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BRILLIANT Resources: MPAI Frequently Asked Questions

The Mayo-Portland Adaptability Inventory – version 4 (MPAI-4) assesses deficits, activities and participation in individuals with acquired brain injury in rehabilitation programs. The single subscale measuring participation, the Participation Index (M2PI), can be used by itself. The training materials have primarily been developed for the use of the MPAI-4 and M2PI in stroke outpatient programs; however, the information could be applicable across all acquired brain injury rehabilitation.

General Scoring Questions

1. Why do you score a client one point higher when they use an assistive device such as a cane or leg brace, but don’t do the same for when they wear glasses for the vision question?

Yes, the use of an assistive device is automatically a score of 1 or more, whereas wearing glasses (pre-diagnosis) is a 0. 


If a client wears glasses they are not penalized because they do not have an appreciable effect on the patient’s abilities (and thus their rehabilitation), unless the patient is wearing glasses as a result of the injury or diagnosis in which case the score is 1 or more. In contrast, assistive devices are always considered to have an effect on a patient’s ability as it relates to their rehabilitation, meriting a score of 1 or more.

2. How do you assess writing if there is a problem due to a motor disability? In verbal communication (question 7A) or in use of hands (question 2)?

Difficulty with writing would be considered in both of these scores. Difficulty writing informs the use of hands score as an indicator of fine motor skill and coordination, but writing is not assessed directly here. It is directly scored in verbal communication, as one form of communication along with speaking and understanding language. 

3. What do you do if questions such as question 9 about memory or question 10 about the client’s fund of knowledge are difficult to answer due to aphasia?

No item on the MPAI-4 should be left blank. Use your best judgment to score the item and making a note stating any issues you had providing an accurate score. The discussion with the interdisciplinary team will hopefully address this gap in understanding of the client, or obtaining an accurate understanding of the individual’s memory and knowledge may become part of the treatment plan.

4. How does question 28B about primary social roles for those without and who not desire paid employment differ from questions 24 about leisure and recreational activities and question 26 about independence in maintaining her residence?

Both questions 24 and 26 ask if the client needs support to do certain activities that may be meaningful or enriching. Question 28B differs from these questions because it is primarily asking how many hours the patient spends doing social activities, as opposed to the level of support that they need to do these activities.

5. Should I assess a 65-year-old and 90-year-old differently on their participation?

Yes, people should be assessed for would be expected for their age-group.

Item Specific Questions

Item 1 : Mobility A client who is temporarily using a wheelchair functionally and who transitions to walking with difficulty (and with close assistance) during the course of the stay could end up with a higher rating at discharge (as if the client is regressing in terms of mobility, while progressing well). Should we rate based on walking potential at discharge (and therefore give a more severe rating even if functional in a wheelchair) or rate as described in the Manual despite the risk of regression?

Rate the current level (i.e., the current level of mobility), not the projected or previous level.

Although there is a risk of a slight regression in rating when a user is functional in a wheelchair and leaves walking rehabilitation with difficulty or assistance, the spirit of the Manual should be maintained as much as possible. In any case, if the user uses a wheelchair, he/she is rated at least at level 2.

Item 2: Is it correct to give a client with arm hemiplegia a score of 2 on question 2 about use of hands if they are very functional with one hand?

If the client can only use one hand but have adapted to require no external assistance, they would receive a score of 1. If they require assistance, they would receive a score of 2.

Item 3 : Vision Should visual symptoms (especially in mild CBTs) be scored in item 3 (vision), 12 (visuospatial abilities) or further reflected in items 16 (pain and headaches) and 17 (fatigue)?

Visual difficulties and symptoms (double or blurred vision, at rest or with physical or mental exertion, sensitivity to light, etc.) are rated under item 3 (vision), while other related elements (e.g., pain behind the eyes with exertion) are rated under the respective item as appropriate (e.g., item 16 pain and headaches). On the other hand, low mental effort/rapid reading fatigue is rated under item 17 (fatigue). Item 12 (visuospatial abilities) specifically reflects problems with visual perception and visuospatial orientation/attention.

Item 4 : Hearing Should hyperacusis or increased sensitivity to sound stimuli with a functional impact be considered in this item?

Hearing difficulties and symptoms such as hyperacusis and hypersensitivity to noise are rated under item 4 (hearing).

Item 9 : Memory What can be done when working memory weaknesses (without episodic memory problems) have an impact on an aphasic user?

If working memory weaknesses are reported by the user or are documented and have a mild impact on functioning, they should be rated at Level 1 on this item (memory) of the A) ABILITIES scale, as the Manual indicates that memory problems at this level may be associated with other factors such as concentration difficulties or others.

The functional impact of greater working memory weaknesses will also be considered in the rating of scale C) PARTICIPATION.

Item 21: In the scoring for question 21 about family and significant relationships, what is meant by family functioning and how does stress relate to it?

In this question, family functioning refers to any stress with close family and friends (not only blood-relatives) that is affecting household tasks being accomplished or the provision of mutual support. The premise of this item is that family functioning is affected by the level of stress on the family. So, these two concepts are intertwined in this item. Higher stress = poorer family functioning = higher score.

Item 21 : Family/Significant relationships Should we assess the level of stress experienced by the family or their difficulty in adapting to the situation and their propensity to compensate for the person's diminished capacities?

The intent is to assess the impact of stress on family functioning, not the family’s ability to compensate for the consumer’s difficulties in performing tasks and responsibilities. When in doubt, refer to the more general % hindrance of activities rather than the specific examples described in the Manual, which are not exhaustive.

Item 21 : Family/Significant relationships What is the definition of family that should be considered (e.g., when users do not live with their families per se, are single, or their families are abroad)?

Referring to the description of item 21, the term “family” generally means relatives who live together or nearby, but more broadly this item includes any type of significant relationship that can provide concrete support to the person, even if that relationship is at a distance.  

Item 21 : Family/Significant relationships What do we do when the user has no family or significant relationships (e.g., homeless person)?

Anyone without meaningful supportive relationships would be rated 3 or 4 in the Handbook: “no family cohesion” or “dysfunctional family life” (rated 3), or “no cohesion at all” (rated 4).  

Item 23: For question 23, should COVID-19 be taken into account? During COVID-19, everyone's social contacts were diminished.

Taking the client’s social life pre-injury (during and pre-COVID) and their satisfaction with their current level of social contact may be the most appropriate scoring method. If the person is satisfied with their current level of social contact, then it being reduced due to the pandemic isn’t necessarily an issue. If they are not satisfied, then there are obstacles to be overcome and that should be reflected in the score they receive.

Items 23 and 24: Social Contacts and Leisure Activities What do we do when the problem seems obvious to the team, but the user does not complain about it himself?

Score according to what is observed by the team rather than solely on the basis of the problem reported or not by the user.  

Item 25 : Personal Care What if the person had margi- nal functioning before the brain injury (e.g., did not wash or did not wash well)?

Score on current need for assistance to complete tasks with a socially acceptable outcome, regardless of the type of assistance required (i.e., physical assistance, stimulation, reminders), even if this is not significantly different from the premorbid picture.  

Item 26 : Home This item includes two different concepts: the level of supervision required to return home and the resumption of activities of daily living (ADL). How to rate when a user does not need supervision, but does not perform DLA because of physical/cognitive limitations?

Consider the supervision required to do the tasks (not to remain alone). Assess what the person is doing in terms of socio-residential and associated responsibilities, not their ability to stay on their own.  

Item 26: Home What if an inpatient is able to function at home, but is being held in-house due to medical issues (e.g. urinary tract infection)?

Score according to the user’s ability to perform domestic activities as in the assessment during in-house scenarios.

Item 26: Home What should be done when the user did not perform any or very few domestic tasks before the brain injury because of a specific family organization (e.g.: the spouse took on all or most of the tasks) and he or she still does not perform these activities even though he or she is capable of doing so?

If the user does not require assistance with these tasks, but does not do them for cultural reasons, for example, score 0 (as if he/she were capable). However, if he/she does not do them (or did not do them before) because he/she requires encouragement/reminders/stimulation (i.e., any form of assistance), then score at the severity level corresponding to functioning. 

Item 27: For question 27 about transportation, if a person can independently use public transportation and has never had a driver's license, do we rate them 0 or 1?

If the person lives in an area where public transportation is available such that they do not need assistance to get around, then a score of 0 is appropriate. If they live in an area where they do not have access to public transit, then they are dependent on someone else to drive them and should receive a score of 1 or more. This score would depend on how often they require someone to drive them as opposed to walking or biking to get where they need to go, for example.

Item 27: For question 27 about transportation, could a person have a rating of 1, if they are independently able to book and travel by paratransit but are not able to drive a car?

This is a good example of a score of 1 or 2 for someone who can’t drive but is fairly independent. If they are restricted to using specialized adaptive transit and cannot take standard public transit options, a score of 2 may be more appropriate.

Item 27 : Transports If a user is safe but only for 15 minutes and then feels dizzy or less well, they can drive, but it is not functional. Based on the % of activity impairment, he/she could score 3. However, the Manual indicates that a rating of 3 is generally for a person who cannot drive. What would his rating be?

Stick to the functional level. Even if they have the ability to drive, because it’s only for a short time, it restricts them significantly in doing that activity. So this issue needs to be reflected in the rating.  

Items 28A and 28B: Paid Work and Other Main Occupation What item is used to score people who are not looking for work, even if they could be considered employable (e.g., social assistance)?

These persons should be considered as not having a working status. Therefore, item 28B (not 28A) should be marked with a check mark in the box “Person at home, without children or dependants”.  

Items 28A and 28B: Paid Work and Other Main Occupation What if the user, who has a second brain injury, was not working because of a work stoppage following the first brain injury?

If the person was unemployed prior to the most recent brain injury, rate item 28B, not 28A, as they are not considered to be gainfully employed at that time.  

Items 28A and 28B: Paid Work and Other Main Occupation What if work abilities remain unassessed at the end of outpatient rehabilitation because the client is transferred to another program specifically for this purpose?

Do as for all the other items and rate the status at the time the MPAI-4 is completed, even if the user is likely to change in this respect later on.  

The data will have to be interpreted according to the organization of services in place in each of the settings. A comment could be included in the section of the questionnaire to this effect in order to identify this type of situation in the database.  

Item 28B: How do I choose someone’s primary social role on question 28B when they fit under multiple?

Question 28B gives several options to select for primary social role, including childrearing/care-giving, homemaker without childrearing or caregiving, student, volunteer and retired. The primary role of the patient should be selected; however you can take all their activities that fit under this question into account when scoring it.

The question of diagnosis The MPAI-4 and its use The implementation of MPAI-4 In some items, the Manual description refers to a diagnosis. What if there is no diagnosis, but the level of severity seems to match the one described?

Detach from the term diagnosis (it is an example to show that it is clinically significant) and try to focus on the clinical and functional impact. Although it may be helpful, it is not essential to have the diagnosis from the professional who can make it.

Premature Termination of Rehabilitation" box When to use it?

In the case of premature termination (the user stops his rehabilitation), it is agreed to check the box “Premature termination of rehabilitation” and to indicate a comment on the reason in the section at the end of the questionnaire. Completion of the MPAI-4 will be optional and will depend on where the user is in his or her progress (e.g.: if close to discharge, the final MPAI-4 could be completed). 

Part D. Pre-existing and Associated Conditions At what points should items 30-35 be scored pre-reach and post- reach?

At the beginning of inpatient or outpatient rehabilitation, score items 30-35 at the pre-and post-brain injury level (to reflect pre- morbid and associated conditions at the beginning of rehabilitation, i.e., at the initial IIP). At the end of rehabilitation, score these items at the post-brain injury level (to reflect the presence of these conditions at the end of rehabilitation, i.e., final IIP).  

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