12 Must-Have questionnaires and assessment tools to evaluate upper limb in neurorehabilitation
Telemedicine and telerehabilitation systems make possible the provision of quality, long-term rehabilitation for patients who really need it, or who do not have the resources to access it. The World Health Organisation itself considers the implementation of these new technologies as an investment to contribute to health, economic and social development.
However, for their implementation in clinical practice, quality research studies are needed to evaluate both the effectiveness and safety of these eHealth or telemedicine tools in patients. We at ReHand know this well at first hand, having validated their effectiveness and safety in studies of more than 600 patients.
Therefore, it was proposed to select those scales, questionnaires and/or tools that should be used in clinical practice, based on the published literature. Thus, this Guide of recommendations for the assessment of the Upper Limb with neurological involvement (mainly stroke) in the rehabilitation process was recently published, with the aim of applying its conclusions to both clinical practice and research.
European Evidence-based recommendations for clinical assessment of the upper limb in neurorehabilitation (CAULIN)
In order to obtain robust recommendations, a highly structured analysis was carried out, synthesising information from the following sources:
1) Systematic reviews on outcome assessment of the upper limb in stroke;
2) Existing clinical practice guidelines, analysing their recommendations and evidence in the assessment of the upper limb in different neurological disorders and
3) Consensus of more than 200 experts (occupational therapists, physiotherapists, researchers…) on the use of upper limb assessment tools in neurorehabilitation, by means of a Delphy study.
The extracted data were organised into 3 levels:
1) Core Set (3-star rating): those assessments with robust evidence in their validity, reliability, responsiveness and clinical utility AND that were recommended by at least two of the sources.
2) Extended Set (2-star rating): those assessments with robust evidence of validity, reliability, responsiveness and clinical utility OR that were recommended by at least two of the sources.
3) Supplementary Set (1-star rating): those assessment tools that demonstrated some level of evidence of validity, reliability, responsiveness and clinical utility OR were recommended by at least one of the sources.
Once this process was completed, they obtained the following results:
Results of the analysis to assess the upper limb
1) 3-star assessment tools that you must use
The results agreed that the Fugl-Meyer Upper Limb Scales (FMA-UE) and the Action Research Arm Test (ARAT) should be included as basic (3-star) assessments of upper limb function and activity capacity.
The FMA-UE and ARAT should be routinely applied in clinical practice with neurological patients undergoing conventional or technology-enhanced upper limb rehabilitation.
2) Extended assessment tools you can use
As extended assessments (2 stars) of the upper limb, it adds 6 instruments that may be useful in clinical practice but are recommended as standard for research.
Kinematic measures that assess the quality and execution of movement at the level of body function are recommended, although it is not clear which variables are appropriate. Examples such as quality of movement or smoothness.
To assess activity level, 4 instruments with slightly different approaches are added: Box and Block Test (BBT; unilateral timed gross motor dexterity), Chedoke Arm Hand Activity Inventory (CAHAI; focused on bilateral task performance), Wolf Motor Function Test (WMFT; uni and bilateral timed performance and ability score), Nine Hole Peg Test (NHPT; unilateral timed assessment of manual dexterity).
The ABILHAND (assessment of patient-reported manual ability) to assess the patient’s self-perceived level of activity performance.
3) Supplementary Assessments to evaluate the Upper Limb after stroke.
Within the 1-star supplementary assessment instruments, additional tools are proposed that can be used for specific research purposes:
In body function the Motricity Index (MI), the Chedoke-McMaster Stroke Assessment (CMSA) and the Stroke Rehabilitation Assessment Movement (STREAM) were added.
At the activity level, the Frenchay Arm Test (FAT) and the Motor Assessment Scale (MAS), as well as the monitoring of the actual amount of use of the upper limb in daily activities by means of accelerometers, inertial units, etc…
A summary of the recommendations can be found here:
We now talk about each of them, with VIDEOS and LINKS to the documents and pdfs so that you can use them in your daily clinical practice!
Questionnaires and Instruments for the Assessment of the Upper Limb after Stroke
Fugl-Meyer Assessment (Upper Extremity), FMA-UE
It is a tool that, through direct observation, assesses motor performance based on 33 items that are rated from 0 to 2 (0 = cannot do it, 1 = partially does it, 2 = maximum performance). The FMA-UE takes about 30 min to complete and has a final score ranging from 0 (no functional limitation) to 66 (maximum limitation/disability) (Singer and Garcia-Vega 2017). This scale has shown excellent reliability and construct validity (Gor-García-Fogeda et al. 2014), and has been validated for use in Spanish (Barbosa et al. 2019). A shortened version of the FMA-EU, which includes 6 of the original items, has recently been implemented. This version is faster and easier to administer and appears to have good psychometric properties (Amano et al. 2020).
📋 Download the FMA-EU pdf in English here:
📽 Video on the Fugl-Meyer Upper Limb Questionnaire:
Action Research Arm Test (ARAT)
The ARAT scale assess the motor ability of the upper limb through 4 basic movements (grasping, squeezing, pinching and gross dexterity). It is structured in 19 tasks (at distal or proximal level), which are given a value from 0 to 3, with higher values indicating better performance.
Its final score ranges from 0 to 57, making it a valid and very reliable scale. It usually takes 7-10 minutes to administer due to its hierarchical assessment (i.e. if the patient cannot perform the simplest movement, the rest of the movements are not assessed).
Although ARAT requires a kit of material (picture below) to be able to apply it, there is an open-access publication on how to prepare your own ARAT KIT and the standardised protocol to perform the test:https://journals.sagepub.com/doi/10.1177/1545968307305353
📋 Link to original ARAT article:
📽 Link to ARAT video: https://www.youtube.com/watch?v=avZkBk3PfEY
Box and Block Test (BBT)
Manual dexterity test, using a wooden box with 2 compartments and 150 blocks. The objective is to move the maximum number of blocks (one by one) from one compartment to another in 60 seconds.
📋 Link to Box and Block Test article: https://pubmed.ncbi.nlm.nih.gov/3160243/
📽 Link to Box and Block Test demonstration: https://www.youtube.com/watch?v=OOC6G3vO1kw
Chedoke Arm Hand Activity Inventory (CAHAI)
The CAHAI is a validated upper extremity measure that uses a 7-point quantitative scale to assess functional recovery of the arm and hand after stroke. The purpose of this measure is to assess the functional ability of the paretic arm and hand to perform tasks that have been identified as important by individuals after stroke.
It was developed to complete the Chedoke-McMaster Stroke Assessment (CMSA) score.
📋 The Chedoke Arm Hand Activity Inventory (CAHAI) tool was first described: https://www.tandfonline.com/doi/abs/10.1310/JU8P-UVK6-68VW-CF3W
Manual and Chedoke Arm and Hand Activity Inventory scale in pdf: https://www.cahai.ca/layout/content/CAHAI-Manual-English-v2.pdf
More info about Chedoke Arm and Hand Activity Inventory: https://www.cahai.ca/
📽 Video about Chedoke Arm and Hand Activity Inventory: https://www.youtube.com/watch?v=n3bKbt1w2xI
Wolf Motor Function Test (WMFT)
It is a tool for quantitative assessment of upper limb motor performance through timing and functional tasks. It originally included 15 items, but the modified and most widely used version is a 17-item version, which is composed of 3 parts: 1) Timing, 2) Function and 3) Strength. Items 1-6 include timing of functional tasks, 7-14 measure strength and the remaining 9 items analyse the quality of movement during the tasks.
It is assessed on a score from 0 (no attempt with the affected arm) to 5 (arm participates, movements appear normal). Maximum score 75, and the lower the score, the worse the level of function. Time is included within 120 seconds, giving a WFMT Function and Time.
1 Forearm to table (side),
2 forearm to box (side),
3 extend elbow (side),
4 extend elbow (weight),
5 hand to table (front),
6 hand to box (front),
7 weight to box (lbs),
8 reach and pick up,
9 lift can,
10 lift pencil,
11 lift clip,
12 stack the cards,
13 flip the cards,
14 grip force (lbs),
15 turn the key in the lock,
16 fold towel,
17 lift basket.
📋 Wolf Motor Function Test described for the first time (15 items instead of 17) https://www.ahajournals.org/doi/epub/10.1161/01.STR.32.7.1635
📽 Video about Wolf Motor Function Test https://www.youtube.com/watch?v=yaweehsE944
Nine Hole Peg Test (NHPT)
It consists of a simple test to evaluate manual dexterity. It consists of a plastic console with a shallow dish on one side containing the “Pegs”, and 9 holes on the other side. The test consists of asking the patient to place the Pegs as quickly as possible in the holes, and then remove them again. Time is evaluated.
📋 Reference and description of Nine Hole Peg Test: https://research.aota.org/ajot/article-abstract/57/5/570/8603/Adult-Norms-for-a-Commercially-Available-Nine-Hole?redirectedFrom=fulltext
📽 Video of Nine Hole Peg Test: https://www.youtube.com/watch?v=JaGX-ji9eMA
The ABILHAND questionnaire assesses manual ability focusing on the patient’s perceived difficulty of 23 bimanual activities. Each item is answered on a 3-level scale (impossible, difficult, easy). Item difficulty increases with bimanual participation.
The patient is asked to estimate the ease or difficulty of performing each activity when the activities are performed without any help, regardless of the limb(s) the patient actually uses and the strategies used to perform the activity. The patient is never asked to perform the activities in front of the assessor.
📋 ABILHAND validation in stroke patients: https://www.ahajournals.org/doi/10.1161/01.STR.32.7.1627
📋 Pdf of ABILHAND in english: http://rssandbox.iescagilly.be/abilhand-downloads.html
Motricity Index (MI)
The Motricity Index (MI) scale aims to assess the motor function of a patient after stroke. It is divided into upper and lower limb. Specifically, the upper limb asks questions about the ability to perform gripper, elbow flexion and shoulder abduction.
This website allows you to get the score automatically – try it now! https://www.medicalalgorithms.com/motricity-index-for-motor-impairment-after-stroke
📋 Information about the Motricity Index scale, psychometric status (validity, reliability etc.), validation:
📋 Description of the original 1990 Motricity Index Scale:https://pubmed.ncbi.nlm.nih.gov/2391521/
Chedoke-Mcmaster Stroke Assessment (CMSA)
The Chedoke-Mcmaster Stroke Assessment (CMSA) measures physical impairment and disability in patients with stroke and other neurological impairments. The measure consists of an Impairment Inventory and an Activity (or disability) Inventory.
The first inventory (Impairment Inventory) aims to determine the presence and severity of common physical impairments, to classify or stratify patients for planning, selecting interventions and evaluating their effectiveness, and to predict outcomes. It has six dimensions (recovery phase of arm, hand, leg, foot, postural control and shoulder pain). Each dimension is measured on a 7-point scale. Maximum of 42 points can be obtained.
The disability inventory consists of a gross motor function index and a walking index. Measurement of these attributes is considered important for outcome assessment and for determining the effectiveness of therapeutic interventions. The inventory has a maximum total score of 100 (70 for the gross motor function index, which has 10 items, and 30 for the walking index, with five items). With the exception of item 15, each item is scored on the same 7-point scale as the FIM . To score item 15, the 2-minute gait test 19 is used to assess the gait efficiency of patients who ambulate.
📋 Feasibility and validity study of Chedoke-McMaster Stroke Assessment (CMSA) 1993 https://www.ahajournals.org/doi/abs/10.1161/01.str.24.1.58
📽 Video of Chedoke-McMaster Stroke Assessment (CMSA) : https://www.youtube.com/watch?v=kkZ9zfAbk5U
Stroke Rehabilitation Assessment of Movement Measure (STREAM)
Stroke Rehabilitation Assessment of Movement Measure (STREAM) provides therapists with a quantitative measure of motor functioning and basic mobility deficits among stroke patients by performing 30 voluntary upper extremity (UE) and lower extremity (LE) motor tasks.
📋 Stroke Rehabilitation Assessment of Movement Measure (STREAM) in PDF: https://www.sralab.org/sites/default/files/2017-07/Stroke_Rehabilitation_Assessment_of_Movement_STREAM.pdf
📋Validation study Stroke Rehabilitation Assessment of Movement Measure (STREAM) : https://pubmed.ncbi.nlm.nih.gov/9920188/
Frenchay Arm test (FAT)
The Frenchay Arm Test is a measure tool of upper extremity proximal motor control and dexterity during ADL performance in patients with upper extremity impairments resulting from neurological conditions. The FAT is a measure of upper extremity specific activity limitation.
It takes less than 3 minutes, consists of five test/disapprove tasks, with the patient scoring an I for each task successfully completed. The patient sits at a table with their hands in their lap, and each task starts from this position. The patient is then asked to use their affected arm/hand:
I) Stabilise a ruler, while drawing a line with a pencil held in the other hand. To pass, the ruler must be held firmly.
2) Grasp a cylinder (12 mm in diameter and 5 cm in length), placed on its
side about 15 cm from the edge of the table, lift it up about 30 cm and put it back without dropping it.
3) Take a glass, half full of water placed about 15-30 cm from the edge of the table, drink some water and replace it without spilling.
4) Remove and replace a spring-loaded clothes peg with a 10 mm diameter pin, 15 cm long, placed on a 10 cm base, at a distance of 15 to 30 cm from the edge of the table. Do not drop the clip or tip the pin over.
5) Comb the hair (or imitate it); it should be combed on the top, on the back and on each side of the head.
📋 Frenchay Arm test tool described in 1987: https://pubmed.ncbi.nlm.nih.gov/3612152/
Motor Assessment Scale (MAS)
The Motor Assessment Scale (MAS) is a performance-based scale that was developed as a means of assessing ADL motor function in stroke patients (Carr, Shepherd, Nordholm, & Lynne, 1985). The MAS is based on a task-oriented assessment approach that evaluates functional task performance rather than isolated movement patterns.
It includes eight different items representing eight areas of motor function and one item related to muscle tone on the affected side. Each item is scored on a seven-point scale from 0 to 6.
📋 Link to pdf Motor Assessment Scale (MAS): https://www.physio-pedia.com/images/5/5d/Motor_Assessment_Scale.pdf
📋 Article Motor Assessment Scale (MAS): https://academic.oup.com/ptj/article-abstract/65/2/175/2727795?redirectedFrom=fulltext
Other information relevant to the assessment of the upper limb
With regard to the procedure for applying the assessment instruments, CAULIN results recommend:
✔ Assessments should be carried out at regular intervals at a minimum of four points during the rehabilitation period (at the beginning, at 3, 6 and 12 months after the start).
✔ Global measurements should be applied within 24h after hospital admission and upper extremity specific measurements within the first week.
The NIHSS scale should be performed by trained and certified assessors within 24 hours, and reassessment should be considered prior to discharge from intensive care.
✔ During a rehabilitation programme, evaluation should take place at the beginning of the programme, at the middle of the programme (during the programme), at the end (end of the programme) and at the follow-up (a specified period of time after the end of the programme).
✔ Patients should always be assessed prior to discharge or transfer to promote appropriate follow-up.
✔ Assessment tools should be administered separately from treatment, should last no longer than three hours, and should be carried out by health professionals trained to use them.
We hope you have found this wide range of questionnaires, scales and instruments for the assessment of the upper limb affected by neurological pathology such as stroke useful.
Do you use other scales? would you propose a different one? tell us about it!
Pablo Rodríguez Sánchez-Laulhé
PhD Candidate | PT, Hand Therapy & eHealth Researcher
Prange-Lasonder GB, Alt Murphy M, Lamers I, et al. European evidence-based recommendations for clinical assessment of upper limb in neurorehabilitation (CAULIN): data synthesis from systematic reviews, clinical practice guidelines and expert consensus. J Neuroeng Rehabil. 2021;18(1):162. Published 2021 Nov 8. doi:10.1186/s12984-021-00951-y