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Spatial information content and reliability of hippocampal CA1 neurons: effects of visual input.

The effects of darkness on quantitative spatial firing characteristics of 235 hippocampal CA1 "complex spike" (CS) cells were studied in young and old Fischer-344 rats during food-motivated performance of a randomized, forced-choice task on an eight-arm radial maze. The room lights were turned on or off on alternate blocks of all eight arms. In the dark, a lower proportion of CS cells had "place fields," and the fields were less specific and less reliable than in the light. A small number of cells had place fields unique to the dark condition. Like CS cells, Theta cells showed a reduction in spatially related firing in the dark. The specificity and reliability of the place fields under both light and dark conditions were similar for both age groups. Increasing the salience of the environment, by increasing the light level and the number of visual cues in the light condition, did not affect the specificity or reliability of the place fields. Even though all rats had substantial prior experience with the environment, and were placed on the maze center under normal illumination before the first dark trial, the correlation between the firing pattern in the light and dark increased after the rat first traversed the maze in the light. Thus, even after considerable experience with the environment over days, experiencing the illuminated environment from different locations on a given day was a significant factor affecting subsequent location and reliability of place fields in darkness. While the task was simple and errors rare, rats that made fewer errors (i.e., re-entries into the previously visited arm) also had more reliable place cells, but no such correlation was found with place cell specificity. Thus, the reliability of spatial firing in the hippocampus may be more important for spatial navigation than the size of the place fields per se. Alternatively, both spatial memory and place field reliability may be modulated by a common variable, such as attention.

Action Potentials↗

Reliability between two observers using a protocol for diagnosing essential tremor.

Protocols with demonstrated reliability have been established for the diagnosis of numerous movement disorders. whereas in the essential tremor (ET) literature, there is no discussion about the reliability of diagnostic protocols. Lack of knowledge of the reliability of diagnostic protocols in ET limits the use of these protocols because reliability is an essential requirement for scientific quality in data management. The objective of this study was to determine the reliability of a protocol for diagnosing ET. The protocol consists of a Tremor Interview, a videotaped Tremor Examination, and a diagnostic algorithm. Eighty-three subjects with ET, identified in a community-based health study in Washington Heights-Inwood, New York, were matched with 83 control subjects from the same community. These subjects and their relatives are being recruited to participate in the Washington Heights-Inwood Genetic Study of ET. Two hundred twenty-six subjects have been evaluated to date (35 ET cases, 40 controls, 151 relatives). All 226 underwent an 84-item Tremor Interview and 26-item videotaped Tremor Examination. Diagnoses (normal, possible ET, probable ET, definite ET) were independently assigned by two blinded neurologists specializing in movement disorders. The kappa statistic, k, was used to determine diagnostic agreement between these two neurologists. The concordance rate between two raters using diagnostic categories definite ET, probable ET. possible ET, and normal was 80%; kw = 0.84 (near perfect to perfect agreement). The concordance rate between two raters using two diagnostic categories (definite ET and normal) was 100%; k = 1.00 (perfect agreement). There was high correlation between the two raters' total tremor scores (r = 0.89, p < 0.00001). This diagnostic protocol is highly reliable. Research in ET would greatly benefit from diagnostic protocols with demonstrated reliability.

Adolescent↗

Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects.

BACKGROUND AND PURPOSE: A new parallelogram goniometer was designed by the Rehabilitation Centre of the Royal Ottawa Health Care Group in 1983. The advantage of using such a goniometer is that the clinician is not required to estimate the joint axis of rotation when taking a measurement. The parallelogram goniometer has obtained a good intratester and intertester reliability when measuring active range of motion of hip abduction on eight individuals with hip pathologies. However, the validity of the parallelogram goniometer has not been examined. The purposes of this study were to examine the intratester and intertester reliability and the criterion validity of the parallelogram and universal goniometers for active knee flexion on healthy individuals. SUBJECTS: Sixty healthy university students (44 females and 16 males; mean age of 20.6 yrs.) participated to this study. METHODS: Measurements with the universal and parallelogram goniometers were taken in two different positions, the smaller and larger angles of active knee flexion. All measurements were taken by two trained testers. A radiograph was taken in both positions to serve as the 'gold standard'. The sequence of the measurements and radiographs were randomly selected. The intra and intertester reliability of both goniometers were established by calculating the intraclass correlation coefficients (ICCs) using the repeated-measures ANOVA. The criterion validity was examined by calculating Pearson product-moment correlation coefficients (tau) between each goniometric and radiologic measurements. A 0.05 level of significance was chosen for each statistical test. RESULTS: Intratester reliability ranged from good to excellent for the small angles (ICC = 0.85 and 0.87) and the large angles (ICC = 0.91 and 0.96) when using the parallelogram goniometer. Intertester reliability was fair for the small angles of flexion (ICC = 0.43 to 0.52) and good to excellent for the large angles of flexion (ICC = 0.82 to 0.88). The parallelogram goniometer was found to have greater validity when measuring the large angles of knee flexion (r = 0.73 and 0.77) compared to the small angles of knee flexion (r = 0.33 and 0.41). Similar results of reliability and validity were obtained with the universal goniometer. CONCLUSION: The results of this study have clinical importance. The use of the parallelogram goniometer was found to be as reliable and valid as the universal goniometer when measuring active knee flexion. However, the parallelogram goniometer offered clinicians the advantages of obtaining precise angular measurements with fewer adjustments, and a faster application technique. Further studies on the parallelogram goniometer are necessary among individuals presenting with altered range of motion at different joints.

Adult↗

Reliability of self-reported breast screening information in a survey of lower income women.

BACKGROUND: Self-reported behavior is widely used to estimate the prevalence of breast cancer screening and to evaluate programs for promoting screening, but detailed studies of reliability have not previously been performed. METHODS: Reliability was assessed by comparing responses to questions about screening behavior from repeat personal interviews of 382 women age 40 and older living in low-income census tracts of two Florida communities. Reliability was assessed using Pearson's correlation (r) and kappa (kappa) coefficients. RESULTS: Estimated reliabilities were kappa = 0.38 for "ever had clinical breast examination," kappa = 0.82 for "ever had mammogram," kappa = 0.65 for "mammogram in past year," r = 0.54 for "date of last mammogram," and r = 0.72 for "number of mammograms." The dates of last mammogram reported at the two interviews agreed within 1 month for 64% of the women, while the dates of last clinical breast examination agreed within 1 month for 50% of the women. Reliability of "ever had mammogram" was significantly related to demographic variables. CONCLUSIONS: Women reliably report ever having mammography, but information about timing and frequency has lower reliability. The results have implications for breast screening research because measurement error affects the precision of estimates and the sample sizes needed to detect program effects.

Adult↗

Reliability of psychophysiological responding as a function of trait anxiety.

This study examined the temporal stability of three psychophysiological responses (frontal electromyographic activity, hand surface temperature, and heart rate) recorded over four sessions (days 1, 2, 8, and 28) on 34 subjects, 17 with high Spielberger Trait Anxiety Inventory scores and 17 with low scores. Each session consisted of a 20-minute adaptation period, a baseline condition, and two stressors (one cognitive, the other physical). Two forms of reliability coefficients were employed, intraclass correlations and Pearson Product Moment; the two types of reliability coefficients arrived at the same conclusions. Results indicated that reliability coefficients for the two anxiety groups did not differ on frontal EMG or heart rate responses; however, hand surface temperature responding was considerably less reliable for high anxious individuals than low anxious individuals. Reliability coefficients on absolute scores were, for the most part, reliable. Treating the responses as relative measures (percent change from baseline or simple change scores from baseline) produced smaller and less reliable coefficients. Magnitudes of the three physiological responses did not significantly differ as a function of high or low trait anxiety. Findings are discussed in terms of their clinical, as well as basic psychophysiological, importance.

Adult↗

Reliability and validity of clinical outcome measurements of osteoarthritis of the hip and knee--a review of the literature.

High reliability and validity of clinical rating schemes is crucial for their use as outcome measurements of treatment of hip and knee osteoarthritis. In this paper, we review the empirical evidence on the reliability and validity of commonly used clinical scores. Clinical scores and related reliability and validity studies were identified by systematic literature search. Scores were classified according to the type and joint. Reliability and validity studies were characterized according to design, population, number and qualification of observers, number of measurements, time interval between repeat measurements and results. Reliability and validity studies were reported for only 6 and 15 of the 45 identified clinical scores, respectively. Although comparisons are difficult due to differences in study design, relatively high reliability was reported for most measurements of pain, stiffness, and physical function, while results are less conclusive for clinical signs. Most validity studies focused on the correlation between various scores. Correlation was generally found to be high for overall numerical ratings, but scores often differed with respect to the interpretation of these ratings. Validity has been more comprehensively studied for Lequesne's scores, WOMAC, and ILAS, and these scores have shown satisfactory responsiveness to different treatment effects. Overall, knowledge on reliability and validity of clinical scores of hip and knee osteoarthritis is limited, underlining the need for further properly designed and conducted studies.

Hip↗

Reliability of the Health Utilities Index--Mark III used in the 1991 cycle 6 Canadian General Social Survey Health Questionnaire.

This study presents information on the test-retest reliability of the Health Utility Index--Mark III (HUI) system used in cycle 6 of the Canadian General Social Survey (GSS). The HUI system used in this reliability study consists of an eight-attribute health status classification system (HSCS) and a function for generating a summary score of health-related quality of life. To estimate test-retest reliability, a stratified random sample of individuals (n = 506) completing GSS telephone interviews during August and September, 1991 were interviewed again 1 month later. Weighting adjustments based on the probability of selection were invoked during the analyses to provide unbiased estimates of test-retest reliability for all GSS respondents in the August-September period. The results indicate that the individual questions, attributes and provisional index scores generally provided reliable information on health status in the GSS. The exceptions to this were limitations in speech and dexterity which were reported very infrequently. Kappa estimates of test-retest reliability for individual questions varied from 0.184 to 0.766. For the eight attributes, kappa estimates varied from 0.137 to 0.728. Using the provisional index scores to quantify health overall, a test-retest reliability of 0.767 was obtained (intra-class correlation coefficient).

Activities of Daily Living↗

Factors affecting the reliability of ratings of students' clinical skills in a medicine clerkship.

OBJECTIVE: To determine the overall reliability and factors that might affect the reliability of ratings of students' clinical skills in a medicine clerkship. DESIGN: A nine-item instrument was used to evaluate students' clinical skills. Raters were also asked to provide a grade of each student's overall clinical performance. Generalizability studies were performed to estimate the reliability of the ratings. The effects of rater experience and clerkship setting were investigated by regression analysis. SETTING: Teaching hospitals and community-based sites in three Northwestern states. PARTICIPANTS: All students (328) who had completed the 12-week clerkship in internal medicine at one medical school during the academic years 1987-1989. Raters included attending physicians, chief residents, and other residents. RESULTS: Seven observations were needed to provide a reliable rating of the overall clinical grade. More observations were needed to obtain reliable ratings for individual items, ranging from seven observations needed for the rating of data gathering skills to 27 observations needed for the rating of interpersonal relationships with patients. Rater experience and clerkship setting (i.e., teaching hospitals vs. community-based clinics) were found, in general, not to affect significantly the ratings received by students. CONCLUSIONS: Reliable ratings of students' overall clinical skills, including overall clinical grades, can be achieved by collecting a minimum of seven observations. More observations are needed to measure reliably the interpersonal aspects of clinical performance. These findings support the use of performance ratings to evaluate clinical skills and knowledge of students in clerkship settings.

Clinical Clerkship↗

Reliability of the timeline follow-back sexual behavior interview.

The reliability of self-reported sexual behavior is a question of utmost importance to human immunodeficiency virus (HIV) prevention research. The Timeline Follow-Back (TLFB) interview, which was developed to assess alcohol consumption on the event level, incorporates recall-enhancing techniques that result in reliable information. In this study, the TLFB interview was adapted to assess HIV-related sexual behaviors and their antecedents, and its reliability was assessed. The interview was administered to 110 participants (46% women, M age = 19.7; range = 18-41), and 58 participants who reported sexual behavior during the previous three months returned one week later for a second interview. Test-retest intraclass correlations (rho) from the TLFB protocol showed that all sexual behaviors were reported reliably (rho range = .86 to .97, median = .96). Bootstrapping, a nonparametric statistical technique, was used for significance testing in the reliability analyses. Reliability was equivalent across each of the three months assessed with the TLFB and was equivalent to conventional assessment methods (i.e. single-item questions). These findings show that the TLFB sexual behavior interview provides reliable reports of sexual behavior over three months and yields event-level data that are extremely valuable for sexual behavior and HIV-prevention research.

Adolescent↗

Inter- and intrajudge reliability of a clinical examination of swallowing in adults.

This study investigates inter- and intrajudge reliability of a clinical examination of swallowing in adults. Several investigations have sought correlations between clinical indicators of dysphagia and the actual presence of dysphagia as determined by videofluoroscopy. Whereas some investigations have reported interjudge reliability for the videofluoroscopic measures employed, none have reported reliability for clinical measures. Without established reliability for rating clinical measures, conclusions drawn regarding the utility of a measure for detecting aspiration can be called into question. Results of the present study indicate that fewer than 50% of the measures clinicians typically employ are rated with sufficient inter- and intrajudge reliability. Measures of vocal quality and oral motor function were rated more reliably than were history measures or measures taken during trial swallows. There is a need to define more clearly the measures employed in clinical examinations and to be consistent in reporting reliability for clinical measures of swallowing function in future research.

Adult↗

Reliability of goniometric measurements and visual estimates of ankle joint active range of motion obtained in a clinical setting.

We examined intratester and intertester reliability for goniometric measurements of ankle dorsiflexion (ADF) and ankle plantar flexion (APF) active range of motion (AROM). Parallel-forms intratester reliability for ankle AROM measurements obtained by the universal goniometer (UG) and by visual estimation (VE) and intertester reliability for VE of ADF and APF were examined. Repeated measurements were obtained on 38 patients with orthopedic problems by 10 physical therapists in a clinical setting. For intratester reliability of measurements obtained with UG, intraclass correlation coefficients (ICC) for all physical therapists were 0.64 to 0.92 (median, 0.825) for ADF and 0.47 to 0.96 (median, 0.865) for APF. Intertester reliability was quantified with use of ICC. ICCs for measurements obtained by UG were 0.28 for ADF and 0.25 for APF; ICC of VE for ADF was 0.34 and was 0.48 for APF. ICC for parallel-forms intratester reliability obtained with UG and VE ranged from 0 to 0.94 (median, 0.58) for ADF and 0 to 0.86 (median, 0.625) for APF. Thus, a physical therapist should use a goniometer when making repeated measurements of ankle joint AROM. Considerable inconsistency exists when two or more physical therapists make repeated goniometric and visual measurements of ankle motion on the same subject. Physical therapists may erroneously conclude that a patient's AROM has changed because of treatment when the change could be attributed to a lack of intertester reliability.

Adolescent↗

Reliability of the TIP and DIP speech-hearing tests for children.

The reliability of SRT and speech intelligibility tests has been studied on adults. Reliability estimates for SRT are between .60 and .90, with standard error estimates from 1.5 to over five dB. For speech intelligibility tests the reliability estimates range from .50 to 90, with standard error of estimates from 2.5% to over 10%. Little has been reported on test reliability with children. For this study the TIP and DIP tests, for threshold and discrimination, respectively, were given to 295 normal and 138 hypacusic children three through twelve years of age. Subjects were retested within one week. TIP test-retest reliability was .72 for normals, and .89 to .99 for hypacusics. DIP test-retest reliability was .46 to .51 for normals and .60 to .93 for hypacusics. Standard error of estimate was about 3 dB for TIP, and 10% for DIP. These values are about the same as the reliability values for adults.

Child↗

Assessing clinical signs of temporomandibular disorders: reliability of clinical examiners.

Data on interrater reliability in assessing a number of clinical signs commonly evaluated in the diagnosis and treatment of temporomandibular disorders (TMD) is presented in this article. Four experienced dental hygienists who were field examiners for a large epidemiologic study of TMD and three experienced clinical TMD specialists (dentists) who are coinvestigators in the same study followed carefully detailed specifications and criteria for examination of TMD patients and pain-free controls. Excellent reliability was found for vertical range of motion measures and for summary indices measuring the overall presence of a clinical sign that could arise from several sources (for example, summary indices of muscle palpation pain). However, many clinical signs important in the differential diagnosis of subtypes of TMD were not measured with high reliability. In particular, assessment of pain in response to muscle palpation and identification of specific temporomandibular joint sounds seemed to be possible only with modest, sometimes marginal, reliability. These modest reliabilities could arise from examiner error because the clinical signs are themselves unreliable, changing spontaneously over time and making it difficult to find the same sign on successive examinations. The finding that, without calibration, experienced clinicians showed low reliability with other clinicians suggests the importance of establishing reliable clinical standards for the examination and diagnostic classification of TMD.

Adult↗

PRES- and orthostatic-induced heart-rate changes as markers of labile hypertension: magnitude and reliability measures.

Split-half and test-retest reliabilities of heart-rate responses to a baroreceptor manipulation and an orthostatic maneuver were compared between subjects with either normal or elevated blood-pressure. Ten subjects showing elevated resting blood-pressure and II normotensive subjects participated in two experimental sessions, each including heart-rate recordings during baroreceptor manipulation and orthostatic challenge. Carotid baroreceptors were manipulated by applying the baroreceptor-specific phase-related external suction (PRES) technique. The orthostatic stimulation procedure (OSP) was a change of body position from lying to standing. Heart rate responses evoked by OSP failed to discriminate significantly between the groups either in the magnitude or the (test, retest) reliability measure. The PRES procedure also failed to discriminate with the conventional magnitude measure, but the reliability measures showed significant differences. Paradoxically, the high-blood-pressure group manifested the higher baroreceptor reliability. The present findings are consistent with the view that operant conditioning produces phasic blood-pressure increases. In this view, blood-pressure increases activate the arterial baroreceptors which, in turn, dampen pain and/or stress sensitivity. Individuals showing high consistency (reliability) in their cardiovascular responses are more likely to learn this form of conditioning, and hence to eventually increase their tonic blood-pressure. High reliability of cardiovascular responses may therefore constitute a risk for hypertension. Aside from such theoretical considerations, the findings indicate that less conventional dependent variables like reliability may be worth exploring in the search for the etiology of essential hypertension, and that, in this search, specificity (relative to baroreceptor function) is more important than the magnitude of the heart-rate changes that are produced.

Adult↗

Reliability of in vivo volume measures of hippocampus and other brain structures using MRI.

Volume reductions of the hippocampus are associated with Alzheimer's disease, schizophrenia, and epilepsy. We used clinically available MRI methods (2D acquisition; inversion recovery and calculated T2 images; 3 mm contiguous slices) that optimize image contrast, quality, and resolution and standardized positioning protocols to maximize the in vivo accuracy (test-retest reliability) of brain volume measurements in volunteers who were scanned two or three times. Volunteers were scanned in the same MRI instrument (intrascanner reliability) as well as in two different instruments (interscanner reliability). A single rater obtained brain volume measures of seven contiguous slices centered on the anterior commissure. The in vivo intrascanner reliability for measures of anterior hippocampus and ventricular volumes was very good, with reliability coefficients [intraclass r (rxx)] ranging between .855 and .997, and a median coefficient of variation (CV) of 6.4%. Reliability was good for amygdala (rxx of .740 and .764) and for total frontal and temporal lobe volumes and white matter volume measures (rxx ranging between .640 and .823, median coefficient of variation was 3.2%). Overall, interscanner reliability was also good. We discuss the implications of our results relative to the possible clinical utility of hippocampal quantification and the feasibility of prospective studies aimed at quantifying progressive neurodegeneration.

Adult↗

Psychological measures: reliability in the assessment of stroke patients.

OBJECTIVE: To determine whether acute stroke patients can give reliable responses to standardized psychological measures. DESIGN: Survey design with retrospective review of Neurobehavioral Cognitive Status Examination (NCSE) scores. SETTING: A rehabilitation hospital in Philadelphia. PATIENTS: 106 consecutive admissions to stroke services at a rehabilitation hospital were evaluated according to the following inclusion criteria: Patients at least 65 years of age, English speaking, having a documented history of cerebrovascular accident (CVA), possession of receptive speech comprehension, and the ability to maintain attention adequate for participation in the study interview. Of the 47 eligible for participation, 10 patients refused participation and 13 were discharged before the interview could be completed. Thus 24 patients were interviewed, with one patient unable to complete the second half of the interview. MAIN OUTCOME MEASURES: In phase 1, the patient's performance on a structured interview (including the Multidimensional Health Locus of Control Scales (MHLC), Life Orientation Test (LOT), and Center for Epidemiological Studies Depression Scale (CES-D) scales) produced a Total Reliability Score, indicating the overall reliability of the patient's responses. In phase 2, NCSE scores were examined (retrospectively) for their ability to predict the patient's Total Reliability Score on the structured interview. RESULTS: Using Total Reliability Scores, 9 patients were categorized as "passing," 9 were categorized as "uncertain," and 5 were categorized as "failing" the interview. The NCSE was predictive for individuals who had a very low likelihood of being able to respond consistently. The NCSE failed to identify which individuals would respond in a reliable fashion. CONCLUSIONS: It is both possible and important to assess response reliability when using psychological measures soon after stroke. Future research will need to document other potential predictors of interview performance, including combinations of NCSE subscales.

Aged↗

Cumulative trauma disorders in the upper extremities: reliability of the postural and repetitive risk-factors index.

OBJECTIVE: This study addresses test-retest reliability of the Postural and Repetitive Risk-Factors Index (PRRI) for work-related upper body injuries. This assessment was developed by the present authors. DESIGN: A repeated measures design was used to assess the test-retest reliability of a videotaped work-site assessment of subjects' movements. SUBJECTS: Ten heavy users of video display terminals (VDTs) from a local banking industry participated in the study. SETTING: The 10 subjects' movements were videotaped for 2 hours on each of 2 separate days, while working on-site at their VDTs. MAIN OUTCOME MEASURE: The videotaped assessment, which utilized known postural risk factors for developing musculoskeletal disorder, pain, and discomfort in heavy VDT users (ie, repetitiveness, awkward and static postures, and contraction time), was called the PRRI. The videotaped movement assessments were subsequently analyzed in 15-minute sessions (five sessions per 2-hour videotape, which produced a total of 10 sessions over the 2 testing days), and each session was chosen randomly from the videotape. The subjects' movements were given a postural risk score according to the criteria in the PRRI. Each subject was therefore tested a total of 10 times (ie, 10 sessions), over two days. The maximum PRRI score for both sides of the body was 216 points. RESULTS: Reliability coefficients (RCs) for the PRRI scores were calculated, and the reliability of any one session met the minimum criterion for excellent reliability, which was .75. A two-way analysis of variance (ANOVA) confirmed that there was no statistically significant difference between sessions (p < .05). Calculations using the standard error of measurement (SEM) indicated that an individual tested once, on one day and with a PRRI score of 25, required a change of at least 8 points in order to be confident that a true change in score had occurred. The significant results from the reliability tests indicated that the PRRI was a reliable measurement tool that could be used by occupational health practitioners on the job site.

Adult↗

The Arm Motor Ability Test: reliability, validity, and sensitivity to change of an instrument for assessing disabilities in activities of daily living.

OBJECTIVE: To continue and expand determination of the reliability, validity, and sensitivity to change of the Arm Motor Ability Test (AMAT), an instrument for assessing deficits in activities of daily living (ADL). DESIGN: The AMAT was administered twice to patients, with an interest interval of either 1 or 2 weeks, by one of two examiners assigned to patients in counterbalanced order. Patients' interest intervals and scores on the arm portion of the Motricity Index was unknown to the raters. SETTING: A referral inpatient neurological rehabilitation center. PATIENTS: Thirty-three subacute stroke inpatients with moderate to mild upper extremity motor deficit: median Motricity-Index-Arm score = 89, median chronicity = 43d, median age = 66yr; 12 were women. MAIN OUTCOME MEASURE AND RESULTS: The AMAT was developed in 1987, and interrater reliabilities at that time were found to range from .95 to .99. The present values for interrater reliability (2 scales) from videotaped test performance were: kappas = .68 to .77. Spearman correlations = .97 to .99. For performance time, interscorer reliability from videotaped test performance was .99. Homogeneities for the three AMAT measures for the total sample (Cronbach's alpha and split-half reliability) were .93 to .99. The test-retest reliabilities for the total sample were .93 to .99. The correlations to the Motricity-Index-Arm score were .45 to .61. The AMAT detected the difference in change occurring as a result of the passage of 1 versus 2 weeks in these subacute inpatients, presumably as a result of intensive therapy and/or spontaneous recovery, confirming the results of an earlier intervention study. CONCLUSION: The AMAT is an instrument with high interrater reliability, internal consistency, and sensitivity to change, as well as having satisfactory concurrent validity.

Activities of Daily Living↗