Chedoke-McMaster Stroke Assessment

Objective

The Chedoke-McMaster SCMSA is a screening and assessment tool utilized to measure physical impairment and disability of an individual following a stroke. The CMSA consists of two inventories. First is the Impairment Inventory, which assesses 6 domains (shoulder pain, postural control and arm, hand, leg and foot movement). Each domain is scored on a 7-point scale (Stage 1 through 7, with 1 most impairment and 7 normal). Second is the Activity Inventory, formerly Disability Inventory, which assesses gross motor and walking function. There are 15 items and is scored on a 7-point scale (1 through 7, complete dependence to independent, respectively).

Purpose

The CMSA has three overall purposes:

1. Stage motor recovery to classify individuals in terms of clinical characteristics
2. Predict rehabilitation outcomes
3. Measure clinically important change in physical function

Intended Population

The CMSA was initially developed for the assessment of patients with stroke, its application has been more widely demonstrated, specifically for the Activity Inventory.

Methods of Use

Users of the CMSA should read the manual prior to administration for the measures and be familiar with relevant administration, scoring and interpretation. No special training is required.

Assessment Set-Up Overview

Physical Setting, Environment and Clothing

• Ensure patient feels comfortable and at ease during administration of assessment
• Distractions kept to a minimum
• Testing room should be comfortable warm and large enough to accommodate a low plinth (large enough to allow patient to roll from supine to sidelying), floor mat and wheelchair
• Access to full flight of stairs and outdoors required for Activity Inventory
• Patients should wear comfortable clothing (i.e., shorts and tank top) exposing knees and elbows
• During testing of shoulder pain, shoulder region should be free of clothing
• Shoes and orthoses not worn during Physical Impairment Inventory, but worn for Activity Inventory

Equipment

All equipment should be assembled ahead of time.

• Foot stool
• Pillows
• 2 meter line marked on the floor
• Chair with armrest
• Adjustable table
• Plastic measuring cup (250 ml)
• Wide, low plinth
• Stop watch
• Floor mat
• Ball, 6.5 cm (2.5 in) in diameter
• 1 liter plastic pitcher with water

Testing

Testing takes approximately 45 to 60 minutes to complete an assessment. It may not be feasible to complete the entire test in one session, however, effort should be made to complete the assessment within 2 days. Prior to assessment, the therapist should check relevant medical history and identify any condition(s) that may put a patient at risk.

During assessment, the physiotherapist's instruction, whether words or gestures, should be clear and concise. To ensure thorough understanding, a movement task may be demonstrated, a patient's limb may be passively moved through a task or patient may be asked to perform a task on the uninvolved side. Once the patient understands, test instructions are given and movement task is observed. Tasks can only be attempted twice in the Impairment Inventory and once in the Activity Inventory.

The following are reasons to end a task or assessment:

• Neither safe nor prudent
• Activity may worsen patient’s condition (i.e., rolling onto painful shoulder)
• Patient becomes excessively fatigued or apprehensive
  

Administration Guidelines

Impairment Inventory

Starting Positions

Standard starting positions are indicated at the top of each Score Form. If standard position is changed, indicate on form. Therapist may assist patient to starting position. When indicated may stabilize part being tested and may provide assistive support (only light support, no weight bearing) to patient so balance is not lost.
Testing begins at:

• Stage 3 for arm, hand and foot
• Stage 4 for postural control and leg

Testing Procedures

When instructing patient, use simple commands. Modifications to instructions may be necessary to ensure patient understands required movements.

Stage	Testing Procedure	Acceptable Assistance	Inacceptable Assistance
2	Involves facilitated active movement, in any range. Testing for tone - part passively put through available range of motion briskly with two repetitions.	Visible muscle contractions qualify as movement. Facilitatory stimulus (i.e., manual stimuli). Maximum of two repetitions per task.	Increased muscle tone alone. Ice or mechanical devices.
3 to 7	Voluntary movement is tested.		Facilitation techniques.
6	Full range of motion with near normal timing and coordination.
7	Full range of motion and rapid complex movements with normal timing. Timing and coordination of the task must be comparable to the uninvolved side.		Movements not equal to uninvolved side.

*Any tasks involved greater than half or full range of motion, compare with range on uninvolved side.

Interpretation and Scoring

Impairment Inventory

Shoulder Pain

When assessing stage of shoulder pain, consider any pain that is present and its relationship to functional activities, even those not involving the shoulder or arm. Steps in the Shoulder Assessment are as follows:

1. Ask questions regarding pain and function
2. Test range of motion
3. Examine shoulder and scapula

Ensure prognostic indicators are noted that assist in predicting shoulder pain. The following indicators are most significant:

• Arm is in low stage of recovery, Stage 1 or 2
• Scapula is misaligned. It can be elevated, depressed, abducted or adducted
• Loss of range of motion with flexion or abduction < 90˚ or external rotation < 60˚

Motor Recovery for Postural Control, Arm, Hand, Leg and Foot

Principles of Motor Recovery:

• Motor recovery from hemiplegia follows a stereotyped sequence of events
• Performance of selected motor tasks, requiring increased complex motor control, indicates central nervous system recovery
• In the early stages, movement first occurs in limb synergy patterns. As stages progress, movement patterns out of the synergy in more complex and independent patterns.
• Postural control, arm, hand, leg and foot may recover at different rates. The stage of recovery of the proximal part of the limbs is often in a higher stage than the distal. Movements involving flexion are at a different stage of recovery than movements involving extension.
• Stages of Motor Recovery measure the amount of neurological impairment
  

Motor Stages of Recovery.

Flexion and Extension Limb Synergies of the Arm, Hand, Leg and Foot.

Scoring the Impairment Inventory

• The patient may attempt each task twice
• Additional attempts that train the patient to achieve a task are not permitted
• To receive credit, patient muscle complete task at least once
• Place an ‘X’ in corresponding box for tasks completed

• If patient fails to complete two of the three tasks in the stage where testing began, move to lower stage until two tasks are accomplished in a single stage.
• If two tasks are accomplished at the stage where testing began, assess the third task, but regardless of result, move up to next stage.
• In order to progress from Stage 6 to 7, need to complete all tasks in Stage 6 and at least 2 tasks in Stage 7.
• The patient’s stage of recovery is the highest stage where at least two of the three tasks are accomplished.
• Put this score in the box provided and note any limitations that will impact function.

Activity Inventory

Purpose of Activity Inventory is to assess the patient’s functional level. Therefore, focus on task accomplishment, not quality of movement.

Description of the Levels of Function and Scores

Level	Description
Independent	Another person is not required for the activity (NO HELPER).
7 - Complete Independence	All of the tasks which make up the activity are typically performed safely, without modification, assistive devices, or aids, and within reasonable time.
6 - Modified Independence	Activity requires any one or both of the following to complete the task: an assistive device (eg. foot orthoses, cane), or more than reasonable time (at least 3 times longer than normal).
Dependent	Another person is required for either supervision or physical assistance in order for the activity to be performed, or it is not performed (REQUIRES HELPER).
Modified Dependence	The subject expends half (50%) or more of the effort. The levels of assistance required are:
5 - Supervision	The client requires no more help than standby supervision, cueing or coaxing, without physical contact.
4 - Minimal Contact Assistance	With physical contact the subject requires no more help than touching, and client expends 75% or more of the effort.
3 - Moderate Assistance	The client requires more help than touching, or expends half (50%) or more (up to 75%) of the effort.
Complete Dependence	The client expends less than half (less than 50%) of the effort. Maximal or total assistance is required, or the activity is not performed. The levels of assistance required are:
2 - Maximal Assistance	The client expends less that 50% of the effort, but at least 25%.
1 - Total Assistance	The client expends less than 25% of the effort, 2 persons are required for assistance, or the task is not tested for safety reasons.

You are expected to score each task, do not leave any item blank. If you decide not to test a task because of your concerns for the client’s safety, assign a score of 1.

Score Interpretation for Impairment and Activity Inventories

The impairment and disability inventories yield total scores out of 42 and 100, respectively, with lower scores indicating greater impairment.