The Melbourne Assessment 2

About the Melbourne Assessment 2

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    What is the MA2

    The Melbourne Assessment 2 is a valid and reliable tool for evaluating quality of upper limb movement in children with a neurological impairment aged 2.5 to 15 years. It is a criterion-referenced test that extends and refines the scale properties of the original Melbourne Assessment. The MA2 measures four elements of upper limb movement quality: movement range, accuracy, dexterity and fluency. It comprises 14 test items of reaching to, grasping, releasing and manipulating simple objects. Each child's test performance is videorecorded for subsequent scoring.

    Scoring is completed for the 30 item scores using a three, four or five point scale and the individually defined scoring criteria. Item scores relating to each element of movement measured are categorised into four corresponding sub-scales. Within each sub-scale item scores are summed to provide a total score for each of the four elements of movement quality measured. A child’s final score on the MA2 is therefore reported as four separate scores, one for each element of movement quality measured. Both the test items and scoring criteria on the MA2 aim to be representative of the most important components of upper limb function.

    It is recommended that the MA2 be used in place of the original tool in both clinical and research applications due to its enhanced scale and measurement properties.

    Development of the MA2

    The MA2 is a revision and extension of the original Melbourne Assessment which was published in 1999. Further investigation of the original tool was undertaken to address identified gaps in tools available to measure quality of upper limb movement for a broad age range of children with neurological impairments (Fedrizzi et al., 2003)

    The lower age limit of 5 years set in development of the original Melbourne Assessment, limited the clinical and research application of the tool for children across a broad age range and excluded younger children who often are targeted to receive early intervention.  The original tool had established evidence of validity and reliability and was being reported in an increasing number of outcome studies (Sanger, et al., 2007; Satila et al., 2006; van Meeteren et al., 2008; Wallen et al., 2007), thus it was deemed of value to investigate if a modified version of the original tool could be used with younger children. A study was undertaken to review the tool, and investigate face and content validity of the modified tool for use with children aged 2 to 4 years. In addition, the measurement properties of the original scale were investigated to identify refinements to the test and scaling system to strengthen the measurement capabilities of the tool. Specifically the scale properties of the four elements of upper limb movement quality measured by the assessment were investigated using methods of Rasch Analysis (Randall, 2009).

    The results of these investigations identified that the modified tool was valid for use with children aged from 2.5 years. It also identified revisions to the scaling of the tool, which included the removal of 2 of the original 16 test items together with removal of 7 of the original 37 score items, and the re-scaling of 7 of the remaining 30 score items. The implementation of these revisions has led to the development of this revised version of the tool, titled The Melbourne Assessment 2 (MA2). The MA2 contains 14 test items, comprising 30 items scores that are organised into four separate uni-dimensional sub-scales. These four sub-scales enable measurement of four specific elements of upper limb movement quality: range, fluency, accuracy and dexterity.

    A further important finding from the psychometric testing of the original scale was the lack of evidence for the uni-dimensionality of the tool across the original 37 items scores. This finding indicated that the practice of summing all items scores to calculate one overall total score for the original tool was not empirically supported. Rather, scores should be summed and reported as four sun-scale totals. Revising the manner in which item scores are summed is a major development to the overall scaling of the tool. In the original tool the summing of one overall total score did not provide information at the level of the specific elements of movement quality scored by the assessment. Clinicians will now be able to confidently use the sum scores from the sub-scales of the MA2 to measure range, accuracy, fluency and dexterity of upper limb movement in children neurological impairment. 

    Who can be assessed?

    The MA2 can be used with children aged 2.5 to 15 years who have either a congenital (for example, cerebral palsy) or an acquired neurological condition.
    The MA2 has been developed for children with a range of different movement disorders including spasticity, dystonia, choreoathetosis and ataxia.
    For children with bilateral involvement, it may be that only one upper limb is assessed. If both upper limbs are to be assessed, each upper limb is assessed and scored separately.

    **Assessment of dominant versus non-dominant limb.
     For most children with congenital unilateral involvement their non-dominant limb will be assessed. For children with unilateral involvement resulting from an acquired neurological condition it may be either their dominant or non dominant limb.
    NB:  The test administration guidelines note the special circumstances for excluding Item 4: Drawing Grasp for cases where the upper limb to be assessed is the child's non-dominant limb. The score sheet also notes to adjust the total possible score for the dexterity sub-scale when item 4 is not completed.

    When to use the MA2

    The MA2 can be used to:

    • identify elements of a child's movement to target for intervention, such as limitations in active range of movement (ROM) or identification of muscles for surgical intervention.
    • compare one child's performance to another over time or following a specific treatment intervention
    • provide a quantitative measure for supporting applications for funding assistance or justification for therapy intervention
    • evaluate changes in an individual's performance pre- and post intervention (such as therapeutic, surgical, neurological and mechanical interventions)
    • provide information to parents, teachers, other staff and clinical students as to a child's progress in a treatment program

    Who can administer and score the MA2?

    Test administrators can be occupational therapists, physiotherapists, other allied health professionals or researchers or medical practitioners qualified in the assessment of upper limb motor control. It is essential that test administrators familiarise themselves with the tool by watching the demonstration video provided and be knowledgeable of the equipment set up and instructions for each test item. It is also important that they understand the components of movements scored for each item before administering the test. The test user should be familiar to the child and experienced in observing movements of children with neurological impairment.

    Scorers of the MA2 need to complete the online training and 'Test Yourself component of the training before using the MA2 in a clinical or research setting. Scorers are also advised to establish reliable scoring of the tool as per the recommendations provided.

    How long does it take?

    The MA2 takes anywhere from 10 to 30 minutes to administer depending on the child's age, level of ability, attention to and understanding of instructions, and co-operation. Scoring of the videorecord takes a further 20 to 30 minutes depending again on the child's co-operation and type of movement disorder and the scorer's level of familiarity with the tool.
    Prior to administering the assessment, the setting up of test equipment and marking of the positions for the placement of the video camera takes approximately ten minutes. Packing up requires about five minutes.

    For younger children test administration may need to be flexible. If a younger child loses attention or chooses not to co-operate with instructions several short assessment sessions may be needed to complete the full assessment however, these should be carried out within a two week period. Also if items need to be presented in a varied sequence to assist in engaging and maintaining the child's attention this is also allowable as it is not the child's level or duration of attention or level of co-operation that is being assessed rather the quality of their upper limb movement.

    About the authors

    Melinda Randall is a paediatric occupational therapist who has worked with children with neurological impairment at The Royal Children’s Hospital, Melbourne since 1985. Melinda is interested in evaluating upper limb treatment outcomes in children with cerebral palsy and has completed her doctoral studies on revising the Melbourne Assessment to include children aged 2 to 15 years and further investigate the construct validity and scale properties of the assessment. The result of her completed studies is the development of a revised version of the tool, titled The Melbourne Assessment 2: a test of unilateral upper limb function.

    Lindy Johnson is a paediatric occupational therapist with experience in clinical, research, teaching and management roles. Lindy was involved in the initial development of the original version of The Melbourne Assessment in 1990-91 and maintained her interest in the assessment during her time of working at The Royal Children’s Hospital, Melbourne from 1990 till 2006.

    Dinah Reddihough is a paediatrician involved in the care of children with multiple disabilities, particularly cerebral palsy and developmental disability. For 25 years Dinah fulfilled the position of Director of Developmental Medicine at The Royal Children’s Hospital, Melbourne. Dinah has also been a key person in establishing both the Victorian Cerebral Palsy Register and SOLVE at the RCH, a research initiative focused on gaining an improved understanding of the causes and outcomes of disabilities in childhood. She now holds the position of Clinical Professor in Developmental Medicine, University of Melbourne and continues her extensive clinical and research activities at The RCH.

    Acknowledgements

    The authors would like to acknowledge the vision of the original group of Melbourne- based clinicians who sought to construct a measure of quality of upper limb movement for children with cerebral palsy, and the children, families and staff who made possible the development of the original Melbourne Assessment. Revision and further extension of the original tool was only made possible with the valuable assistance of:

    • Professor Leeanne Carey, Dr. Christine Imms and Associate Professor Julie Pallant who supervised Melinda Randall's PhD studies on the Melbourne Assessment
    • Margaret Wallen, Helen Bourke-Taylor, Josie Duncan, Cathy Elliot and Siobhan Reid who, along with their respective collaborators, graciously shared de-identified copies of Melbourne Assessment data for undertaking Rasch Analysis
    • the Staff, children and families of the Child Care Centre, and Departments of Occupational Therapy, Rehabilitation and Developmental Medicine at The Royal Children's Hospital, Melbourne without who it would not have been possible to extend the tool for use with younger children

    The research undertaken to develop The Melbourne Assessment 2 was supported by grants from The Royal Children's Hospital (Clinical Award), Faculty Health Sciences, La Trobe University (Postgraduate Award) and the Australian Association of Occupational Therapists (Research Award). Production of The Melbourne Assessment 2 was supported by a grant from the Lynne Quayle Charitable Trust Fund and the William Henry Pawsey Estate as administered by Equity Trustees Limited.

    Psychometrics of the MA and MA2

    Publications about the Melbourne Assessment including reviews of the tool

    1. Bourke- Taylor, H. (2003). Melbourne Assessment of Unilateral Upper Limb Function: construct validity and correlation with the Pediatric Evaluation of Disability Inventory. Developmental Medicine and Child Neurology, 45, 92-96.
    2. Cusick, A., Vasquez, M., Knowles, L., & Wallen, M. (2005). Effect of rater training on reliability of Melbourne Assessment of Unilateral Upper Limb Function scores. Developmental Medicine & Child Neurology, 47(1), 39-45.
    3. Gilmore, R., Sakzewski, L., & Boyd, R. (2010). Upper limb activity measures for 5- to 16-year-old children with congenital hemiplegia: a systematic review. Developmental Medicine & Child Neurology, 52(1), 14-21.
    4. Johnson, L. M., Randall, M. J., Reddihough, D. S., Oke, L. E., Eyrt, T. A., & Each, T. M. (1994). Development of a clinical assessment of quality of movement for unilateral upper limb function. Developmental Medicine and Child Neurology, 36,965-973.
    5. Klingels, H., P. De Cock, et al. (2008). Comparison of the Melbourne Assessment of Unilateral Upper Limb Function and the Quality of Upper Extremity Skills Test in hemiplegic CP. Developmental Medicine & Child Neurology(50): 1-6.
    6. Klingels, K., Jaspers, E., Van de Winckel, A., De Cock, P., Molenaers, G., & Feys, H. (2010). A systematic review of arm activity measures for children with hemiplegic cerebral palsy. Clinical Rehabilitation, 24(10), 887-900.
    7. Randall, M. (2005). Development of 'The Melbourne Assessment of Unilateral Upper Limb Function': A Quantitative Test of Quality of Movement for Children with Cerebral Palsy. In H. D. Fong (Ed.), Focus on Cerebral Palsy Research (pp.93-122). New York: Nova Publishers.
    8. Randall, M., Johnson, L., & Reddihough, D. (1999). The Melbourne Assessment of Unilateral Upper Limb Function: test administration manual. Melbourne: Royal Children's Hospital, Melbourne.
    9. Randall, M., Carlin, J., Chondros, P., & Reddihough, D. (2001). Reliability of the Melbourne Assessment of Unilateral Upper Limb Function. Developmental Medicine and Child Neurology, 43,761-767.
    10. Randall, M., Imms, C., & Carey, L. (2008). Establishing validity of a modified Melbourne Assessment for children ages 2 to 4 years. American Journal of Occupational Therapy, 62(4), 373-383.
    11. Spirtos, M., O'Mahony, P., Malone, M. (2011). Interrater reliability of the Melbourne Assessment of Unilateral Upper Limb Function for Children with Hemiplegic Cerebral Palsy. The American Journal of Occupational Therapy 65(4): 378-83.

    Publications where the Melbourne Assessment was used

    1. Aarts, P. B., Jongerius, P. H., Geerdink, Y. A., van Limbeek, J., & Geurts, A. C. (2010). Effectiveness of modified constraint-induced movement therapy in children with unilateral spastic cerebral palsy: a randomized controlled trial. Neurorehabilitation & Neural Repair, 24(6), 509-518.
    2. Aarts, P., Jongerius, P., Aarts, M., Van Hartingsveldt, M., Anderson, P., & Beumer, A. (2007). A pilot study of the Video Observations Aarts and Aarts (VOAA): a new software program to measure motor behaviour in children with cerebral palsy. Occupational Therapy International, 14(2), 113-122.
    3. Braendvik, S. M., Elvrum, A. K., Vereijken, B., & Roeleveld, K. (2010). Relationship between neuromuscular body functions and upper extremity activity in children with cerebral palsy. Developmental Medicine & Child Neurology, 52(2), e29-34.
    4. Buesch, F. E., Schlaepfer, B., de Bruin, E. D., Wohlrab, G., Ammann-Reiffer, C., & Meyer-Heim, A. (2010). Constraint-induced movement therapy for children with obstetric brachial plexus palsy: two single-case series. International Journal of Rehabilitation Research, 33(2), 187-192.
    5. Cope, S. M., Liu, X. C., Verber, M. D., Cayo, C., Rao, S., & Tassone, J. C. (2010). Upper limb function and brain reorganization after constraint-induced movement therapy in children with hemiplegia. Developmental neurorehabilitation, 13(1), 19-30.
    6. Corn, K., Imms, C., Timewell, G., Carter, C., Collins, L., Dubbeld, S., et al. (2003). Impact of Second Skin Lycra Splinting on the Quality of Upper Limb Movement in Children. British Journal of Occupational Therapy, 66(10), 464-472.
    7. Eliasson, A. C., Shaw, K., Ponten, E., Boyd, R., & Krumlinde-Sundholm, L. (2009). Feasibility of a day-camp model of modified constraint-induced movement therapy with and without botulinum toxin A injection for children with hemiplegia. Physical & Occupational Therapy in Pediatrics, 29(3), 311-333.
    8. Feys, H., Eyssen, M., Jaspers, E., Klingels, K., Desloovere, K., Molenaers, G., & De Cock, P. (2010). Relation between neuroradiological findings and upper limb function in hemiplegic cerebral palsy. European Journal of Paediatric Neurology, 14(2), 169-177.
    9. Fluet, G. G., Qiu, Q., Kelly, D., Parikh, H. D., Ramirez, D., Saleh, S., & Adamovich, S. V. (2010). Interfacing a haptic robotic system with complex virtual environments to treat impaired upper extremity motor function in children with cerebral palsy. Developmental neurorehabilitation, 13(5), 335-345.
    10. Jannink, M. J., van der Wilden, G. J., Navis, D. W., Visser, G., Gussinklo, J., & Ijzerman, M. (2008). A low-cost video game applied for training of upper extremity function in children with cerebral palsy: a pilot study. Cyberpsychology & Behavior, 11(1), 27-32.
    11. Kirton, A., Chen, R., Friefeld, S., Gunraj, C., Pontigon, A. M., & Deveber, G. (2008). Contralesional repetitive transcranial magnetic stimulation for chronic hemiparesis in subcortical paediatric stroke: a randomised trial. Lancet Neurology, 7(6), 507-513
    12. Mackey, A. H., Miller, F., Walt, S. E., Waugh, M. C., & Stott, N. S. (2008). Use of three-dimensional kinematic analysis following upper limb botulinum toxin A for children with hemiplegia. European Journal of Neurology, 15(11), 1191-1198.
    13. Martin, A., Burtner, P. A., Poole, J., & Phillips, J. (2008). Case report: ICF-level changes in a preschooler after constraint-induced movement therapy. American Journal of Occupational Therapy, 62(3), 282-288.
    14. Motta, F., Antonello, C. E., & Stignani, C. (2010). Forced-use, without therapy, in children with hemiplegia: preliminary study of a new approach for the upper limb. Journal of Pediatric Orthopedics, 30(6), 582-587.
    15. Motta, F., Antonello, C. E., & Stignani, C. (2009). Upper limbs function after intrathecal baclofen therapy in children with secondary dystonia. Journal of Pediatric Orthopedics, 29(7), 817-821
    16. Motta, F., Stignani, C., & Antonello, C. E. (2008). Upper limb function after intrathecal baclofen treatment in children with cerebral palsy. Journal of Pediatric Orthopedics, 28(1), 91-96.
    17. Ozer, K., Chesher, S. P., & Scheker, L. R. (2006). Neuromuscular electrical stimulation and dynamic bracing for the management of upper-extremity spasticity in children with cerebral palsy. Developmental Medicine & Child Neurology, 48(7), 559-563.
    18. Postans, N., Wright, P., Bromwich, W., Wilkinson, I., Farmer, S.E., Swain, I. (2010). The combined effect of Dynamic splinting and Neuromuscular electrical stimulation in reducing wrist and elbow contractures in six children with Cerebral palsy. Prosthetics & Orthotics International, 34(1), 10-19.
    19. Rameckers, E.A., Speth, L.A., Duysens, J., Vles, J.S., Smits-Engelsman, B.C. (2009). Botulinum toxin-A in children with congenital spastic hemiplegia does not improve upper extremity motor-related function over rehabilitation alone: a randomized controlled trial. Neurorehabilitation & Neural Repair, 23(3), 218-225.
    20. Rameckers, E. A., Duysens, J., Speth, L. A., Vles, H. J., & Smits-Engelsman, B. C. (2010). Effect of addition of botulinum toxin-A to standardized therapy for dynamic manual skills measured with kinematic aiming tasks in children with spastic hemiplegia. Journal of Rehabilitation Medicine, 42(4), 332-338.
    21. Sakzewski, L., Ziviani, J., Abbott, D. F., Macdonell, R. A., Jackson, G. D., & Boyd, R. N. (2011). Randomized trial of constraint-induced movement therapy and bimanual training on activity outcomes for children with congenital hemiplegia. Developmental Medicine & Child Neurology, 53(4), 313-320.
    22. Sakzewski, L., J. Ziviani, et al. (2011). Best responders after intensive upper-limb training for children with unilateral cerebral palsy. Archives of Physical Medicine & Rehabilitation 92(4): 578-84.
    23. Sakzewski, L., J. Ziviani, et al. (2010). The relationship between unimanual capacity and bimanual performance in children with congenital hemiplegia. Developmental Medicine & Child Neurology 52(9): 811-6.
    24. Sanger, T. D., Bastian, A., Brunstrom, J., Damiano, D., Delgado, M., Dure, L., . . . Welty, L. J. (2007). Prospective open-label clinical trial of trihexyphenidyl in children with secondary dystonia due to cerebral palsy. Journal of Child Neurology, 22(5), 530-537.
    25. Satila, H., Kotamaki, A., Koivikko, M., & Autti-Ramo, I. (2006). Upper limb function after botulinum toxin A treatment in cerebral palsy: two years follow-up of six cases. Pediatric Rehabilitation, 9(3), 247-258.
    26. Schneiberg, S., McKinley, P. A., Sveistrup, H., Gisel, E., Mayo, N. E., & Levin, M. F. (2010). The effectiveness of task-oriented intervention and trunk restraint on upper limb movement quality in children with cerebral palsy. Developmental Medicine & Child Neurology, 52(11), e245-253.
    27. Speth, L. A., Leffers, P., Janssen-Potten, Y. J., Vles, J. S., Speth, L. A. W. M., Janssen-Potten, Y. J. M., & Vles, J. S. H. (2005). Botulinum toxin A and upper limb functional skills in hemiparetic cerebral palsy: a randomized trial in children receiving intensive therapy. Developmental Medicine & Child Neurology, 47(7), 468-473.
    28. van Meeteren, J., Nieuwenhuijsen, C., de Grund, A., Stam, H. J., & Roebroeck, M. E. (2010). Using the manual ability classification system in young adults with cerebral palsy and normal intelligence. Disability & Rehabilitation, 32(23), 1885-1893.
    29. van Meeteren, J., Roebroeck, M., Celen, E., Donkervoort, M., & Stam, H. (2008). Functional activities of the upper extremity of young adults with cerebral palsy: a limiting factor for participation? Disability & Rehabilitation. 30(5), 387-395.
    30. van Meeteren, J., van Rijn, R. M., Selles, R. W., Roebroeck, M. E., & Stam, H. J. (2007). Grip strength parameters and functional activities in young adults with unilateral cerebral palsy compared with healthy subjects. Journal of Rehabilitation Medicine, 39(8), 598-604.
    31. Wallen, M., Ziviani, J., Herbert, R., Evans, R., & Novak, I. (2008). Modified constraint-induced therapy for children with hemiplegic cerebral palsy: a feasibility study. Developmental neurorehabilitation, 11(2), 124-133.
    32. Wallen, M., O'Flaherty, S. J., & Waugh, M. C. (2007). Functional outcomes of intramuscular botulinum toxin type a and occupational therapy in the upper limbs of children with cerebral palsy: a randomized controlled trial. Archives of Physical Medicine & Rehabilitation, 88(1), 1-10.
    33. Wallen, M. A., O'Flaherty S, J., & Waugh, M. C. (2004). Functional outcomes of intramuscular botulinum toxin type A in the upper limbs of children with cerebral palsy: a phase II trial. Archives of Physical Medicine & Rehabilitation, 85(2),192-200.
    34. Yasukawa, A., Patel, P., & Sisung, C. (2006). Pilot study: investigating the effects of Kinesio Taping in an acute pediatric rehabilitation setting. American Journal of Occupational Therapy, 60(1), 104-110.

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