Rehab Measures Instrument
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  2. Activity Card Sort

Activity Card Sort

Last Updated

Purpose

The Activity Card Sort (ACS) is used by occupational therapists to help clients describe their social, instrumental, and leisure activities. It is often used to learn more about the client’s activity patterns and interests in order to promote the development of participation in the client’s meaningful activities.

Link to Instrument

Instrument Details

Acronym ACS

Area of Assessment

Activities of Daily Living
Life Participation
Occupational Performance

Assessment Type

Patient Reported Outcomes

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$112.95

Cost Description

Cost is for American Occupational Therapy Association members; nonmember price is $161.95. The Activity Card Sort (2nd Edition) may be purchased on AOTA’s website at https://myaota.aota.org/shop_aota/product/1247

CDE Status

Not a CDE--last searched 10/3/2023.

Diagnosis/Conditions

  • Brain Injury Recovery
  • Cancer Rehabilitation
  • Multiple Sclerosis
  • Parkinson's Disease & Neurologic Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Populations

Healthy Adults
Stroke
Parkinson's Disease
Older Adults and Geriatric Care
Multiple Sclerosis
Mixed Populations
Mental Health
Cancer

Key Descriptions

  • Designed to help patients describe their occupational histories.
  • Can be used to:
    1) Identify lost activities
    2) Set goals
    3) Monitor rehabilitation
  • Composed of 89 photographs depicting the performance of various activities.
  • Items include:
    1) 20 instrumental activities
    2) 35 low-physical-demand leisure activities
    3) 17 high-physical-demand leisure activities
    4) 17 social activities
  • Three versions of the ACS are available:
    1) Institutional
    2) Recovering
    3) Community Living
  • Information is used by clinicians to design patient-centered interventions.

Number of Items

89

Equipment Required

  • Activity Card Sort Manual
  • Activity Cards
  • Response Forms

Time to Administer

60 minutes

60 minutes or more

Required Training

Reading an Article/Manual

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Updated 7/26/2023 by Allison Antman, Michele Brice, Ari Buslovich, and Leah Thoma, UIC OT students under the direction of Susan Magasi, PhD, Associate Professor, Department of Occupational Therapy and Disability Studies, UIC

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living

Professional Association Recommendation

American Occupational Therapy Association

Considerations

Alternate format versions:

  • Modified ACS
  • Electronic ACS

ACS language versions currently available:

  • North American (US)
  • Israeli
  • Hong Kong
  • Australian
  • United Kingdom
  • Japanese
  • Spanish
  • Netherlands (Dutch)
  • Arabic Heritage

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Cancer

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Test/Retest Reliability

Cancer Patients: (Lyons et al., 2010; n = 36; age = 54 (12); diagnosis: Multiple myeloma= 45%, Non-Hodgkin’s lymphoma = 28%, Leukemia = 19%, Hodgkin’s lymphoma = 8%)

Summary Statistics for the Proportion of Items for Which Participants Were Reliable in Their Designation of an Activity as Previously Done Versus Not Done Previously on the Activity Card Sort (Modified; N = 29)

 

 

 

Domain

Mean (SD)

Median

95% C.I.

Total score (80 activities)

71.9 (14.2)

72.5

66.5–77.3

Instrumental (20 activities)

81.6 (9.7)

85.0

77.9–85.3

Low-Physical-Demand-Leisure (28 activities)

67.4 (19.8)

71.4

59.8–74.9

High-Physical-Demand-Leisure (17 activities)

64.3 (23.8)

70.6

55.2–73.4

Social (15 activities)

76.1 (18.6)

80.0

69.0–83.2

Internal Consistency

Cancer Patients: (Lyons et al., 2010)

ACSm Internal Consistancy (at 1 and 18 Months)

 

 

 

Domain

Alpah at 1 month*

Alpha at 18 months*

Domain

Total score (80 activities)

.87 (Excellent)

.88 (Excellent)

Total score (80 activities)

Instrumental (20 activities)

.89 (Excellent)

.46 (Poor)

Instrumental (20 activities)

Low-Physical-Demand Leisure (28 activities)

.54 (Poor)

.80 (Excellent)

Low-Physical-Demand Leisure (28 activities)

High-Physical-Demand Leisure (17 activities)

.81 (Excellent)

.74 (Adequate)

High-Physical-Demand Leisure (17 activities)

*Cronbach's Alpha

 

 

 

Construct Validity

Cancer Patients: (Lyons et al., 2010)


Correlation of ACSm Total Score Pearson Correlation

 

 

 

Domains

r

Domains

r

Karnofsky Performance Scale

.42

Karnofsky Performance Scale

.42

Overall well-being (FACT–G)

.51

Overall well-being (FACT–G)

.51

Functional well-being (subscale of FACT–G)

.59

Functional well-being (subscale of FACT–G)

.59

ACSm = Activity Card Sort (modified)
FACT–Cog = Functional Assessment of Cancer Therapy–General and Cognitive Scales Cognitive Function subscale
FACT–G = Functional Assessment of Cancer Therapy–General Cognitive Scales

 

 

 

Older Adults and Geriatric Care

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Test/Retest Reliability

Community Dwelling Adults: (Everard et al., 2000; n = 20; aged 65 to 87 years; time between assessments = 74 days)

  • Excellent: Instrumental activities of daily living (r = 0.95)
  • Excellent: Social (r = 0.83)
  • Excellent: Low-demand leisure activity (r = 0.91)
  • Excellent: High-demand leisure activity (r = 0.88)

 

Elderly Adults: (Albert et al., 2009; n = 375; mean age > 70 years; assessed at baseline and 12 months)

  • Adequate test Retest reliabilitiy (r = 0.74)

Criterion Validity (Predictive/Concurrent)

Community Dwelling Adults: (Everard et al., 2000; n = 20; aged 65 to 87 years)

  • Concurrent validity using the Activity Checklist
    • Excellent: Instrumental (r = 0.90)
    • Excellent: Social (r = 0.78)
    • Excellent: Low-demand leisure (r = 0.82)
    • Excellent: High-demand leisure activity (r = 0.72)

 

Older Adults: (Doney and Packer, 2008; n = 93, Mean age = 74.82 (8.64) years; Australian sample)

  • Adequate: ACS-Aus CAL scores (mean = 0.807, SD = 0.12) and AAP scores (mean = 38.080, SD = 7.49); r = 0.434

Construct Validity

Older Adults: (Doney and Packer, 2008)

  • Adequate convergent validity: ACS-Aus CAL scores and PWI scores (mean = 64.760, SD = 10.18) r = 0.354
  • Established discriminative validity: ACS-Aus CAL for a younger group (mean = 0.852, SD = 0.100) and an older gourp (mean = 0.760, SD = 0.120) which were found to be signigicantly different (independent t-test;p = 0.000)

Parkinson's Disease

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Interrater/Intrarater Reliability

Parkinson’s disease: (Poerbodipoero et al., 2015; Participants were administered the Dutch version of the ACS)

  • Excellent interrater/intrarater reliability: (ICC inter-rater = 0.85; ICC intra-rater = 0.89)

Construct Validity

Convergent validity:

Parkinson’s disease (Poerbodipoero et al., 2015; Participants were administered the Dutch version of the ACS)

  • Poor convergent validity between ACS-NL performance scores and Canadian Occupational Performance Measure (COPM) scores (r = 0.19; p < 0.001)
  • Adequate convergent validity between ACS-NL performance scores and the Parkinson’s Disease Questionnaire-39 (PDQ-39) index score, mobility, and ADL domains (r = 0.44 to 0.55, p < 0.001).
  • Poor convergent validity between ACS-NL performance scores and PDQ-39 scores for physical domain (r = 0.27, p < 0.001) and social domain (r = 0.12, p = 0.07).

Discriminative validity:

Parkinson’s disease (Poerbodipoero et al., 2015; Participants were administered the Dutch version of the ACS)

  • Significantly higher level of participation in activities for the mild group (Hoen & Yahr (H&Y) stage 1; n = 46) compared to the moderate group (H&Y stage 3; n = 60) (mean difference 16.4%,U = 524.5, Z = −5.453, p < 0.001).
  • Significantly higher scores for the mild group on self-perceived performance measured with the COPM (U = 1000.5, Z = −2.422, p = 0.015) and health-related quality of life measured by the PDQ-39 (U = 770.5, Z = −3.554, p < 0.001) than for the moderate group.

 

Idiopathic Parkinson Disease: (Duncan & Earhart, 2010; n = 62; Hoehn & Yahr Stages 1–4)

Correlations with other measures of mobility:

 

 

 

 

 

 

 

BBS

FTSTS

6MWT

FOG-Q

DTWV

FWV

BBS

-

-0.16

0.79

-0.68

0.63

0.76

FTSTS

 

-

-0.30

-0.03

-0.27

-0.30

6MWT

 

 

-

-0.44

0.80

0.86

FOG-Q

 

 

 

-

-0.35

-0.38

DTWV

 

 

 

 

-

0.85

BBS = Berg Balance Scale
FTSTS = The Five Times Sit to Stand test
6MWT = The Six Minute Walk Test
DTWV = Dual task walking velocity
FWV = Forward walking velocity

 

 

 

 

 

 

Stroke

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Criterion Validity (Predictive/Concurrent)

Chronic Stroke: (Hartman-Maei et al., 2007; n = 27; first event hemispheric stroke; mean age = 61.59 (7.38) years; Israeli sample, scores of teh test are reported before and after participants completed a community re-integration rehabilitation)

ACS Domain

Before: Mean (SD)

After: Mean (SD)

p

IADL

20.01 (15.60)

25.23 (15.70)

p = 0.000

Leisure social cultural

37.47 (24.41)

46.39 (19.66)

p = 0.000

Leisure Low physical

44.47 (22.72)

58.06 (22.87)

p = 0.000

Leisure High physical

8.26 (11.51)

15.39 (16.33)

p = 0.001

Total activity level

29.72 (14.99)

38.51 (14.91)

p = 0.000

Multiple Sclerosis

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Test/Retest Reliability

Multiple sclerosis: (Hamed & Holm, 2012; n = 105 (43 with MS and 62 healthy adults); mean age  = 45.1 (17.1) for Total Group, 40.8 (9.9) for MS group and 48.0 (20.2) for healthy group); retest administered after one month interval to 30 participants (10 with MS and 20 healthy); Jordanian participants administered Arab Heritage translation of Activity Card Sort (A-ACS)).

  • Acceptable test-retest reliability: (ICC = 0.80, 95% confidence interval of 0.61 to 0.90, p < 0.00)

Internal Consistency

Multiple sclerosis: (Hamed & Holm, 2012; Jordanian participants administered Arab Heritage translation of Activity Card Sort (A-ACS))

  • Excellent internal consistency for all items (α = 0.90)
  • Poor to Excellent internal consistency for domains:
    • Excellent internal consistency for Instrumental Activities of Daily Living (IADL) (α = 0.86)
    • Adequate internal consistency for Low-Physical Demand Leisure (LDL) (α = 0.77)
    • Poor internal consistency for High-Physical Demand Leisure (HDL) (α = 0.69)
    • Excellent internal consistency for LDL/HDL combined (α = 0.84)
    • Adequate internal consistency for Social Activities (SA) (α = 0.73)
    • Adequate internal consistency for Religious Activities (α = 0.74)

Criterion Validity (Predictive/Concurrent)

Concurrent Validity

Multiple sclerosis: (Hamed & Holm, 2012; Jordanian participants administered Arab Heritage translation of Activity Card Sort (A-ACS))

  • Adequate concurrent validity between A-ACS total retained level and the Mayo-Portland Adaptability Inventory (MP) participation index (r = 0.55, p < 0.000)

Construct Validity

Convergent Validity

Multiple sclerosis: (Hamed & Holm, 2012; Jordanian participants administered Arab Heritage translation of Activity Card Sort (A-ACS))

  • Scores/constructs compared: Correlations between participation (the A-ACS total retained participation level) and adaptability (the total scores on the MP) and independence (A-PASS-SR total performance score)
  • Groups compared: MS and healthy combined
  • Adequate convergent validity between A-ACS total retained participation level with MP adaptability score (r = -0.458, p < 0.00) and Arabic version of the Performance Assessment of Self-Care Skills-Self-Report (A-PASS-SR) independence score (r = 0.581, p < 0.00)

Discriminant Validity

Multiple sclerosis: (Hamed & Holm, 2012; Jordanian participants administered Arab Heritage translation of Activity Card Sort (A-ACS))

Aim is to examine the ability of the A-ACS to discriminate between two groups that are known or expected to differ in their participation levels. Scores/constructs compared: A-ACS total current, previous, and retained participation levels.

  • Significantly greater current participation on the A-ACS reported by the healthy group compared to the MS group (F = 5.09, p < 0.03)
  • Significantly greater retained participation levels on the A-ACS reported by the healthy group compared to the MS group (F = 6.01, p < 0.02)
  • No Difference between healthy and MS groups for previous participation levels
  • Significantly greater retained participation levels on the A-ACS reported by the healthy young adult group compared to the MS group (F = 4.98, p < 0.01)
  • No Difference between healthy older adult group and MS group for retained level of previous participation levels

Content Validity

The content validity of the A-ACS was established in a previous study with a sample of 156 younger and older adults from Jordan (Hamed et al., 2011).

  • The study yielded a list of 88 activities classified in five domains: (IADL, LDL, HDL, and SA) and a new religious activities domain (RA).
  • Of the 88 activities in the A-ACS, 19 were unique to the Jordanian/Arab culture.
  • The administration and scoring used in the new A-ACS is the same as the original version.

Mental Health

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Standard Error of Measurement (SEM)

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; mean age = 78.6 (5.70); male = 40; 5-7 months post onset of COVID-19 pandemic; mean activity and participation scores (SD): IADLs (26 items): 14.90 (4.85), L-leisure (18 items): 8.64 (3.13), H-leisure (10 items): 3.67 (1.89), and sociocultural activity (18 items): 7.20 (3.06) Japanese participants administered Activity Card Sort-Japanese Version (ACS-JPN); SEM calculated as SEM = Standard Deviation from the first test x (square root of (1-ICC)))

  • IADL SEM= 4.91 x (square root (1-0.89) = 1.628
  • L-Leisure SEM= 3.17 x (square root (1-0.79) = 1.453
  • H-Leisure SEM= 1.87 x (square root (1-0.71) = 1.007
  • Sociocultural Activity SEM= 3.00 x (square root (1-0.79) =1.375

Minimal Detectable Change (MDC)

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN; MDC calculated as MDC = 1.96 x SEM x square root of 2)

  • IADL MDC = 4.512
  • L-Leisure MDC = 4.027
  • H-Leisure MDC = 2.791
  • Sociocultural Activity MDC = 3.811

Minimally Clinically Important Difference (MCID)

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

  • Significant difference by sex among the 26 IADLs in the ACS-JPN; men showed a mean of 13.6 (4.85) and women showed a mean of 16.5 (4.56), p = 0.012

Cut-Off Scores

Depression Amongst Community-Dwelling Older Adults: (Uemura et al., 2019; Round 1: n = 177, mean age = 69.9 years; male = 79; Round 2: n = 178, mean age = 74.9 years; male = 51; Japanese participants administered ACS-JPN)

  • Round 1: Cut-off set to select most frequent items
    • Mean value<2.0, indicates items done “at least once a year”
    • For items near cutoff score with a large standard deviation, individual differences had a strong influence on the ranking, so such items with standard deviation >1.0 included as potential items of the ACS-JPN
  • Round 2: Cut-off set for most favorable items
    • Mean value <1.75
    • Selection of items participants felt older Japanese adults do “some”, “lots”, or “most” in their lives


 

Normative Data

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

Summary data for scores on Activity Card Sort (Japanese version)

Section/points of outcome measure

Mean (SD)

Median

Normality

IADLs (26 items)

14.95 (4.91)

16.50

0.017

L-leisure (18 items)

8.70 (3.17)

8.50

0.088

H-leisure (10 items)

3.70 (1.87)

3.50

0.207

Sociocultural Activity (18 items)

7.29 (3.00)

7.00

0.292

IADLs (Retention rate)

0.86 (0.24)

0.90

0.000

L-leisure (Retention rate)

0.82 (0.27)

0.90

0.000

H-leisure (Retention rate)

0.67 (0.32)

0.70

0.002

Sociocultural Activity (Retention rate)

0.64 (0.34)

0.70

0.000

Test/Retest Reliability

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

  • Acceptable: ICC = 0.73 all domain activities score; ranged from 0.71 (H-leisure)-0.89 (IADLs)

Internal Consistency

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

  • Excellent: Cronbach’s alpha range from 0.83-0.94 for the four ACS domains

Content Validity

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

  • Sufficient: activities included in ACS-JPN were selected from everyday activities of community dwelling elderly in five diverse regions of Japan
  • “the number of current and previous activities can be quantitatively evaluated in each of these four domains” (p.4)

Responsiveness

Depression Amongst Community-Dwelling Older Adults: (Tanikaga et al., 2023; n = 74; Japanese participants administered ACS-JPN)

  • Statistically significant: difference in the activity retention rates, with H-leisure and sociocultural activities being significantly lower than IADL and L-leisure (p < 0.001)

Mixed Populations

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Construct Validity

Individuals Experiencing Homelessness (IEH): (Tyminski, et al., 2020; IEH (phase 1: n = 13, phase 2: n = 10); non-homeless individuals (phase 2: n = 30); Participants administered ACS-Advancing Inclusive Participation)

  • Initial construct validity study demonstrated differences between occupational participation of those who are homeless and non-homeless in the areas of social engagement, non-sanctioned occupations, work and education, and home management. 

Content Validity

Individuals Experiencing Homelessness (IEH): (Tyminski, et al., 2020; IEH (phase 1: n = 13, phase 2: n = 10); non-homeless individuals (phase 2: n = 30); Participants administered ACS-Advancing Inclusive Participation)

  • “Content validity was obtained using a convenience sample of adult participants receiving services at a local emergency homeless shelter (n = 13). Participants were asked to name the activity card (without written caption), then given the activity verbally and asked if they thought it depicted the image on the card… 28 captions were reworded, 10 items were removed, 1 activity added, 6 new pictures created to better depict the activities and 32 edited for clarity = 76 validated line drawings with follow up clinician questions (p.3)” 

Healthy Adults

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Test/Retest Reliability

Healthy Adults: (Gustafsson et al., 2016; n = 54, female = 41; Australian participants administered ACS-Australian version (18-64))

  • Excellent test-retest reliability for overall activity levels: (ICC = 0.92)
  • Acceptable to Excellent internal consistency for all activity domains:
    • Personal care, daily life, home maintenance: (ICC = 0.88)
    • Recreation and relaxation: (ICC = 0.91)
    • High/low impact physical: (ICC = 0.88)

Internal Consistency

Healthy Adults: (Gustafsson et al., 2016, n = 54)

  • Excellent: Cronbach's alpha (α) for all items = 0.83

 

Bibliography

Albert, S. M., Bear-Lehman, J., et al. (2009). "Lifestyle-adjusted function: variation beyond BADL and IADL competencies." Gerontologist 49(6): 767-777. Find it on PubMed

Doney, R. M. and Packer, T. L. (2008). "Measuring changes in activity participation of older Australians: validation of the Activity Card Sort-Australia." Australas J Ageing 27(1): 33-37. Find it on PubMed

Duncan, R. P. and Earhart, G. M. (2010). "Measuring participation in individuals with Parkinson disease: relationships with disease severity, quality of life, and mobility." Disabil Rehabil. Find it on PubMed

Everard, K. M., Lach, H. W., et al. (2000). "Relationship of activity and social support to the functional health of older adults." J Gerontol B Psychol Sci Soc Sci 55(4): S208-212. Find it on PubMed

Gustafsson, L., Hung, I. H., & Liddle, J. (2016). Test–retest reliability and internal consistency of the activity card sort–Australia (18-64). OTJR: Occupation, Participation and Health, 37(1), 50–56. https://doi.org/10.1177/1539449216681277

Hamed, R., AlHereshy, R., Abu Dahab, S., Collins, B., Fryer, J., Holm, M. B. (2011). The development of Arab Heritage Activity Card Sort (A-ACS). International Journal of Rehabilitation Research, 34(4), 299-306. DOI: 10.1097/MRR.0B013E32834AFC58

Hamed, R., & Holm, M. B. (2012). Psychometric Properties of the Arab Heritage Activity Card Sort. Occupational Therapy International 20(1), 23-34. https://doi.org/10.1002/oti.1335

Hartman-Maeir, A., Eliad, Y., et al. (2007). "Evaluation of a long-term community based rehabilitation program for adult stroke survivors." NeuroRehabilitation 22(4): 295-301. Find it on PubMed

Lyons, K. D., Li, Z., et al. (2010). "Consistency and construct validity of the Activity Card Sort (modified) in measuring activity resumption after stem cell transplantation." Am J Occup Ther 64(4): 562-569. Find it on PubMed

Poerbodipoero, S. J., Sturkenboom, I. H., van Hartingsveldt, M. J., Nijhuis-van der Sanden, M.W.G., & Graff, M.J. (2016) The construct validity of the Dutch version of the activity card sort, Disability and Rehabilitation, 38:19, 1943-1951, DOI: 10.3109/09638288.2015.1107779

Tanikaga, M., Uemura, J.-i., Hori, F., Hamada, T., Tanaka, M. (2023). Changes in Community-Dwelling Elderly’s Activity and Participation Affecting Depression during COVID-19 Pandemic: A Cross-Sectional Study. Int. J. Environ. Res. Public Health, 20, 4228. https://doi.org/10.3390/ijerph20054228

Tyminski, Q. P, et al. (2020). Initial Development of the Activity Card Sort-Advancing Inclusive Participation from a Homeless Population Perspective. Occupational Therapy International. doi: 10.1155/2020/9083082

Uemura, J., Tanikaga, M., Masahiro T., Shimose, M., Hoshino, A., & Igarashi, G. (2019). Selection of Activity Items for Development of the Activity Card Sort–Japan Version. OTJR: Occupation, Participation and Health, Volume 39, Issue 1, https://doi.org/10.1177/1539449218784729 

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