Research Report Reliability of the Fugl-Meyer Assessment for Testing Motor Performance in Patients Following Stroke Background and Purpose. The purpose of this study was t0 establish the inter rater reliability of assessments made with the Pugt-Meyer evaluation of physical performance in a rehabilitation seting. Subjects. Twelve patients (7 male, 5 female), aged 49 10 86 years (R=66), who had sustained a cerebrovascular acci- dent participated in the study. All patients were admitted consecutively 10 a reba: biluation center and were between 6 days and 6 months poststroke. Methods. Three plysical therapists, each with more than 10 years of experience, assessed the patients in a randomized and balanced order using thts assessment. The therapists standantized the assessment approach prior to the study but did not discuss the procedure once the study began. Results. The overall reliability was bigh (overall ‘intraclass correlation coeffcient=.96), and the intraclass correlation coefficients for the subsections of the assessment varied from 61 for pain to .97 for the upper ‘extremity. Conclusion and Discussion. The relative meris of using the Fug Meyer assessment as a research tool versus a clinical asessment Jor stroke are discussed. [Sanford J, Moreland J, Swanson LR, et al. Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther. 1993,73447-454} Key Words: Fg/-Meyer assessment, Motor performance, Reliability, Siroke. Stroke is a major cause of morality average annual morality rate for and disability in many countries. The stroke per 100,000 people is 100.4 in 1 Sanford, PT. Rewearch Coordinator, Rehabilitation Sere, St Peter's Hosp, 8B Maplewood ‘ve, Hariton, Oniaro, Canada UN 425, and AS’ Clatel Professor, School of Occupational Therapy aid Physiotherapy, Faculty of Healh Sciences, McMaster Unnersiy, 1200 Maia St W. ‘Hamilton, Onlatio, Canada USN 375. Address ll covrespondence 10 Ns Sanford the fist adress. | Morclnd, FFs Physat Traps, Physiotherapy Deparment, ChedokeNeMaser Hospi, {Checake Dison, Hain, Ontario, Canada LAN 325, and Clinical Letrer, School of Occup ‘onl Therapy and Physiotherapy, Faculty of Heakh Sciences, MeMaser Universi. 18 Swanson, Fs Decora Cant, Medal Scences Program, MeMaster Unters: Pw straor, PTs Assistant Profesor, School of Occupational Therapy and Physiotherapy. Facuky of Health Seiences, McMaster Universi C Gomnd, #7 1s Associate Pofesoe, Schoo of Occupational Therapy and Physctherpy,Facly lof Heath Sciences, MeMaer University. ‘This study was approved bythe Reseatch Project Advisory Commie of MeMaster Univers and (Check: MeMaster Hospi ‘This research was supported by Gra 6606377145, National Heakh Research and Development Progam, Onawa, Oni, Canad, This article was submited July 20, 1992, and was ascopad March 17,1993 Julle Sanford Julle Moreland Laurie R Swanson Paul W Stratford Carolyn Gowland the United States, 1162 in England and Wales, and 966 in Canada Data compiled from a number of surveys in the United States show that the annual incidence is approximately 100, to 150 per 100,000 people.* Following 2 stroke, patients usually receive in- tensive therapy to promote motor recovery and help them cope with their disability. Reliable and valid measurements of sensorimotor status are required for linical decision-making and research purposes. One measure that has been ‘extensively discussed is the Fugh ‘Meyer evaluation of physical perfor- ‘mance? The FuglMeyer assessment ‘was developed 10 assess physical recovery following stroke. It was pri- ‘marily developed from the earlier ‘works of Twitchell and Beunnstréim + 36/447 Physical Therapy /Volume 73, Number 7uly 1993,Twitchell examined the ontogenetic concept of motor recovery, through the assessment of sequenced reflex and synergistic pattemed movements seen in patients recovering from stroke.’ Based on this recovery se- quence, Brunnstréim identified six sequences of temporal, stepwise stages as a method of assessing motor recovery in patients with hemiplegia following stroke In addition to mo- tor performance, balance, sensation, range of movement, and pain are also. assessed by the FughMeyer items, which examine volitional movement within synergies, partially out of syn ergy, and independent of synergies. ‘The Fug-Meyer motor assessment includes items dealing with the shoul der, elbow, forearm, wrist, and hand in the upper extremiry and the hip, knee, and ankle in the lower extrem. lity, Reflex activity is assessed in the ‘upper and lower extremities at the beginning and end of the motor as sessment, Balance is examined in sitting and standing, Sensation, evalu ated by light touch, #s examined on «wo surfaces in both the upper and lower extremities, and position sense (kinesthesia) and range of motion (ROM) are tested on eight joints, four in each extremity? ‘The FughMeyer assessment, which consists of 155 items, is an impair- ‘ment measure. /mpairment is defined as any loss or abnormality in psycho logical, physiological, or anatomical structure or function With the Fug Meyer assessment, each iter is rated (on a three-point ordinal scale (2 points for the derail being performed completely, 1 point for the detail being performed parially, and 0 for the detail not being performed). The maximum score that can be attained {5 226, The maximum motor perfor mance score is 66 points for the up- per extremity, 34 points for the lower ‘extremity, 14 points for balance, 24 points for sensation, and 44 points ‘each for passive joint motion and joint pain. Joint pain is assessed by ‘moving the joint through its available ROM to assess whether pain occurs at any point in the range. FughMeyer assigned motor function scores t0 stems that assesse! movor function alone, witha total posible score of 100 points, Scores were grouped according to the various levels of imaiement, which were as follows 50 poin'sssevere motor impair ment, 50-84 points=marked motor impalement, 85-95 poinss=moderate ‘motor impairment, and 96-59 points=slight motor impairment® ‘The properties of this instrument have been described by various au- thors (Tab. 1). Most of these authors examined the validity of the instrument. In the original study by FuglMeyer et al? 28 patienis were assessed on five occasions during a ‘year period following stroke. The ‘mean correlation coefficient between the upper- and lower-extremity scores ‘was 882 Other researchers compared scores from the Fugl-Meyer assess- ‘ment with data from the Barthel In- ddex!01; a Bobath assessment! ‘upper-exiremity function tests? and tests for balance in standing, walking performance, and postural stability © ‘The correlation coefficients repored from these studies varied from 54 for the total score to 94 for the upper extremity, thus providing evidence of construct validity Studies to date have examined the ‘construct validity of the FughMeyer assessment in samples of chronically disabled patients following stroke, less work has been done to deter- mine the reliability of measurements obtained with this assessment. Dun- ccan et al reported the interrater reliability of motor performance in the upper and lower extremities and the intrarater reliability ofall sub- Scores and the total Fugl-Meyer score using four physical therapists as evalu- ators, The 19 patients in their study ‘were more than I year poststroke, ‘with a mean time of 31 months since the onset of their stroke. Intrarater Pearson correlations for each sub- score and the total score varied from £86 to 99. The interrater Pearson. correlations for the motor scores of the upper and lower extremities var- ied from .79 t0 99. Because Duncan et al studied subjects who were Chronically disabled following stroke, Physical Therapy /Volume 73, Number 7uly 1993 the generalizability of their cesults is limited to similar patient populations. ‘The study described in this report examined the overall interrater reli ability and the reliability of each sub- section of the FuglMeyer assessment, administered by three raters to pa- tients undergoing active rehabilitation following stroke. ‘The purposes of our study were (1) to examine the interater reliability of measurements obtained with the FuglMeyer assessment and (2) 10 determine the relevance ofthe asses ‘ment for clinical and research pur- poses. The specific ims ofthe study were to determine whether the Fugl- Meyer assessment is able (0 discrimi rate among patients when itis used to evaluate patients’ motor recovery following stroke and to determine the magnitude of the measurement error foe the woul score and score ofthe subsections ofthe assessment. The a prior level of acceptable reliability among eaters was Set at an intraclass correlation coeficient (ICC2.1}) of sareater than 80 for the worl score and subscores. Method ‘This study was part of a larger study that examined the measurement prop- ceries of the Chedoke-McMaster Stoke Assessment 6 Subjects ‘Twelve patients consecutively admit- ted 10 the Chedoke-MeMaster Rehabil: itation Centre, Hamikon, Ontario, Canada, were each assessed by three therapists (see Tab. 2 for descriptions, Of the patients) on separate occasions, ‘The Chedoke-McMaster Rehabilitation Centre isa tertiary care seting at which patients are treated on a daily basis by a multidisciplinary team. The average length of stay per patient was 10 weeks, Patients were included if they were less than 80 years of age, were less than 6 months poststroke, and gave thelr consent to panicipate in the study. 448/37Table 1. summary of Sudies Examining Properties ofthe Fugl Meyer Asessment study Subjects and Methods ‘Type ot stusy Results FuglMeyer et al? 28 patents Content vaisty Mean corlation cosicient between 1975 ‘Stoke foe at leat 24 hours seores~. 88 FuglMeyer assessmont administered at FughMoyer assessment items were ‘8 wooks to 6 months ‘Considered to be consistent withthe 15 patients flowed fo year recovery pattem observed Backe ans 1Oheathy subjects and 10 patients Construct vay Corellon between abnormal postural Duncan” 1963 ‘wi ight hemiparesis secondary to ‘adhstments made by lower extremity (LE) Cerebrovascular accident ‘on balance plattor and Fugl Meyer Balance tests in stancing assessment LE soxes, De Weer and 58 subjects Construct vatisty ‘Spearman tho Harrgen# 1985 Action Rasearch Arm test ans 2 wooks, =.91 FughMeyor ascessmont used at 2 woke, r= 94 wooks and 8 wooks poststroke Peat Berglund and 10 patons with stroke and Construct vay Fugl Meyer assessment and DeSouza tot FughMeyar? upper extremity impairment total scores covaried closely, explaining 1986 FughMeyer assossment and DeSouza ‘more than 99% of he variance Detimana et a.© 1987 DiFabio and ‘Bade, 1900 Weod Dauphinoe et a" 1990, ‘Asoraut ot al? 1988 functional am test ueed fo assess: upper exremity 15 men folowing cerebrovascular ‘accident tstod using Garhel Indo, FughMeyer assessment, and tests of walking Perfomance and postural Stabily using ight photography 10 pations assessed X=14.9 wooks statioko with sonsery organization Balance test anc FugeMeyer 172 patents assessed at admission and 5 weeks poststroke wih FughMeyer assessment and Barthel nex (2 subjects 3.1 manthe postatioke ‘Treated wth Gobath approach for 3 months and assessed thee times ‘Bobath evaluation and Fugl Meyer ‘assessment (wrist and hand rot evaluated) Constvetvalisty Construct valisy Construct valicty FughMeyer assessment used as, ‘a velerence moasure Motor assessments also closely associated, ‘explaining more than 80% ofthe variance Pearson Product Moment Correlation Coeficient '=.75, upper extreity (=.74, motor contd 7=-76, balance ‘=.67, tla scores Peal ‘Spearman tho 7=.55, sensory r=.77 balance = 68, lower extremity Pearson Preduct Moment Coetation Coeficint =.758 at aarrission 7=.8546 at 5 wooks Pear Spearman tho assocision between Bobath ‘appioach and Fug-Meyer assessment at tree times of testing Pet ‘Analysis of variance FuglMeyer assessment cumulated wit bath approach measuroments 1¢=208 (P< 0001), Kusofshy et a2? 16.patiens examined on six occasions Cteton vality Corteatons highest in resuits trom 1982, ‘with Fug! Meyer assessmers trom Uupperexremity ores subacute stage t9 6 months poststroke (motor cont, touch, jnt positon sense) and somatosensory evoked potentials (STEP) test Duncan et al 19 subjects 1 year poststroke Relailty Irwarater Pearson Product: Moment Correlation 1088 4 physical nerapisis Cosffciens Pryscal therapists aciinistered 3 tats r= 85-99 ‘a1 S.veck intervals Inverter upper extremity, r= 97-98 Lowor exramiy, 7=.79-05 Peoot 38/449 Physical Therapy /Volume 73, Number 7/July 1993