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Brief Report
Issue Date: November/December 2015
Published Online: October 19, 2015
Updated: April 30, 2020
Development and Preliminary Reliability of the Functional Upper Extremity Levels (FUEL)
Author Affiliations
  • Stephen Van Lew, MS, OTR/L, is Director of Occupational Therapy, New York University Langone Medical Center, New York, NY; steve.vanlew@nyumc.org
  • Daniel Geller, MS, MPH, OTR/L, is Occupational Therapy Research Clinical Specialist, New York University Langone Medical Center, New York, NY
  • Rachel Feld-Glazman, MS, OTR/L, is Occupational Therapy Program Director, Burke Rehabilitation Hospital, White Plains, NY
  • Nettie Capasso, MS, OTR/L, is Occupational Therapy Assistant Supervisor, New York University Langone Medical Center, New York, NY
  • Adrienne Dicembri, MPH, OTR/L, is Occupational Therapy Supervisor, New York University Langone Medical Center, New York, NY
  • Genevieve Pinto Zipp, EdD, PT, is Professor, Interprofessional Health Sciences and Health Administration Department, and Director, Center for Interprofessional Education in Health Sciences, Seton Hall University, South Orange, NJ
Article Information
Hand and Upper Extremity / Neurologic Conditions / Stroke / Departments / Brief Report
Brief Report   |   October 19, 2015
Development and Preliminary Reliability of the Functional Upper Extremity Levels (FUEL)
American Journal of Occupational Therapy, October 2015, Vol. 69, 6906350010. https://doi.org/10.5014/ajot.2015.016006
American Journal of Occupational Therapy, October 2015, Vol. 69, 6906350010. https://doi.org/10.5014/ajot.2015.016006
Abstract

OBJECTIVE. The Functional Upper Extremity Levels (FUEL) is a new classification tool to assess a person’s upper-extremity functional and physical performance after sustaining a stroke. The aim of this preliminary study was to develop the tool and determine its content validity and interrater reliability.

METHOD. Forty-four licensed occupational therapists ranging in years of experience from 6 mo to 16 yr participated in this study. A two-phase study was conducted: (1) constructing the FUEL and determining its content validity and (2) ascertaining its interrater reliability.

RESULTS. We found that the FUEL had initial content validity and substantial interrater reliability (Fleiss κ = .754).

CONCLUSION. The FUEL can be a useful clinical and research tool in occupational therapy for the assessment and classification of upper-extremity function for people after stroke. Further studies with larger samples and comparison studies with other similar tools are required to support the tool’s reliability and validity.

Upper-extremity (UE) hemiplegia is a common condition after stroke that can have a significant impact on UE function (Kelly-Hayes et al., 2003). Within the past decade, substantial advances have been made in rehabilitation options at the impairment, activity, and participation levels for stroke survivors with UE hemiplegia (Nilsen et al., 2015). Although these newer UE treatment options continue to be explored and scientifically examined, the selection of tools and techniques to promote functional recovery varies among clinicians (Doucet, 2012), and the rehabilitation community continues to lack a common nomenclature or classification tools to measure and describe recovery of the UE after stroke. New assessment tools are required not only to examine the effectiveness of these new UE strategies, but also to describe the recovery of the UE in a meaningful and functional way and provide a common nomenclature for the rehabilitation community. This article discusses the development, content validity, and interrater reliability of the Functional Upper Extremity Levels (FUEL) tool to assess, describe, and assist with treatment planning for poststroke UE function.
Much debate remains in the rehabilitation profession as to whether the bottom-up or top-down approach to assessment is more optimal. A bottom-up approach, grounded in the medical model, considers impairment-level factors first to obtain an understanding of the client’s limitations and strengths and how they affect performance. Conversely, a top-down approach focuses on the client’s actual performance and considers impairment factors later in the process (Weinstock-Zlotnick & Hinojosa, 2004). Because both approaches are valuable in the assessment of clients with UE hemiplegia (Doucet, 2012), development of an assessment tool that supports both approaches is needed. The FUEL tool is rooted in both approaches.
Although several poststroke UE recovery outcome assessments are available to clinicians and researchers, many are outdated, have limitations, and do not classify UE function in a useful way. According to the American Occupational Therapy Association (2010), practitioners should avoid using outdated and obsolete assessment measures and use evidence-based interventions. For example, the Fugl-Meyer Assessment (FMA; Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) is the gold-standard assessment for measuring motor recovery after stroke. The FMA was created from Brunnstrom’s (1966)  seven-stage classification system of UE recovery that had a small description of movement correlated to each stage. It is widely used despite the fact that no research has found that stroke survivors pass through the predictable Brunnstrom stages or supported the effectiveness of Brunnstrom’s movement therapy on people living with disabilities secondary to a neurological event (Fleming-Castaldy & Gillen, 2013). Moreover, the FMA does not address performance in activities of daily living (ADLs) in a functional or meaningful manner but is still used to categorize a patient’s general arm function (Sabari, Capasso, & Feld-Glazman, 2014).
The FMA and other objective outcome measures for UE motor recovery after stroke, such as the Nine-Hole Peg Test (Grice, Vogel, Le, & Mitchell, 2003), Box and Block Test (Mathiowetz, Volland, Kashman, & Weber, 1985), Action Research Arm Test (Lyle, 1981), and Wolf Motor Function Test (Wolf, Thompson, & Winstein, 2010), have their place in research and the clinic because they are valid and responsive to change (Hsieh et al., 2009; Lin, Chuang, Wu, Hsieh, & Chang, 2010). However, we believe the FUEL classification tool is unique because it provides an assessment of UE use after stroke during real daily activities, whereas these other assessments do not. The FUEL provides information about how the UE is used during daily activities that can be shared and understood by clinicians, rather than a numerical score that may or may not correlate with real and meaningful functional use or gains for the person. It can be administered in real-life situations, such as people getting dressed, brushing their teeth, and transferring to a wheelchair, rather than in artificial environments. In addition, unlike other assessments, the FUEL does not require any additional equipment for administration other than daily objects, such as clothes and grooming items. Finally, the FUEL can be used during any functional activity that provides the clinician the opportunity to evaluate the patient during every session, in the context of ADLs, and thus monitor progress and further challenge the patient for optimal recovery.
With the body of research continuing to grow in support of performance-based interventions and with shortened lengths of stay for physical rehabilitation, clinicians frequently cite the need for assessments that are time efficient as well as reliable and valid outcome measures (Rowe, 2013). The need to create and research new classification and assessment tools is essential to provide the best care for patients, improve communication between rehabilitation professionals, demonstrate successful progression of treatment, and provide measureable and meaningful outcomes for third-party payers. The FUEL meets these needs because it is time efficient, can describe and classify the progress of a person’s UE use during functional tasks, can be used across disciplines, and integrates both a top-down and a bottom-up approach to UE assessment. Moreover, it also provides a template for treatment and progression of the UE after stroke.
As shown in Table 1, the FUEL includes seven levels of UE use ranging from nonfunctional to fully functional. Each level in the table includes a general description of how to classify the use of the affected UE during a task. Below each description, in italics, is an example of how one would describe the use of the affected hand during the activity of brushing one’s teeth. Brushing teeth is just one activity example; the FUEL can be used during any functional activity that requires arm use as long as the levels and definitions are adhered to. Therefore, one can classify UE function for different activities, thus taking into account the person, environment, and difficulty of the task. For instance, an occupational therapist may observe a patient using the affected hand as a gross assist for meal preparation but using the affected arm as a semifunctional assist when brushing the teeth. This classification should be based on how the affected UE is used the majority of the time for a given activity.
Table 1.
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth×
LevelDefinition
Nonfunctional• Involved UE is not incorporated into daily activities
• Decreased awareness of involved UE
• No AROM present
Involved UE is not used during grooming task.
Dependent stabilizer• Involved UE is incorporated into activities as a stabilizer but is placed by the less-involved UE or by a caregiver
• Some AROM may be present (scapular, gravity eliminated); however, patient is unable to initiate placement
• Increasing awareness of involved UE during functional tasks
Involved UE is resting on toothbrush to stabilize it (placed by caregiver) while toothpaste is applied with the other hand.
Independent stabilizer• Some AROM is present in involved UE; able to position independently (without use of other UE) in activities
• Used primarily as a weight to stabilize
• No active hand use
Involved UE is stabilizing toothbrush on sink (placed independently) while toothpaste is applied with other hand.
Gross assist• Involved arm and hand are used actively to assist in accomplishing simple functional activities
• Involved UE may still be influenced by synergistic movements or have extreme weakness
• Gross grasp may have developed but no functional release
• Fine motor coordination is not functional
Involved UE is holding toothpaste with a gross grasp while removing the lid with the other hand.
Semifunctional assist• Involved arm and hand are used in activities that require active motor control for pushing, pulling, and stabilizing
• Gross grasp and release have developed, and some individual finger movements may be developing; however, measurements for grasp, pinch, and coordination are below norms
• Hand is able to assist with fastenings
Involved UE picks up toothbrush and holds it while applying the toothpaste with the other hand.
Functional assist• Involved arm and hand have full AROM
• Able to use involved UE for all activities and fine motor tasks, but it remains the assistive UE with mild awkwardness and weakness
Involved UE squeezes the toothpaste onto toothbrush with effort because of weakness.
Fully functional• Involved UE has returned to complete function
• Able to use as dominant UE if premorbidly dominant
• Strength, grasp, pinch, and coordination measurements are all normal
Uses both hands in task; unable to detect a difference between the hands while observing.
Table Footer NoteNote. AROM = active range of motion; UE = upper extremity.
Note. AROM = active range of motion; UE = upper extremity.×
Table 1.
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth×
LevelDefinition
Nonfunctional• Involved UE is not incorporated into daily activities
• Decreased awareness of involved UE
• No AROM present
Involved UE is not used during grooming task.
Dependent stabilizer• Involved UE is incorporated into activities as a stabilizer but is placed by the less-involved UE or by a caregiver
• Some AROM may be present (scapular, gravity eliminated); however, patient is unable to initiate placement
• Increasing awareness of involved UE during functional tasks
Involved UE is resting on toothbrush to stabilize it (placed by caregiver) while toothpaste is applied with the other hand.
Independent stabilizer• Some AROM is present in involved UE; able to position independently (without use of other UE) in activities
• Used primarily as a weight to stabilize
• No active hand use
Involved UE is stabilizing toothbrush on sink (placed independently) while toothpaste is applied with other hand.
Gross assist• Involved arm and hand are used actively to assist in accomplishing simple functional activities
• Involved UE may still be influenced by synergistic movements or have extreme weakness
• Gross grasp may have developed but no functional release
• Fine motor coordination is not functional
Involved UE is holding toothpaste with a gross grasp while removing the lid with the other hand.
Semifunctional assist• Involved arm and hand are used in activities that require active motor control for pushing, pulling, and stabilizing
• Gross grasp and release have developed, and some individual finger movements may be developing; however, measurements for grasp, pinch, and coordination are below norms
• Hand is able to assist with fastenings
Involved UE picks up toothbrush and holds it while applying the toothpaste with the other hand.
Functional assist• Involved arm and hand have full AROM
• Able to use involved UE for all activities and fine motor tasks, but it remains the assistive UE with mild awkwardness and weakness
Involved UE squeezes the toothpaste onto toothbrush with effort because of weakness.
Fully functional• Involved UE has returned to complete function
• Able to use as dominant UE if premorbidly dominant
• Strength, grasp, pinch, and coordination measurements are all normal
Uses both hands in task; unable to detect a difference between the hands while observing.
Table Footer NoteNote. AROM = active range of motion; UE = upper extremity.
Note. AROM = active range of motion; UE = upper extremity.×
×
The tool also includes the external qualifiers of either spontaneous movement or movement that requires minimal, moderate, or maximal verbal, tactile, or demonstrative cues as a result of nonmotor impairments that could affect UE use, such as visual, cognitive, or perceptual difficulties. For instance, if a patient had mild left inattention and gross grasp and release of the hand, one could describe the patient’s level as being able to use the affected UE as a semifunctional assist while brushing teeth, with moderate verbal cues to attend to the left side to find the toothbrush. The FUEL not only captures the unique UE skills involved in the performance of different functional activities but can also provide a template for individual goal setting, treatment planning, and progression of UE use after stroke.
Method
Research Design
The study was performed in two phases: (1) development and construction of the FUEL classification system and determination of its content validity and (2) determination of its interrater reliability.
Phase 1.
The FUEL was developed specifically to assess and classify how a patient incorporates his or her involved UE into a functional context. The scale focuses on the available movements that a patient might possess and has seven levels that a therapist can use to classify the status of the involved UE. The FUEL also has external qualifiers that can be used when classifying the UE into a level on the basis of factors such as presence of spontaneous movement and the types of cues required to initiate movement and function.
The first phase of FUEL construction began with the selection and creation of operational definitions of the scale levels by the authors, all of whom are experts in the area of neurological rehabilitation. Although some of the level titles have been used clinically for years and have been passed down from therapist to therapist (Wilson, 1980), we believe creation of the FUEL is the first attempt to objectify such terms in an ordinal manner. Numerous discussions occurred regarding definitions of the levels, including constructs such as clarity and simplicity. The scale originally had additional levels, but in the process of using the FUEL in clinical applications with many patients, the authors agreed on the current seven levels.
Content validity was assessed by means of experts’ evaluation of the levels, definitions, and qualifiers. Five external experts assessed the tool on the following constructs: practicality, clarity, and simplicity. These experts all had significant experience in the field of neurological rehabilitation and included occupational therapists from clinical settings and academia. Many of these occupational therapists have published research in the field of outcome development and neurological rehabilitation. The levels of agreement were created on the basis of the following guidelines: full agreement (i.e., agreement among all experts), partial agreement (i.e., agreement among more than three experts), and poor agreement (i.e., agreement among fewer than three experts). Full agreement was obtained for the construct of practicality, with partial agreement obtained for clarity and simplicity. The partial agreement for clarity and simplicity arose as a result of questions about how other impairments such as cognition or vision may affect the assessment process for UE function after stroke. Therefore, external qualifiers were added to the tool to account for impairments that were not motor related but that could affect one’s ability to use the arm, such as visual, cognitive, or perceptual impairments. The qualifiers used were either spontaneous movement or movement with varying cues (verbal, tactile, and demonstrative) and the number of cues required to complete the activity (maximal, moderate, and minimal).
In addition, the authors used Lawshe’s (1975)  theoretical model of content validity to assess the significance of the FUEL. Each expert was asked the following question: “Is the knowledge measured by the tool essential, useful but not essential, or not necessary to the performance of the construct?” All five experts agreed that that tool was essential to the performance of the construct. According to Lawshe, this level of agreement indicates a content validity ratio of .99, which denotes a strong level of content validity
Phase 2.
After the FUEL was constructed, we examined its interrater reliability. The interrater reliability study sample consisted of a convenience sample of 44 licensed occupational therapists working in various locations including outpatient, acute care, and inpatient rehabilitation in a large academic medical center. Their clinical experience ranged from 6 mo to 16 yr. All 44 occupational therapists had minimum or no familiarity with the FUEL before this interrater reliability study.
The 44 licensed occupational therapists were given an educational lecture regarding description and use of the FUEL scale. The lecture was supplemented by picture examples and visual demonstration by one of the lecturers. The 44 occupational therapists then watched five different videos of patients completing functional activities, such as feeding, grooming, and dressing, while using their involved UE. They then classified each patient’s UE function into one of the FUEL levels on the basis of the use of the involved UE in the video. The only information given about the patient was lesion side of the brain. For interrater reliability, a Fleiss κ statistic was used because of the ordinal nature of the data. The data analysis was performed with IBM SPSS Statistics (Version 19; IBM Corporation, Armonk, NY).
Results
Assessment of interrater reliability resulted in a Fleiss κ statistic of .754. The level of agreement was very consistent for four of the five videos, but some variance in agreement occurred for the grooming video. Specifically, this video demonstrated a patient performing a grooming task; 70% of the therapists correctly classified the UE as semifunctional assist, and the remaining therapists incorrectly classified it as gross assist. We hypothesized that this video, portraying a middle-level-functioning patient, did not have the clarity of the other videos in this study.
Discussion
The development of the FUEL, an updated and integrated tool to assess and classify UE function after a stroke, is an important step in moving the profession away from antiquated motor scales that do not capture function; more important, it provides a common language for UE function after stroke across rehabilitation disciplines. Occupational therapists are charged with developing and implementing measurement and assessment strategies that characterize the extent to which impairments impede daily occupational performance (Baum, Perlmutter, & Dunn, 2005). Baker, Cano, and Playford (2011)  suggested that no consensus exists on the battery of outcome measures to use when assessing physical recovery after stroke. Selecting a scale to measure physical recovery and function can be difficult for a variety of reasons, including lack of an integrated tool that combines assessment of physical skills and function, symptoms and severity, and variability in stroke recovery. This study established the FUEL’s content validity by means of expert evaluation, as well as a Fleiss κ interrater reliability score of .754. According to Landis and Koch (1977), a Fleiss κ score of .60–.80 suggests substantial agreement. Thus, the study results support the FUEL as a reliable tool to assess and classify a person’s UE motor function after stroke during performance of ADLs.
A secondary attribute of the FUEL, which was not examined in this study, is its ability to assist occupational therapists in justifying patients’ functional status in documentation. It has been used to document progress in patients’ functional use of the UE and to set goals. The current emphasis on formal documentation of progress to justify services has made the creation of mechanisms to clearly and accurately document progress imperative. The FUEL can provide the occupational therapist with a mechanism to measure UE progress in ADLs such as eating, grooming, and dressing. In addition, the FUEL has assisted in facilitating treatment planning and progression for the population with stroke, producing an environment of collaborative treatment planning for patients across disciplines because the authors have all adapted the same FUEL nomenclature for clinical use.
Limitations and Future Research
The FUEL is in the early stages of test development, with this study serving as a pilot because of the convenience sample and its size. Further investigation into the FUEL’s interrater reliability should occur with a larger sample at multiple sites to increase the generalizability and strength of its current reliability. For future interrater reliability studies, a manual will be created similar to those for other outcome measures to assist clinicians in learning how to use the FUEL. Because of time constraints, a limited number of video examples were used during the interrater reliability testing. Further testing should include more video examples of the levels so that the robustness of the interrater reliability statistic can be more established. Finally, comparing the FUEL with other UE classification systems would create a level of criterion validity, as would further studies to substantiate the FUEL’s construct validity.
Implications for Occupational Therapy Practice
The FUEL’s relevance to current practice is paramount, considering the emphasis on performance-based assessments and the need for occupational therapists to assess and classify UE function after stroke in a valid and efficient manner. The findings of this study have the following implications for occupational therapy practice:
  • The use of the FUEL can benefit occupational therapists by requiring minimal setup and equipment to classify UE function after stroke.

  • The FUEL has been proven to be a reliable and valid tool in the assessment and classification of UE function after stroke.

  • This study has produced preliminary psychometric results that should be further studied.

Conclusion
The FUEL, a functional scale for the poststroke UE, was found to be easy to use, practical, and reliable. The FUEL, which uses a combination of top-down and bottom-up approaches, categorizes the levels of function in engagement and participation for a person with UE hemiplegia. It should be used as an adjunct to formal standardized stroke assessments for the UE. The FUEL is not an in-depth assessment of poststroke UE physical skills or function, but it is an easy-to-use scale that has proven to be practical for measuring and classifying UE function in the poststroke population.
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Table 1.
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth×
LevelDefinition
Nonfunctional• Involved UE is not incorporated into daily activities
• Decreased awareness of involved UE
• No AROM present
Involved UE is not used during grooming task.
Dependent stabilizer• Involved UE is incorporated into activities as a stabilizer but is placed by the less-involved UE or by a caregiver
• Some AROM may be present (scapular, gravity eliminated); however, patient is unable to initiate placement
• Increasing awareness of involved UE during functional tasks
Involved UE is resting on toothbrush to stabilize it (placed by caregiver) while toothpaste is applied with the other hand.
Independent stabilizer• Some AROM is present in involved UE; able to position independently (without use of other UE) in activities
• Used primarily as a weight to stabilize
• No active hand use
Involved UE is stabilizing toothbrush on sink (placed independently) while toothpaste is applied with other hand.
Gross assist• Involved arm and hand are used actively to assist in accomplishing simple functional activities
• Involved UE may still be influenced by synergistic movements or have extreme weakness
• Gross grasp may have developed but no functional release
• Fine motor coordination is not functional
Involved UE is holding toothpaste with a gross grasp while removing the lid with the other hand.
Semifunctional assist• Involved arm and hand are used in activities that require active motor control for pushing, pulling, and stabilizing
• Gross grasp and release have developed, and some individual finger movements may be developing; however, measurements for grasp, pinch, and coordination are below norms
• Hand is able to assist with fastenings
Involved UE picks up toothbrush and holds it while applying the toothpaste with the other hand.
Functional assist• Involved arm and hand have full AROM
• Able to use involved UE for all activities and fine motor tasks, but it remains the assistive UE with mild awkwardness and weakness
Involved UE squeezes the toothpaste onto toothbrush with effort because of weakness.
Fully functional• Involved UE has returned to complete function
• Able to use as dominant UE if premorbidly dominant
• Strength, grasp, pinch, and coordination measurements are all normal
Uses both hands in task; unable to detect a difference between the hands while observing.
Table Footer NoteNote. AROM = active range of motion; UE = upper extremity.
Note. AROM = active range of motion; UE = upper extremity.×
Table 1.
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth
Functional Upper Extremity Levels (FUEL) for the Grooming Activity of Brushing Teeth×
LevelDefinition
Nonfunctional• Involved UE is not incorporated into daily activities
• Decreased awareness of involved UE
• No AROM present
Involved UE is not used during grooming task.
Dependent stabilizer• Involved UE is incorporated into activities as a stabilizer but is placed by the less-involved UE or by a caregiver
• Some AROM may be present (scapular, gravity eliminated); however, patient is unable to initiate placement
• Increasing awareness of involved UE during functional tasks
Involved UE is resting on toothbrush to stabilize it (placed by caregiver) while toothpaste is applied with the other hand.
Independent stabilizer• Some AROM is present in involved UE; able to position independently (without use of other UE) in activities
• Used primarily as a weight to stabilize
• No active hand use
Involved UE is stabilizing toothbrush on sink (placed independently) while toothpaste is applied with other hand.
Gross assist• Involved arm and hand are used actively to assist in accomplishing simple functional activities
• Involved UE may still be influenced by synergistic movements or have extreme weakness
• Gross grasp may have developed but no functional release
• Fine motor coordination is not functional
Involved UE is holding toothpaste with a gross grasp while removing the lid with the other hand.
Semifunctional assist• Involved arm and hand are used in activities that require active motor control for pushing, pulling, and stabilizing
• Gross grasp and release have developed, and some individual finger movements may be developing; however, measurements for grasp, pinch, and coordination are below norms
• Hand is able to assist with fastenings
Involved UE picks up toothbrush and holds it while applying the toothpaste with the other hand.
Functional assist• Involved arm and hand have full AROM
• Able to use involved UE for all activities and fine motor tasks, but it remains the assistive UE with mild awkwardness and weakness
Involved UE squeezes the toothpaste onto toothbrush with effort because of weakness.
Fully functional• Involved UE has returned to complete function
• Able to use as dominant UE if premorbidly dominant
• Strength, grasp, pinch, and coordination measurements are all normal
Uses both hands in task; unable to detect a difference between the hands while observing.
Table Footer NoteNote. AROM = active range of motion; UE = upper extremity.
Note. AROM = active range of motion; UE = upper extremity.×
×