Impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery.

BACKGROUND: Research impact is an emerging measure of research achievement alongside traditional academic outputs such as publications. We present the results of applying the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence (CRE) in Stroke Rehabilitation and Brain Recovery (CRE-Stroke, 2014-2019) and report on the feasibility and lessons from the application of FAIT to a CRE rather than a discrete research project. METHODS: Data were gathered via online surveys, in-depth interviews, document analysis and review of relevant websites/databases to report on the three major FAIT methods: the modified Payback Framework, an assessment of costs against monetized consequences, and a narrative account of the impact generated from CRE-Stroke activities. FAIT was applied during the last 4 years of CRE-Stroke operation. RESULTS: With an economic investment of AU$ 3.9 million over 5 years, CRE-Stroke delivered a return on investment that included AU$ 18.8 million in leveraged grants, fellowships and consultancies. Collectively, CRE-Stroke members produced 354 publications that were accessed 470,000 times and cited over 7220 times. CRE-Stroke supported 26 PhDs, 39 postdocs and seven novice clinician researchers. There were 59 capacity-building events benefiting 744 individuals including policy-makers and consumers. CRE-Stroke created research infrastructure (including a research register of stroke survivors and a brain biobank), and its global leadership produced international consensus recommendations to influence the stroke research landscape worldwide. Members contributed to the Australian Living Stroke Guidelines: four researchers' outputs were directly referenced. Based only on the consequences that could be monetized, CRE-Stroke returned AU$ 4.82 for every dollar invested in the CRE. CONCLUSION: This case example in the developing field of impact assessment illustrates how researchers can use evidence to demonstrate and report the impact of and returns on research investment. The prospective application of FAIT by a dedicated research impact team demonstrated impact in broad categories of knowledge-gain, capacity-building, new infrastructure, input to policy and economic benefits. The methods can be used by other research teams to provide comprehensive evidence to governments and other research funders about what has been generated from their research investment but requires dedicated resources to complete.

Effectiveness of knowledge brokering and recommendation dissemination for influencing healthcare resource allocation decisions: A cluster randomised controlled implementation trial.

BACKGROUND: Implementing evidence into clinical practice is a key focus of healthcare improvements to reduce unwarranted variation. Dissemination of evidence-based recommendations and knowledge brokering have emerged as potential strategies to achieve evidence implementation by influencing resource allocation decisions. The aim of this study was to determine the effectiveness of these two research implementation strategies to facilitate evidence-informed healthcare management decisions for the provision of inpatient weekend allied health services. METHODS AND FINDINGS: This multicentre, single-blinded (data collection and analysis), three-group parallel cluster randomised controlled trial with concealed allocation was conducted in Australian and New Zealand hospitals between February 2018 and January 2020. Clustering and randomisation took place at the organisation level where weekend allied health staffing decisions were made (e.g., network of hospitals or single hospital). Hospital wards were nested within these decision-making structures. Three conditions were compared over a 12-month period: (1) usual practice waitlist control; (2) dissemination of written evidence-based practice recommendations; and (3) access to a webinar-based knowledge broker in addition to the recommendations. The primary outcome was the alignment of weekend allied health provision with practice recommendations at the cluster and ward levels, addressing the adoption, penetration, and fidelity to the recommendations. The secondary outcome was mean hospital length of stay at the ward level. Outcomes were collected at baseline and 12 months later. A total of 45 clusters (n = 833 wards) were randomised to either control (n = 15), recommendation (n = 16), or knowledge broker (n = 14) conditions. Four (9%) did not provide follow-up data, and no adverse events were recorded. No significant effect was found with either implementation strategy for the primary outcome at the cluster level (recommendation versus control ß 18.11 [95% CI -8,721.81 to 8,758.02] p = 0.997; knowledge broker versus control ß 1.24 [95% CI -6,992.60 to 6,995.07] p = 1.000; recommendation versus knowledge broker ß -9.12 [95% CI -3,878.39 to 3,860.16] p = 0.996) or ward level (recommendation versus control ß 0.01 [95% CI 0.74 to 0.75] p = 0.983; knowledge broker versus control ß -0.12 [95% CI -0.54 to 0.30] p = 0.581; recommendation versus knowledge broker ß -0.19 [-1.04 to 0.65] p = 0.651). There was no significant effect between strategies for the secondary outcome at ward level (recommendation versus control ß 2.19 [95% CI -1.36 to 5.74] p = 0.219; knowledge broker versus control ß -0.55 [95% CI -1.16 to 0.06] p = 0.075; recommendation versus knowledge broker ß -3.75 [95% CI -8.33 to 0.82] p = 0.102). None of the control or knowledge broker clusters transitioned to partial or full alignment with the recommendations. Three (20%) of the clusters who only received the written recommendations transitioned from nonalignment to partial alignment. Limitations include underpowering at the cluster level sample due to the grouping of multiple geographically distinct hospitals to avoid contamination. CONCLUSIONS: Owing to a lack of power at the cluster level, this trial was unable to identify a difference between the knowledge broker strategy and dissemination of recommendations compared with usual practice for the promotion of evidence-informed resource allocation to inpatient weekend allied health services. Future research is needed to determine the interactions between different implementation strategies and healthcare contexts when translating evidence into healthcare practice. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618000029291.

Implementation interventions to promote the uptake of evidence-based practices in stroke rehabilitation.

BACKGROUND: Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation. OBJECTIVES: To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies. SELECTION CRITERIA: We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention. MAIN RESULTS: Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting. We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI -1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) -0.02, 95% CI -0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI -0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI -0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention. No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction. Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions. Tailoring interventions to identified barriers did not alter results. We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence. AUTHORS' CONCLUSIONS: We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.

How do health professionals prioritize clinical areas for implementation of evidence into practice? A cross-sectional qualitative study.

AIM: The current study aimed to identify and understand the reasons why allied health professionals think certain areas of healthcare service provision are a high priority for implementation of evidence into practice. METHODS: A cross-sectional online survey using open-ended questions was conducted between April and May 2018 to identify potential areas for practice change and characterize how participants justified identified areas of priority. Eligible participants were invited by email and included allied health professionals from public or private health services, governance agencies and universities across Australia. Responses were analysed using qualitative content analysis. RESULTS: There were 149 surveys commenced with 146 respondents completing the survey. Of the 146 respondents, 128 were female, 17 male and one unknown. Most of the respondents were between 40 and 49 years old and had a master's degree. In total respondents from more than 13 different professions completed the survey with 110 respondents having more than 10 years of experience in allied health. Ten themes emerged outlining the main reasons respondents felt that their nominated areas of practice change were a high priority for action. These included closing gaps between practice and policy/recommendation/guideline; closing research evidence to practice gaps; improving access to services; perceived cost-effectiveness of service delivery; improving effectiveness of allied health services; current imbalance between service supply and demand; amount of resources involved in service delivery; extent of the health problem; areas of allied health care futility; and equality of workload across allied health professionals. CONCLUSION: The current research provides insights into the decision-making processes of allied health professionals when prioritizing areas of clinical practice for implementation of evidence into practice. Despite an appetite for evidence-based practice, behaviour change was not always implemented in a consistent and systematic manner. There was variability in the type and application of evidence used by allied health professionals to support clinical practice. Whether a more systematic approach to research translation fosters evidence uptake awaits confirmation. Also awaiting investigation are the economic and societal impacts of consistently implementing research-informed clinical decision-making.

Comparing Participation Outcome Over Time Across International Stroke Cohorts: Outcomes and Methods.

OBJECTIVE: To enable a direct comparison of participation levels in the first year post-stroke, assessed by different outcome measures internationally. DESIGN: Two prospective stroke cohort studies following persons from stroke onset to 12 months post-stroke. SETTING: Community. PARTICIPANTS: Persons with stroke (N=495), not living at a nursing home, from Australia STroke imAging pRevention and Treatment-Prediction and Prevention to Achieve optimal Recovery Endpoints after stroke (START-PrePARE; n=100) and the Netherlands (Restore4stroke; n=395). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Activity Card Sort-Australia and Utrecht Scale for Evaluation of Rehabilitation-Participation. Activity domains were matched across measures to find common denominators and original scoring methods were recoded, hereby enabling a direct comparison of retained activities. RESULTS: Ninety-one (START-PrePARE) and 218 (Restore4stroke) persons with stroke were included for analyses. No major differences in background characteristics were observed between the cohorts; the Dutch cohort suffered from slightly more severe stroke. A higher level of participation was observed (radar charts) in the first months post-stroke for the Australian cohort than in the Dutch cohort, especially for unpaid work (P<.003). At 12 months post-stroke, participation levels were similar, without significant differences in retained activities using the defined common denominators (P>.003). CONCLUSIONS: An international comparison of actual activities that persons re-engage in in the first year post-stroke was achieved using a new method and recoding of data. High levels of participation were observed in both cohorts. Unpaid work showed different frequencies at 2-3 months, contributing to different trajectories over time across cultures. Important insights were gained. Although valuable information is inevitably lost with recoding, the approach may assist future studies on the harmonization of data across cohorts, particularly for 1 of the key outcomes of stroke: participation.

Implementing a protocol for a research impact assessment of the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery.

BACKGROUND: There is growing recognition that the wider benefits of research (economic, social and health impacts) should be assessed and valued alongside traditional research performance metrics such as peer-reviewed papers. Translation of findings into policy and practice needs to accelerate and pathways to impact need to be better understood. This research protocol outlines a mixed methods study to apply the Framework to Assess the Impact from Translational health research (FAIT) to the Centre for Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke). FAIT is purpose-designed to encourage research translation and assess research impact but lacks validation. METHODS/DESIGN: Phase 1 involves application of the FAIT-modified programme logic model to each CRE-Stroke research stream including identifying process, output and impact metrics, as well as end users of the research. A scoping review will inform potential impacts anticipated from CRE-Stroke. In Phase 2, audit and feedback on achievements against plans will track and encourage research translation. Logic models will be updated to account for changes in the research pathways over time. In Phase 3, three proven methods for measuring research impact - Payback, economic assessment and narratives - will be applied to each research stream and the data triangulated and reported in Phase 4. The feasibility of applying FAIT will also be assessed as part of Phase 3. DISCUSSION: Use of prospective, comprehensive research impact frameworks for large interdisciplinary programmes of research is rare. FAIT's application to CRE-Stroke will provide opportunity for the impact of CRE-Stroke to be assessed and a range of impacts beyond standard academic achievements to be reliably reported. The feasibility of FAIT's application will also be assessed and, if necessary, refined. The usefulness of FAIT for encouraging research translation will also be described and may prove useful for other programmes looking to implement a research impact framework.

Implementation of evidence-based weekend service recommendations for allied health managers: a cluster randomised controlled trial protocol.

BACKGROUND: It is widely acknowledged that health policy and practice do not always reflect current research evidence. Whether knowledge transfer from research to practice is more successful when specific implementation approaches are used remains unclear. A model to assist engagement of allied health managers and clinicians with research implementation could involve disseminating evidence-based policy recommendations, along with the use of knowledge brokers. We developed such a model to aid decision-making for the provision of weekend allied health services. This protocol outlines the design and methods for a multi-centre cluster randomised controlled trial to evaluate the success of research implementation strategies to promote evidence-informed weekend allied health resource allocation decisions, especially in hospital managers. METHODS: This multi-centre study will be a three-group parallel cluster randomised controlled trial. Allied health managers from Australian and New Zealand hospitals will be randomised to receive either (1) an evidence-based policy recommendation document to guide weekend allied health resource allocation decisions, (2) the same policy recommendation document with support from a knowledge broker to help implement weekend allied health policy recommendations, or (3) a usual practice control group. The primary outcome will be alignment of weekend allied health service provision with policy recommendations. This will be measured by the number of allied health service events (occasions of service) occurring on weekends as a proportion of total allied health service events for the relevant hospital wards at baseline and 12-month follow-up. DISCUSSION: Evidence-based policy recommendation documents communicate key research findings in an accessible format. This comparatively low-cost research implementation strategy could be combined with using a knowledge broker to work collaboratively with decision-makers to promote knowledge transfer. The results will assist managers to make decisions on resource allocation, based on evidence. More generally, the findings will inform the development of an allied health model for translating research into practice. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) ( ACTRN12618000029291 ). Universal Trial Number (UTN): U1111-1205-2621.

Changing practice in the assessment and treatment of somatosensory loss in stroke survivors: protocol for a knowledge translation study.

BACKGROUND: The treatment of somatosensory loss in the upper limb after stroke has been historically overshadowed by therapy focused on motor recovery. A double-blind randomized controlled trial has demonstrated the effectiveness of SENSe (Study of the Effectiveness of Neurorehabilitation on Sensation) therapy to retrain somatosensory discrimination after stroke. Given the acknowledged prevalence of upper limb sensory loss after stroke and the evidence-practice gap that exists in this area, effort is required to translate the published research to clinical practice. The aim of this study is to determine whether evidence-based knowledge translation strategies change the practice of occupational therapists and physiotherapists in the assessment and treatment of sensory loss of the upper limb after stroke to improve patient outcomes. METHOD/DESIGN: A pragmatic, before-after study design involving eight (n = 8) Australian health organizations, specifically sub-acute and community rehabilitation facilities. Stroke survivors (n = 144) and occupational therapists and physiotherapists (~10 per site, ~n = 80) will be involved in the study. Stroke survivors will be provided with SENSe therapy or usual care. Occupational therapists and physiotherapists will be provided with a multi-component approach to knowledge translation including i) tailoring of the implementation intervention to site-specific barriers and enablers, ii) interactive group training workshops, iii) establishing and fostering champion therapists and iv) provision of written educational materials and online resources. Outcome measures for occupational therapists and physiotherapists will be pre- and post-implementation questionnaires and audits of medical records. The primary outcome for stroke survivors will be change in upper limb somatosensory function, measured using a standardized composite measure. DISCUSSION: This study will provide evidence and a template for knowledge translation in clinical, organizational and policy contexts in stroke rehabilitation. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) retrospective registration ACTRN12615000933550 .

Somatosensory assessment and treatment after stroke: An evidence-practice gap.

BACKGROUND/AIM: Loss of body sensations is common after stroke, impacting negatively on recovery and performance of activities of daily living. Despite advances in the evidence for the assessment and treatment of somatosensory impairment post-stroke, the translation from research into clinical practice has been slow. The aim of this study was to determine current clinical practice of occupational therapists and physiotherapists in the assessment and treatment of somatosensory impairment post-stroke. METHODS: A cross-sectional, self-administered online survey of occupational therapists and physiotherapists currently working with stroke clients in Australian health organisations, identified through an audit of stroke rehabilitation services and a professional member association. RESULTS: 172 clinicians, 62.8% occupational therapists and 37.2% physiotherapists currently working with stroke clients completed the survey. Most respondents (93.0%) indicated routinely assessing for sensory loss in stroke clients. The most commonly used measures were light touch and proprioception, with the majority (70.4%) not using standardised measures. Most respondents (97.7%) reported providing treatment to address sensory impairment, with compensatory strategies and sensory re-education the two most frequently reported. Evidence-based treatment choices were not common and therapists frequently relied on colleagues' opinions and previous experience to inform practice. Therapists commonly experienced barriers to implementing evidence-based sensory rehabilitation, including time constraints, large caseloads and lack of access to evidence-based somatosensory assessment and treatment resources. CONCLUSIONS: Most therapists perceived somatosensory assessment and treatment as important. However, frequently utilised methods lack a sound theoretical or empirical basis. Despite published evidence regarding somatosensory assessment and treatment, an evidence-practice gap exists.

Lesion segmentation from multimodal MRI using random forest following ischemic stroke.

Understanding structure-function relationships in the brain after stroke is reliant not only on the accurate anatomical delineation of the focal ischemic lesion, but also on previous infarcts, remote changes and the presence of white matter hyperintensities. The robust definition of primary stroke boundaries and secondary brain lesions will have significant impact on investigation of brain-behavior relationships and lesion volume correlations with clinical measures after stroke. Here we present an automated approach to identify chronic ischemic infarcts in addition to other white matter pathologies, that may be used to aid the development of post-stroke management strategies. Our approach uses Bayesian-Markov Random Field (MRF) classification to segment probable lesion volumes present on fluid attenuated inversion recovery (FLAIR) MRI. Thereafter, a random forest classification of the information from multimodal (T1-weighted, T2-weighted, FLAIR, and apparent diffusion coefficient (ADC)) MRI images and other context-aware features (within the probable lesion areas) was used to extract areas with high likelihood of being classified as lesions. The final segmentation of the lesion was obtained by thresholding the random forest probabilistic maps. The accuracy of the automated lesion delineation method was assessed in a total of 36 patients (24 male, 12 female, mean age: 64.57±14.23yrs) at 3months after stroke onset and compared with manually segmented lesion volumes by an expert. Accuracy assessment of the automated lesion identification method was performed using the commonly used evaluation metrics. The mean sensitivity of segmentation was measured to be 0.53±0.13 with a mean positive predictive value of 0.75±0.18. The mean lesion volume difference was observed to be 32.32%±21.643% with a high Pearson's correlation of r=0.76 (p<0.0001). The lesion overlap accuracy was measured in terms of Dice similarity coefficient with a mean of 0.60±0.12, while the contour accuracy was observed with a mean surface distance of 3.06mm±3.17mm. The results signify that our method was successful in identifying most of the lesion areas in FLAIR with a low false positive rate.

Rasch analysis of The Melbourne Assessment of Unilateral Upper Limb Function.

AIM: This study investigated the internal construct validity and dimensionality of the Melbourne Assessment of Unilateral Upper Limb Function (Melbourne Assessment), a widely-used measure of quality of upper limb movement, valid for children aged 2 years 6 months to 15 years with cerebral palsy. METHOD: Rasch analysis was used to assess of Melbourne Assessment raw scores for 163 children (94 males, 69 females; mean age 8y, SD 3y 5mo). Analysis was undertaken on the full scale comprising 37 scores and on groups of scores separated into four distinct movement subscales: range of movement, accuracy, dexterity, and fluency. Tests were conducted to evaluate overall model fit, item fit, suitability of the response options, unidimensionality, and differential item functioning (DIF) for sex, child age, and different raters. RESULTS: The results did not support the unidimensionality of the 37-score scale. The four subscales showed adequate model fit after removal of some score items, and rescaling of others. The resulting subscales showed good internal consistency and no DIF for sex or child age. INTERPRETATION: This study provides empirical support for a revised version of the Melbourne Assessment which comprises 14 tasks and 30 movement scores grouped across four separate subscales. Further testing is required to assess the responsiveness of subscales to clinically important change.

Somatosensation assessment using the NIH Toolbox.

Touch sensation is one element of sensory function. As such, somatosensation is one of the sensory domains included in the NIH Toolbox, which is an assessment battery for measuring a range of human functions including emotional health, sensation, cognition, and motor function. We evaluated a variety of methods for inclusion in the NIH Toolbox main battery. In a convenience sample of 409 participants, we evaluated aspects of kinesthesia, pain, and tactile discrimination. We present results on these measures across the lifespan and discuss implications for future studies that use the NIH Toolbox and these measures.

Pain assessment using the NIH Toolbox.

OBJECTIVE: Pain is an important component of health and function, and chronic pain can be a problem in its own right. The purpose of this report is to review the considerations surrounding pain measurement in the NIH Toolbox, as well as to describe the measurement tools that were adopted for inclusion in the NIH Toolbox assessment battery. METHODS: Instruments to measure pain in the NIH Toolbox were selected on the basis of scholarly input from a diverse group of experts, as well as review of existing instruments, which include verbal rating scales, numerical rating scales, and graphical scales. RESULTS: Brief self-report measures of pain intensity and pain interference were selected for inclusion in the core NIH Toolbox for use with adults. A 0 to 10 numerical rating scale was recommended for measuring pain intensity, and a 6-item Patient Reported Outcome Measurement Information System (PROMIS) short form for measuring pain interference. The 8-item PROMIS Pediatric Pain Interference measure was recommended as a supplemental measure. No specific measure was recommended for measuring pain intensity in children. CONCLUSIONS: Core and supplemental measures were recommended for the NIH Toolbox. Additional measures were reviewed for investigators who seek tools for measuring pain intensity in pediatric samples.

Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years.

AIM: This paper reports the second phase of a study to extend the Melbourne Assessment for use with children with neurological impairment aged 2 to 4 years. The aim was to establish if (1) children's scores on the Modified Melbourne Assessment (MMA) and the Quality of Upper Extremity Skills Test (QUEST) showed a moderate to high, positive relation, (2) children had comparable behaviours for task and time demands on both tools, and (3) scores on the MMA could discriminate between children with mild, moderate, and severe levels of upper limb impairment. METHOD: An observational study of 30 children (19 males, 11 females) with neurological impairment aged 2 to 4 years. Twenty-four children had spasticity (20 with a unilateral and four with a bilateral impairment) and two children presented with athetosis, two with ataxia, and two with hypotonia. RESULTS: A high, positive relation was found between children's scores on the MMA and the QUEST (ρ=0.90; p=0.001). The clinical use of the MMA was comparable to the QUEST. MMA scores were able to discriminate between children's levels of upper limb impairment as determined by clinicians' ratings (F(2,27) =67.76, p=0.001). INTERPRETATION: These findings suggest the MMA can be clinically useful for children as young as 2.5 years and has the advantage of being valid for use with older children. Scores from the tool can also provide therapists with a quantitative means of consistently reporting level of upper limb impairment.

Establishing validity of a modified Melbourne Assessment for children ages 2 to 4 years.

BACKGROUND: The Melbourne Assessment of Unilateral Upper Limb Function is a valid tool for measuring quality of upper-limb movement in children ages 5 to 15 with cerebral palsy. This study presents the first phase in establishing the validity of a modified version of the assessment for children ages 2 to 4. OBJECTIVE: We sought to determine whether children without neurological impairment scored within the top 5% on the modified assessment, to investigate compliance with test demands, and to investigate the relationship between the modified tool and the Quality of Upper Extremity Skills Test. METHOD: The test was modified and administered to 32 children without neurological impairment ages 2 to 4. RESULTS: All children ages 2.5 to 4 scored as expected and were compliant with test demands. CONCLUSION: The Modified Melbourne Assessment may be used with children ages 2.5 to 4 without neurological impairment. Investigation with children with neurological impairment is now indicated.