CHAPTER 76: MOTOR ACTIVITY LOG (MAL)
Description
The Motor Activity Log (MAL) is a standardized assessment designed to assess the use of a person’s affected arm and hand during activities of daily living (ADLs) following a stroke. The MAL is composed of two subtests, one pertaining to the amount of use (AOU) and the other pertaining to the quality of movement (QOM) of the affected extremity, where each is delivered in a structured interview format with either the client or caregiver. The MAL consists of 30 ADL items where the subject is asked to rate his or her level of performance over the past week and explores such capabilities as turning on a light switch, wiping off a kitchen counter or other surface, getting up from a chair with armrests, putting on makeup base, lotion, or shaving cream on face, as well as the ability to write on paper or button a shirt (Taub, McCulloch, Uswatte, & Morris, 2011). The MAL uses an 11-point Likert scale (0 to 5), which includes half points. Scores for the AOU subtest range from (0) never use the affected arm for this activity to (5) always use the affected arm for this activity. Scores for the QOM portion range from (0) inability to use the affected arm for this activity to (5) ability to use the affected arm for this activity just as well as before the stroke (van der Lee, Beckerman, Knol, de Vet, & Bouter,2004). Individual item scores are summed with higher scores indicating better performance. Time to administer the exam is approximately 20 minutes.
Psychometrics
Test-retest reliabilities have been reported to be high at r = 0.91 in stable populations, whereas subacute patient reliabilities have ranged from r = 0.79 to 0.82 (Uswatte, Taub, Morris, Vignolo, & McCulloch, 2005). Using the 14-item version, internal consistency data from 29 patients who had performed all 14 activities was α = 0.88 and 0.91 for the AOU and QOM subscales; however, when data that included missing values of activities that were not performed during the past week of 56 subject’s Cronbach’s alpha were similar at α = 0.87 and 0.90 (van der Lee et al., 2004). Another study found the correlation coefficient between the 2 subscales to be 0.95, whereas the internal consistency was α = 0.82 for the AOU and α = 0.87 for the QOM (van der Lee et al., 2004). A study of 59 patients post-cerebrovascular accident established the concurrent validity of MAL-AOU scores at both pre- and post-treatment with the Box and Block Test (BBT) as correlations were found to be 0.37 and 0.49, while with the Nine-Hole Peg Test (NHPT) they were stronger at 0.16 and –0.23, and with the Action Research Arm Test (ARAT) they were 0.31 and 0.32 (Lin, Hsieh, & Chang, 2010). The same study found that the MAL-QOM section had pre- and post-treatment correlations of 0.52 and 0.52 with the BBT, –0.26 and –0.33 with the NHPT, and 0.39 and 0.35 with the ARAT (Lin et al., 2010). A later study found the MAL to correlate somewhat better with the Hand Function subscale of the Stroke Impact Scale at 0.68 to 0.72, as well as mildly with accelerometry, which is motor recovery monitoring, at 0.47 to 0.52 (Uswatte, Taub, Morris, Light, & Thompson, 2006).
Advantages
There is a good amount of research in support of its use in clinical practice and requires no special training or certifications to administer. The MAL also uses ADL-specific activities to gauge motor performance making it a relevant assessment to the profession of occupational therapy. Several versions of the MAL are also available including the 14-, 26-, and 30-item versions.
Disadvantages
Some studies have questioned the stability of its published properties with regard to variations in the way interviews have been or can be performed as well as for the number of activities completed. For example, during assessment the person may not have performed all ADLs in the past week, such as eating half a sandwich or finger foods, leading to varying calculations of total scores and psychometric results (van der Lee Knol et al., 2004). Administration of the MAL also requires participants to watch a video that may be inconsistent with some clinical practices.
Administration
The MAL is standardized and has clearly defined testing techniques as well as scoring guidelines outlined in the examiner’s manual. During assessment the client is asked to consider his or her ADL engagement during the past week, and how well his or her weaker arm functioned as it relates to each item/activity on the test. It is composed of the following 2 subtests delivered in a structured interview format with the client or caregiver: (1) the AOU section and (2) the QOM section, where each is scored along a 5-point rating scale (0 to 5) with half points being assigned as well by the subject. A mean MAL score is calculated for both scales by adding the rating scores for each scale and dividing by the number of items asked. Higher scores indicate better ADL engagement. Participants may also be asked to watch a brief video.
TABLE 76-1
GENERAL SCORING DESCRIPTORS OF THE TWO MOTOR ACTIVITY LOG SUBSCALES
| AMOUNT OF USE SUBTEST |
0. Did not use weaker arm (not used). |
1. Occasionally used weaker arm but very rarely (very rarely). |
2. Sometimes used weaker arm but did the activity most of the time with my stronger arm (rarely). |
3. Used weaker arm about half as much as before the stroke (half pre-stroke). |
4. Used weaker arm almost as much as before the stroke (3/4 pre-stroke). |
5. Used weaker arm as often as before the stroke (same as pre-stroke). |
| QUALITY OF MOVEMENT SUBTEST |
0. Weaker arm was not used at all for the activity (not used). |
1. Weaker arm was moved during that activity but was not helpful (very poor). |
2. Weaker arm was of some use during that activity but needed some help from the stronger arm; moved very slowly or with difficulty (poor). |
3. Weaker arm was used for that activity but the movements were slow or were made only with some effort (fair). |
4. The movements made by my weaker arm for that activity were almost normal but not quite as fast or accurate as normal (almost normal). |
5. The ability to use weaker arm for that activity was as good as before the stroke (normal). |
Adapted from Taub, E., McCulloch, K., Uswatte, .G., & Morris, D. (2011). Motor Activity Log (MAL) manual (pp. 2-3). Birmingham, AL: UAB CI Therapy Research Group.
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