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Rehab Measures: Modified Rankin Handicap Scale

Link to instrument

Measure available at Strokecenter.org (external link) 

Title of Assessment

Modified Rankin Handicap Scale 

Acronym

MRS

Instrument Reviewer(s)

Summary Date

 

Purpose

Categorizes level of functional independence with reference to pre-stroke activities

Description

  • A single-item global outcomes rating scale
  • Assessment is carried out by asking the patient about their activities of daily living, including outdoor activities
  • Information about the patient's neurological deficits on examination, including aphasia and intellectual deficits, should be obtained
  • All aspects of the patient's physical, mental performance, and speech should be combined in the single MRS score
  • One MRS grade should be assigned based on the following criteria (Dromerick, Edwards, & Diringer, 2003):


0.  No symptoms  
1.  No significant disability despite symptoms; able to carry out all usual duties and activities 
2.  Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance 
3.  Moderate disability: requiring some help, but able to walk without assistance 
4.  Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance 
5.  Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 

Area of Assessment

Activities of Daily Living; Functional Mobility 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

ADL; Motor 

Assessment Type

Patient Reported Outcomes 

Length of Test

06 to 30 Minutes 

Time to Administer

5-15 minutes

Number of Items

Equipment Required

None necessary

Training Required

None necessary

Type of training required

No Training 

Cost

Free 

Actual Cost

Free

Age Range

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

Administration Mode

Paper/Pencil 

Diagnosis

Stroke 

Populations Tested

Stroke

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established
 

Normative Data

Acute Stroke: (Table from Dromerick et al, 2003; n = 95, length of rehabilitation was 19.5 (8.3) days)
 
Measure
Mean Change*
Percent of Subjects Changed (%)
Median Change
Floor Effect, Admission

Ceiling Effect, Discharge

MRS
-
47
1 level (0-2)
17 (18%)

0 (0%)

ISTM
-
24
0 level (0-1)
95 (100%)

0 (0%)

BI
28 ± 16.2
100
30 points (0-70)
5 (5%)

26 (27%)

FIM
23.2 ± 10.6
100
22 points (4-55)
0 (0%)

0 (0%)

*Data are mean ± standard deviation. Percent of subjects with a change of score. Data are medians with ranges in parentheses.
BI = Barthel Index
FIM = Functional Independence Measure
ISTM = International Stroke Trial Measure
MRS = Modified Rankin Scale

Test-retest Reliability

Acute Stroke: (Wolfe et al, 1991)
  • Excellent test-retest reliability (Kappa w = 0.95)

Post-Stroke- 6 months: (Wilson et al, 2005)

  • Excellent test-retest reliability
    (Rater 1: Kappa = 0.81; 0.94 and
    Rater 2: Kappa = 0.95; 0.99)

Interrater/Intrarater Reliability

Acute Stroke: (Wolfe et al, 1991; van Swieten et al, 1988; Wilson et al, 2002, 2005; Shinohara et al, 2006; Quin et al, 2008)
 
Study1:
  • Excellent intra-rater reliability (Kappa w = 0.95)
  • Excellent inter-rater reliability (Kappa range 0.75 - 0.96)
Study2:
  • Excellent inter-rater reliability (Kappa = 0.82, out-patient)
  • Adequate inter-rater reliability (Kappa = 0.51, in-patient)
Study 3:
  • Excellent inter-rater reliability (Kappa = 0.78)

Study 4:

  • Excellent inter-rater reliability (ICC = 0.95 neurologists; 0.96 nurses)
Study 5:
  • Adequate inter-rater reliability (Kappa = 067, overall)

Internal Consistency

Not established

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Cup et al, 2003; n = 26; mean age 68 (15) years; Kwon et al, 2004; n = 459; mean age = 70 (11.4) years; Weimar et al, 2004; n = 4246; mean age = 67.1 (69) years)
 
Study1:
  • Excellent concurrent validity with:
         Barthel Index (r = - 0.81)
         Frenchay Activities Index (r = - 0.80)
         EQ-56 (r = 0.68)
  • Adequate concurrent validity with:
         SA-SIP-30 (r = 0.47)
Study 2:

Excellent concurrent validity with:
     Barthel Index (r = - 0.89)
     FIM-motor dimension (r = - 0.89)

Study 3:

  • Excellent concurrent validity with:   
SF-36 Physical Function (r = 0.84)
Barthel Index (r = 0.82)
Close Head Injury (Schaefer et al, 2004)
  • Excellent concurrent validity with:

Signal-intensity abnormal volume on diffusion weighted images (r = 0.77)

Number of lesions on images  (r = 0.66)

  • Adequate concurrent validity with:

Lesion location in the corpus callosum (r = 0.51)

Construct Validity (Convergent/Discriminant)

Acute Stroke: (Tilley et al. 1996, n = 333)

 
Agreement Among Pairs of Binary Outcomes
Outcome
Proportion Agreement
Barthel & Modified Rankin
0.87**
NIH Stroke Scale & Modified Rankin
0.86**
Modified Rankin & Glasgow
0.94**
** Excellent convergent validity

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Acute Stroke: (Dromerick et al, 2003)
  • Adequate Floor Effect in 18% of stroke sample at admission to rehabilitation (see normative data for more information).

Responsiveness

Acute Stroke: (Dromerick et al, 2003)
  • Poor at detecting change compared to the FIM (C = 0.59)*
*see normative data for more information

Professional Association Recommendations

Recommendations from the Neurology Section of the American Physical Therapy Association’s StrokEDGE Taskforce, MSEDGE Taskforce, SCI EDGE Taskforce, and the TBI EDGE Taskforce 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)

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

R

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)

Is this tool appropriate for use in intervention research studies? (Y/N)

StrokEDGE

No

Yes

No

Considerations

The categories within the MRS have been criticized as being broad and poorly defined, left open to the interpretation of the individual rater (Wilson et al, 2002).

Dromerick, Edwards, and Diringer (2003) administered the MRS to 95 stroke rehabilitation inpatients and reported that the MRS displayed an adequate floor effect (18%) at admission to rehabilitation.
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Bibliography

Cup, E. H., Scholte op Reimer, W. J., et al. (2003). "Reliability and validity of the Canadian Occupational Performance Measure in stroke patients." Clin Rehabil 17(4): 402-409. Find it on PubMed

De Haan, R., Horn, J., et al. (1993). "A comparison of five stroke scales with measures of disability, handicap, and quality of life." Stroke 24: 1178-1181. Find it on PubMed

de Haan, R., Limburg, M., et al. (1995). "The clinical meaning of Rankin 'handicap' grades after stroke." Stroke 26: 2027-2030. Find it on PubMed

Dromerick, A. W., Edwards, D. F., et al. (2003). "Sensitivity to changes in disability after stroke: a comparison of four scales useful in clinical trials." J Rehabil Res Dev 40: 1-8. Find it on PubMed

Kwon, S., Hartzema, A. G., et al. (2004). "Disability measures in stroke: relationship among the Barthel Index, the Functional Independence Measure, and the Modified Rankin Scale." Stroke 35: 918-923. Find it on PubMed

Quinn, T. J., Ray, G., et al. (2008). "Deriving modified Rankin scores from medical case-records." Stroke 39: 3421-3423. Find it on PubMed

Schaefer, P. W., Huisman, T. A., et al. (2004). "Diffusion-weighted MR imaging in closed head injury: high correlation with initial glasgow coma scale score and score on modified Rankin scale at discharge." Radiology 233(1): 58-66. Find it on PubMed

Shinohara, Y., Minematsu, K., et al. (2006). "Modified Rankin scale with expanded guidance scheme and interview questionnaire: interrater agreement and reproducibility of assessment." Cerebrovasc Dis 21: 271-278. Find it on PubMed

Tilley, B. C., Marler, J., et al. (1996). "Use of a global test for multiple outcomes in stroke trials with application to the National Institute of Neurological Disorders and Stroke t-PA Stroke Trial." Stroke 27: 2136-2142. Find it on PubMed

van Swieten, J. C., Koudstaal, P. J., et al. (1988). "Interobserver agreement for the assessment of handicap in stroke patients." Stroke 19: 604-607. Find it on PubMed

Weimar, C., Kurth, T., et al. (2002). "Assessment of functioning and disability after ischemic stroke." Stroke 33(8): 2053-2059. Find it on PubMed

Wilson, J. T., Hareendran, A., et al. (2002). "Improving the assessment of outcomes in stroke: use of a structured interview to assign grades on the modified Rankin Scale." Stroke 33(9): 2243-2246. Find it on PubMed

Wolfe, C. D., Taub, N. A., et al. (1991). "Assessment of scales of disability and handicap for stroke patients." Stroke 22: 1242-1244. Find it on PubMed

Year published

1957 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 12/4/2013 5:11 PM  by Jason Raad