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Rehab Measures: Chedoke-McMaster Stroke Assessment Measure

Link to instrument

Chedoke-McMaster Stroke Assessment Measure Manual and Scoring Form (other languages available below) 

Title of Assessment

Chedoke-McMaster Stroke Assessment Measure 

Acronym

CMSA

Instrument Reviewer(s)

Summary Date

 

Purpose

Assesses physical impairment and disability in clients with stroke and other neurological impairment

Description

The CMSA is composed of two inventories:

1. Impairment Inventory: Used to determine the presence and severity of common physical impairments. It has six dimensions:

     1) Recovery stage of the arm
     2) Hand
     3) Leg
     4) Foot
     5) Postural control
     6) Shoulder pain

Each dimension is measured on a 7-point scale, each point corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity.

2. Activity Inventory measures clinically important changes in the client's functional ability. This Activity Inventory is made up of a gross motor function and walking subscale.

  • The Gross Motor Function index consists of the 10 following items:
    1. Supine to side lying on strong side
    2. Supine to side lying on weak side
    3. Side lying to long sitting through strong side
    4. Side lying to sitting on side of the bed through strong side
    5. Side lying to sitting on side of the bed through weak side
    6. Standing
    7. Transfer to and from bed toward strong side
    8. Transfer to and from bed toward weak side
    9. Transfer up and down from floor to chair
    10. Transfer up and down from floor and standing. 
  • The Walking Index consists of the 5 following items:
    1. Walking indoors
    2. Walking outdoors, over rough ground, ramps, and curbs
    3. Walking outdoors several blocks
    4. Stairs
    5. Age and sex appropriate walking distance in meters for 2 minutes.
  • Impairment Inventory is scored on a 7-point scale, where:
    • 1 = Flaccid paralysis
    • 2 = Spasticity is present and felt as a resistance to passive movement
    • 3 = Marked spasticity but voluntary movement present within synergistic patterns
    • 4 = Spasticity decreases
    • 5 = Spasticity wanes but is evident with rapid movement at the extremes of range
    • 6 = Coordination and patterns of movement are near normal
    • 7 = Normal movement.
  • The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity.
  • The minimum score for the Impairment Inventory is 6 and the maximum score is 42 (Gowland et al, 1993).
  • The Activity Inventory is also scored on a 7-point scale, based on the amount of assistance the individual with stroke requires. It is categorized by:
    • The need for assistance from another person
    • The need for equipment, or
    • The need for extra time to accomplish a task.
  • For the Activity Inventory, the scoring key from the Functional Independence Measure is used, where:
    • 1 = The client needs total assistance
    • 2 = Maximal assistance
    • 3 = Moderate assistance
    • 4 = Minimal assistance
    • 5 = Clients needs supervision
    • 6 = Client is modified independent (needs assistance from devices)
    • 7 = Client is timely and safely independent.
  • The maximum score is 100, where higher scores reflect normal function (Finch et al, 2002; Gowland et al, 1993).
  • The maximum score for the gross motor function index is 70
  • The maximum score for the walking index is 30 (Gowland et al, 1993).
  • A 2-point bonus should be assigned for those who walk appropriate distances in meters based on norms for the patient's age and sex, on item 15 (the 2-Minute Walk Test) (Huijbregts at al, 2000)

Area of Assessment

Functional Mobility 

Body Part

Not Applicable 

ICF Domain

Body Function; Activity 

Domain

Motor 

Assessment Type

Observer 

Length of Test

31 to 60 Minutes 

Time to Administer

45-60 minutes

Number of Items

Not applicable  

Equipment Required

  • An adjustable table
  • Chair with armrests
  • Floor mat
  • Pillows
  • A pitcher with water
  • A measuring cup
  • A ball 2.5 inches in diameter
  • A footstool
  • A 2m line marked on the floor
  • Stopwatch

Training Required

The administrative guidelines can be used to learn how to administer the test.  However, a training workshop is recommended to increase confidence in the ability to administer and score the measure accurately.
 
A training workshop is also recommended if the measure is intended to be used to collect data for research purposes.
 
Further information about training can be found at the instrument's website.

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Free

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Stroke 

Populations Tested

  • Stroke
  • Brain Injury
  • Other Neurological Disorders

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Acute Stroke: (Gowland et al 1993; n = 32; mean age = 64; mean time since stroke onset = 9 months)
  • MCID = 8 points (total CMSA via stroke patients) and 7 points (total CMSA via caregivers of stroke patients).

Cut-Off Scores

> 9 on the leg and postural control scores indicates that the individual is able to ambulate independently. (Stevenson, 1999)

Normative Data

Not Established

Test-retest Reliability

Acute Stroke: (Gowland et al, 1993)
  • Excellent test-retest reliability, Disability Inventory (ICC = 0.98)

Interrater/Intrarater Reliability

Acute Stroke: (Gowland et al, 1993)
  • Excellent inter-rater reliability, Impairment inventory ICC = 0.97
  • Excellent inter-rater reliability, Disability inventory ICC = 0.99
  • Excellent intra-rater reliability, Impairment inventory ICC = 0.98

Internal Consistency

Acute Stroke: (Gowland et al, 1993)
  • Excellent internal consistency, Total scale ICC = 0.98

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Gowland et al, 1993)
  • Excellent concurrent validity: Fugl-Meyer (r = 0.95)
  • Excellent concurrent validity: FIM (r = 0.79)
  • Excellent concurrent validity: Barthel Index of ADLs (r = 0.75 -0.87 *Disability Index)
  • Poor concurrent validity with, Barthel Index: areas of shoulder pain & eating and bowel incontinence (r <0.30)
  • Excellent predictive validity, Physical Impairment Scale Leg postural control scores of >9 showed 100% sensitivity and 80% specificity in prediction of independent ambulation.
  • Excellent predictive validity, Total outcome of CMSA stroke assessment could be predicted by 7 items on the Barthel Index (R-2 = 0.75)

Predictive Equations:

Predicting Clinical Outcomes following Stroke Rehabilitation (Gowland et al, 1995):

Outcome Variables
 R squared
 Equation
 CI
Discharge Destination
0.38

5.97 – (0.06 x Gross Motor Function) – (0.21 x Bladder)

±3.5
Length of Stay
0.38

22.03–(1.18 x Leg)–(0.05 x Adult FIMSM)–(0.06 xAge)

±6.9
Adult FIMSM
0.65

39.23+(0.73 x Adult FIMSM)

±29.6
Activity Inventory
0.73

17.45+(0.88 x Gross Motor Function) + (4.30 x Leg)

±23.3
Gross Motor Function
0.7

24.94+(0.76 x Gross Motor Function)–(0.30 x Weeks)

±16.1
Walking
0.71

(Gross Motor Function x 0.28)+(Postural Control+Leg x 1.23)–4.55

±9.2
Shoulder Pain
0.55

2.33+(0.44xShoulder Pain) + (0.28 x Arm)

±1.6
Postural Control
0.60

2.23 + (0.35 x Postural Control) + (0.3 x Leg)

±1.3
Arm
0.80

0.82+(1.03 x Arm)-(0.03 x Weeks)

±1.5
Hand
0.78

0.53+(0.98 x Hand)

±1.5
Leg
0.69

1.83+(0.77 x Leg)-(0.02 x Weeks)

±1.5

Foot

0.73

1.11+(0.90 x Foot)-(0.03 x Weeks)

±1.3

Predictive Equations for Stroke Acute Care can be found HERE

Construct Validity (Convergent/Discriminant)

Acute Stroke: (Gowland et al, 1993)
  • Excellent convergent validity with subscales of the Fugl-Meyer Assessment (FMA)
  • Excellent convergent validity with the CMSA Arm and hand Impairment Inventory and FMA shoulder, elbow, forearm, wrist and hand scale (r = 0.95)
  • Excellent convergent validity with the CMSA Leg and foot Impairment Inventory and FMA hip, knee, foot and ankle scale (r = 0.93)
  • Excellent convergent validity with the CMSA Postural control and FMA balance scale (r = 0.84)
  • Excellent convergent validity with the CMSA Shoulder pain Impairment Inventory and FMA upper limb joint pain scale (r = 0.76)

CMSA Activity Inventory and the Functional Independence Measure (FIM) convergent validity evidence:

  • Excellent convergent validity with the CMSA gross motor function index and the FIM Mobility subscale (r = 0.90)
  • Excellent convergent validity with the CMSA walking index and the FIM Locomotion subscale (r = 0.85)

Content Validity

Moreland, Gowland, Van Hullenar, and Huijbregts (1993) performed a literature review to gather evidence for a theoretical basis of the Chedoke-McMaster Stroke Assessment. All items from both inventories had enough scientific evidence supporting its assumptions. Thus, the authors were able to establish a theoretical basis underlying the content of the Chedoke-McMaster Stroke Assessment.

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

The CMSA Disability Inventory is more sensitive to the FIM at detecting clinically important change. (Gowland et al, 1993)

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 months post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

R

R

R

 

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

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

StrokEDGE

R

R

UR

R

R

 

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

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

StrokEDGE

No

Yes

Yes

Not reported

Considerations

Chedoke-McMaster Stroke Assessment Measure translations:

French:
http://www.physiotherapy.ca/Practice-Resources/Orders

These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

 

Bibliography

Gowland, C., Stratford, P., et al. (1993). "Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment." Stroke 24(1): 58. Find it on PubMed

Huijbregts, M., Gowland, C., et al. (2000). "Measuring clinically-important change with the activity inventory of the Chedoke McMaster Stroke Assessment." Physiotherapy Canada 52(4): 295-304.

Morland, J., Gowland, C., et al. (1993). "Theoretical basis of the Chedoke-McMaster Stroke Assessment." Physiotherapy Canada 45: 231-231.

Year published

1993 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 8/29/2014 1:56 PM  by Jason Raad