Stroke Rehabilitation Assessment of Movement

Last Updated

March 24, 2016

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.

Link to Instrument

Instrument Details

Acronym STREAM

Area of Assessment

Coordination
Functional Mobility
Range of Motion

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Stroke Recovery

Stroke

The STREAM is composed of 30 items distributed across 3 domains:
1) Upper-limb movements (scored on a 3-point ordinal scale
2) Lower-limb movements (scored on a 3-point ordinal scale)
3) Basic mobility items (scored on a 4-point ordinal scale)
Scoring the STREAM:
1) Total of 20 points for each of the limb sub-scales (40 points total)
2) Total of 30 points for the mobility subscale
3) Scores can be transformed, allowing for items that can't be scored
4) 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, and total scores are calculated using the average of the 3 subscale scores.
Instructions for score transformation can be found in the instruments manual.

Number of Items

15 minutes

Required Training

No Training

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Reviewed by Heather Anderson and Rie Yoshida of the StrokEdge II task force, Neurology Section, APTA, March 2016.

Body Part

Upper Extremity
Lower Extremity

ICF Domain

Body Function
Activity

Measurement Domain

Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations for use based on acuity level of the patient:

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
StrokEDGE	No	Yes	Yes	No

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

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

Acute Stroke: (Ward et al, 2011; n = 30; mean age 66.5 (SD 13.7) years; mean time assessed following stroke 7.8 days (SD 3.5; range 3-15); assessed at admission and discharge; mean time in rehabilitation = 23.3 (range 7-53) days)

Spearman Correlations and Corresponding p-values:

STREAM		Admission		Discharge		Change
		FIM	SIS-16	FIM	SIS-16	FIM	SIS-16
Total STREAM	rho: p-value:	0.7766 <.0001	0.7073 <.0001	0.7802 <.001	0.7153 <.0001	0.2535 .1765	0.4456 .0136
Mobility STREAM	rho: p-value:	0.6501 .0001	0.6451 .0001	0.8292 <.0001	0.7985 <.0001	0.3055 .1007	0.2655 .1561
UE STREAM	rho: p-value:	0.7489 <.0001	0.6088 .0004	0.7012 <.0001	0.5499 .0016	0.1277 .5011	0.2461 .1898
LE STREAM	rho: p-value:	0.7905 <.001	0.5992 .0005	0.6954 <.0001	0.6371 .0002	0.2811 .1324	0.1955 .3006

STREAM = Stroke Rehabilitation Assessment of Movement; FIM = Functional Independence Measure; SIS-16 = 16 item Stroke Impact Scale; SRM = Standardized response mean

Acute Stroke: (Ward et al, 2011)

Spearman Correlations (values are Spearman rho coefficients) between Admission FIM, SIS-16 and STREAM Scores and Predicted vs Actual Length of Stay

Measure	Predicted length of stay	Actual length of stay
Motor FIM	-0.9438	-0.6846
SIS-16	-0.6743	-0.7953
Total STREAM	-0.8011	-0.7972
Mobility STREAM	-0.6361	-0.7423
UE STREAM	-0.7717	-0.7469
LE STREAM	-0.8446	-0.7364

P-values are <.0001 for all correlations except for STREAM mobility and predicted length of stay where P = .0002; STREAM = Stroke Rehabilitation Assessment of Movement; FIM = Functional Independence Measure; SIS-16 = 16 item Stroke Impact Scale

Construct Validity

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.

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: (Ward et al, 2011)

Scale	Change score (SD)	Strength	SRM
Total STREAM	12.3 (8.8)	Large	1.40
UE-STREAM	12.4 (12.9)	Large	0.97
LE-STREAM	10.2 (9.9)	Large	1.03
Mobility-STREAM	11.9 (14.4)	Large	0.83
FIM (motor)	23.7 (10.1)	Large	2.34
SIS-16	23.1 (14.0)	Large	1.65

STREAM = Stroke Rehabilitation Assessment of Movement; FIM = Functional Independence Measure; SIS-16 = 16 item Stroke Impact Scale; SRM = Standardized response mean; Change score = difference in score between admission and discharge; Strength = Small (0.20 - < 0.50); Medium (0.50 - < 0.80); Large > 0.80

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

Acute Stroke: (Yu et al, 2013; n = 66; mean age 63.1 (SD 12.1) years; mean time assessed following stroke 18 days (range 6-64)

A moderate to good association (0.80; p < 0.001) between changes in scores on the Mobility STREAM and the Hierarchical Balance Short Form (HBSF); Difference 0.00; 95% CI: (-0.10 – 0.10)

Acute Stroke: (Yu et al, 2012; n = 85; mean age 65.5 (SD 11.6) years; mean time assessed following stroke 19 days (range 5-79)

Moderate external responsiveness (p < 0.001) for changes in Mobility STREAM compared to Balance Computerized Adaptive Test (CAT): (β = 0.67; r²=0.44); compared to Postural Assessment Scale for Stroke patients (PASS): (β = 0.77; r²=0.59)
Sufficient explanatory power of predictive validity (p < 0.001) for changes in Mobility STREAM at discharge compared to Balance CAT: (β = 0.76; r² = 0.57); compared to PASS: (β = 0.80; r² = 0.63)

Subacute Stroke: (Huang et al, 2015)

Group level responsiveness:
- Internal responsiveness: similar among 3 STREAM versions (STREAM-30, STREAM-27, STREAM-15)
- External responsiveness: similar among the 3 STREAM measures. The UL and LL subscales demonstrated moderate external responsiveness and the MO subscale showed high external responsiveness
- The results demonstrate that all versions of stream are equally able to identify changes in movement status and mobility when used in a group
Individual level responsiveness:
- Internal responsiveness: mean SCs for STREAM-27 significantly higher than those of STREAM-15 in all subscales (UL, LL, and MO)
- External responsiveness: significantly more participants found to have important improvement by STREAM-27 or BI than by STREAM-15 and BI in MO subscale
- The results demonstrate that STREAM-27 can detect more participants with significant movement and mobility improvement than STREAM-15

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

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

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

Huang, Y. J., Chen, K. L., Chou, Y. T., Hsueh, I. P., Hou, C. Y., Hsieh, C. L. (2015). "Comparison of the responsiveness of the long-form and simplified stroke Rehabilitation Assessment of Movement: group- and individual-level analysis. Physical therapy 95(8): 1172-83. Find it on PubMed

Ward, I., Pivko, S., Brooks, G., Parkin, K. (2011). “Validity of the stroke rehabilitation assessment of movement scale in acute rehabilitation: a comparison with the functional independence measure and stroke impact scale-16.” Physical Medicine and Rehabilitation 3(11): 1013-21. Find it on PubMed

Yu, W.-H., Chen, K.-L., et al., (2013). “Responsiveness and predictive validity of the Hierarchical Balance Short Forms in people with stroke.” Physical Therapy Journal 93(6): 798-808. Find it on PubMed

Yu, W.-H., Hsueh, I.-P., et al., (2012). “A comparison of responsiveness and predictive validity of two balance measures in patients with stroke.” J Rehab Med (44): 176-180. Find it on PubMed