Rehab Measures - Fugl-Meyer Assessment of Motor Recovery after...

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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)

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

FMA total scores: 9.4

Minimal Detectable Change (MDC)

Chronic Stroke: (Wagner et al, 2008, n = 14, mean age = 59.9 (14.6) years, assessed on average 14 (6.5) months post stroke):

FMA = 5.2 points for the Upper Extremity portion of the assessment

Minimally Clinically Important Difference (MCID)

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

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

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

Acute Stroke: (Duncan et al, 2000)

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)

Excellent Total Motor Score (ICC = .97)
Excellent Sensation (ICC = .81)
Excellent Passive Joint motion (ICC = .95)

Interrater/Intrarater Reliability

Chronic Stroke: (Duncan et al, 1983; n = 19; mean age = 56 (13) years; same PT rating on 3 occasions each 3 weeks apart; VA sample)

Interrater Reliability

Rating

Doman

Pearson's r

Excellent

FMA total score

r = .98-.99

Excellent

Upper Extremity

r = .995 - .996

Excellent

Lower Extremity

r = .96

Excellent

Sensation

r = .95 - .96

Excellent

Joint Range / Pain

r = .86 - .996

Excellent

Balance

r = .89 - .98

Excellent Interrater Reliability: (Duncan et al, 1983; 4 PT's using the above sample)

FMA Domain

Pearson's r

Upper Extremity

r = .98 - .995

Lower Extremity

r = .89 - .95

Acute Stroke: (Sanford et al, 1993; n = 12; mean age = 66 (11.5) years; 0 to 6 months post stroke)

Excellent interrater reliability, FMA Total Score: (ICC = .96)

Rating
FMA Domain

ICC

Excellent
Upper Extremity

.97

Excellent
Lower Extremity

.92

Adequate
Sensation

.85

Adequate
Joint Range of Motion

.85

Poor
Pain

.61

Internal Consistency

Acute Stroke: (Lin et al, 2004; n = 176; mean age = 67.9 (10.9) years; assessed 14, 30, 90 and 180 days after 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)

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

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)

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

Poor correlations between FMA Sensation and Gait speed (r = .05) and comfort (r = .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)

Acute Stroke:

Excellent correlation: modified Balance Subscale on FMA and the Barthel Index; r = .86 - .89 (Mao et al, 2002)
Excellent correlation: FMA and Functional Independence Measures (FIM) administered to 172 inpatients who had recently had a stoke; r = .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)

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 = .76) the Upper Extremity subscore of the motor domain (r = .75) and FMA Motor total score (r = .74)

Chronic Stroke: (Hsieh et al, 2009; onset > 6 months)

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

Acute Stroke: (Woodbury et al, 2008; n = 377; men age = 69.2 (11.2) years)

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

Chronic Stroke: (Crow et al, 2008; n = 62; retrospective analysis)

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

Acute Stroke: (Lin et al, 2004)

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

Acute Stroke: (Mao et al, 2002)

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)

Chronic Stroke: (Hsueh et al, 2009)

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 (.53 and .51)
Small effect sizes on the long version of the measure (.045 and .38)

Professional Association Recommendations

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)

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

Approval Status

Approved

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