Motor Activity Assessment Scale (MAAS)

The Motor Activity Assessment Scale (MAAS) can be used to monitor the level of sedation of a patient in the intensive care unit.

Response to Stimulus	Patient Actions	Response to Commands	Description	Points
does not respond to noxious stimulus			unresponsive	0
responds to noxious stimulus			responsive only to noxious stimuli	1
responds to touch or name being loudly spoken			response to touch or name	2
no external stimulus required to elicit movement	patient moves purposefully	follows commands	calm and cooperative	3
no external stimulus required to elicit movement	patient is picking at sheets/tubes OR uncovering self	follows commands	restless and cooperative	4
no external stimulus required to elicit movement	attempts to sit up OR moves limbs out of bed	does not consistently follow commands	agitated	5
no external stimulus required to elicit movement	patient is pulling at tubes/catheters OR thrashing from side to side OR tries to climb out of bed	does not calm down when asked	dangerously agitated, uncooperative	6

Noxious stimulus – one or more of the following:

(1) suctioning

(2) 5 seconds of vigorous orbital pressure

(3) 5 seconds of vigorous sternal pressure

(4) 5 seconds of vigorous nail bed pressure

Response to stimulus – one or more of the following:

(1) opens eyes

(2) raises eyebrows

(3) turns head towards stimulus

(4) moves limbs

Performance:

• The kappa statistic was 0.83, showing excellent inter-rater reliability.

• The scale was found to be valid and reliable for evaluating mechanically ventilated patients.

Limitations:

• A person who is agitated (level 5 or 6) may show overlap between the 2 levels.

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