Stroke Rehabilitation Assessment of Movement Measure

Link to instrument: STREAM

Acronym:

STREAM

Purpose:

• The STREAM was designed for use by physical therapists to provide a quantitative evaluation of motor functioning for stroke patients. The STREAM was specifically designed to be easy to administer in a clinical setting.
  

Description:

The STREAM is composed of 30 items distributed across 3 domains:

• Upper-limb movements (scored on a 3-point ordinal scale
• Lower-limb movements (scored on a 3-point ordinal scale)
• Basic mobility items (scored on a 4-point ordinal scale)

Scoring the STREAM:

• Total of 20 points for each of the limb sub-scales (40 points total)
• Total of 30 points for the mobility subscale
• Scores can be transformed, allowing for items that can't be scored
• Subscales are converted to a percentage, even though the scores are not interval based. This is done to allow for occasional items that cannot be scored.  Total scores are calculated using the average of the 3 subscale scores
• Instructions for score transformation can be found in the instruments manual

Area of Assessment: Coordination, Functional Mobility, Range of Motion

Body Part: Upper Extremity, Lower Extremity

ICF Domain: Body Function, Activity

Domain: Motor

Assessment Type: Performance Measure

Length of Test: 06 to 30 Minutes

Time to Administer:

15 minutes

Number of Items: 30

Equipment Required:

None

Training Required:

None

Type of training required: No Training

Cost: Free

Actual Cost:

Free

Age Range: Adult: 18-64 years, Elderly adult: 65+

Administration Mode: Paper/Pencil

Diagnosis: Stroke

Populations Tested:

• Stroke

Standard Error of Measurement (SEM):

Chronic Stroke: (Chen et al, 2007; n = 50; mean age = 60.9 (12.8) years; median time between stroke and assessment = 24 months, mean Barthel Index (BI) scores = 15.9 (5.3) points)

• Standard Error of Measurement (SEM) = 1.5 points

Minimal Detectable Change (MDC):

Chronic Stroke: (Chen et al, 2007)

• Smallest Real Difference (SRD) = 4.2 points

Acute Stroke: (Hsueh et al, 2008; n = 50 mean age = 61.9 (11.7) years; onset to admission 18.6 (11.7) days; stay in rehab = 22.3 (5.7) days)

• STREAM Smallest Real Difference:
  Measure	ICC	95% CI	SRD (SRD%)
  STREAM
  UE-STREAM	.97	0.96-0.98	2.8 (14.0)
  LE-STREAM	.98	0.96-0.99	2.5 (12.6)
  Motor-STREAM	.98	0.97-0.99	3.9 (9.9)
  S-STREAM
  UE-S-STREAM	.95	0.92-0.97	11.6 (11.6)
  LE-S-STREAM	.97	0.95-0.98	9.1 (9.1)
  Motor-S-STREAM	.97	0.95-0.98	17.4 (8.7)
  FM
  UE-FM	.98	0.96-0.99	7.2 (10.9)
  LE-FM	.95	0.91-0.97	3.8 (11.3)
  Motor-FM	.98	0.97-0.99	8.4 (8.4)
  S-FM
  UE-S-FM	.93	0.89-0.96	12.2 (12.2)
  LE-S-FM	.96	0.93-0.97	8.6 (8.6)
  Motor-S-FM	.96	0.94-0.98	16.0 (8.0)
  STREAM = Motor Scale of Stroke Rehabilitation Assessment of Movement S-STREAM = Simplified Motor Scale of STREAM SRD = smallest real difference FM = Fugl-Meyer Motor Scale S-FM = Simplified Fugl-Meyer Motor Scale UE = Upper Extremity LE = Lower Extremity

Minimally Clinically Important Difference (MCID):

Stroke: (Hsieh et al, 2008; n = 81 stroke patients who were recruited from Departments of Physical Medicine and Rehabilitation of three hospital in Taiwan; mean age = 55.9 (13.3) years; mean MMSE score = 25.8 (2.8) years; mean STREAM baseline score = 10.27 (7.6) for upper extremity, 9.6 (6.7) for lower extremity, and 16.1 (7.6) for mobility)

• MCID for upper-extremity subscale (n = 42) = 2.2
• MCID for lower-extremity subscale (n = 38) = 1.9
• MCID for mobility subscale (n = 43) = 4.8

Cut-Off Scores:

Not Established

Normative Data:

Acute Stroke: (Ahmed et al, 2003; n = 63; mean age = 67 (14) years; assessed within a week of stroke, then again at 4 weeks and 3 months)

STREAM Norms Over Time with Comparisons:
Instrument		Intial		5 week		3 months
Name	Domain	Mean (SD)	Median	Mean (SD)	Median	Mean (SD)	Median
STREAM	Total Score	75 (26.7)	86	86 (19.1)	94	89 (18.0)	97
	UE subscale	73 (33.3)	90	85 (26.2)	100	88 (24.0)	100
	LE subscale	75 (28.9)	85	86 (22.3)	95	90 (19.0)	100
	Mobility subscale	74 (25.9)	83	88 (16.4)	97	91 (15.0)	97
Barthel Index	Total	72 (27.9)	85	86 (20.4)	100	92 (14.0)	100
Gait speed (m/s)	Total	0.55 (0.38)	0.58	0.82 (0.43)	0.90	0.85 (0.36)	0.93
STREAM = Stroke Rehabilitation Assessment of Movement UE = Upper Extremity LE = Lower Extremity

Test-retest Reliability:

Chronic Stroke: (Chen et al, 2007, n = 50, 7 days between assessments)

 

Test re-test data for the Mobility subscale of the STREAM
First Session Mean (SD)	17.9 (7.2)
Second Session Mean (SD)	17.8 (7.6)
Mean d (SD)	0.1 (2.1)
ICC (95% CI)	0.96 (0.93 to 0.98)*
SEM	1.5
SRD	4.2
*Excellent
d = difference of score between the 2 test sessions ICC = intraclass correlation coefficient CI = confidence interval SEM = standard error of measurement SRD = smallest real difference

 

 

Interrater/Intrarater Reliability:

Chronic Stroke: (Daley et al, 1999; n = 20; mean age = 66.7 (10.7) years; mean time between stroke onset and assessment = 104.5 (42.7) days)

 

Interrater and Intrarater Reliability:
Sub scale	Direct Observation (Interrater Agreement)	Videotaped Assessments (Intrarater Agreement)
Upper-extremity subscale	.994	.963
Lower-extremity subscale	.993	.999
Basic mobility subscale	.982	.999
Total scores on STREAM	.995	.999
GCC = generalizability correlation coefficient Reliability coefficients of .95 or better are recommended

Internal Consistency:

Chronic Stroke: (Daley et al, 1999)

• Internal Consistency (Cronbach's alpha):
  • Excellent: Mobility subscale = .965
  • Excellent: Limb subscales = .979
  • Excellent: overall STREAM scores = .984

Criterion Validity (Predictive/Concurrent):

Acute Stroke: (Ahmed et al, 2003)

 

STREAM Predictive and Concurrent Validity Correlations:
Stream	Time	Box and Block (Affected UE)	Box and Block (Unaffected UE)	Barthel	Balance	TUG	Gait
Total	Initial	.73	.36	.78	.75	.80	.74
	5 weeks	.77	.37	.71	.68	.64	.62
	3 months	.78	.44	.75	.65	.57	.73
UE	Initial	.78	.31	.67	.57	.69	.56
	5 weeks	.79	.36	.66	.61	.49	.53
	3 months	.76	.31	.67	.53	.60	.64
LE	Initial	.53	.40	.71	.73	.75	.74
	5 weeks	.64	.29	.59	.55	.59	.55
	3 months	.70	.30	.63	.55	.51	.65
Mobility	Initial	.66	.55	.84	.88	.85	.83
	5 weeks	.69	.40	.75	.71	.57	.65
	3 months	.66	.40	.82	.78	.62	.76

Construct Validity (Convergent/Discriminant):

Acute Stroke: (Hsueh et al, 2003, n = 59; mean age 64.2 (11.5) years; assessed within 14 days of stroke onset, Taiwanese sample)

 

Convergent Validity and Predictive Validity of the STREAM at 4 Time Points
Days	n	Convergent Validity* (p)	Predictive Validity† (p)
14	57	0.80	0.54
30	54	0.87	0.67
90	44	0.82	0.81
180	43	0.76	--
*Relationships between the STREAM and the BI at 4 time points. †Relationships between the STREAM and the BI at 3 time points (14, 30, and 90 days) after stroke.

 

 

Content Validity:

Items from the initial STREAM were reviewed by two panels of experts made up to 20 physical therapists. Feedback from these experts were used to refine the measure.

Face Validity:

Not statistically assessed

Floor/Ceiling Effects:

Acute Stroke: (Hsueh et al, 2008)

 

STREAM Floor and Ceiling Effects at Admission and Discharge
	At Admission, n (%)		t Discharge, n (%)
	Floor	Ceiling	Floor	Ceiling
UE-STREAM	13 (26.0)	10 (20.0)	4 (8.0)	20 (40.0)
LE-STREAM	10 (20.0)	2 (4.0)	1 (2.0)	12 (24.0)
Motor-STREAM	9 (18.0)	1 (2.0)	1 (2.0)	10 (20.0)
S-STREAM	2 (4.0)	0 (0.0)	0 (0.0)	6 (12.0)
UE = Upper Extremity LE = Lower Extremity STREAM = Motor Scale of Stroke Rehabilitation Assessment of Movement S-STREAM = Simplified Motor Scale of STREAM

 

Acute Stroke: (Hsueh et al, 2003)

 

STREAM Floor and Ceiling Effects at 4 Time Points
Days after Stroke	Floor n (%)	Ceiling n (%)
14 (n = 57)	0 (0)	0 (0)
30 (n = 54)	0 (0)	2 (3.7)
90 (n = 44)	0 (0)	6 (13.6)
180 (n = 43	0 (0)	7 (16.3)

Responsiveness:

Acute Stroke: (Higgins et al, 2005; n = 55; mean age = 66 (15), assessed at 5 weeks after onset)

 

Standard Response Means (SRM) for STREAM:
Sub-scale	SRM	95% Confidence Interval
STREAM Total	0.98	0.74 − 1.17
STREAM (upper limb)	0.75	0.56 − 0.93
STREAM (lower limb)	0.63	0.36 − 0.86

 

Acute Stroke: (Hsueh et al, 2008; assessed at admission and within 48 hours of discharge; mean time in rehabilitation = 22.3 (5.7) days)

 

STREAM Responsiveness:
Scale	Change score (SD)	Strength	Effect Size d	SRM
STREAM
UE-STREAM	3.3 (4.2)	small	0.38	0.78
LE-STREAM	3.3 (3.9)	small	0.44	0.84
Motor-STREAM	6.5 (6.9)	small	0.45	0.95
S-STREAM
UE-S-STREAM	14.5 (12.2)	small	0.49	1.19
LE-S-STREAM	14.7 (12.9)	medium	0.54	1.14
Motor-S-STREAM	29.1 (23.2)	medium	0.53	1.26
FM
UE-FM	8.4 (8.5)	small	0.34	1.00
LE-FM	4.3 (5.2)	small	0.41	0.83
Motor-FM	12.7 (11.0)	small	0.38	1.16
S-FM
UE-S-FM	14.6 (14.4)	small	0.47	1.00
LE-S-FM	14.9 (17.9)	medium	0.51	0.83
Motor-S-FM	29.4 (29.7)	medium	0.51	0.99
STREAM = Motor Scale of Stroke Rehabilitation Assessment of Movement S-STREAM = Simplified Motor Scale of STREAM FM = Fugl-Meyer Motor Scale UE = Upper Extremity LE = Lower Extremity S-FM = Simplified Fugl-Meyer Motor Scale SRM = Standardized Response Mean

 

Acute Stroke: (Hsueh et al, 2003)

 

Responsiveness of the STREAM at Different Stages of Recovery
Days	n	SRM	Wilcoxon z
14–30	51	1.17	6.02*
30–90	43	0.95	4.95*
90–180	43	0.40	2.23†
14–90	43	1.61	5.72*
14–180	43	1.65	5.57*
*P < 0.001; †P < 0.05

Considerations:

 

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Bibliography:

Ahmed, S., Mayo, N. E., et al. (2003). "The Stroke Rehabilitation Assessment of Movement (STREAM): a comparison with other measures used to evaluate effects of stroke and rehabilitation." Phys Ther 83(7): 617-630. Find it on PubMed

Chen, H. M., Hsieh, C. L., et al. (2007). "The test-retest reliability of 2 mobility performance tests in patients with chronic stroke." Neurorehabil Neural Repair 21(4): 347-352. Find it on PubMed

Daley, K., Mayo, N., et al. (1999). "Reliability of scores on the Stroke Rehabilitation Assessment of Movement (STREAM) measure." Phys Ther 79(1): 8-19; quiz 20-13. Find it on PubMed

Higgins, J., Mayo, N. E., et al. (2005). "Upper-limb function and recovery in the acute phase poststroke." J Rehabil Res Dev 42(1): 65-76. Find it on PubMed

Hsieh, Y. W., Wang, C. H., et al. (2008). "Estimating the minimal clinically important difference of the Stroke Rehabilitation Assessment of Movement measure." Neurorehabil Neural Repair 22(6): 723-727. Find it on PubMed

Hsueh, I. P., Hsu, M. J., et al. (2008). "Psychometric comparisons of 2 versions of the Fugl-Meyer Motor Scale and 2 versions of the Stroke Rehabilitation Assessment of Movement." Neurorehabil Neural Repair 22(6): 737-744. Find it on PubMed

Hsueh, I. P., Wang, C. H., et al. (2003). "Comparison of psychometric properties of three mobility measures for patients with stroke." Stroke 34(7): 1741-1745. Find it on PubMed 

Year published: 1986

Instrument in PDF Format: Yes

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