Chedoke-McMaster Stroke Assessment (CMSA): 7 Stages of Motor Recovery
In short
The Chedoke-McMaster Stroke Assessment (CMSA) evaluates physical impairment and activity limitations post-stroke. Learn the 7 stages of motor recovery and clinical scoring.
In this guide (4 sections)
What Is the Chedoke-McMaster Stroke Assessment (CMSA)?
Developed by Gowland et al. in 1993 at McMaster University, the Chedoke-McMaster Stroke Assessment (CMSA) is an evaluative instrument designed to assess motor impairment and functional activity in stroke patients.
The CMSA is composed of two distinct components: the Impairment Inventory (which grades neurological recovery from flaccidity to complex motor control) and the Disability Inventory (measuring gross motor function and walking).
The 7 Stages of Motor Recovery (Impairment Inventory)
The Impairment Inventory evaluates 6 separate anatomical dimensions: Postural Control, Arm, Hand, Leg, Foot, and Shoulder Pain.
Each dimension is classified into one of 7 developmental stages of motor recovery based on Twitchell and Brunnstrom recovery sequences.
| Stage | Recovery Milestone | Characteristic Clinical Presentation | |
|---|---|---|---|
| Stage 1 | Flaccid Paralysis | No voluntary movement, stretch reflexes absent or severely depressed. | |
| Stage 2 | Synergies Emerging / Spasticity Developing | Resistance to passive movement begins; basic reflex synergy patterns appear as involuntary reactions. | |
| Stage 3 | Synergies Performed Voluntarily / Peak Spasticity | Patient can voluntarily initiate mass flexor or extensor synergies; severe spasticity present. | |
| Stage 4 | Spasticity Declining / Combinations Out of Synergy | Spasticity begins to decline; patient can initiate movement patterns that break away from pure mass synergies. | |
| Stage 5 | Relative Independence from Synergies | Spasticity waning; difficult out-of-synergy movements performed; individual joint selectivity emerges. | |
| Stage 6 | Coordination Near Normal / Residual Clumsiness | Spasticity minimal or absent; rapid coordinated movements possible, but coordination lags during high-speed tests. | |
| Stage 7 | Normal Motor Control | Full voluntary control, normal speed, coordination and endurance equal to unaffected side. |
Testing Methodology: The 2-out-of-3 Rule
To test an anatomical dimension, the examiner begins testing at the stage the patient is clinically estimated to function. Each stage contains 3 specific motor tasks.
The 2-out-of-3 Rule: A patient must successfully accomplish at least 2 of the 3 tasks in a given stage to be credited with that recovery level. If they pass, test the next higher stage. If they fail, drop down and test the lower stage.
- Postural Control Dimension: Assesses supine bridge, sitting balance, lateral weight shifts and standing balance.
- Arm & Hand Dimensions: Evaluates shoulder elevation, elbow flexion/extension, isolated wrist extension and opposition pinch.
- Minimal Detectable Change (MDC): An improvement of 6 to 8 points on the total CMSA impairment score indicates genuine clinical recovery.
Frequently Asked Questions
How is shoulder pain graded in the CMSA?
Shoulder Pain is rated on a 7-stage scale from 1 (constant severe pain in arm and shoulder) to 7 (completely pain-free with normal shoulder range of motion).
Can the arm and leg be in different recovery stages?
Yes. It is very common for a stroke patient to achieve Stage 4 or 5 in the lower extremity while remaining at Stage 2 or 3 in the upper extremity.
What is the Disability Inventory component of CMSA?
The Disability Inventory rates 14 functional activities (rolling, bridging, transfers, walking outdoors) on a 1 to 7 point FIM-like functional independence scale.
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