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Rehab Measures: Action Research Arm Test

Link to instrument

Available at the Internet Stroke Center (External Link) 

Title of Assessment

Action Research Arm Test 

Acronym

ARAT

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team in 2011; Updated by Cara Weisbach, PT, DPT and Wendy Romney, PT, DPT, NCS and the SCI EDGE task force of the Neurology Section of the APTA with references from the chronic stroke population in 2012; Updated by Irene Ward, PT, DPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 2012.

Summary Date

1/17/2013 

Purpose

Assesses upper limb functioning using observational methods

Description

The ARAT's is a 19 item measure divided into 4 sub-tests (grasp, grip, pinch, and gross arm movement). Performance on each item is rated on a 4-point ordinal scale ranging from:

  • 3: Performs test normally
  • 2: Completes test, but takes abnormally long or has great difficulty
  • 1: Performs test partially
  • 0: Can perform no part of test

Lyle’s decision rule: Patients who achieve a maximum score on the first (most difficult) item are credited with having scored 3 on all subsequent items on that scale. If the patient scores less than 3 on the first item, then the second item is assessed. This is the easiest item, and if patients score 0 then they are unlikely to achieve a score above 0 for the remainder of the items and are credited with a zero for the other items. The maximum score on the ARTS is 57 points (possible range 0 to 57).

Items can also be summed (van der Lee et al, 2002)

A standardized scoring protocol has been published by Yozbatiran 2008

Area of Assessment

Activities of Daily Living; Coordination; Dexterity; Upper Extremity Function 

Body Part

Upper Extremity 

ICF Domain

Activity 

Domain

Motor 

Assessment Type

Observer 

Length of Test

06 to 30 Minutes 

Time to Administer

10 minutes, dependent on number of items performed

Number of Items

19 

Equipment Required

  • Various sized wood blocks
  • Cricket ball
  • Stone
  • Jug and glass
  • Tube
  • Washer and bolt
  • Ball bearing
  • A marble

Training Required

None

Type of training required

No Training 

Cost

Free 

Actual Cost

Free

Age Range

Adolescent: 13-17 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Multiple Sclerosis; Stroke; Traumatic Brain Injury 

Populations Tested

  • Stroke
  • Multiple Sclerosis
  • Traumatic Brain Injury

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Chronic Stroke: (van der Lee et al, 2001; n = 20; mean age = 62 (IQR = 52.5–71.8) years; median time since stroke = 3.6 years; mean ARAT score = 29.2 points)
  • MCID = 10% of the measures total range (i.e. 5.7 points)

Chronic Stroke: (van der Lee et al, 2001; n = 22, mean age = 58.5 years; mean time since stroke = 3.6 years; Median baseline ARAT score = 38.0 points)

  • MCID = 5.7

Acute Stroke: (Lang et al, 2008; mean age = 64 (14); time between stroke and first assessment = 9.5 (4.5) days)

MCID Raw Score:
MCID if Dominant Side Affected
MCID if Nondominant Side Affected
Raw Value
Percentage of Scale
Effect Size
Raw Value
Percentage of Scale
Effect Size
ARAT
12
21
0.78
17
30
1.10

Cut-Off Scores

Not Established

Normative Data

Chronic Stroke: (van der Lee et al, 2001)
  • Mean (SD) intake ARAT score 29.2 (12.5)
  • Mean (SD) intake Fugl-Meyer Assessment score 49.2 (9.9)

Item norms (based on healthy elderly adults):
Subtest:
Item
Time Limit (s)
Grasp
Block 2.5cm
3.6
Block 5cm
3.5
Block 7.5cm
3.9
Ball 7.5cm
3.8
Stone
3.6
Block 10cm
4.2
Subtest:
Item
Time Limit (s)
Grip
Tube 2.25cm
4.2
Tube 1cm
4.3
Place washer over bolt
4
Pour water from glass to glass
7.9
Subtest:
Item
Time Limit (s)
Pinch
Large marble first finger and thumb
3.8
Large marble second finger and thumb
3.8
Large marble third finger and thumb
4.1
Small marble first finger and thumb
4
Small marble second finger and thumb
4.1
Small marble third finger and thumb
4.4
Subtest:
Item
Time Limit (s)
Gross Movement
Move hand to mouth
2.4
Place hand on top of head
2.7
Place hand behind head
2.7
Time limits (mean + 2 SD of the performance times of 20 healthy elderly subjects)
If performance is slower than the time limit or if the patient loses contact with the back of the chair during performance, the score is 2 instead of 3.

Acute Stroke: (Beebe and Lang, 2009; mean age = 56.9 (10.2), times since stroke onset = 18.6 (5.6) days)
Normative Data:
1 month
3 months
6 months
ARAT
26.4 (23.9)
39.5 (19.7)
41.3 (20.8)
Grip Strength (kg)
9.2 (9.6)
14.0 (10.3)
15.4 (11.4)
9HPT (sec)
88.8 (40.2)
67.8 (41.7)
60.8 (39.7)
SIS: Hand function

19.9 (28.0)

48.4 (32.7)
43.9 (34.2)
9HPT = 9-Hole Peg Test
SIS = Stroke Impact Scale-Hand

Test-retest Reliability

Chronic and Acute Stroke, Multiple Sclerosis & Traumatic Brain Injury: (Platz et al, 2005; n = 23)
 
Interrater Reliability (between 2 raters)
Action Research Arm Test:
 

Rating

ICC
rho
Grasp

Excellent

0.949
0.965
Grip

Excellent

0.947
0.955
Pinch

Adequate

0.894
0.897
Gross movement

Excellent

0.976
0.976
Total score

Excellent

0.965
0.968
Fugl-Meyer Test, arm section
Motor function

Rating

ICC
rho
A Shoulder/elbow/forearm

Excellent

0.954
0 944
B Wrist

Excellent

0.973

0.961

C Hand

Excellent

0.958

0.941

D Co-ordination/speed

Excellent

0.936

0.947

Total motor score

Excellent

0.965

0.951

Sensation

Adequate

0.806

0.672

Passive joint motion/joint pain

Excellent

0.946

0.883

Box and Block Test:

Rating

ICC

rho

Total

Excellent

0.963

0.973

Interrater/Intrarater Reliability

Acute Stroke: (Nijland et al, 2010; n = 40; mean age = 60 (13.6) years; median ARAT score = 38; times since stroke onset < 6 months; Dutch sample)
  • Excellent interrater reliability (ICC = 0.92)
 
Chronic Stroke: (Van der Lee et al, 2001)
  • Excellent Interrater Reliability (ICC = 0.995)
  • Excellent Intrarater Reliability (ICC = 0.989)
Chronic and Acute Stroke, Multiple Sclerosis & Traumatic Brain Injury: (Platz et al, 2005; n = 44)
 
Interrater Reliability (between 2 raters)
Action Research Arm Test:
 

Rating

ICC
rho
Grasp

Excellent

0.997
0.999
Grip

Excellent

0.964
0.958
Pinch

Excellent

0.999
0.999
Gross movement

Excellent

0.984
0.984
Total score

Excellent

0.998
0.996
Fugl-Meyer Test, arm section
Motor function

Rating

ICC
rho
A Shoulder/elbow/forearm

Excellent

0.989
0 984
B Wrist

Excellent

0.987

0.983

C Hand

Excellent

0.987

0.984

D Co-ordination/speed

Excellent

0.971

0.971

Total motor score

Excellent

0.997

0.995

Sensation

Excellent

0.979

0.969

Passive joint motion/joint pain

Excellent

0.983

0.980

Box and Block Test:

Rating

ICC

rho

Total

Excellent

0.993

0.993

 
Chronic Stroke: (Yozbatrin et al, 2008)
 
Interrater Reliability
Action Research Arm Test
Rating
ICC
rho
Grasp
Excellent
0.9992
1.0
Grip
Excellent
0.996
0.99
Pinch
Excellent
0.997
0.98
Gross Movement
Excellent
0.978
0.93
Total Score
Excellent
0.9986
0.96
 
Intrarater Reliability
Action Research Arm Test
Rating
ICC
rho
Grasp
Excellent
0.98
0.93
Grip
Excellent
0.97
0.93
Pinch
Excellent
0.99
0.98
Gross Movement
Excellent
0.93
0.91
Total Score
Excellent
0.99
0.99
 
 

Internal Consistency

Acute Stroke: (Nijland et al, 2010)
  • Excellent Internal Consistency (alpha = 0.985)

Criterion Validity (Predictive/Concurrent)

Chronic Stroke: (van der Lee et al, 2001)

  • Evidence of concurrent validity confirmed by comparison with the upper limb subtest of the Fugl- Meyer Assessment and the Motor Assessment Scale.

Chronic Stroke: (Yozbatiran et al, 2008)

  • Excellent correlation between ARAT and arm motor score of the Fugl-Meyer (r = 0.94, p<0.01)

Construct Validity (Convergent/Discriminant)

Chronic and Acute Stroke, Multiple Sclerosis & Traumatic Brain Injury: (Platz et al, 2005; n = 56; mean age = 54, range = 13-92 years)
 
Construct Validity: correlational analysis (Spearman's rho)
Fugl-Meyer motor
Action Research Arm Test
Box and Block Test
Action Research Arm Test

0.925

1

0.951

Fugl-Meyer motor
1
0.925
0.921
Fugl-Meyer sensation
0.239
0.298
0.285
Fugl-Meyer joint motion/pain
0.470
0.421
0.433
Box and Block Test
0.921
0.951
1
Motricity Index
0.861
0.811
0.798
Ashworth Scale
-0.422
-0.296
0.383
Modified Barthel Index
0.086
0.049
0.044
Correlational analysis were based on the (first) assessment of 56 patients
 
The above table indicate the ARAT's is strongly related to the:
  • Fugl-Meyer motor
  • Box and Block Test
  • Motricity Index

Negatively related to the Ashworth Scale, moderately related to the Fugl-Meyer sensation and joint motion/pain scales and Not related to the Modified Barthel Index

Content Validity

The ARAT is a modified version of the Upper Extremity Function Test (UEFT)

Face Validity

Not Established

Floor/Ceiling Effects

Acute Stroke: (Lin et al, 2009; n = 53; mean age = 64; Taiwanese sample)
 
% of Individuals who Experienced Floor and Ceiling Effects:
Days Post Stroke
Floor
Ceiling
14
41.5
9.4
30
17.0
20.8
90
11.3
20.8
180

11.3

22.6

 
Acute Stroke: (Nijland et al, 2010)
  • Floor effects for scores < 3
  • Ceiling effects for scores > 54

Responsiveness

Chronic Stroke: (van der Lee et al, 2002; n = 31 (RIQ = 52–66) years; mean baseline ARAT score = 30.27; > 1 year post stroke)
  • 1.2 points (using Lyle’s decision rule) 
  • 1.7 points (summing items)

Acute Stroke: (Lin et al, 2009; n = 53; mean age = 64; Taiwanese sample)

Responsiveness:
Days Post Stoke
Effect Rating

Interpretation

Effect Size
14–30
Small
Poor
0.49
14–90
Moderate
Adequate
0.70
14–180 Moderate Adequate

0.79

Acute Stroke: (Beebe and Lang, 2009)

Responsiveness:
Measure

1–3 months

1–6 months

ARAT
0.55
0.63
9HPT
0.52
0.66
SIS-Hand

1.02

0.86

Acute Stroke (Lang et al, 2006; mean age = 64 (14), Admission NIHSS = 5.3 (1.8); time between stroke and first assessment = 9.5 (4.5) days)

Responsiveness of the ARAT
Method
Day 0 to Day 14
Day 0 to Day 90
Single population all demonstrated large effect sizes
ARAT total score
1.018
1.390
ARAT gross subscore
0.729
0.984
ARAT grasp subscore
1.042
1.224
ARAT grip subscore

1.017

1.324

ARAT pinch subscore

0.854

1.494

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

LS

LS

LS

StrokEDGE

R

R

R

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

R

R

R

R

R

TBI EDGE

LS

LS

R

R

R

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

LS

LS

 

 

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

No

No

No

Not reported

StrokEDGE

Yes

Yes

Yes

Not reported

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

The ARAT and WMFT are highly correlated and as such may not provide significant levels of incremental validity
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Beebe, J. A. and Lang, C. E. (2009). "Relationships and Responsiveness of Six Upper Extremity Function Tests During the First Six Months of Recovery After Stroke." Journal of Neurologic Physical Therapy 33(2): 96-103 Find it on PubMed

Lang, C., Edwards, D., et al. (2008). "Estimating minimal clinically important differences of upper extremity measures early after stroke." Archives of physical medicine and rehabilitation 89(9): 1693. Find it on PubMed

Lang, C. E., Wagner, J. M., et al. (2006). "Measurement of upper-extremity function early after stroke: properties of the action research arm test." Arch Phys Med Rehabil 87(12): 1605-1610. Find it on PubMed

Lin, J.-H., Hsu, M.-J., et al. (2009). "Psychometric comparisons of 4 measures for assessing upper-extremity function in people with stroke." Phys Ther 89: 840-850. Find it on PubMed

Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492. Find it on PubMed

McDonnell, M. (2008). "Action research arm test." Aust J Physiother 54(3): 220. Find it on PubMed

Nijland, R., van Wegen, E., et al. (2010). "A comparison of two validated tests for upper limb function after stroke: The Wolf Motor Function Test and the Action Research Arm Test." J Rehabil Med 42(7): 694-696. Find it on PubMed

Platz, T., Pinkowski, C., et al. (2005). "Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study." Clin Rehabil 19: 404-411. Find it on PubMed

van der Lee, J. H., Beckerman, H., et al. (2001). "The responsiveness of the Action Research Arm test and the Fugl-Meyer Assessment scale in chronic stroke patients." J Rehabil Med 33(3): 110-113. Find it on PubMed

Van der Lee, J. H., De Groot, V., et al. (2001). "The intra- and interrater reliability of the action research arm test: a practical test of upper extremity function in patients with stroke." Arch Phys Med Rehabil 82(1): 14-19. Find it on PubMed

van der Lee, J. H., Roorda, L. D., et al. (2002). "Improving the Action Research Arm test: a unidimensional hierarchical scale." Clin Rehabil 16(6): 646-653. Find it on PubMed

Yozbatiran, N., Der-Yeghiaian, L., et al. (2008). "A standardized approach to performing the action research arm test." Neurorehabil Neural Repair 22(1): 78-90. Find it on PubMed

Year published

1981 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 12/3/2010 6:22 PM  by Jason Raad 
Last modified at 8/28/2014 2:53 PM  by Jason Raad