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Example Report

  • As with all forms of writing it is desirable to report results from the Melbourne Assessment 2 (MA2) in a clear and concise manner.

    An example of how to report a child's performance and scores on the MA2 is provided below. Depending on the purpose of the report it may be appropriate to add further descriptive information about the child's movement abilities.

    It is recommended that you:
     
    1. Start with a general description of the assessment (see example).

    2. For each sub-scale, state how many test items the child completed and their percentage scores.

    3. Make a general comment on the child's ability to comply with and perform test items.

    4. Report on the sub-scales (i.e. element(s) of movement) with which the child experienced difficulty and those in which they performed well.

    Describe the factors influencing their ability to perform 'quality' movements (for example increased tone, reduced ROM at which joints, presence of tremor). Comment how the presence of these limited or impeded the child's performance on the tasks observed.

    Add additional observations or comments about the child's performance at the end of the report

    Example report

    Child's Name: MarkUR number: 
    DOB:Date of assessment:
    Age at assessment:11 yearsTherapist:
    Diagnosis:CP - left hemiplegia

              
    Assessments used: The Melbourne Assessment 2: a test of unilateral upper limb function.

    The Melbourne Assessment 2 is a standardized assessment of quality of unilateral upper limb movement for children aged 2.5 to 15 years with neurological impairments. The assessment scores 4 elements of movement quality (range, accuracy, fluency and dexterity) as a child performs 14 everyday tasks. The tasks require the child to reach, grasp, release and manipulate simple items such as a crayon, pellet and cube. Movement elements are scored on a 3, 4 or 5 point scale according to specific criteria. Scores are arranged into 4 sub-scales according to the element of movement being rated. A child's total raw score for each sub-scale is converted to a percentage of the maximum possible score for that sub-scale.

    Mark was scored on 13 of the test items using his left upper limb. He was not administered Item 4 Drawing grasp as the assessment involved his non-dominant hand.
    Mark was co-operative throughout the testing situation and was able to comply with all aspects of the test and follow all instructions with minimal prompting.
    His final raw score (with percentage score) for each sub-scale was:

    • Range of movement: 17/27 (63%)
    • Accuracy of reach and placement: 25/25 (100%)
    • Dexterity of grasp, release and manipulation: 11/17 (68.8%)
    • Fluency of movement: 14/21 (66.7%)

    Mark was able to perform all movements required using his left upper limb but his performance was affected by the increased effort required and his reduced range of elbow extension, forearm supination and thumb abduction and opposition.

    For items scoring accuracy of reach and placement he scored full marks. His greatest difficulty was with sub-items scoring range of movement and dexterity. 
    Mark's active use of his left upper limb was also interrupted during the assessment by occasional involuntary increases in tone in his limb, most commonly involving the limb posturing into shoulder internal rotation, elbow flexion, forearm pronation and wrist flexion. Fluency of movements was also reduced due to the increased effort required.

    [Additional information which may or may not be required…
    Range of movement
    In items requiring reach either forwards or to the side, Mark was limited in the degree of elbow and wrist extension he could achieve and he was also unable to achieve full supination (turning palm to face the ceiling) of his left forearm. Mark had sufficient range of movement in his left upper limb to reach to his bottom, head, top of opposite shoulder and mouth. 


    Accuracy and fluency of reach
    Mark was able to reach with accuracy to a target as well as to body parts such as his mouth and opposite shoulder. However, he had difficulty with performing movements fluently when performing reaching tasks.

    Dexterity of grasp, release and manipulation
    When grasping items with his left hand, Mark typically postured into wrist flexion and forearm pronation.  He was able to pick up a crayon from the table using his whole hand to grasp the crayon. He held the crayon with the point of the crayon on the thumb side of the hand (that is, using a palmar pronate grasp) with wrist flexion and ulnar deviation. 
    Mark had difficulty picking up small pellets using his left hand, but was eventually successful with holding the pellet between his thumb and the side of his index finger (that is, using a lateral grasp) with finger and thumb joints flexed. 
    Mark was able to release the crayon and pellet with accuracy and control into a small container but performed this action with his wrist flexed and his thumb adducted.

    Finger dexterity
    Mark did not demonstrate the presence of in-hand manipulation skills and required the assistance of the table surface to turn over a small block.]

    Summary:
    Mark demonstrated the capacity to use his left upper limb for simple reach and grasp activities but his performance was impeded by his reduced active range of elbow and wrist extension, forearm supination, thumb abduction on effort and reduced dexterity with finger and in-hand movements.  When attempting difficult tasks Mark showed a mild increase in tone distally. In bilateral tasks, Mark would spontaneously stabilise objects or assist with grasping an item using his left hand with only a minimal delay.

    Recommendations:
    [list as required]

    Please call/page me on [phone number/pager] if you have questions about any of the information contained in this report.

    [Name]
    Occupational Therapist

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