Purpose

The Berg Balance Scale (BBS) quantitatively assesses balance in older adults.

In-Depth Review

Purpose of the measure

The Berg Balance Scale (BBS) quantitatively assesses balance in older adults.

Available versions

The BBS was published in 1989 by Berg, Wood-Dauphinee, Williams and Maki.

Features of the measure

Items:
In this 14-item scale, patients must maintain positions and complete moving tasks of varying difficulty. In most items, patients must maintain a given position for a specified time.

Scoring:
Patients receive a score from 0-4 on their ability to meet these balance dimensions. A global score can be calculated out of 56. A score of 0 represents an inability to complete the item, and a score of 56 represents the ability to independently complete the item.

• 0-20 on the BBS represents balance impairment;
• 21-40 on the BBS represents acceptable balance;
• 41-56 on the BBS represents good balance.

Subscales:
None typically reported.

Equipment:
Only simple and easily accessible equipment is needed to complete the BBS. This includes a ruler, stopwatch, chair, and a step or stool. Also, the patients will require enough room to move 360 degrees.

Training:
No special training is required to administer the BBS. It has been deemed highly reliable when administered by individuals with no formal training on the administration of the scale.

However, it is important to note that in order to ensure the safety of the patient, the BBS should only be administered by individuals with knowledge on how to safely manage those with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The BBS is a risky assessment where a patient could fall if not supervised by someone with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. expertise.

Time:
The scale takes approximately 10-15 minutes to complete. The patient must be directly observed to assess whether the task was completed.

Alternative forms of the BBS

• A short form of the BBS (BBS-3P), which is composed of 7 items, has been developed (Chou, Chien, Hsueh, Sheu, Wang, & Hsieh, 2006).
• The BBS-3P was found to be psychometrically similar (including test reliability, validity, and responsivenessThe ability of an instrument to detect clinically important change over time.
  ) to the original BBS for people with stroke.
• The BBS-3P takes less than 10 minutes to complete and requires only a chair and an object that the patient can retrieve from the floor. The BBS-3P is scored based on 3 levels: unable to complete the task, partially completes task, and able to complete the task. The 7 items included in the BBS-3P are: reaching forward with outstretched arm, standing with eyes closed, standing with one foot in front, turning to look behind, retrieving object from floor, standing on one foot, and changing from a sitting to standing position.
• Compared with the original BBS, the BBS-3P is a quick and simple measure to complete in either a clinical or a research setting.

Client suitability

Can be used with:

• Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who understand spoken or written language who will find the items challenging.

The BBS was originally designed as a quantitative measure of balance and risk for falls in community-dwelling elderly patients. It has been shown to be a reliable and valid measure of balance in the elderly client with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used in:

• More active elderly post-stroke patients.
• Post-stroke patients who are younger.
  There may be a ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." with these patients, in that the items may not be sufficiently challenging to measure higher-level balance such as walking outdoors.
• Severely affected patients such as patients who cannot leave a seated position.
  There may be a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
  with these patients, as there is only one item assessing balance in the seated position.

Instead, you may wish to consider the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients (PASS), which was designed as a balance assessment for patients with stroke that is applicable for all patients, even those with the most severe postural performance (Benaim, Pérennou, Villy, Rousseaux, & Pelissier, 1999).

Mao, Hsueh, Tang, Sheu, and Hsieh (2002) compared the psychometrics of the BBS to those of the balance subscale of the Fugl-Meyer Assessment and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients in 123 patients with stroke up to 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset and found that the FM-B and BBS showed a significant floor or ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." at some days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. points, whereas the PASS did not show these effects.

In what languages is the measure available?

• Translated and validated in Portuguese (Miyamoto, Lombardi, Berg, Ramos, & Natour, 2004).
• Translated and validated in French (Institut de réadaptation de Montréal).
• Translated (not yet validated) in: Iceland, Norway, Sweden, Denmark, Finland, Italy, the Netherlands, Poland, Korea, Japan, Spain, and Hong Kong and Germany.

Summary

What does the tool measure?	Balance in older adults
What types of clients can the tool be used for?	The BBS was developed for use with community-dwelling elderly individuals. It can also be used in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment.
Time to administer	Approximately 10-15 minutes to complete by direct observation.
Versions	Short form of the BBS (BBS-3P)
Other Languages	Translated and validated in Portuguese, French. Translated (not yet validated) in the following countries: Iceland, Norway, Sweden, Denmark, Finland, Italy, the Netherlands, Poland, Korea, Japan, Spain, and Hong Kong and Germany.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study has reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.. Test-retest: One study has reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). . Intra-rater: One study has reported excellent intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. . Inter-rater: Two studies have reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. .
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: The items were selected based on interviews with 12 geriatric clients and 10 professionals. The list of items was revised following a pretest of all preliminary items. Criterion: Concurrent: Excellent correlations with the Fugl-Meyer balance subscale, Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients, Functional Reach, Tinetti Balance Scale, Timed Up and Go test and Single-Leg Stance; adequate to excellent correlations with the Motor Assessment Scale sitting section and Rivermead Mobility Index (although poor correlations with the weight shift test and step-up tests); adequate correlations with the Barthel Index mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). , dynamic Balance Master measures, and postural sway. Predictive: Predicted risk of falling over next 12 months, moderately predictive of length of stay in rehabilitation unit, predicted motor ability 180 days after stroke; not a significant predictor of mean steps per day. Construct: Convergent/Discriminant: Excellent correlations with the Barthel Index, and Fugl-Meyer balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). ; adequate to excellent correlations with the Functional Independence Measure. Known Groups: One study reported that the BBS is able to differentiate between patients according to level of functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second. .
Floor/Ceiling Effects	Significant floor and ceiling effects have been detected in the BBS.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." /specificity of the BBS with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
Does the tool detect change in patients?	One study reports general sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." to change and two studies report large responsivenessThe ability of an instrument to detect clinically important change over time. to change. Two studies indicate moderate responsivenessThe ability of an instrument to detect clinically important change over time. to change 6 weeks to 3 months post-stroke, but poor responsivenessThe ability of an instrument to detect clinically important change over time. following these times. One study reported a minimum absolute change score of 6 points represents genuine change.
Acceptability	This direct observation test is not suitable for severely affected patients as it assesses only one item related to balance while sitting. Active individuals will find it too simple. The scale is not suitable for use by proxy.
Feasibility	The BBS requires no specialized training to administer, however, the BBS should only be administered by individuals with knowledge on how to safely manage those with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. as the BBS is a risky assessment where a patient could fall if not supervised by someone with stroke expertise. Relatively little equipment or space is required.
How to obtain the tool?	Click here to find a copy of the BBS.

Psychometric Properties

Overview

Berg, Wood-Dauphinee, Williams, and Maki (1992), and Berg, Wood-Dauphinee, and Williams (1995) examined both the validityThe degree to which an assessment measures what it is supposed to measure.
and reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the BBS. Following these psychometric studies, current research on the BBS has focused mainly on comparing the psychometrics of the BBS to other balance measures (eg. Mao, Hsueh, Tang, Sheu, & Hsieh, 2002) and on testing the psychometrics of the short form of the BBS, the BBS-3P (Chou et al., 2006).

Floor/Ceiling Effects

In a study by Mao et al. (2002), three common balance scales (BBS, the Balance subscale of the Fugl-Meyer Assessment, and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients) were compared. A significant floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
was detected in the BBS and the balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl- Meyer 14 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. One possible explanation for this effect is that the least demanding item in these two tests is to sit independently. As patients with severe impairments may be unable to do any of the other activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
– for example, stand on one foot, step up on a stool etc. – even as they improve, the result is a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
(the score does not show change for those with severe impairments). Thus, in those with severe impairments, you may wish to consider using another scale such as the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients, which is applicable to all strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients. The BBS also had a significant ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." at 90 and 180 days after stroke onset for those with higher-level function, suggesting that the BBS may not be able to discriminate balance function after 90 days, the point at which people typically reintegrate into leisure and community activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. :
Berg et al. (1995) conducted a study to assess the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the BBS in both elderly long-term care residents and patients with stroke. The BBS was administered to elderly residents (n=113) at baseline, and at 3, 6 and 9 months, and to patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=70) at 2, 4, 6 and 12 weeks post-stroke onset. At each evaluation, Cronbach’s alphas were greater than 0.83 and 0.97 for the elderly residents and patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. respectively, showing that the BBS has excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency..

Intra-rater:
Flansbjer, Blom & Brogardh (2012) conducted an intra-rater test-retest reproducibility study whereby 50 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were assessed with the BBS on 2 occasions, 7 days apart, by one rater. Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was excellent (ICC=0.88). The mean difference of test scores, measured by the Bland and Altman technique, was high and positive (d=0.72), indicating a learning effect.
Note: When performing a Bland and Altman analysis, a mean difference close to zero indicates higher agreement between measurements.

Inter-rater and intra-rater:
Berg et al. (1995) also assessed inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
. Therapists administered the BBS to 35 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. within 24 hours of the independent rater. Similarly, caregivers were asked to test the elderly residents within one week of the independent rater. To assess intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
, 18 residents and 6 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients were assessed one week apart by the same rater. There was agreement between the raters (ICC = 0.98) and the same rater was consistent at two points in time (ICC = 0.97).

Stevenson (2001) examined inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the BBS among 48 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. assessed by two different raters at initial assessment (T1) and second assessment within 24 hours (T2). Agreement between T1 and T2 data was excellent (ICC = 0.92).

Validity

Content:
The items were selected based on interviews with 12 geriatric clients and 10 professionals. The list of items was revised following a pretest of all preliminary items.

Criterion:
Concurrent:
Flansbjer, Blom & Brogardh (2012) reported excellent relationships between the BBS and the Single-Leg Stance (SLS) in 50 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (r=0.65 – 0.79, p<0.001), using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson's r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
coefficients.

Liston and Brouwer (1996) showed that BBS scores related to dynamic Balance Master measures (r ? 0.48) in 20 ambulatory hemiparetic subjects.

Mao et al. (2002) reported excellent relationships between BBS scores and the balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer (r = 0.90 to 0.92), and Postural Assessment Scale for Stroke Patients (r = 0.92 to 0.95) at 4 assessment times (14, 30, 90, and 180 days post-stroke).

Tyson and DeSouza (2004) tested the concurrent validities of the sitting section of the Motor Assessment Scale, the Berg Balance Scale and Rivermead Mobility Index using Spearman’s rho and found that BBS scores correlated with the the appropriate comparator tests (r = 0.32 to 0.74), except the weight shift test and step-up tests which did not form significant relationship with Berg Balance Scale (r = 0.26 and 0.19 respectively).

Smith, Hembree, and Thompson (2004) found that the BBS correlated with Functional Reach (r = 0.78). When the relationship between the two measures for subjects with similar motor impairments were examined (based on the four categories of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. severity from the motor section of the Fugl-Meyer as suggested by Duncan et al. (1992)), correlations differed according to patient severity, with the lowest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
being for those with moderately severe motor impairmentLoss of strength and coordination, decrease in arm or leg movement
(a score of 36-55 on the Fugl-Meyer; r = 0.24), and the highest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
for those with moderate motor impairments (a score of 56-79 on the FM; r = 0.80).

Thirty-one elderly clients were measured on the BBS, and on lab measures of postural sway and clinical measures of balance and mobility including the Tinetti Balance SubscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, the Barthel mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, and the Timed Up and Go Test. Postural sway correlated adequately with the BBS (r = -0.55), and clinical measure correlations ranged from poor (r = -0.46) to excellent (r = -0.67) and were negatively correlated (note: low scores on postural sway and clinical measures indicate normal function, whereas a high score on the BBS indicates normal function, resulting in a negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
). CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Tinetti Balance SubscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was excellent (r = 0.91), and the BBS adequately correlated with the Barthel mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r = 0.67). CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Timed Up and Go Test was excellent and negative (r = -0.76), meaning that a low score on the Timed Up and Go Test (a low score suggests normal functioning) corresponds to a high score on the BBS (a high score indicates balance is intact) (Berg et al., 1992).

In this same study, correlations between scores on the BBS and ratings of 113 residents of a home for the elderly and their caregivers ranged from poor to adequate (elderly: r=0.39 to r=0.41; caregivers: r=0.47 to r=0.61) (Berg et al., 1992).

Predictive:
One hundred thirteen elderly individuals were followed for 12 months, and were classified as having 0, 1, and > 2 falls during that time. The relative risk of falling over the next 12 months was 2.7 times more likely in patients who obtained a BBS score < 45 (Berg et al., 1992).

Admission BBS was adequately predictive of length of stay (LOS) in rehabilitation unit (r = -0.39) (this negative relationship suggests that a higher BBS score results in a shorter length of stay) (Juneja et al., 1998).

In Mao et al. (2002), the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the BBS was assessed by comparing the results of the BBS at 14, 30, and 90 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with that of the Motor Assessment Scale at 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by use of Spearman’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. The scores of the BBS at the earlier 3 days after stroke points were highly correlated with the MAS scores on evaluations on 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (r > 0.8), indicating excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
.

Fulk, Reynolds, Mondal & Deutsch (2010) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the 6MWT and other widely used clinical measures (FMA LE, self-selected gait-speed, SIS and BBS) in 19 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The BBS was found to not be a significant predictor of mean steps per day (r = 0.54; P = 0.016). Although gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed and balance were related to walking activity, only the 6MWT was found to be a predictor of community ambulation in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:
Convergent/Discriminant:
Seventy acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. clients were tested on the BBS, the Barthel Index, and the balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer Assessment at 4, 6 and 12 weeks post-stroke. Correlations between the BBS and the Barthel Index were excellent (ranging from r = 0.80 to r=0.94, and correlations between the BBS and the balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer ranged from adequate to excellent (ranging from r = 0.62 to r = 0.94) (Berg et al., 1992).

BBS scores were also reported to correlate with the Functional Independence Measure (r = 0.57 to 0.70) (Juneja, Czyrny, & Linn, 1998) and r = 0.76 (Wee, Bagg, & Palepu, 1999).

Known Groups:
Stevenson (2001) examined the known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured.
of the BBS among 48 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Dunn’s method. Patients were grouped according to Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Category (FAC) scores: ASSIST (FAC score ? 2, requiring physical assistance, n=16), SBA (FAC score = 3, requiring stand-by assistance, n=17) or INDEP (FAC score ? 4, independently ambulant, n=15). There was a significant difference between the INDEP and ASSIST groups (Q = 4.47, p<0.05) and the INDEP and SBA groups (Q = 3.07, p<0.05), but not between the SBA and ASSIST groups.

Responsiveness

Flansbjer, Blom & Brogardh (2012) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the BBS among 50 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who were assessed on 2 occasions, 7 days apart. The standard error of measurement (SEM), i.e. the smallest change that indicates a real improvement for a group of individuals, was 3%. The smallest real difference (SRD) for a single individual was 8%.

Stevenson (2001) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the BBS among 48 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. assessed by different raters over three intervals – initial assessment (T1), second assessment within 24 hours (T2), and third assessment after approximately 1 to 2 weeks of intervention (T3). Patients were categorized into one of three groups according to Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Category (FAC) scores: ASSIST (FAC score ≤ 2, requiring physical assistance); SBA (FAC score = 3, requiring stand-by assistance); and INDEP (FAC score ≤ 4, independently ambulant). All groups demonstrated statistically significant increases in BBS performance from T1 to T3 (Wilcoxon Signed Rank Test, W = 77.4 – 106, p ≤ 0.002), but not from T1 to T2. Minimal Detectable Change (MDC)Minimal Detectable Change (MDC) refers to the minimal amount of change outside of error that reflects true change by a patient between two time points (rather than a variation in measurement). from T1 to T2 = 5.8 (90% CI) indicating that a minimum absolute change score of 6 points represents change in a patient’s BBS performance when assessed by two different raters within 24 hours (all patients ± 6; INDEP group ± 6; SBA group ± 5; ASSIST group ± 7).

Mao et al. (2002) assessed the responsivenessThe ability of an instrument to detect clinically important change over time.
of the BBS, the Balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer Test, and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients by calculating effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(ES) (dividing the mean change scores by the standard deviation of the change score in the same subjects). The ES showed that the BBS was moderately responsive in detecting changes before 90 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The ES for the BBS were greatest in the interval between 14 and 30 days (0.80) and diminished the further one moved through time from the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. event (30 to 90 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., ES = 0.69). The ES for the BBS was considered poor at 90-100 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (ES = 0.40). The changes in the BBS at each stage were significant.

To determine whether the responsivenessThe ability of an instrument to detect clinically important change over time.
of the measures varied depending on the initial stroke-induced deficits, patients were stratified into 1 of the following 3 groups on the basis of their Balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer Test scores: 0 to 35, severe; 36 to 79, moderate; and 80, mild. The responsivenessThe ability of an instrument to detect clinically important change over time.
of the BBS at different stages for subjects with different levels of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. severity (ES = 0.21) suggested that the BBS is generally sensitive to change over time after a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. However, the BBS was found to be less responsive than the Balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the Fugl-Meyer Test and Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients for severe patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., at 14 to 30 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The reason for this finding might be that the BBS was not originally designed for patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., and only one item of the scale assesses balance ability in the sitting position. Because sitting balance is one of the first postures to be restored after a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., it seems that the BBS is lacking items to detect change in patients who are unable to stand independently.

Wood-Dauphinee, Berg, Bravo, and Williams (1997) reported an ES of 0.66 for initial 6-week post-stroke evaluation period, ES = 0.25 for 6-12 weeks post-stroke, and an overall ES = 0.97.

Salbach et al. (2001) used standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores.
(SRM = mean change/standard deviation of change) to estimate the responsivenessThe ability of an instrument to detect clinically important change over time.
of the 5-metre walk test, the 10-metre walk test, the BBS, the Barthel Index , the StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Rehabilitation Assessment of Movement, and the Timed Up and Go in 50 subjects with residual gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
deficits after a first-time strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The SRM from 8-38 days post-stroke for the BBS was 1.04. The BBS was rated as the second most responsive measure (the 5-metre walk test was the most responsive measure) and was recommended for use in patients who have suffered a severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

English, Hillier, Stiller, and Warden-Flood (2006) investigated the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed, the BBS and the Motor Assessment Scale in 78 subjects receiving inpatient rehabilitation following a first or recurrent strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. to detect change over time. Subjects were assessed within one week of admission and one week of discharge. The BBS was sensitive to change (only two patients showed no change) and demonstrated a large ES (d = 1.01).

References

• Benaim, C., Pérennou, D. A., Villy, J., Rousseaux, M., Pelissier J. Y. (1999). Validation of a Standardized Assessment of Postural Control in Stroke Patients: The Postural Assessment Scale for Stroke Patients (PASS). Stroke, 30, 1862-1868.
• Berg, K.O., Wood-Dauphinee, S., Williams, J. L., Maki, B. (1989). Measuring balance in the elderly: Validation of an instrument. Physiotherapy Canada, 41(6), 304-311.
• Berg, K., Wood-Dauphinee, S. L., Williams, J. I., Maki, B. E. (1992). Measuring balance in the elderly: Validation of an instrument. Canadian Journal of Public Health, 83(S2), S7-S11.
• Berg, K., Wood-Dauphinee, S. L., Williams, J. I. (1995). The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Sc and J Rehabil Med, 27(1), 27-36.
• Chou, C. Y., Chien, C. W., Hsueh, I. P., Sheu, C. F., Wang, C. H., Hsieh, C. L. (2006). Developing a Short Form of the Berg Balance Scale for People With Stroke. Physical Therapy, 86(2), 195-204.
• Juneja, J., Czyrny, J. J., Linn, R. T. (1998). Admission balance and outcomes of patients admitted for acute inpatient rehabilitation. Am J Phys Med Rehabil, 77, 388-393.
• Liston, R., Brouwer, B. J. (1996). Reliability and validity of measures obtained from stroke patients using the balance master. Arch Phys Med Rehabil, 77, 425-430.
• English, C. K., Hillier, S. L., Stiller, K., Warden-Flood, A. (2006). The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke. Clin Rehabil, 20(1), 52-55.
• Fulk, G. D., Reynolds, C., Mondal, S., & Deutsch, J. E. (2010). Predicting home and community walking activity in people with stroke. Arch Phys Med Rehabil, 91, 1582-1586.
• Flansbjer, U-B., Blom, J., & Brogardh, C. (2012). The reproducibility of Berg Balance Scale and the Single-Leg Stance in chronic stroke and the relationship between the two tests. Physical Medicine & Rehabilitation, 4(3), 165-170.
• Mao, H. F., Hsueh, I. P., Tang, P. F., Sheu, C. F., Hsieh, C. L. (2002). Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke, 33, 1022.
• Miyamoto, S. T., Lombardi, I. J., Berg, K. O., Ramos, L. R., Natour, J. (2004). Brazilian version of the Berg balance scale. Braz J Med Biol Res, 37(9), 1411-1421.
• Salbach, N. M., Mayo, N. E., Higgins, J., Ahmed, S., Finch, L. E., Richards, C. L. (2001). Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil, 82, 1204-1212.
• Scherfer, E., Bohls, C., Freiberger, E., Heise, K. F., Hogan, D. (2006). Berg-Balance-Scale – German Version – Translation of a standardized instrument for the assessment of balance and risk of falling. Physioscience, 2, 59-66.
• Smith, P. S., Hembree, J. A., Thompson, M. E. (2004). Berg Balance Scale and Functional Reach: Determining the best clinical tool for individuals post acute stroke. Clin Rehabil, 18, 811-818.
• Stevenson, T.J. (2001). Detecting change in patients with stroke using the Berg Balance Scale. Australian Journal of Physiotherapy, 47, 29-38.
• Tyson, S. F., De Souza, L. H. (2004). Reliability and validity of functional balance tests post stroke. Clin Rehabil, 18, 916-923.
• Wee, J. Y. M., Bagg, S. D., Palepu, A. (1999). The Berg Balance Scale as a predictor of length of stay and discharge in an acute stroke rehabilitation setting. Arch Phys Med Rehabil, 80, 448-452.
• Wood-Dauphinee, S., Berg, K. O., Bravo, G., Williams, J. L. (1997). The Balance Scale: responsiveness to clinically meaningful changes. Can J Rehab, 10, 35-50.

See the measure

Click here to find a copy of the full BBS

By clicking here, you can access a video showing how to administer the assessment.

Purpose

The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment index. It is designed to assess motor functioning, sensation, balance, joint range of motion and joint pain in patients with post-stroke hemiplegia (Fugl-Meyer, Jaasko, Leyman, Olsson, & Steglind, 1975; Gladstone, Danells, & Black, 2002). It is applied clinically and in research to determine disease severity, describe motor recovery, and to plan and assess treatment.

In-Depth Review

Items:

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

• Motor function (in the upper and lower extremities)
• Sensation (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 (Gladstone et al. 2002; Poole & Whitney, 2001). Items of the FMA are intended to assess recovery within the context of the motor system. Functional tasks are not incorporated into the evaluation (Chae, Labatia, & Yang, 2003).

Time:

Sections of the FMA are often administered separately, however it takes approximately 30-35 minutes to administer the total FMA (Poole & Whitney, 2001). The average length of time for FMA administration of the Motor function, Sensation and Balance subscores have reported to range from 34 to 110 minutes, with a mean administration time of 58 minutes (Malouin, Pichard, Bonneau, Durand & Corriveau, 1994). When the motor scale is administered on its own, it takes approximately 20 minutes to complete.

A major criticism of the FMA is that it is a lengthy measure to administer (Gladstone et al., 2002). Sometimes it takes longer than 35 minutes to complete, such as when it is administered to aphasic or severely affected patients (Kusoffsky, Wadell, & Nilsson, 1982; Dettmann, Linder, & Sepic, 1987).

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 function 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 score: ranges from 0 to 24 points. Divided into 8 points for light touch and 16 points for position sense.
• Balance score: ranges from 0 to 14 points. Divided into 6 points for sitting and 8 points for standing.
• Joint range of motion score: ranges from 0 to 44 points.
• Joint pain score: ranges from 0 to 44 points.

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

Source: Finch, Brooks, Stratford, & Mayo, 2002

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 = HemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.	36-55 = Severe
85-94 = Moderate	85-95 = Hemiparesis	56-79 = Moderate
95-99 = Slight	96-99 = Slight motor dyscoordination	> 79 = Mild

Each of the five FMA domains can be separated to test a specific construct. For example, to assess upper extremity function, the subsections specifically dealing with upper extremity movement, sensation, joint motion and pain can be examined without administering the rest of the scale. Scoring of the FMA will depend on the number of items included in the subsection selected for testing.

Crow et al. (2008) proposed a shortened method of administration for the upper and lower extremity portions of the FMA. Using Guttman analysis the authors determined that scale items in the upper and lower limb sections fulfill the criteria for a valid hierarchy. Clinically this means that rather than administering the entire test, a clinician may choose to begin administering at a point in the scale that appears appropriate to the observed level of patient recovery. If a patient is able to accomplish all of the remaining scale items in the section, they are awarded a full score for that section. Likewise, when the individual being tested is unable to accomplish all the scale items in a given section, a score of 0 is given for any remaining untested, more advanced, items. This method of assessment reduces the time required to perform the test. Full guidelines for hierarchical testing procedures are provided by Crow et al. (2008)

Equipment:

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 (Poole & Whitney, 2001; Sullivan et al., 2011):

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

Subscales:

There are five domains that can be assessed independently: Motor function; Sensation; Balance; Joint range of motion; and Joint pain. Sensation and Joint pain are more subjective in nature and are used less frequently (Gladstone et al., 2002). Sullivan et al. (2011) published a FMA manual of procedures, which includes training procedures for clinical practice and research trials, in an effort to standardize assessment procedures.

Training:

The FMA should be administered by a trained physical therapistIn charge of the "assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues." (Suggested by Philips et al, 2002)
, occupational therapistIn charge of the "assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education."(Suggested by Philips et al, 2002)
or other rehabilitation professional on a one-to-one basis with the patient (Gladstone et al., 2002).

Guidelines provided by Fugl-Meyer et al. (1975) suggest that the client should be instructed verbally and/or with a demonstration of the test. The evaluator is permitted to assist the patient in the testing of the wrist and hand to stabilize the arm (Fugl-Meyer et al., 1975). In patients confined to their beds, the joint range of shoulder abduction should be performed only to 90 degrees and extension of the hip to 0 degrees.

Alternative Forms of Fugl-Meyer Assessment (FMA)

In 1975, Fugl-Meyer, Jaasko, Leyman, Olsson, and Steglind published the FMA.

Revision to balance subscore

Subsequent to problems reported with sitting balance items (Malouin et al., 1994), Hseuh et al. (2001 as reported in Mao, Hsueh, Tang, Sheu, & Hsieh, 2002) proposed slight modifications to the scoring of the two problematic reaction items. In this modified version, patients receive a score of 0 if they lose balance easily, 1 if they partially lose balance, and 2 if they maintain sitting balance well when firmly pushed on the affected or non-affected side. The validity of the modified FMA-Balance was found to be excellent (r = 0.84).

12-item short form

Hseih et al. (2007) developed a 12-item short form of the FMA based on the upper and lower extremity domains of the FMA. Items were retained on the basis of representativeness of Brunnstrom staging and item difficulty assessed via Rasch analysis.

Client suitability

Can be used with:

• Acute and chronic patients post-stroke in settings from an acute care hospital (Wood-Dauphinee, Williams, & Shapiro, 1990) to the community (Nadeau, Arsenault, Gravel & Bourbonnais, 1999).
• Although it takes longer to administer, the FMA can be applied to severely affected patients or patients with aphasia.

Should not be used in:

• Patients who need a proxy to complete. As with other impairment indices, the FMA is scored by direct observation and therefore it cannot be used with proxy respondents.
• The FMA should not be used to detect fine or complex movements or coordination, as it measures gross limb movement only. A scale that employs a finer evaluation of isolated movements and the complete range of motor function of the upper limb only is the Motor Status Score. This scale has been found to be a reliable and valid assessment of upper limb impairment and disability following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (Ferraro et al., 2002).
• As an assessment of motor recovery within the context of the motor system, the FMA may separate motor recovery from functional recovery. Therefore, the FMA may not be responsive to functional improvements in chronic populations (van der Lee et al., 2001). In these instances, a more appropriate tool for assessing functional improvements in chronic populations is the Action Research Arm Test (assesses upper extremity function only).

In what languages is the measure available?

• English
• French canadian (Arsenault, Dutil, Lambert, Corriveau, Guarna, & Drouin, 1988)

Summary

What does the tool measure?	Motor function, sensation, balance, joint range of motion and joint pain.
What types of clients can the tool be used for?	Patients with post-stroke hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.
Is this a screening or assessment tool?	Assessment
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.
Versions	Modified FMA-Balance subscore 12-item short form
Other Languages	Translated and validated in French
Measurement Properties
Reliability	Internal consistency: Out of three studies examining internal consistency, all three reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.. Test-retest: Out of six studies examining test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). , five reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). . Two studies examined item-level agreement and found that light touch items on the FMA Sensation subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). ranged from poor to adequate; the Joint pain subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). was found to have only adequate reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . , however total FMA test-retest remained excellent in these studies. The study that examined longitudinal stability of the FMA items, as calculated using Rasch Analysis, reported that scores across two testing occasions are comparable. Inter-rater: Out of four studies examining inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. , all four reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. (with the exception of the Balance subscore, which was found to be poor in one study).
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: Items in a modified 30-items FMA reflect the same construct, except for the item hook grasp. Based on a Guttman Scale Analysis, the motor functioning subscales can be arranged in a hierarchical sequence, allowing the use of a shortened method of administration of the FMA. Criterion: Predicted Motor Assessment Scale scores at 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. FMA lower extremity (FMA-LE) admission subscores predicted the rehabilitation discharge Functional Independence Measure mobility and locomotion scores. FMA admission scores predicted the rehabilitation discharge Barthel Index scores. FMA-LE scores were poor predictors of mean steps per day. Excellent correlations with Barthel Index, Motor Assessment Scale (except sitting balance items on both scales), Sensory Organization Balance Test, Action Research Arm Test, DeSouza scale, Chedoke-McMaster Stroke Assessment scale, Berg Balance Scale, Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Rehabilitation Assessment of Movement (STREAM), the shortened versions of the FMA and STREAM, performance assessments of walking velocity and velocity index, and Arm Motor Ability Test. Construct: The FMA lower extremity subscore was able to distinguish between patients who needed assistance in walking and between three levels of self-care ability (dependent, partly dependent, and independent). Excellent correlations between the FMA and Barthel Index (except with FMA Sensastion subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). ); the FMA Motor upper extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and the Action Research Arm Test; the FMA and Bobath Assessment of upper extremity; the FMA and Functional Independence Measure; the FMA Motor subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and various measures of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety. .
Floor/Ceiling Effects	A poor ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." has been found with the Sensation subscore. A poor floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect." has been found with the modified Balance subscore of the FMA at 14 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Another study reported an excellent floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect." and an adequate ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." for the FMA motor scores both at admission and discharge from a rehabilitation program.
Does the tool detect change in patients?	Out of 5 studies examined, 1 reported that the FMA has a large ability to detect change, 1 reported moderate, 1 reported small to moderate, and 2 reported a small ability to detect change.
Acceptability	Administration of the entire FMA is lengthy. The test is scored by direct observation and cannot be completed by proxy respondent.
Feasibility	The FMA must be administered by a trained physical or occupational therapistIn charge of the "assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education."(Suggested by Philips et al, 2002) . It does not require any specialized equipment and can be administered across a variety of settings and has been tested for use in longitudinal assessments.
How to obtain the tool?	The FMA can be obtained by following the link below (from the Institute of Rehabilitation Medicine, University of Goteberg, Goteberg, Sweden). http://www.neurophys.gu.se/sektioner/klinisk_neurovetenskap_och_rehabilitering/neurovetenskap/rehab_med/fugl-meyer/ A version of the measure is also provided in Fugl-Meyer et al. (1975), and in the book by Dittmar, S. S. and Gresham, G. E. (1997) entitled Functional assessment and outcome measures for the rehabilitation health professional. The FMA manual of procedures developed by Sullivan et al. (2011), can be obtained by following the link below: http://stroke.ahajournals.org/cgi/content/full/STROKEAHA.110.592766/DC1

Psychometric Properties

Overview

The FMA has been used as the gold standardA measurement that is widely accepted as being the best available to measure a construct.
against which the validityThe degree to which an assessment measures what it is supposed to measure.
of other measures has been assessed. However, the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and validityThe degree to which an assessment measures what it is supposed to measure.
of the Balance subscore (the sitting balance items in particular) of the FMA has been shown to be questionable. As mentioned in the available versions section, revisions to the scoring of the Balance subscore appear to have resulted in an increase in reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(Mao et al. 2002), however, further testing of the modification is required. The Sensation subscore of the FMA has also been criticized for poor face, construct and predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
and responsivenessThe ability of an instrument to detect clinically important change over time.
(Lin, Hsueh, Sheu, & Hsieh, 2004).

Floor/Ceiling Effects

Lin et al. (2004) examined the psychometric properties of the FMA Sensation subscore and found that these subscore had large ceiling effects at each assessment time. At 14-30 days post-stroke, 44.4% of the patients achieved the highest score, at 30-90 days, 48.9%, at 90-180 days, 62.7% and at 14-180 days, 72.1%.

Mao et al. (2002) compared the psychometric properties of the Berg Balance Scale, the modified Balance subscore of the FMA, and the Postural Assessment Scale for Stroke Patients in 123 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients followed up prospectively 14, 30, 90, and 180 days after stroke onset. The modified Balance subscore of the FMA showed large floor effects (29.3%) at 14 days after stroke.

Hsueh, Hsu, Sheu, Lee, Hsieh and Lin (2009) analyzed the floor and ceiling effects for the FMA, the shortened version of the FMA, the Stroke Rehabilitation Assessment of Movement (STREAM), and the shortened version of the STREAM in 50 clients with chronic stroke. Participants were assessed at admission and discharge from a rehabilitation ward. At admission, the FMA and the shortened version of the STREAM demonstrated an excellent floor effect and ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." with no participants scoring the minimum or maximum scores. The other measures showed adequate floor and ceiling effects with 2 to 18% of patients scoring the lowest or highest scores. At discharge, the FMA and the shortened version of the STREAM demonstrated an excellent floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
with 0% of participants scoring 0. The other measures showed adequate floor and ceiling effects, with the proportion of patients scoring the minimum and maximum scores ranging from 1 to 20%.

Reliability

Lin et al. (2004) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the FMA in 176 patients with stroke from 14 to 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Cronbach’s alphas for the FMA at four time points post-stroke were excellent, ranging from alpha = 0.94 to 0.98. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the total score of the FMA was also excellent, with an intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. of 0.93. However, item-level agreement for light touch items on the FMA Sensation subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
ranged from poor to adequate (weighted kappa ranged from 0.30 to 0.55).

Platz, Pinkowski, van Wijck, Kim, di Bella, and Johnson (2005) tested the test-retest and the inter-rater reliabilities of the FMA upper extremity items (including items from the Motor function, Sensation and passive Joint motion/Joint pain subscores), the Action Research Arm Test, and the Box and Block Test in patients with upper limb paresis either from strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=37), multiple sclerosis (n=14), or from traumatic brain injury (n=5). Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA, calculated using ICC’s, was excellent (ICC = 0.97 for Total motor score; ICC = 0.81 for Sensation, ICC = 0.95 for passive Joint motion/Joint pain). Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the FMA upper extremity subscore as calculated using the ICC was also excellent (ICC = 0.99 for Total motor score; ICC = 0.98 for Sensation; and ICC = 0.98 for passive Joint motion/Joint pain).

Mao et al. (2002) compared the psychometric properties of the Berg Balance Scale, the modified Balance subscore of the FMA, and the Postural Assessment Scale for Stroke Patients, in 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. followed up prospectively 14, 30, 90, and 180 days after stroke onset. The median of weighted kappa statistics for each item of the FMA Balance subscore was 0.79 (ranging from 0.71 to 0.95), indicating excellent individual item agreement. The ICC for the total score of the FMA Balance subscore was 0.92 (ranging from 0.88 to 0.95), indicating excellent total score agreement. The Cronbach’s alpha for the FMA Balance subscore ranged from alpha = 0.85 to 0.91 on all follow-up times, indicating high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency..

Duncan, Propst, and Nelson (1983) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
and the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the FMA in 18 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was examined with 5 different therapists. Pearson correlations between therapists for each component of the FMA Motor domain upper extremity subscale were found to be excellent, ranging from r = 0.96 to r = 0.97. The Motor domain lower extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
correlations were also excellent, ranging from r = 0.83 to r = 0.95. The Total score correlation was high (r = 0.99). Only the reflex and coordination subscores in the upper extremity were found to be unreliable as they were significantly different between the raters across the test times.

To assess the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA in Duncan et al. (1983), one therapist evaluated patients on three separate occasions at 3-week intervals. Pearson correlations were excellent for the Total FMA score (r = 0.98 to r = 0.99), Motor domain upper extremity subscore (r = 0.995 to r = 0.996), Motor domain lower extremity subscore (r = 0.96), Sensation subscore (r = 0.95 to r = 0.96), Joint range of motion/Joint pain subscore (r = 0.86 to r = 0.99) and Balance subscore (r = 0.89 to r = 0.98). No significant differences across evaluation times were found (as assessed by a repeated measures analysis of variance).

Sanford, Moreland, Swanson, Stratford, and Gowland (1993) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the FMA in 12 patients between 6 days to 6 months post-stroke. Patients were evaluated one day apart by three physical therapists. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the FMA was found to be excellent, with an overall ICC of 0.96 for the Total score. The ICCs for the Motor domain upper extremity subscore, Motor domain lower extremity subscore, Balance, Sensation, and Joint range of motion were excellent (0.97, 0.92, 0.93, 0.85 and 0.85, respectively). The ICC for the Joint pain subscore was the least reliable, but still adequate, with an ICC of 0.61.

Beckerman, Vogelaar, Lankhorst, and Verbeek (1996) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA in 49 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Patients were evaluated twice by one therapist, three weeks apart. The ICC for the Motor domain lower extremity subscore was excellent (ICC = 0.86), but was found to be poor for the Balance subscore (ICC = 0.34). Although the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Balance subscore was not found to be very reliable, indicating that the patients’ performance was inconsistent, the inter-rater agreement was high.

Van der Lee, Beckerman, Lankhorst and Bouter (2001) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA Motor domain upper extremity subscore in 22 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Two baseline measurements were performed before treatment, as well as a follow-up measurement after 2 weeks. Using limits of agreement as a measure of test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
, a mean difference on test-retest within a stable population during the baseline period (14-20 days) on the Motor domain upper extremity subscore was small (0.8 points).

Woodbury, Velozo, Richards, Duncan, Studenski, and Lai (2008) investigated the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA through longitudinal stability of the upper extremity items in 377 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with a mean age of 60.2 years (SD 11.2). Longitudinal stability reflects the invariance of an item-difficulty hierarchy of a measure across 2 testing occasions. Assessments with a slightly modified FMA (the 3 reflex items were removed with the remaining 30 items arranged in a hierarchical sequence) were performed at admission and at 6 months post-stroke. Longitudinal equivalence of the FMA item structure was analyzed by estimating the relationship between item-difficulty calibrations at baseline and 6 months follow-up. Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. was performed and showed excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(ICC = 0.95). Consistency of item-difficulty calibrations across testing occasions disregarding clients’ characteristics such as age and gender, as calculated using Differential Item Functioning (DIF), showed that only two items on the FMA (1: shoulder flexion to 180° with elbow extended and 2: movement of the arm with normal speed) had a large DIF, which implied that those two items were unstable between assessments. Despite those items, the authors reported that the scores across testing occasions could still be compared as a repeat Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
with the unstable items removed found a small difference on the FMA scores (0.06 logits).

Hsueh et al. (2009) analyzed the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the FMA, the STREAM, and their shortened versions in 60 clients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were assessed twice within a 1 week interval. Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
, as calculated using Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient was excellent for all four measures: FMA (ICC = 0.98), the shortened version of the FMA (ICC = 0.96), the STREAM (ICC = 0.98) and the shortened version of the STREAM (ICC = 0.97).

Sullivan et al. (2011) developed a standardized measurement method and rater training program for the FMA and then used inter-rater and intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
to examine the effectiveness of the program. After attending the training program, 17 physiotherapists and one expert rater (with 30 years experience) evaluated 15 patients with subacute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The initial assessments were video-recorded and later reviewed by the expert rater. The intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the expert rater, as calculated using ICC was excellent for all domains of the FMA (ranging from ICC = 0.95 to 1.0). The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
between the expert rater and trained therapists, as calculated using ICC, was also excellent for all domains of the FMA (ranging from ICC = 0.87 to 0.99).

Validity

Content:

Woodbury, Velozo, Richards, Duncan, Studenski, and Lai (2008) investigated the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the upper extremity items of the FMA in 377 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with a mean age of 60 years (SD 11,2). Assessments with a slightly modified FMA (the 3 reflex items were removed with the remaining 30 items arranged in a hierarchical sequence) were performed at admission and at 6 months post-stroke. At the follow-up evaluation, the 30-item Fugl-Meyer Assessment, as calculated using Rasch AnalysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
, showed an acceptable fit statistics, except for the item hook grasp. This result suggests that all items reflect the same construct, except for the item hook grasp.

Crow & Harmeling-van der Wel (2008) analyzed the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the motor functioning domain of the FMA in 62 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by performing a Guttmann Scale Analysis. Each motor functioning subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the FMA, excluding the reflex items, was arranged in a hierarchical sequence of difficulty according to the total number of passes per item. All subscales, when analyzed separately, exceed the critical values for two indices: coefficient of reproducibility (> 0,9) and coefficient of scalability (>0,7). When analyzing across all upper and lower extremity items (ignoring the subscales) the coefficient of reproducibility (0,8) and scalability (0,6) were just below the acceptable levels. The results of this study suggest the existence of a valid, cumulative, and unidimensional Guttman scale within each motor functioning subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. In summary, if the client succeeds in completing the most difficult item in a subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, this suggests he/she will succeed in the easier items for that same subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. Similarly, failure on an item suggests the client will be unable to complete the remaining more challenging items in the subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. Therefore, a shortened method of administration of the FMA can be used with clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Criterion:

There is a lack of information available regarding the criterion validityExamines the extent to which a measure provides results that are consistent with a gold standard . It is typically divided into concurrent validity and predictive validity .
of the FMA, as the FMA was created at a time when no other similar impairment index existed against which the FMA could be tested (Gowland, Van Hullenaar, & Torresin, 1995; Gowland, Stratford, & Ward, 1993).

Bernspang et al. (1987) used the Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient and found that the FMA correlated excellently with self-care ability scores (r = 0.64) in 109 clients measured within 2 weeks of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Nadeau et al. (1999) identified the most important clinical variables for determining gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed in 16 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. using Pearson’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. The FMA Sensation subscore correlated poorly with both comfortable and maximal gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speeds (r = 0.14 and r = 0.05, respectively). Patients with decreased sensation and a score below 12, combined with the strength of the hip flexors, and ankle plantar flexors predicted maximal gait speed. Excellent correlations were found between the FMA Total motor score and comfortable (mean 0.76 meters/second; r = 0.61) and maximal speeds (mean 1.09 meter/second; r = 0.61).

Concurrent:
Wood-Dauphinee et al. (1990) compared the FMA to the Barthel Index in 167 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. at two time points: the acute stage (3 to 5 days post-stroke), and 5 weeks post-stroke. Using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients, the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the FMA Motor domain upper extremity subscore and the Barthel Index total score was excellent at both the acute stage (r = 0.75) and at 5 weeks (r = 0.82). Similarly, excellent correlations were found between the FMA Motor domain lower extremity subscore and the Barthel Index at the acute stage (r = 0.77) and at 5 weeks (r = 0.89).

Poole and Whitney (1988) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the FMA with the Motor Assessment Scale in 30 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. High correlations were found between the total scores on the FMA and the Motor Assessment Scale (r = 0.88), and between specific item scores, except sitting balance (ranging from r = 0.28 to r = 0.92).

Malouin et al. (1994) administered the FMA and the Motor Assessment Scale to 32 patients early after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., and reported an excellent Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
for Total FMA and Total Motor Assessment Scale scores (r = 0.96). The correlations for items from the Motor Assessment Scale and corresponding FMA items were excellent, ranging from r = 0.65 to r = 0.93. The FMA Sensation scores of light touch (r = 0.64) and position sense (r = 0.67) correlated with the Motor Assessment Scale’s Balance score, but not with FMA Sitting balance items (r = 0.12 and -0.10 respectively) suggesting that the FMA sitting balance test is not valid for measuring balance. Standing balance correlations ranged from moderately to highly correlated with both the Motor Assessment Scale and FMA light touch and position sense (ranging from r = 0.43 to r = 0.67).

Di Fabio and Badke (1990) examined standing balance and dynamic weight shifting in 10 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. using a sensory organization balance test and the FMA. The results of both clinical tests were compared to determine whether the sensory organization balance test correlated with functional ability using the Spearman rank order correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. Scores on the lower extremity items and balance items of the FMA correlated excellently with the Sensory Organization Balance Test (r = 0.77).

De Weerdt and Harrison (1985) compared the Motor domain upper extremity subscore of the FMA with the Action Research Arm Test. Both assessments were administered to 53 hospital inpatients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who suffered a motor deficit. The Action Research Arm Test and the FMA were excellently correlated at both 2 weeks (r = 0.91) and at 8 weeks (r = 0.94) post-stroke.

Berglund and Fugl-Meyer (1986) compared the FMA to the DeSouza scale (another assessment of upper limb function) in 50 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who suffered a motor deficit. Excellent correlations were found with the Upper extremity Motor scores (r = 0.90). The two tests co-varied, and explained 90% of the variation in the Total scores and 80% of the Motor scores.

Gowland et al. (1993) demonstrated the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment scale with the FMA. The Total score of the impairment inventory of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment Scale correlated highly with that of the FMA (r = 0.95). Correlations reported between impairment subscores on the FMA and corresponding subscores from the impairment inventory of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment ranged from adequate to excellent (r = 0.76 to r = 0.95).

Mao et al. (2002) compared the Berg Balance Scale, the modified Balance subscore of the FMA, and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., in 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. followed up prospectively at 14, 30, 90, and 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. There was excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
(as measured by Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient) between the Balance subscore of the FMA and the Berg Balance Scale and Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. at all follow-up times (ranging from r = 0.90 to r = 0.97).

Kusoffsky, Wadell and Nilsson (1982) reported a relationship between sensory functioning and subsequent motor recovery, as excellent correlations between sensory evoked potentials in 16 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. was observed. The relationship between sensory evoked potentials and the FMA upper extremity subscore was the most strong, and the relationship between the FMA lower extremity subscore was less strong. The strength of the relationship endured regardless of when the FMA was administered.

Feys, Van Hees, Bruyninck, Mercelis and De Weerdt (2000) assessed the role of sensory evoked potentials and motor evoked potentials in the prediction of arm motor recovery in 64 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with a motor deficit of the arm. Patients were followed from 2 weeks to 12 months post-stroke. In this study, a poor relationship was found between sensory evoked potentials and the FMA.

Dettmann et al. (1987) administered the FMA and a walking performance test using interrupted light photography and postural maneuvers while standing on a force platform in 15 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Correlations between the FMA Total scores and performance assessments of walking velocity (r = 0.64), cadence (r = 0.58), stride-length (r = 0.53), non-paretic stance (r = 0.59), velocity index (r = 0.67), and platform measures of upright stability (r = 0.52 to r = 0.69) ranged from adequate to excellent.

Poole and Whitney (1988) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the Motor Assessment Scale and the FMA in 30 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent correlations between FMA items and corresponding MAS items were found (ranging from r = 0.64 to r = 0.92). However, one exception was the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
of the FMA sitting balance with the MAS balance while sitting, which were poorly correlated (r = 0.28).

Chae, Labatia, and Yang (2003) evaluated the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the Arm Motor Ability Test using the FMA as the criterion measure of post-stroke upper limb motor impairmentLoss of strength and coordination, decrease in arm or leg movement
in 30 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent Spearman correlations between upper extremity scores of the FMA and Arm Motor Ability Test functional ability scores (r = 0.94) as well as between upper extremity scores of the FMA and Arm Motor Ability Test quality of movement scores (r = 0.94) were reported.

Hsueh et al. (2009) analyzed the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the FMA, the shortened version of the FMA, the STREAM, and the shortened version of the STREAM in 50 clients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent Spearman correlations were found between all four measures (ranging from rho = 0.91 to rho = 0.99).

Predictive:
Mao et al. (2002) compared the psychometric properties of the Berg Balance Scale, the modified Balance subscore of the FMA, and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. at 14, 30, 90, and 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. Excellent Spearman correlations were found between the scores of the Balance subscore of the FMA at the earlier 3 time points and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. scores (ranging from r = 0.80 to r = 0.87), indicating excellent predictive validityof the FMA modified Balance subscore.

Chae, Johnston, Kim, and Zorowitz (1995) found that FMA lower extremity admission subscores predicted the rehabilitation discharge Functional Independence Measure mobility (r = 0.63) and locomotion (r = 0.74) scores in 48 patients at 6 weeks post-stroke.

Hsueh et al. (2009) analyzed whether the motor scores of FMA, of the shortened version of the FMA, the STREAM, and the shortened version of the STREAM measured at admission to a rehabilitation program were able to predict Barthel Index scores at discharge in 50 clients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent Spearman correlations were found between the Barthel Index scores and the FMA (rho = 0.72), the shortened version of the FMA (rho = 0.74), the STREAM (rho = 0.75) and the shortened version of the STREAM (rho = 0.77). These results suggest that all measures were able to predict Barthel Index scores at discharge.

Fulk, Reynolds, Mondal & Deutsch (2010) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the 6MWT and other widely used clinical measures (FMA-LE, self-selected gait-speed, SIS and BBS) in 19 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The FMA-LE was found to be a poor predictor of mean steps per day (r = 0.06; p = 0.798). Although gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed and balance were related to walking activity, only the 6MWT was found to be a predictor of community ambulation in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:

Several validation studies have provided good evidence that the FMA is measuring what it is intended to measure. The construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the FMA has been examined by comparing the scale with other measures of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. recovery that reflect post-stroke independence in activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living or disability level.

Sonde, Gip, Fernaeus, Nilsson, and Viitanen (1998) found that FMA scores reflected changes in upper extremity scores after low frequency transcutaneous electric nerve stimulation. A Mann-Whitney U-test was used to test the significance of the differences in FMA scores at the start and end of the study between the treatment and control groups. This test revealed that the FMA scores differed significantly between the treatment and control groups (Mann-Whitney U = 130.5). Further, the Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the FMA scores was excellent (r = 0.95).

Chae, Bethoux, Bohine, Dobos, Davis, and Friedl (1998) assessed the efficacy of neuromuscular stimulation in enhancing the upper extremity motor and functional recovery of 28 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. FMA scores reflected changes in upper extremity scores after neuromuscular stimulation. Parametric analyses revealed significantly greater gains in FMA scores for the treatment group immediately following treatment (13.1 versus 6.5), at 4 weeks after treatment (17.9 versus 9.7), and at 12 weeks after treatment (20.6 versus 11.2). Gains were observed in FMA scores but not with Functional Independence Measure scores.

Kraft, Fitts, and Hammond (1992) tested functional improvement in the upper limb of 22 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who received either EMG-initiated electrical stimulation of wrist extensors, low-intensity electrical stimulation of wrist extensors combined with voluntary contractions, proprioceptive neuromuscular facilitation exercises, or no treatment. During the course of treatment, FMA scores of patients receiving proprioceptive neuromuscular facilitation improved 18%, patients receiving low-intensity electrical stimulation of wrist extensors combined with voluntary contractions improved 25%, and patients receiving EMG-initiated electrical stimulation of wrist extensors improved 42%. FMA improvement of the treated groups was significant from pre-treatment to post-treatment, and the improvement was maintained at three-month and nine-month follow-up sessions. In contrast, the control group showed no significant change in FMA scores or grip strength.

Feyes, deWeerdt, Seltz, Steck, Spichinger, and Vereeck (1998) randomized 100 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. to an experimental group that received sensorimotor stimulation for 6 weeks or to a control group. Patients were evaluated before, during, and after the intervention period and at 6 and 12 months after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Only scores on the FMA showed group differences at follow-up. Scores on the Action Research Arm Test and the Barthel Index did not show group differences.

Duncan et al. (1998) randomized 20 patients with mild or moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who had completed inpatient rehabilitation to receive a home-based exercise program or usual care. The experimental group demonstrated more improvement in the FMA Motor domain upper and lower extremity subscores than did the usual care group. However, the differences in motor recovery were only significant for the Motor domain lower extremity (Motor domain upper extremity mean change in score = 8.4 versus 2.2; Motor domain lower extremity mean change in score = 4.7 versus -0.9).

Malouin et al. (1994) tested 32 patients with the FMA and the Motor Assessment Scale on two consecutive days and found that the FMA distinguished between patients with minimal recovery better than the Motor Assessment Scale. Adequate to excellent negative correlations between score differences and levels of recovery (upper extremity r = -0.50 and lower extremity r = -0.69) were found, indicating that the largest differences between the two measures were in earlier stages of recovery or among more severely affected individuals.

Platz et al. (2005) tested the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the FMA upper extremity items (including items from the Motor function, Sensation and passive Joint motion/Joint pain subscores), the Action Research Arm Test, the Box and Block Test and the Motricity Index, using the Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient, in patients with upper limb paresis either from strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=37), multiple sclerosis (n=14) or from traumatic brain injury (n=5). Excellent correlations were found between the FMA and the Action Research Arm Test (r = 0.93), the Box and Block Test (r = 0.92), and the Motricity Index (r = 0.86). The FMA was also correlated with more general measures of impairment and activity limitation, including the Ashworth Scale, the Hemispheric StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale and the modified Barthel Index. An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the FMA and the Hemispheric StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale (r = -0.69), and an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the FMA and the Ashworth Scale (r = -0.42). Only a poor correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the FMA and the modified Barthel Index (r = 0.09).
Note: Correlations were negative because a high score on the FMA indicates normal performance, where as a low score on the Hemispheric StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale or the Ashworth Scale indicates normal performance.

Fugl-Meyer and Jaasko (1980) compared the FMA Motor domain to performance on activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living scale in 64 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. more than 6 months after hospital discharge. The activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living scale was comprised of 52 items examining independence in feeding, hygiene, dressing, locomotion, housework, and psychosocial functioning. Excellent correlations were found between the degree of motor impairmentLoss of strength and coordination, decrease in arm or leg movement
as measured by the FMA and the activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living scale (activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living total score r = 0.75; hygiene r = 0.89; locomotion r = 0.76; feeding r = 0.72; and dressing r = 0.76).

Convergent:
Mao et al. (2002) compared the psychometric properties of the Berg Balance Scale, the modified Balance subscore of the FMA, and the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients, in 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. followed up prospectively 14, 30, 90, and 180 days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. Excellent correlations were found using the Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient between the scores of the FMA Balance domain and the scores of the Berg Balance Scale at all four time points (ranging from r = 0.86 to r = 0.89), indicating excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
.

Rabadi and Rabadi (2006) examined 104 inpatients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. at a rehabilitation unit. The Action Research Arm Test, the Motor domain upper extremity subscore of the FMA, the NIH StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale, the Functional Independence Measure total score, and Functional Independence Measure activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living subscore were administered. Using the Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient, the Action Research Arm Test and the Motor domain upper extremity subscore of the FMA correlated excellently with one another, both at admission (r = 0.77) and at discharge (r = 0.87). The Motor domain upper extremity subscore of the FMA and the Functional Independence Measure activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of daily living subscore at the time of admission were adequately correlated (r = 0.54).

Arsenault et al. (1988) treated 62 patients with hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease. with the Bobath approach to treatment for a period of three months. During this time they were evaluated on three occasions. Using Spearman’s Rho, the FMA correlated excellently with the Bobath Assessment of upper extremity pre- (r = 0.73) and post-rehabilitation (r = 0.85), with both measures showing change across time periods.

Dettmann et al. (1987) administered the FMA and the Barthel Index to 15 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Patients were assessed at an average of 2 years post-stroke. Pearson correlations between FMA and Barthel Index scores were excellent for the FMA Total score (r = 0.67), the FMA Motor subscore (r = 0.74), the Motor domain upper extremity subscore (r = 0.75), and the Balance subscore (r = 0.76). In this study, the authors measured walking performance using photographic analysis of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
pattern and velocity, and postural stability while standing on a force platform. The FMA Motor domain lower extremity subscore correlated well with most of the gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
measurements, and the FMA Balance subscore correlated well with the stability index. The Sensation subscore did not correlate significantly with any of these measures of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
or upright stability.

Shelton, Volpe, and Reding (2000) compared the FMA to the Functional Independence Measure in 172 inpatients in a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation hospital within 90 days of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Total FMA scores were highly correlated with total Functional Independence Measure scores (r = 0.63). The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the FMA Motor domain upper extremity subscore and the Functional Independence Measure self-care scores was excellent (r = 0.61), as was the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the Motor domain lower extremity subscore of the FMA and the Functional Independence Measure mobility score (r = 0.74).

Lin et al. (2004) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the FMA Sensation subscore using Spearman’s Rho in 176 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The FMA Sensation subscore was poor to adequately correlated with the Barthel Index (ranging from r = 0.38 to r = 0.53). FMA Sensation subscore was also poor to adequately correlated to the FMA Motor domain subscore at different post-stroke stages of recovery, indicating low to moderate convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
(ranging from r = 0.31 to r = 0.44).

Known groups:
Poole and Whitney (1988) administered the Motor Assessment Scale and the FMA to 30 patients with hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease.. The FMA lower extremity subscore was able to distinguish between patients who needed assistance in walking better than gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed at speeds less than 0.34 meters/second (r = 0.62).

Bernspang, Asplund, Eriksson, and Fugl-Meyer (1987) administered the FMA to 109 patients within two weeks of having an acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The FMA was found to distinguish between three levels of self-care ability (dependent, partly dependent, and independent).

Responsiveness

Mao et al. (2002) reported a significant change in the modified FMA Balance subscore between times of assessment (14, 30, 90 and 180 days post-stroke). Effect sizes were large in the interval between 14 and 30 days (ES = 0.82) and weakened the further one moved through time from the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. event (90-180 days was small, ES = 0.33). The overall effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(14-180 days) was large (ES = 1.14). When patients were grouped by level of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. severity, the highest overall FMA Balance subscore effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
among severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients was an ES = 1.57.

Van der Lee et al. (2001) examined 22 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. who underwent intensive forced-use treatment to improve upper extremity function. A responsivenessThe ability of an instrument to detect clinically important change over time.
ratio (the ratio of the mean change after the experimental intervention and the standard deviation of the mean change during the baseline period) of 2.03 was reported for the Action Research Arm Test and 0.41 for the FMA Motor score. A higher responsivenessThe ability of an instrument to detect clinically important change over time.
ratio indicates greater responsivenessThe ability of an instrument to detect clinically important change over time.
, suggesting that the Action Research Arm Test is more responsive than the FMA to improvement in upper extremity function in response to a forced-use treatment intervention. This was also reflected by the number of patients who improved more than the upper limit of agreement on the Action Research Arm Test during the intervention period, 12 (54.5%), in comparison to only 2 (9.1%) on the FMA, indicating further that the Action Research Arm Test is more responsive to change than the FMA.

Rabadi and Rabadi (2005) assessed the responsivenessThe ability of an instrument to detect clinically important change over time.
of the Action Research Arm Test and the FMA in evaluating recovery of upper extremity function in 104 inpatients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The mean change in score from admission to discharge was 10 ± 15 for the Action Research Arm Test and 10 ± 13 for the FMA Motor score. The responsivenessThe ability of an instrument to detect clinically important change over time.
to change as measured by the standard response mean (SRM) was moderate for both the Action Research Arm Test (SRM = 0.68) and for the FMA Motor score (SRM = 0.74).

Lin et al. (2004) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the FMA Sensation subscore using the standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores.
(SRM) in 176 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Small (90-180 days SRM = 0.27; 14-30 days SRM = 0.42; 30-90 days SRM = 0.43) to moderate (14-180 days SRM = 0.67) responsivenessThe ability of an instrument to detect clinically important change over time.
was reported for the FMA Sensation subscore.

Wood-Dauphinee et al. (1990) compared the FMA to the Barthel Index in 167 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. assessed shortly after admission to the hospital and 5 weeks later. Using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients, the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between mean change scores for FMA Upper and lower extremity Motor subscores and total Barthel Index scores was adequate (r = 0.57). Small effect sizes were reported for the FMA Motor scale from admission to 5 weeks post-stroke (0.2 for upper extremity, 0.19 for lower extremity, 0.33 for balance ability, and 0.24 for Total score). The results of this study suggest that the FMA Motor scale has small responsivenessThe ability of an instrument to detect clinically important change over time.
.

Duncan, Lai and Keighley (2000) examined the speed and extent of recovery in 459 patients over the first 6 months following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Spontaneous improvement was observed for mild, moderate, and severe strokes as measured by the FMA. Within the first month post-stroke, maximum recovery was achieved, and began to plateau around 6 months post-stroke. The recovery curves of the FMA upper extremity and lower extremity Motor subscales’ corresponded to the recover curves of the Barthel Index and the NIH StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Scale. If recovery is defined by achieving an FMA score > 90, then 36.8% of the patients in this study were considered to have recovered.

Shelton et al. (2000) found a moderate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the change in Total FMA score with the change in Total Functional Independence Measure score (r = 0.44). Linear regression analysis demonstrated that with every 24-point increase in Functional Independence Measure score, a 10-point increase in FMA Motor score is observed, indicating that improvement in motor impairmentLoss of strength and coordination, decrease in arm or leg movement
is associated with significant functional recovery. Change in both upper and lower extremity FMA Motor subscores correlated poorly with the change in self-care and mobility Functional Independence Measure subscores (r = 0.23 and r = 0.18, respectively).

Hsueh et al. (2009) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the FMA, the StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Rehabilitation Assessment of Movement (STREAM) and their shortened versions in 50 clients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were assessed at two points in time: at admission and at discharge from a rehabilitation program. Both the STREAM and the FMA shortened versions demonstrated a moderate effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
of 0.53 and 0.51, while the STREAM and FMA demonstrated a small effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
of 0.45 and 0.38, respectively.

References

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• Lin, J-H., Hsueh, I-P., Sheu, C-F., Hsieh, C-L. (2004). Psychometric properties of the sensory scale of the Fugl-Meyer Assessment in stroke patients. Clinical Rehabilitation, 18, 391-397.
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• Mao, H. F., Hsueh, I. P., Tang, P. F., Sheu, C. F., Hsieh, C. L. (2002). Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke, 33, 1022-1027.
• Nadeau, S., Arsenault, A. B., Gravel, D. Bourbonnais, D. (1999). Analysis of the clinical factors determining natural and maximal gait speeds in adults with a stroke. American Journal of Physical Medicine & Rehabilitation, 78(2), 123-130.
• Nilsson, L., Carlsson, J., Grimby, G., Nordholm, L. (1998). Assessment of walking balance and sensorimotor performance of hemiparetic patients in the acute stages after stroke. Physiother Theory Pract, 14, 149-157.
• Platz, T., Pinkowski, C., van Wijck, F., Kim, I-H., di Bella, P., Johnson, G. (2005). Reliability and validity of arm function assessment with standardized guidelines for the Fugl-Meyer Test, Action Research Arm Test and Box and Block Test: a multicentre study. Clinical Rehabilitation, 19, 404-411.
• Poole, J.L. & Whitney, S.L. (1988). Motor Assessment Scale for stroke patients: Concurrent validity and interrater reliability. Archives of Physical Medicine and Rehabilitation, 69, 195-197.
• Poole, J. L., Whitney, S. L. (2001). Assessments of Motor Function Post Stroke: A Review. Physical & Occupational Therapy in Geriatrics, 19(2), 1-22.
• Rabadi, M. H., Rabadi, F. M. (2006). Comparison of the Action Research Arm Test and the Fugl-Meyer Assessment as measures of upper-extremity motor weakness after stroke. Arch Phys Med Rehabil, 87, 962-966.
• Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C. (1993). Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phy Ther, 73, 447-54.
• Shelton, F. N. A. P., Volpe, B. T., Reding, M. J. (2000). The effect of motor impairment on disability
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See the measure

How to obtain the FMA?

The FMA can be obtained by following the link below (from the Institute of Rehabilitation Medicine, University of Goteberg, Goteberg, Sweden).

http://www.neurophys.gu.se/sektioner/klinisk_neurovetenskap_och_rehabilitering/neurovetenskap/rehab_med/fugl-meyer/

or through this link form the University of Gothenburg: https://neurophys.gu.se/english/departments/clinical_neuroscience_and_rehabilitation/rehabilitation-medicine/fugl-meyer

A version of the measure is also provided in Fugl-Meyer et al. (1975), and in the book by Dittmar, S. S. and Gresham, G. E. (1997) entitled Functional assessment and outcome measures for the rehabilitation health professional.

Purpose

The GAITRite system was developed in response to the need for an objective way to quantify gait and ambulatory status. The GAITRite System measures spatio-temporal parameters of gait such as cadence, step length and velocity, providing clinically relevant information that is useful in devising treatment plans and evaluating treatment outcomes. The system tracks parameters over time and can be used to generate progress and status reports.

In-Depth Review

Purpose of the measure

The GAITRite System was developed in response to the need for an objective way to quantify gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
and ambulatory status. Spatio-temporal parameters of gait, such as cadence, step length and velocity, are recorded and calculated using the GAITRite System and software. The GAITRite System tracks parameters over time and can be used to generate progress and status reports, providing clinically relevant information that is useful in devising treatment plans and evaluating treatment outcomes. While visual assessment of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
is more commonly used clinically, studies have demonstrated poor reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
.

According to producers of the GAITRite system (2010), the system can aid in the following tasks:

• Documentation of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
  patterns prior to any intervention
• Measurement of functional ambulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
  immediately following treatment/intervention
• Documentation of the effect of intervention
• Identification of the relationship between objective gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
  parameters and subjective findings
• Refinement of proper alignment and fit of prosthetics & orthotics
• Selection of appropriate assistive devicesAssistive devices are any piece of equipment that you use to make your daily activities easier to perform.
  
• Objective measurement to justify ongoing intervention

Available versions

There are no other available versions.

Features of the measure

Items:

An electronic walkway (61cm wide x 288cm long – additional custom sizes are available), containing a total of 18,432 sensors sensor pads, is connected to the USB port of Windows® XP/Vista/7 personal computer (CIR Systems, Inc., 2010).

What to consider before beginning:

• Assess patients’ balance and gait abilities prior to having them walk across the GAITRite walkway, to ensure adequate support is provided during assessment.
• Barefoot testing is not recommended.

Scoring and Score Interpretation:

The GAITRite System provides spatio-temporal parameters of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
; it does not provide a score.

Time:

The setup of the GAITRite System is reported to be time efficient. The GAITRite System administration time is dependent on patient ambulation speed and efficiency.

Training requirements:

The GAITRite System has been reported to yield highly accurate and reliable data regardless of the examiner. However, in order to ensure consistency in testing protocol, the manufacturers of GAITRite System, CIR Systems, offer an Examiner Accreditation course. Examiners who successfully complete the accreditation process are awarded an accreditation certificate valid for a period of 1 year. Do you know how long the course is?
Please contact CIR Systems for further details.

Equipment:

For further information regarding equipment and set-up, please refer to the GAITRite Electronic Walkway Technical Reference guide:
http://www.gaitrite.com/Downloads/GAITRite_Measurement_Definitions.pdf

Alternative Forms of GAITRite

There are no alternative forms of the GAITRite System reported, however there are different model numbers.

Client suitability

Can be used with:

• Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
• Patients requiring assistive devicesAssistive devices are any piece of equipment that you use to make your daily activities easier to perform.
  and ambulatory aids such as crutches, walkers, or canes (GAITRite, 2010).
• Patients utilizing biped and quadruped locomotion (CIR Systems, Inc., 2012).

Should not be used in:

• None reported.

Languages of the measure

The GAITRite system is not a language based assessment tool.

Summary

What does the tool measure?	Spatio-temporal parameters of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety. .
What types of clients can the tool be used for?	The GAITRite system can be used with, but is not limited to, clients with stroke.
Is this a screening or assessment tool?	Assessment
Time to administer	The time to administer is dependent on familiarity of system set-up and use, and patient ambulatory status.
Versions	There are no alternative versions.
Other Languages	Not applicable.
Measurement Properties
Reliability	Test-retest : One study found excellent test re-test reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . of the GAITRite system among patients with (stage of) stroke.
Validity	Concurrent: One study found moderate to excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the GAITRite system with the Clinical Stride Analyzer in a healthy population.
Floor/Ceiling Effects	No studies have examined the floor or ceiling effects of the GAITRite system in clients with stroke.
Does the tool detect change in patients?	No studies have examined the responsiveness of the GAITRite system in clients with stroke. However, the GAITRite system has the capacity to track parameters over time and can be used to generate progress and status reports.
Acceptability	There is no placement of devices on the patient allowing the patient to ambulate as close to their usual as possible.
Feasibility	The GAITRite system is portable and can be laid over any flat surface (CIR Systems, Inc., 2010).
How to obtain the tool?	For further information on the GAITRite system, please contact: CIR Systems, Inc 376 Lafayette Ave, Suite 202 Sparta, NJ 07871 Toll Free: (888) 482-2362 Phone: (973) 862-6151 Fax: (973) 862-6451 Email: sales@gaitrite.com

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the GAITRite System. One study involving patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., and another involving healthy adults were identified and reviewed for the purposes of this module.

Floor/Ceiling Effects

No studies have investigated the floor or ceiling effects of the GAITRite System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Reliability

Internal constancy:
No studies have investigated the internal consistency of the GAITRite System in patients with stroke.

Test-retest:
Kuys, Brauer and Ada (2011) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the GAITRite System in measuring spatio-temporal parameters of gait (i.e gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed, cadence, step length (paretic and non-paretic limb), step time (paretic and non-paretic limb), stance phase as a percentage of the gait cycle (paretic and non-paretic limb) in a group of 21 people following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. undergoing inpatient rehabilitation. Participants were asked to walk the distance of the GAITRIte walkway two separate times within 48 hours, at a self-selected speed. Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was found to be excellent for all spatio-temporal parameters in the overall group (ICC=0.72-0.94), as calculated using Intraclass Correlation Coefficient. Patients were also categorized as ‘poor’ and ‘better’ ambulators, using the Motor Assessment Scale score (MAS) (poor: MAS Item 5 score 3 – 4, average gait speed = 0.54 m/s; better: MAS Item 5 score 5 – 6, average gait speed = 0.79 m/s). The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was found to be stronger for poorer ambulators compared to better ambulators (ICC ≥ 0.57 vs ICC ≥ 0.41). Results of this study indicate that test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the GAITRite System is slightly higher for individuals with more limited mobility.

Intra-rater:
No studies have investigated the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the GAITRIte System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Inter-rater:
No studies have investigated the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the GAITRite System in patients with stroke.

Validity

Content:

No studies have investigated the content validity of the GAITRIte System in patients with stroke.

Criterion:

Concurrent:
Bilney, Morris and Webster (2002) compared the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the GAITRite System with the Clinical Stride Analyzer (CSA) for quantification of the spatio-temporal gait parameters (gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed, cadence, stride length, single leg support time – right and left, double limb support as a percentage of the gait cycle – right and left) in 25 healthy subjects. The CSA was selected as the criterion measure due to its wide clinical use in measuring spatiotemporal parameters of gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
. Subjects were asked to walk the GAITRite walkway over three trials at three different speeds: self-selected speed, fast and slow speed. Excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
was found between the two measures for speed, cadence and stride length (ICC=0.99) at self-selected, slow and fast speeds, as calculated using Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance.. Concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
for quantification of single leg stance phase was found to be moderate to excellent (ICC = 0.52-0.86 across the three gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speeds); and double limb support as a percentage of gait cycle was also found to have moderate to excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
(ICC = 0.44-0.57) between the two measures.

Predictive:
No studies have investigated the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the GAITRIte System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Construct:

Convergent/Discriminant:
No studies have investigated the convergent or discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess.
of the GAITRite System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Known Groups:
No studies have investigated the known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured.
of the GAITRite System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
/ SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
No studies have investigated the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
/specificity of the GAITRite System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Responsiveness:

No studies have investigated the responsivenessThe ability of an instrument to detect clinically important change over time.
of the GAITRite System in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

References

• Bilney, B., Morris, M. & Webster, K. (2003). Concurrent related validity of the GAITRite walkway system for quantification of the spatial and temporal parameters of gait. Gait and Posture, 17, 68-74.
• Kuys, S.S., Brauer, S.G. & Ada, L. (2011). Test-retest reliability of the GAITRite System in people with stroke undergoing rehabiliation. Disability and Rehabilitation, 33 (19-20), 1848. 1853.

See the measure

For further information regarding obtaining a GAITRite system, please contact CIR Systems, Inc.:

CIR Systems, Inc.
376 Lafayette Ave, Suite 202
Sparta, NJ 07871

Toll Free: (888) 482-2362
Phone: (973) 862-6151
Fax: (973) 862-6451
Email: sales@gaitrite.com

Purpose

The Motor Assessment Scale (MAS) is a performance-based scale that was developed as a means of assessing everyday motor function in patients with stroke (Carr, Shepherd, Nordholm, & Lynne, 1985). The MAS is based on a task-oriented approach to evaluation that assesses performance of functional tasks rather than isolated patterns of movement (Malouin, Pichard, Bonneau, Durand, & Corriveau, 1994).

In-Depth Review

Purpose of the measure

The Motor Assessment Scale (MAS) is a performance-based scale that was developed as a means of assessing everyday motor function in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (Carr, Shepherd, Nordholm, & Lynne, 1985). The MAS is based on a task-oriented approach to evaluation that assesses performance of functional tasks rather than isolated patterns of movement (Malouin, Pichard, Bonneau, Durand, & Corriveau, 1994).

Available versions

In 1985, Janet H. Carr and Roberta B. Shepherd published the MAS.

Features of the measure

Items:

The MAS is comprised of 8 items corresponding to 8 areas of motor function. Patients perform each task 3 times and the best performance is recorded.

• Supine to side lying
• Supine to sitting over the edge of a bed
• Balanced sitting
• Sitting to standing
• Walking
• Upper-arm function
• Hand movements
• Advanced hand activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
  

Also included is a single item, general tonus, intended to provide an estimate of muscle tone on the affected side (Carr et al., 1985).

Scoring:

All items (with the exception of the general tonus item) are assessed using a 7-point scale from 0 – 6. A score of 6 indicates optimal motor behavior. For the general tonus item, the score is based on continuous observations throughout the assessment. A score of 4 on this item indicates a consistently normal response, a score > 4 indicates persistent hypertonus, and a score < 4 indicates various degrees of hypotonus (Carr et al., 1985).

Item scores (with the exception of the general tonus item) can be summed to provide an overall score out of a possible 48 points (Malouin et al., 1994). Successfully completing a higher-level item suggests that the individual is able to perform the lower level items that correspond to lower scores, and thus these lower items can be skipped from the assessment (Sabari et al., 2005).

A major criticism of the MAS is that the general tonus item is difficult to assess, as there are no guidelines regarding the testing of tone, where it should be tested or how to score the item when the tone varies between the leg, arm, and trunk (Poole & Whitney, 1988). For this reason, this item is often omitted (Malouin et al., 1994; Loewen & Anderson, 1990).

Another issue with the MAS is that scoring hierarchies are not always consistent. Sabari et al. (2005) used Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
to examine the validityThe degree to which an assessment measures what it is supposed to measure.
of the scoring hierarchies for the Upper Arm Function, Hand Movements and Advanced Hand Activities’ subscales and found that only the Upper Arm Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
demonstrated an appropriate hierarchy in terms of task difficulty. A later study by Miller, Slade, Pallant and Galea (2010), validated the test item difficulty hierarchy in the Upper Arm Function and Hand Movements subscales, but not the Advanced Hand ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. For example, some studies have reported that patients who could complete the most difficult task of the Advanced Hand ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
category (holding a comb and combing hair at the back of head) were unable to complete an easier item (drawing horizontal lines) (Poole & Whitney, 1988; Malouin et al., 1994), meaning that the items are not ordered according to their estimated difficulty (Miller et al., 2010).

Equipment:

Although a number of items are required to administer the MAS, the equipment is easy to acquire. The following equipment is needed:

• Stopwatch
• Eight Jellybeans
• Polystyrene cup
• Rubber ball
• Stool
• Comb
• Spoon
• Pen
• Two Teacups
• Water
• Prepared sheet for drawing lines
• Cylindrical object like a jar
• Table

Subscales:

The upper limb items of the MAS can be used independent of the rest of the scale.

Training:

The instructions for the proper administration of the MAS are provided directly on the scale itself. Carr et al. (1985) recommend a short instruction and practice period, where the MAS is administered to at least six patients prior to using the test in a formal setting.

Time:

Carr et al. (1985) state that the MAS should take approximately 15 minutes to complete, however, other studies have reported administration times ranging from 15 to 60 minutes (Poole & Whitney, 1988; Malouin et al., 1994).

Alternative form of the Motor Assessment Scale

• Modified Motor Assessment Scale (MMAS). Loewen and Anderson (1988) modified item descriptions and deleted the general tonus item. In a study on 7 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., the MMAS demonstrated acceptable inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
  . This modified version is still scored on a 7-point scale from 0 – 6.
• Upper Limb/Extremity Motor Assessment Scale (UL-MAS or UE-MAS). In this form of the MAS, only the three upper limb items are used as a scale to assess upper limb function. In a study evaluating this version, substantial reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
  and validityThe degree to which an assessment measures what it is supposed to measure.
  (Cronbachs alpha = 0.83; Spearmans rho = 0.70) (Lannin, 2004; Hsueh & Hsieh, 2002).

Client suitability

Can be used with:

• Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used in:

• Patients who require a proxy to complete. As with other impairment indices, the MAS is scored by direct observation and should not be used with proxy respondents.
• When assessing severely affected patients or patients with aphasia, we recommend that although it takes longer to administer, the Fugl-Meyer Assessment of Sensorimotor Recovery After StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (FMA) – another measure to assess motor functioning in patients with stroke – should be used instead of the MAS.

In what languages is the measure available?

• English (Carr et al., 1985)
• Norwegian (Kjendahl, Jahnsen, & Aamodt, 2005)

Summary

What does the tool measure?	Everyday motor functioning
What types of clients can the tool be used for?	Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	Studies have reported administration times ranging from 15 to 60 minutes.
Versions	Upper Limb/Extremity Motor Assessment Scale (UL-MAS or UE-MAS); Modified Motor Assessment Scale (MMAS)
Other Languages	English and Norwegian
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the MAS. Test-rest: Only one study has examined the test-rest reliability of the MAS, reporting excellent test-retest. Intra-rater: No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. of the MAS. Inter-rater: Out of two studies that examined the inter-rater reliability of the MAS, both reported excellent inter-rater (with the exception of the general tonus item, which demonstrated poor inter-rater reliability).
Validity	Content: No formal content validation is available. Items and scoring options are based on observations of the improvement of a large number of patients. Criterion: Excellent correlations between the MAS and the Fugl-Meyer Assessment. Construct: Excellent correlations between the MAS and Mobility items from the Mobility Scale for Acute Stroke Patients and adequate correlations between the MAS and a simple measure of functional sitting balance (sitting arm raise and forward reach tests).
Does the tool detect change in patients?	One study found minimal floor and ceiling effects for the UL-MAS in acute/subacute post-stroke patients. In another study, large floor and ceiling effects for Upper Arm Function and Hand Movements items and substantial floor effects for Advanced Hand Activities were found; however, the study has been criticized for inclusion of participants that were as long as 6 years post-stroke. One study examined the ability of the MAS to detect change and found that the walking item had a large ability to detect change, and the arm items had a small ability to detect change.
Acceptability	The MAS is a fairly simple and short measure to administer. A proxy respondent is not appropriate for this performance-based measure. For severely affected patients or patients with aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person's ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person's intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada), we recommend administering the Fugl-Meyer Assessment of Sensorimotor Recovery After StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (FMA) rather than the MAS.
Feasibility	A short instruction and practice period is recommended prior to administering the test in a formal setting. A number of items are required as equipment for the MAS, however all items are readily available.
How to obtain the tool?	The MAS is available for free and can be found in Carr et al. (1985). Click here to view a copy of the MAS.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the MAS.

Floor and Ceiling Effects

Sabari et al. (2005) used Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
to examine the validityThe degree to which an assessment measures what it is supposed to measure.
of the scoring hierarchies of the Upper Limb subscales of the MAS and found large floor and ceiling effects for subscales 6 and 7 (31 and 28 percent for both respectively) and large floor effects for subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
8 (38 percent). Participants were a mean of 104 days post-stroke, within a range of 3 days to 6.4 years.

In a later study, Miller, Slade, Pallant and Galea (2010) used Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
to evaluate the psychometric properties of the Upper Limb subscales of the MAS (UL-MAS) in post-stroke patients and found adequate floor and ceiling effects (14 and 9 percent respectively). Participants were a mean of 64.8 days post stroke, within a range of 4 to 193 days. Miller at al. questioned the clinical applicability of results from Sabari et al. because some participants were as long as 6 years post-stroke and in clinic the MAS is generally administered in the acute/subacute phase.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the MAS.

Test-retest:
Carr et al. (1985) evaluated the test-retest reliability of the MAS in 14 patients with stroke who were examined by the same rater on two occasions, with a 4-week interval between assessments. Test-retest correlations were excellent, ranging from r=0.87 to r=1.00 (the average correlation was r=0.98).

Intra-rater:
No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the MAS.

Inter-rater:
Carr et al. (1985) selected 5 patients at various stages of recovery for inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
testing. Twenty physical therapists and physical therapy undergraduate students were raters (the general tonus item was excluded from the evaluation). Overall, the MAS was found to have excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
, with a mean correlation of r = 0.95. The greatest agreement was achieved on the balanced sitting item (r = 0.99), and the least agreement was on the sitting to standing item (r = 0.89).

Poole and Whitney (1988) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the MAS in 24 patients with stroke. Two examiners observed and scored each subject independently. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the total MAS (r = 0.99), and for the individual items (ranging from r = 0.92 to r = 1.00) was excellent, with the exception of the general tonus item, which demonstrated poor reliability (r = 0.29).

Validity

Content:

Carr et al. (1985) based items and scoring options of the MAS on observations of the improvement of a large number of patients. Thus, no formal content validation is available (Carr et al., 1985).

Criterion:

Concurrent:
Malouin, Pichard, Bonneau, Durand and Corriveau (1994) assessed the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the MAS in comparison to the Fugl-Meyer Assessment early after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and reported excellent Spearman’s correlations for total scores (r = 0.96, excluding the general tonus item). Correlations between MAS items and corresponding Fugl-Meyer Assessment items were excellent (ranging from r = 0.65 to r = 0.93). The MAS Balance score correlations with the Fugl-Meyer Assessment-Sensation scores of light touch and position sense were excellent (r = 0.64 and r = 0.67, respectively), but correlations with the Fugl-Meyer Assessment Balance items were poor (r = 0.12 and r = -0.10, respectively).

Poole and Whitney (1988) assessed the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the MAS in comparison to the Fugl-Meyer Assessment in a more chronic population and found similar results to Malouin et al. (1994). Excellent Spearman’s correlations were found for total score (r = 0.88), and for individual items (ranging from r = 0.64 to r = 0.92), with the exception of sitting balance, which correlated poorly (r = 0.28).

Construct:

Miller at al. (2010) examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of test item 72 (radial deviation of the wrist). Radial deviation is no longer thought to be an isolated movement occurring at the wrist and is now believed to occur as a part of a coordinated synergy (Mason, Gomez & Ebner, 2001 as cited in Miller, Slade, Pallant & Galae, 2010) or program of movement (Marotta, Medendorp & Crawford, 2003 as cited in Miller et al., 2010). In addition, radial deviation is often reduced in individuals over 65 years, thus impacting results for item 72. The evidence suggests that item 72 adds little meaning to the assessment of motor recovery in patients with stroke.

Convergent/Discriminant:

Simondson et al. (2003) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of a new scale, the Mobility Scale for Acute Stroke Patients with other established scales (MAS, Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Classification system, Functional Independence Measure, Barthel Index). Mobility items from the Mobility Scale for Acute StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients had an excellent correlation with corresponding items on the MAS (r = 0.89), demonstrating the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the MAS.

Tyson and DeSouza (2004) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the MAS in 48 patients post-stroke. It was found that a simple measure of functional sitting balance (sitting arm raise and forward reach tests) correlated adequately with the sitting item of the MAS (r = 0.33 and r = 0.54).

Known groups:
No studies have examined the known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured.
of the MAS.

Responsiveness

Dean and Mackey (1992) reported significant differences between mean scores for each item on the MAS from admission to discharge from strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation after an average of 71 days of rehabilitation.

Nugent, Schurr and Adams (1994) found an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = 0.45) between the number of repetitions of a weight-bearing exercise (designed to strengthen the leg extensor muscles) and the change in the MAS score for the walking item among 25 patients receiving inpatient rehabilitation. To be included in the study, subjects had to have a score greater than 0 but less than 6 on the walking item of the MAS. All of the patients who practiced the exercise achieved independent walking for at least a 3m distance, which gave a final MAS score of three or greater.

English and Hillier (2006) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the MAS in 61 rehabilitation inpatients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The ability of the MAS to detect change was limited in this sample. The MAS item 5 (walking) showed a large effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(ES) (ES = 1.02) and was able to detect change amongst lower functioning subjects (12 patients showed no change). The other items of the MAS were less responsive, in particular, the effect sizes for the arm items (items 6 to 8) change scores were small (ES ranged from 0.36 to 0.5) and between 44.3 and 63.9% of subjects did not change on these measures. In addition, over 80% of subjects were rated at the extremes of the scales on all three of the arm items. These findings suggest that clinicians should be cautious in choosing the MAS to measure change in patients as for some subgroups and for certain items, clinical change is unlikely to be detected by this tool.

References

• Carr, J. H., Shepherd, R. B., Nordholm, L., Lynne, D. (1985). Investigation of a new motor assessment scale for stroke patients. Phys Ther, 65, 175-180.
• Dean, C. M., Mackey, F. M. (1992). Motor assessment scale scores as a measure of rehabilitation outcome following stroke. Aust J Physiother, 38, 31-35.
• English, C. K., Hillier, S. L. (2006). The sensitivity of three commonly used outcome measures to detect change amongst patients receiving inpatient rehabilitation following stroke. Clinical Rehabilitation, 20, 52-55.
• Hsueh, I-P., Hsieh, C-L. (2002).Responsiveness of two upper extremity function instruments for stroke inpatients receiving rehabilitation. Clinical Rehabilitation, 16(6), 617-624.
• Kjendahl, A., Jahnsen, R., Aamodt, G. (2005). Motor Assessment Scale in Norway: Translation and inter-rater reliability. Advances in Physiotherapy, 7(1), 7-12.
• Lannin, N. A. (2004). Reliability, validity and factor structure of the upper limb subscale of the Motor Assessment Scale (UL-MAS) in adults following stroke. Disability & Rehabilitation, 26(2), 109-116.
• Loewen, S. C., Anderson, B. A. (1988). Reliability of the Modified Motor Assessment Scale and the Barthel Index. Phys Ther, 68, 1077-1081.
• Loewen, S. C., Anderson, B. A. (1990). Predictors of stroke outcome using objective measurement scales. Stroke, 21, 78-81.
• Malouin, F., Pichard, L., Bonneau, C., Durand, A., Corriveau, D. (1994). Evaluating motor recovery early after stroke: comparison of the Fugl-Meyer Assessment and the Motor Assessment Scale. Arch Phys Med Rehabil, 75(11), 1206-1212.
• Miller, K.J., Slade, A.L., Pallant, J.F., Galea, M.P. (2010). Evaluation of the psychometric properties of the upper limb subscales of the Motor Assessment Scale using a Rasch analysis model. J Rehabil Med, 42, 315-322.
• Poole, J. L., Whitney, S. L. (1988). Motor assessment scale for stroke patients: concurrent validity and interrater reliability. Arch Phys Med Rehabil, 69(3), 195-197.
• Sabari, J. S., Lim, A. L., Velozo, C. A., Lehman, L., Kieran, O., Lai, J. S. (2005). Assessing arm and hand function after stroke: a validity test of the hierarchical scoring system used in the motor assessment scale for stroke. Arch Phys Med Rehabil, 86(8), 1609-1615.
• Simondson, J. A., Goldie, P., Greenwood, K. M. (2003). The mobilityscaleforacute stroke patients: Concurrent validity. Clinical Rehabilitation, 17(5), 558-564.

See the measure

How to obtain a copy of the MAS?

The MAS is available for free and can be found in Carr et al. (1985).

Click here to view a copy of the MAS.

Purpose

The Postural Assessment Scale for Stroke Patients (PASS) assesses balance in lying, sitting and standing positions. It was designed specifically for patients with stroke and is suitable for all individuals regardless of postural performance.

In-Depth Review

Purpose of the measure

The Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients (PASS) is comprised of 12 items of increasing difficulty that measure balance in lying, sitting and standing. It was designed specifically for patients with stroke, regardless of postural competence (Barros de Oliveira et al., 2008; Mao et al., 2002). The PASS measures the patient’s ability to maintain stable postures as well as equilibrium in changes of position (Di Monaco et al., 2010). It includes items not assessed by the Berg Balance Scale (Blum & Korner-Bitensky, 2008) and demonstrates better psychometric properties than the Berg Balance Scale and the Fugl-Meyer Assessment modified balance subscale (Mao et al., 2002).

Available versions

The PASS was developed in 1999 by Benaim et al. as an adaptation of the Fugl-Meyer Assessment balance subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(Benaim et al., 1999). It was originally developed in French and has since been translated into English and Swedish (SwePASS). Short forms of the PASS, with fewer items (5-item SFPASS) and/or smaller scoring scales (PASS-3P), have also been developed.

Features of the measure

Items:

The PASS consists of 12 items of graded difficulty:

Maintaining a posture

• Sitting without support (sitting on the edge of a 50cm-high examination table with feet touching the floor)
• Standing with support (feet position free, no other constraints)
• Standing without support (feet position free, no other constraints)
• Standing on nonparetic leg (no other constraints)
• Standing on paretic leg (no other constraints)

Changing Posture

• Supine to affected side lateral
• Supine to nonaffected side lateral
• Supine to sitting up on edge of table
• Sitting on edge of table to supine
• Sit-to-stand (without any support, no other constraints)
• Stand-to-sit (without any support, no other constraints)
• Standing, picking up a pencil from the floor (without any support, no other constraints) (Barros de Oliveira et al., 2008)

Scoring:

The PASS consists of a 4-point scale where items are scored from 0 – 3. The total score ranges from 0 – 36 (Barros de Oliveira et al., 2008).

Item 1: Sitting without support

• 0 = cannot sit
• 1 = can sit with slight support (e.g. by 1 hand)
• 2 = can sit for more than 10 seconds without support
• 3 = can sit for 5 minutes without support

Item 2: Standing with support

• 0 = cannot stand, even with support
• 1 = can stand with strong support of 2 people
• 2 = can stand with moderate support of 1 person
• 3 = can stand with support on only 1 hand

Item 3: Standing without support

• 0 = cannot stand without support
• 1 = can stand without support for 10 seconds or leans heavily on 1 leg
• 2 = can stand without support for 1 minute or stands slightly asymmetrically
• 3 = can stand without support for more than 1 minute and at the same time perform arm movements above the shoulder level

Items 4 and 5: Standing on the nonparetic / paretic leg

• 0 = cannot stand on the leg
• 1 = can stand on the leg for a few seconds
• 2 = can stand on the leg for more than 5 seconds
• 3 = can stand on the leg for more than 10 seconds

Items 6 – 10

• 0 = cannot perform the activity
• 1 = can perform the activity with much help
• 2 = can perform the activity with little help
• 3 = can perform the activity without help

Description of tasks:

Items are graded by difficulty, whereby lying and sitting items are easier than standing items. Items 6 (supine to the affected side lateral) and 7 (supine to nonaffected side lateral) are the easiest items; item 5 (standing on the paretic leg) is the most difficult item of the assessment (Benaim et al., 1999).

Time:

The PASS takes 1 to 10 minutes to administer (Benaim et al., 1999).

Training requirements:

No special training is required, although clinicians should have an understanding of balance impairment and related safety issues following stroke.

Chien et al. (2007b) note that the different scoring criteria for several items of the PASS may pose difficulties for less-trained assessors, and recommends the simpler SFPASS as an alternative.

Equipment:

• 50cm-high examination table (e.g. Bobath plane)
• Chronometer
• Pen

Alternative forms of the PASS

Chien et al. (2007b) developed a short form PASS (SFPASS) by conducting an item analysis of the PASS in a sample of 278 patients with stroke, and selecting items with the best measurement properties (i.e. highest internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. and greatest responsiveness). The SFPASS focuses on assessment of bed mobility and sit-to-stand. The SFPASS comprises 5 items (Liaw et al., 2012):

• Standing on the nonparetic leg
• Supine to sitting up on the edge of the table
• Sitting on the edge of the table to supine
• Sitting to standing up
• Standing up to sitting down

SFPASS items are scored on a 3-point scale and total scores range from 0 to 15. The SFPASS is simpler and quicker to administer than the PASS (Liaw et al., 2012).

Persson et al. (2011) developed a Swedish version of the PASS (SwePASS) in response to perceived need to clarify scoring criteria and item descriptions. The SwePASS defines the scoring criteria “much help” as “support from 2 persons”, and “little help” as “support from 1 person”. Items 4, 7 and 10 have been clarified or modified. The SwePASS comprises the same 12 items as the PASS, and the same ordinal scale scoring (0-3), with a maximum score of 36.

Client suitability

Can be used with:

• Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., regardless of postural competencies.

Should not be used in:

• None reported

In what languages is the measure available?

• French
• English
• Swedish

Summary

What does the tool measure?	Balance
What types of clients can the tool be used for?	Patients following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., regardless of balance performance
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	10 minutes
Versions	wePASS (Swedish version) SFPASS (5-item, 3-scale short form) PASS-3P (12-item, 3-scale form)
Other Languages	French, Swedish
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistency: – Three studies have reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the PASS. – One study reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of PASS trunk control items (PASS-TC). – One study reported adequate to excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the SFPASS. Test-retest: – Three studies reported adequate to excellent intra-rater reliability of individual PASS items and excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of PASS total scores. Further, one study reported small limits of agreement using Bland-Altman plots, indicating high stability with low natural variation. – One study reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of individual items and total score of the SFPASS. Intra-rater: One study reported adequate to excellent same-day intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. of the SwePASS in patients with acute stroke. Inter-rater: – Two studies reported adequate to excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of individual PASS items and excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the PASS total score. – One study reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the PASS-TC. – One study reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the SwePASS.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: No studies have reported on the content validity of the PASS. Criterion: Concurrent: Four studies examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the PASS and reported excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." with the Berg Balance Scale, FMA modified balance scale (FMA-B), Trunk Impairment Scale (TIS), SFPASS and PASS-3P. Predictive: – Six studies reported that the PASS shows adequate to excellent predictive validity for function at 90 days post-stroke or on discharge from rehabilitation, but poor predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of function after 1 year. Two studies reported excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of mobility at 180 days post-stroke or on discharge from rehabilitation. – One study reported that the PASS-TC shows excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of ADL function at 6 months post-stroke and is a stronger predictor of function than the BI or Fugl-Meyer Assessment (FMA) motor test. – Two studies reported that the SFPASS shows adequate to excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. for function on discharge from rehabilitation or at 90 days post-stroke. Construct: Convergent/Discriminant: – Four studies examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the PASS and reported excellent correlations with the BI; FIM total score, transfer tasks and locomotor tasks; and motricity scores of the upper and lower limb. Adequate negative correlations were found with the star cancellation test of spatial inattention; pressure sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." of the upper and lower limb; and measurement of postural stabilization and postural orientation with respect to gravity. The PASS demonstrated no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Ashworth Scale. – One study reported that the PASS-TC demonstrates excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. with the BI and FMA-B. – Two studies have examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the SFPASS or PASS-3P and reported that both measures show excellent correlations with the BI and FIM. Known Groups: No studies have reported on the known-groups validityThe degree to which an assessment measures what it is supposed to measure. of the PASS.
Floor/Ceiling Effects	Three studies have reported no floor or ceiling effect of the PASS from acute to chronic stages of stroke recovery. However, one study reported a poor floor effect at 90 days post-stroke.
Does the tool detect change in patients?	– Six studies have examined responsiveness and found that the PASS is able to detect change in stroke. The PASS demonstrates good responsiveness before 90 days post-stroke but low responsivenessThe ability of an instrument to detect clinically important change over time. at later stages of recovery. Further, the PASS is more responsive to detecting change in moderate to severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. than mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. – Three studies have examined responsivenessThe ability of an instrument to detect clinically important change over time. in the PASS-3P or SFPASS and reported that both measures are able to detect change in acute and subacute stroke. SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." & specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). : No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." or the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). of the PASS.
Acceptability	The PASS was designed for patients with stroke, regardless of balance function.
Feasibility	The PASS is quick and simple test to administer, and requires minimal equipment and no specialized training.
How to obtain the tool?	The tool is available on line: http://www.brightonrehab.com/wp-content/uploads/2012/02/Postural-Assessment-Scale-for-Stroke-Patients-PASS.pdf

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Postural Assessment Scale for StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Patients (PASS). Eleven papers were reviewed.

Floor/Ceiling Effects

Benaim et al. (1999) examined the frequency distribution and density trace of PASS scores in 58 patients at 30 and 90 days post-stroke. While a uniform distribution was noted at 30 days post-stroke, there was a pronounced peak around the highest values at 90 days as 38% of patients had achieved the maximum score. Testing on 30 age-matched healthy subjects revealed that 90% of participants achieved the maximum score.

Mao et al. (2002) examined the floor and ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." of the PASS on a sample of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. at 14, 30, 90 and 180 days post-stroke. Floor and ceiling effects were adequate at all time points (floor effect range 2.2-3.8%; ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." range 3.3-17.5%).

Chien et al. (2007b) examined the floor and ceiling effects of the PASS among 287 patients at 14 days post-stroke, and a second cohort of 197 patients. The PASS demonstrated no significant floor effects (6.3%, 6.1% respectively) or ceiling effects (2.8%, 1.7% respectively) in either cohort.

Chien et al. (2007b) also examined the floor and ceiling effects of the 5-item SFPASS among 287 patients at 14 days post-stroke, and a second cohort of 197 patients. The SFPASS demonstrated no significant ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." in either cohort (7.0%, 8.4%). A poor floor effect (20.2%) was seen in the first cohort, but was not evident in the second cohort (16.2%).

Yu et al. (2012) reported no significant floor or ceiling effect of the PASS among 85 patients with stroke (most with acute stroke and severe disability) on admission to (<15%) or discharge from (<10%) a rehabilitation ward.

Reliability

Internal constancy:
Benaim et al. (1999) reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the PASS (α=0.95) when examined on a sample of 58 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. using Cronbach α-coefficient. The authors concluded that the PASS is homogenous and is likely to produce consistent responses. Further, there was a strong correlation between the sums of maintaining-position and changing-position items (r=0.86, p<0.001).

Mao et al. (2002) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the PASS on a sample of 112 patients with stroke at 14, 30, 90 and 180 days post-stroke, using Cronbach’s α coefficient. Excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. was reported at all time points (α range = 0.94-0.96).

Hsieh et al. (2002) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the trunk control items of the PASS (PASS-TC: items 1, 6, 7, 8, 9) in a sample of 182 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Results from two raters indicated excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the PASS-TC (α=0.93-0.94), measured using Cronbach’s α.

Chien et al. (2007b) examined the internal consistency of the PASS on a sample of 287 patients at 14 days post-stroke, and a second cohort of 197 patients. Excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (α=0.96) was reported in both cohorts, measured using Cronbach’s α.

Chien et al. (2007b) also examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the SFPASS on a sample of 287 patients at 14 days post-stroke, and a second cohort of 197 patients. Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. was adequate in the first cohort (α=0.66) and excellent in the second cohort (α=0.93), as measured using Cronbach’s α.

Chien et al. (2007b) noted that the high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the PASS may indicate redundancy among items.

Test-retest:
Benaim et al. (1999) measured test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the PASS on 12 patients with stroke, using α-coefficient for individual items and Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson's r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
for the total score. The authors reported adequate to excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
for individual items (average α=0.72, range 0.45 – 1) and excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
for the total score (r=0.98, p<0.001). Further, a Bland-Altman plot showed that differences between scorings were weak (0.5) and homegenous (differences were within or very near the 95% confidence limits of the mean).

Chien et al. (2007a) examined the 2-week test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the PASS among 20 patients with chronic stroke, and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC=0.84), measured using a 1-way random effects model intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance..

Liaw et al. (2008) examined 7-day test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the PASS in a sample of 52 patients with chronic stroke, using the intraclass coefficient for relative reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(i.e. the degree to which individuals maintain their position in a sample with repeated measures), and Bland-Altman plots and standard error of measurement (SEM) for absolute reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(i.e. the degree to which repeated measurements vary for individuals). Relative test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was excellent (ICC=0.97). Bland-Altman plots revealed small limits of agreement (-2.72 to 3.52), indicating high stability with low natural variation. The SEM was small (1.14%), indicating that the PASS is useful to identify real change.

Liaw et al. (2012) examined the 7-day test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the SFPASS among a sample of 52 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using the weighted α statistic for individual items and intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. for the total score. The authors reported adequate to excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for individual items (mean α=0.78, range 0.66 – 0.84) and excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
for total scores (ICC=0.93, 95% CI 0.88-0.96). Bland-Altman plots of the differences between measurements from the two test sessions against the mean of the two test sessions for each patient revealed small limits of agreement (1.99 to -2.33), indicating high stability with low natural variation. Standard error of measurement (SEM) was 5.2%, representing a small and acceptable level of measurement error.
Note: When performing a Bland and Altman analysis, a mean difference close to zero indicates higher agreement between measurements.

Intra-rater:
Persson et al. (2011) examined the same-day intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the SwePASS in a sample of 114 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of items was excellent (r=0.88-0.98) when measured using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
, and adequate to excellent (α=0.70-0.93) when measured using Kappa coefficient.

Inter-rater:
Benaim et al. (1999) measured inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the PASS using α-coefficient for individual item reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson's r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
for total score reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
. Two clinicians assessed patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. on the same day, with a total sample of 12 patients. The authors reported adequate to excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for individual items (average α=0.88, range 0.64-1) and excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the total score (r=0.99, p<0.001). Further, a Bland and Altman plot for inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
showed that differences between scorings were weak (0.5) and homegenous (differences were within or very near the 95% confidence limits of the mean).

Mao et al. (2002) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the PASS using α-coefficient for individual item reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson's r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
for total score reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
. Two clinicians assessed patients at 14 days post-stroke on the same day, with a total sample of 112 patients. Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for individual items was adequate to excellent (median α=0.88, range 0.61-0.96) and inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the total score was excellent (ICC=0.97, 95% CI 0.95-0.98).

Hsieh et al. (2002) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the trunk control items of the PASS (PASS-TC: items 1, 6, 7, 8, 9) in a sample of 182 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Results indicated excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the PASS-TC (ICC=0.97), measured using intraclass correlation coefficient.

Persson et al. (2011) examined the same-day inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the SwePASS in a sample of 114 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
. The inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of items was excellent (r=0.77-0.99).

Validity

Content:

No studies have reported on the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the PASS.

Criterion:

Concurrent :
Mao et al. (2002) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the PASS, Berg Balance Scale (BBS) and the Fugl-Meyer Assessment modified balance scale (FMA-B), using Spearman’s α correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. A sample of 123 patients with stroke was followed at 14, 30 (n=110), 90 (n=93), and 180 (n=80) days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. There was excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
between the PASS and the FMA-B (α=0.95-0.97) and between the PASS and the BBS (α= 0.92-0.95) at all time points.

Wang et al. (2004) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the PASS, Berg Balance Scale (BBS) and modified versions of both assessments that used 3-level scales (12-item PASS-3P, 14-item BBS-3P) in a sample of 77 patients with stroke, using Spearman’s α correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient and Intraclass CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient. There was excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
between all measures (rho α 0.91, P<0.0001); of note, agreement between the PASS and the BBS (α=0.94, P<0.0001), and between the PASS and the PASS-3P (α=0.94, P<0.0001; ICC=0.97, 95% CI 0.96-0.98.) was excellent.

Chien et al. (2007b) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the PASS and the 5-item SFPASS in a sample of 287 patients at 14 days post-stroke, using a random effects model intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance.. There was excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
between the PASS and the 5-item SFPASS (ICC= 0.98; 96% variance). This result was repeated in a subsequent cohort of 179 patients (ICC=0.98). Further, Bland-Altman plots revealed no systematic trend between the difference and mean score of the PASS and the 5-item SFPASS (mean difference 1.6, limits of agreement range from -3.7 to 6.8). This suggests that the PASS and the SFPASS can be used interchangeably.

Di Monaco et al. (2010) reported excellent concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
between the PASS and the Trunk Impairment Scale (TIS) (α=0.849, P<0.001), measured in a sample of 60 patients on admission to inpatient rehabilitation.

Predictive:
Benaim et al. (1999) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS by comparing PASS scores at 30 days post-stroke with FIM scores at 90 days post-stroke on a sample of 58 patients. Correlations between the PASS and FIM total score (r=0.75, p<0.001), transfer items (r=0.74, p<0.006) and locomotion items (r=0.71, p<0.001) indicate that it is possible to predict functional recovery from PASS scores at 30 days post-stroke.

Mao et al. (2002) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS, Berg Balance Scale and the Fugl-Meyer Assessment modified balance scale at 14, 30 and 90 days post-stroke by comparison with the Motor Assessment Scale walking subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
score at 180 days post-stroke, in a sample of 123 patients. The PASS demonstrated excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
at all time points (α=0.86-0.90), as measured using Spearman’s p correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient.

Hsieh et al. (2002) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the trunk control items of the PASS (PASS-TC: items 1, 6, 7, 8, 9) in a sample of 169 patients by comparing PASS-TC scores taken at 14 days post-stroke with Barthel Index (BI) and Frenchay ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
Index (FAI) scores taken at 6 months post-stroke. The PASS-TC demonstrated excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
(r=0.68, p<0.001), as measured using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. The PASS-TC was found to be a stronger predictor of comprehensive ADL function than the Barthel Index or the Fugl-Meyer motor test.

Wang et al. (2004) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS and a modified version of the PASS that used a 3-level scale (12-item PASS-3P) in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by comparing scores taken at 14 (n=226) and 30 days (n=202) post-stroke with Barthel Index (BI) scores taken at 90 days post-stroke, using Spearman’s α correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. Both versions of the PASS demonstrated excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
at 14 days (p=0.78) and 30 days (p=0.82) post-stroke.

Chien et al. (2007a) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS in a sample of 32 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by comparing PASS score taken within 3 months of the strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with Barthel Index and Frenchay ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
Index scores taken approximately 1 year later. Results indicated poor predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
(r2=0.24), as measured using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient.

Chien et al. (2007b) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS and SFPASS in a sample of 218 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by comparing scores on each test at 14 days post-stroke with Barthel Index (BI) scores at 90 days post-stroke. Results indicated adequate predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS (r=0.49) and the SFPASS (r=0.48). The authors replicated the process on a second cohort of 179 patients by comparing PASS and SFPASS scores on admission to rehabilitation with BI scores on discharge from hospital. Results revealed excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS (r=0.83) and the SFPASS (r=0.82), as measured using product-moment correlations.

Di Monaco et al. (2010) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS and the Trunk Impairment Scale (TIS) by comparing scores on admission to inpatient rehabilitation with FIM discharge scores, in a sample of 60 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Results indicated excellent predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS (α=0.687, p<0.001), as measured using Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
. PASS admission scores were also significantly associated with FIM change scores (P<0.001), FIM effectiveness (P=0.017) and destination at discharge (P=0.032).

Yu et al. (2012) examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS and the Balance Computerized Adaptive Test (Balance CAT) by comparing scores on admission to a rehabilitation ward with Barthel Index (BI) and StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Rehabilitation Assessment of Movement mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(MO-STREAM) discharge scores in a sample of 85 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Correlations between PASS and BI scores (α =0.62, r2=0.39, p<0.001) and between PASS and MO-STREAM scores (α =0.80, r2=0.63, p<0.001) indicated sufficient predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the PASS, as measured using α and r2 from a simple linear regression analysis. This indicates that PASS scores at admission can predict discharge function and mobility.

Construct:

Convergent/Discriminant :
Benaim et al. (1999) examined correlations between PASS performance and clinical scales of functional status, motricity, spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, spatial inattention and somatosensory threshold among 58 patients at 30 days post-stroke, using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Excellent correlations were found with FIM total score (r=0.73), transfer tasks (r=0.82) and locomotor tasks (r=0.73); and motricity scores of the lower limb (r=0.78) and upper limb (r=0.63). Adequate negative correlations were found with the star cancellation test of spatial inattention (r=-0.53) and pressure sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of the lower limb (r=-0.45) and upper limb (r=-0.42). There was no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
, measured using the Ashworth Scale. The authors also examined the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between PASS performance and equilibrium, measured using a rocking platform, among a smaller sample of 31 patients at 90 days post-stroke, and reported adequate negative correlations with measurement of postural stabilization (r=-0.48) and postural orientation with respect to gravity (r=0.36).

Mao et al. (2002) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the PASS, Berg Balance Scale and the Fugl-Meyer Assessment modified balance scale by comparison with the Barthel Index (BI), using Spearman’s p correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. A sample of 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. was followed at 14, 30 (n=110), 90 (n=93), and 180 (n=80) days after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. onset. There was excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
between the PASS and the BI (α=0.88-0.92) at all time points.

Hsieh et al. (2002) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the trunk control items of the PASS (PASS-TC: items 1, 6, 7, 8, 9) by comparison with the Barthel Index (BI) and Fugl-Meyer balance test (FM-B), in a sample of 182 patients at 14 days post-stroke. The PASS-TC demonstrated excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
with the BI (r=0.89) and the FM-B (r=0.73), using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient.

Wang et al. (2004) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the PASS and the PASS-3P by comparison with the Barthel Index (BI), in a sample of 77 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The PASS and the PASS-3P both demonstrated excellent convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
with the BI (α=0.84, (α=0.82 respectively), measured using Spearman p correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient.

Chien et al. (2007b) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the PASS and the 5-item SFPASS by comparison with the Barthel Index (BI) and FIM in a sample of 287 patients at 14 days post-stroke. The PASS and the SFPASS both demonstrated excellent correlations with the BI (PASS r=0.87; SFPASS r=0.86) and the FIM (PASS r=0.75; SFPASS r=0.75).

Known Group:
No studies have reported on the known-groups validityThe degree to which an assessment measures what it is supposed to measure.
of the PASS.

Responsiveness

Mao et al. (2002) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS in a sample of 123 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by comparing scores taken at 14, 30 (n=110), 90 (n=93) and 180 (n=80) days post-stroke. There was a significant change in PASS scores at all stages (14-30 days, 30-90 days, 90-180 days, 14-90 days and 14-180 days post-stroke), measured using Wilcoxon matched-pairs signed-rank tests. Effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
was large at the interval between 14-30 days post-stroke (ES=0.89), became moderate in the interval between 30-90 days (ES=0.64) and low in the interval 90-180 days (ES=0.31). The overall effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(14-180 days) was large (ES=1.12). These results indicate that the PASS demonstrates good responsivenessThe ability of an instrument to detect clinically important change over time.
before 90 days post-stroke but low responsivenessThe ability of an instrument to detect clinically important change over time.
at later stages of recovery. The authors also examined responsivenessThe ability of an instrument to detect clinically important change over time.
according to strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. severity and found that the PASS is more responsive to detecting change in moderate to severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. than mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. across most time intervals. The overall effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(14-180 days) was largest among patients with severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (ES=1.54).

Wang et al. (2004) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS and the PASS-3P in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. by comparing scores taken at 14 days (n=202), 30 days (n=167) and 90 days (n=167) post-stroke. There was a significant change in PASS and PASS-3P scores at all stages (14-30 days, 30-90 days and 14-90 days post-stroke), measured using Wilcoxon matched-pairs signed-rank tests. Both measures demonstrated a large effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
in the interval 14-30 days post-stroke (SRM=0.84 and 0.86 respectively) and 14-90 days post-stroke (SRM=1.02 and 1.04 respectively), but only a moderate effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
in the interval 30-90 days post-stroke (SRM=0.65 and 0.67 respectively), measured using standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores.
(SRM). The authors examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS and the PASS-3P according to severity of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. – mild (Fugl-Meyer Assessment score ≥ 80), moderate (FMA score 36-79) and severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (FMA score 0-35). Both measures showed a moderate effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
among patients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (PASS SRM range 0.43-0.78; PASS-3P SRM range 0.46-0.78), moderate to large effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
among patients with moderate strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (PASS SRM range 0.52-1.12; PASS-3P SRM range 0.56-1.19), and a large effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
among patients with severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (PASS SRM range 0.92-1.35; PASS-3P SRM range 0.92-1.34). The effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
of both measures was consistently larger in the intervals 14-30 days post-stroke and 14-90 days post-stroke, than 30-90 days post-stroke.

Chien et al. (2007a) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS in a sample of 40 patients with subacute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., measured using Cohen’s effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
. The PASS was administered twice over a 2-week interval, during which time patients received an intensive rehabilitation program that comprised postural training and weight shift exercises for more than 2 hours per day, 5 days a week. The effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
after 2 weeks was small (d=0.41). The minimal detectable change (MDC)Minimal Detectable Change (MDC) refers to the minimal amount of change outside of error that reflects true change by a patient between two time points (rather than a variation in measurement). (i.e. the threshold value that determines whether score changes are beyond chance) was 2.22 (95% CI) at an individual score level, and 0.50 (95% CI) at a group score level.

Chien et al. (2007b) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS in a sample of 262 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The change score from 14 days post-stroke to 30 days post-stroke was significant (4.9, p<0.01) and the effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
was small (ES=0.42). A small effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(ES=0.43) was also seen in a subsequent cohort of 179 patients who were assessed at admission to rehabilitation and again on discharge from hospital.

Chien et al. (2007b) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the 5-item SFPASS in a sample of 262 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The change score from 14 to 30 days post-stroke was significant (5.4, p<0.01) and the effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
was small (ES=0.44). A small effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
(ES=0.42) was also seen in a subsequent cohort of 179 patients who were assessed at admission to rehabilitation and again on discharge from hospital.

Chien et al. (2007b) reported on the Standard Error of Measurement (i.e. an estimate of the dispersion of scores that would be obtained if the measure was administered to a patient multiple times) of the PASS and the 5-item SFPASS in a cohort of 287 patients at 14 days post-stroke. The SEM of the PASS was 2.4 (4.7, 95% CI). The SEM of the 5-item SFPASS in the same cohort was 3.4 (6.7, 95% CI). This score is lower than 10% of the highest possible score of 36, which indicates that the measurement error does not exceed clinical importance.

Liaw et al. (2008) examined the smallest real difference (SRD – the smallest change threshold that indicates a real improvement for a single individual) of the PASS in a sample of 52 patients with chronic stroke. Participants were assessed by the same clinician on 2 occasions, 7-days apart. The SRD was 3.2, indicating that a change of more than 4 points in the total score for the PASS in chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients is not likely to be attributable to chance variation or measurement error.

Liaw et al. (2012) examined the minimal detectable change (MDC)Minimal Detectable Change (MDC) refers to the minimal amount of change outside of error that reflects true change by a patient between two time points (rather than a variation in measurement). of the Short Form PASS (SFPASS) in a sample of 52 patients with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were assessed by the same clinician on two occasions, 7 days apart. Results indicate that a change in an individual’s SFPASS scores greater than 2.16 points can be interpreted as true change (95% CI).

Yu et al. (2012) examined the internal and external responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS in a sample of 85 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. There was a significant change in PASS scores from admission to discharge (Wilcoxon Z=7.7, p<0.001), and the effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the "effect size correlation".
was large (d=0.87), indicating adequate internal responsivenessThe ability of an instrument to detect clinically important change over time.
. External responsivenessThe ability of an instrument to detect clinically important change over time.
was calculated by comparing PASS change scores (admission to discharge) with change scores from the Barthel Index (BI) and the mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Rehabilitation Assessment of Movement (MO-STREAM), using α and r2 from a simple linear regression analysis. Results revealed a fair association between PASS and BI changes scores (α =0.44, r2=0.20, p<0.001) and a moderate association between PASS and MO-STREAM change scores ((α =0.77, r2=0.59, p<0.001) indicating sufficient external responsivenessThe ability of an instrument to detect clinically important change over time.
of the PASS to changes in function and mobility following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
 & specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
 or the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
 of the PASS.

References

• Barros de Oliveira, C., Torres de Medeiros, I.R., Ferreira Frota, N.A., Greters, M.E., & Conforto, A.B. (2008). Balance control in hemiparetic stroke patients: main tools for evaluation. Journal of Rehabilitation Research and Development, 45(8), 1215-26.
• Benaim, C., Perennou, D.A., Villy, J., Rousseaux, M., & Pelissier, J.Y. (1999). Validation of a standardized assessment of postural control in stroke patients: The Postural Assessment Scale for Stroke Patients (PASS). Stroke, 30, 1862-8.
• Blum, L. & Korner-Bitensky, N. (2008). Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Physical Therapy, 88, 559-66.
• Chien, C-W., Hu, M-H., Tan, P-F., Sheu, C-F., & Hsieh, C-L. (2007a). A comparison of psychometric properties of the Smart Balance Master system and the Postural Assessment Scale for Stroke in people who have had mild stroke. Archives of Physical Medicine and Rehabilitation, 88, 374-80.
• Chien, C-W., Lin, J-H., Wan, C-H., Hsueh, I-P., Sheu, C-F., & Hsieh, C-L. (2007b). Developing a short form of the Postural Assessment Scale for People with Stroke. Nuerorehabilitation and Neural Repair, 21, 81-90.
• Di Monaco, M., Trucco, M., Di Monaco, R., Tappero, R., & Cavanna, A. (2010). The relationship between initial trunk control or postural balance and inpatient rehabilitation outcome after stroke: a prospective comparative study. Clinical Rehabiltiation, 24, 543-54.
• Hseih, C-L., Sheu, C-F., Hsueh, I-P., & Wang, C-H. (2002). Trunk control as an early predictor of comprehensive activities of daily living function in stroke patients. Stroke, 33, 2626-30.
• Liaw, L-J., Hsieh, C-L., Hsu, M-J., Chen, H-M., Lin, J-H., & Lo, S-K. (2012). Test-retest reproducibility of two short-form balance measures used in individuals with stroke. International Journal of Rehabilitation Research, in press. Epub ahead of print retrieved from http://journals.lww.com/intjrehabilres/Abstract/publishahead/Test_retest_reproducibility_of_two_short_form.99818.aspx
• Liaw, L-J., Hsieh, C-L., Lo, S-K., Chen, H-M., Lee, S., & Lin, J-H. (2008). The relative and absolute reliability of two balance performance measures in chronic stroke patients. Disability and Rehabilitation, 30(9), 656-61.
• Mao, H-F., Hsueh, I-P., Tang, P-F., Sheu, C-F., & Hsieh, C-L. (2002). Analysis and comparison of the psychometric properties of three balance measures for stroke patients. Stroke, 33, 1022-7.
• Persson, C.U., Hansson, P-O., Danielsson, A., & Sunnerhagen, K.S. (2011). A validation study using a modified version of Postural Assessment Scale for Stroke Patients: Postural stroke study in Gothenburg (POSTGOT). Journal of NeuroEngineering and Rehabilitation, 8, 57-64.
• Wang, C.H., Hsueh, I.P., Sheu, C.F., Yao, G., & Hsieh, C.L. (2004). Psychometric properties of 2 simplified 3-level balance scales used for patients with stroke. Physical Therapy, 84(5), 430-8.
• Yu, W-H., Hsueh, I-P., Hou, W-H., Wang, Y-H., & Hsieh, C-L. (2012). A comparison of responsiveness and predictive validity of two balance measures in patients with stroke. Journal of Rehabilitation Medicine, 44, 176-80.

See the measure

How to obtain the PASS?

The PASS is available on line at: http://www.brightonrehab.com/wp-content/uploads/2012/02/Postural-Assessment-Scale-for-Stroke-Patients-PASS.pdf