In this section
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.
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.
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
The MA2 can be used to:
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
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.
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.
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:
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.
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