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ALS Functional Rating Scale – Revised (ALSFRS-R)

Tracks how ALS affects everyday physical function, across speech, movement, and breathing.

By Claire White

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What it measures

The ALSFRS-R asks 12 questions across four areas of daily function. Speech, salivation, and swallowing cover bulbar function. Handwriting, cutting food, and dressing cover fine motor function. Turning in bed, walking, and climbing stairs cover gross motor function. The last questions cover breathing.

Each question is scored from 0 to 4, where 4 is normal function. The 12 answers add up to a single score.

What the result tells you

The total runs from 0 to 48. A higher score means more function is retained. Most people take the ALSFRS-R more than once, because the change in score over time is what tracks the course of the condition.

The score is reference information for you and your care team. It does not diagnose ALS and does not set your treatment.

Used for

Related instruments

Evidence, psychometrics and provenance

Created by Cedarbaum and colleagues in 1999, who added respiratory questions to the original ALS Functional Rating Scale. Patient self-report has been validated against in-clinic clinician scoring.

Psychometrics

Internal consistency (total)α 0.82
Test-retest reliabilityICC 0.95
Inter-rater reliabilityICC 0.93–0.97
Self-report agreementICC 0.93

Reliability and agreement on a 0 to 1 scale. Higher is better.

Construct validity
Tracks strength and quality of life; predicts survival
Responsiveness
≈ 1 point/month; MID 3.8 over 3 months
Dimensionality
Multidimensional on Rasch analysis; report subscores

A note on the total score. Internal consistency is high, but several Rasch analyses find the ALSFRS-R is not unidimensional, so summing all 12 items into one number is contested. The measurement literature recommends reporting the bulbar, motor, and respiratory subscores, or an interval-transformed total.

References

Original

  1. 1.Cedarbaum JM, et al. The ALSFRS-R: a revised ALS functional rating scale that incorporates assessments of respiratory function. J Neurol Sci. 1999;169(1-2):13-21.

Validation and self-report

  1. 2.Montes J, et al. Validation of a self-administered version of the ALSFRS-R. Neurology. 2006.
  2. 3.Maksymowicz S, et al. Polish validation of the ALSFRS-R. Neurol Sci. 2020;42(3):943-949.
  3. 4.Vasta R, et al. Longitudinal agreement of ALSFRS-RSE with ALSFRS-R. Amyotroph Lateral Scler Frontotemporal Degener. 2024.

Structure and dimensionality

  1. 5.Franchignoni F, et al. Evidence of multidimensionality in the ALSFRS-R: a Rasch analysis. J Neurol Neurosurg Psychiatry. 2013;84(12):1340-5.
  2. 6.Bacci ED, et al. Item response theory analysis of the ALSFRS-R. 2015.
  3. 7.Rooney J, et al. What does the ALSFRS-R measure? J Neurol. 2017.

Responsiveness and progression

  1. 8.Boddy SL, et al. Minimal important difference of the ALSFRS-R. Amyotroph Lateral Scler Frontotemporal Degener. 2025;26(3-4):249-258.
  2. 9.PRECISION-ALS Extant Study. ALSFRS-R progression rates. Amyotroph Lateral Scler Frontotemporal Degener. 2025.

This assessment uses a validated instrument and is reference information, not a diagnosis.