Assessing Arm and Hand Function After Stroke: A Validity Test of the ...

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ORIGINAL ARTICLE

Assessing Arm and Hand Function After Stroke: A Validity Test of the Hierarchical Scoring System Used in the Motor Assessment Scale for Stroke Joyce S. Sabari, PhD, OTR, Ai Lian Lim, MA, OTR, Craig A. Velozo, PhD, OTR/L, Leigh Lehman, MS, Owen Kieran, MD, Jin-Shei Lai, PhD, OTR/L ABSTRACT. Sabari JS, Lim AL, Velozo CA, Lehman L, Kieran O, Lai JS. Assessing arm and hand function after stroke: a validity test of the hierarchical scoring system used in the motor assessment scales for stroke. Arch Phys Med Rehabil 2005;86:1609-15. Objective: To evaluate the validity of the scoring hierarchy for the 3 upper-limb items on the Motor Assessment Scale (MAS). Design: Application of Rasch analysis to 3 independent measurement scales, each representing the upper-arm function, hand movements, and advanced hand activities items of the MAS. Setting: Inpatient and outpatient occupational therapy (OT) programs in a department of rehabilitation of an urban hospital center. Participants: One hundred patients (67 men, 33 women; average age, 54.3⫾14.4y; average time since stroke onset, 104d) attending OT for stroke rehabilitation. Interventions: Not applicable. Main Outcome Measure: The MAS for stroke (upper-arm function, hand movements, and advanced hand activities sections). Results: Rasch analysis provided support for the validity of hierarchical scoring criteria for the upper-arm scale. This analysis, however, identified inconsistencies in the hierarchical scoring criteria for the hand function and advanced hand activities scales and, when considering measurement error, only small differences in difficulty level between several behavioral criteria. Conclusions: The findings lead to suggestions for changes in the behavioral criteria hierarchy for upper-limb items on the MAS and highlight the importance of using statistical analyses

From the State University of New York, Downstate Medical Center, Brooklyn, NY (Sabari); Bellevue Hospital Center/New York University School of Medicine, New York, NY (Lim); Department of Veterans Affairs Medical Center, Gainesville, FL (Velozo); Occupational Therapy, University of Florida, Gainesville, FL (Velozo); Rehabilitation Science Doctoral Program, College of Public Health and Health Professions, University of Florida, Gainesville, FL (Lehman); Department of Rehabilitation Medicine, Bellevue Hospital Center, New York, NY (Kieran); Department of Rehabilitation Medicine, School of Medicine, New York University, New York, NY (Kieran); and Center on Outcomes Research and Education, Northwestern University and Evanston Northwestern Healthcare, Evanston, IL (Lai). Presented as a poster to the American Academy of Physical Medicine and Rehabilitation, 2001. Supported by the New York University Challenge Fund and the New York University School of Education Challenge Fund. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated Reprint requests to Joyce Sabari, SUNY Downstate, Box 81, 450 Clarkson Ave, Brooklyn, NY 11203, e-mail: [email protected]. 0003-9993/05/8608-9418$30.00/0 doi:10.1016/j.apmr.2004.12.028

to test the validity of proposed hierarchies of behavioral criteria in functional assessments. Key Words: Arm; Hand; Motor skills; Rehabilitation; Stroke. © 2005 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation HE MOTOR ASSESSMENT SCALE (MAS)1,2 for stroke shows strong potential for replacing the Fugl-Meyer Assessment (FMA)3 as the standardized assessment of choice in clinical evaluation and outcome studies of stroke rehabilitation. Whereas the FMA is based on outdated theoretical constructs advanced in the 1950s and 1960s by Twitchell4 and Brunnstrom,5 the MAS is based on the more current taskoriented approach to evaluation6 and evidence-based views about motor relearning after stroke.7 The MAS has been reviewed positively in the rehabilitation literature8 and has tested well for reliability1,9 and concurrent validity with both the FMA9-11 and the Action Research Arm Test.10,12 The test is easy to administer by trained physical or occupational therapists, and its structured format of functional task observation is appealing to therapists.13 The MAS has been used as an outcome measure in stroke studies of upper-limb training,14,15 sit-to-stand training,16,17 lower-limb strength training,18 rehabilitation to improve balance and gait,19,20 and comparison of different physiotherapy approaches in a general stroke rehabilitation program.21,22 The MAS consists of 8 items representing the following areas of motor behavior: supine-to-side lying onto intact side; supine to sitting over side of bed; balanced sitting; sitting to standing; walking; upper-arm function; hand movements; and advanced hand activities. Each item is scored on a 7-point (range, 0 – 6) hierarchical scale.23,24 The scoring criteria for the bed mobility, balance, sit-to-stand, and walking items are characterized by clear hierarchies of motor performance, such that it would be unlikely for a person to achieve the criterion for a higher score without also demonstrating the criteria for achieving all lower scores for the specified item. For example, the hierarchical score for supine to sitting on the edge of the bed is determined by the amount of assistance needed and speed of performing the functional task. Similarly, the hierarchical score for balanced sitting is based on graded increments of displacement of the person’s center of mass. Use of a hierarchical scoring system works well for these items, because it reduces the time required for test administration. If a person can achieve the criterion for a score of 6 on a selected item, the therapist does not need to test the criteria for scores from 1 to 5. Although there is support for using the 3 upper-limb items of the MAS as an independent scale,25 the hierarchical criteria for scoring these items is less obvious than the hierarchies used in assigning scores to other aspects of motor function assessed by

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VALIDITY TEST OF UPPER-LIMB ITEMS ON THE MAS, Sabari

the MAS. Of the 3 upper-limb items, only the upper-arm function item seems to be based on theoretic rationale. One premise is that movements requiring greater control against the force of gravity are incrementally more difficult to perform. A second conceptual basis for scoring is that incremental increases in requirements for control over greater numbers of degrees of freedom (ie, independent movements at 1 or more joints) enhance the difficulty level of motor tasks (appendix 1). Carr and Shepherd, creators of the MAS, have never articulated a conceptual rationale for the choice and sequencing of criteria for scoring the hand movements and advanced hand activities items (see appendix 1). Furthermore, pilot testing by Poole and Whitney9 has shown that subjects may be capable of meeting the criteria for higher scores on these items even when they are unable to successfully perform criteria associated with lower scores on the same test item. Thus, there is need to evaluate the validity of the hierarchical scoring system. The purpose of our study was to assess the validity of the scoring hierarchy for the 3 upper-limb items on the MAS by using Rasch analysis. Because these items are scored hierarchically, for the purpose of our study each of the 3 MAS items was assessed as an independent measurement scale consisting of 6 independent behaviors (see Methods). Upper-limb function, hand movements, and advanced hand activities will heretofore be described as scales, because they were treated as such in our analysis. Rasch analysis provides investigators with a valuable method for assessing the psychometric properties of measurement scales26-28 and has been applied to several neurorehabilitation assessments.29-35 Findings from Rasch analysis have led to recommendations that improved these scales by enhancing unidimensionality, enhancing efficiency through elimination of unnecessary items, and improving sensitivity by adding items where large gaps in difficulty between scale items were identified. We selected Rasch analysis for our study because Rasch orders behaviors on the latent trait being measured based on how difficult the behavior is to perform—that is, items easier to perform will receive lower mean calibrations and items harder to perform will receive higher mean calibrations. In addition, because error estimates are associated with each mean item calibration, the analysis can be used to identify whether the difficulty level between hierarchical behaviors is sufficiently different to warrant the inclusion of all behavioral criteria within a hierarchical scale. Specifically, using item calibrations from a sample of 100 stroke patients, we assessed the continuum of difficulty for each of the behavioral criteria used in scoring the upper-arm movements, hand movements, and advanced hand activities components of the MAS. METHODS Instrument As described elsewhere, each item of the MAS is scored on a 7-point hierarchical scale, from 0 to 6, according to specified criteria.1,2 For the purposes of this validity assessment, the 3 items of concern (upper-arm movements, hand movements, advanced hand activities) were treated as scales, with each scale consisting of 6 behavioral criteria. Raters assigned a yes or no score to a subject’s performance of each of the 6 behavioral criteria for each of the 3 scales. For the purposes of objectivity, the behavioral criteria were listed in a counterbalanced order on the data collection forms. In this article, findings from the Rasch analysis will be reported separately for each of the 3 scales, with each behavioral criterion described as an item within the scale. In clinical use of the MAS, these Arch Phys Med Rehabil Vol 86, August 2005

scales are actually 3 items of the assessment, each having 6 behavioral criteria leading the examiner to assign a single score ranging from 0 to 6 for each item. Rater Training and Establishment of Interrater Reliability Eight raters, all licensed occupational therapists at a large municipal hospital, participated in an extensive training program. Two authors (JSS, ALL), the trainers, are skilled at administering the MAS and based the instruction on training videotapes created by the developers of the MAS,1 published scoring criteria,1 and unpublished specifications provided by the test developers. Rater training included group sessions and individual supervision during test administration to volunteers with hemiparesis. To establish interrater reliability, each rater assigned scores to 2 videotaped stroke volunteers as they attempted to perform each item on the upper-arm function, hand movements, and advanced activities scales. A 2-way mixed-effect model intraclass correlation coefficient of .99 was achieved, based on agreement among the 8 raters and a criterion rating determined by the trainers. Data Collection The Department of Rehabilitation Medicine at Bellevue Hospital Center approved the upper-limb MAS scales as standard screening measures for all patients referred to occupational therapy (OT) for intervention to improve upper-limb function after stroke. Subsequently, the trained raters collected data as part of the standard assessment protocol for all patients who met this criterion. The institutional review board approved the retrospective use of these data for the study. The Sample We tested 100 consecutive patients referred to OT at Bellevue Hospital, during a period of 18 months, for intervention to improve upper-limb function after stroke. Age was normally distributed within a range of 18 to 94 years, with 54 years as both the mean and median age of study participants. Thirtythree participants were women; 67 were men. Length of time since stroke onset ranged from 3 days to 6.5 years, with 83% of participants having sustained their stroke within 3 months of testing. Fifty-seven patients had sustained occlusive and 37 had sustained hemorrhagic strokes. Side of lesion was evenly divided, with 51% having sustained right hemisphere and 49% left hemisphere pathology. Ninety-six percent of participants reported right-hand dominance. Data Analysis Winsteps software,36,a a computer software for Rasch analysis, was used to conduct separate Rasch analyses on each of the 3 upper-limb scales of the MAS to examine the hierarchical order of criterion behaviors. Before examining the item hierarchies of each scale, the extent to which items contribute to a unidimensional construct was determined using goodness-of-fit statistics—that is, the mean square (MnSq) standardized residuals produced for each item of the instrument.37 The MnSq represents observed variance divided by true variance, and the desired value of the MnSq for an item is 1.0. For clinical observations, Wright and Linacre38 suggest reasonable ranges of MnSq fit values between 0.5 and 1.7 that are associated with standardized z values less than 2.0. High values (ie, ⬎1.7) indicate that scores are variant or erratic, which suggests that an item does not belong with the other items on the same continuum or that the item is being misinterpreted.

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VALIDITY TEST OF UPPER-LIMB ITEMS ON THE MAS, Sabari Table 1: Item Fit Item

Upper-Arm Function Scale Lying, protract shoulder girdle with arm in elevation Lying, hold extended arm in elevation for 2 seconds Flexion and extension of elbow to take palm to forehead with arm Sitting, hold extended arm in forward flexion at 90° to body for 2 seconds Sitting, patient lifts arm into above position, holds it there for 10 seconds, and then lowers it Standing, hand against wall, maintain arm position while turning body toward wall Hand Movements Scale Sitting, extension of wrist Sitting, radial deviation of wrist Sitting, elbow into side, pronation and supination Reach forward, pick up large ball of 14-cm (5-in) diameter with both hands and put it down Pick up a polystyrene cup from table and put it on table across other side of body Continuous opposition of thumb and each finger more than 14 times in 10 seconds Advanced Hand Activities Scale Picking up the top of a pen and putting it down again Picking up jellybean from cup and placing it in another cup Drawing horizontal lines to stop at a vertical line 10 times in 20 seconds Holding a pencil, making rapid consecutive dots on a sheet of paper Taking a dessert spoon of liquid to the mouth Holding a comb and combing hair at back of head

Infit (MnSq)

ZSTD

1.27 0.95 0.41 1.18 0.64 1.19

0.50 ⫺0.10 ⫺1.90 0.50 ⫺0.90 0.20

0.89 1.00 1.23 1.09 0.66 1.07

⫺0.40 0.00 0.70 0.30 ⫺1.60 0.20

1.13 0.77 1.00 0.84 0.92 0.99

0.40 ⫺1.00 0.00 ⫺0.80 ⫺0.40 0.00

Abbreviation: ZSTD, standard deviation of the mean.

After analyzing item fit, we evaluated the hierarchical order of behavioral criteria for each of the 3 constructs, based on their locations (calibrations) on the construct continuum being measured (ie, upper-arm movements, hand movements, advanced hand activities). These calibrations, presented in odds ratio logarithm transformed units (logits), indicate the relative difficulty level of each behavioral criterion (or, as tested in our study, each behavior within the scale) for scores on the upperarm movements, hand movements, and advanced hand activities items of the MAS. A behavioral criterion with a higher (or larger) calibration value indicates that this behavior is more challenging to the participants than a behavior with a lower (or smaller) calibration value. Rasch analysis also enabled us to determine whether behavioral criteria were sufficiently different from each other to warrant inclusion of specific criteria within a scale. In this analysis, “gaps” (where 2 items differed sufficiently in difficulty level) were determined using the formula t ⫽ ⱍ(A ⫺ B) ⁄ 兹(SEA2 ⫹ SEB2)ⱍ ⬎ 1.96

Upper-Arm Function The hierarchy of scoring was generally upheld for the 100 participants in this study. Behavioral criterion 1 (protracting the shoulder girdle in a lying position) was the easiest criterion

(1)

where A and B represent the 2-item calibrations and SEA and SEB represent the standard errors of these 2 items (JM Linacre, personal communication, Feb 19, 2004). Further, Rasch analysis provided information as to whether the averaged difficulty of these behavioral criteria matched the ability level of the sample under study. The analysis generated maps of person ability calibrations plotted on the same linear continuum as item difficulty calibrations, making it possible to identify ceiling or floor effects. RESULTS Item Fit Table 1 shows item infit values (MnSq) and standard deviations from the mean. All items met the acceptable criterion (below 1.7).

Fig 1. Comparison between subjects and upper-arm function scale. Each X in the item column represents the item difficulty calibration. See appendix 1 for descriptions of the criteria behaviors.


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for subjects to achieve (fig 1). This was followed by success with criteria 3, 2, 4, and 5. For these participants, it was easier to flex and extend the elbow while holding the arm in an elevated position (criterion 3) than to maintain extension at the elbow while simultaneously keeping the glenohumeral joint (GHJ) in a position of external rotation (criterion 2). Criterion 6 (standing with arm extended against a wall) was almost 2 SEs more difficult than criterion 5 (sitting, lift, hold, lower arm), and criterion 5 was almost 1 SE more difficult than criterion 1. Technically, the difficulty level of criterion 2 (palm to forehead) did not differ from than that of criteria 3 and 4, because the mean calibrations for all these criteria were within 1 SE of each other. Significant floor and ceiling effects were found for this sample. Thirty-one participants did not achieve any of the criteria (total raw score, 0), and 28 participants successfully completed all items (total raw score, 6). Hand Movements The hierarchy of scoring was not upheld in this study (fig 2). The behavioral criterion 3 (pronation and supination of forearm) was easiest for these participants. This was followed successively by criterion 1 (wrist extension), criterion 4 (reach, pick up, and put down large ball), criterion 5 (pick up and transport polystyrene cup), and criterion 2 (radial deviation of wrist). Of these 5 behaviors, only criterion 2 differed from criterion 3 (pronation/supination of forearm), because the mean difficulty calibrations of criteria 1, 4, and 5 were within 1 SE of criteria 3 and 2. Criterion 6 (thumb opposition) was upheld in this sample as the most difficult criterion in the hand moveFig 3. Comparison between subjects and advanced hand activities scale. See appendix 1 for descriptions of the criteria behaviors.

ments scale. However, there was a large gap of almost 2 SEs between thumb opposition and all other behavioral criteria. As in the upper-arm scale, significant floor and ceiling effects were found in this sample. Thirty-one data participants did not achieve any of the criteria, and 28 participants showed ability to complete all items. Advanced Hand Activities

Fig 2. Comparison between subjects and hand movement scale. See appendix 1 for descriptions of the criteria behaviors.


The hierarchy of scoring for advanced hand activities was upheld only for criteria 1 and 2 (fig 3). Behavioral criterion 1 (pick up and release the top of a pen) was the easiest. Criterion 2 (pick up and place jelly beans from 1 cup to another) was the next easiest to achieve, with a significant difference in difficulty level from criterion 1. After this, however, the observed hierarchy of criteria differed substantially from the hierarchy proposed in the MAS. Criteria 5 (using a spoon) and 6 (holding a comb and combing hair at back of head) were almost identical in their difficulty level. Behavioral criterion 4 (making rapid dots with a pen) was significantly more difficult than criteria 2, 5, and 6, with 28% of participants successfully achieving this. The most difficult behavior, criterion 3 (drawing 10 horizontal lines in 20s), was approximately 1 SE more difficult than criterion 4, also representing a significant difference in difficulty level. This test was the best of the 3 scales with regard to ceiling effect, with only 9 participants achieving a perfect score. However, there was a floor effect, with 38 participants failing to score above 0.


DISCUSSION Upper-Arm Function Rasch analysis supports the general hierarchy of behavior on the upper-arm scale and, indirectly, supports the scale’s conceptual foundations related to the effects of gravity and the degrees of freedom problem.39 Movements of the shoulder are easier to perform while supine (criteria 1, 3, 2) than while sitting or standing (criteria 4, 6, 5) because of the absence of gravitational torque when the shoulder is flexed to 90° in the supine position. A task in which the person is expected to control a single movement at only 1 joint (criterion 1) is easier to perform than are tasks in which the person must simultaneously control multiple positions. We concluded that criterion 2 (lying, hold extended arm in elevation with external rotation) measures a similar level of ability as criteria 3 (lying, flex and extend elbow) and 4 (sitting, hold in forward flexion at 90° for 2s). Criterion 2 could be removed without sacrificing sensitivity of the scale. Our findings suggest the need to add a new criterion task between criterion 5 (sitting, lift, hold, and lower arm) and criterion 6 (maintain hand position on wall while turning body inward). Although Rasch analysis showed a floor effect, we believe that criterion 1 represents the most minimal level of upper-arm motor control. Therefore, we do not recommend adding an easier criterion. However, because a ceiling effect was identified, we recommend a behavioral criterion at a higher difficulty level than criterion 6. We suggest a reaching and pointing task that requires the person to touch 3 sequential points on a wall. Each point would require 90° of glenohumeral flexion and changes in all 3 cardinal planes of motion. To avoid the need to use hand movements during the task, the patient would pass this criterion by using any means of touching the points on the wall—for example, with a fist or an outstretched finger. Hand Movements Rasch analysis of the hand movements scale does not support the MAS developers’ guiding premise that discrete, proximal hand movements (criterion 1, extend wrist; criterion 2, radially deviate wrist; criterion 3, pronate and supinate forearm) will be easier to perform than functional activities requiring simultaneous control over multiple movements at a variety of joints (criterion 4, reach, pick up and put down large ball; criterion 5, pick up and place polystyrene cup). This finding is consistent with results from other studies, which indicate that functional tasks may be easier to perform after stroke than isolated, abstract movements.40,41 According to Rasch analysis of the current sample, criteria 1, 3, 4, and 5 are all testing a similar level of difficulty in hand movements. Based on this finding of redundancy in difficulty levels, we recommend eliminating criteria 1, 4, and 5. Three additional criteria of incrementally greater difficulty than criterion 2 (wrist radial deviation) are needed to narrow the current gap of almost 2 SEs between criterion 6 (timed, repeated thumb opposition) and all other behavioral criteria on this scale. We recommend that, to be true to this scale’s named construct— hand movements— these behavioral criteria all represent discrete movements rather than functional tasks. We recommend the following criteria: mass finger extension, a thumb motion to be determined, and a timed tapping task with any preferred finger. Further testing, with subsequent Rasch analysis, would be needed to determine whether these items are hierarchically more difficult to achieve, are significantly different in difficulty level from each other and from the remaining behavioral criteria on this scale, and successfully close the gap in difficulty

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level between timed, repeated thumb opposition and wrist radial deviation. Although Rasch analysis showed both ceiling and floor effects on the hand movements scale, we do not recommend adding an additional easier item, because it is understood that a percentage of stroke survivors never regain discrete hand movements. We do not recommend adding a more difficult item than timed thumb opposition, because higher-order functional hand performance is tested in the more difficult criteria of the advanced hand activities scale. Advanced Hand Activities Two conceptual hierarchies emerge from Rasch analysis of the advanced hand activities scale. First, Bernstein’s degrees of freedom problem39 is supported by the finding that pincer grasp and release activities (criteria 1, 2) are easier than activities in which the subject must maintain static grasp and simultaneously perform complex movements at other upper-limb joints (criteria 6, 5, 4, 3). Second, timed writing tasks (criteria 4, 3) are more difficult than other hand tasks (criteria 2, 6, 5), even when functional grasp must be maintained during simultaneous movement at proximal joints. Based on redundancy in difficulty levels, we recommend eliminating criterion 6 (holding comb and combing hair), because it tests the same skill level as criterion 5 (using spoon) and is influenced by a factor unrelated to hand function— namely, the challenge of simultaneously externally rotating and flexing the GHJ beyond 90° while maintaining functional grasp. One positive feature of the MAS is that, in offering separate scales for upper-arm and hand function, assessment results provide the evaluator with discrete information about shoulder function and hand use. We believe that criteria used for scoring each of the upper-limb items should relate, to the extent possible in a task-oriented behavior, only to the designated scale. This is particularly important in light of current understanding that patients may vary in their recovery sequence, with some patients experiencing earliest upper-limb motor control at the shoulder girdle and others developing their first poststroke movements in their fingers.7 It is conceivable for a patient to achieve advanced hand recovery without concomitant recovery in proximal shoulder control. Certainly, therapeutic interventions will likely present patients with task challenges to combine proximal and distal control. However, it is advantageous to have a measurement tool that provides discrete information about proximal function and distal function, so that therapists and researchers can be specific in assessing outcomes and planning therapeutic challenges. The floor effect revealed by Rasch analysis indicates the need for a criterion that will be easier than picking up and placing the pen cap. We suggest a criterion that requires a person to depress any button on a remote control device positioned in the hand. Because Rasch analysis showed no ceiling effect on this scale, we recommend keeping criterion 3 as the most difficult behavioral criterion for the advanced hand activities component of the MAS. Limitations Although the sample reflects a normal distribution of demographic variables, there is no way of knowing whether it reflects a heterogeneous sample of motor abilities after stroke. Therefore, findings related to floor and ceiling effects should be interpreted with caution. Before final changes are made to the scales, we recommend validation in a larger sample. Arch Phys Med Rehabil Vol 86, August 2005

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CONCLUSIONS Rasch analysis of a sample of 100 stroke rehabilitation patients provided support for the hierarchical scoring criteria proposed by the MAS developers for the upper-arm function scale. This analysis, however, suggested different hierarchical scoring criteria for the hand function and the advanced hand activities scales and, when measurement error is considered, only small differences in difficulty level between several of the behavioral criteria on all 3 scales assessing upper-limb function. We identify these inconsistencies and suggest changes in the scoring criteria to improve validity of the arm items on the MAS. In addition, Rasch analysis provided insights about the difficulty level of specific upper-limb motor behaviors for stroke survivors. These insights may be helpful to rehabilitation professionals in designing the sequence for therapeutic interventions to improve upper-limb function after stroke. Finally, this study’s results highlight the importance of using empirical analysis to test the validity of proposed hierarchies of behavioral criteria in functional assessments of rehabilitation patients, especially when those tests are designed to proceed in the order of item challenge. Acknowledgment: We thank the occupational therapists at Bellevue Hospital who assisted with data collection.

APPENDIX 1: CRITERIA FOR SCORING UPPER-LIMB ITEMS ON THE MAS Upper-Arm Function 1. Lying, protract shoulder girdle with arm in elevation. (Therapist places arm in position and supports it with elbow in extension.) 2. Lying, hold extended arm in elevation for 2 seconds. (Therapist should place arm in position and patient must maintain position with some external rotation. Elbow must be held within 20° of full extension.) 3. Flexion and extension of elbow to take palm to forehead with arm as in 2. (Therapist may assist supination of forearm.) 4. Sitting, hold extended arm in forward flexion at 90° to body for 2 seconds. (Therapist should place arm in position and patient must maintain position with some external rotation and elbow extension. Do not allow excess shoulder elevation.) 5. Sitting, patient lifts arm to above position, holds it there for 10 seconds, and then lowers it. (Patient must maintain position with some external rotation. Do not allow pronation.) 6. Standing, hand against wall. Maintain arm position while turning body toward wall. (Have arm abducted to 90° with palm flat against the wall.) Hand Movements 1. Sitting, extension of wrist. (Therapist should have patient sitting at a table with forearm resting on the table. Therapist places cylindrical object in palm of patient’s hand. Patient is asked to lift object off the table by extending the wrist. Do not allow elbow flexion.) 2. Sitting, radial deviation of wrist. (Therapist should place forearm in mid–pronation-supination, ie, resting on ulnar side, thumb in line with forearm and wrist in extension, fingers around a cylindrical object. Patient is asked to lift hand off table. Do not allow elbow flexion or pronation.) Arch Phys Med Rehabil Vol 86, August 2005

3. Sitting, elbow into side, pronation and supination. (Elbow unsupported and at a right angle. Three-quarter range is acceptable.) 4. Reach forward, pick up large ball of 14-cm (5-in) diameter with both hands and put it down. (Ball should be on table so far in front of patient that he has to extend arms fully to reach it. Shoulders must be protracted, elbow extended, wrist neutral or extended. Palms should be kept in contact with the ball.) 5. Pick up a polystyrene cup from table and put it on table across other side of body. (Do not allow alteration in shape of cup.) 6. Continuous opposition of thumb and each finger more than 14 times in 10 seconds. (Each finger in turn taps the thumb, starting with index finger. Do not allow thumb to slide from one finger to the other, or to go backwards.) Advanced Hand Activities 1. Picking up the top of a pen and putting it down again. (Patient stretches arm forward, picks up pen top, releases it on table close to body.) 2. Picking up 1 jellybean from a cup and placing it in another cup. (Teacup contains 8 jellybeans. Both cups must be at arms’ length. Left hand takes jellybean from cup on right and releases it in cup on left.) 3. Drawing horizontal lines to stop at a vertical line 10 times in 20 seconds. (At least 5 lines must touch and stop at the vertical line.) 4. Holding a pencil, making rapid consecutive dots on a sheet of paper. (Patient must do at least 2 dots a second for 5 seconds. Patient picks pencil up and positions it without assistance. Patient must hold pen as for writing. Patient must make a dot not a stroke.) 5. Taking a dessert spoon of liquid to the mouth. (Do not allow head to lower towards spoon. Do not allow liquid to spill.) 6. Holding a comb and combing hair at back of head. Reprinted from Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985;65:179, with permission of the American Physical Therapy Association. References 1. Carr JH, Shepherd RB, Nordholm L, Lynne D. Investigation of a new motor assessment scale for stroke patients. Phys Ther 1985; 65:175-80. 2. Carr J, Shepherd R. Motor Assessment Scale for Stroke, amended version. Sydney (Aust): Sch of Physiotherapy, Faculty of Health Sciences, Univ Sydney; 1994. 3. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient: A method of evaluation of physical performance. Scand J Rehabil Med 1975;7:13-31. 4. Twitchell TE. The restoration of motor function following hemiplegia in man. Brain 1951;74:443-80. 5. Brunnstrom S. Movement therapy in hemiplegia. New York: Harper & Row; 1970. 6. Shumway-Cook A, Woollacott MH. Motor control: theory and practical applications. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000. 7. Carr J, Shepherd R. Neurological rehabilitation: optimizing motor performance. Oxford: Butterworth-Heinemann; 1998. 8. Gresham GE, Duncan PW, Stason WB, et al. Post-stroke rehabilitation. Clinical practice guideline no. 16. Rockville: US Department of Health and Human Services; 1995. AHCPR Publication No. 95-0662.


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