Motor Activity Log (MAL)

Evidence Reviewed as of before: 28-03-2019
Author(s): Annabel McDermott, OT
Content consistency: Gabriel Plumier

Purpose

The Motor Activity Log (MAL) is a subjective measure of an individual’s real life functional upper limb performance. The MAL is administered by semi-structured interview to determine (a) how much, and (b) how well the individual uses his upper limb in his own home (Ashford et al., 2008, Li et al., 2012; Simpson & Eng, 2013).

In-Depth Review

Purpose of the measure

The Motor Activity Log (MAL) was developed by Taub et al. (1993) as a subjective outcome measure of an individual’s real life functional upper limb performance. The MAL is administered by semi-structured interview to determine (a) how much (Amount of Use – AOU), and (b) how well the individual uses his upper limb (Quality of Movement – QOM) in his own home (Ashford et al., 2008, Li et al., 2012; Simpson & Eng, 2013).

Available versions

There are four versions of the original MAL-30, according to number of items.

  • MAL-14: contains unilateral and simple items, to detect change in individuals with limited arm function.
  • MAL-26: contains the same items as the MAL-14 as well as 11 additional items and 1 optional item chosen by the patient; this version includes some bilateral tasks.
  • MAL-28: contains the same items as the MAL-14 and MAL-26, and additional items that challenge reach and strength.
  • MAL-12: a short version of the MAL-28 (Ashford et al., 2008).

Other adaptations of the MAL include:

  • Graded Motor Activity Log (Morera Silva et al., 2018)
  • Lower-Functioning Motor Activity Log (LF-MAL)
  • Lower-Extremity Motor Activity Log
  • Pediatric Motor Activity Log – Revised

Features of the measure

The MAL is comprised of two scales:

  • Amount of Use (AOU) scale – the amount the individual uses the paretic arm; and
  • Quality of Movement (QOM) scale – the patient’s perceived quality of movement while performing the functional activity (Ashford et al., 2008).

The MAL-QOM scale captures components of amount of arm use and has been shown to be more reliable than the MAL-AOU scale, and as such can be used independently (Uswatte & Taub, 2005).

Items:

Items the original MAL-30

  1. Turn on a light with a light switch
  2. Open drawer
  3. Remove an item from a drawer
  4. Pick up phone
  5. Wipe off a kitchen counter or other surface
  6. Get out of a car
  7. Open refrigerator
  8. Open a door by turning a door knob/handle
  9. Use a TV remote control
  10. Wash your hands
  11. Turning water on/off with knob/lever on faucet
  12. Dry your hands
  13. Put on your socks
  14. Take off your socks
  15. Put on your shoes
  16. Take off your shoes
  17. Get up from a chair with armrests
  18. Pull chair away from table before sitting down
  19. Pull chair toward table after sitting down
  20. Pick up a glass, bottle, drinking cup, or can
  21. Brush your teeth
  22. Put on makeup base, lotion, or shaving cream on face
  23. Use a key to unlock a door
  24. Write on paper
  25. Carry an object in your hand
  26. Use a fork or a spoon for eating
  27. Comb your hair
  28. Pick up a cup by a handle
  29. Button a shirt
  30. Eat half a sandwich or finger foods

Additional Items for the MAL-45

  • Removing bills from a wallet
  • Taking individual coins out of a pocket or purse
  • Removing keys out of a pocket or purse
  • Using a zipper pull
  • Pouring liquid from a bottle
  • Buckling a belt
  • Popping top of beverage can
  • Removing top from a medicine bottle
  • Keypad press
  • Use of keyboard/computer
  • Putting on or taking off watch band
  • Putting on glasses
  • Pumping a soap dispenser
  • Swiping a credit card or a card for an ATM
  • Adjusting a home or hotel air conditioner or heat

Items of the MAL-12:

  1. Pick up phone
  2. Open a door by turning a door knob
  3. Eat half a sandwich or finger food
  4. Turn water on/off with faucet
  5. Pick up a glass
  6. Pick up toothbrush and brush teeth
  7. Use a key to open a door
  8. Letter writing/typing
  9. Use removeable computer storage
  10. Pick up fork or spoon, use for eating
  11. Pick up cup by handle
  12. Carry an object from place to place

Items of the MAL-14:

  1. Putting arm through coat sleeve
  2. Steady myself while standing
  3. Carry an object from place to place
  4. Pick up fork or spoon, use for eating
  5. Comb hair
  6. Pick up cup by handle
  7. Hand craft/card playing
  8. Hold a book for reading
  9. Use towel to dry face or other body part
  10. Pick up a glass
  11. Pick up toothbrush and brush teeth
  12. Shaving/makeup
  13. Use a key to open a door
  14. Letter writing/typing

The MAL-26 includes the 14 items from the MAL-14 as well as the following items:

  1. Pour coffee/tea
  2. Peel fruit/potatoes
  3. Dial number on the phone
  4. Open/close a window
  5. Open an envelope
  6. Take money out of a wallet or purse
  7. Undo buttons on clothing
  8. Buttons on clothing
  9. Undo a zip
  10. Do up a zip
  11. Cut fingernails (affected hand)
  12. Other optional activity

Items of the MAL-28:

  1. Turn on a light with a light switch
  2. Open a drawer
  3. Remove item of clothing from drawer
  4. Pick up phone
  5. Wipe kitchen counter
  6. Get out of car
  7. Open refrigerator
  8. Open a door by turning a door knob
  9. Use a TV remote control
  10. Wash your hands
  11. Turn water on/off with faucet
  12. Dry your hands
  13. Put on your socks
  14. Take off your socks
  15. Put on your shoes
  16. Take off your shoes
  17. Get up from chair with armrests
  18. Pull chair away from table before sitting
  19. Pull chair toward table after sitting
  20. Pick up a glass
  21. Pick up toothbrush and brush teeth
  22. Use a key to unlock a door
  23. Steady self while standing
  24. Carry an object from place to place
  25. Comb hair
  26. Pick up cup by handle
  27. Buttons on clothing (shirt, trousers)
  28. Eat half a sandwich or finger food

For each item, the individual is asked whether he/she attempted the activity in the past 7 days, and the relevant score is assigned according to his/her response. The examiner can verify the response by paraphrasing it back to the individual (Uswatte & Taub, 2005). The MAL can also be used with caregivers.

Scoring:

The MAL is administered by semi-structured interview and items are scored by patients according to their performance of each task over the past 7 days; the MAL-28 can also be used to score performance over the past 3 days (Ashford et al., 2008; Uswatte & Taub, 2005).

The MAL adopts a 6-point ordinal scale, although patients can attribute a half-score, resulting in 11-point Likert scales with specified anchoring definitions at 6 points (Uswatte & Taub, 2005):

Amount of Use scale scoring

  • 0: Never – The weaker arm was not used at all for that activity.
  • 1: Very rarely – Occasionally used the weaker arm, but only very rarely.
  • 2: Rarely – Sometimes used the weaker arm but did the activity most of the time with the stronger arm.
  • 3: Half pre-stroke – Used the weaker arm about half as much as before the stroke.
  • 4: Three quarters pre-stroke – Used the weaker arm almost as much as before the stroke.
  • 5: Same – Used the weaker arm as often as before the stroke.

Quality of Movement scale scoring

  • 0: Never – The weaker arm was not used at all for that activity.
  • 1: Very rarely – The weaker arm was moved during the activity but was not very helpful.
  • 2: Rarely – The weaker arm was of some use during the activity but needed some help from the stronger arm but moved very slowly or with difficulty.
  • 3: Fair – The weaker arm was used for that activity, but the movements were slow or were made only with some effort.
  • 4: Almost normal – The movements made by the weaker arm for the activity were almost normal but not quite as fast or accurate as normal
  • 5: Normal – The ability to use the weaker arm for that activity was as good as before the stroke.

Scale total scores (summary scores) are the mean of the item scores.

What to consider before beginning:

The MAL is subject to experimenter bias and also the patient’s ability to accurately recall upper limb use (Page & Levine, 2003; Uswatte & Taub, 2005).

Ashford et al. (2008) noted an inadequate relationship between overall/item scores and the qualitative meaning, and an unclear Minimal clinically important difference.

Taub & Uswatte (2000) discuss the use of the MAL as an outcome measure in Constraint-Induced Movement Therapy (CIMT) research and recommend an upper cut-off score of 2.5 on the MAL-AOU, as the effect of stroke can impose an upper physiological limit on the amount of improvement that can be produced. The authors also note that individuals who score > 2.5 do not demonstrate learned non-use, which is the aim of CIMT.

Time:

All versions of the MAL are administered through structured interview with the patient and/or carer and require more than 10 minutes to administer. (Ashford et al., 2008).

Training requirements:

The MAL can be administered by health professionals who have reviewed the manual and literature.

Equipment:

Survey instrument and pencil.

Client suitability

Can be used with:

The MAL is suitable for use with adults and elderly adults following stroke and their caregivers. It is suitable for use in the subacute and chronic stages of stroke recovery.

Should not be used in:

Not specified.

The MAL is often used to measure outcomes following constraint induced movement therapy (Li et al., 2012; Page, 2003). The MAL is commonly used in research in conjunction wi with the Wolf Motor Function Test, Fugl-Meyer Assessment or the Action Research Arm Test (Santisteban et al., 2016; Simpson & Eng, 2013).

In what languages is the measure available?

  • Brazilian-Portuguese (Saliba et al., 2011)
  • English
  • German (Khan et al., 2013)
  • Portuguese (Pereira et al., 2011)
  • Turkish translation and cultural adaptation (Cakar et al., 2010).

Summary

What does the tool measure? Real life upper limb performance.
What types of clients can the tool be used for? Individuals following stroke and their caregivers.
Is this a screening or assessment tool? Assessment
What domain of the ICF does this measure? Activity/participation
Time to administer 20 minutes
Versions
  • MAL-30
  • MAL-28
  • MAL-26
  • MAL-14
  • MAL-12
  • Graded Motor Activity Log
  • Lower-Functioning Motor Activity Log (LF-MAL)
  • Lower-Extremity Motor Activity Log
  • Pediatric Motor Activity Log – Revised
Other Languages Brazilian-Portuguese, English, German, Portuguese, Turkish.
Measurement Properties
Reliability

Internal consistency:

  • MAL-14: 2 studies reported excellent internal consistency.
  • MAL: 1 study reported excellent internal consistency; 1 study reported excellent internal consistency among patients with mild-moderate hemiparesis and adequate to excellent internal consistency among patients with severe hemiparesis.
  • MAL-28 (Turkish): 1 study reported excellent internal consistency.
  • MAL-30 (German): 1 study reported excellent internal consistency.
  • Grade 4/5 MAL: 1 study reported excellent internal consistency.

Test-retest reliability:

  • MAL-14: 1 study reported excellent test-retest reliability; 1 study reported adequate to excellent test-retest reliability.
  • MAL: 1 study reported excellent test-retest reliability; 1 study reported adequate to excellent test-retest reliability.
  • MAL-28 (Turkish): 1 study reported excellent test-retest reliability.
  • MAL-28 (Brazilian): 1 study reported excellent test-retest reliability.
  • MAL-45: 1 study reported excellent test-retest reliability.
  • Grade 4/5 MAL: 1 study reported excellent test-retest reliability.

Intra-rater reliability:

No studies have reported on the intra-rater reliability of the MAL.

Inter-rater reliability:

MAL-14: 1 study reported adequate inter-rater reliability.

Validity

Content:

  • No studies have reported on content validity of the MAL.

Criterion:

Concurrent:

  • MAL-14: 1 study reported excellent correlations with accelerometry.
  • MAL: 3 studies reported an excellent correlation with SIS – Hand function domain; adequate correlations with the BBT, ARAT, FAI; poor to adequate correlations with SIS, SS-QOL, NEADL; and poor correlations with the Nine Hole Peg Test.
  • MAL-30 (German): 1 study reported excellent negative correlations with WMFT-PT; excellent correlations with WMFT-FA and Grip strength scores, CMSA – Arm and Hand scores, isometric strength.
  • MAL-45: 1 study reported excellent correlations with the Abilhand.

Predictive:

  • No studies have reported on predictive validity of the MAL.

Construct:

  • MAL-14: 1 study reported excellent correlations between QOM and AOU patient/carer change scores; 1 study reported an excellent correlation between AOU and QOM scales.
  • MAL: 1 study reported an excellent correlation between AOU and QOM scales; 1 study reported an adequate correlation between AOU and QOM scales; 1 study conducted item analysis and removed 2 items due to low item-total correlations and reliability coefficients; 1 study conducted item fit analysis and principal component analysis.
  • MAL (Brazilian): 1 study reported an excellent correlation between AOU and QOM scales.
  • MAL-30 (German): 1 study reported excellent correlations between AOU and QOM scales.
  • MAL-28 (Turkish): 1 study reported an excellent correlation between AOU and QOM scales.
  • LF-MAL: 1 study reported an adequate correlation between the AOU and QOM scales.

Convergent/Discriminant:

  • MAL-14: 3 studies reported excellent correlations with ARAT, accelerometry, Simple Test for Evaluating Hand Function (STEF).
  • MAL: 7 studies reported excellent correlations with Actual Amount of Use Test, WMFT; adequate to excellent correlations with accelerometry ratios, SIS 2.0 – Hand function scale, FMA-UE; adequate correlations with ARAT, Motor Assessment Scale – Upper Extremity, 16 Hole Peg Test, grip strength; SF-36 – Physical domain; poor to adequate correlations with accelerometry ratios of the less affected arm; poor correlations with the SIS 2.0 – Mobility scale.
  • MAL-28 (Turkish): 1 study reported excellent correlations with WMFT-FA; adequate negative correlations with the WMFT-PT.
  • MAL (Brazilian): 1 study reported adequate correlations with grip strength of the more affected arm.

Known Group:

  • MAL: 1 study reported correlations with accelerometry was stronger among patients with paresis of the dominant arm vs. the non-dominant arm.
Floor/Ceiling Effects
  • Floor effects are evident when detecting change in lower level and passive functional tasks.
  • One study found modest floor effects when the MAL-28 was administered to patients with upper extremity motor recovery at Brunnstrom stage III and higher; and modest floor effects when the LF-MAL was administered to patients with upper extremity motor recovery at Brunnstrom stage III and lower.
Does the tool detect change in patients? The MAL can be used to detect change
Acceptability The MAL reflects real life functional performance. It is simple and non-invasive to administer.
Feasibility The MAL is a free tool that requires no additional equipment. It can be administered in the clinical setting or the patient’s home. No additional training is required.
How to obtain the tool?

Click here to see the Motor Activity Log manual.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the MAL. Twenty-six studies were identified, most of which included patients in the chronic phase of stroke recovery. This review includes different versions of the MAL – the original MAL-30, MAL-28, MAL-14, MAL-45, LF-MAL, Grade 4/5 MAL and Turkish, Brazilian and German versions.

Floor/Ceiling Effects

Chuang et al. (2017) examined floor/ceiling effects of the 30-item MAL in a sample of 403 patients with chronic stroke. The MAL was administered to patients with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and higher. Results showed modest floor effects within this cohort, whereby 17.3% of participants received minimum scores on the MAL.

Chuang et al. (2017) examined floor/ceiling effects of the LF-MAL in a sample of 134 patients with chronic stroke. The LF-MAL was administered to patients with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and lower. Results showed modest floor effects within this cohort, whereby 16.4% of participants received minimum scores on the LF-MAL.

Reliability

Internal consistency:
van der Lee et al. (2004) examined internal consistency of the MAL-14 in a sample of 56 patients with chronic stroke, using Cronbach’s alpha. Correlation among items was excellent for the MAL-AOU (a = 0.87) and the MAL-QOM (a = 0.90). Limits of agreement ranged from -0.70 to 0.85 for the MAL-AOU and from -0.61 to 0.71 for the MAL-QOM, indicating reproducibility sufficient to detect an individual change of approximately 12-15% of the range of the scale.

Uswatte et al. (2005b) examined internal consistency of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers, using Cronbach’s alpha. Correlation among items was excellent for patients’ MAL-QOM (a = 0.87) and caregivers’ MAL-AOU and MAL-QOM (a > 0.83). The authors also examined internal consistency of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke. Correlation among items was excellent for the MAL-QOM (a = 0.81).

Uswatte et al. (2006b) examined internal consistency of the MAL-28 in a sample of 222 patients with subacute/chronic stroke and their caregivers, using Cronbach’s alpha. Responses from both patient and caregiver groups showed excellent correlation among items for the MAL-AOU (patients a = 0.94; caregivers a = 0.95) and the MAL-QOM (patients a = 0.94; caregivers a = 0.95).

Huseyinsinoglu et al. (2011) examined internal consistency of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using Cronbach’s alpha. Internal consistency was excellent for the MAL-AOU (a = 0.96) and MAL-QOM (a = 0.96).

Khan et al. (2013) examined internal consistency of the MAL-30 (German version) in a sample of 42 patients with acute to chronic stroke, using Cronbach’s alpha. Measures were taken at baseline, discharge from rehabilitation and at 6-month follow-up. Internal consistency for the MAL-AOU and MAL-QOM were excellent at all timepoints (a = 0.98-0.995). The authors also calculated internal consistency based on an elimination procedure of items that scored “N/A” down to 26 items and reported that internal consistency remained high at all timepoints (a = 0.94-0.98).

Taub et al. (2013) reported on internal consistency of the Grade 4/5 MAL, referencing unpublished data from Morris (2009) that used a sample of 30 individuals with stroke, using Cronbach’s alpha. Internal consistency for the Grade 4/5 MAL was excellent (a = 0.95).

Chuang et al. (2017) examined the 6-point rating system of the MAL and found rater difficulty discriminating among the 6 levels of functional ability. Results showed that 15 items of the MAL-AOU and MAL-QOM displayed disordering of step difficulty. Accordingly, the 6 levels were collapsed into 4 levels to restore reversed threshold (0 = 0; 1-2 = 1; 3-4 = 2; 5 = 3); using the 4-point system 9 items still showed disordered ordering, so the levels were further collapsed into 2 categories (0 = 0; 1 to 3 = 1), at which point all items exhibited ordering. The authors examined unidimensionality of the 30-item MAL in a sample of 403 patients with chronic stroke, using the revised scoring system. Item fit analysis of the MAL revealed that 7 items* of the MAL-AOU and MAL-QOM were a poor fit and were removed. Principal component analysis (PCA) of the remaining 23 items showed that Rasch measures accounted for 76% of the variance for both the MAL-AOU and MAL-QOM, with an eigenvalue of the first residual factor of 2.7. This indicates that the 23 items constitute unidimensional constructs. The authors examined reliability of the revised MAL (23 items, 4-point rating system), using Rasch analysis. With Pearson separation values of 2.4 and 2.6 for the MAL-AOU and MAL-QOM respectively, the revised version was sensitive to distinguish among 3 strata of upper limb performance. Pearson reliability coefficients were 0.85 and 0.87 (respectively), suggesting good reliability. Results showed no Differential Item Functioning (DIF) items across age, gender or hand dominance. Item difficulty hierarchy was consistent with clinical expectation, however items were more difficult than individuals’ ability, suggesting unsuitable targeting for the participants of this sample.

* Misfit items: (6) Get out of car; (12) Dry your hands; (18) Pull a chair away from the table before sitting down; (19) Pull chair toward table after sitting down; (21) Brush your teeth; (24) Write on paper; (29) Button a shirt.

Chuang et al. (2017) examined the 6-point rating system of the LF-MAL and found disordered thresholds; accordingly, the 6 levels were collapsed into 3 levels to restore reversed threshold (0 = 0; 1-3 = 1; 4-5 = 2); this 3-point rating system achieved step ordering. The authors examined unidimensionality of the LF-MAL in a sample of 134 patients with chronic stroke, using the revised 3-point scoring system. Item fit analysis of the LF-MAL-AOU revealed that 6 items were out of the acceptable range; PCA of the remaining 24 items showed that the Rasch dimension explained 70.5% of the variance, with an eigenvalue of 2.6 of the first residual factor. Item fit analysis of the LF-MAL-QOM revealed that 7 items were out of the acceptable range; PCA of the remaining 23 items showed that the Rasch dimension explained 71.0% of the variance, with an eigenvalue of the first residual factor of 2.5. The authors examined reliability of the revised LF-MAL (25 items, 3-point rating system), using Rasch analysis. With Pearson separation values of 1.9 for both the LF-MAL-AOU and LF-MAL-QOM, the revised version was sensitive to distinguish 2 strata of upper limb performance. Pearson reliability coefficients were 0.79 for both the LF-MAL-AOU and LF-MAL-QOM, indicating acceptable reliability. Results showed no DIF items across age, gender or hand dominance. Item difficulty hierarchy was consistent with clinical expectation, however items were more difficult than individuals’ ability, suggesting unsuitable targeting for the participants of this sample.

* Misfit items: (5) Wipe off a kitchen counter or another surface; (6) Get out of a car; (7) Open a refrigerator; (19) Apply soap to your body while bathing (LF-MAL-QOM only); (21) Brush your teeth; (23) Steady yourself while standing; (24) Carry an object in your hand.

Moreira Silva et al. (2018) examined internal consistency of the MAL-30 in a sample of 66 individuals with chronic stroke, using Cronbach’s alpha. Participants were classified according to upper extremity motor function using the Fugl-Meyer Assessment – Upper Extremity (FMA-UE): mild to moderate hemiparesis (FMA-UE ≥ 32, n = 49) or severe hemiparesis (FMA-UE ≤31, n = 17). Internal consistency of the MAL-AOU and MAL-QOM was excellent among participants with mild-moderate hemiparesis (a = 0.95), and adequate to excellent among participants with severe hemiparesis (MAL-AOU: a = 0.79; MAL-QOM: a = 0.89). Rasch analysis was used to further evaluate reliability of the MAL-30. Item calibration of the MAL-AOU and MAL-QOM revealed one misfit (#19: Pull a chair toward table after sitting down). Item separation index of the MAL-AOU and MAL-QOM was 2.92 and 2.59 (respectively) suggesting 5 levels of difficulty for the MAL-AOU and 4 levels of difficulty for the MAL-QOM. Pearson separation index of the MAL-AOU and MAL-QOM was 2.62 and 2.58 (respectively), suggesting 4 ability levels for both the MAL-AOU and the MAL-QOM.

Test-retest:
Miltner et al. (1999) examined test-retest reliability of the MAL in a sample of 15 patients with chronic stroke. Measures were taken within a 2-week interval before participants began constraint-induced movement therapy. Test-retest reliability was excellent (r = 0.98).

Johnson et al. (2003) examined test-retest reliability of the MAL-45 in a sample of 12 patients with chronic stroke, using Pearson’s correlation coefficient. Measures were taken within a 3-week interval. Test-retest reliability was excellent for the MAL-AOU (r=0.96) and MAL-QOM (r = 0.99).

van der Lee et al. (2004) examined test-retest reliability of the MAL-14 in a sample of 56 patients with chronic stroke, using the Bland and Altman method. Measures were taken within a 2-week interval before participants commenced an intervention program. Test-retest reliability was excellent for the for MAL-AOU (r = 0.70 to 0.85) and the MAL-QOM (r = 0.61 to 0.71).

Uswatte et al. (2005b) examined test-retest reliability of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers, using Pearson correlation coefficients. Test-retest reliability was excellent for patient MAL-QOM scores (r = 0.91), and adequate for patient MAL-AOU scores (r = 0.44), and caregiver MAL-AOU and MAL-QOM scores (r = 0.61, r = 0.50 respectively).

Uswatte et al. (2006b) examined 2-week test-retest reliability of the MAL-30 in a sample of 116 patients with subacute/chronic stroke and their caregivers, using Intra Class Coefficients (ICC). Test-retest reliability for the MAL-AOU and MAL-QOM was excellent among patients (ICC = 0.79, ICC = 0.82, respectively), and adequate among caregivers (ICC = 0.66, ICC = 0.72, respectively). There was a trend toward an increase from test 1 to test 2 among both patients and caregivers (patient MAL-AOU: 0.3 ± 0.6, p = 0.04; patient MAL-QOM: 0.3 ± 0.5, p = 0.02; caregiver MAL-AOU: 0.4 ± 0.7, p = 0.05; caregiver MAL-QOM: 0.4 ± 0.7, p = 0.02), although increases were less than the minimal clinically important difference (< 0.5 points).

Huseyinsinoglu et al. (2011) examined 3-day test-retest reliability of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using intraclass coefficients (ICC) and Spearman correlation coefficients. Test-retest reliability was excellent for the MAL-AOU (ICC = 0.97, r = 0.94) and the MAL-QOM (ICC = 0.96, r = 0.93).

Saliba et al. (2011) examined test-retest reliability of the MAL (Brazilian version), using intra-class correlation coefficients (ICC). Test-retest reliability for the MAL-AOU and MAL-QOM was excellent (ICC = 0.98).

Taub et al. (2013) reported on test-retest reliability of the Grade 4/5 MAL, referencing unpublished data from Morris (2009) that used a sample of 10 individuals with stroke. Test-retest reliability for the Grade 4/5 MAL was excellent (r = 0.95).

Intra-rater:
No studies have reported on the intra-rater reliability of the MAL.

Inter-rater:
Uswatte et al. (2005b) examined inter-rater reliability of the MAL-14 in a sample of 41 patients with chronic stroke and their caregivers using Intra Class Coefficients (ICC). Participants received Constraint-Induced Movement Therapy (CIMT) or time-matched general fitness rehabilitation for two weeks. Reliability between patient and carer pre-treatment scores was adequate (ICC = 0.52, p < 0.01); reliability between patient and carer change scores following treatment was adequate (ICC = 0.7, p < 0.0001).

Validity

Content:

No studies have reported on content validity of the MAL.

Criterion:

Concurrent:
Johnson et al. (2003) examined concurrent validity of the MAL-45 in a sample of 12 patients with chronic stroke by comparison with the Abilhand, using Pearson correlation coefficients. Correlations with the Abilhand were excellent for the MAL-AOU (r = 0.71, p < 0.05) and MAL-QOM (r = 0.88, p < 0.05).

Uswatte et al. (2005b) examined concurrent validity of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke by comparison with accelerometry of the affected arm, using Pearson correlation coefficients. Correlations between the MAL-QOM and accelerometer recordings at pre-treatment (r = 0.70, p < 0.05) were excellent. Correlations between MAL-QOM change scores from pre-treatment to post-treatment and corresponding change scores on accelerometer readings were also excellent (r = 0.91, p < 0.01).

Lin et al. (2010a) examined concurrent validity of the MAL-30 by comparison with the Nine Hole Peg Test (9HPT), the Box and Block Test (BBT) and the Action Research Arm Test (ARAT), using Spearman rank correlation coefficients. Patients with chronic stroke (n=59) were randomized to receive distributed constraint-induced movement therapy, bilateral arm training or neurodevelopmental therapy, and measures were taken at baseline and post-treatment (3 weeks). Correlations at baseline and post-treatment were significant and adequate with the BBT (MAL-AOU: r = 0.37, r = 0.49; MAL-QOM: r = 0.52, r = 0.52) and the ARAT (MAL-AOU: r = 0.31, r = 0.32; MAL-QOM: r = 0.39, r = 0.35). Correlations with the 9HPT were significant for the MAL-QOM only (r = -0.26, r = -0.33).

Lin et al. (2010b) examined concurrent validity of the MAL-30 by comparison with the Stroke Impact Scale 3.0 (SIS) and the Stroke-Specific Quality of Life Scale (SS-QOL), using Spearman rank correlation coefficients. Patients with chronic stroke (n = 74) were randomized to receive distributed constraint-induced movement therapy, bilateral arm training or neurodevelopmental therapy, and measures were taken at baseline and post-treatment (3 weeks). There were significant poor to adequate correlations between the MAL-AOU and most SIS domains at baseline (r = 0.24-0.58) and post-treatment (r = 0.24-0.59). There were significant excellent correlations between the MAL-QOM and the SIS – Hand function domain at baseline (r = 0.65) and post-treatment (r = 0.68), and significant poor to adequate correlations between the MAL-QOM and most other SIS domains at baseline (r = 0.26-0.52) and post-treatment (r = 0.28-0.51). There were significant correlations between the MAL-AOU and some SS-QOL domains at baseline (r = 0.25-0.37) and post-treatment (r = 0.24-0.35), and between the MAL-QOM and some SS-QOL domains at baseline (r = 0.28-0.38) and post-treatment (r = 0.26-0.39).

Wu et al. (2011) examined concurrent validity of the MAL-30 in a sample of 77 patients with chronic stroke by comparison with a modified version of the Nottingham Extended ADL Scale (NEADL) and the Frenchay Activities Index (FAI), using Spearman rank correlation coefficients. Measures were taken at pre-treatment and 3 weeks later at post-treatment. Correlations with the NEADL were poor to adequate (MAL-AOU: r = 0.3; MAL-QOM: r = 0.2-0.3). Correlations with the FAI were adequate (MAL-AOU: r = 0.3-0.4); MAL-QOM: r = 0.3).

Khan et al. (2013) examined cross-sectional concurrent validity of the MAL-30 (German version) by comparison with the Wolf Motor Function Test (WMFT) – Time and Functional ability subtests, the Chedoke McMaster Stroke Assessment (CMSA) – Arm and Hand subtests, the grip strength scale, and isometric strength measured by handheld dynamometer (mean of shoulder and elbow flexion and extension), using Spearman’s rank correlation coefficients. Patients with acute to chronic stroke (n = 42) received inpatient rehabilitation and measures were taken at baseline; discharge from hospital and at 6-month follow-up. Significant negative correlations were seen with the WMFT – Time scores (MAL-AOU r = -0.747 – -0.878; MAL-QOM r = -0.770 – -0.901). Correlations were excellent at all time points with the WMFT – Functional ability (MAL-AOU r = 0.769 – 0.808, MAL-QOM r = 0.789 – 0.837), the CSMA – Arm (MAL-AOU r = 0.680 – 0.765; MAL-QOM r = 0.691 – 0.798) and CSMA – Hand (MAL-AOU r = 0.692 – 0.801; MAL-QOM r = 0.717 – 0.803), grip strength (MAL-AOU r = 0.698 – 0.716; MAL-QOM r = 0.659-.0733) and isometric strength (MAL-AOU r = 0.643-0.719; MAL-QOM r = 0.714-0.726).

Predictive:
No studies have examined predictive validity of the MAL.

Construct:

Uswatte et al. (2006b) conducted item analysis of the original MAL-30 using item-total correlations, reliability and proportion of missing data (with an a priori cut-off of 20%) in a sample of 222 patients with subacute/chronic stroke and their caregivers. Of the 30 items, 25 items were completed by > 80% of caregivers and 28 items were completed by > 80% of patients; analysis of these 28 items indicated item-total correlations > 0.5 for 92% of items, and reliability coefficients > 0.5 for 89% of items. The remaining 2 items (write on paper: 48% missing data; put makeup/shaving cream on face: 20% missing data) showed lower item-total correlations and reliability coefficients and were dropped accordingly.

van der Lee et al. (2004) examined construct validity of the MAL-14 in a sample of 56 patients with chronic stroke, using Spearman’s correlation coefficient. There was an excellent correlation between the MAL-AOU and MAL-QOM (r = 0.95, p < 0.001).

Uswatte et al. (2005b) examined construct validity of the MAL-14 (QOM scale only) in a sample of 27 patients with chronic stroke by comparison with patient/caregiver MAL-AOU scores, using Pearson correlation coefficients. Correlations were excellent between MAL-QOM change scores from pre-treatment to post-treatment and corresponding change scores in patient MAL-AOU (r = 0.80, p < 0.01), carer MAL-AOU (r = 0.73, p < 0.01) and carer MAL-QOM (r = 0.70, p < 0.01).

Uswatte et al. (2006a) examined construct validity of the MAL-30 in a sample of 169 individuals with subacute/chronic stroke, using Pearson correlation coefficient. There was an excellent correlation between the MAL-AOU and MAL-QOM (r = 0.92, p < 0.001).

Huseyinsinoglu et al. (2011) examined construct validity of the MAL-28 (Turkish version) in a sample of 30 patients with stroke, using Spearman’s correlation coefficient. The correlation between the MAL-AOU and the MAL-QOM was excellent (r = 0.95).

Saliba et al. (2011) examined construct validity of the MAL (Brazilian version) in a sample of 77 individuals with chronic stroke, using Rasch analysis. There was an excellent correlation between the MAL-AOU and the MAL-QOM (r = 0.97, p < 0.0001).

Khan et al. (2013) examined construct validity of the MAL-30 (German version), using Spearman’s rank correlation coefficients. Patients with acute to chronic stroke (n = 42) received inpatient rehabilitation and measures were taken at baseline, discharge from hospital and at 6-month follow-up. There was an excellent correlation between the MAL-AOU and MAL-QOM at all timepoints (r = 0.994, 0.982, 0.980).

Chuang et al. (2017) examined construct validity of the MAL-30 in a sample of 403 patients with chronic stroke with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and higher, using Rasch analysis. Correlation between the MAL-AOU and MAL-QOM was adequate (r = 0.603), indicating that the subscales are not highly correlated and can be perceived as different concepts.

Chuang et al. (2017) examined construct validity of the LF-MAL in a sample of 134 patients with chronic stroke with motor recovery of the proximal and distal upper limb at Brunnstrom stage III and lower, using Rasch analysis. Correlation between the LF-MAL-AOU and LF-MAL-QOM was adequate (r = 0.607), indicating that the subscales are not highly correlated and can be perceived as different concepts.

Convergent/Discriminant :
van der Lee et al. (2004) examined cross-sectional convergent validity of the MAL-14 by comparison with the Action Research Arm Test (ARAT) in a sample of 56 patients with chronic stroke, using Spearman’s correlation coefficient. There were excellent correlations between the MAL-AOU and the ARAT (r = 0.63, p < 0.001) and between the MAL-QOM and the ARAT (r = 0.63, p < 0.001).

Uswatte et al. (2005a) examined convergent validity of the MAL-14 in a sample of 20 patients with chronic stroke by comparison with accelerometry of the affected arm, using Spearman rank correlations. There was an excellent correlation between the MAL-14 and accelerometry (r = 0.74, p < 0.001).

Uswatte et al. (2006a) examined convergent validity of the MAL-30 (QOM scale only) in a sample of 169 patients with subacute/chronic stroke by comparison with accelerometry of the affected arm and the Actual Amount of Use Test (AAUT), using Pearson correlation coefficients. Correlations between the MAL-QOM and accelerometry ratios (ratio summary variable, impaired arm summary variable) were adequate (r = 0.52, r = 0.41 respectively, p < 0.001). The correlation between the MAL-QOM and AAUT was excellent (r = 0.94, p < 0.001).

Uswatte et al. (2006b) examined convergent validity of the MAL-30 in a sample of 222 patients with subacute/chronic stroke and their caregivers by comparison with accelerometry of the affected arm, and the SIS 2.0 – Hand function scale, using Pearson correlation coefficients. Comparison of the MAL with accelerometry ratios showed adequate to excellent correlations for patient scores (MAL-AOU: r = 0.47; MAL-QOM: r = 0.52, p < 0.01), and adequate correlations for caregiver scores (MAL-AOU: r = 0.57; MAL-QOM, r = 0.61, p < 0.01). Comparison of the MAL and SIS – Hand function scores showed excellent correlations for patient scores (MAL-AOU: r = 0.68; MAL-QOM: r = 0.72, p < 0.01), and adequate correlations for caregiver scores (MAL-AOU: r = 0.35, MAL-QOM: r = 0.40, p < 0.01).

Uswatte et al. (2006b) examined divergent validity of the MAL-30 in a sample of 222 patients with subacute/chronic stroke and their caregivers by comparison with accelerometry of the less affected arm, and the SIS 2.0 – Mobility scale, using Pearson correlation coefficients. Comparison of the MAL with accelerometry ratios of the less affected arm showed poor correlations for patient scores (MAL-AOU: r = 0.14; MAL-QOM: r = 0.14, p > 0.05), and poor to adequate correlations for caregiver scores (MAL-AOU: r = 0.25; MAL-QOM, r = 0.23, p < 0.001). Comparison of the MAL and SIS – Mobility scores showed poor correlations for patient scores (MAL-AOU: r = 0.14; MAL-QOM: r = 0.14, p > 0.05), and poor correlations for caregiver scores (MAL-AOU: r = 0.10, MAL-QOM: r = 0.07, p > 0.05).

Hammer and Lindmark (2010) examined cross-sectional convergent validity of the MAL-30 by comparison with the FMA-UE, ARAT, Motor Assessment Scale – Upper Extremity score (MAS-UE), 16-hole peg test (16HPT) and the Grippit ratio of isometric grip strength, using Spearman’s correlation coefficient. Patients with subacute stroke (n = 30) were randomized to receive forced use therapy or standard upper limb rehabilitation, and measures were taken at baseline, post-treatment (2 weeks) and follow-up (3 months). Correlations were significant and adequate with all measures: FMA-UE (r = 0.43-0.52); ARAT (r = 0.31-0.51); MAS-UE (r = 0.41-0.54); 16HPT (r = -0.41 – -0.67); Grippit (r = 0.41-0.53).

Huseyinsinoglu et al. (2011) examined convergent validity of the MAL-28 (Turkish version) by comparison with the WMFT – Performance Time (WMFT-PT) and – Functional Ability (WMFT-FA) scores in a sample of 30 patients with stroke. There were excellent correlations with the WMFT-FA (MAL-AOU, r=0.63; MAL-QOM: r = 0.63), and adequate negative correlations with the WMFT-PT (MAL-AOU: r = -0.56; MAL-QOM: r = -0.55).

Saliba et al. (2011) examined convergent validity of the MAL (Brazilian version) by comparison with grip strength of the more severely affected upper limb in a sample of 77 individuals with chronic stroke, using Rasch analysis. There were adequate correlations between grip strength and the MAL-AOU (r = 0.51, p < 0.0001) and the MAL-QOM (r =0 .57, p < 0.0001).

Sterr et al. (2014) examined divergent validity of the MAL in a sample of 65 patients with chronic stroke by comparison with the Short Form 36 (SF-36), Stroke Impact Scale (SIS), Hospital Anxiety and Depression Scale (HADS) and Visual Analog Mood Score (VAMS), using regression analysis. Participants received four different Constraint-Induced Movement Therapy (CIMT) treatment protocols that differed in intensity and use of a constraint. Following treatment there was a significant positive association between the MAL-AOU and the SF-36 Physical domain (r = 0.38m p = 0.025) and a trend towards a moderate association with the SIS Total score (r = 0.43, p = 0.061).

Shindo et al. (2015) examined convergent validity of the MAL-14 in a sample of 34 patients with acute/subacute stroke by comparison with the Simple Test for Evaluating Hand Function (STEF), using Spearman’s correlation coefficient. There was a significant and excellent correlation between the assessments (MAL-AOU: r = 0.805; MAL-QOM: r = 0.768).

Simpson, Conroy & Beaver (2015) examined convergent validity of the MAL-28 in a sample of 9 patients with stroke, by comparison with the FMA, Wolf Motor Function Test and Stroke Impact Scale, using Spearman’s correlation coefficient. There were excellent correlations between baseline MAL-AOU and FMA (ρ = 0.6889, p < 0.0132) and MAL-QOM and FMA (ρ = 0.7276, p < 0.0073).

Moreira Silva et al. (2018) examined convergent validity of the MAL-30 in a sample of 66 individuals with chronic stroke by comparison with the FMA-UE, using Spearman’s correlation coefficient. There was a significant and excellent correlation with the FMA-UE (MAL-AOU: r = 0.87; MAL-QOM: r = 0.87).

Chen et al. (2018) examined convergent validity of the MAL in a sample of 82 patients with stroke by comparison with accelerometry of the affected arm, using Pearson’s correlation coefficient. There was an adequate correlation with accelerometry (MAL-AOU: r = 0.47; MAL-QOM: r = 0.57).

Known Group:
Uswatte et al. (2006b) examined known-group validity of the MAL in a sample of 222 patients with subacute/chronic stroke and their caregivers. Correlations between the MAL and accelerometry ratio was stronger among patients with paresis of their dominant arm (MAL-AOU: r = 0.56; MAL-QOM: r = 0.59) than among patients with paresis of the non-dominant arm (MAL-AOU: r = 0.28; MAL-QOM: r = 0.34).

Responsiveness

Taub et al. (1993) reported on Effect sizes (ES) of the MAL in a sample of 9 patients with chronic stroke. Participants received two weeks of upper extremity restraint and measures were taken at baseline, post-treatment and follow-up (1 month, 2 years). Effect sizes were large from baseline to 1-month follow-up (2.80) and from baseline to 2-year follow-up (2.95).

Kunkel et al. (1999) reported on ES of the MAL in a sample of 5 patients with chronic stroke. Participants received two weeks of Constraint-Induced Movement Therapy (CIMT) and measures were taken at baseline, post-treatment and follow-up (3 months). Effect sizes were large from baseline to post-treatment (MAL-AOU: 9.57; MAL-QOM: 3.24), and from baseline to 3-month follow-up (MAL-AOU: 7.59; MAL-QOM: 1.99).

Taub et al. (1999) reported on ES of the MAL in a sample of patients with stroke who received CIMT and reported a large effect size for lower-functioning individuals (n = 11, d = 4.0) and higher functioning individuals (n = 40, d = 3.3). The ES was larger for lower-functioning patients due to lower variability in scores from baseline to post-treatment.

Miltner et al. (1999) reported on ES of the MAL in a sample of 15 patients with chronic stroke. Participants received two weeks of CIMT and measures were taken at baseline, post-treatment and follow-up (4 weeks and 6 months). Effect sizes were large from first contact to post-treatment (MAL-AOU: 2.07; MAL-QOM: 1.33), from first contact to 4 weeks post-treatment (MAL-AOU: 2.98; MAL-QOM: 1.70), and from first contact to 6-month follow-up (MAL-AOU: 2.68; MAL-QOM: 2.14).

van der Lee et al. (1999) reported on ES of the MAL in a sample of 66 patients with chronic stroke. Participants were randomly assigned to receive forced manual therapy or bimanual training based on neurodevelopmental techniques for two weeks. A 25-item modified version of the MAL was used. There were no significant between-group differences in MAL-QOM scores following treatment. There was a significant difference in MAL-AOU scores, in favour of forced use therapy. The mean difference in gain was 0.52 points (95% CI, 0.11-0.93). Improvements exceeded the Minimal Clinically Important Difference of 0.50 within both groups. The treatment effect was clinically relevant for patients with hemineglect.

van der Lee et al. (2004) examined responsiveness and longitudinal construct validity of the MAL-14 in a sample of 56 patients with chronic stroke who were randomized to receive CIMT or bimanual training for a 2-week intervention period. Responsiveness was measured by responsiveness ratios (RR). Results showed adequate responsiveness for the MAL-AOU and MAL-QOM (RR = 1.9, 2.0 respectively). Longitudinal validity was measured by comparing MAL change scores with the Action Research Arm Test (ARAT) change scores and a global change rating (GCR), using Spearman’s correlation coefficient. Change scores between measures were not significant nor highly correlated (MAL-AOU vs. ARAT: r = 0.16, p = 0.23; MAL-QOM vs. ARAT: r = 0.16, p = 0.25; MAL-AOU vs. GCR: r = 0.20, p = 0.15; MAL-QOM vs. GCR: r = 0.22, p = 0.10).

Uswatte et al. (2005b) examined responsiveness of the MAL-14 in a sample of 41 patients with chronic stroke who received CIMT or time-matched general fitness rehabilitation, and their caregivers. Responsiveness was measured by responsiveness ratios (RR). Results showed high responsiveness for patient scores (MAL-AOU: 3.2; MAL-QOM: 4.5), and caregiver scores (MAL-AOU: 4.3; MAL-QOM: 3.0).

Uswatte et al. (2005b) examined responsiveness of the MAL-14 in a sample of 27 patients with chronic stroke who received an automated form of constraint-induced movement therapy (AutoCITE) or general fitness rehabilitation. Responsiveness was measured by responsiveness ratios; results showed high responsiveness for the MAL-AOU and MAL-QOM (RR = 3.8, 5.0, respectively).

Hammer and Lindmark (2010) examined responsiveness and longitudinal construct validity of the MAL-30 in a sample of 30 patients with subacute stroke who were randomized to receive forced use therapy or standard upper extremity rehabilitation. Responsiveness was measured according to effect size (ES), standard response means (SRM) and responsiveness ratios (RR) from baseline to post-treatment (2 weeks), and from baseline to follow-up (3 months). Effect sizes for the MAL-AOU and MAL-QOM were moderate to large from baseline to post-treatment (MAL-AOU: 0.51; MAL-QOM: 0.54) and from baseline to follow-up (MAL-AOU: 1.02; MAL-QOM: 1.17), indicating sensitivity to change. Standard response means were large from baseline to post-treatment (MAL-AOU: 1.28; MAL-QOM: 1.03), and from baseline to follow-up (MAL-AOU: 1.14; MAL-QOM: 1.19). The greater SRM compared to ES reflects smaller variability in change scores than baseline scores. Responsiveness ratios were large from baseline to post-treatment (MAL-AOU: 1.22; MAL-QOM: 1.23) and from baseline to follow-up (MAL-AOU: 2.44; MAL-QOM: 2.69). Longitudinal construct was measured by comparison with the FMA-UE, ARAT, Motor Assessment Scale – Upper Extremity score (MAS-UE), 16-hole peg test (16HPT) and the Grippit ratio of isometric grip strength, using Spearman’s correlation coefficient. Correlations with the MAS-UE were significant and adequate from baseline to follow-up (MAL-AOU r = 0.53, MAL-QOM r = 0.47); and with the FMA-UE from baseline to post-treatment (MAL-AOU r = 0.44, MAL-QOM r = 0.67) and from baseline to follow-up (MAL-AOU r = 0.39, MAL-QOM r = 0.43).

Khan et al. (2013) examined responsiveness of the German MAL-30 in a sample of 42 patients with acute to chronic stroke, using standard response mean (SRM). Participants were stratified into two groups according to level of arm and hand function using the Chedoke McMaster Stroke Assessment (CSMA). Measures were taken at baseline, discharge from rehabilitation and 6-month follow-up. Change scores from the lower-function group (CSMA arm and hand score ≤ 6) revealed high responsiveness of the MAL-AOU and MAL-QOM from baseline to discharge (SRM = 0.93, 0.94 respectively) and baseline to follow-up (SRM = 0.95. 0.98 respectively), but poor from discharge to follow-up (SRM = 0.20, 0.42 respectively). Change scores from the high-function group (CSMA arm and hand score > 6) showed high responsiveness of the MAL-AOU and MAL-QOM from baseline to discharge (SRM = 1.43, 1.31 respectively) and from baseline to follow-up (SRM = 1.34, 1.33, respectively), but poor responsiveness from discharge to follow-up (SRM = 0.22, 0.24 respectively). The authors concluded that the MAL is a responsive measure when the intervention period is included in the measured time interval.

Simpson & Eng (2013) conducted a literature review of upper limb assessments commonly used in stroke rehabilitation, including the MAL. In studies that measured outcomes following CIMT, the observed change (i.e. patients’ perceptions of change, effect size) was 1.6-6.2 times larger than measures of functional change such as the ARAT or WMFT. Similarly, assessments which measure perceived function in the individual’s environment require larger percentage changes than laboratory-based performance measures to surpass the measurement error. Minimal Detectable Change for the MAL-AOU ranged from 72.5% to 86.7% (90% and 95% confidence levels).

Taub et al. (2013) reported on effect size (ES) of the Lower Functioning MAL (LF-MAL) in a sample of 6 individuals with chronic stroke who used orthotics/splints and adaptive equipment outside the laboratory over 6 sessions (Phase A), then received mCIMT + neurodevelopmental therapy for 15 consecutive weekdays with continued use of assistive devices (Phase B). Effect sizes were calculated from (i) baseline to pre-mCIMT; (ii) pre-mCIMT to post-mCIMT; and (iii) baseline to post-mCIMT and were large at all timepoints (ES = 2.6, 2.1, 3.0, respectively, p < 0.002).

Sterr et al. (2014) reported on treatment effect in a sample of 65 patients with chronic stroke. Participants received four different CIMT treatment protocols that differed in intensity and use of a constraint. Whole-group analysis showed a significant and large treatment effect from baseline to post-treatment (MAL-AOU: d = 1.19; MAL-QOM: d = 1.38); the treatment effect from post-treatment to 6-month follow-up was small but significant for the MAL-AOU only (d = 0.4). Treatment effect was not significant at 12-month follow-up. There was a significant positive association between training intensity and improvement in MAL-AOU scores.

Sensitivity & Specificity:
Chen et al. (2012) examined minimal detectable change (MDC) of the MAL. This study used data from the EXCITE trial, in which 222 patients with subacute/chronic stroke who were randomized to receive constraint induced movement therapy (CIMT) for 2 weeks (n = 106) or no treatment (n = 116). MDC with 90% confidence intervals was calculated from pre-post test data from the control group. The MDC of the MAL-AOU was 16.8% (Standard Error of the Mean 7.2%), indicating that a change in amount of use of the affected upper limb greater than 16.8% is required so as to be 90% certain that the change is not due to measurement error. The MDC (90% CI) for the MAL-QOM was 15.4% (SEM 6.6%), indicating higher sensitivity than the MAL-AOU scale. After treatment, the CIMT group showed an 84.6% increase in MAL-AOU scores and a 72.2% increase in MAL-QOM scores. Both MAL scores exceeded the MDC and were sensitive to change in the context of this intervention.

Simpson, Conroy & Beaver (2015) examined sensitivity of the MAL-28 in a sample of 9 patients with stroke, by comparison with the Fugl-Meyer Assessment, the Wolf Motor Function Test and Stroke Iimpact Scale. Measures were taken at baseline, post-treatment and follow-up, and correlations were analysed using Spearman’s correlation coefficient. Changes in MAL-AOU scores were sensitive to changes in SIS physical domain scores (ρ = 0.7342, p < 0.0243). Changes in MAL-QOM scores were sensitive to changes in WMFT Functional Ability scores (ρ = 0.6245, p < 0.0722).

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How to obtain the Motor Activity Log?

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