Fugl-Meyer Assessment of Sensorimotor Recovery After Stroke (FMA)

Purpose of the measure

The Fugl-Meyer Assessment (FMA) is a stroke-specific, performance-based impairment index. It is designed to assess motor functioning, sensation, balance, joint range of motion and joint pain in patients with post-stroke hemiplegia (Fugl-Meyer, Jaasko, Leyman, Olsson, & Steglind, 1975; Gladstone, Danells, & Black, 2002). It is applied clinically and in research to determine disease severity, describe motor recovery, and to plan and assess treatment.

Features of the measure

Items:
The scale is comprised of five domains and there are 155 items in total:

  • Motor function (in the upper and lower extremities)
  • Sensation (evaluates light touch on two surfaces of the arm and leg, and position sense for 8 joints)
  • Balance (contains 7 tests, 3 seated and 4 standing)
  • Joint range of motion (8 joints)
  • Joint pain

The motor domain includes items assessing movement, coordination, and reflex action of the shoulder, elbow, forearm, wrist, hand, hip, knee, and ankle. Items in the motor domain have been derived from Twitchell’s 1951 description of the natural history of motor recovery following stroke and integrates Brunnstrom’s stages of motor recovery (Gladstone et al. 2002; Poole & Whitney, 2001). Items of the FMA are intended to assess recovery within the context of the motor system. Functional tasks are not incorporated into the evaluation (Chae, Labatia, & Yang, 2003).

Time:
Sections of the FMA are often administered separately, however it takes approximately 30-35 minutes to administer the total FMA (Poole & Whitney, 2001). The average length of time for FMA administration of the Motor function, Sensation and Balance subscores have reported to range from 34 to 110 minutes, with a mean administration time of 58 minutes (Malouin, Pichard, Bonneau, Durand & Corriveau, 1994). When the motor scale is administered on its own, it takes approximately 20 minutes to complete.

A major criticism of the FMA is that it is a lengthy measure to administer (Gladstone et al., 2002). Sometimes it takes longer than 35 minutes to complete, such as when it is administered to aphasic or severely affected patients (Kusoffsky, Wadell, & Nilsson, 1982; Dettmann, Linder, & Sepic, 1987).

Scoring:
Scoring is based on direct observation of performance. Scale items are scored on the basis of ability to complete the item using a 3-point ordinal scale where 0=cannot perform; 1=performs partially; and 2=performs fully. The total possible scale score is 226.

Points are divided among the domains as follows:

  • Motor function score: ranges from 0 (hemiplegia) to 100 points (normal motor performance). Divided into 66 points for upper extremity and 34 points for the lower extremity.
  • Sensation score: ranges from 0 to 24 points. Divided into 8 points for light touch and 16 points for position sense.
  • Balance score: ranges from 0 to 14 points. Divided into 6 points for sitting and 8 points for standing.
  • Joint range of motion score: ranges from 0 to 44 points.
  • Joint pain score: ranges from 0 to 44 points.

Classifications for impairment severity have been proposed based on FMA Total motor scores (out of 100 points):

Source: Finch, Brooks, Stratford, & Mayo, 2002

Fugl-Meyer (1980)

Fugl-Meyer et al. (1975)

Duncan, Goldstein, Horner,
Landsman, Samsa, & Matchar (1994)

< 50 = Severe

 

0-35 = Very Severe

50-84 = Marked

≤ 84 = Hemiplegia

36-55 = Severe

85-94 = Moderate

85-95 = Hemiparesis

56-79 = Moderate

95-99 = Slight

96-99 = Slight motor dyscoordination

> 79 = Mild

Each of the five FMA domains can be separated to test a specific construct. For example, to assess upper extremity function, the subsections specifically dealing with upper extremity movement, sensation, joint motion and pain can be examined without administering the rest of the scale. Scoring of the FMA will depend on the number of items included in the subsection selected for testing.

Crow et al. (2008) proposed a shortened method of administration for the upper and lower extremity portions of the FMA. Using Guttman analysis the authors determined that scale items in the upper and lower limb sections fulfill the criteria for a valid hierarchy. Clinically this means that rather than administering the entire test, a clinician may choose to begin administering at a point in the scale that appears appropriate to the observed level of patient recovery. If a patient is able to accomplish all of the remaining scale items in the section, they are awarded a full score for that section. Likewise, when the individual being tested is unable to accomplish all the scale items in a given section, a score of 0 is given for any remaining untested, more advanced, items. This method of assessment reduces the time required to perform the test. Full guidelines for hierarchical testing procedures are provided by Crow et al. (2008)

Equipment:
The FMA requires a mat or bed, a few small objects and several different tools for the assessment of sensation, reflexes, and range of motion:

Materials needed (Poole & Whitney, 2001; Sullivan et al., 2011):

  • Scrap of paper
  • Ball
  • Cotton ball
  • Pencil
  • Reflex hammer
  • Cylinder (small can or jar)
  • Goniometer
  • Stopwatch
  • Blindfold
  • Chair
  • Bedside table

Subscales:
There are five domains that can be assessed independently: Motor function; Sensation; Balance; Joint range of motion; and Joint pain. Sensation and Joint pain are more subjective in nature and are used less frequently (Gladstone et al., 2002). Sullivan et al. (2011) published a FMA manual of procedures, which includes training procedures for clinical practice and research trials, in an effort to standardize assessment procedures.

Training:
The FMA should be administered by a trained physical therapist, occupational therapist or other rehabilitation professional on a one-to-one basis with the patient (Gladstone et al., 2002).

Guidelines provided by Fugl-Meyer et al. (1975) suggest that the client should be instructed verbally and/or with a demonstration of the test. The evaluator is permitted to assist the patient in the testing of the wrist and hand to stabilize the arm (Fugl-Meyer et al., 1975). In patients confined to their beds, the joint range of shoulder abduction should be performed only to 90 degrees and extension of the hip to 0 degrees.

Alternative Forms of Fugl-Meyer Assessment (FMA)

In 1975, Fugl-Meyer, Jaasko, Leyman, Olsson, and Steglind published the FMA.

Revision to balance subscore.

Subsequent to problems reported with sitting balance items (Malouin et al., 1994), Hseuh et al. (2001 as reported in Mao, Hsueh, Tang, Sheu, & Hsieh, 2002) proposed slight modifications to the scoring of the two problematic reaction items. In this modified version, patients receive a score of 0 if they lose balance easily, 1 if they partially lose balance, and 2 if they maintain sitting balance well when firmly pushed on the affected or non-affected side. The validity of the modified FMA-Balance was found to be excellent (r = 0.84).

12-item short form

Hseih et al. (2007) developed a 12-item short form of the FMA based on the upper and lower extremity domains of the FMA. Items were retained on the basis of representativeness of Brunnstrom staging and item difficulty assessed via Rasch analysis.

Client suitability

Can be used with:

    • Acute and chronic patients post-stroke in settings from an acute care hospital (Wood-Dauphinee, Williams, & Shapiro, 1990) to the community (Nadeau, Arsenault, Gravel & Bourbonnais, 1999).
    • Although it takes longer to administer, the FMA can be applied to severely affected patients or patients with aphasia.

Should not be used in:

    • Patients who need a proxy to complete. As with other impairment indices, the FMA is scored by direct observation and therefore it cannot be used with proxy respondents.
    • The FMA should not be used to detect fine or complex movements or coordination, as it measures gross limb movement only. A scale that employs a finer evaluation of isolated movements and the complete range of motor function of the upper limb only is the Motor Status Score. This scale has been found to be a reliable and valid assessment of upper limb impairment and disability following stroke (Ferraro et al., 2002).
    • As an assessment of motor recovery within the context of the motor system, the FMA may separate motor recovery from functional recovery. Therefore, the FMA may not be responsive to functional improvements in chronic populations (van der Lee et al., 2001). In these instances, a more appropriate tool for assessing functional improvements in chronic populations is the Action Research Arm Test (assesses upper extremity function only).
In what languages is the measure available?

  • English
  • French canadian  (Arsenault, Dutil, Lambert, Corriveau, Guarna, & Drouin, 1988)