Letter by Stinear and Byblow regarding article, "patient-reported measures provide unique insights into motor function after stroke".

1 that illustrated the importance of measuring motor function, not just impairment and disability, after stroke. These authors report results from 43 people who had experienced stroke between 5 days and 9.4 years before assessment. Global measures of disability (modified Rankin Scale) and impairment (National Institutes of Health Stroke Scale) were made, as well as measures of impairment specific to the upper limb (Fugl-Meyer [FM] scale and Purdue pegboard test). Patient-reported measures of upper limb function were also made: the difficulty of hand use (hand domain of the Stroke Impact Scale [SIS]) and amount of affected arm use (Motor Activity Log [MAL]). Nearly two-thirds of patients with minimal or no disability or impairment measured with the modified Rankin Scale, National Institutes of Health Stroke Scale, or FM scale reported difficulty with hand movements or reduced arm use. This is an important reminder that patients who are able to pass an assessment of disability and upper limb impairment can still experience considerable difficulty when attempting to use the affected upper limb in daily activities, which, in turn, reduces their use of the limb for these activities. It also highlights the limitations of using global measures, such as the modified Rankin Scale and National Institutes of Health Stroke Scale, as trial end points for treatments aimed at specific domains, such as motor function. However, another interesting aspect of the data set went without comment. The impairment threshold for regaining use of the affected upper limb in activities of daily living is actually high. Figure 2 clearly shows that only patients with an FM score >55 (of 66) had an average SIS and MAL scores that were at least half the maximum scores. The average SIS scores ranged from 1 (cannot do at all) to 5 (not difficult at all), and only patients with an FM score of ≥55 achieved an average SIS score of ≥3 (somewhat difficult). Patients with an FM score <25 had an average SIS score of 1, indicating that they found all the hand domain tasks so difficult with their affected hand that they could not perform them at all. Similarly, the average MAL scores ranged from 0 (weaker arm is not used) to 5 (weaker arm is used as much as before the stroke), and only patients with an FM score of ≥55 achieved an average MAL score of ≥2.5 (between 2=rarely used and 3=used half as much …