The only way of really knowing if something works, is to compare the “before” with the “after” and look at the difference. The same applies to therapy after stroke.
So how can we find out if an intervention is effective?

Why we assess what we do

Over the years, stroke rehabilitation has developed immensely. A broad range of interventions and treatments are available and therapists have to assess their therapy strategies to optimize the outcome. (1)

The question is how to best assess progress.
Knowing that stroke is a disabling long-term condition, the measurement of function, activity, and participation seems reasonable. The ICF (International Classification of Functioning, Disability, and Health) as a classification system provides structure and can help linking deficits to assessments. (2)

Furthermore, therapists and clinicians should choose assessment based on evidence and the question of interest. Qualitative and quantitative assessment tools are needed to better understand and guide the recovery process. (3)

The world of assessments

Improving motor performance, cognitive skills and independency are common rehabilitation goals after stroke. For setting individual goals, finding core problems and evaluate them, a variety of tools, called assessments, are available. Performance measures can involve mobility and other functional activities, there are often used to detect and monitor progress.

Choosing the right assessments is a therapist’s task. Different factors such as usefulness and expected administration time have to be considered. (4)

For therapists: How to choose an assessment

There are some questions you have to ask yourself before picking an assessment.

  • What do I want to measure?
  • What does the tool measure?
  • What types of clients can the tool be used for?
  • Is this a screening or assessment tool?
  • How much time is needed to administer it?
  • Does the tool detect a change in patients?

In addition, there are measurement properties that show how good an assessment tool is: Reliability, validity, acceptability, and feasibility.

Reliability – states the degree of accuracy of an assessment

Validity – states how likely it is that the outcome of the assessment corresponds with the real world

Acceptability – how well an assessment is accepted by the tester and the testee

Feasibility – how practical and easy an assessment can be performed (5, 3)

The floor and ceiling effects

Assessments are designed with a target group in mind. An Assessment should always say what the intended target group is. Having a significant proportion of the group score at the bottom (floor) or top (ceiling) of the range of possible scores can mean that the tool could miss changes in the performance of patients. This can make an assessment invalid. (6)

Overall it can be said that the evaluation of a stroke survivor is best to be performed by an interdisciplinary team, each member of the team has their own field of expertise and assessments.

Stroke guidelines suggest that patients should be assessed every 30 days. For doing this properly and efficiently, effective assessments are needed. Stroke guidelines also give information to clinicians in the choice of measurement tools in an inpatient and outpatient setting. (7)

For patients: What is my benefit?

Sometimes it seems like all that is happening in a therapy session is testing and talking.

Knowing the outcome of the assessments that were taken can help you understand your situation and therapy planning. Furthermore, setting goals together with your therapist based on the outcome of assessments can give you better points of measurements. In addition, looking back on repeated assessments can show you how far you’ve already come.

The Problem with assessments

You can only pick the right assessment if you know what you want to measure.
In addition, some assessments are quick but are not standardized. Manual administration can also be a point of failure. (3)

Out of the pool of available assessment tools, there are some that are more research-oriented and some that are made for clinical settings. As a result, picking a research-oriented assessment for clinical purposes can cost a lot of time and effort. (8)

Often multifactorial assessments are required in evaluating risk and potential in stroke patients in some cases. For example balance and attention are needed for being a pedestrian. A valid statement can only be made if both factors are considered at the same time. There is no “Test it all” – assessments when it comes to complex deficits after stroke. Nevertheless, there are some assessments that focus on performance and activities instead of singular functions. The goal of these assessments is closely related to typical day-to-day conditions rather than monitor a test environment. (9)

Although it’s preferable to use standardized assessments, non-standardised assessments are also currently in use in stroke rehabilitation. Using them is sometimes necessary because there are no others, but the lack of standardization should be taken into account in the results. (10)

New Assessments

If there is no “optimal” assessment, why not develop one?

Knowing the broad range of deficits after a stroke and the interdisciplinary team that is necessary for treatment it becomes clear that it’s not that easy.

New assessments need to be evaluated and tested for their properties and potential sources of errors. In order to optimize assessments, technology can assist in clinical utility and acceptance. Instead of developing new assessments, digitalizing existing assessments can support easier use. (3)

What’s new?

Using technology for assessments is something that is common in some areas of expertise and can open ways to faster, easier and more valid assessments.

VR (virtual reality) for example offers several benefits as an assessment tool. One of them being a 3D environment with dynamic stimuli that can be regulated. An easy change between immersive and non-immersive displays can offer options for extended assessments. VR-Tests have the potential to become screening instruments in neuropsychological assessments. (11,12)

Other technologies that are used for assessments are automated robot/assisted assessments. Higher sensibility, better reliability, and usability are the goal of switching to robotic technology. The limiting factor for its adoption is often the lack of technical expertise or the amount of equipment that which required. (3, 8, 13)

How rewellio includes assessments

Right now we are working on our assessment tool kit. Tailored to support therapists, we provide a digital assessment service that will help with the use of an easy to perform assessments. Having all assessments in one place allows the patients to oversee their progress and the therapists to get a full picture of a patient’s abilities by accessing previous assessments. The interdisciplinary approach allows collaboration within shared patients.

In-app assessments enable testing and retesting during an exercise and can visualize the current progress. For example, by marking the position of the hand in the room in comparison to the head, a “functional reach” can be detected.

What do you think about having all the assessments of a patient in one place?
Do you think sharing the outcomes of assessments and the overall process over time can help patients to stay motivated?

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Bibliography

    1. Quinn, T., Harrison, & McArthur. (2013). Assessment scales in stroke: clinimetric and clinical considerations. Clinical Interventions in Aging, 8, 201. https://doi.org/10.2147/CIA.S32405
    2. World Health Organization. (2011) ICF: International Classification of Functioning, Disability, and Health. Geneva, Switzerland: World Health Organization.
    3. Rinderknecht, M. D., Lambercy, O., Raible, V., Büsching, I., Sehle, A., Liepert, J., & Gassert, R. (2018). Reliability, validity, and clinical feasibility of a rapid and objective assessment of post-stroke deficits in hand proprioception. Journal of NeuroEngineering and Rehabilitation, 15(1), 47. https://doi.org/10.1186/s12984-018-0387-6
    4. Scrivener, K., Sherrington, C., & Schurr, K. (2013). A systematic review of the responsiveness of lower limb physical performance measures in inpatient care after stroke. BMC Neurology, 13(1), 4. https://doi.org/10.1186/1471-2377-13-4
    5. Blum, L., & Korner-Bitensky, N. (2008). Usefulness of the Berg Balance Scale in Stroke Rehabilitation: A Systematic Review. Physical Therapy, 88(5), 559–566. https://doi.org/10.2522/ptj.20070205
    6. Scrivener, K., Schurr, K., & Sherrington, C. (2014). Responsiveness of the ten-metre walk test, Step Test and Motor Assessment Scale in inpatient care after stroke. BMC Neurology, 14(1), 129. https://doi.org/10.1186/1471-2377-14-129
    7. Winstein, C. J., Stein, J., Arena, R., Bates, B., Cherney, L. R., Cramer, S. C., … Zorowitz, R. D. (2016). Guidelines for Adult Stroke Rehabilitation and Recovery. Stroke, 47(6), e98–e169. https://doi.org/10.1161/STR.0000000000000098
    8. Contu, S., Hussain, A., Kager, S., Budhota, A., Deshmukh, V. A., Kuah, C. W. K., … Campolo, D. (2017). Proprioceptive assessment in clinical settings: Evaluation of joint position sense in upper limb post-stroke using a robotic manipulator. PLOS ONE, 12(11), e0183257. https://doi.org/10.1371/journal.pone.0183257
    9. Yang, L., He, C., & Pang, M. Y. C. (2016). Reliability and Validity of Dual-Task Mobility Assessments in People with Chronic Stroke. PLOS ONE, 11(1), e0147833. https://doi.org/10.1371/journal.pone.0147833
    10. Kitsos, G., Harris, D., Pollack, M., & Hubbard, I. J. (2011). Assessments in Australian stroke rehabilitation units: a systematic review of the post-stroke validity of the most frequently used. Disability and Rehabilitation, 33(25–26), 2620–2632. https://doi.org/10.3109/09638288.2011.575526
    11. Ogourtsova, T., Souza Silva, W., Archambault, P. S., & Lamontagne, A. (2017). Virtual reality treatment and assessments for post-stroke unilateral spatial neglect: A systematic literature review. Neuropsychological Rehabilitation, 27(3), 409–454. https://doi.org/10.1080/09602011.2015.1113187
    12. Fordell, H., Bodin, K., Bucht, G., & Malm, J. (2011). A virtual reality test battery for assessment and screening of spatial neglect. Acta Neurologica Scandinavica, 123(3), 167–174. https://doi.org/10.1111/j.1600-0404.2010.01390.x
    13. Rinderknecht, M. D., Dueñas, J. A., Held, J. P., Lambercy, O., Conti, F. M., Zizlsperger, L., … Gassert, R. (2019). Automated and Quantitative Assessment of Tactile Mislocalization After Stroke. Frontiers in Neurology, 10(June), 1–10. https://doi.org/10.3389/fneur.2019.00593