Rivermead Motor Assessment (RMA)

Purpose

The Rivermead Motor Assessment (RMA) assesses the motor performance of patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and was developed for both clinical and research use.

In-Depth Review

Purpose of the measure

The Rivermead Motor Assessment (RMA) assesses the motor performance of patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and was developed for both clinical and research use.

Available versions

The RMA was developed by Lincoln and Leadbitter in 1979.

Features of the measure

Items:

The RMA consists of test items in three sections that are ordered hierarchically, that is, the first items are easier and become increasingly more difficult toward the end of the evaluation.

The three sections test:

• Gross function (13 items)

(e.g. walking with and without out an aid, negotiating stairs with and without the rail, walking, turning and retrieving an object, and running).

• Leg and trunk movements (10 items)

(e.g. standing on one leg and flexing the knee in a weight bearing position).

• Arm movements (15 items)

(e.g. control items such as pronating/supinating the forearm and bouncing a ball, and functional items such as cutting putty, grasping and releasing objects, and tying a bow).

The items are scored as pass or fail. Traditionally, when three consecutive attempts to complete an item are failed within a given subsection, the test is stopped as it is assumed that all subsequent items in the subsection will also be failed, so not all items in the section need to be administered (known as ‘Guttman scaling’). However, recent studies suggest that the hierarchical ordering of the items in all three subscales differ from that proposed by the developers (Adams, Ashburn, Pickering & Taylor, 1997; Adams Pickering, Ashburn & Lincoln, 1997; Kurtais et al., 2009) and as a result, it has been recommended that all items in each of the subscales be administered. In an effort to avoid over-burdening patients and to reduce administration time, the ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." of three consecutive failures should be applied (Kurtais et al., 2009).

For patients with an additional disability, for example, an amputation, the principle of stopping after 3 consecutive errors should not be applied (Lincoln & Leadbitter, 1979).

As an example of the RMA items and Guttman scaling, below are the items for the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the RMA.

Can the patient:

1. Sit unsupported (without holding on edge of bed feet unsupported)

2. Transfer from lying to sitting on side of bed (using any method)

3. Transfer from sitting to standing

4. Transfer from wheelchair to chair towards unaffected side (may use hands)

5. Transfer from wheelchair to chair towards affected side (may use hands)

6. Walk 10 meters indoors with an aid (any walking aid, no standby help)

7. Climb flight of stairs independently (any method, may use banister and aid)

8. Walk 10 meters indoors without an aid (no standby help or walking aid)

9. Walk 10 meters, pick up beanbag from floor, turn and carry back (may use aid to walk)

10. Walk outside 40 meters (may use walking aid, no standby help)

11. Walk up and down 4 steps (may use any aid but may not hold on to railing)

12. Run 10 meters (must be symmetrical)

13. Hop on affected leg 5 times on the spot (must hop on ball of foot without stopping to regain balance, no help with arms)

Scoring:

Each item on the RMA is coded 0 or 1, depending on whether the client does the activity according to specific instructions. A score of 0 = a ‘no’ response; a score of 1 = a ‘yes’ response. Each subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
is scored by summing the points allocated for all items within that subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
.

If a patient refuses to perform an item (e.g. out of anxiety), score a ‘0’ for that item.

Time:

The ambulatory client with a recovering upper extremity takes approximately 45 minutes to assess; more severely disabled patients take less time (Lincoln & Leadbitter, 1979).

Subscales:

The RMA has three subscales: Upper Limb/Extremity (‘Arm’); Lower Limb/Extremity (‘Leg’) and Trunk; Gross Function.

Equipment:

• Block of 20 cm height
• Pencil
• Volleyball
• Tennis ball
• Piece of paper
• Fork and knife
• Plate and container (use box of putty as container)
• Beanbag
• Cord
• Putty
• Watch with chronometer
• Non-slip mat

Training:

No specialized training is required to administer the RMA. However, the RMA should be administered by a physiotherapist with knowledge on how to safely manage those with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. The RMA is a risky assessment where a patient could fall if not supervised by someone with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. expertise.

Alternative forms of the Rivermead Motor Assessment

The Rivermead Mobility Index (RMI) (Collen, Wade, & Bradshaw, 1991).

The RMI was developed from the RMA Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
. This measure focuses on body mobility and is comprised of a series of 14 questions and one direct observation. The RMI covers a range of activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
from turning over in bed to running and has been reported to be a reliable and valid measure of mobility in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (Collen et al., 1991; Hsieh, Hsueh, & Mao, 2000).

Client suitability

Can be used with:

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

Should not be used with:

• In individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. aged 65 and older, Guttman scaling is only retained with the gross function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
  (Adams, Pickering, Ashburn, & Lincoln, 1997) and therefore should be used with caution in these individuals as they may not be able to perform some of the specific tasks (e.g. a patient with osteo-arthritis may not be able to climb stairs) but may be able to perform subsequent tasks that are deemed more challenging (e.g. walking for an extended period of time).
• Guttman scaling (i.e. the notion that if the patient agrees with any specific item on the list, they will also agree with all previous questions) may not be appropriate to assess function in the hemiplegic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. client. This method of test administration is also not appropriate in assessing the kind of loss in function owing to focal lesions that arise in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. clients, in whom impairment of some function may be unrelated to impairment of other functions

In what languages is the measure available?

The RMA is only available in English (United Kingdom).

Summary

What does the tool measure?	Motor performance
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment
Time to administer	The RMA takes approximately 45 minutes to administer to an ambulatory client with a recovering upper extremity (less time with more severely disabled patients).
Versions	Rivermead Mobility Index (RMI), developed from the RMA Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). .
Other Languages	None
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the RMA and reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. for all subscales of the RMA. Test-rest: One study examined the test-rest reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . of the RMA and reported adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). for the Leg and Trunk, and Arm subscales. Intra-rater: No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the RMA. Inter-rater: One study examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the RMA and reported that on the Gross Function and Leg and Trunk subscales, there were no significant differences on average scores for all patients across all raters. For the Arm subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). , there was significant difference across raters, attributed to only one of the raters.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: Excellent correlations with the Barthel Index at initial, 1 month and 1 year follow-up. Predictive: A low RMA gross motor score at 6 weeks post-stroke has been reported as predictive of failure to walk at 18 months post-stroke. Construct: Convergent/Discriminant: Excellent correlations between the RMA Upper Extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and the Motricity Index Upper Extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). . Excellent correlations between the RMA and the total score of the Functional Independence Measure (FIM) and with the FIM Motor subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). , and adequate correlations between the RMA and the FIM Cognitive subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). . Excellent correlations between the verbal method of completing the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). of the RMA and the typical performance method of completion.
Floor/Ceiling Effects	One study examined the ceiling effectA ceiling effect occurs when test items aren’t challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes – the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also “floor effect.” of the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). of the RMA and reported a poor ceiling effectA ceiling effect occurs when test items aren’t challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes – the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also “floor effect.”.
Does the tool detect change in patients?	Two studies examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the RMA. The RMA was found it to be responsive to change in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and it was reported that a total score difference of plus or minus 3 is likely to represent a clinically relevant change in functional level.
Acceptability	The RMA should be used with caution with individuals with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. aged 65 and older as they may not be able to perform some of the specific tasks but may be able to perform subsequent tasks that are deemed more challenging. Guttman scaling may not be appropriate to assess function in the hemiplegic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. client or to assess the loss in function owing to focal lesions that arise in strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. clients, in whom impairment of some functions may be unrelated to impairment of other functions.
Feasibility	The RMA takes approximately 45 minutes to administer and is typically administered by a physical therapistIn charge of the “assessment and treatment of motor functioning, including motor control, strength and physical conditioning; balance, gait and mobility retraining; home and community visits; patient and family education regarding mobility and safety issues.” (Suggested by Philips et al, 2002) . The measure is simple to administer and consists of test items in three sections (Upper Limb/Extremity; Lower Limb/Extremity and Trunk; Gross Function) that are ordered hierarchically does not require any formal training or specialized equipment.
How to obtain the tool?	Please click here to obtain a copy of the RMA.

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Rivermead Motor Assessment (RMA).

Floor/Ceiling Effects

Williams, Robertson, Greenwood, Goldie, and Morris (2006) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of a new measure, the High-Level Mobility Assessment Tool (HiMAT) and the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the RMA in 103 patients following traumatic brain injury. The Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the RMA was found to have a poor ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect.", with 51.5% of patients achieving the maximum score.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Kurtais et al. (2009) investigated the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the RMA in 107 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the RMA, as calculated using Cronbach’s alpha was excellent for all RMA subscales (Gross Function α = 0.93; Leg and Trunk α = 0.88; and Arm α = 0.95).

Test-retest:
Lincoln and Leadbitter (1979) had 7 raters examine 10 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (4-week interval) and reported adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r = 0.66), and excellent correlations for the Leg and Trunk, and Arm subscales (r = 0.93, and r = 0.88, respectively) of the RMA.

Inter-rater:
Lincoln and Leadbitter (1979) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the RMA by having 7 raters evaluate 7 patients who were administered the RMA by videotape. Analysis of variance (ANOVA) of the scores obtained indicated that for all three subscales, variability between patients was higher than the variability between raters (F tests from ANOVA are reported but no ICCs). On the Gross Function and Leg and Trunk subscales, there were no significant differences on average scores for all patients across all raters. For the Arm subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, there was significant difference across raters, attributed to only one of the seven raters. Revised scoring instructions were therefore produced for the Arm subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, but further testing is required.

Validity

Content:

Content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
with Guttman scaling is evaluated on the extent to which total scores predict the number of consecutive items passed. In a study of 51 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., critical values for two indices, coefficient of reproducibility and coefficient of scalability, were all exceeded. The results of this study confirm the existence of a valid, cumulative, and unidimentional Guttman scale (Lincoln & Leadbitter, 1979).

Criterion:

Concurrent:
Endres, Nyary, Banhidi, and Deak (1990) administered the RMA and the Barthel Index to 53 patients who presented with a strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and who took part in a rehabilitation program. Scores on the RMA correlated excellently with scores on the Barthel Index at initial (r = 0.84), 1 month (r = 0.78), and 1 year (r = 0.63) follow-up.

Predictive.
Collin and Wade (1990) reported that a low RMA Gross Motor score at 6 weeks post-stroke was found to be predictive of failure to walk at 18 months post-stroke.

Construct:

Convergent/Discriminant:
Collin and Wade (1990) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the RMA with two different tests: the Motricity Index (Collin & Wade, 1990), the Trunk Control Test (Collin & Wade, 1990). They believed the Motricity Index and the Trunk Control Test were the tests requiring comparison, and the RMA was used as the “established” measure. The correlations between the Motricity Index Upper Extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
scores and the RMA Upper Extremity subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
scores across 3 time periods (6, 12, and 18 weeks after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.) were excellent (r = 0.76, 0.73, and 0.74, respectively).

Soyuer and Soyuer (2005) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the RMA with the Functional Independence Measure (FIM – Keith, Granger, Hamilton, & Sherwin, 1987) in 100 patients with ischemic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The assessments were conducted 7-10 days and 3 months post-stroke. At 7-10 days post-stroke, the total score for the RMA had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the total score on the FIM (r = 0.87) and with the FIM Motor subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r = 0.90). The total score of the RMA had an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the FIM Cognitive subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r = 0.46). At 3 months post-stroke the total RMA had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the total score on the FIM (r = 0.88) and with the Motor subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the FIM (r = 0.89). The RMA had an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Cognitive subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the FIM (r = 0.52).

Sackley and Lincoln (1990) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of a verbal method of completing the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the RMA with the typical performance method of completion in 49 patients with chronic strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between these two methods of administration (r = 0.98).

Kurtais et al. (2009) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the RMA with the Functional Independence Measure (FIM) in 107 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (mean 5.6 months post-stroke). Assessments were performed at admission and discharge from a rehabilitation unit. The Gross Function and Leg and Trunk subscales of the RMA had excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with all three sections of the FIM (Motor; Self-Care; and Mobility) on admission and discharge (ranging from 0.702 to 0.865); however, the Arm subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the RMA was found to only have adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with all three sections of the FIM at both admission and discharge from the rehabilitation unit (0.386-0.483).

Known groups:
Endres et al. (1990) administered the RMA to 53 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. participating in a rehabilitation program. Patients were grouped according to RMA motor deficit scores at entry (RMA score 0-9; 10-15; and >15). Adequate correlations were found between RMA score and infact size at initial (r = -0.52), 1 month (r = -0.47), and 1 year (r = -0.53) follow-up sessions.

Responsiveness

Collen, Wade, and Batshaw (1990) reported that a total score difference of ±3 points in the RMA is likely to represent a clinically relevant change in functional level.

Kurtais et al. (2009) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the RMA (adapted for use in a Turkish population) in 107 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. (mean 5.6 months post-stroke). Assessments were performed at admission and discharge from a rehabilitation unit. The effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the “effect size correlation”.
and standard response mean (SRM) were calculated for all three subscales of the RMA (Gross Function; Leg and Trunk; and Arm). Moderate effect sizeEffect size (ES) is a name given to a family of indices that measure the magnitude of a treatment effect. Unlike significance tests, these indices are independent of sample size. The ES is generally measured in two ways: as the standardized difference between two means, or as the correlation between the independent variable classification and the individual scores on the dependent variable. This correlation is called the “effect size correlation”.
was found for the Gross Function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(0.51) and small effect sizes for the Leg and Trunk and Arm subscales (0.45 and 0.38 respectively). The Gross Function, Leg and Trunk and Arm subscales had SRMs of 0.83, 0.86 and 0.60 respectively.

References

• Adams, S. A., Ashburn, A., Pickering, R. M., Taylor, D. (1997). The scalability of the Rivermead Motor Assessment in acute stroke patients. Clin Rehabil, 11, 42-51.
• Adams, S. A., Pickering, R. M., Ashburn, A., Lincoln, N. B. (1997). The scalability of the Rivermead Motor Assessment in nonacute stroke patients. Clin Rehabil, 52-59.
• Barer, D., Nouri, F. (1989). Measurement of activities of daily living. Clin Rehabil, 3, 179-187.
• Collin, C., Wade, D. (1990). Assessing motor impairment after stroke: A pilot reliability study. Journal of Neurology, Neurosurgery, and Psychiatry, 53, 576-579.
• Collen, F. M., Wade, D. T., Bradshaw, C. A. (1990). Mobility after stroke: Reliability of measures of impairment and disability. Int Disabil Stud, 12, 6-9.
• Collen, F. M., Wade, D. T., Robb, G. F., Bradshaw, C. M. (1991). The Rivermead Mobility Index: A further development of the Rivermead motor assessment. Int Disabil Stud, 13, 50-54.
• Collin, C., Wade, D. (1990). Assessing motor impairment after stroke: a pilot reliability study. J Neurol Neurosurg Psychiatry, 53(7), 576-579.
• Endres, M., Nyary, I., Banhidi, M., Deak, G. (1990). Stroke rehabilitation: A method and evaluation. International Journal of Rehabilitation Research, 13, 225-236.
• Hsieh, C-L., Hsueh, I-P., Mao, H-F. (2000). Validity and responsiveness of the Rivermead Mobility Index in stroke patients. Journal of Rehabilitation Medicine, 32(3), 140-142.
• Keith, R. A., Granger, C. V., Hamilton, B. B., Sherwin, F. S. (1987). The functional independence measure: A new tool for rehabilitation. Adv Clin Rehabil, 1, 6-18.
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• Sackley, C., Lincoln, N. (1990). The verbal administration of the gross function section of the Rivermead Motor Assessment. Clin Rehabil, 4, 301-303.
• Soyuer, F., Soyuer, A. (2005). Ischemic stroke: Motor impairment and disability with relation to age and lesion location (Turkish). Journal of Neurological Sciences, 22(1), 43-49.
• Streiner, D. L., Norman, G. R. (1989). Health measurement scales: A practical guide to their development and use. Oxford: Oxford University Press.
• Tyson, S., DeSouza, L. (2002). A systematic review of methods to measure balance and walking post-stroke. Part 1: Ordinal scales. Physical Therapy Reviews, 7, 173-186.
• Williams, G., Robertson, V., Greenwood, K., Goldie, P., Morris, M. E. (2006). The concurrent validity and responsiveness of the high-level mobility assessment tool for measuring the mobility limitations of people with traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 87(3), 437-442.

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