The Fugl-Meyer Assessment After Stroke

By Carole Lewis, PT, DPT, GCS, GTC, MSG, MPA, PhD, FAPTA, and Keiba Shaw, EdD, MPT, MA

The total cost of having a cerebrovascular accident (e.g., CVA; stroke) to the United States is estimated to be about $43 billion per year, with direct costs for medical care and therapy estimated to be approximately $28 billion per year.¹ Indirect costs from lost productivity and other factors has been estimated at about $15 billion per year, with an average cost of care for a patient up to 90 days after a stroke equaling $15,000.¹

Forty percent of individuals who have had a stroke will experience impairments ranging from moderate to severe that may require special care and attention from caregivers and rehabilitation personnel. Due to this fact, measuring recovery after stroke is important as it can help establish treatment plans and prepare the patient, family and significant others for anticipated, if not expected outcomes. In an attempt to quantify the motor and sensory recovery of individuals who had a stroke, the Fugl-Meyer Assessment for Motor Recovery After Stroke was developed.²

Scale Description

The Fugl-Meyer (FM) is widely used in clinical trials and rehabilitation settings that treat people after stroke. It is considered to be one of the most thorough measures of impairments in motor functioning after stroke, and is used as an objective measure of impairment and subsequent recovery in individuals poststroke and hemiplegia.³ The FM is a 226-point, 155-item Likert scale developed as an evaluative measure of recovery from individuals who have sustained a hemiplegic stroke. Each item on the FM is rated on a three-point ordinal scale (0 = cannot perform, 1 = performs partially, 2 = performs fully) and has scales that measure motor performance, sensory function, balance, joint range of motion and joint pain.

The motor performance subscale scores range from 0 (hemiplegia) to a maximum of 100 points (normal motor performance) with further delineation occurring for the upper extremity (maximum points of 66) and lower extremity (maximum points of 34). There is a maximum of 24 points on sensory function, 14 points for sitting and standing balance, 44 points for range of motion, and 44 points for joint pain. The scores on the subscales are grouped according to various levels of impairment. A score less than 50 = severe motor impairment, 50-84 points = marked motor impairment, 85-95 points = moderate motor impairment, and 96-99 points = slight motor impairment.⁴

Item construction for the FM was done based on empirical observations of recovery patterns as documented as early as 1951 by Twitchell,⁵ later followed by Bobath⁶ and Brunnstrom⁷ in patients who had hemiplegia as a result of stroke.³

Reliability

Reliability of the scales of the Fugl-Meyer has been examined in many studies.^8,9 Lin et al examined the psychometric properties of the sensory scale of the FM and found a significant ceiling effect, poor to moderate inter-rater reliability for the four items of light touch (weighted kappa ranging from .30-.55), although inter-rater reliability for the total score on the sensory scale was high (ICC = .93).⁸ Cronbach's alpha examining internal consistency at various time points after stroke, ranged from .94 to .98. Duncan et al examined interrater reliability on upper and lower extremity motor performance and total scores in a sample of 19 patients less than one year post stroke.⁹

Pearson correlation coefficients were high for the total score (.98-.99; range =. 86 to .99), upper extremity motor (.99), and lower extremity motor (.96). Interrater Pearson correlation for the motor scores of the upper and lower extremities ranged from .79 to .99.¹⁰ Sanford et al studied inter-rater reliability and found overall reliability (total score) to be .96, with intraclass correlation coefficients for the subscales varying from .61 (pain) to .97 (upper extremity motor).¹⁰

Validity

Validity of the FM has also been examined. Poor to moderate validity and low to moderate responsiveness were also seen at different stages post stroke and recovery. This study found that the ability to predict function in activities of daily living (ADLs) was low, with weak correlations shown with items on the Barthel Index that measure function in ADLs.

Lin and colleagues⁸ attribute the differences between the findings in their study and others^11,12 that have shown good predictive abilities of the FM on ADL function to noted ceiling effects seen in their study. Responsiveness—the ability to detect change in function (in this case, sensation) over time on the FM–was found to be moderate 14 to 180 days post-stroke, but found to be low before 90 days post-stroke for 90 to 180 days of stroke recovery. This may be due, according to Lin et al, to insufficient scale resolution to detect patients' improvement before 90 days after a stroke or to sensory gains that may have plateaued after 90 days.

Administration of the Fugl-Meyer

There is no formal training (other than the requirement that you are a trained physical or occupational therapist) or special equipment needed to administer the FM. Administration of the FM takes approximately 30 to 40 minutes, depending on the patient, and can be performed bedside (in acute care) or in the inpatient rehabilitation or outpatient settings.

The length of time to do the test may be a deterrent to some therapist who are looking to most efficiently maximize the time spent with their patients post stroke.

Poor cognition and/or aphasia may complicate the reliability of the ratings on the subscales. Scoring guidelines are provided for each subscale provided with the FM. A clinically meaningful improvement may be indicated by more than a 10-point change in FM motor scores.³

Overall, the Fugl-Meyer appears to be a reliable and valid assessment tool for the evaluation of individuals post stroke. There are, however, some caveats. The sensory portion of FM appears to be less reliable in patients who are cognitively impaired or who have aphasia. In addition, patients who have only mild deficits as a result of their strokes will likely score high on the FM–encountering a ceiling effect.

Therefore, consideration should be taken as to whether to use the FM on individuals who have less than moderate to severe impairments. In spite of these precautions, the Fugl-Meyer maintains its status as a clinically relevant and useful research tool for evaluating changes in motor impairment following stroke.

References are available online at www.advanceweb.com/PT. Select "References" on the left menu bar.

Dr. Lewis is a private practice and consulting clinical specialist for ProfessionalSportsCare and Rehab. She lectures exclusively for GREAT Seminars and Books, Inc. Dr. Lewis is also the author of numerous textbooks. Her Website address is www.greatseminarsandbooks.com. Dr. Shaw is an assistant professor in the physical therapy program at the University of South Florida dedicated to the area of geriatric rehabilitation. She lectures exclusively for GREAT Seminars and Books in the area of geriatric function.