Fugl-Meyer Assessment of Motor Recovery after Stroke

 

Original Editor - Sinead Greenan

Top Contributors - Sinead Greenan, Adam Vallely Farrell, Andeela Hafeez, Kim Jackson, Oyemi Sillo, Vanessa Rhule, WikiSysop, Candace Goh, Areeba Raja, 127.0.0.1, Evan Thomas, Scott Buxton and Naomi O'Reilly  

Objective

The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment index. It is designed to assess motor functioning, balance, sensation and joint functioning in patients with post-stroke hemiplegia. It is applied clinically and in research to determine disease severity, describe motor recovery, and to plan and assess treatment.

Intended Population

The FMA was designed to be used for patients with post-stroke hemiplegic patients of all ages.

Method of Use

Features of the Outcome Measure

Items: 

The scale is comprised of five domains and there are 155 items in total:

• Motor functioning (in the upper and lower extremities)
• Sensory functioning (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints)
• Balance (contains 7 tests, 3 seated and 4 standing)
• Joint range of motion (8 joints)
• Joint pain

The motor domain includes items assessing movement, coordination, and reflex action of the shoulder, elbow, forearm, wrist, hand, hip, knee, and ankle. Items in the motor domain have been derived from Twitchell’s 1951 description of the natural history of motor recovery following stroke and integrates Brunnstrom’s stages of motor recovery . Items of the FMA are intended to assess recovery within the context of the motor system. Functional tasks are not incorporated into the evaluation.

Equipment Required:

The FMA requires a mat or bed, a few small objects and several different tools for the assessment of sensation, reflexes, and range of motion:

Materials needed;

• • Scrap of paper
  • Ball
  • Cotton ball
  • Pencil
  • Reflex hammer
  • Cylinder (small can or jar)
  • Goniometer
  • Stopwatch
  • Blindfold
  • Chair
  • Bedside table

Scoring:

Scoring is based on direct observation of performance. Scale items are scored on the basis of ability to complete the item using a 3-point ordinal scale where 0=cannot perform, 1=performs partially and 2=performs fully. The total possible scale score is 226.

Points are divided among the domains as follows:

• Motor score: ranges from 0 (hemiplegia) to 100 points (normal motor performance). Divided into 66 points for upper extremity and 34 points for the lower extremity.
• Sensation: ranges from 0 to 24 points.  Divided into 8 points for light touch and 16 points for position sense.
• Balance: ranges from 0 to 14 points.  Divided into 6 points for sitting and 8 points for standing.
• Joint range of motion: ranges from 0 to 44 points.
• Joint pain: ranges from 0 to 44 points.

Classifications for impairment severity have been proposed based on FMA Total motor scores (out of 100 points):

Fugl-Meyer (1980)	Fugl-Meyer et al. (1975)	Duncan, Goldstein, Horner, Landsman, Samsa, & Matchar (1994)
< 50 = Severe		0-35 = Very Severe
50-84 = Marked	≤ 84 = Hemiplegia	36-55 = Severe
85-94 = Moderate	85-95 = Hemiparesis	56-79 = Moderate
95-99 = Slight	96-99 = Slight motor dyscoordination	> 79 = Mild

Time to administer:

It takes approximately 30-35 minutes to administer the total FMA. Administration of the motor, sensation and balance subscores range from 34 to 110 minutes, with a mean administration time of 58 minutes. When the motor scale is administered on its own, it takes approximately 20 minutes to complete.

Evidence

Reliability

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, General Rehab Sample) 

• Excellent Total Motor Score (ICC = 0.97)
• Excellent Sensation (ICC = 0.81)
• Excellent Passive Joint motion (ICC = 0.95)

Interrater/Intrarater Reliability:

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

Rating	Domain	Pearson's r
Excellent	FMA total score	r = 0.98-0.99
Excellent	Upper Extremity	r = 0.995 - 0.996
Excellent	Lower Extremity	r = 0.96
Excellent	Sensation	r = 0.95 - 0.96
Excellent	Joint Range / Pain	r = 0.86 - 0.996
Excellent	Balance	r = 0.89 - 0.98

Validity

Criterion Validity:

Stroke:

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

• 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) 

Construct Validity:

Stroke:
Acute Stroke:

• Excellent correlation: modified Balance Subscale on FMA and the Barthel Index; r = 0.86 - 0.89 (Mao et al, 2002) 
• Excellent correlation: FMA and Functional Independence Measures (FIM) administered to 172 inpatients who had recently had a stoke; r = 0.63 (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, Chronic Stroke) 

• 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 = 0.76) the Upper Extremity subscore of the motor domain (r = 0.75) and FMA Motor total score (r = 0.74)

Responsiveness

Stroke:

(Mao et al, 2002, Acute Stroke) 

• 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

(Hsueh et al, 2009, Chronic Stroke) 

• 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 (0.53 and 0.51)
• Small effect sizes on the long version of the measure (0.045 and 0.38)

Resources

• Fugl-Meyer Assessment of Motor Recovery After Stroke
• Fugl-Meyer Assessment: Upper Extremity (FMA-UE)
• Fugl-Meyer Assessment: Lower Extremity (FMA-LE)
• Fugyl-Meyer assessment of Physical Performance: Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial