Motor Assessment Scale (MAS)

Evidence Reviewed as of before: 07-11-2010
Author(s): Lisa Zeltzer, MSc OT
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

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 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).

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 activities

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 analysis to examine the validity of the scoring hierarchies for the Upper Arm Function, Hand Movements and Advanced Hand Activities’ subscales and found that only the Upper Arm Function subscale 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 Activities subscale. For example, some studies have reported that patients who could complete the most difficult task of the Advanced Hand Activities 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 stroke, the MMAS demonstrated acceptable inter-rater reliability. 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 reliability and validity (Cronbachs alpha = 0.83; Spearmans rho = 0.70) (Lannin, 2004; Hsueh & Hsieh, 2002).

Client suitability

Can be used with:

  • Patients with stroke.

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 Stroke (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 stroke
Is this a screening 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
Reliability
  • No studies have examined the internal consistency of the MAS.
  • Only 1 study has examined the test-rest reliability of the MAS, reporting excellent test-retest.
  • No studies have examined the intra-rater reliability of the MAS.
  • Out of 2 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).

  • No studies have examined the internal consistency of the MAS.
  • Only 1 study has examined the test-rest reliability of the MAS, reporting excellent test-retest.
  • No studies have examined the intra-rater reliability of the MAS.
  • Out of 2 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).
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 aphasia, we recommend administering the Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (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 analysis to examine the validity 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 subscale 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 analysis 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 consistency:
No studies have examined the 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 reliability of the MAS.

Inter-rater:
Carr et al. (1985) selected 5 patients at various stages of recovery for inter-rater reliability 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 reliability, 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 reliability of the MAS in 24 patients with stroke. Two examiners observed and scored each subject independently. The inter-rater reliability 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 validity of the MAS in comparison to the Fugl-Meyer Assessment early after stroke 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 validity 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 validity 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 validity of a new scale, the Mobility Scale for Acute Stroke Patients with other established scales (MAS, Functional Ambulation Classification system, Functional Independence Measure, Barthel Index). Mobility items from the Mobility Scale for Acute Stroke Patients had an excellent correlation with corresponding items on the MAS (r = 0.89), demonstrating the convergent validity of the MAS.

Tyson and DeSouza (2004) examined the convergent validity 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 validity 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 stroke rehabilitation after an average of 71 days of rehabilitation.

Nugent, Schurr and Adams (1994) found an adequate 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 responsiveness of the MAS in 61 rehabilitation inpatients with stroke. The ability of the MAS to detect change was limited in this sample. The MAS item 5 (walking) showed a large effect size (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.

Table of contents
We need your feedback