Skip to main content
  

Rehab Measures: Fugl-Meyer Assessment of Motor Recovery after Stroke

Link to instrument

Scoring sheet can be obtained from the American Physical Therapy Association (external link) 

Title of Assessment

Fugl-Meyer Assessment of Motor Recovery after Stroke 

Acronym

FMA

Instrument Reviewer(s)

Summary Date

 

Purpose

  • Evaluates and measures recovery in post-stroke hemiplegic patients
  • Used in both clinical and research settings
  • One of the most widely used quantitative measures of motor impairment (Gladstone et al, 2002)

Description

  • Items are scored on a 3-point ordinal scale
    • 0 = cannot perform
    • 1 = performs partially
    • 2 = performs fully
  • Maximum Score = 226 points 
  • The Five domains assessed include:
    • Motor function (UE maximum score = 66; LE maximum score = 34)
    • Sensory function (maximum score = 24)
    • Balance (maximum score = 14)
    • Joint range of motion (maximum score = 44)
    • Joint pain (maximum score = 44)
  • Subscales can be administered without the using the full test
  • Modified (abbreviated) versions have been developed (Hsueh et al, 2008)

Area of Assessment

Activities of Daily Living; Functional Mobility; Pain 

Body Part

Not Applicable 

ICF Domain

Body Function 

Domain

Motor; Sensory 

Assessment Type

Observer 

Length of Test

06 to 30 Minutes 

Time to Administer

30 minutes (shortened versions > 10 minutes)

Number of Items

226 items across 5 domains 

Equipment Required

The FMA Motor Test requires:

  • Tennis ball
  • A small spherical shaped container
  • A tool to administer reflex tests
  • Enough space is needed for a patient to move around freely
  • If possible, space should be a quiet, private room with few distractions

Training Required

Review of manual

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Nominal - cost of equipment only

Age Range

Adolescent: 13-17 years; Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Stroke 

Populations Tested

The FMA was designed for post-stroke hemiplegic patients of all ages

Standard Error of Measurement (SEM)

Stroke
(Sanford et al, 1993; n = 12; mean age = 66 years; stroke onset < 6 months, Acute Stroke)
  • FMA total scores: 9.4

Minimal Detectable Change (MDC)

Stroke:
(Wagner et al, 2008, n = 14, mean age = 59.9 (14.6) years, assessed on average 14 (6.5) months post stroke, Chronic Stroke)
  • FMA = 5.2 points for the Upper Extremity portion of the assessment

Minimally Clinically Important Difference (MCID)

Stroke:

(Shelton et al, 2001; n = 171; mean age 70 (11) years; assessed within 17 (12) days of stroke, Acute Stroke)

FMA Motor Scores from Admission to Discharge

  • 10 point increase in FMA Upper Extremity = 1.5 change in discharge FIM
  • 10 point increase in FMA Lower Extremity = 1.9 change in discharge FIM

Cut-Off Scores

Stroke:

(Duncan et al, 2000; n = 459; mean age = 70 (11.4) years; stroke onset within 14 days, Acute Stroke)

Six month outcomes by modified Rankin classifications
Rankin
1
2
3
4
5
6
Fugl-Meyer
99.31 (1.49)
91.76 (9.51)
82.94 (17.18)
62.58 (24.04)
39.15 (25.42)
16.69 (23.89)
NIH
0.07 (0.27)
0.78 (1.12)
2.06 (1.63)
3.93 (2.55)
7.94 (4.80)
18.71(11.74)
Barthel
99.23 (1.88)
98.97 (2.83)
96.52 (5.08)
83.40 (13.50)
42.83 (18.25)
6.43 (8.86)
SF36-PFI
85.38 (9.46)
70.12 (21.06)
54.23 (22.98)
29.38 (21.04)
8.68 (11.87)
1.67 (4.08)

Normative Data

Stroke:

(Duncan et al, 2000, Acute Stroke)

Percent of cohort that achieved recovery
NIH<1
Fugl-Meyer>90
Barthel>90
SF36 Female PFI>66
SF36 Male PFI>75
Rankin<1
Rankin<2
Baseline
10.46
13.07

8.06

0.00
0.00
1.74
12.20
1 Month
16.78
12.85
26.14
9.44
12.08
5.45
21.57
3 Month
11.11
7.84
13.94
10.73
11.59
9.80
12.85
6 Month
6.54
3.05
9.15
3.86
4.83
7.41
7.19
Never
55.10
63.20
42.70
76.00
71.50
75.60
46.20

Test-retest Reliability

General Rehab Sample: 

(Platz et al, 2005; n = 37 stroke, 14 MS, and 5 TBI patients; assessed twice within a 7 day interval, General Rehab Sample)

  • Excellent Total Motor Score (ICC = 0.97)
  • Excellent Sensation (ICC = 0.81)
  • Excellent Passive Joint motion (ICC = 0.95)

Interrater/Intrarater Reliability

Stroke:
(Duncan et al, 1983; n = 19; mean age = 56 (13) years; same PT rating on 3 occasions each 3 weeks apart; VA sample, Chronic Stroke)
Interrater Reliability
Rating
Doman
Pearson's r
Excellent
FMA total score
r = 0.98-0.99
Excellent
Upper Extremity
r = 0.995 - 0.996
Excellent
Lower Extremity
r = 0.96
Excellent
Sensation
r = 0.95 - 0.96
Excellent
Joint Range / Pain

r = 0.86 - 0.996

Excellent
Balance
r = 0.89 - 0.98
 
Excellent Interrater Reliability:
(Duncan et al, 1983; 4 PT's using the above sample)
FMA Domain
Pearson's r
Upper Extremity
r = 0.98 - 0.995 
Lower Extremity
r = 0.89 - 0.95
(Sanford et al, 1993; n = 12; mean age = 66 (11.5) years;  0 to 6 months post stroke, Acute Stroke)
  • Excellent interrater reliability, FMA Total Score: (ICC = 0.96)

Rating
FMA Domain
ICC
Excellent
Upper Extremity
0.97
Excellent
Lower Extremity
0.92
Adequate
Sensation
0.85
Adequate
Joint Range of Motion
0.85
Poor
Pain
0.61

Internal Consistency

Stroke:
(Lin et al, 2004; n = 176; mean age = 67.9 (10.9) years; assessed 14, 30, 90 and 180 days after stroke, Acute Stroke)
  • Excellent internal consistency: alpha = 0.94 to 0.98 across 4 administrations
Subsection to FMA Total Score Correlations:
(Wood-Dauphinee et al, 1990; n = 167; assessed at admission and 5 weeks)
  • Excellent correlation : Upper Extremity & FMA Total (r = 0.97)
  • Excellent correlation: Mower Extremity & FMA Total (r = 0.90)
  • Adequate correlation: Balance & FMA Total (r = 0.88)

Criterion Validity (Predictive/Concurrent)

Stroke:

(Malouin et al, 1994; n = 32; mean age = 60; mean time since stroke = 64.5 days, Acute Stroke)

  • Excellent FMA & Motor Assessment Scale (MAS) total score correlations (r = 0.96)  
  • Poor FMA & MAS sitting balance item correlations (r = -0.10)
  • Motor and sensory FMA scores 5 days post-stroke were the strongest predictor of motor recovery 6 months post-stroke (Duncan et al, 1992)

 

Gait Speed (Nadeau et al, 1999; n = 16; mean age = 47.9 (15.6) years; mean number of months post-stroke = 43.9, Chronic Stroke)

  • Poor correlations between FMA Sensation and Gait speed (r = 0.05) and comfort (r = 0.14)
  • Excellent correlations between FMA total motor scores and gait speed (m = 1.09 meter per second; r = 0.61); and comfort (m = 0.76 meters per second; r = 0.61)

Construct Validity (Convergent/Discriminant)

Stroke:
Acute Stroke:
  • Excellent correlation: modified Balance Subscale on FMA and the Barthel Index; r = 0.86 - 0.89 (Mao et al, 2002)
  • Excellent correlation: FMA and Functional Independence Measures (FIM) administered to 172 inpatients who had recently had a stoke; r = 0.63 (Shelton et al, 2000)
  • FMA effectively distinguished between three levels of self care (Independent, Partly Dependant, and Dependant) in a sample of 109 recent (< 90 days) stroke survivors (Bernspang et al, 1987).
  • FMA was a better measure of higher-level recovery than the MAS (Malouin, et al, 1994)
 
Chronic Stroke
 (Dettmann et al, 1987; n = 15; mean age = 64 years; mean time since stroke, 2 years, Chronic Stroke)
  • The FMA and the Barthel Index were used to assess a group of 15 participants at an average of 2 years post stroke.  Correlations between the measures were excellent (r = 0.67). The strongest correlations were observed in the Balance subscore (r = 0.76) the Upper Extremity subscore of the motor domain (r = 0.75) and FMA Motor total score (r = 0.74)
 
(Hsieh et al, 2009; onset > 6 months, Chronic Stroke)
FMA Construct Validity (Spearman's rho followed by 95% CI)
  • Excellent correlation between FMA and Action Research Arm Test: 0.73** (0.58, 0.83)
  • Excellent correlation between FMA and Wolf Motor Function Test-TIME: 0.76** (0.63, 0.86)
  • Excellent correlation between FMA and Wolf Motor Function Test-Functional Ability Scale: 0.71** (0.56, 0.82)
  • Adequate correlation between the FMA and FIM-motor: 0.49** (0.27, 0.66)
*P < 0.05
**P < 0.01

Content Validity

Stroke:
(Woodbury et al, 2008; n = 377; men age = 69.2 (11.2) years, Acute Stroke)
Upper extremity (modified version, 3 reflex items removed)
  • Administered at admission and 6-months post stroke
  • Rasch Analysis demonstrated adequate fit for each of the 30 items except the hook grasp item
  • Results suggest items contained in modified FMA, (except the hook grasp item) were assessing the same underlying construct
 
(Crow et al, 2008; n = 62; retrospective analysis, Chronic Stroke)
Upper and lower-extremity (excluding balance) portions of FMA: 
  • Items within a scale are valid, unidimensional and cumulative
  • Results suggest that if a patient is able to successfully complete an item of a certain difficulty, that same patient should be able to complete less difficult items,  implying that a shortened administration of the FMA may produce valid results

Face Validity

Gladestone et al, 2002: 
  • Face and content validity for the motor domain are "very good"
  • Scaling is heavily weighted for the upper extremity
  • Reflexes may be overrepresented in the scoring system

Floor/Ceiling Effects

Stroke: (Lin et al, 2004, Acute Stroke)
  • Ceiling effects have been observed with the Sensation subscore. The following percentages of acute stroke patients reaching the highest possible score:
Days Post Stroke
% Highest Possible  Score
14-30  days
44.4%
14-180 days
72.1%
30-90  days
48.9%
90-180 days
48.9%
90-180 days
 62.7%

  • Possible ceiling effects on hand and lower extremity items (Gladstone, et al, 2002).
  • Floor effects have been reported for the modified Balance domain.  The strongest effects were observed 14 days post stroke with 29.3% of participants not able to achieve the lowest possible score on the measure (Mao et al, 2002)

Responsiveness

Stroke:

(Mao et al, 2002, Acute Stroke)

  • Excellent on the modified version of the FMA Balance score
    • Between assessments at 14, 30, 90 and 180 days post-stroke
    • Responsiveness decreased as the time between stroke and assessments increased

Moderate to Low: (Lin et al, 2004) responsiveness was found for the Sensation subscale of the FMA as assessed by Standardized Response Means (SRM).

  • Means were low at:
    • 14-30 days: SRM = 0.42
    • 30-90 days: SRM = 0.43
    • 90-180 days: SRM = 0.27  
  • Moderate responsiveness when assessed from 14 to 180 days (SRM = 0.67)

(Hsueh et al, 2009, Chronic Stroke)

  • Small to moderate  effect sizes were observed on the FMA, the Stroke Rehabilitation Assessment of Movement instrument (STREAM) and each of the measures shortened versions. 
  • Moderate effect sizes on the shortened version of both measures (0.53 and 0.51)
  • Small effect sizes on the long version of the measure  (0.045 and 0.38)

Professional Association Recommendations

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 (VEDGE) 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

HR

HR

HR

 

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

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

HR

HR

HR

HR

HR

 

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

Yes

Yes

Yes

Not reported


Considerations

Limitations: (Gladstone et al, 2002)

  • The Sensation, Balance, Joint Range of Motion and Joint Pain domains have been criticized as less well suited for this instrument given its intended purpose
  • Joint Range of Motion may be a confounding variable, so the inclusion of the Joint Pain domain may be unnecessary
  • Distal fine motor functions may be underrepresented
  • Finger movement not assessed (but gross hand function is included)
  • Arm scores are more heavily weighting the leg scores
  • Better measure of balance are now available
  • Inclusion of subjective items on the Sensation and Joint Pain domains may reduce the measures reliability
  • The Sensory Scale’s psychometric properties suggest that is should NOT be used to assess stroke patients (Lin et al, 2004)
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Bernspang, B., Asplund, K., et al. (1987). "Motor and perceptual impairments in acute stroke patients: effects on self-care ability." Stroke 18: 1081-1086. Find it on PubMed

Crow, J. L. and Harmeling-van der Wel, B. C. (2008). "Hierarchical properties of the motor function sections of the Fugl-Meyer assessment scale for people after stroke: a retrospective study." Phys Ther 88: 1554-1567. Find it on PubMed

Dettmann, M. A., Linder, M. T., et al. (1987). "Relationships among walking performance, postural stability, and functional assessments of the hemiplegic patient." Am J Phys Med 66: 77-90. Find it on PubMed

Duncan, P. W., Goldstein, L. B., et al. (1992). "Measurement of motor recovery after stroke. Outcome assessment and sample size requirements." Stroke 23(8): 1084-1089. Find it on PubMed

Duncan, P. W., Lai, S. M., et al. (2000). "Defining post-stroke recovery: implications for design and interpretation of drug trials." Neuropharmacology 39(5): 835-841. Find it on PubMed

Duncan, P. W., Propst, M., et al. (1983). "Reliability of the Fugl-Meyer assessment of sensorimotor recovery following cerebrovascular accident." Phys Ther 63: 1606-1610. Find it on PubMed

Gladstone, D. J., Danells, C. J., et al. (2002). "The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties." Neurorehabil Neural Repair 16: 232-240. Find it on PubMed

Hsieh, Y. W., Wu, C. Y., et al. (2009). "Responsiveness and validity of three outcome measures of motor function after stroke rehabilitation." Stroke 40(4): 1386-1391. 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

Lin, J. H., Hsueh, I. P., et al. (2004). "Psychometric properties of the sensory scale of the Fugl-Meyer Assessment in stroke patients." Clin Rehabil 18(4): 391-397. Find it on PubMed

Malouin, F., Pichard, L., et al. (1994). "Evaluating motor recovery early after stroke: comparison of the Fugl-Meyer Assessment and the Motor Assessment Scale." Arch Phys Med Rehabil 75: 1206-1212. Find it on PubMed

Mao, H.-F., Hsueh, I. P., et al. (2002). "Analysis and comparison of the psychometric properties of three balance measures for stroke patients." Stroke 33: 1022-1027. Find it on PubMed

Nadeau, S., Arsenault, A. B., et al. (1999). "Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke." Am J Phys Med Rehabil 78: 123-130. Find it on PubMed

Platz, T., Pinkowski, C., et al. (2005). "Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study." Clin Rehabil 19: 404-411. Find it on PubMed

Sanford, J., Moreland, J., et al. (1993). "Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke." Phys Ther 73: 447-454. Find it on PubMed

Shelton, F. D., Volpe, B. T., et al. (2001). "Motor impairment as a predictor of functional recovery and guide to rehabilitation treatment after stroke." Neurorehabil Neural Repair 15(3): 229-237. Find it on PubMed

Wagner, J. M., Rhodes, J. A., et al. (2008). "Reproducibility and minimal detectable change of three-dimensional kinematic analysis of reaching tasks in people with hemiparesis after stroke." Phys Ther 88(5): 652-663. Find it on PubMed

Wood-Dauphinee, S. L., Williams, J. I., et al. (1990). "Examining outcome measures in a clinical study of stroke." Stroke 21: 731-739. Find it on PubMed

Woodbury, M. L., Velozo, C. A., et al. (2008). "Longitudinal stability of the Fugl-Meyer Assessment of the upper extremity." Arch Phys Med Rehabil 89: 1563-1569. Find it on PubMed

Year published

1975 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 9/3/2014 11:46 AM  by Jason Raad