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Motricity Index

Motricity Index

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Purpose

The Motricity Index (MI) is an ordinal method of measuring limb strength developed by Demeurisse et al in 1980.

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Instrument Details

Acronym MI

Area of Assessment

Upper Extremity Function
Functional Mobility

Assessment Type

Observer

Cost

Not Free

Actual Cost

$0.00

Populations

Key Descriptions

  • In the original study, numerous arm and leg movements were analyzed in the first six months post stroke. One movement at the proximal, middle and distal joints from the arm and leg was selected to represent strength at each joint. Based on an analysis of early stroke recovery in the first 6 months post stroke, weighted scores were developed to represent the difficulty of progressing from one muscle grade to the next. Maximum total arm score is 99+ (range 0-99) and the same for the leg score. Guidelines for administering the MI were developed by Collin and Wade 1990.
  • Upper Extremity tests: shoulder abduction, elbow flexion, pinch grip

    Lower Extremity tests: hip flexion, knee extension, dorsiflexion
    (Tests administered in the sitting position)

    Scoring for all movements except grip:
    0 - No movement
    9 - Palpable contraction in muscle, but no movement
    14 - Visible movement, but not full range and not against
    gravity
    19 - Full range of movement against gravity, but not
    resistance
    25 - Full movement against gravity but weaker than the other side
    33 - Normal power

    Grip scoring
    0 - No movement
    11 - Beginnings of prehension
    19 - Able to grip cube, but not hold it against gravity examiner may need to lift the wrist)
    22 - Able to grip and hold the cube against gravity
    26 - Able to grip and hold the cube against a weak pull, but weaker
    than the other side
    33 - Normal power

Number of Items

6 items on each side (3 for the arm; 3 for the leg)

Equipment Required

  • 2.5 cm x 2.5 cm cube

Time to Administer

5 minutes

5 minutes for experienced examiners working with patients who are cognitively intact

Required Training

No Training

Age Ranges

Adults

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initial review completed by Maggie Bland, PT, DPT, NCS and Nancy Byl, PT, MPH, PhD, FAPTA and the StrokEdge Task Force of the Neurology Section of the APTA 2016.

Body Part

Upper Extremity
Lower Extremity

ICF Domain

Body Function
Body Structure

Measurement Domain

Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Stroke Taskforce (StrokEDGE 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:

 

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)

Subacute

(CVA 2 to 6 months)

Chronic

(> 6 months)

StrokEDGE

HR

HR

HR

 

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

 

Acute Care

Inpatient Rehabilita-

tion

Skilled Nursing Facility

Out

patient

Rehabilitation

Home Health

StrokEDGE

HR

HR

HR

HR

HR

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)

StrokEDGE

Yes

Yes

Yes

No

Considerations

This test is fast and easy to learn and administer, but as with other measures attempting to grade strength in the stroke population, it is only one piece of the puzzle. The ability to generate force and power in a muscle is necessary for movement, but in the presence of increased tone or without the ability to coordinate and grade the movement, full function is not restored.

 

Although test procedures are vague on patient position for testing,, the test is usually administered with the patient sitting. Shoulder abduction begins with the arm at the side and elbow flexed to 90 o.

 

The test has excellent reliability and excellent reported construct, concurrent validity particularly relative to and predictive validity correlating admission levels of limb strength and recovery of upper limb function and walking ability.

 

(Gor-Garcia-Fogeda et al,2014) In this systematic review of 2b level studies, six measurement scales for gross motor function were included: (Motor Assessment Scale, Fugl-Meyes Assessment,, Sodring Motor Evaluation for Stroke Patients, Stroke Rehabilitation Assessment of Movement, Motricity Index and Rivermead Motor Assessment. All six scales ( including the MI) were found to be useful for clinical research and clinical practice, but the scales for which the most psychometric properties have been established in clinical trials were the Fugl Meyer Assessment (FMA) and the Stroke Rehabilitation Assessment of Movement (STREAM)

 

(Geroin et al, 2013) performed a systematic review of outcome measures used following motor training using electromechanical and robotic devices in patients post stroke. A total of 45 scales were identified from 27 studies involving 966 subjects. The most commonly used outcome measures were: Functional Ambulation Category (18 studies) , 10- Meter Walking Test (13 studies), Motricity Index (12 studies), 6- Minute Walking Test (11 studies), Rivermead Mobility Index (8 studies) and the Berg Balance Scale (8 studies). All of the outcome measures belonged to the activity domain of the ICF except the MI which was classified as a measurement of body function and structure. No scales belonged to the participation category. For the MI, Inter-rater reliability and Construct validity were excellent.

Stroke

back to Populations

Standard Error of Measurement (SEM)

Chronic Stroke: (Fayazi, Dehkord, Dadgoo, & Salehi, 2012; n = 20; age range = 37 to 76; time post stroke range = 3 months to 4 years; male = 10; female = 10)

  • SEM for entire group (n = 20): 4.66

Minimal Detectable Change (MDC)

Chronic Stroke: calculated using SEM from (Fayazi et al., 2012)

  • MDC: 12.92

Minimally Clinically Important Difference (MCID)

MCID is not reported in the literature.

Cut-Off Scores

Upper Extremity Hemiparesis: (Sunderland, Tinson, Bradley, & Hewer, 1989; n = 38; age range = 31 to 82; average age = 67; left arm affected, n = 21; right arm affected = 17; MCA stroke, n = 36; brainstem stroke, n = 2)

  • 1 month cut-off scores > 18 indicates a score above zero on Frenchay Arm Test at 6 months, measuring functional use of affected limb

Normative Data

Acute/Chronic Stroke: (Demeurisse, Demol, & Robaye, 1980; n = 100; measured at 11 days, 2, 4 and 6 months post stroke; mean age (total) = 69, 59 men, mean age = 67; 41 women, mean age = 71; left side hemiplegia = 36, right side hemiplegia = 64)

*Authors do not report the normative data, but the measure and subsequent norms were developed using this population

Subacute/Chronic Stroke: (Collin & Wade, 1990; n = 36; weeks post stroke = 6 (27 weeks), 12 (25 weeks); 18 (14 weeks); age range (male) = 15 to 77; mean age (male) = 56.1; age range (female) = 45-69; mean age (female) = 59.9; right side hemiplegia = 21)

  • Observer 1 upper extremity (SD): 30 (36)

  • Observer 2 upper extremity (SD): 31 (39)

 

Mean

Standard Deviation

Observer 1

30

36

Observer 2

31

39

Acute/Subacute Stroke: (Bohannon, 1999; n = 15; age range = 46 to 81; mean age = 66.7; within 15 days of onset; no comorbidities affecting upper extremity)

  • Pinch-grasp mean, median, range score: 15.2; 20.5; 0-33.0

  • Elbow flexion mean, median, range score: 19.7; 25.0; 0-33.0

  • Shoulder abduction mean, median, range score: 18.7; 22.0; 0-33.0

  • Total motricity mean, median, range score: 54.6; 70.5; 1-100.0

Motricity Index Subscale

Mean (95% CI)

Median

Range

 

Pinch-Grasp

15.2 (5.5-24.9)

20.5

0-33.0

Elbow Flexion

19.7 (10.3-29.1)

25.0

0-33.0

 

Shoulder Abduction

18.7 (10.6-26.8)

22.0

0-33.0

Total Motricity

54.6 (28.2-81.0)

70.5

1-100.0

 

Acute/Chronic Stroke: (Hsieh et al., 1998; n = 50; mean age = 65; male = 30; female = 20; median, range days post onset = 55 (8-535); subarachnoid hemorrhage = 7; cerebral hemorrhage = 13; cerebral infarction = 21; other = 9; right-sided paresis = 22; left-sided paresis = 23; bilateral paresis = 5)

  • Mean score for total upper extremity motricity: 46.2 (31.9)

Subacute/Chronic Stroke: (Jacob-Lloyd, Dunn, Brain, & Lamb, 2005; upper extremity n = 22; age > 60 years, n = 85%(of total study n = 55); assessed average of 76 days post onset and 6 months + 76 days (average) post onset)

  • Discharge (average 76 days post onset) median: 77

  • Discharge (average 76 days post onset) IQR: 77-84

  • 6 month post discharge median: 100

  • 6 month post discharge IQR: 77-100

Time Post Onset

Median

IQR

Discharge (76 day average)

77

77-84

 

6 months post discharge

100

77-100

 

 

Lower Extremity:

 

Subacute/Chronic Stroke: (Collin & Wade, 1990)

  • Observer 1 lower extremity (SD): 52 (20)

  • Observer 2 lower extremity (SD): 55 (22)

 

Median

Standard Deviation

Observer 1

52

20

Observer 2

55

22

Subacute/Chronic Stroke: (Jacob-Lloyd et al., 2005)

  • Discharge (average 76 days post onset) median: 76

  • Discharge (average 76 days post onset) IQR: 52-94

  • 6 month post discharge median: 76

  • 6 month post discharge IQR: 48-100

Time post onset

Median

IQR

Discharge (76 day average)

76

52-94

 

6 months post discharge

76

48-100

Subacute Stroke: (Cameron & Bohannon, 1999; n = 15; age range = 29 to 77; mean age = 53.7; male = 11; female = 4; left-sided hemiparesis = 8; right-sided hemiparesis = 7)

  • Hip flexion mean: 20.3

  • Hip flexion standard deviation: 6.5

  • Hip flexion range: 9-33

  • Knee extension mean: 21.2

  • Knee extension standard deviation: 7.7

  • Knee extension range: 0-33

  • Ankle dorsiflexion mean: 11.7

  • Ankle dorsiflexion standard deviation: 10.6

  • Ankle dorsiflexion range: 0-33

  • All mean: 54.3

  • All standard deviation: 20.9

  • All range: 10-100

Motricity Index Subscale

Mean

Standard deviation

Range

Hip flexion

20.3

6.5

9-33

Knee extension

21.2

7.7

0-33

Ankle dorsiflexion

11.7

10.6

0-33

All

54.3

20.9

10-100

Chronic: (Fayazi et al., 2012)

  • Mean score at week 1 (SD): 58.20 (17.683)

  • Mean score at week 2 (SD): 56.60 (19.632)

 

Week 1

Week 2

Mean score (SD)

58.20 (17.683)

56.60 (19.632)

Test/Retest Reliability

Chronic Stroke: (Fayazi et al., 2012)

  • Excellent test-retest reliability: (ICC = .93)

Interrater/Intrarater Reliability

Subacute/Chronic Stroke: (Collin & Wade, 1990)

  • Excellent interrater reliability: MI arm (Spearman’s rho = .88, p < 0.001)

  • Excellent interrater reliability: MI leg (Spearman’s rho = .87, p < 0.001)

  • Excellent interrater reliability: MI side (Spearman’s rho = .88, p < 0.001)

Chronic Stroke: (Fayazi et al., 2012)

  • Excellent intra-rater reliability (ICC = 0.93, 95% CI = 0.84-0.97, p < 0.001)

Internal Consistency

Normative Sample: (Haley et al., 1992; n = 412)

  • Excellent: Cronbach's alpha = .95-.99*

*Scores > .9 may indicate redundancy in scale questions.

Acute Stroke: (Cameron & Bohannon, 2000; n = 15)

  • Adequate: Cronbach α of lower extremity = .77

  • Upper extremity = unknown

Criterion Validity (Predictive/Concurrent)

Predictive validity

Subacute/Chronic Stroke: (Collin and Wade, 1990)

  • Excellent predictive validity of MI score at 6 weeks and walking ability at 18 weeks

Upper Extremity Hemiparesis: (Sunderland et al., 1989)

  • Cut off scores on Motricity Index at 1 month were best predictor of functional outcomes at 6 months when compared with percentage grip, the Motor Club Assessment, Frenchay Arm Test, and the 9-Hole Peg Test (Sunderland et al., 1989)

 

Subacute/Chronic Stroke: (Collin & Wade, 1980)

  • At 6 weeks post stroke, lower scores on the MI-Leg combined with the Trunk Control Test predicted failure to walk by 18 weeks.

One Year or More Post Stroke: (Kong et al., 2011; n = 140; mean age = 61.0 (13.3); male, n = 88; UE MI mean = 21.0 (25.9); LE MI mean = 29.8 (27.2); Modified Barthel Index mean = 42.8 (26.3); Dysphasia, n = 37; Neglect, n = 32; Sensory impairment, n = 80)

  • Only 28.3% gained upper limb dexterity post stroke

  • Sensory impairment, severe spasticity and low scores on MAS, UEMI and LEMI were significantly correlated to poor dexterous function

  • Severe spasticity was correlated with low UEMI score and poor dexterity

  • Poor dexterous function was predicted by a severe stroke, neglect, sensory impairment, total/partial anterior circulation stroke and low MBI, UEMI and LEMI scores on rehabilitation admission

  • The most important predictor of dexterity was the UEMI score on admission to rehabilitation

  • The ability to do a pin grip at admission to acute rehabilitation was a predictor of recovering UE dexterity ( e.g. the probability of regaining dexterity was 3.4% in patients with absent pinch group but 80% in those with MI scores of 22 or higher)

Factors correlating MI scores to Upper Limb Dexterity

Variable

Upper Limb

Dexterity

Yes No

P Value

Upper Extremity MI score (Rehab)

 

Lower Extremity

MI score (Rehab)

48.7

(20.7)

11.2

(19.1)

 

 

55.0

(17.6)

19.8

(23.7)

 

 

 

<0.001

 

 

<0.001

Stroke: (Bland et al., 2012; two samples of patients in an inpatient rehabilitation facility unit (n = 110 and 159; mean age 62 (14) and 63 (15), respectively)

  • Admission Lower extremity MI was 65 (26) and 59 (30), respectively in patients subacute post stroke

  • Adequate correlation between Lower Extremity MI at admission and speed of 10-meter walk speed at discharge (r = 0.47)

  • The lower extremity MI did not explain a significant amount of the variance in walking speed at discharge nor differentiate household versus community.

Ischemic or Hemorrhagic Stroke: (Aufman et al., 2013; n = 198; mean age of nondrivers = 64.1 (± 14.0); mean age of nonreturners = 59.9 (±13); mean age of returners = 61.5 (± 13.7))

  • LEMI and FIM-C explained 30% of the variance in patients who returned to driving at six months post-stroke.

Acute Stroke: (Cameron & Bohannon, 2000)

  • Excellent predictive validity of dynamometer measurements and MI arm scores (r = 0.78)

  • Excellent predictive validity of dynamometer measurements and MI leg scores (r = 0.91)

 

Concurrent validity

Stroke: (Arwert et al, 2016; n = 51; average time since stroke = 8 months (3-27 months); female, n = 16)

  • Excellent concurrent validity between the MHQ and the Arm MI for all patients (r = 0.78)

  • Average concurrent validity between the MHQ and the Arm MI for patients with less than 100 on the Arm MI (r = 0.65)

  • Average to Excellent concurrent validity between Arm MI and functional subscales of the MHQ

Subscales of the MHQ

MI correlation

Overall Hand Function

0.80

ADL

0.67

Pain

0.43

Work Performance

0.59

Aesthetics

0.67

Satisfaction

0.72

MHQ Total

0.78

Upper Extremity: (Sunderland et al., 1989)

  • When comparing the 9 Hole Peg Test, Motor Club Impairment, Frenchay Arm Test and MI Arm Score, the MI Arm test was the most sensitive measure in detecting early change

Stroke: (Bohannon, 1999)

  • Excellent concurrent validity between dynamometry measurements of the upper extremity and the MI Arm Score (r = 0.89; p<0.001)

Acute Stroke: (Cameron & Bohannon , 2000), (Bohannon, 1999), (Sunderland et al., 1989)

  • Excellent concurrent validity between dynamometry measurements and Leg MI

    • Hip Flexion (r = .85)

    • Knee Extension (r = .83)

    • Ankle Dorsiflexion (r = .89)

    • All (r = .78)

  • Excellent concurrent validity between dynamometry measurements and Arm MI

    • MI Pinch Grasp and Dynamometry Hand Grasp (r = .81)

    • Elbow Flexion (r = .87)

    • Shoulder Abduction (r = .80)

    • All (r = 0.91)

Subacute/Chronic Stroke: (Collin & Wade, 1990)

  • Excellent concurrent validity between the Rivermead Motor Assessment and the MI

Time

RMA/MI-arm

RMA/MI-leg

6 weeks

0.76*

0.81*

12 weeks

0.73*

0.81*

18 weeks

0.74**

0.75**

* p < 0.001; ** p < 0.01

Post Stroke Hemiplegia: (Lu et al., 2015; n = 22; mean age = 54.8 (8.5); male, n = 18; able to walk independently; mean Leg MI score = 70.4 (21.5); Chinese sample)

  • Adequate concurrent validity of the Wisconsin Gait Scale (WGS) with the MI (r = -0.687; p < 0.01)

  • Excellent concurrent validity of the Gait Abnormality Rating Scale (GARS) with the MI (r = -0.742; p < 0.01)

Within 6 Months Post Stroke: (Meyer et al., 2015; n = 122; males, n = 77; mean post stroke time = 82 days; average age = 67 (58.8-76.1; Belgian sample)

  • Upper limb somatosensory impairments were common, with prevalence rates 21%- 54%

  • Poor to Adequate concurrent validity between somatosensory deficits and MI scores for the UE (r =  -0.56 to 0.35)

  • Poor to Adequate concurrent validity between somatosensory and motor deficits (r = 0.22-0.61)

  • There were consistently stronger correlations between motor and somatosensory deficits in patients with visuospatial neglect ( r = 0.44-0.78) compared to patients without neglect (r = 0.08-0.59)

  • The MI median (interquartile range) was 67.5 for patients overall and 23 (0-83) for those with Neglect and 76 for patients without neglect (p < 0.02)

Somatosensation

Association with MI

Exteroceptive

Em-NSA light touch

Em-NSA pressure

Em NSA pinprick

PTT light touch

Proprioceptive

Em-NSA movement sense

TFT position sense

Higher Cortical

Em-NSA sharp/dull

NSA stereognosis

Two point discrimination

 

0.318

0.337

0.348

-0.564

 

0.394

-0.354

 

0.220

0.535

-0.316

Em-NSA = Erasmus MC modification of the revised Nottingham Sensory Assessment; TFT = Thumb Finding Test; Statistically significant adequate correlations

Ischemic or Hemmorhagic Stroke: (Bertrand et al., 2015; n = 34)

Participants were recruited from an acute neurology ward after their first stroke, and were administered the MI Arm, Chedoke Arm and Hand Activity Inventory (CAHAI), and the ABILHAND questionnaire.

  • Excellent concurrent validity between the MI Arm and the CAHAI at weeks 2, 4, 8, and 12 (r = 0.87-0.94)

  • Excellent concurrent validity between the MI Arm at weeks 1, 2, 4, 8, and 12 and the ABILHAND at week 12 (r = 0.69-0.82)

Construct Validity

Subacute/Chronic Stroke: (Collin & Wade ,1990)

  • Excellent convergent validity of the MI arm score and the MI leg score with the Rivermead Motor Assessment

Weeks Post Stroke

RMA Arm vs MI Arm

RMA Leg vs MI Leg

6 (n = 27)

0.76**

0.81**

12 (n = 25)

0.73**

0.81**

18 (n = 14)

0.74*

0.75*

**p < 0.001; *p < 0.01; RMA = Rivermead Motor Assessment; MI = Motricity Index

Content Validity

When the Motricity Index was initially developed, Demeurisse et al. (1980, p. 388) applied a Hotelling’s analysis and determined that, “because of the nearness of these coefficients, the sum of the values of the six items in question is a good measurement of analytical motricity.”

Content validity was not discussed in the literature. The Motricity Index, however, is often used when examining validity, reliability and responsiveness of other rehab measures (Wade, 1988; Benaim et al., 1999; Bertrand et al., 2015)

Floor/Ceiling Effects

Upper Extremity:

  • Adequate ceiling effects: 100% of participants scored above midpoint; 18% gained maximum score (Jacob-Lloyd et al., 2005)

  • A comparison of grip strength among the Frenchay Arm Test, the Motor Club, the 9-Hole Peg Test and the MI revealed floor effects on admission for the Frenchay and Peg Test, yet the MI demonstrated 57% of patients had measurable pinch grip within first 3 weeks of stroke; only 2% had normal pinch grip (Sunderland et al., 1989).

  • When all patients were examined 0% showed a floor effect and 28% showed a ceiling effect with respect to the MI Arm.

  • In the subgroup with MI Arm score <100, 0% of patients had a floor or ceiling effect (Arwert et al., 2016)

 

Lower Extremity:

  • Poor ceiling effects: 76% of participants scored at or above midpoint; 24% gained maximum score (Jacob-Lloyd et al., 2005)

Responsiveness

Upper Extremity:

  • Large responsiveness (ES = 0.91, Z = 5.45, p < 0.001) to detecting changes < 3 months after stroke. Measurements were done within the first 72h of admission and on the last day of hospital stay (Safaz et al., 2009).

  • Increase observed for MI tests administered 6 weeks apart, but no statistical measure noted (Collin & Wade, 1990)

  • Moderate sensitivity to detecting change < 3 months after stroke (Effect Size = .70) (Sunderland et al., 1989; n = 31; assessed at initial-1 month; 1-3 months)

  • Small sensitivity to detecting change > 3 months after stroke (Effect size = .29) (Sunderland et al., 1989; n = 31; assessed at 3-6 months)

 

Lower Extremity:

  • Small sensitivity to detecting change in the acute phase. Mean number of days between tests = 9.6 days (effect size = .30; SRM = 1.0) (Vos-Vromans et al., 2005).

Bibliography

Arwert HJ, Keizer S, Kromme CH, Vliet Vlieland TP, Meesters JJ. (2016) Validity of the Michigan Hand Outcomes Questionnaire in Patients With Stroke. Archives of physical medicine and rehabilitation. 97(2):238-44.

Aufman, EL, Bland, MD, Barco, PP, Carr, DB, Lang CE. (2013) Predictors of return to driving after stroke. Am J Phys Med Rehabil 92(3): 1-8. .

Bertrand AM, Fournier K, Wick Brasey MG, Kaiser ML, Frischknecht R, Diserens K. (2015) Reliability of maximal grip strength measurements and grip strength recovery following a stroke. JHT 28(4):356-62. .

Bland MD, Sturmoski A, Whitson M, Connor LT, Fucetola R, Huskey T, et al. (2012) Prediction of discharge walking ability from initial assessment in a stroke inpatient rehabilitation facility population. Archives of physical medicine and rehabilitation. 93(8):1441-7. .

Bohannon R (1999) Motricity index scores are valid indicators of paretic upper extremity strength following stroke. J Phys Ther Sci. 11:59-61.

Cameron D, Bohannon R. (2000) Criterion validity of lower extremity Motricity Index scores. Clin Rehabil. 14:208.

Collin C, Wade D. (1990) Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg, Paych 53:576-579

Demeurisse G, Dermol O, Robaye E (1980) Motor evaluation in vascular hemiplegia. European Neurology. 19(6): 381-389

Fayazi M, Dehkordi SN, Dadgoo M, Salehi M. Test-retest reliability of Motricity Index strength assessments for lower extremity in post stroke hemiparesis. (2012) Medical journal of the Islamic Republic of Iran. 26(1):27-30. .

Geroin C, Mazzoleni S, Smania N, Gandolfi M, Bonaiuti D, Gasperini G, et al. (2013) Systematic review of outcome measures of walking training using electromechanical and robotic devices in patients with stroke. Journal of rehabilitation medicine. 45(10):987-96. .

Gor-Garcia-Fogeda MD, Molina-Rueda F, Cuesta-Gomez A, Carratala-Tejada M, Alguacil-Diego IM, Miangolarra-Page JC. (2014) Scales to assess gross motor function in stroke patients: a systematic review. Arch of Phys Med & Rehab. 95(6):1174-83. .

Kong KH, Chua KS, Lee J. (2011) Recovery of upper limb dexterity in patients more than 1 year after stroke: Frequency, clinical correlates and predictors. NeuroRehabilitation. 28(2):105-11. .

Lu X, Hu N, Deng S, Li J, Qi S, Bi S. (2015) The reliability, validity and correlation of two observational gait scales assessed by video tape for Chinese subjects with hemiplegia. Journal of physical therapy science. 27(12):3717-21. .

Meyer S, De Bruyn N, Lafosse C, Van Dijk M, Michielsen M, Thijs L, et al. (2015) Somatosensory Impairments in the Upper Limb Poststroke: Distribution and Association With Motor Function and Visuospatial Neglect. Neurorehabilitation and neural repair. 1-12. .

Sunderland A, Trinson D, Bradley L, Hewer R (1989) Arm function after stroke: an evaluation of grip strength as a measure of recovery and a prognostic indicator. J of Neurol, Neurosurg &Psych. 52: 1267-1272. .

Vos-Vromans et al (2005) Responsiveness of the ten meter walking test and other measures in patients with hemiparesis in the acute phase. Phys Ther Prac. 21:173 (abstract only)