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RehabMeasures Instrument

Moss Attention Rating Scale

Last Updated

Purpose

The MARS is an observational tool used to measure attention-related behaviors after TBI.

Link to Instrument

Instrument Details

Acronym MARS

Cost

Free

Diagnosis/Conditions

  • Brain Injury Recovery

Populations

Key Descriptions

  • 22 items
  • Raw scores range from 22-110; a spreadsheet available on the COMBI website allows for computation of interval scores from 0-100 with logit scores provided for raw scores).
  • Ratings are made on a 5-point Likert scale that indicates the degree to which an item describes a patient’s behavior:
    1= definitely false
    2= false, for the most part
    3= sometimes true, sometimes false
    4= true, for the most part
    5= definitely true
  • Items include phrases that reflect both good and impaired attention (with reverse scoring for those items that describe impairment) so that a higher score reflects better attention.
  • There is no manual for test administration because it was designed to be used by a variety of rehabilitation professionals for simple assessment of behavior.
  • A specific observation time is recommended for use of the scale (e.g. during PT sessions) for the past 2-3 days.
  • Ratings are intended to be the average level of attention during the observation period instead of the worst or best performance observed.

Number of Items

22

Time to Administer

5 minutes

Therapists are requested to complete the rating sheet based on observation of the patient over the past 2-3 days in therapy session(s) or some defined observation period (e.g. half hour over lunch). Ratings can be completed in less than 5 minutes.

Required Training

No Training

Instrument Reviewers

Initially reviewed by Karen McCulloch, PT, PhD, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 6/2012

ICF Domain

Body Structure
Body Function

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

R

HR

LS

LS

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

N/A

N/A

N/A

N/A

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

This tool is recommended for use in the acute or inpatient rehabilitation setting for patients with moderate to severe traumatic brain injury, but is not appropriate for patients in a vegetative or minimally conscious state.

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Brain Injury

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Interrater/Intrarater Reliability

Traumatic Brain Injury: (Whyte et al, 2003; n=223 patients with TBI in model systems rehabilitation centers; mean age 37 (17.9) years; mean GCS 8.4 (4.2); Rancho Level of Cognitive Functioning >III; tested 3-17 days after admission to acute rehabilitation; mean time post injury tested= 11.4 days)

  • Excellent correlation of ratings by OT and PT (r=.64); OT with tendency to rate patient attention lower than PT on average

Traumatic Brain Injury: (Whyte et al, 2008; n=149 patients with TBI at Rancho Level IV or higher; Mean age 43.3(197) years; mean ED GCS score 9.8(4.5))

  • Ratings by 52 staff for 924 ratings demonstrated adequate to excellent interrater reliability for rehabilitation disciplines of OT, PT, SLP (ICC=.69-.78 at initial rating and 0.67-0.72 at discharge)
  • Nursing ratings were in the adequate range from 0.59-0.68 at initial rating and 0.48-0.59 at discharge from rehab

Internal Consistency

Traumatic Brain Injury: (Whyte et al, 2003)

  • Excellent internal consistency (a=0.95)

Criterion Validity (Predictive/Concurrent)

Predictive validity: 

Traumatic Brain Injury:  (Hart et al, 2009; n=107; mean age 41.5(19.4) years; GCS at ED admission mean 8.6(5.1)) 

  • MARS score was a significant predictor of outcome (Disability Rating Score) by follow-up at one year, better than severity of injury measures or a battery of attention subtests.

Construct Validity

Traumatic Brain Injury: (Hart et al, 2006; n=372 patients with TBI at model systems centers; mean age 37(17.9) years; mean GCS 8.4 (4.2); Rancho Level of Cognitive Functioning >III)

  • Factor analysis resulted in factors that have excellent to adequate correlations as follows: sustained attention/restlessness r=.75; sustained attention/initiation r=.66; initiation/restlessness r=.46) 
  • Changes in MARS scores (transformed to logits) were significantly associated with a composite measure of attention and cognitive FIM scores (Hart et al, 2009)

Content Validity

  • A pilot study was conducted with an initial 53 item research version of the test, which was reduced to a 45 item version of the MARS (Whyte et al, 2003).
  • Following Rasch analysis with a sample of 223 patients with moderate to severe TBI, person separation and separation reliability values met the criterion levels. Misfit items were analyzed to determine whether they should be retained for further testing (Whyte et al, 2003). 
  • Following item analysis and exploratory and confirmatory factor analysis, a final version of 22 items was retained. Half of the items on the MARS can be used to generate factor scores in the following areas (Hart et al, 2006): 
    • 1- restlessness/distractibility (5 items) 
    • 2- initiation (3 items) 
    • 3- sustained/consistent attention (3 items)

Face Validity

Initial items were chosen based on literature review, expert consultation and use of focus groups with expert clinicians. Initial items were pilot tested on 10 patients by multiple rehab disciplines to create a draft version of the test for research. This was tested further with another sample of 20 patients with TBI prior to conducting a larger study using Rasch analysis. (Whyte et al, 2003).

Responsiveness

A subsample of studygroup (n=104) demonstrated MARS score increases of 9.9 on average during rehabilitation, with score changes from 7.8 (OT) to 13.1(nursing) (Whyte et al 2008).

Bibliography

Hart, T., Whyte, J., et al. (2009). "Construct validity of an attention rating scale for traumatic brain injury." Neuropsychology 23(6): 729-735.

Hart, T., Whyte, J., et al. (2006). "Dimensions of disordered attention in traumatic brain injury: further validation of the Moss Attention Rating Scale." Arch Phys Med Rehabil 87(5): 647-655.

Whyte, J., Hart, T., et al. (2003). "The Moss Attention Rating Scale for traumatic brain injury: initial psychometric assessment." Arch Phys Med Rehabil 84(2): 268-276.

Whyte, J., Hart, T., et al. (2008). "The moss attention rating scale for traumatic brain injury: further explorations of reliability and sensitivity to change." Archives of Physical Medicine & Rehabilitation 89(5): 966-973.