Intra and inter-raters reliabilities of a stepped clinical assessment of chronic spastic paresis in adults
Dr Marjolaine BAUDEa, Dr Catherine-Marie LOCHEa, Dr Caroline GAULT-COLASa, Ms Maud PRADINESa, Prof Jean-Michel GRACIESa
a CHU Henri Mondor
Objective. To determine intra and inter-raters reliabilities of a stepped clinical assessment in chronic spastic paresis for upper and lower limbs in adults.
Methods. Eighteen adult subjects (age 50±14 years, women 21%) with upper and lower limbs chronic hemiparesis were evaluated by four raters (3 PMR, 1 physiotherapist, age 47±11 years; experience in spastic paresis 14±9 years). This assessment involves performing a passive muscle stretch at 2 velocities, very slow and very fast, followed by an active maximal movement by the patient against the tested muscle and then a 15 seconds series of active movements of maximal amplitude of which only the last one is measured. Eight muscles were tested: shoulder extensors, elbow flexors, wrist flexors, fingers flexors, gluteus maximus, rectus femoris, soleus and gastrocnemii. Five parameters were collected: maximal range of passive motion XV1, angle of catch XV3, spasticity grade Y, maximal range of active motion XA, and residual range of motion XA15 after 15 seconds of rapid alternating movements. Each patient was evaluated on two occasions by each rater one week apart. After the first 9 patients, a 2-hour training was organized before assessing the last 9 patients. Main outcome measures were intra-class correlation coefficient (ICC) and its 95% confidence interval (CI 95%) for quantitative data and agreement frequencies for ranges of movement (ordinal data).
Results. Before training, intra and inter-reliabilities were excellent: intra-rater ICCs by parameter all muscles taken together: XV1 0,90[0,60-0,98], XV3 0,84[0,45-0,96], XA 0,92[0,68-0,98], XA15 0,90[0,68-0,98] and inter-raters ICCs, XV1 0,90[0,72-0,97], XV3 0,83[0,56-0,95], XA 0,95[0,87-0,99], XA15 0,95[0,86-0,98]. After training, both reliabilities improved: intra-rater ICCs, XV1 0,91[0,65-0,98], XV3 0,92[0,66-0,98], XA 0,94[0,67-0,99], XA15 0,93[0,64-0,99] and inter-raters ICCs, XV10,91[0,74-0,98], XV3 0,91[0,75-0,97], XA 0,94[0,85-0,99], XA15 0,96[0,87-0,99] (p<0,05). Training also improved intra and inter-raters agreement frequencies for ranges of movement (Y): respectively 75% and 70% before training, 84% and 76% after training (p<0,05).
Discussion. The stepped clinical assessment shows an excellent reliability to evaluate resistance against movement in chronic spastic paresis in the upper and lower limbs of adults. Training, associated with further improvement in reliability, needed nevertheless to be strenghtened for shoulder extensors, fingers flexors and rectus femoris.
Keywords : spastic paresis, spasticity, reliability, clinical assessment, rehabilitation