The Associated Reaction Rating Scale: a clinical tool to measure associated reactions in the hemiplegic upper limb

Objective: To determine what items should be included in a clinical assessment tool developed to measure associated reactions in the hemiplegic upper limb and to assess the reliability of the resultant measure. Design: Development through a structured consultative process using focus group methodology. Evaluation of inter- and intra-rater reliability between two independent observers. Subjects: Nineteen consecutive hemiplegic patients admitted to Northwick Park Hospital for rehabilitation following stroke. Methods: Focus groups were conducted in two centres, comprising physiotherapists experienced in the clinical management of brain injury. The groups identified four key characteristics related to severity of associated reactions, which became the items of the rating scale. Evaluation of inter- and intra-rater reliability was undertaken by comparison of agreement between ratings of associated reactions occurring during a single standardized task (sit-to-stand), by two senior physiotherapists in 19 subjects. Results: There were good correlations between the two raters in total (rho 0.89 p < 0.005) and modal scores (rho 0.88 p < 0.005). Reliability testing of each item revealed moderate to very good inter-rater agreement (weighted kappa values 0.43-0.85) and good to very good intra-rater agreement (weighted kappa values 0.61-0.87). A slight tendency for one rater to score more severely than the other only reached significance for one item (excursion). Overall (modal) severity scores showed a good level of agreement (kappa 0.76-0.81) both between and within raters. Conclusion: Items to be included in a clinical assessment tool to measure associated reactions in the hemiplegic upper limb were determined. Reliability of the resultant measure was found to be encouraging. These results however apply only to observations made during a specific standardized task (sit-to-stand) and further study of sensitivity to change and reproducibility in different tasks is required before the findings can be extrapolated into routine practice.