Validation of the Spanish Version of Fugl-meyer Assessment in Spanish Post-stroke Population

Validation of the Spanish Version of Fugl-meyer Assessment in Spanish Post-stroke Population | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Validation of the Spanish Version of Fugl-meyer Assessment in Spanish Post-stroke Population Pablo Blas-Zamorano, David Pérez-Cruzado, José-Antonio Merchán-Baeza This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7887724/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background : The Fugl-Meyer Assessment (FMA) is one of the most recommended scales for assessing upper and lower limb sensorimotor function in stroke survivors. This study aims to evaluate the psychometric properties of the Spanish version of the FMA in order to validate it in the Spanish stroke population. Methods : A validation study was conducted in which 110 stroke survivors were evaluated, and 65 of them were re-evaluated. Psychometric properties were assessed using exploratory factor analysis, internal consistency, reliability, measurement error, criterion validity, hypothesis testing, and responsiveness. Results : The exploratory analysis generated seven factors. Internal consistency was excellent (α = 0.982). Test-retest reliability was excellent (ICC = 0.98). The criterion validity found between FMA-Total and FMA-UE was 0.97, and between FMA-Total and FMA-LE was 0.89. The correlation between FMA and ENVI-R was demonstrated and significant (r = 0.34–0.5). Conclusion : The Spanish version of the FMA can be used in research and clinical practice after demonstrating adequate and significant psychometric properties. The use of this scale will improve the quality of assessment of upper and lower limb sensorimotor function in stroke patients and allow for reliable comparisons. Health sciences/Health care Health sciences/Medical research Health sciences/Neurology Biological sciences/Neuroscience Fugl-Meyer Assessment Sensorimotor Function Assessment Psychometric properties Validation Figures Figure 1 INTRODUCTION Stroke is the second cause of death (Feigin et al., 2023) and the leading cause of disability worldwide (Hua et al., 2023). Each year, 15 million people suffer a stroke worldwide; of these, 5 million die, and another 5 million are permanently disabled, placing a burden on the family and community (Katan & Luft, 2018). The burden of disability after stroke is significant and increasing very rapidly, and the incidence of stroke is increasing in young and middle-aged people under 55 years of age globally (Feigin et al., 2023). The burden of stroke is estimated to increase by 50% in the coming years, from 6.6 million cases in 2020 to 9.7 million cases in 2050 (Feigin et al., 2023). In Spain, strokes are the leading cause of disability in adults and the second leading cause of dementia (Masjuan et al., 2011). In 2023, 23,173 deaths from stroke were recorded, of which 12,817 were women (Díaz-Guzmán et al., 2012). Studies estimate that the incidence of stroke is 187 cases per 100,000 inhabitants per year, which is higher than in England, Germany, and France, but lower than in other neighboring countries such as Italy, Greece, and Portugal (Díaz-Guzmán et al., 2012). Physical limitations are common impairments after stroke, manifested in many physiological domains and motor aspects such as spasticity, muscle synergies, coordination, strength, range of motion, dexterity, skin sensation, position sense, and arm stability (Ingram et al., 2023; Li et al., 2023; Zhao et al., 2023). All of them cause an inability to use the upper extremity to reach, grasp, and manipulate objects, affecting the performance of daily living tasks such as dressing, feeding, or bathing (Dawson et al., 2023; Ingram et al., 2023) and have a detrimental impact on the quality of life (Zhao et al., 2023). With this data, it is necessary to have tools available to assess the different physical deficits caused by stroke. There are many tools to evaluate stroke patients’ sensorimotor and functional construct. Some of them are the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Box and Block Test (BBT), etc (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023). Choosing the most appropriate instrument to assess upper extremity sensorimotor function in stroke patients is challenging, and the choice should depend on the measurement properties and feasibility of the instrument (Prinsen et al., 2018). Some systematic reviews demonstrate that the FMA is the most commonly used for clinical practice and research and has seen an increase in its use in recent years (Bushnell et al., 2015; Santisteban et al., 2016; Yu et al., 2023). FMA is internationally known, with different versions and translations into different languages and cultures (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023; Lin et al., 2021; Tauchi et al., 2022; Yu et al., 2023). The FMA is the “gold standard” for assessing upper extremity sensorimotor function due to its ability to assess aspects such as movement within synergies, mixed synergies, reflexes, wrist, hand, grip, coordination, and speed of movements. Thus, it provides a large amount of information that is very useful for understanding the sensorimotor capacity of the affected upper limb after a stroke (Bushnell et al., 2015; Gunduz et al., 2023; Santisteban et al., 2026). A recent review has evaluated the psychometric properties of 22 versions and translations of FMA, comparing them according to the COSMIN methodology, and found that the full version of the 50-item FMA is the most valid for assessing upper limb sensorimotor function in the post-stroke population (de Blas-Zamorano et al., 2025). After reviewing and analyzing the systematic review of the different versions of FMA, it was found that no psychometric properties of the Spanish version of FMA (Barbosa et al., 2019) have been evaluated, except for content validity and cross-cultural validity (Barbosa et al., 2019). Validating assessment instruments in research and clinical practice settings is necessary to ensure that the concepts explored by a tool are consistent between the original and target contexts. Validating a scale in another country, context, or language allows for the tool to be used by therapists in that country, enabling them to offer better interventions (Gjersing et al., 2010). These aspects are even more relevant in the case of upper limb neurorehabilitation, which has a smaller number of assessment scales than other specialties or constructs (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023), and is mostly available in languages other than Spanish (de Blas-Zamorano et al., 2025). As a result, they either cannot be used in Spain or their use is biased due to a lack of validation (Gjersing et al., 2010). This study aimed to validate the Spanish version of FMA in the Spanish population who have suffered a stroke. Clinical trial number: not applicable MATERIALS AND METHODS Study design Validation study of the Spanish version of the FMA scale, available on the University of Gothenburg website (https://www.gu.se/en/neuroscience-physiology/fugl-meyer-assessment#spanish), in the Spanish population who have suffered a stroke. Fugl-Meyer Assessment Fugl-Meyer Assessment is an impairment measure consisting of 155 items, rated on a 3-point ordinal scale (0–2). It includes 33 items for upper extremity, 17 items for lower extremity, 7 items for balance, 12 items for sensation, and 22 items for passive joint motion and joint pain. FMA includes three categories: (1) motor function, (2) balance, and (3) sensation. The maximum score value for each of these categories and subcategories is as follows: the motor function for the upper (66 points) and lower (34 points) extremities; balance in sitting (6 points) and in standing (8 points); touch (24 points); and position sense (16 points). The motor part of the scale includes 50 items of upper and lower extremity motor function, with a possible score range from 0 to 100 points (66 from upper extremity subscale and 34 from lower extremity subscale (de Blas Zamorano et al., 2025; Sanford et al., 1993). Validation process To validate the Spanish version of the FMA, the scale was administered to 110 people who had suffered a stroke. Participants were continuously recruited between February and September 2024, across nine private and state-funded neurorehabilitation centers across Spain. Participants met the following inclusion and exclusion criteria: Inclusion criteria: (a) adults (18–99 years); (b) having suffered at least one stroke; and (c) being able to actively move (Daniels 4/5) the unaffected/less affected side of the body. Exclusion criteria: (a) absence/decreased response to the environment (Glasgow less than 15); (b) inability to understand the therapist’s instructions; (c) being on a basic life support device; (d) being aggressive or posing a risk to self or others; and (e) being bedbound. All potentially eligible individuals were informed and asked to read and sign an informed consent form containing all information regarding the research and their participation. Once signed, they were scheduled to participate in the study on a specific date at their referral rehabilitation center. To assess the criterion validity of the FMA, these 110 individuals were evaluated using the Nottingham Stroke Dressing Scale-Revised (NSD-R), a clinical assessment scale for dressing performance and independence in activities of daily living (Fletcher-Smith et al., 2011; Fletcher-Smith, 2011; Walker & Linciln, 1990; Walker and Lincoln, 1991; Walker, 1992; Walker et al., 2003; Walker et al., 2004; Walker et al., 2012). This scale is widely used in clinical practice and research with post-stroke patients and is a valid and reliable instrument in this population (Fletcher-Smith et al., 2011; Fletcher-Smith, 2011; Walker & Linciln, 1990; Walker and Lincoln, 1991; Walker, 1992; Walker et al., 2003; Walker et al., 2004; Walker et al., 2012). The principal investigator, a clinical occupational therapist familiar with and proficient in the FMA and ENVI-R scales, administered the scale and assessed and reassessed upper and lower limb sensorimotor function. A reassessment was conducted in 59.1% of the sample between 1 and 4 months after the initial assessment. The examiner did not compare scores during or after the testing session, and completed tests remained blind to the other investigators until all assessments were completed. Statistical analysis Sociodemographic and clinical variables were expressed as means and percentages. Age, phase (acute/chronic), geographic location, and sex were specified. The Kaiser-Meyer-Olkin (KMO) test measured sampling adequacy, and Bartlett’s test of sphericity was used to check for redundancy between variables; KMO >0.5 was considered good, together with significant values for Bartlett’s test of sphericity («IBM Kaiser-Meyer-Olkin measure for identity correlation matrix ”United States», 2011). Exploratory factor analysis (EFA) with maximum likelihood extraction and varimax rotation was estimated for the internal structure of the new questionnaire. The scale’s internal consistency was measured using Cronbach’s α statistical analysis (Cronbach et al., 1951). This data was presented in absolute terms and by factor. The intraclass correlation coefficient (ICC) was used to measure intra-observer reliability. The standard error of the measurement was used to determine the measurement error. The convergent criterion validation refers to the evaluation of instruments that assessed variables that measured similar constructs or that should show a similar relationship. The relationship of these scores with the variables was used to validate the scale. The Spearman correlation coefficient was used to evaluate convergent validity between the FMA full version, FMA Upper Extremity (FMA-UE), FMA Lower Extremity (FMA-LE), and the ENVI-R scale. To estimate the aforementioned correlations, the Kolmogorov-Smirnov test was first used to determine whether the sample was parametric or nonparametric. Since the sample was significant and nonparametric, the Spearman test was used to obtain correlation coefficients. A statistical significance level of 0.05 was considered for all hypothesis tests. The statistical analysis was performed using SPSS version 29 (IBM, USA). Ethical considerations This research was approved by the Ethics Committee of the University of Malaga, under registration number 7-2024-H, and complies with the fundamental ethical precepts established by the Declaration of Helsinki and the Belmont Report, as well as current Spanish legal regulations regarding clinical research, especially Law 14/2007, of July 3, on Biomedical Research. The protection and confidentiality of the information are guaranteed at all times. The processing, communication, and transfer of personal data of all participating subjects complied with the provisions of Organic Law 3/2018, of December 5, on the protection of personal data and the guarantee of digital rights, and its data development regulations. The data were treated confidentially and assigned a correlative code. Under no circumstances were the patients’ names and surnames or other data that could compromise their privacy included. The data were processed electronically and incorporated into an automated personal data file. RESULTS Participants One hundred and ten participants who met the inclusion criteria were included in this study sample. No patients were lost during data collection. Of the study participants, 73.64% were in the chronic phase (n = 81), and 26.36% were in the acute phase (n = 29). The mean patient age was 62 ± 13.62 years. Men represented 60% of the total sample (n = 66) and women 40% (n = 44). Clinical validation Exploratory factor analysis The translated version of the scale was subjected to exploratory factor analysis (EFA). The Bartlett’s Test of Sphericity score was significant (X2 = ∞; df = 7,528.38; p <0.001); the Chi-squared Test was also significant (Value = 1,567.54; p 1 and the Screeplot (Figure 1) showed a seven-factor solution that explained 81% of the total variance. The loading of each item in each factor was determined by a loading greater than 0.3 (Tables 1 and 2). Internal consistency The Spanish version of the FMA showed good overall internal consistency values (α = 0.982). To further analyze this psychometric property, internal consistency was calculated if one item was deleted, finding good internal consistency values, with the highest values for items 1, 2, 34, and 35 (α = 0.983), while all other items showed a very similar value (α = 0.982) (Table 3). Test-retest reliability The Spanish version of the FMA demonstrated satisfactory reliability when administered a second time to 65 patients (59.1% of the sample) between 1 and 4 months after the initial assessment. Test-retest reliability was measured using an intraclass correlation coefficient (ICC), and the analyzed data showed excellent test-retest properties (ICC 0.98, 95%). Measurement error The standard measurement error showed a convenient score, with a standard error of the mean score of 3.17. Criterion validity The Spanish version of the FMA showed a very good convergent correlation fit when comparing its total score with the score of the Upper Extremity subscale (FMA-UE) and the Lower Extremity subscale (FMA-LE). Significant correlations were found, with the correlation between the FMA-Total and FMA-UE being r = 0.97, and between the FMA-Total and FMA-LE being r = 0.89. Hypothesis testing The Spanish version of the FMA showed a good correlation with the ENVI-R scale. A significant correlation between the FMA and the ENVI-R was confirmed, with a score of r = 0.50. A significant correlation was also found between FMA-UE and ENVI-R (r = 0.34), and between FMA-LE and ENVI-R (r = 0.39), thus confirming the proposed hypothesis. DISCUSSION The Spanish version of the Fugl-Meyer Assessment Scale has been available since 2016, when it was translated into Spanish in Spain(Ferrer-González, 2016). However, its psychometric properties have not been evaluated. The Colombian Spanish version has been available since 2019 (Barbosa et al., 2019). Despite this, it has not yet been validated in the Spanish population who have suffered a stroke, even though it is one of the most recommended scales for use in the assessment of upper limb sensorimotor function in this population (Bushnell et al., 2015; de Blas-Zamorano et al., 2025; Gunduz et al., 2023; Kwakkel et al., 2023). In Spain, other validated scales for assessing upper limb sensorimotor function are available, such as the Box and Block Test (Noce et al., 2024) and ARAT (Fernández-Solana et al., 2022). However, a wider variety of scales for assessing this construct in Spanish is needed, as this enhances the assessment of stroke patients, allows for comparing results, selects the most appropriate assessment for each individual, and provides greater rigor in treatment and research. The clinical validation of the Spanish version of the FMA was subjected to statistical analysis of its psychometric properties (exploratory factor analysis, internal consistency, reliability, measurement error, criterion validity, hypothesis testing, and responsiveness), showing good agreement for most items. These statistical properties were adequate and significant (De Vet et al., 2024; Koo et al., 2016; Motal de la Rubia, 2019), providing a highly valid version recommended for the assessment of sensorimotor function in people who have suffered a stroke. All psychometric properties of the FMA have been previously evaluated; however, only the content validity of the Spanish version was analyzed during translation and cross-cultural adaptation (Barbosa et al., 2019). Furthermore, the previous studies were conducted with smaller samples (n = 10 (Barbosa et al., 2019) and n = 103 (Ferrer-González, 2016)); therefore, this study represents the largest study of the Spanish version of the FMA, as well as the first factor analysis of that version. The EFA yielded a seven-factor model, rotated with Varimax, which explained 81% of the total variance. 37 This is the first time that an exploratory analysis has been performed on the full 50-item version of the FMA, as exploratory factor analyses of other versions of the FMA have shown different factors in the structural validity of their versions, such as the FMA-UE-Rom 38 or the FMA-UE-w/h (Chen et al., 2014), which presented a unidimensional construct. On the other hand, for the FMA-UE, solutions of one (Tauchi et al., 2022) and four (Woodbury et al., 2007) factors have been found, although the version in which the most factors have been found was the FMA-UE-w/h, with 12 factors (Persch et al., 2015). The version most similar to the one carried out in this study is the translation of the original version of FMA into Urdu, which presented two factors (Ikram et al., 2022). No other version of FMA has been found that has a structure like the Spanish version of FMA. Regarding the internal consistency of the Spanish version of the FMA, excellent levels of internal consistency were found, with a high Cronbach’s alpha score (α = 0.982) (Koo et al., 2016) for the scale in general. These values are higher than those of other language versions, such as the Japanese version (α = 0.973) (Amano et al., 2018; Tauchi et al., 2023) and the Urdu version (α = 0.80–0.87) (Ikram et al., 2022), showing concordance with more cross-culturally similar versions, such as the Polish version (Goliwas et al., 2024). When compared with other assessment scales of the same construct in the post-stroke Spanish population, such as the ARAT scale, a higher internal consistency score was found for FMA than for ARAT, which has a Cronbach’s Alpha score of 0.96 (Noce et al., 2024). The test-retest reliability of the Spanish scale was assessed using an ICC, which showed excellent reliability properties (Liljequist et al., 2019; Martínez-Pérez & Pérez-Martín, 2023), with a score of 0.98 (95% ICC). This score is very similar to that obtained in other studies (Lin et al., 2021) and is slightly lower than that obtained in the Japanese version of the FMA (ICC = 0.99–1) (Amano et al., 2018). Considering that this score was for simultaneous inter-rater, when this population was assessed with non-simultaneous inter-rater, the ICC score ranged from 0.81 to 0.98 (Amano et al., 2018). Other studies of the original version of the FMA also showed higher ICCs for both inter- and intra-rater measurements (ICC = 0.99) (See et al., 2013). The score obtained with this Spanish version of the FMA remains high and significant, being slightly higher than that obtained in previous studies with the original version of the FMA (ICC = 0.96 (Sanford et al., 1993); ICC = 0.95–0.98 (Hsueh et al., 2008)) and higher than other translations such as the Korean version of the FMA (ICC >0.72) (Kim et al., 2021). Nevertheless, the Spanish version of the FMA has exhibited excellent reliability properties. This is consistent with previous studies, suggesting that the various translations and validations of the FMA in different languages are valid and reliable versions for assessing upper and lower limb sensorimotor function in stroke survivors. The authors used the total score of the Spanish version of the FMA and the ENVI-R to measure criterion validity, showing positive correlations in both cases (Spearman rho: FMA vs. ENVI-R = 0.50; FMA-UE vs. ENVI-R = 0.34; FMA-LE vs. ENVI-R = 0.39), such that the variables vary, without implying causality, and that the distribution of the variable is abnormal (Akoglu, 2018; Schober et al., 2018). This is the first study to analyze the correlation between the Spanish version of the FMA and any other scale, in this case, the ENVI-R scale. Through this correlation, the hypothesis proposed in this study was confirmed, and adequate responsiveness was achieved for the Spanish version of the FMA. Looking at the different findings and the comparisons with other scales, the Spanish version of the FMA presents similar and even higher values than other versions in other languages or other assessment scales of the same construct for the same population, in some psychometric properties such as internal consistency (Amano et al., 2018; Ikram et al., 2022) or reliability (Hsueh et al., 2008; Kim et al., 2021; Lin et al., 2021; Sanford et al., 1993; See et al., 2013). Given the good psychometric properties found after the validation process, it can be stated that the Spanish version of the FMA is a very suitable and recommendable scale for assessing sensorimotor function in upper and lower limbs in the Spanish population who have suffered a stroke. Limitations and strengths of the study One limitation of this study was that the validation sample size was not very large (Terwee et al., 2018). Among the limitations is that the sample was obtained through convenience sampling, in which the patients agreed to participate at their rehabilitation center after being invited by the researcher. Another limitation is that the assessments were not performed by two independent evaluators, making it impossible to assess inter-rater reliability (Lujan-Tangarife & Cardona-Arias, 2015). Its main strength is that this article is the first validation of the Spanish version of the FMA in a Spanish population. Furthermore, no previous study has analyzed the psychometric properties examined in this study for the Spanish version of the FMA. In the future, it would be advisable to validate the Spanish version of the FMA in people with other conditions that cause limitations in sensorimotor function of the upper and lower limbs. CONCLUSION The validation process of the Spanish version of the FMA has demonstrated that this scale could be used in the Spanish population after a stroke for the assessment of upper limb sensorimotor function. It was also verified that the values obtained for the psychometric properties were adequate and significant when using the Spanish version of the FMA. Based on these results, the use of the Spanish version of the FMA can be recommended and defended in research and clinical practice. The use of this Spanish version of the FMA will allow a reliable comparison of stroke outcomes between regions and countries where other cross-culturally adapted and validated versions exist. Declarations Conflict of Interest Statement No potential conflict of interest was reported by the authors. Data Availability Statement The datasets generated and/or analyzed during the current study are not publicly available due to the data protection and confidentiality law of the evaluated people and their respective healthcare centers, in accordance with the provisions of the Ethics Committee of the University of Malaga, Spanish legal regulations regarding clinical research, especially Law 14/2007, of July 3, on Biomedical Research, and the Organic Law 3/2018, of December 5, on the protection of personal data and the guarantee of digital rights, and its data development regulations, but they are available through the corresponding author upon reasonable request. Authors Contributions All authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE): Substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; drafting the article; or revising it critically for important intellectual content. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Akoglu H. User’s guide to correlation coefficients. Turk J Emerg Med. 2018 Sept;18(3):91-3. Amano S, Umeji A, Uchita A, Hashimoto Y, Takebayashi T, Takahashi K, et al. Clinimetric properties of the Fugl-Meyer assessment with adapted guidelines for the assessment of arm function in hemiparetic patients after stroke. Topics in Stroke Rehabilitation 2018;25:500–8. https://doi.org/10.1080/10749357.2018.1484987. Barbosa NE, Forero SM, Galeano CP, Hernández ED, Landinez NS, Sunnerhagen KS, et al. 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Intraclass correlation - A discussion and demonstration of basic features. PLoS One. 2019;14(7):e0219854. Lin G-H, Huang C-Y, Lee S-C, Chen K-L, Lien J-JJ, Chen M-H, et al. A 10-item Fugl-Meyer Motor Scale Based on Machine Learning. Physical Therapy 2021;101:pzab036. https://doi.org/10.1093/ptj/pzab036. Luján Tangarife J, Cardona Arias J. Construcción y validación de escalas de medición en salud: revisión de propiedades psicométricas. Archivos de Medicina. 2015;11(3.1). Martínez Pérez JA, Pérez Martin PS. [Intraclass correlation coefficient]. Semergen. 2023 Apr;49(3):101907. Masjuan J, Alvarez-Sabín J, Arenillas J, Calleja S, Castillo J, Dávalos A, et al. [Stroke health care plan (ICTUS II. 2010)]. Neurologia. 2011 Sep;26(7):383-96. Méndez Martínez C, Rodón Sepúlvda MA. Introducción al análisis factorial exploratorio. Revista Colombiana de Psiquiatría. 2012;41(1):197-207. Moral De La Rubia J. Revisión de los criterios para validez convergente estimada a través de la Varianza Media Extraída. Psychol. 2019 Nov;13(2):25-41. Noce MP, Valera-Gran D, Hurtado-Pomares M, Serrano-Reina E, Soler-Pons C, Navarrete-Muñoz EM. Spanish translation and cross-cultural adaptation of the Box and Block Test: a pilot study in adults with chronic acquired brain injury. Brain Impair. 2024 Sep;25:IB24014. Persch AC, Gugiu PC, Velozo CA, Page SJ. Rasch Analysis of the Wrist and Hand Fugl-Meyer: Dimensionality and Item-Level Characteristics. Journal of Neurologic Physical Therapy 2015;39:185–92. https://doi.org/10.1097/NPT.0000000000000096. Prinsen CAC, Mokkink LB, Bouter LM, Alonso J, Patrick DL, De Vet HCW, et al. COSMIN guideline for systematic reviews of patient-reported outcome measures. Qual Life Res 2018;27:1147–57. https://doi.org/10.1007/s11136-018-1798-3. Roman N, Miclaus R, Repanovici A, Nicolau C. Equal Opportunities for Stroke Survivors’ Rehabilitation: A Study on the Validity of the Upper Extremity Fugl-Meyer Assessment Scale Translated and Adapted into Romanian. Medicina 2020;56:409. https://doi.org/10.3390/medicina56080409. Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C. Reliability of the Fugl-Meyer Assessment for Testing Motor Performance in Patients Following Stroke. Physical Therapy 1993;73:447–54. https://doi.org/10.1093/ptj/73.7.447. Santisteban L, Térémetz M, Bleton J-P, Baron J-C, Maier MA, Lindberg PG. Upper Limb Outcome Measures Used in Stroke Rehabilitation Studies: A Systematic Literature Review. PLoS ONE 2016;11:e0154792. https://doi.org/10.1371/journal.pone.0154792. Schober P, Boer C, Schwarte LA. Correlation Coefficients: Appropriate Use and Interpretation. Anesth Analg. 2018 May;126(5):1763-8. See J, Dodakian L, Chou C, Chan V, McKenzie A, Reinkensmeyer DJ, et al. A Standardized Approach to the Fugl-Meyer Assessment and Its Implications for Clinical Trials. Neurorehabil Neural Repair 2013;27:732–41. https://doi.org/10.1177/1545968313491000. Tauchi Y, Kyougoku M, Takahashi K, Okita Y, Takebayashi T. Dimensionality and item-difficulty hierarchy of the Fugl-Meyer assessment of the upper extremity among Japanese patients who have experienced stroke. Topics in Stroke Rehabilitation 2022;29:579–87. https://doi.org/10.1080/10749357.2021.1965797. Tauchi Y, Kyougoku M, Okita Y, Takebayashi T. Structural validity and internal consistency of a hypothesized factor structure of the Fugl-Meyer Assessment of the upper extremity. Top Stroke Rehabil. 2023 Jul;30(5):501–11. Terwee CB, Prinsen C a. C, Chiarotto A, Westerman MJ, Patrick DL, Alonso J, et al. COSMIN methodology for evaluating the content validity of patient-reported outcome measures: a Delphi study. Qual Life Res. mayo de 2018;27(5):1159-70. Walker MF, Lincoln NB. Factors influencing dressing performance after stroke. J Neurol Neurosurg Psychiatry. 1991 Aug;54(8):699-701. Walker MF, Lincoln NB. Reacquisition of dressing skills after stroke. Int Disabil Stud. 1990;12(1):41-3. Walker M. Dressing ability after stroke. Nurs Times. 1992 Jan;88(1):51. Walker CM, Walker MF, Sunderland A. Dressing after a Stroke: A Survey of Current Occupational Therapy Practice. British Journal of Occupational Therapy. 2003 Jun;66(6):263–8. Walker CM, Sunderland A, Sharma J, Walker MF. The impact of cognitive impairment on upper body dressing difficulties after stroke: a video analysis of patterns of recovery. J Neurol Neurosurg Psychiatry. 2004 Jan;75(1):43-8. Walker MF, Sunderland A, Fletcher-Smith J, Drummond A, Logan P, Edmans JA, et al. The DRESS trial: a feasibility randomized controlled trial of a neuropsychological approach to dressing therapy for stroke inpatients. Clin Rehabil. 2012 Aug;26(8):675-85. Woodbury ML, Velozo CA, Richards LG, Duncan PW, Studenski S, Lai S-M. Dimensionality and Construct Validity of the Fugl-Meyer Assessment of the Upper Extremity. Archives of Physical Medicine and Rehabilitation 2007;88:715–23. https://doi.org/10.1016/j.apmr.2007.02.036. Yu B, Kaku A, Liu K, Parnandi A, Fokas E, Venkatesan A, et al. Quantifying Impairment and Disease Severity Using AI Models Trained on Healthy Subjects. ArXiv 2023:arXiv:2311.12781v1. Zhao K, He C, Xiang W, Zhou Y, Zhang Z, Li J, et al. Evidence of synergy coordination patterns of upper-limb motor control in stroke patients with mild and moderate impairment. Front Physiol 2023;14:1214995. https://doi.org/10.3389/fphys.2023.1214995. Tables Tables 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7887724","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":623213409,"identity":"58441785-8e10-411b-9011-6c2ac653f56e","order_by":0,"name":"Pablo Blas-Zamorano","email":"","orcid":"","institution":"University of Málaga","correspondingAuthor":false,"prefix":"","firstName":"Pablo","middleName":"","lastName":"Blas-Zamorano","suffix":""},{"id":623213410,"identity":"b8503a1c-598a-451f-a76c-04b5a748e592","order_by":1,"name":"David Pérez-Cruzado","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYDCCAxCKsYG9gWQtPAdI1iKRQKQOvtvNzz7z/LGT7Zd8Y7rhB4ONPUEtkneOGc/m4Uk2njk7x+xmD0NaYgMhLQY3cpiZeSSYEzfczjG7wcNwmLDzIFoM6hM33DxjdvMPw3/CDoNoSTicuOEGj9ltHoYDjAQdBvIL45wDx41n9qSV3ZYxSCbsF2CIPWZ486datp/98LabbyrsCDuMQQLVnYQ1oGsZBaNgFIyCUYAFAAAD6z3rdXX4pQAAAABJRU5ErkJggg==","orcid":"","institution":"University of Malaga","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Pérez-Cruzado","suffix":""},{"id":623213411,"identity":"c4419760-76d4-41e8-a9e1-398bf471bd45","order_by":2,"name":"José-Antonio Merchán-Baeza","email":"","orcid":"","institution":"University of Vic","correspondingAuthor":false,"prefix":"","firstName":"José-Antonio","middleName":"","lastName":"Merchán-Baeza","suffix":""}],"badges":[],"createdAt":"2025-10-17 14:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7887724/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7887724/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107483165,"identity":"a98894d9-1642-4d5f-b09c-c1bb1e06370b","added_by":"auto","created_at":"2026-04-22 02:26:36","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":88984,"visible":true,"origin":"","legend":"\u003cp\u003eScree plot\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7887724/v1/4cc31693aa6ebed3d83416a0.png"},{"id":107486811,"identity":"5b5742af-a06d-49ef-9f86-277dca0ecb58","added_by":"auto","created_at":"2026-04-22 02:39:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":357339,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7887724/v1/3c05765a-20e0-4f66-a26e-4bd36083a176.pdf"},{"id":107484547,"identity":"d8f14bb8-1424-4493-92db-3eedcb3f6252","added_by":"auto","created_at":"2026-04-22 02:32:23","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":313026,"visible":true,"origin":"","legend":"","description":"","filename":"Table1factcharact.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7887724/v1/d259c90d515b8043618cc9ef.pdf"},{"id":107243445,"identity":"f4bef314-d38c-4d77-970c-ab1c76955443","added_by":"auto","created_at":"2026-04-19 07:51:32","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":309309,"visible":true,"origin":"","legend":"","description":"","filename":"Table2factloadings.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7887724/v1/9187a8d62e29ca928e7d50f3.pdf"},{"id":107484146,"identity":"8688c0bc-4b4c-4aed-8526-a070ee9fb1b4","added_by":"auto","created_at":"2026-04-22 02:30:56","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":172784,"visible":true,"origin":"","legend":"","description":"","filename":"Table3intconsitemdeleted.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7887724/v1/938b3ca4806a55d07b8a40e4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eValidation of the Spanish Version of Fugl-meyer Assessment in Spanish Post-stroke Population\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eStroke is the second cause of death (Feigin et al., 2023) and the leading cause of disability worldwide (Hua et al., 2023). Each year, 15 million people suffer a stroke worldwide; of these, 5 million die, and another 5 million are permanently disabled, placing a burden on the family and community (Katan \u0026amp; Luft, 2018).\u003c/p\u003e\n\u003cp\u003eThe burden of disability after stroke is significant and increasing very rapidly, and the incidence of stroke is increasing in young and middle-aged people under 55 years of age globally (Feigin et al., 2023). The burden of stroke is estimated to increase by 50% in the coming years, from 6.6 million cases in 2020 to 9.7 million cases in 2050 (Feigin et al., 2023).\u003c/p\u003e\n\u003cp\u003eIn Spain, strokes are the leading cause of disability in adults and the second leading cause of dementia (Masjuan et al., 2011). In 2023, 23,173 deaths from stroke were recorded, of which 12,817 were women (D\u0026iacute;az-Guzm\u0026aacute;n et al., 2012). Studies estimate that the incidence of stroke is 187 cases per 100,000 inhabitants per year, which is higher than in England, Germany, and France, but lower than in other neighboring countries such as Italy, Greece, and Portugal (D\u0026iacute;az-Guzm\u0026aacute;n et al., 2012).\u003c/p\u003e\n\u003cp\u003ePhysical limitations are common impairments after stroke, manifested in many physiological domains and motor aspects such as spasticity, muscle synergies, coordination, strength, range of motion, dexterity, skin sensation, position sense, and arm stability (Ingram et al., 2023; Li et al., 2023; Zhao et al., 2023). All of them cause an inability to use the upper extremity to reach, grasp, and manipulate objects, affecting the performance of daily living tasks such as dressing, feeding, or bathing (Dawson et al., 2023; Ingram et al., 2023) and have a detrimental impact on the quality of life (Zhao et al., 2023).\u003c/p\u003e\n\u003cp\u003eWith this data, it is necessary to have tools available to assess the different physical deficits caused by stroke. There are many tools to evaluate stroke patients\u0026rsquo; sensorimotor and functional construct. Some of them are the Fugl-Meyer Assessment (FMA), Action Research Arm Test (ARAT), Wolf Motor Function Test (WMFT), Box and Block Test (BBT), etc (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023).\u003c/p\u003e\n\u003cp\u003eChoosing the most appropriate instrument to assess upper extremity sensorimotor function in stroke patients is challenging, and the choice should depend on the measurement properties and feasibility of the instrument (Prinsen et al., 2018). Some systematic reviews demonstrate that the FMA is the most commonly used for clinical practice and research and has seen an increase in its use in recent years (Bushnell et al., 2015; Santisteban et al., 2016; Yu et al., 2023). FMA is internationally known, with different versions and translations into different languages and cultures (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023; Lin et al., 2021; Tauchi et al., 2022; Yu et al., 2023).\u003c/p\u003e\n\u003cp\u003eThe FMA is the \u0026ldquo;gold standard\u0026rdquo; for assessing upper extremity sensorimotor function due to its ability to assess aspects such as movement within synergies, mixed synergies, reflexes, wrist, hand, grip, coordination, and speed of movements. Thus, it provides a large amount of information that is very useful for understanding the sensorimotor capacity of the affected upper limb after a stroke (Bushnell et al., 2015; Gunduz et al., 2023; Santisteban et al., 2026).\u003c/p\u003e\n\u003cp\u003eA recent review has evaluated the psychometric properties of 22 versions and translations of FMA, comparing them according to the COSMIN methodology, and found that the full version of the 50-item FMA is the most valid for assessing upper limb sensorimotor function in the post-stroke population (de Blas-Zamorano et al., 2025).\u003c/p\u003e\n\u003cp\u003eAfter reviewing and analyzing the systematic review of the different versions of FMA, it was found that no psychometric properties of the Spanish version of FMA (Barbosa et al., 2019) have been evaluated, except for content validity and cross-cultural validity (Barbosa et al., 2019).\u003c/p\u003e\n\u003cp\u003eValidating assessment instruments in research and clinical practice settings is necessary to ensure that the concepts explored by a tool are consistent between the original and target contexts. Validating a scale in another country, context, or language allows for the tool to be used by therapists in that country, enabling them to offer better interventions (Gjersing et al., 2010). These aspects are even more relevant in the case of upper limb neurorehabilitation, which has a smaller number of assessment scales than other specialties or constructs (Bushnell et al., 2015; Gunduz et al., 2023; Kwakkel et al., 2023), and is mostly available in languages other than Spanish (de Blas-Zamorano et al., 2025). As a result, they either cannot be used in Spain or their use is biased due to a lack of validation (Gjersing et al., 2010).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aimed to validate the Spanish version of FMA in the Spanish population who have suffered a stroke.\u003c/p\u003e\n\u003cp\u003eClinical trial number: not applicable\u003c/p\u003e"},{"header":"MATERIALS AND METHODS ","content":"\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eValidation study of the Spanish version of the FMA scale, available on the University of Gothenburg website (https://www.gu.se/en/neuroscience-physiology/fugl-meyer-assessment#spanish), in the Spanish population who have suffered a stroke.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFugl-Meyer Assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFugl-Meyer Assessment is an impairment measure consisting of 155 items, rated on a 3-point ordinal scale (0\u0026ndash;2). It includes 33 items for upper extremity, 17 items for lower extremity, 7 items for balance, 12 items for sensation, and 22 items for passive joint motion and joint pain.\u003c/p\u003e\n\u003cp\u003eFMA includes three categories: (1) motor function, (2) balance, and (3) sensation. The maximum score value for each of these categories and subcategories is as follows: the motor function for the upper (66 points) and lower (34 points) extremities; balance in sitting (6 points) and in standing (8 points); touch (24 points); and position sense (16 points).\u003c/p\u003e\n\u003cp\u003eThe motor part of the scale includes 50 items of upper and lower extremity motor function, with a possible score range from 0 to 100 points (66 from upper extremity subscale and 34 from lower extremity subscale (de Blas Zamorano et al., 2025; Sanford et al., 1993).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eValidation process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo validate the Spanish version of the FMA, the scale was administered to 110 people who had suffered a stroke.\u003c/p\u003e\n\u003cp\u003eParticipants were continuously recruited between February and September 2024, across nine private and state-funded neurorehabilitation centers across Spain. Participants met the following inclusion and exclusion criteria:\u003c/p\u003e\n\u003cp\u003eInclusion criteria: (a) adults (18\u0026ndash;99 years); (b) having suffered at least one stroke; and (c) being able to actively move (Daniels 4/5) the unaffected/less affected side of the body.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: (a) absence/decreased response to the environment (Glasgow less than 15); (b) inability to understand the therapist\u0026rsquo;s instructions; (c) being on a basic life support device; (d) being aggressive or posing a risk to self or others; and (e) being bedbound.\u003c/p\u003e\n\u003cp\u003eAll potentially eligible individuals were informed and asked to read and sign an informed consent form containing all information regarding the research and their participation. Once signed, they were scheduled to participate in the study on a specific date at their referral rehabilitation center.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo assess the criterion validity of the FMA, these 110 individuals were evaluated using the Nottingham Stroke Dressing Scale-Revised (NSD-R), a clinical assessment scale for dressing performance and independence in activities of daily living (Fletcher-Smith et al., 2011; Fletcher-Smith, 2011; Walker \u0026amp; Linciln, 1990; Walker and Lincoln, 1991; Walker, 1992; Walker et al., 2003; Walker et al., 2004; Walker et al., 2012). This scale is widely used in clinical practice and research with post-stroke patients and is a valid and reliable instrument in this population (Fletcher-Smith et al., 2011; Fletcher-Smith, 2011; Walker \u0026amp; Linciln, 1990; Walker and Lincoln, 1991; Walker, 1992; Walker et al., 2003; Walker et al., 2004; Walker et al., 2012).\u003c/p\u003e\n\u003cp\u003eThe principal investigator, a clinical occupational therapist familiar with and proficient in the FMA and ENVI-R scales, administered the scale and assessed and reassessed upper and lower limb sensorimotor function. A reassessment was conducted in 59.1% of the sample between 1 and 4 months after the initial assessment.\u003c/p\u003e\n\u003cp\u003eThe examiner did not compare scores during or after the testing session, and completed tests remained blind to the other investigators until all assessments were completed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSociodemographic and clinical variables were expressed as means and percentages. Age, phase (acute/chronic), geographic location, and sex were specified.\u003c/p\u003e\n\u003cp\u003eThe Kaiser-Meyer-Olkin (KMO) test measured sampling adequacy, and Bartlett\u0026rsquo;s test of sphericity was used to check for redundancy between variables; KMO \u0026gt;0.5 was considered good, together with significant values for Bartlett\u0026rsquo;s test of sphericity (\u0026laquo;IBM Kaiser-Meyer-Olkin measure for identity correlation matrix \u0026rdquo;United States\u0026raquo;, 2011). Exploratory factor analysis (EFA) with maximum likelihood extraction and varimax rotation was estimated for the internal structure of the new questionnaire.\u003c/p\u003e\n\u003cp\u003eThe scale\u0026rsquo;s internal consistency was measured using Cronbach\u0026rsquo;s \u0026alpha; statistical analysis (Cronbach et al., 1951). This data was presented in absolute terms and by factor. The intraclass correlation coefficient (ICC) was used to measure intra-observer reliability. The standard error of the measurement was used to determine the measurement error.\u003c/p\u003e\n\u003cp\u003eThe convergent criterion validation refers to the evaluation of instruments that assessed variables that measured similar constructs or that should show a similar relationship. The relationship of these scores with the variables was used to validate the scale. The Spearman correlation coefficient was used to evaluate convergent validity between the FMA full version, FMA Upper Extremity (FMA-UE), FMA Lower Extremity (FMA-LE), and the ENVI-R scale. To estimate the aforementioned correlations, the Kolmogorov-Smirnov test was first used to determine whether the sample was parametric or nonparametric. Since the sample was significant and nonparametric, the Spearman test was used to obtain correlation coefficients.\u003c/p\u003e\n\u003cp\u003eA statistical significance level of 0.05 was considered for all hypothesis tests.\u003c/p\u003e\n\u003cp\u003eThe statistical analysis was performed using SPSS version 29 (IBM, USA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Ethics Committee of the University of Malaga, under registration number 7-2024-H, and complies with the fundamental ethical precepts established by the Declaration of Helsinki and the Belmont Report, as well as current Spanish legal regulations regarding clinical research, especially Law 14/2007, of July 3, on Biomedical Research. The protection and confidentiality of the information are guaranteed at all times. The processing, communication, and transfer of personal data of all participating subjects complied with the provisions of Organic Law 3/2018, of December 5, on the protection of personal data and the guarantee of digital rights, and its data development regulations. The data were treated confidentially and assigned a correlative code. Under no circumstances were the patients\u0026rsquo; names and surnames or other data that could compromise their privacy included. The data were processed electronically and incorporated into an automated personal data file.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne hundred and ten participants who met the inclusion criteria were included in this study sample. No patients were lost during data collection. Of the study participants, 73.64% were in the chronic phase (n = 81), and 26.36% were in the acute phase (n = 29). The mean patient age was 62 \u0026plusmn; 13.62 years. Men represented 60% of the total sample (n = 66) and women 40% (n = 44).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical validation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eExploratory factor analysis\u003c/p\u003e\n\u003cp\u003eThe translated version of the scale was subjected to exploratory factor analysis (EFA). The Bartlett\u0026rsquo;s Test of Sphericity score was significant (X2 = \u0026infin;; df = 7,528.38; p \u0026lt;0.001); \u0026nbsp;the Chi-squared Test was also significant (Value = 1,567.54; p \u0026lt;0.001). Therefore, the data were subjected to exploratory factor analysis with maximum likelihood extraction and Varimax rotation. The Eigenvalue \u0026gt;1 and the Screeplot (Figure 1) showed a seven-factor solution that explained 81% of the total variance.\u003c/p\u003e\n\u003cp\u003eThe loading of each item in each factor was determined by a loading greater than 0.3 (Tables 1 and 2).\u003c/p\u003e\n\u003cp\u003eInternal consistency\u003c/p\u003e\n\u003cp\u003eThe Spanish version of the FMA showed good overall internal consistency values (\u0026alpha; = 0.982). To further analyze this psychometric property, internal consistency was calculated if one item was deleted, finding good internal consistency values, with the highest values for items 1, 2, 34, and 35 (\u0026alpha; = 0.983), while all other items showed a very similar value (\u0026alpha; = 0.982) (Table 3).\u003c/p\u003e\n\u003cp\u003eTest-retest reliability\u003c/p\u003e\n\u003cp\u003eThe Spanish version of the FMA demonstrated satisfactory reliability when administered a second time to 65 patients (59.1% of the sample) between 1 and 4 months after the initial assessment. Test-retest reliability was measured using an intraclass correlation coefficient (ICC), and the analyzed data showed excellent test-retest properties (ICC 0.98, 95%).\u003c/p\u003e\n\u003cp\u003eMeasurement error\u003c/p\u003e\n\u003cp\u003eThe standard measurement error showed a convenient score, with a standard error of the mean score of 3.17.\u003c/p\u003e\n\u003cp\u003eCriterion validity\u003c/p\u003e\n\u003cp\u003eThe Spanish version of the FMA showed a very good convergent correlation fit when comparing its total score with the score of the Upper Extremity subscale (FMA-UE) and the Lower Extremity subscale (FMA-LE). Significant correlations were found, with the correlation between the FMA-Total and FMA-UE being r = 0.97, and between the FMA-Total and FMA-LE being r = 0.89.\u003c/p\u003e\n\u003cp\u003eHypothesis testing\u003c/p\u003e\n\u003cp\u003eThe Spanish version of the FMA showed a good correlation with the ENVI-R scale. A significant correlation between the FMA and the ENVI-R was confirmed, with a score of r = 0.50. A significant correlation was also found between FMA-UE and ENVI-R (r = 0.34), and between FMA-LE and ENVI-R (r = 0.39), thus confirming the proposed hypothesis.\u003c/p\u003e"},{"header":"DISCUSSION ","content":"\u003cp\u003eThe Spanish version of the Fugl-Meyer Assessment Scale has been available since 2016, when it was translated into Spanish in Spain(Ferrer-Gonz\u0026aacute;lez, 2016). However, its psychometric properties have not been evaluated. The Colombian Spanish version has been available since 2019 (Barbosa et al., 2019). Despite this, it has not yet been validated in the Spanish population who have suffered a stroke, even though it is one of the most recommended scales for use in the assessment of upper limb sensorimotor function in this population (Bushnell et al., 2015; de Blas-Zamorano et al., 2025; Gunduz et al., 2023; Kwakkel et al., 2023). In Spain, other validated scales for assessing upper limb sensorimotor function are available, such as the Box and Block Test (Noce et al., 2024) and ARAT (Fern\u0026aacute;ndez-Solana et al., 2022). However, a wider variety of scales for assessing this construct in Spanish is needed, as this enhances the assessment of stroke patients, allows for comparing results, selects the most appropriate assessment for each individual, and provides greater rigor in treatment and research.\u003c/p\u003e\n\u003cp\u003eThe clinical validation of the Spanish version of the FMA was subjected to statistical analysis of its psychometric properties (exploratory factor analysis, internal consistency, reliability, measurement error, criterion validity, hypothesis testing, and responsiveness), showing good agreement for most items. These statistical properties were adequate and significant (De Vet et al., 2024; Koo et al., 2016; Motal de la Rubia, 2019), providing a highly valid version recommended for the assessment of sensorimotor function in people who have suffered a stroke.\u003c/p\u003e\n\u003cp\u003eAll psychometric properties of the FMA have been previously evaluated; however, only the content validity of the Spanish version was analyzed during translation and cross-cultural adaptation (Barbosa et al., 2019). Furthermore, the previous studies were conducted with smaller samples (n = 10 (Barbosa et al., 2019) and n = 103 (Ferrer-Gonz\u0026aacute;lez, 2016)); therefore, this study represents the largest study of the Spanish version of the FMA, as well as the first factor analysis of that version. The EFA yielded a seven-factor model, rotated with Varimax, which explained 81% of the total variance.\u003csup\u003e37\u003c/sup\u003e This is the first time that an exploratory analysis has been performed on the full 50-item version of the FMA, as exploratory factor analyses of other versions of the FMA have shown different factors in the structural validity of their versions, such as the FMA-UE-Rom\u003csup\u003e38\u003c/sup\u003e or the FMA-UE-w/h (Chen et al., 2014), which presented a unidimensional construct. On the other hand, for the FMA-UE, solutions of one (Tauchi et al., 2022) and four (Woodbury et al., 2007) factors have been found, although the version in which the most factors have been found was the FMA-UE-w/h, with 12 factors (Persch et al., 2015). The version most similar to the one carried out in this study is the translation of the original version of FMA into Urdu, which presented two factors (Ikram et al., 2022). No other version of FMA has been found that has a structure like the Spanish version of FMA.\u003c/p\u003e\n\u003cp\u003eRegarding the internal consistency of the Spanish version of the FMA, excellent levels of internal consistency were found, with a high Cronbach\u0026rsquo;s alpha score (\u0026alpha; = 0.982) (Koo et al., 2016) for the scale in general. These values are higher than those of other language versions, such as the Japanese version (\u0026alpha; = 0.973) (Amano et al., 2018; Tauchi et al., 2023) and the Urdu version (\u0026alpha; = 0.80\u0026ndash;0.87) (Ikram et al., 2022), showing concordance with more cross-culturally similar versions, such as the Polish version (Goliwas et al., 2024). When compared with other assessment scales of the same construct in the post-stroke Spanish population, such as the ARAT scale, a higher internal consistency score was found for FMA than for ARAT, which has a Cronbach\u0026rsquo;s Alpha score of 0.96 (Noce et al., 2024).\u003c/p\u003e\n\u003cp\u003eThe test-retest reliability of the Spanish scale was assessed using an ICC, which showed excellent reliability properties (Liljequist et al., 2019; Mart\u0026iacute;nez-P\u0026eacute;rez \u0026amp; P\u0026eacute;rez-Mart\u0026iacute;n, 2023), with a score of 0.98 (95% ICC). This score is very similar to that obtained in other studies (Lin et al., 2021) and is slightly lower than that obtained in the Japanese version of the FMA (ICC = 0.99\u0026ndash;1) (Amano et al., 2018). Considering that this score was for simultaneous inter-rater, when this population was assessed with non-simultaneous inter-rater, the ICC score ranged from 0.81 to 0.98 (Amano et al., 2018). Other studies of the original version of the FMA also showed higher ICCs for both inter- and intra-rater measurements (ICC = 0.99) (See et al., 2013). The score obtained with this Spanish version of the FMA remains high and significant, being slightly higher than that obtained in previous studies with the original version of the FMA (ICC = 0.96 (Sanford et al., 1993); ICC = 0.95\u0026ndash;0.98 (Hsueh et al., 2008)) and higher than other translations such as the Korean version of the FMA (ICC \u0026gt;0.72) (Kim et al., 2021). Nevertheless, the Spanish version of the FMA has exhibited excellent reliability properties. This is consistent with previous studies, suggesting that the various translations and validations of the FMA in different languages are valid and reliable versions for assessing upper and lower limb sensorimotor function in stroke survivors.\u003c/p\u003e\n\u003cp\u003eThe authors used the total score of the Spanish version of the FMA and the ENVI-R to measure criterion validity, showing positive correlations in both cases (Spearman rho: FMA vs. ENVI-R = 0.50; FMA-UE vs. ENVI-R = 0.34; FMA-LE vs. ENVI-R = 0.39), such that the variables vary, without implying causality, and that the distribution of the variable is abnormal (Akoglu, 2018; Schober et al., 2018). This is the first study to analyze the correlation between the Spanish version of the FMA and any other scale, in this case, the ENVI-R scale. Through this correlation, the hypothesis proposed in this study was confirmed, and adequate responsiveness was achieved for the Spanish version of the FMA.\u003c/p\u003e\n\u003cp\u003eLooking at the different findings and the comparisons with other scales, the Spanish version of the FMA presents similar and even higher values than other versions in other languages or other assessment scales of the same construct for the same population, in some psychometric properties such as internal consistency (Amano et al., 2018; Ikram et al., 2022) or reliability (Hsueh et al., 2008; Kim et al., 2021; Lin et al., 2021; Sanford et al., 1993; See et al., 2013). Given the good psychometric properties found after the validation process, it can be stated that the Spanish version of the FMA is a very suitable and recommendable scale for assessing sensorimotor function in upper and lower limbs in the Spanish population who have suffered a stroke.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and strengths of the study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne limitation of this study was that the validation sample size was not very large (Terwee et al., 2018). Among the limitations is that the sample was obtained through convenience sampling, in which the patients agreed to participate at their rehabilitation center after being invited by the researcher. Another limitation is that the assessments were not performed by two independent evaluators, making it impossible to assess inter-rater reliability (Lujan-Tangarife \u0026amp; Cardona-Arias, 2015).\u003c/p\u003e\n\u003cp\u003eIts main strength is that this article is the first validation of the Spanish version of the FMA in a Spanish population. Furthermore, no previous study has analyzed the psychometric properties examined in this study for the Spanish version of the FMA.\u003c/p\u003e\n\u003cp\u003eIn the future, it would be advisable to validate the Spanish version of the FMA in people with other conditions that cause limitations in sensorimotor function of the upper and lower limbs.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThe validation process of the Spanish version of the FMA has demonstrated that this scale could be used in the Spanish population after a stroke for the assessment of upper limb sensorimotor function. It was also verified that the values obtained for the psychometric properties were adequate and significant when using the Spanish version of the FMA. Based on these results, the use of the Spanish version of the FMA can be recommended and defended in research and clinical practice. The use of this Spanish version of the FMA will allow a reliable comparison of stroke outcomes between regions and countries where other cross-culturally adapted and validated versions exist.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the data protection and confidentiality law of the evaluated people and their respective healthcare centers, in accordance with the provisions of the Ethics Committee of the University of Malaga, Spanish legal regulations regarding clinical research, especially Law 14/2007, of July 3, on Biomedical Research, and the Organic Law 3/2018, of December 5, on the protection of personal data and the guarantee of digital rights, and its data development regulations, but they are available through the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have agreed on the final version and meet at least one of the following criteria (recommended by the ICMJE): Substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; drafting the article; or revising it critically for important intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAkoglu H. 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Evidence of synergy coordination patterns of upper-limb motor control in stroke patients with mild and moderate impairment. Front Physiol 2023;14:1214995. https://doi.org/10.3389/fphys.2023.1214995.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 3 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Fugl-Meyer Assessment, Sensorimotor Function, Assessment, Psychometric properties, Validation","lastPublishedDoi":"10.21203/rs.3.rs-7887724/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7887724/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The Fugl-Meyer Assessment (FMA) is one of the most recommended scales for assessing upper and lower limb sensorimotor function in stroke survivors. This study aims to evaluate the psychometric properties of the Spanish version of the FMA in order to validate it in the Spanish stroke population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A validation study was conducted in which 110 stroke survivors were evaluated, and 65 of them were re-evaluated. Psychometric properties were assessed using exploratory factor analysis, internal consistency, reliability, measurement error, criterion validity, hypothesis testing, and responsiveness.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The exploratory analysis generated seven factors. Internal consistency was excellent (α = 0.982). Test-retest reliability was excellent (ICC = 0.98). The criterion validity found between FMA-Total and FMA-UE was 0.97, and between FMA-Total and FMA-LE was 0.89. The correlation between FMA and ENVI-R was demonstrated and significant (r = 0.34–0.5).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The Spanish version of the FMA can be used in research and clinical practice after demonstrating adequate and significant psychometric properties. The use of this scale will improve the quality of assessment of upper and lower limb sensorimotor function in stroke patients and allow for reliable comparisons.\u003c/p\u003e","manuscriptTitle":"Validation of the Spanish Version of Fugl-meyer Assessment in Spanish Post-stroke Population","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 07:51:27","doi":"10.21203/rs.3.rs-7887724/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-20T17:57:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"63142358309363639686734924392618556083","date":"2026-04-08T14:35:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-08T09:53:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T10:21:27+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-03T10:21:53+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-31T13:08:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-10-31T13:05:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e1c2eeb3-5bfb-449c-a0fc-1ebde5b546ba","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":66439845,"name":"Health sciences/Health care"},{"id":66439846,"name":"Health sciences/Medical research"},{"id":66439847,"name":"Health sciences/Neurology"},{"id":66439848,"name":"Biological sciences/Neuroscience"}],"tags":[],"updatedAt":"2026-04-19T07:51:27+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 07:51:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7887724","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7887724","identity":"rs-7887724","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}