on data collected at 14, 30, 90 and 180 days after stroke. Reliability (inter-rater reliability and internal consistency), validity (convergent and predictive validity) and responsiveness of the FMA-S were examined. The inter-rater agreement of the total score of the FMA-S was excellent, with an intraclass correlation coefficient of 0.93. The Cronbach's alphas of the FMA-S at four time points after stroke ranged from 0.94 to 0.98, indicating excellent internal consistency. However, the FMA-S showed a significant ceiling effect (more than 44.4% of the subjects achieving the highest score), poor to moderate inter-rater reliability for light touch items (weighted kappa ranging from 0.30 to 0.55), low to moderate validity (Spearman's rho ranging from 0.29 to 0.53), and low to moderate responsiveness (standardized response mean ranging from 0.27 to 0.67) at different post-stroke stages of recovery. The psychometric properties of the FMA-S in measuring sensory function do not support its clinical use in stroke patients. Further studies on methods to improve the psychometric properties of the FMA-S are needed.

CONTEXT Unlike other areas of medicine, psychiatry is almost entirely dependent on patient report to assess the presence and severity of disease; therefore, it is particularly crucial that we find both more accurate and efficient means of obtaining that report. OBJECTIVE To develop a computerized adaptive test (CAT) for depression, called the Computerized Adaptive Test-Depression Inventory (CAT-DI), that decreases patient and clinician burden and increases measurement precision. DESIGN Case-control study. SETTING A psychiatric clinic and community mental health center. PARTICIPANTS A total of 1614 individuals with and without minor and major depression were recruited for study. MAIN OUTCOME MEASURES The focus of this study was the development of the CAT-DI. The 24-item Hamilton Rating Scale for Depression, Patient Health Questionnaire 9, and the Center for Epidemiologic Studies Depression Scale were used to study the convergent validity of the new measure, and the Structured Clinical Interview for DSM-IV was used to obtain diagnostic classifications of minor and major depressive disorder. RESULTS A mean of 12 items per study participant was required to achieve a 0.3 SE in the depression severity estimate and maintain a correlation of r = 0.95 with the total 389-item test score. Using empirically derived thresholds based on a mixture of normal distributions, we found a sensitivity of 0.92 and a specificity of 0.88 for the classification of major depressive disorder in a sample consisting of depressed patients and healthy controls. Correlations on the order of r = 0.8 were found with the other clinician and self-rating scale scores. The CAT-DI provided excellent discrimination throughout the entire depressive severity continuum (minor and major depression), whereas the traditional scales did so primarily at the extremes (eg, major depression). CONCLUSIONS Traditional measurement fixes the number of items administered and allows measurement uncertainty to vary. In contrast, a CAT fixes measurement uncertainty and allows the number of items to vary. The result is a significant reduction in the number of items needed to measure depression and increased precision of measurement.

The Symbol Digit Modalities Test (SDMT) is commonly used to evaluate an individual's switching attention and processing speed. However, its test-retest reliability and practice effect are not well known in patients with stroke, limiting its utility in both clinical and research settings. The present study examined the two aforementioned psychometric properties of the oral-format SDMT on a group of 30 outpatients with stroke. The oral-format SDMT demonstrated excellent test-retest reliability (ICC = 0.89) and a small practice effect (Cohen's d = 0.26) within a 1-week interval. A practice effect-corrected reliable change index [-5.29, 10.89] was also provided to help clinicians and researchers interpret their clients' test results. Patients' characteristics and the test-retest interval should be considered before applying the findings of the present study to clinical settings.

Objectives: To develop a computerized Digit Vigilance Test (C-DVT) with lower random measurement error than that of the DVT and to examine the concurrent validity, ecological validity, and test-retest reliability of the C-DVT in patients with stroke. Design: A cross-sectional study. Patients: Forty-four patients with stroke. Methods: We developed and tested the C-DVT. To examine the psychometric properties, the participants completed both the C-DVT and DVT twice with a 14-day interval. Results: We developed the C-DVT on the basis of expert input and examinee feedback. C-DVT scores were highly correlated with DVT scores (ρ = 0.75), supporting the concurrent validity. The C-DVT scores were moderately correlated with the scores of the Barthel Index and the Activities of Daily Living Computerized Adaptive Testing system (ρ = -0.60~-0.57), supporting the ecological validity. The test-retest agreement of the C-DVT was excellent (intra-class correlation coefficient = 0.92). The random meas...

The trunk control items of the Postural Assessment Scale for Stroke Patients (PASS-TC) have been proposed for use in examining patients with stroke. The purpose of this study was to examine the discriminative and predictive validities and the evaluative properties of the PASS-TC at 14, 30, 90, and 180 days after stroke onset. A total of 269 patients with stroke participated in this prospective study. The PASS-TC was administered at the 4 time points after stroke onset. The distributions of the PASS-TC scores were used to determine the discriminative ability to distinguish between individuals at the 4 time points. A comprehensive activities of daily living (CADL) measure was administered 1 year after stroke onset as an external criterion for examining the predictive ability of the PASS-TC. Changes in PASS-TC scores between the intervals of 14 to 30, 30 to 90, and 90 to 180 days after stroke onset were used to examine the evaluative properties of the measure. The PASS-TC scores exhibi...

To investigate practice effect and test-re-test reliability of the Five Digit Test (FDT) over four serial assessments in patients with stroke. Single-group repeated measures design. Twenty-five patients with stroke were administered the FDT in four consecutive assessments every 2 weeks. The FDT contains four parts with five indices: 'basic measures of attention and processing speed', 'selective attention', 'alternating attention', 'ability of inhibition' and 'ability of switching'. The five indices of the FDT showed trivial-to-small practice effects (Cohen's d = 0.03-0.47) and moderate-to-excellent test-re-test reliability (intra-class correlation coefficient = 0.59-0.97). Practice effects of the five indices all appeared cumulative, but one index, 'basic measures of attention and processing speed', reached a plateau after the second assessment. The minimum and maximum values of the 90% confidence interval (CI) of reliable change index modified for practice (RCIp) for this index were [-17.6, 11.2]. One of five indices of the FDT reached a plateau, whose minimum and maximum values of the 90% CI RCIp are useful to determine whether the change in an individual's score is real. However, clinicians and researchers should be cautious when interpreting the test results of these four indices over repeated assessments.

The lack of knowledge about the responsiveness and predictive validity of a set of Hierarchical Balance Short Forms (the HBSF) in people with stroke limits the utility of the HBSF in both clinical and research settings. The purpose of this study was to investigate the responsiveness and predictive validity of the HBSF in people receiving inpatient rehabilitation after stroke. A prospective cohort study was conducted. Sixty-six participants completed both the 6-item HBSF and the 12-item Postural Assessment Scale for Stroke (PASS) after admission to the rehabilitation ward and before hospital discharge. The standardized effect size (ES) and the standardized response mean (SRM) were used to investigate the internal responsiveness of the HBSF and the PASS. Changes in the Barthel Index and the mobility subscale of the Stroke Rehabilitation Assessment of Movement were used as the external criteria for examining external responsiveness. Moreover, the admission scores on the HBSF and the PASS and the discharge scores on the Barthel Index and mobility subscale of the Stroke Rehabilitation Assessment of Movement were analyzed to investigate the predictive validity of the 2 balance measures. The internal responsiveness of the HBSF was high (ES>0.9, SRM>1.6). The SRM of the HBSF was significantly larger than that of the PASS, whereas the ES of the HBSF was not significantly larger than that of the PASS. The external responsiveness and predictive validity of the HBSF were sufficient and similar to those of the PASS (external responsiveness: r≥.35; predictive validity: r≥.67). The convenience sampling of people receiving inpatient rehabilitation after stroke may limit the generalization of the results. The HBSF has sufficient responsiveness and predictive validity in people receiving inpatient rehabilitation after stroke and is thus recommended for both clinicians and researchers.