Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES)

Evidence Reviewed as of before: 08-09-2015
Author(s): Annabel McDermott, OT
Editor(s): Annie Rochette, PhD OT
Expert Reviewer: Prof. Ann Van de Winckel, PhD, MSc, PT
Content consistency: Gabriel Plumier

Purpose

The MESUPES measures quality of movement performance of the hemiparetic arm and hand in stroke patients. Authors of the assessment are Perfetti & Dal Pezzo (original version of the scale) and Ann Van de Winckel, PhD, MSc, PT (final version of the scale). The original publication of the final version of the scale is by Van de Winckel et al. (2006).

In-Depth Review

Purpose of the measure

The MESUPES measures quality of movement performance of the hemiparetic arm and hand in stroke patients.

Available versions

The original version of the MESUPES comprised 22 items within three categories of arm function (10 items), hand function (9 items) and functional tasks (3 items).

The final version of the measure, analyzed with Principle Component Analysis and Rasch analysis resulted in a 17-item version with two categories of arm function (8 items) and hand function (“range of motion” 6 items; and “orientation during functional tasks” 3 items) (Van de Winckel et al., 2006).

Features of the measure

Items

The original MESUPES is comprised of 22 items in three subscales:

  1. Arm function: 10 items
  2. Hand function: 9 items
  3. Functional tasks: 3 items

The final version of the MESUPES is comprised of 17 items in two subscales:

  1. MESUPES–Arm function: 8 items with 6 response categories (0-5)
  2. MESUPES–Hand function: 9 items with 3 response categories (0-2).

During the MESUPES–Arm subset, patients are required to perform specific movements of the upper limb in three consecutive phases:

  1. The task is performed passively
  2. The therapist assists the patient during the movement
  3. The patient performs the task by him/herself.

During the MESUPES–Hand subsets, patients are instructed to perform specific movements of the hand and fingers by themselves.

Scoring

As the MESUPES adopts an ordinal scale, Rasch analysis has been performed to translate ordinal data into interval measures (logit scores) (Van de Winckel et al., 2006).

Online scoring will soon be available to enable users to input the ordinal scores and retrieve logits scores immediately (personal correspondence, Van de Winckel, 2015).

Subset 1: Arm function

The MESUPES–Arm subset evaluates ‘normal’ movement of the hemiparetic limb, which can be judged by comparison with movement of the patient’s unaffected arm. Only qualitatively ‘normal’ movements of the arm are scored.

The tasks are performed in three phases. The number of phases evaluated depends on the level of ability the patient has, to perform the movement correctly.

Testing phase Points achieved
1. The therapist moves the patient’s arm and hand and evaluates muscle tone first.
No adequate adaptation of tone to movement: 0 points
Adequate adaptation of tone (normal tone) to at least part of the movement: 1 point
2. If the patient exhibits normal tone, the patient participates in the movement and the therapist evaluates muscle contractions.
The patient demonstrates functionally and qualitatively correct muscle contraction in at least part of the movement: 2 points
3. If the patient exhibits normal muscle contraction, the patient performs the movement independently and the therapist assesses range of movement.

A score is given for the range of motion that the patient can perform with good quality of motion.

Part of the movement is performed normally: 3 points
Total range of normal movement is done slowly or with great effort: 4 points
The patient demonstrates normal movement performance: 5 points

The patient is allowed to repeat test items with a maximum of three attempts; the patient is awarded the highest score achieved. See the measure for more scoring information.

Subset 2: Hand function (Range of Motion)

Performance of movement and measurement of range of motion is not compared with the unaffected hand for this subset. Only qualitatively normal movements of the hand and fingers are scored.

Testing procedure Points achieved
The patient performs the instructed movement actively and the therapist assesses range of movement between 0-2cm qualitatively and quantitatively. 0-2 points
no movement: 0 points
movement amplitude < 2 cm 1 point
movement amplitude ≥ 2 cm 2 points

Subset 3: Hand function (Orientation during functional tasks)

Quality of movement is not compared with the unaffected hand for this subset.

Testing procedure Points achieved
The patient manipulates materials as instructed and the therapist assesses whether the patient is able to orient the wrist and fingers to the object throughout the movement in a normal way. 0-2 points
no movement or movement with abnormal orientation of fingers and wrist towards the object: 0 points
movement with normal orientation of fingers or wrist towards the object: 1 point
whole movement correct: 2 points

The maximum achievable score is 58 (MESUPES-Arm maximum score is 40; MESUPES-Hand maximum score is 18). The patient is awarded one score for each task, and the highest score is retained. A score of 0 is awarded when the patient demonstrated inadequate tone, abnormal muscle contractions, synergic (flexor/extensor) or mass movement patterns (Appendix 2, Instructions, Van de Winckel et al. , 2006).

What to consider before beginning

The first four items are performed in supine; all other items are performed in a sitting position with hips and knees at 90 degrees and elbows resting on the table. The patient can be provided support to maintain a sitting position if required. The patient cannot be assessed (and therefore awarded a point) if he/she is not able to sit in an upright position for a task. The therapist can reposition the patient’s upper extremity before beginning each new task, and should wait until the tone is normalized before starting a new task. If the patient is not able to achieve a relaxed starting position, he/she is awarded a score of 0 for the item.

The patient must be given clear instructions using the following steps:

  1. The therapist explains the task verbally and demonstrates the movement
  2. The patient is asked to perform the task with the non-affected side first to ensure he/she understands the demands of the task.

Time

It takes approximately 10 minutes to administer the evaluation (between 5min for patients with very poor or very good motor impairment – about 15min for patients with more severe hypertonia).

Training requirements

Instructions are given in Appendix 2 (Van de Winckel et al., 2006) and are available here online. These instructions should suffice for trained clinicians (physical therapists, occupational therapists etc).

For the original evaluation, seven raters were trained for an hour to familiarize them with the assessment protocol (Van de Winckel et al., 2006). In Johansson & Hager’s study (2012), raters underwent a 2h training session.

An instructional video will soon be made available online. In the meantime, the developer of the MESUPES (Prof. Ann Van de Winckel, avandewi@umn.edu) can be contacted to address questions concerning the use of the MESUPES.

Equipment

  • Plinth or mat
  • Desk and chair, positioned so that the patient is sitting with hip and knees in 90 degrees flexion
  • Wooden or plastic block marked with 1cm and 2cm to measure range of movement during hand tasks
  • One larger and one smaller plastic bottle (cylinder; diameter 6 cm, like a 20fl oz or 591ml soda or water bottle)
  • One smaller plastic bottle (cylinder, diameter 2.5cm, height 8cm, like a round correction fluid bottle, as shown in the figure)
  • Dice (1.5 x 1.5 cm)

Client suitability

Differential item functioning was performed with Rasch analysis to test the stability of item hierarchy (from easy to difficult items) on several variables.

There is no differential item functioning across subgroups of gender, age (<60 / ≥60 years), time since stroke (< 3 months / ≥ 3 months), country of residence, side of lesion and type of stroke (hemorrhagic, ischemic) (Van de Winckel et al. 2006), meaning that the hierarchy of items (from easy to difficult) is maintained across all stroke patients groups with the above mentioned variables.

Can be used with:

  • Individuals with stroke

Should not be used with:

  • The measure is intended for use with adult patients with stroke; there is insufficient evidence regarding psychometric properties of the tool with other populations, including a pediatric population.

In what languages is the measure available?

  • Catalan (available online, Van de Winckel A, 2015)
  • Dutch (Flemish) (available online, Van de Winckel, A., 2015)
  • English (available online, Van de Winckel et al., 2006)
  • French (available online, Van de Winckel A, 2015)
  • German (available online, Van Bellingen, T., Van de Winckel, A., et al. 2009. Chapter 1: Assessment in Neurorehabilitation. In Neurology (2nd ed.) (192-201). Huber.
  • Italian – (available online, Van de Winckel A, 2015) (Perfetti & Dal Pezzo, original version)
  • Portuguese (available online, Van de Winckel A, 2015)
  • Spanish (available online, Van de Winckel A, 2015)
  • Swedish (available online, Johansson & Hager, 2012)/li>

Summary

What does the tool measure? The MESUPES measures quality of movement performance of the hemiparetic arm and hand in patients with stroke.
What types of clients can the tool be used for? The MESUPES was developed for use with adults with stroke.
Is this a screening or assessment tool? Assessment tool
Time to administer 10 minutes (range 5-15min)
ICF Domain
  • Body function/structure
  • Activity

Versions Final version (Van de Winckel et al., 2006) = 17 items (total score /58; MESUPES-arm score /40; MESUPES-hand score /18)
Languages

Available online on StrokEngine:

  • Catalan
  • Dutch (Flemish)
  • English
  • French
  • German
  • Italian
  • Portuguese
  • Spanish
  • Swedish
Measurement Properties
Reliability

Internal consistency

One study has reported on the internal consistency of the MESUPES using Principal Component Analysis and Rasch analysis. Results showed high person separation indices and unidimensionality within subtests.

Intra-rater

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

Inter-rater

Two studies have reported on the inter-rater reliability of the MESUPES in patients with subacute to chronic stroke and reported good to very good agreement between raters for subtests; moderate to very high item reliability; and sufficient absolute reliability of the total score.

Test-retest reliability

Two studies have reported on the test-retest reliability of the MESUPES in patients with subacute to chronic stroke and reported good to very good agreement over 24-48 hours.

Validity

Content

One study investigated validity of the 17-item MESUPES and reported unidimensionality of the arm and hand scales.

Criterion

Predictive Validity

No studies have reported on predictive validity of the MESUPES.

Concurrent Validity

One study examined concurrent validity of the MESUPES and reported high correlations with the Modified Motor Assessment Scale (MMAS).

Construct

Known Groups

No studies have reported on known group validity of the MESUPES.

Convergent/Discriminant Validity

No studies have reported on convergent/discriminant validity of the MESUPES.

Floor/Ceiling Effects No studies have reported on the floor/ceiling effects of the MESUPES.
Does the tool detect change in patients?
  • No studies have reported on the sensitivity or specificity of the MESUPES.
  • 1 study reported MDC scores of 8, 7 and 5 (95%, 90% and 80% CI, respectively)
Acceptability Administration of the MESUPES is easy and fast. The measure is inexpensive and requires minimal standard equipment.
Feasibility The MESUPES requires no specialized training to administer. However, the MESUPES should only be administered by clinicians with knowledge of stroke and clinical assessment of tone, muscle contraction and movement.
How to obtain the tool? See the measure

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the MESUPES. Two English studies were identified.

Floor and ceiling effect

No studies have reported on the floor or ceiling effects of the MESUPES.

Van de Winckel (personal correspondence, 2015) noted that in the study by Van de Winckel et al. (2006) in which 396 patients with low to high motor performance following stroke were assessed using the MESUPES less than 5% of patients achieved a score of 0 on the arm items and less than 20% of participants achieved the maximum score. Approximately 42% of participants achieved a score of 0 on the hand items and less than 5% of patients achieved a maximum score on the hand items.

Reliability

Internal consistency
Van de Winckel et al. (2006) examined internal consistency of the MESUPES in a sample of patients with stroke using Principal Component Analysis and Rasch analysis. Rasch analysis was used to determine ‘item-trait interaction’, which shows the degree of invariance across the intended dimension, and ‘person separation index’. Internal consistency was obtained when the MESUPES was divided into the MESUPES-Arm (8 items) and MESUPES-Hand (9 items) subtests. Rasch analysis and fit statistics showed that both subtests adhered to unidimensional characteristics, whereby all items in the subtests pertain to the same construct. The person separation index was 0.99 for the MESUPES-Arm and 0.97 for the MESUPES-Hand, indicating very high internal consistency.

Inter-rater
Van de Winckel et al. (2006) investigated inter-rater reliability of the MESUPES in a sample of 56 patients with subacute to chronic stroke. Assessments were conducted by 2 assessors over 24 hours. Inter-rater reliability, calculated using intra-class correlation coefficients (ICCs) was excellent for the arm function total score (ICC=0.95, 95% CI 0.91-0.97) and hand function total score (ICC=0.97, 95% CI 0.95-0.98). Assessment of inter-rater reliability by weighted percentage agreement and weighted kappa confirmed item reliability for the arm function subtest (weighted kappa coefficient = 0.62-0.79; weighted percentage agreement 85.71-98.21); scores were not derived for hand function items as more than 50% of the sample scored 0.

Johansson & Hager (2012) investigated inter-rater reliability of the MESUPES in a sample of 42 patients with subacute to chronic stroke. Assessments were conducted by 2 therapists within 48 hours. Inter-rater reliability, calculated by percentage agreement using linear-weighted kappa analysis revealed good to very good agreement between raters (kappa range 0.63-0.96). Relative and absolute reliability was measured using intra-class correlation coefficients (ICCs) and standard error of measurement (SEM): item reliability was moderate to very high (ICC=0.63-0.96); reliability of subscores and the total score was very high (ICC=0.98, 95% CI 0.96=0.99); and the total score demonstrated sufficient absolute reliability (SEM=2.68).

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

Test-retest
See inter-rater reliability above for results also pertaining to test-retest reliability.

Validity

Content

The original version of the MESUPES developed by Perfetti & Dal Pezzo comprised 22 items across three categories of (i) arm function (10 items); (ii) hand function (9 items); and (iii) functional tasks (3 items).

Van de Winckel et al. (2006) investigated validity and unidimensionality of the MESUPES in a sample of 396 patients with subacute to chronic stroke. Principle Component Analysis (PCA) of the original 22-item version revealed two dimensions: arm function and hand function. Rasch analysis of these two separate scales identified misfit among five items (respectively 2 arm items and 3 hand items). Following removal of these items, subsequent Rasch analysis of the remaining 17 items and fit statistics confirmed unidimensionality of both arm and hand scales:

Person fit Item fit Person separation index
Arm function -0.51±1.19 -0.65±1.07 0.99
Hand function -0.12±0.71 0.15±1.21 0.97

Test items followed an order of increasing difficulty with no reversed thresholds and no differential item functioning (DIF) according to gender, age (<60, ≥60), side of hemiparesis, time since stroke (< 3 months, ≥ 3 months), type of stroke or country (Van de Winckel et al., 2006).

Criterion

Predictive
No studies have reported on the predictive validity of the MESUPES.

Concurrent
Johansson & Hager (2012) investigated concurrent validity of the MESUPES in a sample of 42 patients with subacute to chronic stroke by comparison with the Modified Motor Assessment Scale (MMAS), using Spearman’s rho. Correlations were high between the MESUPES total scores and the MMAS (r=0.87); MESUPES arm items and MMAS (r=0.84); and MESUPES hand items and MMAS (r=0.80).

Construct

Known Group Validity
No studies have reported on the known group validity of the MESUPES.

Convergent/Discriminant Validity

No studies have reported on convergent/discriminant validity of the MESUPES.

Responsiveness

Johansson & Hager (2012) assessed minimal detectable change (MDC) of the MESUPES with a sample of 42 patients with subacute to chronic stroke. Patients were assessed at two time points 48 hours apart. The authors reported change scores of 8, 7 and 5 (95%, 90% and 80% confidence intervals, respectively) were required for certainty of true change.

Sensitivity & Specificity
No studies have reported on sensitivity/specificity of the MESUPES.

References

  • Johansson, G.M. & Hager, C.K. (2012). Measurement properties of the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES). Disability & Rehabilitation, 34(4):288-94. DOI: 10.3109/09638288.2011.606343
  • Van de Winckel, A., Feys, H., van der Knaap, S., Messerli, R., Baronti, F., Lehmann, R., Van Hemelrijk, B., Pante, F., Perfetti, C., & De Weerdt, W. (2006). Can quality of movement be measured? Rasch analysis and inter-rater reliability of the Motor Evaluation Scale for Upper Extremity in Stroke Patients (MESUPES). Clinical Rehabilitation, 20, 871-84.

See The Measure

How to obtain the MESUPES

Click on the language below:

Please click here for an instructional video on how to use the scale.

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