Rivermead Motor Assessment (RMA)

Evidence Reviewed as of before: 22-03-2011
Author(s): Lisa Zeltzer, MSc OT; Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Katie Marvin, MSc; PT Candidate

Purpose

The RMA assesses the motor performance of patients with stroke 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 stroke 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 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 subscale 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 subscale is scored by summing the points allocated for all items within that subscale.

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 stroke. The RMA is a risky assessment where a patient could fall if not supervised by someone with stroke 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 subscale. 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 activities from turning over in bed to running and has been reported to be a reliable and valid measure of mobility in patients with stroke (Collen et al., 1991; Hsieh, Hsueh, & Mao, 2000).

Client suitability

Can be used with:

  • Patients with acute and chronic stroke.

Should not be used with:

  • In individuals with chronic stroke aged 65 and older, Guttman scaling is only retained with the gross function subscale (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 stroke 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 stroke 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 stroke.
Is this a screening 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 subscale.
Other Languages None
Measurement Properties
Reliability
  • One study examined the internal consistency of the RMA and reported excellent internal consistency for all subscales of the RMA.
  • One study examined the test-rest reliability of the RMA and reported adequate test-retest reliability of the Gross Function subscale and excellent test-retest reliability for the Leg and Trunk, and Arm subscales.
  • One study examined the inter-rater reliability 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 subscale, there was significant difference across raters, attributed to only one of the raters.
  • No studies have examined the intra-rater reliability of the RMA.
Validity

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 subscale and the Motricity Index Upper Extremity subscale. Excellent correlations between the RMA and the total score of the Functional Independence Measure (FIM) and with the FIM Motor subscale, and adequate correlations between the RMA and the FIM Cognitive subscale. Excellent correlations between the verbal method of completing the Gross Function subscale of the RMA and the typical performance method of completion.

Floor/Ceiling Effects One study examined the ceiling effect of the Gross Function subscale of the RMA and reported a poor ceiling effect.
Does the tool detect change in patients? Two studies examined the responsiveness of the RMA. The RMA was found it to be responsive to change in clients with stroke 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 stroke 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 stroke client or to assess the loss in function owing to focal lesions that arise in stroke 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 therapist. 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 validity of a new measure, the High-Level Mobility Assessment Tool (HiMAT) and the Gross Function subscale of the RMA in 103 patients following traumatic brain injury. The Gross Function subscale of the RMA was found to have a poor ceiling effect, with 51.5% of patients achieving the maximum score.

Reliability

Internal consistency:
Kurtais et al. (2009) investigated the internal consistency of the RMA in 107 patients with stroke. 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 stroke (4-week interval) and reported adequate test-retest reliability of the Gross Function subscale (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 reliability 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 subscale, there was significant difference across raters, attributed to only one of the seven raters. Revised scoring instructions were therefore produced for the Arm subscale, but further testing is required.

Validity

Content:

Content validity 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 stroke, 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 stroke 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 validity 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 subscale scores and the RMA Upper Extremity subscale scores across 3 time periods (6, 12, and 18 weeks after stroke) were excellent (r = 0.76, 0.73, and 0.74, respectively).

Soyuer and Soyuer (2005) examined the convergent validity of the RMA with the Functional Independence Measure (FIM – Keith, Granger, Hamilton, & Sherwin, 1987) in 100 patients with ischemic stroke. 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 correlation with the total score on the FIM (r = 0.87) and with the FIM Motor subscale (r = 0.90). The total score of the RMA had an adequate correlation with the FIM Cognitive subscale (r = 0.46). At 3 months post-stroke the total RMA had an excellent correlation with the total score on the FIM (r = 0.88) and with the Motor subscale of the FIM (r = 0.89). The RMA had an adequate correlation with the Cognitive subscale of the FIM (r = 0.52).

Sackley and Lincoln (1990) examined the convergent validity of a verbal method of completing the Gross Function subscale of the RMA with the typical performance method of completion in 49 patients with chronic stroke. An excellent correlation was found between these two methods of administration (r = 0.98).

Kurtais et al. (2009) examined the convergent validity of the RMA with the Functional Independence Measure (FIM) in 107 patients with stroke (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 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 subscale of the RMA was found to only have adequate 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 stroke 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 responsiveness of the RMA (adapted for use in a Turkish population) in 107 patients with stroke (mean 5.6 months post-stroke). Assessments were performed at admission and discharge from a rehabilitation unit. The effect size and standard response mean (SRM) were calculated for all three subscales of the RMA (Gross Function; Leg and Trunk; and Arm). Moderate effect size was found for the Gross Function subscale (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.
  • Kurtais, Y., Kucukdeveci, A., Elhan, A., Yilmaz, A., Kalli, T., Sonel Tur, B. et al. (2009). Psychometric properties of the Rivermead Motor Assessment: Its utility in stroke. Journal of Rehabilitation Medicine, 41, 1055-1061.
  • Lincoln, N. B., Leadbitter, D. Assessment of motor function in stroke patients. Physiotherapy, 65, 48-51.
  • 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.

See The Measure

How to obtain the RMA?

Please click here to obtain a copy of the RMA.

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