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NEURO ASSESSMENTS ICF - Coggle Diagram

- - - - UPRIGHT MOTOR CONTROL TEST (UMCT)
        
        EXT
        
        ANKLE
        
        INSTRUCTIONS
        
        "stand as straight as you can"
        
        Lift up your unaffected leg (R/L)
        
        keep your knee straight and rise up onto your toes as high as you can
        
        SCORING
        
        WEAK: knee collapses into FLX, Knee wobbles between FLX/EXT, or EXT thrust/hyperext cannot be controlled by examiner
        
        uncontrolled trunk lean and buckles at hip and knee --> ankle
        
        MODERATE: maintains neutral knee and ankle (tibia vertical but cannot lift heel off the ground (less concentric control)
        
        STRONG: knee maintains neutral and lifts heel off the floor on command (any degree of heel lift while maintaining knee in neutral)
        
        EXCESSSIVE: severe equinus or varus position prevents the patient from maintaining stable position even with the use of a wedge
        
        significant EV/PF contracture --> if wedge doesnt correct = excessive
        
        UNABLE TO TEST: patient has knee flexion cc
        
        KNEE
        
        WHY?
        
        good determination for NEED OF AFO
        
        Stance phase gait (LR/MST) = SLS
        
        INSTRUCTIONS
        
        bend both knees: "stand on both feet with your knees bent"
        
        eccentric knee EXT
        
        Lift unaffected leg: "keep your knees bent and lift your R/L (unaffected) leg"
        
        straighten leg (if able to maintain): "straighten your R/L (affected) knee as much as you can"
        
        concentric knee EXT
        
        SCORING
        
        WEAK: unable to maintain stance on single leg with knee flexed (collapses or heel rises)
        
        MODERATE: able to maintain stance on single leg with knee flexed (no further collapse
        
        STRONG: supports body weight on a flexed knee and upon request straightens knee to end of available knee EXT range (hyperEXT allowed)
        
        EXCESSIVE: unable to posiiton knee in flexion (pre-test position) due to extensor thrust/extensor tone or hypertonicity (Bilat knee FLX)
        
        UNABLE TO TEST: Absence of plantargrade foot or other such condition renders the test invalid
        
        HIP
        
        SET UP
        
        may hold patients hand must allow patient to stand without any assistance at LE
        
        SCORING:
        
        WEAK: Uncontrolled trunk or hip FLX
        
        MODERATE: Cannot maintain trunk fully erect (or at end of hip EXT ROM) but patient can stop forward motion prior to falling, or trunk wobbles back and forth, or patient hyperEXT trunk on hip
        
        STRONG: maintains erect posture with hip at neutral or end of available range
        
        INSTRUCTIONS
        
        stand on both legs as straight as you can
        
        Now stand as straight as you can on just your affected (R/L) - lift your unaffected leg - keep standing as straight as you can
        
        SET UP
        
        guard hip and knee
        
        let patient shift over, and bend, dont overgaurd initiallhy
        
        FLX
        
        KNEE
        
        predictor: differentiated household (weak/moderate grade) from community ambulators (strong grade)
        
        SCORING:
        
        WEAK: no motion, or knee flexes < 30 deg, OR completes 3x repetitions of any range in > 10 seconds
        
        MODERATE: flexes knee between 30-60 deg, 3x in 10 secs or less
        
        STRONG: flexes knee > 60 deg, 3x times in 10 seconds or less.
        
        ANKLE
        
        SCORING
        
        WEAK: no motion, or less than neutral DF, or unable to perform 3x repetitions in 10 seconds or less
        
        NO MODERATE GRADE
        
        STRONG: actively DFs to at least neutral 3x times, in 10 seconds or less
        
        HIP
        
        SET UP:
        
        any orthoses off
        
        non-slip surfaces
        
        SCORING:
        
        WEAK: no motion, or hip flexes < 30 deg, OR performs 3x reps of any range in > 10 seconds
        
        MODERATE: flexes hip between 30-60 deg, 3x times in 10 seconds or less
        
        STRONG: Flexes hip > 60 deg, 3x times in 10 seconds or less
        
        *make sure it is true hip flx and not compensation via trunk ext/pelvic tilt
        
        time = primary scoring criteria
        
        "swing phase"
        
        INSTRUCTIONS
        
        stand as straight as you can
        
        bring your affected knee towards your chest 3x as high, fast, and safe as you can"
        
        keep your toes up (DF)
        
        if you can, hold your leg up on the 3rd try
        
        WHY?
        
        quick
        
        most functional test: gait (stance/swing), upright posture and weight bearing
        
        mm performance vs. specific mm strength (no selectivity needed)
        
        SET UP:
        
        1 PT (and 1 assistant if available and appropriate)
        
        PT responsible for safety, assitant help with environment and UE support
        
        dr.russel way: sit on stool, able to stabilize better and see limb move better
        
        use table if no assistant
        
        consider fatigue: learn to accurately grade all 3 (hip, knee, ankle) at the same time
        
        Pt APPROPRIATENESS
        
        can follow simple instructions
        
        needs no greater than 1-person assist for single and double limb stance
        
        SCORING (GENERAL)
        
        STRONG
        
        MODERATE
        
        WEAK
    - - 5X SIT TO STAND (STS)
        
        WHY?
        
        Fxnl LE strength (minimize UE use = cross arms)
        
        dynamic balance (mvmt analysis/descent control and quality)
        
        mm endurance
        
        quantify fxnl change in transitional mvmts
        
        SET UP:
        
        chair 16" (43cm) and against a wall
        
        timer = fwd trunk lean + lift off --> sit down
        
        1x practice trial
        
        minimize distractions
        
        PT be close (stand on stool so block knee + hold pt gait belt)
        
        INSTRUCTION:
        
        sit and stand up 5x times as quickly, safely, and accurately as you can
        
        when standing, stand all the way up (want full ext)
        
        avoid: back of knees on chair AND back on back of chair (document if do this)
        
        OUTCOMES:
        -fail: inability to complete 5x or use of complete UE support
        
        Pt APPROPRIATENESS:
        
        can use UE if demand necessary
        
        can give pt assistance
        
        DOCUMENTATION:
        
        document if use UE and if PT assisted
        
        can track progress of: assistance level, descent, balance, support
        
        modifications
        
        PSYCHOMETRICS
        - cut off score: 12 seconds discriminatory for healthy elderly vs. CVA
      - SUPINE HIP EXT
        
        WHY?
        
        assess hip EXT strength in modified position (prone/plantigrade positioning challenging)
        
        SET UP:
        
        lower the bed for good PT body mechanics (level squat, no deep squat)
        
        pt position: supine with heels off mat (ideal); can perform with heels on mat if needed
        
        PT position: at pt feet
        
        INSTRUCTION:
        
        assess PROM 1st (SLR 50-70* needed)
        
        "when I say go, dont let me lift your leg and keep your hip position locked"
        
        STOP TEST: once pt back off the table
        
        GRADING:
        
        0 = Absent: no resistance felt with weight matching the weight of the LE
        
        1 = Trace. NOT SCORED FOR THIS TEST (unable to palpate/see contraction in supine)
        
        2 = Poor: hip flexes but minimal resistance that is assumed to be more than just the weight of the LE (difference between weight of leg vs. push down resistance; PROM differentiates 0 vs. 2)
        
        3 = Fair: hip flexes but a strong amount of resistance is felt with pelvis not lifting or minimally lifting (comes back down)
        
        4 = Good: hip flexion occurs before the pelvis lifts but pelvis and low back lift fully off the mat ("off tempo/not locked/unsynced")
        
        5 = Normal: hip remains locked in neutral and pelvis and back raised together while being lifted
  - - - STEREOGENOSIS
      - 2-POINT DISCRIMINATION
      - VIBRATION
      - GRAPHESTHESIA
      - TEMPERATURE
  - - - WHY?
        
        selective movement or not
        
        draw out synergy with different movements
        
        want to see synergistic patterns
        
        reliability of MMT info
      - DOES NOT TEST:
        
        which synergistic pattern is present
        
        extent of synergistic pattern
      - INSTRUCTIONS
        
        LE
        
        SITTING (heel on ground)
        A) Knee FLX PROM (> 90* FLX)
        B) Knee FLX AROM
        
        REFLEX ALGORITHM
        NO MOVEMENT
        
        NOT ABLE
        
        partial DF ROM
        
        synergistic pattern noted
        
        SUPINE ALGORITHM (decr demand)
        
        Test #1: Single Knee to Chest (SKTC)
        
        Test #2: Resisted Massed EXT "MMT" (triple EXT)
        
        YES, ABLE
        
        performs SOME movement in supine (normal)
        
        partial/decreased ROM in supine
        
        1 more item...
        
        NOT ABLE
        
        movement is fully synergistic in supine
        
        1 more item...
        
        2.REFLEX
        ALGORITHM
        CONT'D
        
        2 more items...
        
        if heel up:
        
        gastroc shortness
        
        ROM stiffness
        
        YES, ABLE
        
        full DF ROM
        
        no synergy noted
        
        STANDING ALGORITHM (incr demand)
        
        Test #1:
        
        A) hip EXT + Knee FLX PROM
        
        B) instruction: "stand straight up and kick heel to butt" AROM
        quad stiffness/shortness may impede ROM
        
        YES, ABLE
        
        no synergy pattern
        
        1 more item...
        
        NOT ABLE
        
        synergy pattern noted
        
        unable to perform BOTH standing tests
        
        1 more item...
        
        UE
        
        SITTING
        Flex arm to 90 without elbow flexion or shoulder abduction
        
        NOT ABLE
        
        Check for Common UE synergistic pattern
        
        NOT ABLE
        
        no movement at all
        
        1 more item...
        
        YES
        
        1 more item...
        
        YES, ABLE
        
        Check if patient can ABD shoulder to go WITHOUT elbow FLX
        
        NOT ABLE
        
        1 more item...
        
        YES, ABLE
        
        1 more item...
    - - SCORING:
        
        Selective Movement: no synergy
        
        Selective Pattern Overlay: synergy AFTER 50% ROM
        
        Deviation from Patterned Movement: synergy BEFORE 50% ROM
        
        Patterned Movement: synergy = immediate and through ANY available ROM
      - INSTRUCTIONS
        
        Pt position: sidelying with assement leg facing up and exposed
        
        assess PROM (variable: based on before synergy kicks in)
        
        therapist: provide support of leg to eliminate effect of gravity
        
        patient will follow specific instructions to move the assessment leg with gravity eliminated, one segment at a time (from one ENDROM to the other)
        
        observe movement at the hip, knee, and ankle separately
        
        END OF TEST: moment you see any synergy
        
        to test SELECTIVE FLX:
        
        start with patient's LE in available END ROM EXT (hip EXT + knee EXT + ankle PF)
        
        From ENDROM EXT position, ask pt to MOVE INTO FLX AT EACH JOINT INDIVIDUALLY
        
        as pt moving = palpate to see if movement comes from each joint
        
        to test SELECTIVE EXT:
        
        start with patient's LE in available ENDROM FLX (hip FLX + knee FLX + ankle DF)
        
        from ENDROM flexed position, ask patient to move into EXT at each joint individually
        
        for selective knee EXT = BEWARE OF HAMSTRING FLEXIBILITY
  - - - SET UP
        
        pt: supine/sitting
        
        test area of pt should be unclothed and accessible
        
        do this test after mvmt analysis
        
        pt = relax (biggest impediment = pt doesnt relax fully --> little voluntary effort = high PNS response --> give higher MAS score)
      - INSTRUCTIONS
        
        stabilize body part being tested
        
        start mm in shortened position
        
        move joint SLOWLY through available ROM (to assess PROM) --> THEN with INCR'D SPEED
        
        quick stretch = rapid + full ROM
        
        repeat mvmt no more than 3x trials (usually do 1x to avoid informing the pt what to expect)
        
        UE (less used)
        
        Finger FLX & EXT
        
        Wrist: PRON & SUP
        
        Wrist: FLX & EXT
        
        Elbow: FLX & EXT
        
        LE (in this order)
        
        Ankle: DFs & PFs
        
        Knee: FLXors & EXTsors (abduct leg to do this off the side of the bed)
        
        Hip ABDuctors & ADDuctors
        
        Hip FLXors (hip neutral, not SLR) & EXTsors (no trailing limb = but should test this)
      - SCORING
        
        0 = Normal: no increase in mm tone
        
        1 = Slight increase in tone: manifested by catch and release OR minimal resistance at END RANGE ROM
        
        1+ =Slight increase in tone: mainfested by catch and release FOLLOWED BY minimal resistance thorughout remainder (less than 1/2) of ROM
        
        2 = more marked increase in tone throughout MOST OF ROM: affected part easily moved
        
        3 = considerable increase in tone: passive (quick stretch) movement is DIFFICULT
        
        4 = affected part is RIGID in FLX or EXT
    - - WHY?
        
        assess affect of upright position on QS response
        
        observe quality and ANGLE of QS response
      - SET UP
        
        pt strong side stands on step
      - INSTRUCTIONS
        
        test: PFs, Knee EXT, SLR
      - SCORING
        
        Degrees of ROM at which feel a "catch"
  - - - LEVEL OF CONSCIOUSNESS
        
        A. RESPONSIVENESS
        
        B. QUESTIONS
        
        C. COMMANDS
        
        BEST GAZE (track finger)
        
        VISUAL (peripheral vision acuity)
        
        FACIAL PARALYSIS
        
        MOTOR
        
        A. ARM (L/R)
        
        B. LEG (L/R)
        
        LIMB APRAXIA (mvmt planning)
        
        SENSORY
        
        BEST LANGUAGE
        
        DYSARTHRIA (ability to articulate speech)
        
        EXTINCTION & INATTENTION (sensory modality)
- - - - INSTRUCTION:
        
        comfortable pace:
        
        when PT says "go" walk in a straight line safely and comfortably until you reach the chair/cone
        
        fast pace:
        
        when PT says "go" walk in a straight line fast BUT AS SAFE AS POSSIBLE as if you were crossing the street in a hurry until reach cone/chair
      - PSYCHOMETRICS:
        
        cut-score:
        
        <0.4 m/s: household ambulation (physiologic, limited, unlimited)
        
        0.4-0.8 m/s: limited community ambulation (least, most)
        
        ≥0.8 m/s: community ambulation
        
        : MDC:
        
        0.05 m/s TBI
        
        MCID:
        
        0.10-0.14 m/s stroke
        
        0.15 m/s TBI free
        
        0.25 m/s TBI fast
      - WHY?
        
        assess walking speed
        
        assess steady-state walking speed over a short distance
        
        easy to administer with minimal equipment required
        
        good reliability for stroke population
      - WHO?
        
        NOT APPROPRIATE
        
        MOD-MAX A pts (lots of physical assistance)
        
        cant walk full 10 m without rest
      - SET UP
        
        10m distance is not necessary (can calculate difference)
        
        chairs at each end
        
        2m at beginning at end of 10 m to account for accel and decel
        
        pt should utilize orthoses and AD as required
      - SCORING (INCOMPLETE)
        
        INDEPENDENT: another person is not required for the activity (no helper)
        
        7: COMPLETE INDEPENDENCE: all tasks which make up the activity are typically perfomed safely without modification, AD, aids, and within a reasonable amount of time
        
        6: MODIFIED INDEPENDENCE: one or more of the following may be true: AD required to complete task; activity takes more than reasonable time (at least 3x longer than normal); safety/risk considerations
        
        DEPENDENT: another person is required for either superivison or physical assistance in order for the activity to be performed, or it is not performed (requires helper)
        
        5: SUPERVISION
        
        4: MINIMAL CONTACT ASSITANCE
        
        3: MODERATE ASSITANCE
        
        COMPLETE DEPENDENCE
        
        2: MAXIMAL ASSISTANCE
        
        TOTAL ASSITANCE
      - CLASSIFICATIONS
        (gait speed and %normal)
        
        PHYSIOLOGIC: 0.10 (7%N)
        
        LIMITED HOUSEHOLD: 0.23 (17%N)
        
        UNLIMITED HOUSEHOLD: 0.27 (20%N)
        
        MOST LIMITED COMMUNITY: 0.40 (29%N)
        
        LEASAT LIMITED COMMUNITY: 0.58 (43%N)
        
        COMMUNITY: 0.8 (59%N)
      - Documentation
        
        walk test performed
        
        pace instructed
        
        walking speed (m/s)
        
        test details for comparison at re-test
        
        assistance level
        
        walking aid (level of aid)
        
        orthosis used/shoes worn
        
        % of norm and ambulatory classification
    - - PSYCHOMETRICS:
        
        MDC:
        
        61m sub-acute stroke
        
        34.4m chronic stroke
        
        MCID:
        
        50m chronic stroke
      - INSTRUCTION:
        
        aim: walk as far as possible
        
        walk around the cones as many times as possible
        
        pt allowed to stop and rest (stand, sit, lean ok)
        
        after rest: start walking as soon as you can
        
        pt no talking except:
        
        need rest
        
        feeling unwell (chest pain, dizzy, etc)
        
        PT INSTUCTION (During):
        
        tell pt every minute how much time is left and that they are doing well
        
        if pt rests:
        
        continue timing
        
        every 30 sec after tell pt "please walk again if able"
        
        at 6 min = stop
      - WHY?
        
        ENDURANCE
        
        easy to administer with minimal equipment required
        
        excellent reliability for stroke population
      - WHO?
        
        not everyone is appropriate (see contraindications)
        
        appropriate
        
        pt who can walk independently
        
        pt MIN A at waist (not at LE)
        
        AD/orthosis use allowed
        
        pt who can follow multi-step instructions
      - DOCUMENTATION
        
        walk test performed
        
        walkway distance
        
        distance walked (m)
        
        test details for re-test comparison
        
        assist level
        
        walking aid
        
        orthosis used/shoes worn
        
        RPE
        
        HR/BP
        
        number of rests
        
        % of norm
  - - - TIMED UP AND GO (TUG)
        
        VARIATION: dual task
        
        manual: hold cup of water
        
        cognitive: ask pt to either...
        
        count (standard): backwards from 100 by 7 or 3 intervals
        
        name names starting with certain letter
        
        name months in reverse (NO BASELINE ALLOWED)
        
        state every other letter of the alphabet in order
        
        PSYCHOMETRICS:
        
        cut off
        
        ≥13.5 seconds = fall risk in community dwelling adults
        
        MDC
        
        2.9s
        
        Percentage of Cost: < 10%
        
        [(dual-reg)/reg)x100]
        
        INSTRUCTION:
        
        pt sit in chair (start)
        
        feet behind line
        
        hands in lap
        
        back on back of chair
        
        when PT says "go" and pt starts any movement (start timer)
        
        walk at comfortable and safe speed to the line/cone/chair and walk around it in either direction
        
        turn around and come back
        
        sit back down (end/stop timer)
        
        1x practice trial allowed
        
        WHY?
        assess dynamic postural control, transitions, turns, and locomotion
      - DYNAMIC GAIT INDEX (DGI)
        
        WHY?
        assess individual's ability to maintain balance while walking and performing various tasks
        
        assess likelihood of falls
        
        activity based clinical tool to assess gait, balance and fall risk
        
        WHO?
        
        MS
        
        PD
        
        BI (brain injury)
        
        CVA
        
        Vestibular
        
        Geriatric
        
        SCORING
        
        ordinal scale: 0-3 (3=normal, 2=mild impairment, 1= moderate impairment, 0 = severe impariment)
        
        total: 24 points
        
        ITEMS (8)
        
        gait level surface
        
        change in gait speed
        
        gait with horizontal turns
        
        gait with vertical turns
        
        gait and pivot
        
        step over obstacle
        
        step around obstacle
        
        steps/stairs
        
        PSYCHOMETRICS
        
        CVA
        
        MDC:
        
        Chronic CVA: 2.6 points
        
        overall CVA population: 4 points or 16% change
        NO MCID/CUT OFF
        
        BRAIN INJURY
        
        CUT OFF SCORE
        
        19/24 = 28% probability of falling
        
        24/24 = 6% probability of falling
        
        0/24 = 100% probability of falling
        
        ELDERLY
        
        MDC: 2.9 points
        
        MCID: 1.9 points
        
        CUT OFF SCORE: < 19/24 = increased risk of falling
      - FUNCTIONAL GAIT ASSESSMENT (FGA)
        
        WHY?
        
        assess:
        
        postrual stability during walking
        
        individual's ability to perform multiple motor tasks while walking
        
        WHO?
        
        CVA
        
        vestibular
        
        geriatric
        
        Parkinsons dz (PD)
        
        CLOSE SUPERVISION Pts
        
        SET UP
        
        SCORING
        
        0-3 ordinal scale
        
        3: normal
        
        2: mild impairment
        
        1: moderate impairment
        
        0: severe impairment
        
        total: 30 points
        
        ITEMS
        
        gait level surface
        
        change in gait speed
        
        gait with horizontal head turns
        
        gait with vertical head turns
        
        gait and pivot turn
        
        step over obstacle
        
        gait with narrow base of support
        
        gait with eyes closed
        
        ambulating backwards
        
        steps (4x)
        
        PSYCHOMETRICS
        
        CUT SCORE
        
        ≤ 22/30: predicts falls in community dwelling older adults
        
        MDC
        
        4.2 points (clinically 5 point change)
    - - *POSTURAL ASSESSMENT FOR STROKE SCALE (PASS)
        
        TRUNK IMPAIRMENT SCALE (TIS)
        
        SCI
        
        SCALE FOR CONTRAVERSIVE PUSHING
        
        ITEMS (12)
        
        Clincial Order
        
        BED ROLLING
        
        A) Supine --> Non-paretic
        
        B) Supine --> Paretic
        
        SUPINE --> SIT
        
        SIT UNSUPORTED
        
        SIT --> STAND
        
        STANDING
        
        A) with support
        
        B) without support
        
        C) stand on nonparetic leg
        
        D) stand on paretic leg
        
        E) pick object off the floor
        
        STAND --> SIT
        
        SIT --> SUPINE
        
        Official Order
        
        SITTING WITHOUT SUPPORT
        
        STANDING WITH SUPPORT
        
        STANDING WITHOUT SUPPORT
        
        STANDING ON NONPARETIC LEG
        
        STANDING ON PARETIC LEG
        
        SUPINE TO PARETIC SIDE LATERAL
        
        SUPINE TO NONPARETIC SIDE LATERAL
        
        SUPINE TO SITTING UP ON EDGE OF MAT
        
        SITTING ON EDGE OF MAT TO SUPINE
        
        SITTING TO STANDING UP
        
        STANDING UP TO SITTING DOWN
        
        STANDING, PICKING UP PENCIL FROM THE FLOOR
        
        SCORING
        
        ITEMS #6-12 = changing postures
        (3) Can do without assistance
        (2) can do with little assistance
        (1) can do with a lot of assistance
        (0) can't do
        
        ITEM #1: Sitting Without Support
        (3) Can sit for 5 minutes without support
        (2) Can sit for more than 10 seconds without support
        (1) Can with slight support (for example, by 1 hand for stabilization)
        (0) cannot sit
        
        ITEM #2: Standing With Support
        (3) Can stand with the support of only 1 hand
        (2) Can stand with moderate support of 1 person (more help if patient loses balance)
        (1) Can stand with strong support of 2 people
        (0) cannot stand, even with support
        
        ITEM #3: STANDING WITHOUT SUPPORT
        (3) Can stand without support for more than 1 minute and simultaneously perform arm movements and about shoulder level
        (2) Can stand without support for 1 minute or stands slightly asymmetrically
        (1) Can stand without support for 10 seconds or leans heavily on 1 leg
        (0) cannot stand without support
        
        ITEM #4: STANDING ON NONPARETIC LEG
        (3) Can stand on nonparetic leg for more than 10 seconds
        (2) Can stand on nonparetic leg for more than 5 seconds
        (1) Can stand on nonparetic leg for a few seconds
        (0) cannot stand on nonparetic leg
        
        ITEM #5: Standing on Paretic Leg
        (3) Can stand on paretic leg for more than 10 seconds
        (2) Can stand on paretic leg for more than 5 seconds
        (1) Can stand on paretic leg for a few seconds
        (0) Cannot stand on paretic leg
        
        WHY?
        
        measure the ability of an individual with stroke to:
        
        to maintain balance in a static posture (items 1-5)
        
        to maintain balance while changing postures (items 6-12)
        
        SET UP
        
        50cm-high mat table
        
        stop watch
        
        pen
        
        PSYCHOMETRICS
        
        CUT SCORE: > 12.5 total points at ~30 days s/p CVA is a positive indicator for ambulatory capacity
        
        MDC
        
        Chronic Stroke: 3.2
        
        Subacute Stroke: 2.2
        
        Acute Stroke: 1.8
        
        NORMATIVE DATA
        
        healthy older adult (>65 years): 35.7/36 total points
      - *FUNCTION IN SITTING TEST (FIST)
        
        ITEMS (14)
        
        OFFICIAL ORDER
        
        NUDGES
        
        NUDGES
        
        WHY?: assess ability to respond to unknown disruption of balance
        
        RANDOM
        
        ANT NUDGE = sternum
        
        POST NUDGE = btwn scapular spines
        
        LAT NUDGE = acromion on "strong" side (push twd affected side)
        
        lightest pressure needed to perturb balance
        
        only one push for each direction
        
        STATIC SITTING
        
        SITTING STATIC BALANCE
        "Sit tall with your hands in your lap"
        
        timed: 30 seconds (no partial credit)
        
        SITTING, SHAKE "NO"
        
        INSTRUCTIONS
        
        sit tall without using your hands (unless you must for balance)
        
        when I say "look Left/Right" turn head towards that direction
        
        continue looking in that direction until I tell you to look the other direction
        
        keep head in that position until I tell you to look straight
        
        LOOK FOR:
        
        weight shift
        
        full ROM in both directions
        
        test PROM if unusual AROM
        
        SITTING, EYES CLOSED
        
        INSTRUCTIONS
        
        close your eyes
        
        remain sitting tall
        
        hands in lap (unless needed for safety)
        
        Timed: 30 seconds
        
        SITTING, LIFT FOOT
        
        INSTRUCTIONS
        
        sit with hands in lap
        
        lift unaffected leg and foot off the floor (1 inch)
        
        repeat 2x in a row
        
        TURN FOR OBJECT BEHIND
        
        INSTRUCTIONS
        
        "turn around and pick up this object I have placed behind you"
        
        can use either arm
        
        NO blind reaching/swiping
        
        Object
        
        small + easy to grasp
        
        use tape measure/pen/small object
        
        placed at length of examiner's hand (base of palm at coccyx to finger tips posterior to hips
        
        FORWARD REACH
        
        INSTRUCTIONS
        
        "reach forward with unaffected as far as you can while maintaining your balance"
        
        keep other arm in lap
        
        goal is to get your stomach to touch your thighs (Full ROM)
        
        and return to normal sitting position
        
        N2K: restrictions (orthopedic), surgery precautions
        
        assess PROM 1st if needed
        
        LATERAL REACH
        
        INSTRUCTIONS
        
        "reach out to the side as far as you can with your unaffected side"
        
        keep hand at shoulder height
        
        make sure you unweight the opposite side of your bottom (MUST DO THIS = CL Isch tub lift off)
        
        keep feet on floor
        
        PICK OBJECT OFF FLOOR
        
        INSTRUCTIONS
        
        "pick this object up off the floor with your hand"
        
        can use either hand
        
        keep other hand resting in your lap
        
        SET UP
        
        place small/lightweight object between 1st MTP joints of feet
        
        Dont want uncontrolled mvmt
        
        POSTERIOR SCOOT
        
        INSTRUCTIONS
        
        "move backwards two inches without using your arms"
        
        SET UP
        
        use tape measure
        
        start from standardize position for each direction of scoot
        
        can help pt get back to standardize position bc not part of test
        
        ANTERIOR SCOOT
        
        INSTRUCTIONS
        
        "move forward 2 inches without using your arms"
        
        LATERAL SCOOT
        
        INSTRUCTIONS
        
        "move sideways 2 inches without using your arms"
        
        SET UP
        
        start from standard position
        
        patient can move to their preferred side
        
        CLINICAL ORDER
        
        SITTING
        
        A. STATIC
        
        B. SHAKE "NO"
        
        C. EYES CLOSED
        
        D. LIFT FOOT
        
        TURN FOR OBJECT BEHIND
        
        REACH
        
        A. FORWARD
        
        B. LATERAL
        
        PICK OBJECT OFF FLOOR
        
        SCOOT
        
        A. POSTERIOR
        
        B. ANTERIOR
        
        C. LATERAL
        
        3X NUDGES THROUGHOUT TEST
        
        warn patient before
        
        dont do if engaged in other test (esp. if eyes closed)
        
        SCORING (0-4)
        
        (4) INDEPENDENT: completes task independently and successfully (sway ok)
        
        (3) VERBAL CUES/INCR'D TIME: Completes task independently and successfully and only needs more time/cues
        
        cues include: safety cues (i.e. make sure to reach AFTER Ischial tuberosities off)
        
        if truly don't understand instructions = may repeat instructions (use clinical judgement)
        
        (2) UPPER EXTREMITY SUPPORT: must use UE support/assistance to complete successfully
        
        if need UE for 1x test = reset to optimal position
        
        if need UE ALL THE TIME = don't reset every time
        
        (1) NEEDS ASSISTANCE: unable to complete without physical assistance (document level: min, mod, max)
        
        only jump in if concerned for patient = let patient do it as much as they can
        
        (0) DEPENDENT: Requires complete physical assist; unable to complete successfully even with physical assist
        
        WHY?
        
        need reactive postural control in sitting
        
        can fall from seated
        
        perturbations in seated positions can happen
        
        SET UP
        
        PT position: SIT IN FRONT
        
        pt position: STANDARDIZED
        
        seated on edge of bed (EOB) with half the femur supported (neutral ABD/ADD/ROT)
        
        hips and knees at 90/90
        
        feet flat on floor or other support
        
        hands placed in lap unless needed for support
        
        time to administer: 15 mins or less
        
        equipment required:
        
        standard hospital bed without air mattress
        
        stopwatch
        
        small tape measure
        
        may use step-stool to support feet if needed
        
        WHO?
        
        best suited for patients with:
        
        ability to follow simple directions, verbal or nonverbal
        
        known or suspected sitting balance deficits
        
        impulsiveness (confined to seated position may be better)
        
        safety issues in sitting
        
        slow movement
        
        poor seated motor control
        
        lower level patients who:
        
        cannot tolerate other balance tests
        
        are unable to stand/ambulate without excessive assistance or devices
        
        NOT APPROPRIATE
        
        cognition deficits
        
        pts who cant sit without back support for trunk (dynamic tasks will be difficult; some static items with support of arms are appropriate)
        
        PSYCHOMETRICS
        
        MDC: 5.5 points (95% confidence)
        
        MCID: change of > 6.5 points (inpatient rehab)
        
        CUT SCORE: < 42/56 points
        
        indicates higher likelihood of discharge NOT to home (with/without assistance)
        
        measured within first 5 days of inpatient rehab
        
        INSTRUCTIONS
        
        INTRO:
        
        see how well you balance yourself in sitting
        
        ask pt to:
        
        sit with best posture and balance
        
        move to reach and scoot
        
        warn about nudges: test balance reactions
        
        ensure safety
        
        remind pt not to use hands during test
        
        LMK if need break
        
        questions?
    - - QUALITATIVE SCALE
        
        inpatient standardized definitions
        
        Normal (4): maintains steady balance without handhold support. Accepts maximal challenge and can shift weight easily within full rance in all directions.
        
        Good (3): maintains balance without handhold support, limited postural sway. Accepts moderate challenge; maintains balance while picking object off the floor
        
        Fair(2): maintains balance with handheld support; may require occasional minimal assistance. Accepts minimal challenge; able to maintain balance while turning head/trunk
        
        Poor (1): Requires handhold support and moderate-maximal assistance to maintain position. Unable to accept challenge or move without loss of balance
      - ROMBERG / SHARPENED ROMBERG
        
        No metrics
        
        ROMBERG
        
        SHARPENED ROMBERG
        
        same as romberg but in TANDEM STANCE
        
        INSTRUCTIONS
      - SINGLE LEG STANCE TEST
      - WHY?
        
        determine assistance for transitions
      - SET UP
        
        pt wearing comfy shoes
        
        make note if see UE move during tests
    - - FUNCTIONAL REACH TEST (FRT)
      - BERG BALANCE SCALE (BBS)
        
        WHY?
        
        assess balance and fall risk ("entry level test")
        
        static and dynamic activities (static >> dynamic)
        
        won't see if will fall with gait
        
        SET UP
        
        patient wearing socks and shoes
        
        time to administer: 15-20 min
        
        equipment needed:
        
        stopwatch
        
        chair (standard height) with and without arm rests
        
        measuring tape/ruler
        
        object to pick off the floor
        
        step stool (8 to 9 inch)
        
        SCORING:
        
        5-point ordinal scale (0-4)
        
        0: lose balance/cant perform
        
        4: can perform without assistance/AD
        
        points vary in items
        
        total possible score = 56
        
        ITEMS:
        
        I. STATIC
        
        sit to stand
        
        standing unsupported
        
        sitting with back unsupported and feet supported
        
        stand to sit
        
        transfer (pivot)
        
        standing unsupported with eyes closed
        
        standing unsupported with feet together
        
        reaching forward with outstretched arm while standing
        
        II. DYNAMIC
        
        picking up an object from the floor from standing position
        
        turning to look behind over L and R shoulders while standing
        
        turning 360 degrees
        
        place alternate foot on step/stool while standing unsuppported
        
        standing unsupported with one foot in front
        
        standing on 1 leg
        
        PSYCHOMETRICS:
        
        MDC
        
        acute CVA: 6.9
        
        chronic CVA: 2.5-4.66
        
        CUT-OFF
        
        < 45/56 score: individuals may be at greater risk of falling (CVA)
        
        56/56 score = "functional balance" (not perfect, doesnt mean wont fall)
        
        WHO
        
        adult populations (not just neuro-affected patients)
    - - (modified) CLINICAL TEST of SENSORY INTERACATION and BALANCE (mCTSIB)
      - BALANCE EVALUATION SYSTEMS TEST (BEST)/ Mini-BEST
        
        WHY?
        
        ID balance limitations
        
        ID underlying impairments leading to balance problems
        
        SET UP
        
        flat-heeled shoes OR shoes + socks OFF (standard)
        
        SCORING
        
        use of AD = 1 less point
        
        0: if pt requires physical assistance
        
        *Mini BEST
        
        ITEMS
        
        CATEGORIES
        
        SENSORY ORIENTATION
        
        INCLINE - EYES CLOSED
        
        "mCTSIB":
        STANCE (FEET TOGETER) + HANDS ON HIPS
        
        2 more items...
        
        DYNAMIC GAIT
        
        "FGA"
        
        4 more items...
        
        TUG + DUAL TASK
        
        POSTURAL CONTROL
        
        ANTICIPATORY
        
        3 more items...
        
        REACTIVE:
        Compensatory Stepping Correction
        
        3 more items...
        
        SCORING
        
        0-2 scale
        
        Max score: 28
        
        items # 3,6 = include score for WORST SCORE ONLY (one side)
        
        item #14: if gait slows > 10% of standard TUG then score should decr by 1 point (lowest
        
        PSYCHOMETRICS
        
        no MDC for CVA
        
        MDC (generalized balance disorders): 3.5
        
        CUT OFF SCORE: ≤ 17.5/28
        
        ID those with hx of falling
        
        BEST
        
        MDC: 7.81 sub acute stroke
        CUT OFF SCORE: > 49% = higher fxning ability
        
        systems
        
        biomechanical restraints
        
        stability limits/verticality
        
        anticipatory postural adjustments
        
        postural responses
        
        sensory orientation
        
        stability in gait
        
        Items (36)
        
        scoring = 0-3
        
        limitations:
        
        administration time
    - - ACTIVITIES-SPECIFIC BALANCE CONFIDENCE SCALE (ABC)
        
        used in OP
        
        give to patient to fill out
        
        administer as HW or at end of session (shouldn't take session time)
        
        WHY?
        
        how confident pt is with activities
        
        ID activities important to patient
        
        helps with goal setting/addressing pt concerns
        
        WHO?
        
        tells who has likely experienced fall in hx/past
        
        SCORING
        
        high score = high confidence = low falls
        
        low score = low confidence = high falls
        
        if pt doesnt do activity in items = take it out of score (i.e. if dont do 1x activity = 1600 total points --> 1500 total points)
        
        Total score: 1600 points
        
        ITEMS
        
        16 item scale
        
        items should match with assessment
        
        usually mismatched deficits (with confidence - either over or underconfident)
  - - - Spinal Cord Independence Measure (SCIM-III)
        
        adaption of FIM for SCI pop
        
        research tool
        
        in SCIEDGE doc
        
        Items
        
        Respiraiton and Sphincter control (4 items)
        
        40 points
        
        Respiration (breath independently)
        
        Sphincter Management: bladder
        
        Sphincter Management: bowel
        
        Use of toilet
        
        Mobility (9 items)
        
        40 points
        
        Mobility in bed & actions to prevent Pressure Sores/Ulcers (ability to position self to prevent PUs)
        
        Transfers
        
        Bed to WC
        
        WC to Toilet/tub
        
        WC to car
        
        Ground to WC
        
        Mobility (walking or WC)
        
        indoors
        
        Moderate Distances
        
        outdoors
        
        stair management
        
        Self-care (4 items)
        
        20 points
        
        Feeding
        
        Bathing
        
        Dressing
        
        Grooming
- - - - SET UP
        
        patient survey
        
        easy to administer
        
        part of intake form or HW after 1st visit
        
        available in multiple languages
        
        proxy version
      - WHY?
        
        patient perspective
        
        how life impacted by stroke
        
        Tx/plan development
        
        goal setting
      - SCORING
        
        lower score = less fxn pt believes they have
        
        score items pt may not do/done in past week
        
        Formula:
        
        [(actual raw score - lowest possible score)/(lowest possible raw score)] x 100
      - PSYCHOMETRICS
        
        general
        
        MDC: 8
        
        MCID: 9.4-14.1
        
        strength
        
        MDC: 9.2
        
        MCID: 24.0
        
        ADL/iADL
        
        MDC: 5.9
        
        MCID: 17.3
        
        Mobility
        
        MDC: 4.5
        
        MCID: 15/1
        
        Hand Function
        
        MDC: 17.8
        
        MCID: 25.9
      - Short version:
        SIS-16 (16 items)
        
        validated against longer form
    - - WHO?
        
        designed for TBI population
        
        used in other populations as well
      - WHY?
        
        assess reintegration to normal social activities
      - ITEMS (11)
        
        I move around my living quarters as I feel necessary
        
        I move around my community as I feel necessary
        
        I am able to take trips out of town as I feel are necessary
        
        I am comfortable with how my self-care needs (dressing feeding toileting bathing) are met.
        
        I spend most of my days occupied in work activity that is necessary or important to me.
        
        I am able to participate in recreational activities (hobbies crafts sports reading television games
        computers etc.) as I want to.
        
        I participate in social activities with family friends and.or business acquaintances as is necessary
        or desirable to me.
        
        I assume a role in my family which meets my needs and those of other family members.
        
        In general I am comfortable with my personal relationships.
        
        In general I am comfortable with myself when I am in the company of others.
        
        I feel that I can deal with life events as they happen.
      - OUTCOMES
        
        better reliability when given by proxy (TBI)
      - SCORING
        
        each item rated on anchored VAS (visual analog scale): "does not describe my situation" & "fully describes my situation"
    - - ITEMS
        
        Dimension A: Physical health
        
        Scale 2: Role-Physical (RP)
        
        cut down time
        
        accomplished less
        
        limited in kind
        
        had difficulty (accomplish goal)
        
        Scale 3: Bodily Pain (BP)
        
        Pain-magnitude
        
        Pain-interfere
        
        Scale 1: Physical Functioning (PF)
        
        Vigorous activities
        
        Moderate activities
        
        Lift, carry groceries
        
        climb several flights
        
        climb 1x flight
        
        bend, kneel
        
        walk mile
        
        walk several blocks
        
        walk 1x block
        
        bathe, dress
        
        Scale 4: General Health (GH)
        
        General health rating
        
        Excellent
        
        as healthy as anyone
        
        sick easier
        
        health worse
        
        Scale 5: Vitality (VI)
        
        Pep/life
        
        Energy
        
        Worn out
        
        Tired
        
        Dimension B: Mental health
        
        Scale 6: Social Functioning (SF)
        
        Social-extent
        
        Social-time
        
        Scale 7: Role-Emotional (RE)
        
        Cut down time
        
        Accomplished less
        
        not careful
        
        Scale 8: Mental Health (MH)
        
        Nervous
        
        Down in dumps
        
        Peaceful
        
        Blue/sad
        
        Happy
        
        Change in reported health
      - WHO?
        
        all people with disabilities
  - - - SCORING
        
        7 point Likert Scale
      - shorter form
    - - longer form
      - valuable = directed/impacted by a stroke
      - SCORING
        
        5 point Likert Scale
    - - ITEMS (1)
        
        "all things considered, how do you view your life?"
      - SCORING
        
        visual analog scale??/range
        
        "so bad, couldn't imagine it getting worse"
        
        "so-so"
        
        "so good couldn't imagine it getting better"