Assessments are almost completely worthless unless they point directly to the 100% recovery protocols. I see nothing here that suggests you go from the assessment to the chosen 100% recovery protocol.
Interrater reliability of the Fugl-Meyer Motor assessment in stroke patients: a quality management project within the ESTREL study
Karin Wiesner1,2*
Anne Schwarz3
Louisa Meya4
Josefin Emelie Kaufmann1,4
Christopher Traenka1,4Andreas Rüdiger Luft3,5
Jeremia Philipp Oskar Held3,6†Stefan Engelter1,4†- 1Neurorehabilitation and Neurology, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
- 2Department of Health Professions, Bern University of Applied Sciences, Bern, Switzerland
- 3Division of Vascular Neurology and Neurorehabilitation, Department of Neurology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
- 4Department of Neurology and Department of Clinical Research, University of Basel and University Hospital Basel, Basel, Switzerland
- 5Cereneo Center of Neurology and Rehabilitation, Zurich, Switzerland
- 6Valens Clinics, Reha Center Triemli, Vitznau, Switzerland
Introduction: The Fugl-Meyer Motor Assessment (FMMA) is recommended for evaluating stroke motor recovery in clinical practice and research. However, its widespread use requires refined reliability data, particularly across different health professions. We therefore investigated the interrater reliability of the FMMA scored by a physical therapist and a physician using video recordings of stroke patients.
Methods: The FMMA videos of 50 individuals 3 months post stroke (28 females, mean age 71.64 years, median National Institutes of Health Stroke Scale score 3.00) participating in the ESTREL trial (Enhancement of Stroke Rehabilitation with Levodopa: a randomized placebo-controlled trial) were independently scored by two experienced assessors (i.e., a physical therapist and a physician) with specific training to ensure consistency. As primary endpoint, the interrater reliability was calculated for the total scores of the entire FMMA and the total scores of the FMMA for the upper and lower extremities using intraclass correlation coefficients (ICC). In addition, Spearman’s rank order correlation coefficients (Spearman’s rho) were calculated for the total score and subscale levels. Secondary endpoints included the FMMA item scores using percentage agreement, weighted Cohen’s kappa coefficients, and Gwet’s AC1/AC2 coefficients.
Results: ICCs were 0.98 (95% confidence intervals (CI) 0.96–0.99) for the total scores of the entire FMMA, 0.98 (95% CI 0.96–0.99) for the total scores of the FMMA for the upper extremity, and 0.85 (95% CI 0.70–0.92) for the total scores of the FMMA for the lower extremity. Spearman’s rho ranged from 0.61 to 0.94 for total and subscale scores. The interrater reliability at the item level of the FMMA showed (i) percentage agreement values with a median of 77% (range 44–100%), (ii) weighted Cohen’s kappa coefficients with a median of 0.69 (range 0.00–0.98) and (iii) Gwet’s AC1/AC2 coefficients with a median of 0.84 (range 0.42–0.98).
Discussion and conclusion: The FMMA appears to be a highly reliable measuring instrument at the overall score level for assessors from different health professions. The FMMA total scores seem to be suitable for the quantitative measurement of stroke recovery in both clinical practice and research, although there is potential for improvement at the item level.
Introduction
Motor impairment is one of the most important disabilities associated with stroke and can significantly affect the quality of life (1). Muscle weakness, abnormal synergy, and spasticity are among the motor deficits commonly assessed in stroke patients (2). Considering the repair processes, measuring motor recovery after stroke is very important. The Fugl-Meyer Motor Assessment (FMMA) (3) is strongly recommended as a clinical and research tool for the evaluation of changes in motor impairment after stroke (4). It was a key component of the assessment recommendations for improving the methodology of adult rehabilitation and recovery trials (5) and clinical motor rehabilitation (6), which should be repeated at different measurement time points. The inclusion of the upper extremity FMMA (FMMA-UE) in further recommendations for outcome measurement after stroke has confirmed its importance (7, 8).
The maximum total score per side is 66 points for the FMMA-UE and 34 points for the lower extremity FMMA (FMMA-LE) (4). The FMMA items are rated on an ordinal scale with the scores 0 = cannot perform, 1 = performs partially and 2 = performs fully (4). The practical implementation of the test and the assessment of its individual items require standardized, sound training as well as routine. These aspects can be promoted by a uniform test version in the different languages of the respective countries of application. Upon completion of the present project, standardized FMMA test forms translated into more than 10 different languages were available [e.g., at https://www.gu.se/en/neuroscience-physiology/fugl-meyer-assessment (9)]. However, to the best of our knowledge, no standardized, validated German version of the test is currently available. Therefore, we developed an adapted German version of the assessment, based on the original article and protocols of the University of Gothenburg (3, 10, 11). The corresponding assessment forms can be found in the Supplementary Table S1. The interprofessional application of this German version of the FMMA into clinical trials requires good psychometric properties in terms of the validation process.
A high interrater reliability of the German version of the FMMA across different health professions is essential for the use of the assessment in clinical studies, but also for its application in daily rehabilitation practice. The English version of the FMMA showed excellent intra- and interrater reliability (4). Platz et al. (12) found a very high interrater reliability of the FMMA-UE with intraclass correlation coefficients (ICC) based on video recordings. In the Sullivan et al. (13) study, interrater agreement between expert and therapist raters using video recordings was high for the FMMA total scores with an ICC value of 0.98 as well as for total scores of the FMMA-UE with 0.99 and moderate to high for the FMMA-LE total scores with 0.91. Based in part on the strong evidence for validity, reliability, responsiveness, and clinical utility, the FMMA-UE was incorporated into the core set of European evidence-based recommendations for Clinical Assessment of Upper Limb In Neurorehabilitation (CAULIN) (7).
In this context, refined reliability data and the availability of transculturally adapted, validated FMMA versions in different languages are even more important. Investigating the interrater reliability of new FMMA versions using sufficiently large samples is a relevant component in this regard. Therefore, we aimed to investigate (i) the interrater reliability of the German FMMA across health professions and (ii) the comparability of the psychometric properties of the German FMMA with those of the English version.
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