Frequently Asked Questions
Below you will find the answers to some of the most common questions
related to the CAHAI.
The list is updated regularly, so if you have an unanswered question,
please contact us.
The only thing that I should be stating to the patient in the beginning is to explain to them the purpose of the assessment, reassure them that some areas may be difficult and not to get frustrated. Lastly the exact instructions per task. With that said I am confused on scoring. When to verbally cue and when not to. Let's use task 1 as an example. Upon immediately observing the patient rest their arms on the table, should I say then and there, "please do not rest your arms on the table?" If they do it again, then I would repeat myself...? Regardless if they placed their arms on the table top 1 or 2 times, that would be a score of a 5? Upon the third time of observing the patient rest their arms on the table top, that would be a score of a 4? And then continuously would be a 3?
You want to try to make sure that the client has understood the task.... so that you can demonstrate twice how to do the task, cue them twice to use both hands, and twice remind them not to rest their elbows on the table. We are trying to simulate daily activities, most of which we do in standing. However, given that the majority of our clients are more than likely in wheelchairs and/or have balance/ endurance issues, we give the test in sitting .. this sometimes prompts people to rest their elbows on the table when they really don’t need to; having said that, many individuals with upper limb weakness, are unable to hold their hands up, and therefore are using the table as a support. If that is the case, they would receive a score of 3, as 50% of the stabilization effort is provided by the desk top, provided you saw signs of manipulation of either the arm (in reaching) or in the hand. If you had to cue more than 2 (e.g. client is apraxic or has an agonsia) but provide no physical assistance and they complete the task, they would get a 5 ( like the FIM). If they rested their arms momentarily on the table (light touch), they would get a score of 4 (minimal assist), provided they were showing signs of manipulation and stabilization in the task.
So for each task we are allowed to demonstrate twice and cue twice not to place arms on table top. Even if you demonstrate twice and cue twice, would the patient receive a score of 6 or 7? Or because youcued twice, that would drop their score down to 5?
When to verbally cue and when not to. Let's use task 1 as an example. Upon immediately observing the patient rest their arms on the table, should I say then and there, ""please do not rest your arms on the table?"" If they do it again, then I would repeat myself...? Regardless if they placed their arms on the table top 1 or 2 times, that would be a score of a 5? Upon the third time of observing the patient briefly rest their arms on the table top, that would be a score of a 4? And then continuously would be a 3?
Here are some key considerations for scoring.
First you need to clearly demonstrate (twice) to the client that they should not rest their arms on the table. You want to ensure that they really understand the task expectations.
When they start the task, If the client does rest their arms you should ask them to stop and restart the task. You are allowed to do this twice.
If after two tries, they continue to rest their arm then they would score a 3 (using the table as support), 4 (rest for a second) or 5 (verbal cueing to not rest results in success).
Will results of this assessment be valid if we complete portions of it at different times or on different days. For example if a patient cannot tolerate completing the assessment in one sitting can we finish another session?
In testing the reliability of the CAHAI, we did not videotape but had different therapists applying the measure on different days. The measure’s inter and intra reliability is very robust, so you could definitely feel comfortable in doing the assessment over two or three days. The shortened measure ( CAHAI-7) is also an alternative.
My client is not likely to require physical assistance, e.g., in tasks such as opening a jar of coffee but might touch his elbows to the table. Am I right that I would score a 4 (touches table briefly) for this even if physical assistance was not required?
Yes, the individual is using the table as an assist even when briefly touching down. This points to the need for strengthening the musculature of the upper limb.
Can a patient score a 3 if the weaker arm performs only 50-74% of the effort to complete the tasks, even if physical assistance isn’t required?
Yes. The individual would score a 3 (a) if he/she only performed 50% of the task (look at the task component charts) e.g., where they partially wring out the facecloth but most of the wringing is accomplished with the non-affected hand or (b) he/she needs assistance from somewhere (self, therapist or environment).
When picking up the pitcher, where should the patient’s hand be? Should he/she hold the pitcher by the handle (palm on handle and fingers wrapped around handle) or can they put his/her hand between the handle and the pitcher (palm on pitcher and back on hand on handle)?
The patient may choose how they want to hold the pitcher so long as he/she is able to complete the task within the qualifiers outlined on the score sheet.
How should the client hold the ruler? Does it have to be with their fingertips or can they use the palm? If they use their palm, it may rest on the paper and so they are stabilizing both.
The client may hold the ruler in any fashion they choose (palm, closed fist, fingertips). You must then look at the qualifiers for each of the scores based on this. Does the ruler move, are they able to make a straight line, or is the arm resting on the table, etc?
How should the evaluator position themselves when demonstrating and observing the client?
The evaluator should stand on the affected side and be prepared to give physical assistance if needed to complete the task.
The use of dycem during the tasks: Does one leave the dycem on the table for the client to decide whether they need to use it or does the therapist decided if the client needs the Dycem?
The therapist should observe the patient attempt the task, and if he/she feels that the performance would be improved with dycem, then supply it.
If the client does not use the Dycem on their first attempt and we decide to give them the Dycem, do we score the client on the attempt with the Dycem or the attempt without Is the attempt with the Dycem considered the second attempt or can they try it twice?
You would score the client using the dycem as this is a device (6). With the dycem, the client would be allowed to attempt the task twice, and if successful would score a 6. If the client was unable to successfully complete the task, you would then assess how much of the task the affected upper limb performed, and score accordingly.
Wring out the washcloth: Does the amount of water left in the cloth need to be evaluated to determine a score? How does one measure the water?
Yes, the amount of water matters, as it indicates how well the affected hand is squeezing out the water. After the client completes the task, the therapists takes the cloth and squeezes out the water; if there is only minimal seepage (25%), score a 4; more water, score a 3.
When re-evaluating a client, should they be using the same strategy?
Yes, for test- retest purposes, the client should use the same strategy. However, you would note that the client wanted to change the strategy, and you could repeat the CAHAI, allowing the client to try the new way of completing the task.
Can you tell me what is considered a minimum clinically significant change on CAHAI, if there is one? (e.g. on COPM, average improvement of 2 score points is considered clinically/statistically significant).
On the CAHAI- 13, an individual would have to change 6.3 points in order to show true change when true change has actually occurred ( out of 91). In comparison, for the Action Research Arm Test, a person would have to change 5.7 points to show true change (out of 56). The CAHAI-9 and CAHAI- 13 show greater longitudinal validity than the ARAT (.86 and .82 vs .76 ) indicating that the CAHAI would identify over 80% of the time true change in the paretic upper limb.
I am enquiring about the meaning of the CAHIA scores when re testing. Is their a particular score that indicates clinical; or stat significance when re testing the client? Ie change of 5 demononstrates meaningful change.
On the CAHAI- 13, an individual would have to change 6.3 points in order to show true change when true change has actually occurred ( out of 91). In comparison, for the Action Research Arm Test, a person would have to change 5.7 points to show true change (out of 56). The CAHAI-9 and CAHAI- 13 show greater longitudinal validity than the ARAT (.86 and .82 vs .76 ) indicating that the CAHAI would identify over 80% of the time true change in the paretic upper limb.
We are considering tests and measures for application in a stoke specialty program. The CAHAI is currently one of the tests we are evaluating. Has any research related to the MCID been completed to date and can you provide that to me? We use the minimal clinically important difference as a basis for goal writing when training new clinicians.
On the CAHAI- 13, an individual would have to change 6.3 points in order to show true change when true change has actually occurred ( out of 91). In comparison, for the Action Research Arm Test, a person would have to change 5.7 points to show true change (out of 56). Reference is : Test-retest reliability, validity and sensitivity of the Chedoke Arm and Hand Activity Inventory: A new measure of upper limb function for survivors of stroke. Barreca, Stratford, Lambert, Masters, Streiner, Arch Phys Med Rehabil , Vol 86, August 2005. The CAHAI-9 and CAHAI- 13 show greater longitudinal validity than the ARAT (.86 and .82 vs .76 ) indicating that the CAHAI would identify over 80% of the time true change in the paretic upper limb.
I would like to know more information about beginning to use the CAHAI in an environment previously unfamiliar with the CAHAI. Below I have provided my context and my question for you. Context: I have just started a new placement at the Student Rehabilitation Outpatient Clinic at Royal Columbian Hospital in New Westminster, BC. Due to the student-led nature of this placement, there is freedom to develop the assessments, interventions and other resources as part of our individual learning and to facilitate the learning of other / future students. The clinic facilitators, a Physiotherapist and an Occupational Therapist, are not familiar with this assessment but are keen to implement it due to my preliminary feedback as to the utility and functional picture the CAHAI presents. My question: How would my facilitators and I go about implementing and using this assessment as part of the student-led clinic's assessment tools?
We are delighted that you are finding the CAHAI useful. I think it is a great idea to demonstrate its utility to other therapists. A couple of suggestions: Everyone can access the administration guidelines and score sheets for free on www.cahai.ca. If you do lunchtime sessions, I would suggest ½ hour summarizing the development and psychometric properties of the measure (the references are included on the site) or I can mail you the articles that you cannot get. You could purchase the administration DVD that we made, which is $29.00 plus shipping which is very good for demonstrating the measure, with an accuracy test included (which you can play a couple of times, have the therapist decide on the score, and then show them the answer. On the DVD everything in on menu. The other suggestion is to have a couple of patients. You administer the measure, and the watching therapists decide on a score, after looking at the administration guidelines. This prompts discussion so you could probably do this a couple times, with various types of clients ( e.g. someone with very little motor return , someone with mixed return, and a higher level individual).
I was just wondering how you interpret the scores from the different versions? I did this inventory on a client of mine and I do not know what to do with the score I got for her. Is there a standard score that I can check to see where she is functionally? Is there a range in the scores that says whether they are in the moderate range, maximum range, etc based on their score?
There are no standardized norms for the CAHAI for any of the versions. However, we know from the upper extremity literature that there is almost a perfect correlation between the degree of impairment and the resulting amount of function. For all the versions of the CAHAI (-7,8,-9-13) the lower the score, the greater impairment. For the CAHAI 13, a score of 13/91 would indicate that the client has no stabilization in the affected upper limb. The higher the scores, the more activity is detected. Your question would be a great research project, should you continue your studies. For true change to occur, the client would have to achieve a change of 6.3 points on the CAHAI (out of 91) to show real change in function. As the CAHAI is so sensitive to clinically important change, it is a great tool to show your client what to work on (reach, grasp, stabilization, beginning mobilization of arm or hand, etc) and then retest at a later date to see if your treatment was effective.
Could you email me guidelines for the application of the Chedoke Arm and Hand Activity Inventory. Could you also explain whether there is a relationship between this scale and the Chedoke-McMaster Stroke Assessment?
We now have a website (www.cahai.ca) where you can download the administration guidelines and score sheets for free. We also have an excellent training DVD available for $29.00 plus shipping. Some of the authors of the CMSA were also investigators for the CAHAI ( Barreca, Gowland, Stratford). The original idea of the CAHAI was to complete the CMSA as an activity measure of arm and hand function. However, in the end it was decided to keep the two measures separate. The relationship of the arm and hand CMSA stages to the CAHAI is almost 1:1, that is impairment to activity. If the client has little motor return, it is highly likely that the person will score very low on the CAHAI, and alternatively, if the individual has better motor recovery, they will perform better on the CAHAI.
We are now discovering the CAHAI with patients. It is really interesting. Unfortunatelly, it is really difficult to find the same glasses. Do you have any references? Is it possible to use sunglasses?
You can purchase eye-glasses in Canada in drug stores, dollar stores, etc. Sunglasses would do, as our reading glasses, etc. are getting thicker. We now have a website (www.cahai.ca) where you can download the administration guidelines and score sheets for free.
Do I have to make a poncho and vest or can I just purchase these items from a store?
Yes, you do have to make it. The outline is at the end of the administration guidelines.
We have been trialing the CAHAI and have managed to put together a kit for your scale. One major concern expressed by one of the researchers is the hygiene side of things. The scale does have a lot of fabric being used in it. In the current climate of tighter infection control regulations, what do you'll advise regarding using the kit between patients ? Do you advise they are washed before reuse ? This could be a limiting factor for use in hospital setting ? Please let us know your thoughts on this.
This is a good question. We usually have a couple of kits on the go. All patients are required to cleanse their hands prior to use. For those
patients with MRSA, there is a problem, as it is with everything in OT and PT. One then has to wash the poncho and vest, but if you have a couple of kits, then the measure can still be administered to others. The other solution is to use the CAHAI 7 which eliminates the poncho, but you still need to deal with the vest .. the other items in the kit can be cleaned with solution, and the towel can be a hospital one, to eliminate washing it. No perfect answer, but with a couple of extra vests made, I think it is still worthwhile to use the measure, as we know the clients really enjoy it.
Hi, I am a fourth year occupational therapy student from Australia doing a subject on outcome measures. I have chosen the CAHAI as my main outcome measures to evaluate. I am quite confused as to who the developers are. The one name that kept popping out was Susan Barreca, I was wondering if there are any other developers of the CAHAI, and when it is developed.
The original investigators were: Susan Barreca (prime), Carolyn Gowland, Paul Stratford, Maria Huijbregts, Jeremy Griffiths, Wendy Torresin, Magen Dunkley, Patricia Miller and Lisa Masters. We began in 1994 considering the theoretical constructs of the measure and what it would look like. The measure took 10 years in its development until our first paper was published in 2004. Cynthia Lambert and Dr.Streiner joined in as investigators at a later date.
would like to have information about the scoring of CAHAI. What does the total score mean? Is there chart that can help me to understand the score?
We have not done any studies that interpret range of CAHAI scores. However, as the relationship of impairment to function in the upper limb is almost 1: 1, you can deduct that the higher the score, the lesser the impairment. A score of 13/ 91 would indicate no ability to stabilize. A score close to 91 would indicate almost complete function. The higher the score, the greater the function.When you use the CAHAI, you will be fascinated to see how different items elicit different scores. It was intended to reflect the wide range of abilities, and especially capturing those clients who have severe impairment, showing them how they need to stabilize with their affected limb and then progress to some mobilizing. We know that our clients can perform most upper limb functional items one-handed; the CAHAI was intended to measure how much the paretic upper limb contributes to bilateral tasks. So there is certainly room for future research.
When the person uses the involved UE as a stabilizer is the highest score they can get a three? Is it easily to objectively measure how much assist the therapist is giving to the involved arm?
When the affected upper limb is only used as a stabilizer, the highest score is a 2. A score of 3 means that the therapist observes some type of manipulation occurring. In order to judge how much assistance the therapist is giving to her/his client, there is an element of judgement. We have provided details, but as with the FIM, the therapist has to calculate how much of the task the client is actually doing. A score of 4 indicates light touch, 3 is when the client is doing 50% of the task, etc. If the therapist is doing all the work, it is always a 1. It is probably the hardest to judge between a 2 or 3 ... 25% or more.
The role of the weak hand is composed by arm mobility/hand manipulation and stabilization. This role represents 100% of one hand performance. Does this mean that the two parts of components (Arm mobility and hand manipulation / Stabilization) are worth 50% each without consideration of the number of components in each part?
The upper limb is comprised of arm stabilization and manipulation, as well as hand stabilization and manipulation. We choose bilateral tasks only, so you could think of the completion of the task requiring 200% effect, 100% from each upper limb. We know that our clients can complete tasks one-handed, so the measure is intended to quantify how much the paretic upper limb does of its 100% of the task. To your question, not necessarily, the number of components can help you to identify approximate percentages of completion.
Should we give a minimum score of 3 if we see any components of Arm mobility and hand manipulation even if the paretic upper limb doesn’t realized 49% of the task?
Yes, as soon as you see any component of manipulation the minimum score is 3.
Should we consider a component of “arm mobility and hand manipulation” as a whole or as a part (e.g. Reaches and grasps)? As parts E.g. 1: If we observe a reach but not a grasp, should we have to consider the component filled in part or not at all? Filled in part E.g. 2: In task 4, if the patient reaches but not grasps and lifts glass off the table, should we consider that he demonstrates a component of mobility and manipulation?
Yes. The components should be considered as parts and so, each component can be partially completed. For example, you might see a reach without the grasp, or even partial completion (e.g. the patient is only able to partially reach).
In task 6 (Do up five buttons): A subject had fastened four buttons but, based on the component chart, he didn’t perform 75% of the effort to complete the task with his paretic upper limb. Should we give a score of 4 even he didn’t perform 75% of the effort to complete the task?
Indeed, in the description of the score 4, the term "OR" could suggest that if one of both possibilities is filled, a score of 4 should be given. In this case, you would have to factor in both of these things. If the patient completed 75% of the effort with the paretic upper limb for 4 of the buttons but was unable to complete the 5th (I assume for reasons of something like fatigue or unable to reach one button) then they would have completed 75% of 80% (or 60%). The descriptions of the scores are to be used as a guide of certain examples that you might see and are not meant as sole factors to decide on the score that is assigned.
In task 9 (Cut Medium Resistance Putty): A subject had shown some components of arm mobility and hand manipulation but cut only two pieces of putty. Should we give a score of 3? Does the client need to be able to cut 4 pieces or more to obtain a minimum score of 3?
No, once you see any component of hand manipulation, the minimum score would be 3
we understood that the patient has to complete entirely each task with the assistance of the assessor when necessary. Nevertheless, the description of the 7 points of activity scale suggests that some tasks could be not realized completely. What should we understand about the partial completion of the task suggested in the scoring? E.g. In task 6: Does this mean (as we think) that only the assessor does up the last button (if the client fastens four buttons with his both hand)? Or that the client could stop the task if he wants?
The client can complete only as much as they are able to but the item is then scored on only the parts of the task that they have completed. In the example you provided, regardless of whether the assessor does up the button or the client leaves it undone, the client did not complete this and therefore cannot get full score. The reason we encourage the assessor to assist is because at times it will allow the client to complete more of the task.
5 up – no physical assist:
5 -supervision, cueing i.e. especially for patients with apraxia or agnosias or cognitive difficulties, where motor-wise they are OK, but their cognitive deficits limits them. We see these types of patients, often the learned non-use ones that CIT targets. The CAHAI was intended to show meaningful change, and the efficacy of rehabilitation, so if on an initial assessment, the client could not complete the task without cueing, hopefully with training, the discharge assessment will reflect treatment progress
6- use of assistive devices, or extra time or safety (e.g. waving knife dangerously, unsteady on stairs carrying bag)
7 - the affected upper limb would have to perform its share of the bilateral task safely, without any aids (including the assistance of the therapist) and within a reasonable time.
4 and below involves physical assist, whether from the client’s other hand, the table, from the therapist,
- The most difficult to determine seems to be between 3 and 4, hence the DVD concentrates on this.
- A 1 is always easy, as there is no stabilization occurring
- 2- stabilization is observed
- 3 –one is seeing manipulation
- 4 is only light touch.
Please clarify how you score each item.
The idea behind the measure is to assess how much the paretic limb contributes to a bilateral task, assuming the left and right arm and hand each does 100% of a bilateral task. The first thing is to assess how the patient is using the arm and hand.. (a) to hold the coffee jar with stabilizing (holding) is the major component or a manipulator (twisting, turning, pinching, grasping, releasing, etc) by grasping the lid. When you decide that, then you look at the task component chart to see how much of the task the paretic limb is accomplishing. For example, if the patient chooses to hold the coffee jar, then you look under the guidelines that outline what is required for the holding of the coffee jar.. able to keep it off the table, holding it without any assistance from therapist or the table, able to reach for the jar, etc. If the patient uses his non paretic hand to bring the jar closer, then you already are scoring then lower. You then refer to the administration guidelines for the scoring. If the patient is unable to complete 24% of the task, they would get a 1, If they stabilized only, then a 2, if they showed signs of manipulation, at least a 3; if they need light touch (from the table, the therapist, their other hand), then a 4, if they needed cueing, coaxing, then a 5 (but no physical assistance); if safety was an issue or 3 times the normal time, then a 6, if they were able to complete the task in a timely fashion with no assistance, then a 7.
I was wondering what was the score when a patient is able to perform the
task without physical contact but tilt his trunk to raise (passively) his
arm . For exemple, the patient is able to hold jar off the table and use the
other hand to open the jar, without resting arms on the table but he tilt
his trunk on the healthy side (abd-flex compensation of the arm). Is it a 7
or a 4?
It is interesting
to look at the various tasks, and observe closely the different strategies
clients use to compensate for weakness and poor motor control. I would score
your client's performance as a 4, as he is performing 75% of the task, but
still unable to overcome the stronger flexor synergy.
I'm writting becsause we""ll begin the project for reliability evaluation
for the CAHAI Brazilian version. We have thinking about do the reliability from video and at the same time, to compare the pontuation done for the same evaluator
giving at the moment of evaluation and one week latter from the video. The inter-ratter reliability will be done only for the score take from the video. Do you agree that the reliability study from video it""ll be valid?? Please let us know as soon as you can because we""ll submit the project for evaluation.
Your project sounds very interesting. We have explored using videos to help determine reliability.
The largest source of variability when administering the measure, actually is the patient or client themselves. Videos actually remove much of this variability and therefore reliability testing done using video is most likely an overestimate (and probably a large one) of the reliability of the measure. We consulted with a colleague who is an expert in the measurement of psychometric properties of measures and he concurred that video is not the best way to go.
Before using this tool, we would need to translate it to Hebrew.
Therefore, we are requisitioning your permission to translate the assessment and instructions into Hebrew.
We plan to use the CAHAI in conjunction with other upper extremity assessments such as the Fugl-Meyer Motor Assessment and the Motor Activity Log. The correlations with these assessments will help to further validate this tool.
In our Lit search we found that you have published two articles regarding the validity and reliability of the CAHAI. Are there any more?
It is great that you want to translate the CAHAI into Hebrew. We are delighted, and would only ask that when it is completed, that you provide us either a copy of the translation or a link as we now have a website (www.cahai.ca). There are 4 articles in total on the development on the CAHAI. If you let me know which ones you have, I will send the others.