4. Overview
Introduce Action Research Arm Test (ARAT)
ARAT kit (and how to make your own!)
Administering the ARAT
Positioning
Scoring
Tasks in the ARAT (Grasp, Grip, Pinch, and Gross Movement)
Scoring sheet
Object placement
5. ARAT
Purpose of Assessment: The purpose of the
Action Research Arm Test is to assess the
client’s recovery of upper limb function
following a cognitive impairment by
observing the client perform various
activities including grasp, grip, pinch, and
gross movements (Lyle, 1981).
Tests arm motor status after stroke or TBI
(both affected and non-affected side).
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
6. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
7. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
8. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
9. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
10. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
11. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
12. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
13. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
14. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
15. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
16. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
17. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
18. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
19. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
20. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
21. ARAT Kit
Items used:
Stainless steel can
4 Wood blocks: 10cm, 7.5cm, 5cm,
2.5cm
Cricket ball
Sharpening Stone
Long & short dowels with threaded
rod
Long & short stainless steel tubing
Plank with threaded receivers
Threaded rods for tubes
Washer
2 Plastic cups
Marble
2 Ball bearings
22. DIY ARAT Kit
Stainless steel can- ~$5
4 Wood blocks: 10cm, 7.5cm, 5cm, 2.5cm- ~$10
Cricket ball- ~$7
Sharpening Stone- ~$10
Long & short dowels with threaded rod- ~$5
Long & short stainless steel tubing- ~$5
Plank with threaded receivers- ~$10
Threaded rods for tubes- ~$5
Washer- ~$5
2 Plastic cups- ~$6
Marble- ~$5
2 Ball bearings- ~$5
23. Administering the ARAT
Hierarchical order of difficulty for each domain:
Hardest task in a domain tested first!
If perfect (score=3), then give top score (3) for all
tasks in that domain
If score is 0-2, then proceed to second task, which
is the easiest in the domain
If they score 0 on the second task, then score 0 for
remaining tasks in that domain. If they score 1-
3, continue with other tasks in that domain.
Approach allows for easy and rapid assessment of
motor function.
10-20 minutes total for ARAT score of both arms
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
24. Scoring
Each of 19 tasks rated on an ordinal
4-point scale (i.e. 0, 1, 2, or 3)
Maximum score is 57 on each side
Higher scores indicate better arm
motor status
Each task is graded according to:
grasp involved
arm movement components
body postureLyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
25. Things to keep in mind...
Assess each arm separately
Demonstrate the task before the client performs it
For each of the 4 domains: score the good arm, then the affected arm, then go
to next domain
Do not move on to the next task until the participant completes the task or the
task exceeds 60 seconds to perform.
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
26. Positioning of the participant
Upright, standard chair with firm back, no armrests, comfortable, enough room
for upper extremity mobility.
Table level approximates subject’s mid-abdomen, best is 30 cm between
tabletop and chair seat.
Trunk must remain in contact with the back of the chair.
Head neutral and upright.
Legs in front of the chair; feet in contact with floor.
Both hands in pronated position on the table, except for ‘Gross Movement’
subscale, where hands on lap.Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
28. Scoring
To score a 3:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
29. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
30. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
31. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Task is completed but
either “with great difficulty
or abnormally long”
Great difficulty means
either abnormal quality of
the grasp, abnormal arm
movement components, or
abnormal body postures
Abnormally long means 5-
60 seconds
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
32. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Task is completed but
either “with great difficulty
or abnormally long”
Great difficulty means
either abnormal quality of
the grasp, abnormal arm
movement components, or
abnormal body postures
Abnormally long means 5-
60 seconds
To score a 1:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
33. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Task is completed but
either “with great difficulty
or abnormally long”
Great difficulty means
either abnormal quality of
the grasp, abnormal arm
movement components, or
abnormal body postures
Abnormally long means 5-
60 seconds
To score a 1:
Partially completes the task
within the 60 seconds
allotted
Regardless of the quality of
grasp, arm movement
components, or posture
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
34. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Task is completed but
either “with great difficulty
or abnormally long”
Great difficulty means
either abnormal quality of
the grasp, abnormal arm
movement components, or
abnormal body postures
Abnormally long means 5-
60 seconds
To score a 1:
Partially completes the task
within the 60 seconds
allotted
Regardless of the quality of
grasp, arm movement
components, or posture
To score a 0:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
35. Scoring
To score a 3:
Task is performed
normally: defined as
appropriate grasp, arm
movement components,
and posture
Task is performed in < 5
seconds
To score a 2:
Task is completed but
either “with great difficulty
or abnormally long”
Great difficulty means
either abnormal quality of
the grasp, abnormal arm
movement components, or
abnormal body postures
Abnormally long means 5-
60 seconds
To score a 1:
Partially completes the task
within the 60 seconds
allotted
Regardless of the quality of
grasp, arm movement
components, or posture
To score a 0:
Unable to perform any part
of the task within the 60
seconds allotted
Thus, unable to grasp or
complete any of the arm
movement components
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
36. Tasks
19 tasks across 4 domains
Grasp (6 tasks)
Grip (4 tasks)
Pinch (6 tasks)
Gross Motor (3 tasks)
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
37. Important Components For Each Domain
Normal movement pattern for each task
Scoring for each task
Object positioning
Delivery of instructions
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
38. Grasp
Various objects (blocks, ball, stone) have to be lifted off the table up to the top
of the shelf
Subject is asked to grasp, lift up, place, and release each object
6 tasks, thus 6 objects, but same instructions and scoring system
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
39. Grasp- Scoring
Sheet
Start with most difficult task,
grasping the 10cm block
If score = 3, then grasp domain
score = 18; move to next
domain
If the score is 0-2, continue to
easiest task, grasping the
2.5cm block
If the score for the 2.5cm block = 0,
then score 0 for remaining tasks
in that domain; move to next
domain
If the score for the 2.5cm block = 1-Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
40. Grasp: Object
Position
Hand being tested placed lateral to
the object
Examiner not allowed to stabilize
objects
Cricket ball stabilized in a storage
container
Sharpening stone placed on its
narrow long side; if falls,
reposition for up to 60 seconds
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
41. Grasp
Instructions
“Grasp the block [ball, sharpening
stone], lift it up, and place it on top
of the shelf, then let go of it.”
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
42. Normal Arm & Hand Movements
Task 1-4:
Blocks displaced vertically to shelf
Hand voluntarily opens and adjusts to the size of the blocks using a grip that involves thumb and
finger opposition.
Task 5:
Cricket ball is displaced vertically to shelf
Using a spherical grasp
Task 6:
Sharpening stone is displaced vertically to shelf
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
43. Examples of Normal Movement:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
44. Abnormal Movement for Grasp:
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
45. Grip
This domain requires the subject to:
Pour water from one cup to the other
Horizontally displace alloy tubes
Horizontally displace a washer to a bolt
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
46. Grip- Scoring
Sheet
Start with most difficult task,
pouring water
If score = 3, then grip domain score
= 12; move to next domain
If the score is 0-2, continue to
easiest task, displacing the
2.25cm (larger) alloy tube
If the score for the alloy tube = 0,
then score 0 for remaining tasks
in that domain; move to next
domain
If the score for the alloy tube = 1-3,
continue with scoring the rest ofLyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
47. Grip- Object
Position
Pouring Task:
Cups on each side of
subject’s midline
Examiner/subject can
stabilize
receiving cup
while pouring
Cup is filled with
water half full
Alloy Tube Task:
Pegs placed on
start and target
positions
Washer Task:
Pegs/container
placed on start
and target
positions
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
48. Grip
Instructions
“Pour the water from this cup to that
other cup.”
or
“Grasp this tube [washer] and place
it here [onto the peg on the plank].”
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
49. Normal Arm & Hand Movements
Task 7:
Uses cylindrical grip around glass.
Forearm pronation to pour.
Forearm supination to return to table.
Task 8 & 9:
Use three-jaw-chuck or any grasp involving the pads of the thumb opposed with any pads of
fingers.
Forearm is between neutral position and pronation.
Elbow extends to reach target,
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
50. Normal Movement for Grip Domain
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
51. Abnormal Movement for Grip Domain
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
52. Pinch
This domain requires:
Participant’s ability to independently move the fingers in opposition to the thumb
Participants are asked to grasp marble or ball bearing from a container, lift, and
release into target container atop shelf.
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
53. Pinch- Scoring
Sheet
Start with most difficult task, ball
bearing gripped with ring finger
and thumb
If score = 3, then pinch domain
score = 18; move to next
domain
If the score is 0-2, continue to
easiest task, marble gripped
with index finger and thumb
If the score for the marble = 0, then
score 0 for remaining tasks in
that domain; move to next
domain
If the score for the marble = 1-3,
continue with scoring the rest of
the tasks in pinch domain
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
54. Pinch- Object Positioning
Place container on top of the storage box/shelf
Place other container on tabletop halfway between midline and shoulder
Ball bearing/marble placed within lower container
Hand being tested placed lateral to container
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
55. Pinch
Instructions
•“Grasp the ball
bearing/marble
[using these
fingers], lift it up,
and place it in the
container on top of
the shelf”
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
56. Normal Hand & Arm Movements
Tasks 11, 13, 14:
Grasp requirements include opposition of pads of ring finger and thumb; middle finger and thumb;
and index finger and thumb.
Tasks 12,15, 16:
Grasp requirements include opposition of pads of index finger and thumb; ring finger and thumb;
and middle finger and thumb.
For all tasks in this domain, forearm is in neutral and pronation.The elbow first
flexes when grasping the object and extends when reaching to the top of the
shelf. Shoulder goes into flexion to reach the top of the shelf and shoulder
stabilizes during release of the object.Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
57. Normal Movement for Pinch
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
58. Abnormal Movement for Pinch
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
59. Gross Movement
Requires the subject to move the hand to various
positions on the head and face
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
60. Gross Movement:
Scoring Sheet
For gross movement, most difficult
and easiest task collapsed into
one: placing the hand behind
the head
Start with the task of placing the
hand behind the head
If score = 3 then gross movement
domain score = 9; ARAT
completed
If the total score for this subscale is
0, then score 0 for remaining
tasks in that domain; ARAT
completed
If the score is 1-2, then continue
with scoring the rest of the
tasks in the gross movement
domain
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
61. Gross Movement: Object Position
Start with both hands, pronated on lap
Head kept in a neutral upright position
Subject to touch
Back of head (not neck) with the palmar hand
Top of the head (not forehead) with palmar hand
Mouth (not chin) with palmar hand
Fingers can be flexed if unable to extend/abduct the digits
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
62. Normal Movement
Task 17:
Palmar side of hand contacts back (dorsal/posterior) side of head.
Task 18:
Palmar side of hand to top of head.
Task 19:
Palmar side of hand to mouth.
For all tasks,forearm alternates between supination and pronation. The elbow
goes into full flexion. There is shoulder abduction, flexion, and external
rotation.Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
63. Normal Movement
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
64. Abnormal Movement
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in physical rehabilitation treatment and research." Int J Rehabil Res 4(7333761): 483-492.
65. References
Lyle, R. C. (1981). "A performance test for assessment of upper limb function in
physical rehabilitation treatment and research." International Journal of
Rehabilitation and Research, 4(4), 483-492.
Yozbatiran, N., Der-Yeghiaian, L., & Cramer, S. C. (2008). A standardized
approach to performing the action research arm test. Neurorehabilitation
And
Neural Repair, 22(1), 78-90.
Editor's Notes
Ashley & Courtney
Courtney
Ashley
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Ashley- A number of therapies are in development to improve motor outcome in human subjects with stroke. Evaluation of such interventions, as well as the natural course of recovery after stroke, is highly reliant on the performance of the outcome measures employed. The utility of an outcome measure to detect change in neurologic status is influenced by its clinimetric properties such as validity and reliability, as well as by the extent to which test administration is standardized. Arm motor deficits are common after stroke. Several measures are available for the study of arm motor function after stroke, including the Action Research Arm Test (ARAT). This test, first described by Lyle, evaluates 19 tests of arm motor function, both distally and proximally. Each test is given an ordinal score of 0, 1, 2, or 3, with higher values indicating better arm motor status. The total ARAT score is the sum of the 19 tests, and thus the maximum score is 57.
This presentation therefore includes step-by-step directions that provides a detailed, standardized approach to scoring the ARAT. Most studies using the ARAT cite Lyle’s original article that introduced the scale and is a main source referenced in this presentation.
Ashley-
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Ashley- ~$80
The basic testing materials, as originally outlined by Lyle, are a chair without armrests, a table, various sized wooden blocks, a cricket ball, a sharpening stone, alloy tubes, a washer and bolt, 2 glasses, marbles, and ball bearings. Also required are 2 planks for placing the alloy tubes, 1 plank to place the washer, 2 tobacco tin lids, and a 37-cm high shelf.
Courtney
To administer the ARAT, you first have to start with the most difficult task in each domain. So the four domains are grasp, grip, pinch and gross movement, administered in that order. So first you would start in the grasp domain by using the 10cm block. If the client scores a 3/3 then you have completed testing that arm for that domain. However, if the client scores below a 3, you go to the next task on the list which happens to be the easiest task in the domain. If the participant scores a zero, then you are done testing in that domain for that arm and they receive a zero for that whole subscale. If they score a 1-3 on the easiest task, continue with the other tasks in the domain. This approach speeds the assessment up and usually takes between 10 and 20 minutes to complete.
Courtney-
When scoring the ARAT, we need to keep in mind that each subscale constitutes a hierarchical Guttman scale, which basically means that all items are ordered according to ascending difficulty. So as mentioned previously, if the client succeeds in completing the most difficult item in a subscale, this suggests he/she will succeed in the easier items for that same subscale and thus receive the highest score of a 3 on the remainder of those tasks in that subscale. Similarly, failure on an item suggests the client will be unable to complete the remaining more challenging items in the subscale. There are 19 tasks total, 6 in the grasp subscale, 4 in the grip subscale, 6 in the pinch subscale, and 3 in the gross movement subscale. The max score a participant can receive is a 57 on each arm. The higher the score, the better the participant’s arm motor status is. When grading, you are looking at grasp involved, arm movement components, body posture, and time to perform the task. (http://www.strokengine.ca/indepth/arat_indepth/)
Courtney-
Now before administering and scoring the ARAT, we should remember a few key points. First, make sure to asses each arm separately. Demonstrate the task so the participant knows exactly what’s expected of them. When testing each domain, score the good arm first, then the affected arm, and then continue on to the next domain. Never move on to the next task unless the participant is done or the task exceeds 60 seconds to perform.
Courtney-
One of the most important things to keep in mind when administering the ARAT is to make sure the participant is positioned correctly. The participant must be sitting upright in a standard chair with a firm back. There should be no armrests. The participant should be comfortable. And there should be enough room for functional arm mobility. The height of the table should be approximately 30cm between the tabletop and the seat of the chair, or about at the participant’s mid-abdomen. The participants trunk must stay rested against the back of the chair to reduce compensatory strategies. The head should remain in a neutral position and upright. Legs should be in the front of the chair with feet on the floor. And both hands should remain in a pronated position on top of the table, except when testing gross movement.
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So here is a more detailed diagram depicting the layout of the ARAT. The subject sits close to the table, with a 15-cm distance from the anterior torso to the front edge of table, as previously stated. In our experience, this distance allows enough upper-extremity mobility for the subject to be able to reach the top of the shelf, but maintains emphasis on the required body posture during testing. The use of a nonslip mat that is placed over the table is highly recommended. We have found it useful to draw prestated positions for each test object on this mat. Further specifications for position of testing materials are specified under the instructions for each subscale.
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Alright so now lets break down the scoring in the ARAT.
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In order to score a 3, the highest score for each task, the task needs to be performed “normally.” This means that the task was performed with appropriate grasp, appropriate arm movement components, and appropriate posture. Also in order to score a 3, the task needs to be performed in under 5 seconds.
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In order to score a 2 on a task, the participant must complete the task with great difficulty or take an abnormally long time to do so. “Great difficulty” is defined as the participant exhibiting abnormal quality of grasp, abnormal arm movement components, or abnormal body postures. In order for the task to be considered “abnormally long,” the participant needs to take 5 to 60 seconds to complete the task.
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In order for the participant to score a 1 on a task, the task needs to be done incompletely within the 60 seconds. This is regardless of grasp quality, arm movement components quality, or posture quality.
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Finally, in order to score a 0 on a task, the participant must be completely unable to perform any aspect of the tasks within the 60 seconds. This means that the participant was unable to grasp or complete any of the arm movement components.
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So to reiterate, there are 19 tasks total across 4 domains. There are 6 grasp tasks, 4 grip tasks, 6 pinch tasks, and 3 gross motor tasks. These domains are tested in this order and again, the most difficult task in each domain is administered first.
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When testing these domains, it’s important to keep some important components in mind. First, you’re looking at normal movement patterns for each task, scoring the task, focusing on the position of the objects and ensuring your delivery of the instructions are sufficient. Next, we’re going to further break down these different domains and look at what normal movement vs abnormal movement looks like and how to score participants.
Ashley
Ashley
Ashley- The nonslippery mat is placed over the table, and then the shelf and testing objects are placed in their predrawn positions (Figure 2). This approach has the shelf placed lengthwise, 20 ± 5 cm away from the proximal edge of the table on the mat; however, if the subject does not have sufficient range of motion for the fingertips to reach the top of shelf, such as due to contractures or increased tone, then the examiner can adjust this distance as needed. The items are placed, one at a time during the appropriate test, halfway between the subject’s midsagittal line and the axillary line of the arm being tested. The hand being tested should be placed pronated, immediately lateral to the testing object, with the other hand also pronated atop the table. For all of the blocks, the assessor should not stabilize the object, nor can the subject stabilize the object with the nontested hand. For the sharpening-stone task, the stone has to be placed on its narrow long side in a slightly diagonal position (parallel to the axis of the palmar creases) for ease of grasping. If the sharpening stone falls to its side during grasping attempts, it can be repositioned onto its narrow long side by the examiner for up to 60 seconds. The 2 tin lids are used as the initial and final sites for the cricket ball. The distance between the proximal edge of the lower tin lid and the proximal edge of the table is 5 cm, whereas the proximal edge of the upper tin lid is the same as the proximal edge of the shelf. If desired, the upper tin lid can be attached to the top of the shelf using Velcro, in order to maintain stability, while the lower lid can be stabilized by the assessor as needed during task performance.
Ashley- The subject is asked to grasp, lift vertically, place, and then release each object (block, ball, or stone) onto the top of the shelf. The instructions spoken to the subject are to “grasp the block [cricket ball, sharpening stone] that I have placed here, lift it up, and place then release it on top of that shelf.”
Ashley
Ashley- Start with the task of grasping the 10-cm block (the most difficult task in this subscale); if the score is 3, then the total score for this subscale is 18 for the arm being tested, and no further tasks need be tested for this arm on this subscale. If the score is 0 to 2, then continue to the task of grasping the 2.5-cm block (the easiest task in this subscale). If the score is 0, then the total score for this subscale is 0, and no further testing is required for this arm on this skip to subscale. If the score for the 2.5-cm block task is 1-3, however, continue with scoring all tasks in this subscale. Score 3 indicates normal, complete, timely task completion. The subject must grasp the object, lift it up, and release it onto the shelf, all within 5 seconds, to obtain a score of 3. Appropriate hand movement components and arm movement components (Table A3) must be used, as well as posture requirements. The subject should not have the score reduced if the object falls off the shelf after successful task completion. The subject may release the object on any place on the shelf (Figure 3a-f). Score 2 is given when the subject completes the task but does so “with great difficulty and/or takes abnormally long time.” The subject can display great difficulty when (1) not using appropriate hand movement components (Table A3), even if the task is otherwise completed (Figure 3g-h); (2) the subject displays abnormal arm movement components, such as abnormal object release when the object is brought to the shelf (Figure 3i); or (3) abnormal posture is evident (eg, if subject’s trunk completely loses contact with the back of the chair). A score of 2 is also assigned if task completion takes 5 to 60 seconds. For score 1, there are several possible means by which the subject can partially perform the task and thus receive a score of 1. For example, if the subject grasps and lifts the object, but does not reach the level of the shelf within the 60 seconds. A subject who can hold and lift the object—even with abnormal hand movement components and arm movement components —and lift it off the table any distance would score a 1 (Figure 3g and 3h). The subject must initiate some form of hand movement component to hold and lift the object, in order to attain a score of 1. Score 0 indicates that the subject is unable to perform any part of the task within 60 seconds. A score of 0 would apply, for example, if the subject cannot open the hand to grasp the object, cannot extend and/or abduct the fingers or thumb to the size of object, at all within 60 seconds and/or the subject attempts to manipulate the object into the hand on the side being tested by stabilizing the object against the shelf or against the nontested hand, and/or moves the object across the table without any voluntary hand opening (Figure 3j). These are all permitted but provide no points and cannot be used to achieve a hold and lift hand movement component.
Ashley- Examples of incorrect performance: In the first picture, the thumb is not involved while grasping the 2.5 cm3 block. In the middle picture, the block falls off the shelf before release is completed. And the last picture, , there's an incorrect grasp for lateral pinch
Courtney
Now we’ll look at the second domain to be tested - grip. This domain requires the participant to complete 4 tasks including pouring water from one cup to another, horizontally displacing 2 different sized alloy tubes and horizontally displacing a washer to a bolt.
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In the grip domain, the hardest task is pouring water from one glass to another class so we would start the participant there. Like in the previous domain, if the participant scores a perfect 3 then the remaining tasks in the domain are also awarded a 3 for a total of 12 points. But if the participant scores below a 3, you move to the next task on the list which is the easiest task - displacing a 2.25cm alloy tube. If the score for this task is a 0, then all tasks in this Grip domain will also be a 0. If the score is between 1 and 3, then you continue testing the rest of the tasks. Displacing the 1cm alloy tube from one side of the table to the other would be next. And finally, putting a washer over a bolt.
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The next thing that you need to focus on when administering the Grip domain of the ARAT is object positioning. For the pouring task, there should be a cup on each side of the subject’s midline. One of the cups should be half-filled with water. And the receiving cup can be stabilized by the examiner or the subject. The alloy tube task should be set up with the pegs placed in their start and target positions, and same with the washer task.
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Prior to starting each task, the subject is given verbal instructions and a demonstration of what the task should look like. The verbal instructions for the grip domain are to “pour the water from this cup to that other cup” or for the other tasks, “grasp this tube (or washer) and place it here” (onto the peg)
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To assess whether the subject’s movements are “normal,” the administrator needs to focus on these specific aspects. For task 7, which is pouring the water from one glass to another, the subject needs to use a cylindrical grip around the glass, use forearm pronation to pour the water, and use forearm supination to return to the table. For tasks 8 and 9, which is moving the different sized alloy tubes from the starting peg to the target peg, “normal” movements include using a 3 jaw chuck or any other grasp involving the pads of the thumb opposed with the pad of another finger, having the forearm between the neutral and pronated position, having the elbow extend to reach the target peg, and moving the shoulder in various directions and be stabilized when the object is released. And the last task in the grip domain, task 10, is transferring the washer from the starting peg to the target. For this task, “normal movement” involves a 3 jaw chuck grasp, the forearm between neutral position and pronation, the elbow extends to reach the target peg, and movement at the shoulder again happens in various directions and is stable when the washer is released.
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These pictures depict what “abnormal” movements would look like within the grip domain? So what’s wrong with this first picture? Yes the grasp. The subject isn’t using a 3 jaw chuck grip. What about the second one? Yes the grip again. The subject should be using any kind of grip involving the pad of the thumb opposing to the pad of another finger. And finally what’s wrong with this last one? The subject should be using pronation to pour the water, but instead she’s leaning her whole body to try to get the water into the other glass.
Ashley
Ashley
Ashley- The mat is placed over the table, with testing objects placed in their predrawn positions. The 2 tin lids are placed in the same positions as stated in the grasp subscale. Each marble or ball bearing is placed within the lower tin lid, and the subject is asked to grasp the object with the appropriate fingers, lift it up to the shelf, and release it into the target lid. Notes can be recorded in relationship to fingernail length as desired, but this does not change scoring.
Ashley- The subject is asked to grasp a ball bearing or a marble from a tin lid, lift it up vertically, then place and release it into a target tin lid placed on the shelf. This requires that the subject independently move the fingers in opposition to the thumb with accompanying distal mobility and stabilization. The instructions spoken to the subject are to “grasp the ball bearing [marble] using these fingers, lift it up, and place it in the tin on top of the shelf.”
Ashley
Ashley- . This subscale starts with the task of lifting the 6-mm ball bearing, the most difficult task; if score is 3, then the total score for the arm being tested on this subscale is 18, and no further testing is needed for this arm on this subscale. If the score is 0 to 2, then next is the task of lifting the marble with the first finger and thumb, that is, the easiest task in this subscale. If the score is a 0, then the total score for this arm on this subscale is 0, and no further testing is required for this arm on this subscale. If the score is 1 to 3, continue with scoring all tasks in this subscale. An important note specific to pinch subscale tasks is that correct hand movement components (finger opposition; see in the first picture under the abnormal movement slide) must be present to score more than 0. Thus, regardless of arm movement components, posture, and time used, the score can only be 0 if an incorrect finger opposition is employed, for example, holding the object in the palm with all 4 fingers flexed and thumb adducted/flexed (see in second picture in abnormal movement slide). As an extension of this note, task completion, necessary for a score of 2 or 3, is only deemed to be present if correct hand movement components are used. In addition, a score of 3 can only be generated if the finger opposition specifically uses the pads of the fingers. A score of 3 is awarded for normal, complete, timely task completion. The subject grasps the marble or ball bearing from the tin, lifts the object up to the shelf, and releases it into the target tin, all within 5 seconds. The task is completed using correct arm movement components, as well as hand movement components, including finger pads, while maintaining proper posture. The score is not reduced if the object bounces off the shelf after successful task completion. A score of 2 is awarded if (1) the quality of the arm movement component or the hand movement component is abnormal, as might occur for example with inability to release the object from the fingers into the target tin, or if the object falls out of the tin/off the shelf when attempting to release, or if the subject is unable to use the pads of the fingers to grasp the object (see first picture in abnormal movement slide); (2) abnormal posture is displayed (eg, if subject’s trunk completely loses contact with the back of the chair); or (3) performance takes 5 to 60 seconds. A score of 1 is awarded if the subject partially completes the task, for example, grasps the object, lifts it up, but drops the object or is unable to reach the height of the shelf. The task must be completed within 60 seconds. With a score of 0, the subject is unable to initiate the task within 60 seconds or, again for this subscale only, does not display the correct hand movement components, that is, finger opposition. The subject (1) is unable to open the hand to grasp the test object, that is, to extend and/or abduct the fingers or thumb to at least the size of the object; (2) attempts to manipulate the object into the fingers by stabilizing it with the non tested hand or some other object; (3) moves the object in the tin lid without any voluntary finger/thumb extension; or (4) attempts take greater than 60 seconds.
Ashley- . Examples of incorrect performance: The first picture, the subject is unable to use the pads of the appropriate fingers to grasp the marble. In the second picture, the subject uses palm to hold the ball bearing without any finger/thumb opposition.
Courtney-
And finally, gross movement, the final domain of the ARAT. This domain requires the subject to move their hand to various positions on the head and the face.
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There are 3 tasks involved in the gross movement domain. First, we start with moving the subjects hand to the back of the head. This task is considered both the hardest and easiest task, so if the subject scores a 3 on this then they get a 3 on the remaining tasks for a total score of 9. Similarily, if the subject scores a 0 on this first task then they get a 0 on the remaining tasks. If the subject scores either a 3 or a 0, the ARAT is completed. But if the subject scores between a 1 and a 2, then you continue with scoring the rest of the tasks. (hand to top of head and then hand to mouth).
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Object positioning for the gross movement domain is a little different than the previous domains. First, the subject needs to start with both hands pronated in their lap. The head must be kept in a neutral, upright position. For the tasks in this domain the subject will touch the back of their head, not their neck, with the palmar aspect of their hand, the top of their head, not their forehead, with the palmar aspect of their hand, and their mouth, not their chin, with the palmar aspect of their hand. If for some reason the subject is unable to extend or abduct the digits, they can flex them instead.
Courtney-
To assess whether or not the subject is using “normal movements” for the gross movement domain, these aspects need to be examined. First, for task number 17, which is touching the back of the head, the subject must use the palmar side of their hand and make contact with the back side of their head. For task number 18, which is touching the top of the head, the subject must use the palmar side of the hand to touch the top of the head. And for task number 19, which is touching the mouth, the subject must again use the palmar side of the hand to reach up and touch their mouth. With each of these tasks, the subject needs to alternate between supination and pronation of the forearm. The elbow must also go into flexion and the shoulder needs to ABduct, flex and externally rotate.
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So here are examples of the 3 tasks in the gross movement domain achieved with “normal movement.” Notice for each of these the subject is s=using the palmar aspect of his hand and there is supination/pronation of the forearm.
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And finally, these are two examples of abnormal movement within the gross movement domain. In the first picture the subject isn’t using the palmar aspect of her hand and in the second she is using compensatory strategies to avoid full elbow flexion.
