Chedoke-McMaster Stroke Assessment

Evidence Reviewed as of before: 19-08-2008
Author(s): Sabrina Figueiredo, BSc; Katie Marvin, MSc, PT Candidate
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Lisa Zeltzer, MSc OT

Purpose

The Chedoke-McMaster Stroke Assessment measures physical impairment and disability in clients with stroke and other neurological impairment. The measure consists of an Impairment Inventory and an Activity Inventory (Moreland, Gowland, Van Hullenaar, & Huijbregts, 1993). The first inventory aims to determine the presence and severity of common physical impairments, to classify or stratify patients when planning, selecting interventions and evaluating their effectiveness and to predict outcomes. The second inventory measures changes in physical function (Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, Sanford, Barreca, Vanspall, & Plews, 1993). The Chedoke-McMaster Stroke Assessment is a discriminative, predictive and evaluative tool.

In-Depth Review

Purpose of the measure

The Chedoke-McMaster Stroke Assessment measures physical impairment and disability in clients with stroke and other neurological impairment. The measure consists of an Impairment Inventory and an Activity Inventory (Moreland, Gowland, Van Hullenaar, & Huijbregts, 1993). The first inventory aims to determine the presence and severity of common physical impairments, to classify or stratify patients when planning, selecting interventions and evaluating their effectiveness and to predict outcomes. The second inventory measures changes in physical function (Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, Sanford, Barreca, Vanspall, & Plews, 1993). The Chedoke-McMaster Stroke Assessment is a discriminative, predictive and evaluative tool. It is recommended that measures of motor impairment, such as the Chedoke-McMaster Stroke Assessment, be accompanied by a measure of functional disability such as the Barthel Index (BI) or Functional Independence Measure (FIM) (Poole & Whitney, 2001).

Available versions

There is only one version of the Chedoke-McMaster Stroke Assessment, which was developed by Gowland, Van Hullenar, Moreland, Vanspall, Barreca, Ward, Huijbregts, Stratford and Barclay-Goddard from the original work by Brunnstrom.

A complimentary measure for the Chedoke-McMaster Stroke Assessment, the Chedoke Arm and Hand Inventory (CAHAI), was developed by Barreca, Gowland, Stratford, Huijbregts, Griffiths, Torresin, Dunkley, Miller and Masters, in 2004, to assess, exclusively, the recovery of the paretic upper limb. To date, there are three different versions of the CAHAI. The original version comprehends 13 items, which was then shortened to a version with 9 and 7 items. This CAHAI is summarized in its own module.

Features of the measure

Items:

The Chedoke-McMaster Stroke Assessment is a performance-based measure that consists of two inventories: the Impairment Inventory and the Activity Inventory.
The Impairment Inventory is used to determine the presence and severity of common physical impairments. It has six dimensions (recovery stage of the arm, hand, leg, foot, postural control, and shoulder pain). Each dimension is measured on a 7-point scale (Gowland et al., 1993). The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity. The Impairment Inventory is considered to be a discriminative and predictive tool (Huijbregts, Gowland, & Gruber, 2000; Moreland et al., 1993).

The Activity Inventory was originally called the Disability Inventory. Its name changed in 1999, in accordance with the World Health Organization (WHO) terminology (Huijbregts et al., 2000). The aim of this inventory is to measure clinically important changes in the client’s functional ability. This Activity Inventory is made up of the gross motor function and walking indexes.

The gross motor function index consists of the 10 following items: 1 – supine to side lying on strong side; 2 – supine to side lying on weak side; 3 – side lying to long sitting through strong side; 4 – side lying to sitting on side of the bed through strong side; 5 – side lying to sitting on side of the bed through weak side; 6 – standing; 7 – transfer to and from bed toward strong side; 8 – transfer to and from bed toward weak side; 9 – transfer up and down from floor to chair; 10 – transfer up and down from floor and standing. The walking index consists of the 5 following items: 11 – walking indoors; 12 – walking outdoors, over rough ground, ramps, and curbs; 13 – walking outdoors several blocks; 14 – stairs; 15 – age and sex appropriate walking distance in meters for 2 minutes. (Finch et al., 2002; Gowland et al., 1993; Huijbregts at al., 2000). The Activity Inventory is considered an evaluative tool (Huijbregts at al., 2000; Moreland et al., 1993).

Scoring:

The Impairment Inventory is scored on a 7-point scale, where 1 – is flaccid paralysis; 2 – spasticity is present and felt as a resistance to passive movement; 3 – marked spasticity but voluntary movement present within synergistic patterns; 4 – spasticity decreases; 5 – spasticity wanes but is evident with rapid movement at the extremes of range; 6 – coordination and patterns of movement are near normal; and 7 – normal movement. The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity. The minimum score for the Impairment Inventory is 6 and the maximum score is 42 (Gowland et al., 1993).

The Activity Inventory is also scored on a 7-point scale, based on the amount of assistance the individual with stroke requires. It is categorized by the need for assistance from another person, the need for equipment, or the need for extra time to accomplish a task (Huijbregts at al., 2000). For the Activity Inventory, the scoring key from the Functional Independence Measure (Keith, Granger, Hamilton & Sherwin, 1987) is used, where 1 – the client needs total assistance; 2 – maximal assistance; 3 – moderate assistance, 4 – minimal assistance, 5 – clients needs supervision; 6 – client is modified independent (needs assistance from devices); 7 – client is timely and safely independent (Gowland et al., 1993).

The maximum score is 100, where higher scores reflect normal function (Finch et al., 2002; Gowland et al., 1993). More specifically, the maximum score for the gross motor function index is 70 and for the walking index is 30 (Gowland et al., 1993). Additionally, a 2-point bonus should be assigned for those who walk, appropriate distances, in meters, accordingly to the norms for their age and sex, on item 15 (the 2-Minute Walk Test) (Huijbregts at al., 2000).

Detailed administration guidelines and scoring are in the development manual that can be obtained by emailing to the following address: djohnstn@mcmaster.ca at a cost of $50.00 CAD.

Time:

The time to administer the Chedoke-McMaster Stroke Assessment typically varies from 45 to 60 minutes depending on the client’s ability to complete the required task (Finch et al., 2002; Gowland et al., 1993; Poole & Whitney, 2001). Clients with severe stroke will typically take longer to accomplish all tasks when compared to clients with mild stroke.

Subscales:

The Chedoke-McMaster Stroke Assessment is divided into two inventories: Impairment and Activity. The Activity Inventory, initially called the Disability Inventory, subdivides into gross motor and walking indexes (Finch et al., 2002; Gowland et al., 1993; Huijbregts at al., 2000).

Equipment:

  • An adjustable table (Finch et al., 2002)
  • A chair with armrests (Finch et al., 2002)
  • A floor mat (Finch et al., 2002)
  • Pillows (Finch et al., 2002)
  • Pitcher with water (Finch et al., 2002)
  • Measuring cup (Finch et al., 2002)
  • A ball 2.5 inches in diameter (Finch et al., 2002)
  • A footstool (Finch et al., 2002)
  • 2m line marked on the floor (Finch et al., 2002)
  • A stopwatch (Finch et al., 2002)

Training:

Training is provided by the authors at McMaster University in Hamilton, Ontario. Further information about training can be obtained by emailing: pmiller@mcmaster.ca

Alternative forms of the Chedoke-McMaster Stroke Assessment

None.

Client suitability

Can be used with:

  • Clients with stroke.
  • Clients with other neurological impairment

Should not be used with:

  • Clients younger than 19 years old (Finch et al., 2002), as the measure was developed with adults and its psychometrics properties were tested only for this population.
  • It is not suited to proxy use.

In what languages is the measure available?

English, French and German

Summary

What does the tool measure? The Chedoke-McMaster Stroke Assessment measures specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia.
What types of clients can the tool be used for? The Chedoke-McMaster Stroke Assessment can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Screening and assessment.
Time to administer An average of 45 to 60 minutes.
Versions There are no alternative versions.
Other Languages French.
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the Chedoke-McMaster Stroke Assessment.
  • One study has examined the test-retest reliability of the Chedoke-McMaster Stroke Assessment and reported excellent test-retest reliability using ICC.
  • One study has examined the intra-rater reliability of the Chedoke-McMaster Stroke Assessment and reported excellent intra-rater reliability using ICC.
  • Three studies have examined the inter-rater reliability of the Chedoke-McMaster Stroke Assessment and reported excellent inter-rater reliability using ICC.
Validity

Content:

Two studies have examined the content validity of the Chedoke-McMaster Stroke Assessment.

Criterion:

Concurrent Validity:

One study has examined the concurrent validity of the Chedoke-McMaster Stroke Assessment and reported excellent correlation between the Chedoke-McMaster Stroke Assessment total score and the Fugl-Meyer Assessment total score and the Functional Independence Measure (FIM) total score, using Pearson correlation.

Predictive Validity:

One study has examined the predictive validity of the Chedoke-McMaster Stroke Assessment and reported it is a predictor of functional ability and sensorimotor recovery after stroke.

Construct:

Convergent validity:

Two studies examined convergent validity of the Chedoke-McMaster Stroke Assessment, 1 reported excellent correlations between similar impairments from the Impairment Inventory and the Fugl-Meyer Assessment and between similar activity limitations from the Activity Inventory and the Functional Independence Measure, using Pearson Correlation. The other reported excellent correlation between totals scores on the Activity Inventory (AI) of the Chedoke-McMaster Stroke Assessment and the Clinical Outcomes Variable Scale at admission, discharge and change from admission to discharge.

Known Groups:

One study examined known groups validity of the Chedoke-McMaster Stroke Assessment and reported that it is able to distinguish between subjects who changed little (<20 on FIM), and those who change more (>20 on FIM), using student t-test.

Floor/Ceiling Effects No studies have examined floor/ceiling effects of the Chedoke-McMaster Stroke Assessment.
Sensitivity/ Specificity No studies have examined the sensitivity/specificity of the Chedoke-McMaster Stroke Assessment.
Does the tool detect change in patients? Two studies have examined the responsiveness of the Chedoke-McMaster Stroke Assessment and reported that it has a large variance ratio and a minimal clinically-important change is expressed by a change of 8 units in the Activity Inventory.
Acceptability Administration of the entire Chedoke-McMaster Stroke Assessment is lengthy. The test is scored by direct observation.
Feasibility The Chedoke-McMaster Stroke Assessment must be administered by a trained physical or occupational therapist. It does not require any specialized equipment.
How to obtain the tool?

The Chedoke-McMaster can be ordered by email: djohnstn@mcmaster.ca

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Chedoke-McMaster Stroke Assessment in individuals with stroke. We identified six studies. The Chedoke-McMaster Stroke Assessment appears to be responsive in clients with stroke.

Floor/Ceiling Effects

No studies have examined the floor/ceiling effects of the Chedoke-McMaster Stroke Assessment.

Reliability

Test-retest:

Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, et al. (1993) examined the test-retest reliability of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, at a mean age of 64 years. Participants were re-assessed with a 5-day interval. The test-retest reliability for the Activity Inventory, as calculated using Intraclass Correlation Coefficient (ICC), was excellent (ICC = 0.98), as were the gross motor function (ICC = 0.96) and walking (ICC = 0.98) indexes.

Intra-rater:

Gowland et al. (1993) estimated the intra-rater reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, at a mean age of 64 years. Participants were assessed at admission to the rehabilitation center, and their performances were videotaped. Scoring on the second evaluation was based on the videotape recorded previously. The intra-rater reliability, as calculated using ICC was excellent for both Impairment Inventory evaluations (ICC = 0.98), as well as for the dimension’s shoulder pain (ICC = 0.96), postural control (ICC = 0.96), arm (ICC = 0.95), hand (ICC = 0.93), leg (ICC = 0.98) and foot (ICC = 0.94).

Inter-rater:

Gowland et al. (1993) estimated the inter-rater reliability of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, at a mean age of 64 years. Participants were assessed simultaneously by two raters. The ICC for the total score showed excellent agreement (ICC = 0.97), as well as for the dimension’s shoulder pain (ICC = 0.95), postural control (ICC = 0.92), arm (ICC = 0.88), hand (ICC = 0.93), leg (ICC = 0.85) and foot (ICC = 0.96).

Gowland et al. (1993) examined the inter-rater reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, at a mean age of 64 years. Participants were re-assessed within 5 days by a second rater. The inter-rater reliabilities as calculated using ICC were excellent for the Impairment Inventory (ICC = 0.99), as well as for the gross motor function (ICC = 0.98) and walking (ICC = 0.98) indexes.

Crowe, Harmer, and Sharp (1996) assessed the inter-rater reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke Assessment in 28 participants with Acquired Brain Injury. Participants were assessed with a 2-week interval by two therapists. Agreement between raters for the Impairment Inventory, as calculated using ICC, was excellent (r = 0.99).
Note: The severity of the Acquired Brain Injury and the reason for the 2 weeks delay when measuring inter-rater reliability were not specified by the authors.

Validity

Content:

Moreland, Gowland, Van Hullenar, and Huijbregts (1993) performed a literature review to gather evidence for a theoretical basis of the Chedoke-McMaster Stroke Assessment. All items from both inventories had enough scientific evidence supporting its assumptions. Thus, the authors were able to establish a theoretical basis underlying the content of the Chedoke-McMaster Stroke Assessment.

Huijbregts, Gowland, and Gruber (2000) carried out a survey in 34 clients with stroke and 27 caregivers to verify whether the content in the Activity Inventory is representative of skills that are important to that population. On a scale where 1 is not at all important and 7 is extremely important, all items received a 7 from at least one person in each group. For most items, the mean level was above 5, except for the 2-Minute Walk Test, which had the lowest score from both clients (1.78) and caregivers (3.52). The two most important items according to clients’ and caregivers’ perspective was standing and transferring from and to bed towards the strong side.

Criterion:

Concurrent:

Gowland et al. (1993) compared the Chedoke-McMaster Stroke Assessment with the Fugl-Meyer Assessment –FMA (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) and the Functional Independence Measure (FIM) (Keith, Granger, Hamilton & Sherwin, 1987) in 32 participants with stroke. Using Pearson Correlation Coefficients, the correlation between the Chedoke-McMaster Stroke Assessment total score and the FMA total score (r = 0.95) and the FIM total score (r = 0.79) were excellent.

Predictive:

Gowland (1984) examined whether the Chedoke-McMaster Stroke Assessment was able to predict sensorimotor recovery at discharge from an active rehabilitation program. Predictive validity of the Chedoke-McMaster Stroke Assessment was examined in 335 active stroke rehabilitation inpatients. Assessments were performed at admission to and at discharge from the rehabilitation center. The length of stay varied from 1 to 49 weeks with an average of seven weeks. At discharge, the 23 independent variables selected were able to predict 11 out of 14 outcomes. Among these independent variables, stage of recovery of the leg was found to be the most important predictive variable, followed by weeks’ post-stroke and gross motor performance.

Valach, Singer, Hartmeier, Hofer & Cox Steck (2003) examined whether scores from the Chedoke-McMaster Stroke Assessment (CMSA) were predictive of scores on the Barthel Index (BI) and vice versa, in 127 patients with vascular brain-damage. Regression analysis revealed that as few as 3 items on the CMSA disability index were needed to predict BI scores, however 6 to 8 items on the BI were needed to predict CMSA scores. Although only a few items on the CMSA were required to predict BI scores, there was still a large portion of unexplained variance and thus, it is recommended that both the BI and CMSA be performed in situations where a comprehensive evaluation of patients is desired.

Construct:

Convergent/Discriminant:

Gowland et al. (1993) evaluated the convergent validity of the Chedoke-McMaster Stroke Assessment by comparing similar impairments between the Impairment Inventory and the Fugl-Meyer Assessment (FMA) (Fugl-Meyer et al., 1975). Correlations, as calculated using Pearson Correlation Coefficients, were excellent between postural control (Impairment Inventory) and balance (FMA) (r = 0.84); arm and hand (Impairment Inventory) and shoulder, elbow, forearm, wrist and hand (FMA) (r = 0.95); leg and foot (Impairment Inventory) and hip, knee, foot and ankle (FMA) (r = 0.93); shoulder pain (Impairment Inventory) and upper limb joint pain (FMA) (r = 0.76). Furthermore, the authors compared similar activity limitations between the Activity Inventory and the Functional Independence Measure (FIM) (Keith et al., 1987). Correlations, as calculated using Pearson Correlation Coefficients were excellent between the gross motor function index (Activity Inventory) and the Mobility subscale of the FIM (r = 0.90) and between the walking index (Activity Inventory) and the Locomotion subscale of the FIM (r = 0.85).

Sacks et al. (2010) evaluated the construct validity of the Chedoke-McMaster Stroke Assessment Activity Inventory (AI) and the Clinical Outcomes Variable Scale (COVS) (Seaby & Torrance, 1989) in 24 geriatric inpatients (mean age 83 years) receiving care in a rehabilitation unit. Correlations between AI and COVS total scores at admission and discharge, and change in total scores from admission to discharge, as calculated by Pearson Correlation Coefficients, were excellent (r=0.92, r=0.91 and r=0.84 respectively). All subscales of the AI and COVS demonstrated excellent correlation at admission, discharge and change from admission to discharge, except for the walking subscale, which was found to have adequate correlation for change from admission to discharge (r=0.59).

Known groups:

Crowe at al. (1996) analyzed whether the Activity Inventory was able to distinguish between subjects who changed little (<20) and those who change more (>20) on the Functional Independence Measure (FIM) (Keith et al., 1987) in 28 clients with Acquired Brain Injury. Known groups validity, as calculated using a student t-test, showed that the Activity Inventory is able to distinguish between clients with lower and higher scores on FIM.

Responsiveness

Gowland et al. (1993) estimated the responsiveness of the Activity Inventory and the Functional Independence Measure (FIM) (Keith et al., 1987) in 32 participants with stroke. Participants were assessed at two points in time: at admission and discharge from the rehabilitation centre. Variance ratios were calculated. Compared to the FIM, the Activity Inventory had a greater variance ratio (0.53 for Activity Inventory vs. 0.30 for FIM) suggesting that the Activity Inventory of Chedoke-McMaster Stroke Assessment is a more sensitive measure to detecting change.

Huijbregts et al. (2000) assessed clinically-important changes based on a global rating of change for the Activity Inventory, gross motor function index, and walking index in 34 clients. For the Activity Inventory, no change was represented by a mean change in score of 0, small changes by a mean change in score of 8, and moderate to large changes by a mean change in score of 20. For the gross motor function index, no change was represented by a mean change in score of 1, small changes by a mean change in score of 7, and moderate to large changes by a mean change in score of 7. For the walking index, no change was represented by a mean change in score of 1, small changes by a mean change in score of 5, and moderate to large changes by a mean change in score of 13. All this information suggests that for the client, a minimum change of 20 points in the Activity Inventory score is required for him to perceive a moderate to large change. Furthermore, important change as perceived by the client and the real change score of the measure have an excellent correlation (r = 0.74).

Sacks et al. (2010) evaluated the responsiveness of the Activity Inventory (AI) of the Chedoke-McMaster Stroke Assessment and the Clinical Outcomes Variable Scale (COVS) (Seaby & Torrance, 1989) in 24 geriatric inpatients (mean age 83 years) receiving care on a rehabilitation unit. Large effect sizes were found for both the AI and COVS (1.53 and 1.43); and a stronger standardized response mean (SRM) was found for the COVS compared to that of the AI (2.30 and 1.83). Results from this study suggest that both measures are responsive to change in geriatric patients but the COVS is more responsive than the AI in this population.

References

  • Crowe, J., Harmer, D., & Sharpe, D. (1996). Reliability of the Chedoke-McMaster Disability Inventory in acquired brain injury. Physiotherapy Canada, 48(1), 25.
  • Finch, E., Brooks, D., Stratford, P.W, & Mayo, N.E. (2002). Physical Outcome Measures: A guide to enhance physical outcome measures. Ontario, Canada: Lippincott, Williams & Wilkins.
  • Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
  • Gowland, C., Stratford, P., Ward, M., Moreland, J., Torresin, W., Van Hullenaar, S. et al. (1993). Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke, 24, 58-63.
  • Gowland, C., Van Hullenaar, S., Torresin, W., et al. (1995). Chedoke-McMaster Stroke Assessment: development, validation, and administration manual. Hamilton, ON, Canada: School of Rehabilitation Science, McMaster University.
  • Gowland, C. (1984). Predicting sensorimotor recovery following stroke rehabilitation. Physiotherapy Canada, 36, 313-320.
  • Gowland, C. (1982). Recovery of motor function following stroke: profile and predictors. Physiotherapy Canada, 34, 77-84.
  • Huijbregts, M.P., Gowland, C., Gruber, R. (2000). Measuring clinically important change with the Activity Inventory of the Chedoke-McMaster Stroke Assessment. Physiotherapy Canada, 52, 295-304.
  • Keith, R.A, Granger, C.V., Hamilton, B.B., & Sherwin, F.S. (1987). The Functional Independence Measure: a new tool for rehabilitation. In: Eisenberg, M.G. & Grzesiak, R.C. (Ed.), Advances in clinical rehabilitation (pp. 6-18). New York: Springer Publishing Company.
  • Moreland, J., Gowland, C., Van Hullenar, S., Huijbregts, M. (1993). Theoretical basis of the Chedoke-McMaster Stroke Assessment. Physiotherapy Canada, 45, 231-238.
  • Poole, J.L. & Whitney, S.L. (2001). Assessment of motor function post stroke: A review. Physical and Occupational Therapy in Geriatrics, 19, 1-22.
  • Sacks, L., Yee, K., Huijbregts, M., Miller, P.A., Aggett, T. & Salbach, N.M. (2010). Validation of the activity inventory of the Chedoke-McMaster Stroke Assessment and the Clinical Outcome Variables Scale to evaluate mobility in geriatric clients. Journal of Rehabilitation Medicine, 42, 90-92.
  • Valach, L., Signer, S., Hartmeier, A., Hofer, K. & Cox Steck, G. (2003). Chedoke-McMaster Stroke Assessment and modified Barthel Index self-assessment in patients with vascular brain damage. International Journal of Rehabilitation Research, 26, 93-99.

See The Measure

How to obtain the Chedoke-McMaster Stroke Assessment

The Chedoke-McMaster can be ordered by email: djohnstn@mcmaster.ca

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