Clinical utility of Chedoke Arm and Hand Activity Inventory: An investigation of its use with adults following stroke in an acute hospital setting.

Acute stroke care is characterised by a focus on rapid, thorough assessment and early management (National Stroke Foundation, 2007) and the upper limb is a common focus for assessment by occupational therapists. Upper limb assessment practices in the acute care setting need to be applicable to a population that displays a wide range of abilities as a result of differing levels of stroke severity (Lannin, 2004). Often multiple assessment tools are utilised throughout this process due to the variation in stroke manifestations and the clients' changing needs as they recover (Woodson, 1995). Two approaches to upper limb assessment common in the acute setting are assessment at the impairment level and general assessment of the upper limb in the context of a self care assessment. However, neither of these approaches specifically measures the client’s ability to use the upper limb in a functional manner. An alternative approach is assessment of upper limb ability which is defined as the use of the arm in meaningful activity and incorporates activities of daily living. The Chedoke Arm and Hand Activity Inventory-9 (CAHAI-9) is one assessment that examines upper limb ability for clients with stroke. The CAHAI-9 demonstrates excellent reliability and validity (Rowland & Gustafsson, 2008), however there is minimal documentation of clinical utility. Clinical utility refers to how easy an assessment is to use (Law et al., 1990) and is one of the most significant influences on the actual use of an assessment in a clinical situation (Law, Baum, & Dunn, 2005). The purpose of this research was to investigate the clinical utility of the CAHAI-9 in the acute stroke setting and included a preliminary and main study. The preliminary study involved a retrospective review of the clinical application of the Action Research Arm Test (ARAT), Arm Motor Ability Test (AMAT), and Chedoke Arm and Hand Activity Inventory (CAHAI) in one acute stroke setting. Thirty-three medical records of clients admitted to a major metropolitan acute stroke unit were reviewed. Inclusion criteria were: (a) admission between March and August 2006, (b) new diagnosis of stroke, (c) upper limb involvement, and (d) assessed by an occupational therapist with ARAT, AMAT or CAHAI. The results could not identify which assessment was most suited to the acute stroke setting. Additional criteria were applied to select CAHAI-9 for further investigation in the main study. The main study incorporated a multi-centre, mixed methods design. The aim was to investigate the clinical utility of CAHAI-9 in an acute stroke setting. There were two groups of participants; occupational therapists and clients with stroke. Thirty-two occupational therapists from eight hospitals completed 100 CAHAI-9 assessments on 92 clients with stroke over 6 months. In the first phase, the occupational therapist participants completed a series of questionnaires regarding the clinical utility of CAHAI-9 and these data were summarised descriptively. In the second phase, both therapists and clients with stroke were invited to be involved in a qualitative investigation into CAHAI-9’s clinical utility. Twenty-one of the thirty-two occupational therapist participants participated in semi-structured focus groups. Five clients with acute stroke were recruited by consecutive sampling from one metropolitan hospital and participated in structured individual interviews. The focus groups and interviews were transcribed verbatim and were analysed thematically. The results of the quantitative and qualitative data were compared to identify patterns of convergence and variation in opinions regarding the clinical utility of CAHAI-9. Overall, participants reported that the CAHAI-9 could be administered in the acute care setting and the majority of CAHAI-9 assessments could be conducted by the bedside. Although the practical aspects of CAHAI-9 administration were well suited to the acute stroke setting, the participants expressed concern about the scoring reliability and the effectiveness of the training DVDs. Overall the participants found CAHAI-9 was useful for supporting clinical decision making by identifying non-motor deficits, facilitating communication and continuum of care decisions. Participants agreed that CAHAI-9 was suitable for assessment of moderate upper limb deficits, and were less sure of suitability for assessment of severe upper limb deficits. There were varying opinions within the therapists and clients regarding CAHAI-9 suitability for assessment of mild upper limb deficits. Overall, the clinical utility of CAHAI-9 appears supported by the results of this study with the majority of therapists indicating they would use CAHAI-9 again with the clients they assessed. Further studies should address therapists’ reduced scoring confidence by developing an alternative CAHAI-9 training program that meets the learning requirements of Australian therapists. Limitations of this study and future research directions are discussed