What is the MA2?

The Melbourne Assessment 2 (MA2) is a valid and reliable criterion-referenced test for evaluating four elements of upper limb movement quality in children with a neurological impairment aged 2.5 to 15 years: (i) Range of movement, (ii) Accuracy of reach and placement, (iii) Dexterity of grasp, release and manipulation and (iv) Fluency of movement. 

The full test comprises 14 test items which require a child to reach to, grasp, release and manipulate simple objects. Each child's test performance is video recorded for subsequent scoring.

Scoring is completed across the 30 score items using a three, four or five point scale and individually defined scoring criteria. Item scores relating to each element of movement measured are summed within the corresponding sub-scale. A child’s final score on the MA2 is 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.

How was the MA2 developed?

The MA2 was developed following further investigation of the original Melbourne Assessment published in 1999. Further Investigations were undertaken to:

1.     Establish validity of the original tool for use with younger children.

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 are frequently 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. 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 (Randall, 2012).

2.     Investigate the measurement properties of the original scale.

Specifically the scale properties of the assessment were investigated using methods of Rasch Analysis. Refinements to the test items and scaling system identified the tool comprised four distinctive scales, each measuring a separate element of upper limb movement quality (Randall, 2014).

The incorporation of modifications to extend the original tool for use with younger children and scaling refinements have produced the MA2.

Who can be assessed using the MA2?

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.

What information does the MA2 provide?

The MA2 can:

• 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 and clinical staff 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 and medical practitioners qualified in the assessment of upper limb motor control. It is essential that test administrators are familiar 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 they understand the components of movements scored for each item before administering the test.

Scorers of the MA2 should be experienced in observing movements of children with neurological impairment. In addition, they 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 online.

How long does the MA2 take to administer and score?

The MA2 takes 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 video record 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 five 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. If items need to be presented in a varied sequence to assist in engaging and maintaining the child's attention this is 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 undertook the extension and revision of the original Melbourne Assessment for her doctoral studies. 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 the Victorian Cerebral Palsy Register and is an international leader and researcher in the field of cerebral palsy.

Acknowledgements

The authors would like to acknowledge the vision of the original group of Melbourne-based clinicians who sought to construct a quantitative measure of quality of upper limb movement for children with cerebral palsy. Also importantly, we thank 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

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. Randall, M., Imms, C. & Carey, L. (2012). Further evidence of validity of the Modified Melbourne Assessment for neurologically impaired children aged 2 to 4 years. Developmental Medicine & Child Neurology. 54(5): 424-428

12. Randall, M., Imms, C., Carey, L. & Pallant.J. (2014). Rasch analysis of the Melbourne Assessment of Unilateral Upper Limb Function. Developmental Medicine and Child Neurology. 56(3):665-672 DOI: 10.1111/dmcn.12391.
    
    
13. 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.