Physiotherapy 90 (2004) 132–138

Measurement of mobility following stroke: a comparison

of the Modified Rivermead Mobility Index and
the Motor Assessment Scale夽
Louise Johnson a,∗ , James Selfe b
a Division of Physiotherapy, School of Health Studies, University of Bradford, Unity Building,
25 Trinity Road, Bradford, West Yorkshire BD5 0BB, UK
b Allied Health Professions Unit, University of Central Lancaster, Lancaster, UK

Abstract

Background and purpose The Modified Rivermead Mobility Index (MRMI) is a newly developed outcome measure that aims to evaluate
the effectiveness of physiotherapy on mobility following stroke. Any new measurement tool requires extensive testing of its validity and
reliability before it can be recommended for use in clinical practice or research. The purpose of this study was to investigate the concurrent
validity of the MRMI when measuring mobility in patients who have had a stroke. The internal consistency and test administration times of
the MRMI and Motor Assessment Scale (MAS) were also investigated.
Methods Twenty-six hospitalised acute/sub-acute stroke patients from the Medical and Elderly wards of a General Hospital in West Yorkshire
were assessed independently with the MRMI and MAS. Test administration time was also recorded.
Results Limits of agreement indicated that on average subjects scored three points higher on the MRMI than the MAS (mobility-related
items). Ninety-five percent of subjects scored between one point lower and seven points higher on the MRMI than the MAS. Both scales
possessed high internal consistency (MRMI α = 0.949 and MAS α = 0.953). Individual items also possessed high internal consistency
(MRMI α = 0.743–0.959, MAS = 0.854–0.893) except the sitting balance items (MRMI α = 0.304 and MAS α = 0.545). Both scales took
an average of 17 min to administer.
Conclusions The mean difference between scores on the MRMI and MAS was small enough to allow clinicians to use either scale to measure
mobility in stroke patients. Both scales possessed high internal consistency except the sitting balance items that may be measuring a different
construct to mobility. The MRMI and MAS are sufficiently quick to administer to advocate use in routine clinical practice.
© 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Keywords: Validity; Measurement; Stroke; Outcomes; Mobility

Introduction concern has been expressed that it may not be responsive

In today’s climate of evidence-based practice the need
to use valid, reliable and clinically sensitive outcome
measures to evaluate effectiveness of interventions is ac-
knowledged [1]. The Rivermead Mobility Index (RMI)
is considered to be a valid and reliable tool that assesses
mobility in stroke patients [2–5]. The RMI measures 15
mobility-related items using a two-point ordinal scale but
夽 This research was undertaken by L. Johnson as the dissertation
towards the award of M.Sc. in Physiotherapy. Dr. J. Selfe assisted in data
analysis and writing of this paper.
∗ Corresponding author. Tel.:+01274-236587.
E-mail address: l.johnson4@bradford.ac.uk (L. Johnson).
to small clinically significant changes in mobility status
[2,6].
The Modified Rivermead Mobility Index was subse-
quently developed from the RMI to provide a more respon-
sive measure of mobility [7]. The MRMI uses a six-point
ordinal scoring system to record whether activities can be
achieved with the help of two people, one person, super-
vision, an aid or independently. The items include turning
over, moving from a lying to sitting position, sitting bal-
ance, standing up from sitting, standing, transfers, walking
and stair-climbing.
In a previous study of hospitalised stroke patients the
MRMI demonstrated high inter-rater reliability (ICC =
0.98) and was more responsive to change in mobility status

0031-9406/$ – see front matter © 2004 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.physio.2004.01.004
 L. Johnson, J. Selfe / Physiotherapy 90 (2004) 132–138
than the original RMI. The MRMI also demonstrated high
internal consistency (Cronbach’s alpha = 0.93) [8]. This
indicated that items within the scale were closely related
and therefore appeared to measure a similar construct; mo-
bility [9]. The internal consistency of individual items was
not reported.
The Motor Assessment Scale (MAS) is a measure of
motor impairment and mobility in stroke patients [10].
The MAS uses a seven-point ordinal scale to measure five
mobility-related activities that are similar to the MRMI
activities; rolling from supine to side-lying, rising from
supine to a sitting position, balanced sitting, standing up
from a sitting position and walking. Three additional items
measure upper limb impairment and function. The MAS
has documented validity and reliability [10–13]. Its in-
ternal consistency has not been reported. One limitation
of the MAS is that it only measures stair-mobility in the
highest ranked sub-category of the walking item. In or-
der to score, patients have to be able to go up and down
four steps three times with no rail and within 35 s. Conse-
quently the MAS lacks clinical sensitivity when measuring
stair-mobility in patients following stroke. Reported times
for administering the MAS vary between 15 and 36 min
[10,13].
Before the MRMI can be recommended for use in clinical
practice or research the degree to which it measures charac-
teristics associated with mobility should be established [14].
Scores on the MRMI should therefore relate to those of a
previously validated measure of the same construct (concur-
rent validity) [15,16]. This is important if accurate conclu-
sions are to be drawn from clinical interventions [17]. It is
also important for a scale to be relatively quick to administer
if it is to gain widespread clinical use [18].
The main purpose of this study was to establish
whether the MRMI is a valid measure of mobility in the
acute/sub-acute stroke phase. This was achieved by in-
vestigating the concurrent validity of the MRMI with the
Motor Assessment Scale (MAS). This aimed to establish
whether the MRMI could be used as an alternative to the
MAS when measuring mobility. The MAS was selected
as the ‘gold standard’ because of its documented validity
and reliability and because it assesses similar components
of mobility to the MRMI. The study also investigated the
internal consistency and test administration time of the two
scales.
Method
Subjects
Suitable patients were over 21 years old and had suf-
fered a stroke resulting in residual hemiplegia within
the past 3 months. Diagnosis was confirmed by comput-
erised tomography. Patients also needed to be undergo-
ing physiotherapy, medically stable and able to follow
133
simple instructions. Subjects meeting these criteria were
excluded if they had severe cognitive problems, were
registered blind or suffered musculo-skeletal pain that
limited mobility. All subjects gave written informed con-
sent. The Local Research Ethics Committee approved the
study.
Raters
A researcher (L.J.) scored the MRMI and two physiother-
apists scored the MAS. Different test administrators were
used in order to eliminate the possibility of knowledge of
scores on one scale biasing scores on the second scale. The
researcher had 6 years experience in stroke rehabilitation,
one therapist had 4 years and the other 6 months experi-
ence. The two more experienced raters were familiar with
the MAS the third was not. All had regularly used the MRMI
for at least 6 months.
Procedure
All stroke patients admitted to the medical and elderly
wards of a General Hospital in West Yorkshire between
November 2001 and January 2002 were screened for eli-
gibility to participate in the study by the researcher (L.J.).
Prior to the main investigation five subjects with varied
levels of mobility gave written informed consent to par-
ticipate in a pilot study. This aimed to standardise testing
procedures and maximise inter-rater reliability between
test administrators. The test administrators studied the
MRMI and MAS guidelines and practised scoring the
MAS with between two and four patients prior to the
pilot study. The researcher administered the MAS and
MRMI whilst all three raters independently scored subjects’
performance.
In the main investigation each subject was assessed us-
ing the two scales. The MRMI was administered by one of
the two physiotherapists and the MAS by the researcher.
Assessors were blind to each others scores and were not
involved in the treatment of subjects. For each subject the
tests were administered separately but on the same day and
in the same location before any physiotherapy intervention
was carried out. Order of test administration was alternated
between subjects to control for practice and fatigue effects.
At least 1 hour elapsed between tests. Test administration
was timed.
Analysis
Data were analysed using SPSS version 11.00 for Win-
dows (SPSS Inc, Chicago, IL) Excel ’98 Microsoft Of-
fice (Microsoft Corporation, Redmond, WA). Only the
mobility-related items of the MAS were compared in the
study of concurrent validity because the MRMI does not
include upper limb items. Total scores on the MRMI and
MAS (mobility-related items) were 40 and 30 points,
134 L. Johnson, J. Selfe / Physiotherapy 90 (2004) 132–138

respectively. To establish whether there was a consistent Table 1

bias between the two scales the raw scores from each Reasons for exclusion from study
subject on each scale were plotted. Since the scales use dif- Reason for exclusion Frequency
ferent ranges consistency of differences between scores in Died between consenting & assessment 2
the lower half of the scales and scores in the upper half of Discharged before test administered 3
the scales were then visually analysed. Further comparisons Refused 2
were made by transforming raw scores into percentages Unable to follow instructions 8
of their maximum possible scores. Percentage scores on No longer receiving physiotherapy 2
Registered blind 1
the two scales were then analysed using the Bland–Altman Musculo-skeletal pain limited mobility 1
method of agreement [19]. In this method the difference Medically unwell 2
between paired percentage scores is plotted against the Bilateral symptoms 2
mean of paired measurements. This determined the limits of Total 23
agreement between total scores on the MRMI and MAS. In
the absence of a ‘true measure’ of mobility the mean of the
paired measurements indicated the best estimate of the true The difference in raw scores on the MRMI and the MAS
value [19]. are shown in Fig. 1. All subjects scored higher on the MRMI
All items within a multi-item unidimensional scale should than the MAS. The differences in scores were similar for
measure the same construct (internal consistency). Inter- those subjects scoring in the lower half of the range (approx-
nal consistency of the MRMI and the MAS was analysed imately five points) and similar for those subjects scoring in
by computing Cronbach’s alpha [9]. For each scale the the upper half of the range (approximately 10 points).
item-total correlation and alpha if each item was deleted When the scores were transformed into percentage of
were calculated. This indicated whether each scale as a maximum possible score 23 subjects (90%) scored higher
whole and each item within each scale measured a similar and two (7%) scored lower on the MRMI compared to the
construct [9,20]. Cronbach’s alpha values between 0.80 and MAS. One subject scored equally on both scales. The dif-
0.90 are considered very good [9,21]. ferences between percentages of maximum possible scores
on the MAS and MRMI for the study sample were normally
distributed. It was therefore appropriate to analyse the limits
Results of agreement between percentage scores on the two scales as
interval data [22,23]. Fig. 2 displays the limits of agreement
Pilot study between percentages of total scores on the MAS and MRMI.
The mean difference between scores on the MAS and
There was never more than two-point disagreement be- MRMI was 7% (S.D. 4.8%). This difference equates to
tween total scores assigned by the raters to each subject a mean of 3 points more on the MRMI (S.D. 2 points).
on the MRMI or one point on the MAS (mobility-related Ninety-five percent of differences in scores lie within two
items). Complete agreement occurred on 90 (75%) of 120 standard deviations of the mean. Ninety-five percent of
comparisons between individual items on the MRMI and 58 MRMI raw scores were therefore between seven points
(77%) of 75 comparisons on the MAS. Inter-rater reliabil- above and one point below the MAS scores. The magnitude
ity was considered sufficiently high to progress to the main of the difference between percentages of paired measure-
study. ments did not appear to systematically vary between low,
middle or high scores.
Main study
Internal consistency
Forty-nine stroke patients were admitted to the hospital
during the study period. Twenty-three patients were ineli- Cronbach’s alpha for the MRMI was 0.949 and for
gible. The remaining 26 subjects participated in the study. the MAS (items 1–8) 0.953. Table 3 displays corrected
Table 1 displays the reasons for exclusion from the study. item-total correlations and Cronbach’s alpha if each
Thirteen men and 13 women participated. Their mean age
was 77 years (S.D. 9, range 45–88). Subjects were on aver- Table 2
age 29 days post-stroke (S.D. 18, range 7–83). Twenty-four MAS (mobility items) and MRMI scores
subjects had suffered a cerebral infarct, two a cerebral haem- Score MAS (items 1–5) MRMI
orrhage.
Median 16.5 26.5
Semi-interquartile 9.1 11.8
Concurrent validity range
Range 2–26 4–36
Table 2 summarises the MAS and MRMI scores of the Mean score (%) 48 (S.D. 29, range 55 (S.D. 28, range
study sample. 7–87) 10–90)
 L. Johnson, J. Selfe / Physiotherapy 90 (2004) 132–138 135

40

30
Score on MRMI and MAS

20

10

MRMI total score (Upper point)

MAS total score (Lower point)
0
1 3 5 7 9 11 13 15 17 19 21 23 25
Case Number
Fig. 1. Comparison of MRMI and MAS (mobility items) scores.

item was removed from the analysis. On each scale Test administration time
the lowest item-total correlation was for the sitting bal-
ance item (MRMI α = 0.304, MAS α = 0.545). If On average the MAS took 16 min and 39 s to adminis-
these items were deleted α increased to 0.966 and 0.961, ter (S.D. 3 min and 30 s, range 6–20 min). The MRMI took
respectively. 16 min and 32 s (S.D. 4 min and 8 s, range 5–20 min).

10
Difference between percent of paired measurements (MAS

5
+ 2 SD

0
0 10 20 30 40 50 60 70 80 90 100
minus MRMI)

-5

-10

-15

– 2 SD

-20
Mean of paired measurements

Fig. 2. Limits of agreement between percentages of total scores on the MAS (items 1–5) and MRMI.
136 L. Johnson, J. Selfe / Physiotherapy 90 (2004) 132–138
Table 3
Cronbach’s alpha coefficients for MRMI and MAS scales
MRMI scale item Corrected item-total Alpha if item
correlation deleted
Turning over 0.872 0.940
Lying to sitting 0.809 0.942
Sitting balance 0.304 0.966
Sitting to standing 0.943 0.933
Standing 0.912 0.936
Transfers 0.959 0.931
Walking indoors 0.936 0.934
Stairs 0.743 0.946
Discussion
Concurrent validity
The main purpose of the study was to establish whether
the MRMI demonstrated concurrent validity so that it could
be used as an alternative measure of mobility to the MAS.
Exact agreement between paired scores was not anticipated
because the scales did not utilise the same scoring range
nor did they measure exactly the same mobility-related ac-
tivities. It was therefore necessary to establish how closely
scores on the two scales related to each other and whether
there was a consistent bias between scores. A mean differ-
ence of three points (out of 40) may be small enough to
be clinically acceptable and allow therapists to select either
of these outcome measures when measuring the average ef-
fectiveness of physiotherapeutic interventions in a group of
patients. The decision on which scale to use may be based
on a number of factors such as patient population clinician
preference and clinical environment.
The higher average percentage scores on the MRMI com-
pared to the MAS could indicate that subjects had greater
levels of independent mobility despite motor impairments.
This is because the MRMI is a measure of a patient’s ability
to perform an activity but does not measure quality of per-
formance [8]. Higher scores were awarded if an activity was
performed independently in any manner. In contrast in or-
der to score highly on the MAS subjects needed to perform
tasks in a specified time and use normal movement patterns
[10]. This possible explanation of the average higher scores
on the MRMI challenges the assumption commonly held by
physiotherapists that quality of movement translates directly
into greater functional ability [24]. If this were the case then
scores on the two scales might be expected to approximate
more closely.
An alternative explanation of the higher average scores on
the MRMI is that the MRMI items were easier to perform
than the corresponding MAS items. For example the MRMI
sit to stand item only required the subject to stand up once.
The MAS required subjects to stand up and sit down three
times in 10 s. Subjects therefore needed to have a higher
level of mobility to gain a comparable numerical score on
the corresponding MAS item. Additionally stair-climbing is
MAS scale item Corrected item-total Alpha if item
correlation deleted
Supine to side-lying 0.892 0.942
Supine to sitting 0.870 0.943
Balanced sitting 0.545 0.961
Sitting to standing 0.878 0.943
Walking 0.881 0.949
Upper arm function 0.893 0.942
Hand movements 0.889 0.942
Advanced hand activities 0.854 0.945
a separate item within the MRMI whilst on the MAS stairs
are only included as the highest level of mobility within
the walking item where patients are required to negotiate
stairs without a rail within a set time. The MRMI items
may therefore have a lower ‘ceiling effect’ than the MAS
whereby subjects gain a maximum score and the MRMI
item would be unable to detect further improvement over
time [20]. This supports the use of the MRMI in the earlier
stages of rehabilitation and the use of the MAS in the later
stages or with subjects with milder impairments.
Clinicians may select the MRMI in the acute phase when
a ‘ceiling effect’ is less likely. It could also provide objective
information to other members of the inter-disciplinary team
regarding for example the amount of assistance required
when a patient is getting in/out of bed or walking. In contrast
during the later stages of rehabilitation or in mildly impaired
stroke patients the MAS might be preferable to measure
higher levels of mobility or if objective measurement of
‘quality’ of movement is required.
Internal consistency
A range of items needs to be assessed within a scale in
order to acquire a comprehensive picture of the construct of
interest [25]. Internal consistency is therefore important in
multiple-item scales because it indicates whether all items
are measuring a similar construct [9,20]. The MRMI and
the MAS possessed high internal consistency overall. Indi-
vidual items on both scales also demonstrated high internal
consistency (except the sitting balance items). Sitting bal-
ance may therefore measure a different construct or be an
imperfect measure of the mobility.
Test administration time
The MRMI and the MAS both took an average of 17 min
to administer. This included administration of the upper
limb items on the MAS. Both scales were sufficiently quick
to administer to have clinically utility. The results of the
present study question the opinion that the MAS might be
too time-consuming for routine clinical use [7]. The MRMI
took slightly longer than the 10–15 min stated in an earlier
study [8]. The MAS administration time was similar to that
 L. Johnson, J. Selfe / Physiotherapy 90 (2004) 132–138
reported by Carr et al. in 1985 [10] (15 min) but less than
the 36 min reported by Malouin et al. [13]. The discrepancy
in times between this and the present study is not easily ex-
plained. In the present study the median score on the MAS
was 16.5. It is possible that the MAS may take longer to ad-
minister with patients who score higher on the scale because
more sub-items may need to be tested.
Limitations
The researcher (L.J.) was experienced in stroke rehabili-
tation and familiar with the MAS. Less experienced physio-
therapists might have taken longer to administer the MAS.
Different therapists scoring the MRMI and the MAS could
have introduced inter-rater variability however utilising dif-
ferent raters eliminated any possibility of knowledge of
scores on one scale biasing scores on the second scale.
This highlights some of the conflicts when attempting to
minimise confounding variables in research. Also there are
some limitations to using a percentage of the maximal pos-
sible score to compare limits of agreement and investigate
whether there was a consistent bias between two scales that
had different ranges of raw scores. Whilst percentage dif-
ferences were clinically less meaningful they did provide an
additional method of comparing the MRMI and MAS. Raw
scores were also analysed for transparency.
Another limitation of the study was the small convenience
sample used that might not reflect the stroke population
from which the sample was selected. Only two physiother-
apists scored the MRMI. A largest sample of therapists
with varied experience may have produced different results.
Patients with chronic stroke and moderate/severe aphasia
or cognitive impairment were excluded from the study. The
results are therefore not generalisable to these sub-sets of
stroke patients.
Further investigation of the concurrent validity of the
MRMI in other settings and with different stroke popula-
tions is required. The responsiveness of the MRMI versus
the original RMI and MAS in measuring change in mobility
status also warrants investigation.
Conclusions
The study established that scores on the MRMI were on
average three points higher than scores on the MAS. The
mean difference may be considered small enough to al-
low clinicians to select either of these outcome measures.
This decision may be based on a number of factors such as
severity of impairment, time since stroke, clinical environ-
ment and clinician preference. The MRMI and MAS pos-
sess high internal consistency. Individual items within each
scale therefore appear to measure a similar construct (ex-
cept sitting balance). The MRMI and MAS allow therapists
to document mobility status relatively quickly. This is an
important factor in whether an outcome measure will gain
widespread use.
137
Key messages
• The mean difference of three points higher on the
MRMI than the MAS may be considered small
enough to allow clinicians to select either of these
outcome measures.
• Internal consistency of the scales was high (except
sitting balance).
• The MRMI and MAS both took an average of 17 min
to administer.
Acknowledgements
Thanks are due to Dr. Kerry Kirk who acted as supervisor
during the dissertation and the physiotherapists at Airedale
General Hospital who assisted in data collection. This re-
search was partly funded by the Hospital Savings Associa-
tion and the clinical interest group AGILE.
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