(Test d'Evaluation de la performance des Membres Supérieurs des Personnes. Ãgées) in patients ... are challenged to select measurement tools that are most ...
Clinical Rehabilitation 2002; 16: 166–173
Validity of the TEMPA for the measurement of upper limb function in multiple sclerosis P Feys National Multiple Sclerosis Centre, Melsbroek and Katholieke Universiteit Leuven, Faculty of Physical Education and Physiotherapy, Kinesiology Department M Duportail, D Kos, P Van Asch and P Ketelaer National Multiple Sclerosis Centre, Melsbroek, Belgium Received 3rd July 2000; returned for revisions 22nd August 2000; revised manuscript accepted 9th November 2000.
Objective: To investigate concurrent and construct validity of the TEMPA (Test d’Evaluation de la performance des Membres Supérieurs des Personnes Âgées) in patients with upper limb dysfunction due to multiple sclerosis. Subjects: Forty-three patients with upper limb dysfunction due to multiple sclerosis. Design: Patients performed upper limb tests and were assessed on measures of functional independence. Setting: National Multiple Sclerosis Centre, Melsbroek, Belgium. Main outcome measures: TEMPA, Jebsen Handfunction Test, Nine Hole Peg Test, Functional Independence Measure (FIM) and activities of daily living (ADL) self-questionnaire. Results: The correlation between TEMPA and Jebsen Handfunction and the Nine Hole Peg test respectively is good (0.56–0.87) and high (0.79–0.9). The correlation between TEMPA and the FIM and ADL self-questionnaire was moderate (0.44–0.61) although mostly higher than the correlation between the Jebsen Handfunction and the Nine Hole Peg test respectively and the measures of functionality (0.22–0.55/0.1–0.47). Conclusions: This study provides data supporting the concurrent validity of the TEMPA with the Jebsen Handfunction and the Nine Hole Peg Test in patients with multiple sclerosis. The results suggest construct validity of the TEMPA for the measurement of functionality during activities of daily life in patients with upper limb dysfunction due to multiple sclerosis.
Introduction U pper extremity function plays an important role in the maintenance of functional independence.1,2 U ntil now, there has been no uniform and stanAddress for correspondence: Peter Feys, Katholieke Universiteit Leuven, Faculty of Physical Education and Physiotherapy (FLOK), Tervuursevest 101, 3001 Heverlee, Belgium. e-mail: Peter.Feys@ok.kuleuven.ac.be © Arnold 2002
dardized use of disability scales for the upper limb in neurorehabilitation centres.3,4 Clinicians are challenged to select measurement tools that are most appropriate for their patient population, setting and objectives.5 E xisting measures rather than new ones should be used as far as possible but prior to the selection of an instrument, clinicians need to identify what the outcome measure is supposed to measure.5,6 The occupational therapy department of the 10.1191/0269215502cr471oa
TEMPA in MS National Multiple Sclerosis Centre (B) wanted to describe the functional status of patients with multiple sclerosis (MS) at a given moment in the course of their chronic progressive disease. The execution of a daily task can be accomplished in many different ways and a person can learn to compensate for a de cit in one upper limb by using the other less affected one. The clinical utility of the TEMPA (Test d’Evaluation de la performance des Membres Supérieurs des Personnes  gées) was evaluated to be higher than other tests such as the Jebsen Handfunction Test, Action Research Arm Test, the Nine Hole Peg Test and Rivermead Motor Assessment (arm section) because the tasks are activities of daily life with the inclusion of bilateral tasks and use of a variety of real objects, the outcome parameters are both quantitative (speed of execution) and qualitative (functional rating and task analysis) and a standardized equipment and measurement manual are available.2,5,7 The TEMPA was developed by Desrosiers in 1993.1 Reliability and validity have been shown in elderly and normative data are available for them.1,2,8 The validity of the TEMPA in the elderly cannot necessarily be extrapolated to other groups such as patients with a central nervous system dysfunction.5,9 The objective of this study was to investigate the validity of the TEMPA as a measure of the upper extremity performance in patients with upper limb dysfunction due to multiple sclerosis. Concurrent and construct validity was evaluated.
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Methodology
testing were excluded in order to minimize daily variations of motor performance during the test period. Concurrent validity was evaluated by correlating the performance scores on the TEMPA with the Jebsen Handfunction and the Nine Hole Peg Test, accepted as indicators of a similar concept.5,9 The Nine Hole Peg Test was performed rst, because it was the shortest test, causing the least amount of fatigue. The TEMPA and Jebsen Handfunction Test were performed in random order during separate standardized test sessions (i.e. hour, other therapies before) within a one week time interval as MS patients may suffer greatly from fatigue. Administration time was additionally measured. The opinion of the patient about the TEMPA and Jebsen Handfunction Test was addressed with questions such as ‘Is this test representative of what you are able to do at home?’ and ‘Are you fatigued when performing the test?’. Outcome measure was the visual analogue scale ranging from ‘not at all’ to ‘fully’. The construct validity is the extent to which an instrument measures the intended theoretical construct.5 The TEMPA is designed to assess upper extremity function and should theoretically relate to measures of a patient’s ability to complete activities of daily life. The hypothesis is that the higher the degree of upper extremity performance, the higher the level of independence in activities of daily living. The relationship between the upper limb tests and measures of functionality was investigated. Patients were rated on the self-care items of the FIM 13 and completed Brown’s ADL self-questionnaire.14,15
Subjects and methods The study was performed at the ambulatory rehabilitation unit of the National Multiple Sclerosis Centre, Belgium. MS patients with upper limb dysfunction due to muscle weakness or intention tremor were selected for the trials. Upper limb paresis was assessed using the Motricity Index.10,11 Intention tremor in the upper limb was assessed during the nger-to-nose test scored according to Fahn’s Tremor Rating Scale.12 Patients with cognitive impairment (Mini-Mental State score below 23) or an exacerbation of their MS over the last month prior to
Description of outcome measures The TEMPA is composed of nine standardized tasks which simulate activities of daily life. Four items are unilateral (pick up and move a jar; pick up a pitcher and pour water into a glass; handle coins; pick up and move small objects) and ve bilateral (open a jar and take a spoonful of coffee; unlock a lock and open a pill container; write on an envelope and stick on a stamp; shuf e and deal playing cards; put a scarf around one’s neck). The outcome parameters used in this study are speed of execution (seconds) and the functional rating. The functional rating corresponds
168 P Feys et al. to the subject’s independence in performing each task and is measured using a 4-level scale: 0, the task is successfully completed without hesitation or dif culty; –1, some dif culty with the task; –2, great dif culty in completing the entire task and –3 the individual could not complete the task, even when assistance was offered.8 Summary scores for both outcome measures are obtained by adding the scores assigned to each task: one summary score for unilateral left-sided tasks, one for unilateral right-sided tasks, one for unilateral left-sided and bilateral tasks, one for unilateral right-sided and bilateral tasks, one for bilateral tasks and one combined total score for all tasks. 2 The Jebsen Handfunction Test (JHFT) consists of seven test items which simulate activities of daily life and measures speed of execution.16 The Nine Hole Peg Test (NHPT) is a functional performance test addressing hand dexterity. The time needed to place nine pegs is measured.17 The Functional Independence Measure (FIM) addresses the functionality of the patient. For the purpose of the study, upper limb-related items only (eating, grooming, washing and dressing upper limbs) were selected of the motor part as these items seemed to be more dependent on upper extremity performance. The activities of daily life self-questionnaire (ADL-SQ) addresses patient’s perceived disability. The questionnaire was developed by Brown in 1989 in Parkinson’s patients and has recently been applied on MS patients.15 The patient is asked to rate his performance during 25 activities of daily life on a four-point rating scale describing accurately how easy or dif cult it is to perform the activity (appendix). Data analysis Range (minimum/maximum), median or mean and standard deviation (SD) of the upper limb tests and measures of functionality were calculated to describe the performance of the sample. Subjects who were unable to perform a test item of the speeded upper limb tests were excluded for the calculation of descriptive statistics. These subjects were given a maximal time limit score for that test item which was used for the correlation analysis. Data analysis comparing the relationship between the different outcome measures was performed with Spearman rank correlation
coef cient. All analyses were conducted using the SAS statistical software. Results Forty-three MS patients gave an informed consent and participated in the trials. The mean age was 46 (SD 11) and mean number of years after the onset of the disease was 15 (SD 9.4). Median EDSS (Expanded Disability Status Scale) was seven and median Mini-Mental State score was 27.18 All but two reported dominance of the right hand. Sample characteristics on the nger-to-nose test and the Motricity Index and the performance of the subjects on the upper limb tests and measures of functionality are presented in Table 1. Twenty-two subjects showed paresis and 21 intention tremor in the upper limbs. Not all subjects could perform each test item of the speeded upper limb tests (TEMPA speed of execution, Jebsen Handfunction and the Nine Hole Peg Test). These subjects were excluded for the calculation of the descriptive statistics. The distribution of the subjects on the Jebsen Handfunction Test and the TEMPA functional rating is shown in Figure 1. The relationships between the different upper limb tests and the measures for functionality are presented in Table 2. The correlation between speed of execution and the functional rating of the TEMPA is 0.75. The correlations between the TEMPA speed of execution and JHFT are high (0.72–0.87) for both arms. The correlations between TEMPA functional rating and the JHFT are high for the left arm (0.73) and moderate for the right arm (0.56–0.61). The correlation between both outcome parameters of the TEMPA and the NHPT are high (0.79–0.9) for both arms. Subject’s opinion concerning the representativeness of the TEMPA and JHFT respectively was 7.3 (SD 1.7) and 5.4 (SD 1.6), which is signi cantly different (ANOVA, paired t-test). Mean answer concerning fatigue during the TEMPA and JHFT respectively was 3.6 (SD 2.8) and 3.5 (SD 2.7). Mean administration time for TEMPA and JHFT respectively was 43.2 (SD 10.6) and 13.5 (SD 5.6) minutes which difference is statistically signi cant (ANOVA, paired t-test).
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Table 1 Performance of the subjects on the Motricity Index and nger-to-nose test, upper limb tests (TEMPA, Jebsen Handfunction and Nine Hole Peg Test) and measures of functionality (FIM and ADL self-questionnaire) N
Min/max
Motricity Index Subgroup ‘paresis’ – left arm Subgroup ‘paresis’ – right arm Subgroup ‘tremor’ – left arm Subgroup ‘tremor’ – right arm
22 22 21 21
0/100 36/100 62/100 54/100
Finger-to-nose test Subgroup ‘paresis’ – left arm Subgroup ‘paresis’ – right arm Subgroup ‘tremor’ – left arm Subgroup ‘tremor’ – right arm
22 22 21 21
TEMPA – functional rating Total score Bilateral tasks Unilateral tasks left arm Unilateral left and bilateral tasks Unilateral tasks right arm Unilateral right and bilateral tasks
43 43 43 43 43 43
–36/–6 –14/–2 –12/0 –26/–2 –12/0 –25/–4
–17 –6 –5 –12 –4 –11
TEMPA – speed of execution (s) Total score Bilateral tasks Unilateral tasks left arm Unilateral left and bilateral tasks Unilateral tasks right arm Unilateral right and bilateral tasks
24 38 31 27 32 28
213/939 113/598 36 167/666 45/359 159/726
435 258 101 335 106 304
Jebsen Handfunction Test (s) Left arm Right arm
34 36
85/418 90/681
221 (104) 298 (169)
Nine Hole Peg Test (s) Left arm Right arm
33 34
17/196 17/207
77 (52) 69 (53)
FIM
43
11/26
19
ADL self-questionnaire
43
32/88
57
Moderate correlations were found between the total summary scores for both outcome parameters of the TEMPA, the left-sided scores on JHFT and NHPT respectively and the FIM. Poor correlations were found between the FIM and the right-sided scores on JHFT and NHPT. Moderate correlations were found between the ADLSQ and both outcome parameters of the TEMPA, which were higher than correlations between the ADL-SQ and the JHFT and NHPT. The correlation between FIM and the ADL-SQ was –0.45.
0/2 0/1 1/5 0/5
Median or mean (SD) 66.9 67.6 84.2 87.5
(27.5) (15.9) (13.7) (15.9)
0 0 2 2.5
(237) (131) (81) (175) (78) (163)
Discussion The TEMPA was selected as a clinical useful outcome measure for the description of the functionality of the upper limbs in patients with multiple sclerosis. Although the TEMPA has been used before in chronic stroke patients, its validity has not yet been shown in persons with neurological dysfunction. 19 The total summary scores on the TEMPA include the assessment of both arms as opposed to the other selected upper limb tests. Therefore, summary scores on unilateral (and bilateral)
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P Feys et al. validity of the TEMPA speed of execution with the Jebsen Handfunction Test. The different correlation values between the TEMPA functional rating and the JHFT for left and right arm are dif cult to explain. Hand dominance is not
Jebsen (s)
tasks were used for comparison with the Jebsen Handfunction and the Nine Hole Peg Test. The TEMPA was considered to be concurrently valid with these tests if validity was present for these summary scores. The results support concurrent
TEMPA–FR Figure 1 Distribution of the subjects on the Jebsen Handfunction test and TEMPA functional rating for the left arm. Table 2 Correlations between upper limb tests (TEMPA, Jebsen Handfunction and Nine Hole Peg Test) and the measures of functionality (FIM and ADL self-questionnaire) Jebsen
NHPT
TEMPA – functional rating Total score Bilateral tasks TEMPA – speed of execution Total score Bilateral tasks Left arm Jebsen Handfunction Test Nine Hole Peg Test TEMPA Unilateral tasks – functional rating Unilateral and bilateral tasks – functional rating Unilateral tasks – speed of execution Unilateral and bilateral tasks – speed of execution Right arm Jebsen Handfunction Test Nine Hole Peg Test TEMPA Unilateral tasks – functional rating Unilateral and bilateral tasks – functional rating Unilateral tasks – speed of execution Unilateral and bilateral tasks – speed of execution
FIM
ADL-SQ
0.52 0.46
–0.48 –0.46
–0.47 –0.44
0.54 0.61
1 0.83
0.83 1
–0.55 –0.47
0.38 0.4
–0.73 –0.73 0.87 0.75
–0.9 –0.85 0.81 0.81
0.53 0.57 –0.51 –0.50
–0.53 –0.48 0.4 0.53
1 0.95
0.95 1
–0.22 –0.1
0.27 0.28
–0.61 –0.56 0.81 0.72
–0.86 –0.79 0.90 0.85
0.1 0.31 –0.25 –0.39
–0.26 –0.4 0.33 0.55
TEMPA in MS
Clinical messages The TEMPA is a valid test for the measurement of upper limb function in patients with multiple sclerosis. The TEMPA takes longer than some other tests of arm function. Further research is needed on comparative utility.
related to the TEMPA tasks in the elderly and normals between 20 and 29 and therefore it is not assumed that the high number of right-handed patients in uenced the correlation values.8,20 Both outcome parameters of the TEMPA are found to be concurrently valid with the Nine Hole Peg Test as high correlations were found. The Nine Hole Peg Test has extensively been used in multiple sclerosis and is included in the MS functional composite outcome measure.15,21–25 The TEMPA was designed to measure upper limb function and, therefore, the hypothesis was that it correlated well to measures of functional independence. Moderate correlations between the TEMPA and FIM and ADL self-questionnaire respectively were found, provisionally suggesting construct validity of the TEMPA. Desrosiers reported in the elderly a higher correlation between the TEMPA and the partial SMAF (functional autonomy measurement system), which is similar to the FIM.2 As in this study, only upper limb-related items of the SMAF were used for data analysis. The sample in this study consisted of patients with paresis or intention tremor which are two different symptoms possibly causing more variability on the tests than those in elderly persons, partially explaining the lower correlation values.8 Patients with manifest cognitive impairment were excluded in this study as these subjects might have negatively in uenced the accuracy of their self-report.14 An underlying hypothesis in the study was that the relationship between TEMPA and the measures of functionality would be stronger than the relationship of the Jebsen Handfunction and the Nine Hole Peg Test respectively with the FIM and ADL-SQ.5 This study provides provisional
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data for this hypothesis for the relationship with the ADL-SQ and with the FIM, right side only. The total summary scores of the TEMPA seem more representative for upper limb-related selfcare functions and perceived ADL performance than an unilateral Jebsen Handfunction and Nine Hole Peg Test. Subjects commented favourably on the TEMPA without reporting more fatigue despite the longer administration time of the TEMPA regarding the JHFT.1,5 However, the patient is instructed and encouraged during the JHFT to perform the test as fast as possible, whereas the time aspect is only mentioned once during the initial instructions in the TEMPA test. The patient is allowed to practise each test item of the TEMPA, emphasizing the quality of the execution process by which the task is completed.2 The researcher rated patient’s performance additionally on a task analysis section which quanti es the dif culties experienced by the subject according to ve dimensions related to upper extremity sensorimotor skills: strength, range of motion, precision of gross movements, prehension and precision of ne movements. This task analysis, which enlarges the administration time of the TEMPA, provides valuable supplementary clinical information to the therapists but was not included in the data analysis of this study. Future research should investigate the reliability of the TEMPA in MS patients as this has not yet been formally addressed and could analyse the internal consistency of the tasks in the TEMPA in order to reduce the administration time. Acknowledgements The authors thank all patients for their participation in these trials. The contribution of B Meuldermans, L Thielens, G Fardin and A Devesse is acknowledged with thanks. The multidisciplinary collaboration of the physiotherapy and occupational therapy departments is appreciated. In the preparation of this study, we have bene ted from the guidance of Professor W De Weerdt (Department of Rehabilitation Sciences, Katholieke Universiteit Leuven), who stimulated research activities.
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TEMPA in MS Appendix – Activities of daily life self-questionnaire14,15 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) 11) 12) 13) 14) 15) 16) 17) 18) 19) 20) 21) 22) 23) 24) 25) 1) 2) 3) 4)
Cut food with a knife and fork Use a spoon to drink soup Hold a cup of tea Pour milk from a bottle or carton Wash and dry dishes Brush your teeth Use a handkerchief to blow your nose Use a bath Use the lavatory Wash your face and hands Tie up your shoelaces Do up buttons Do up a zip Write a letter Put a letter in an envelope Hold and read a newspaper Dial a telephone Make yourself understood on the telephone Watch television Pick up your change in a shop Insert an electric plug into a socket Unlock your front door with a key Walk up and down stairs Get up out of an armchair Carry a full shopping bag Able to do the activity without dif culty Able to do the activity with a little effort Able to do the activity with a lot of effort Cannot do the activity by yourself
1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
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