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PHYSIOTHERAPY OUTCOME MEASURES FOR NEUROLOGICAL AND GERIATRIC REHABILITATION Testing procedures, normative data and references will be provided here for the following commonly used outcome measures: Standing Balance Tests Timed Static Standing Tests Clinical Test of Sensory Interaction of Balance Functional Reach Lateral Reach Step Test Pastor, Day and Marsden Test

Functional Performance Tests Timed Up and Go Timed 10 metre walk calculation of gait parameters (velocity, stride length and cadence)

Composite Functional Performance Scales - The Modified Elderly Mobility Scale - Motor Assessment Scale - The Clinical Outcome Variables scale (COVS) - Berg Balance scale - Functional Independence Measure (FIM) - Disability Rating Scale (DRS) - Glasgow Outcome Scale For an overview of measurement in neurological and geriatric rehabilitation please refer to the following texts: 1. Carr J & Shepherd R (1998) Neurological Rehabilitation- Optimising Motor Performance. Heinneman: London (Chapter 3). 2. Wade DT (1998) Measurement in neurological rehabilitation. Oxford Medical Publications. 3. Quinn L, Gordon J (2003)Functional outcomes documentation for rehabilitation. Saunders: Philadelphia. RM700 .Q85 2003

STANDING BALANCE TESTS Timed Static Standing Tests Equipment required: stopwatch Procedure: Ensure standardised footwear Record time the position is maintained (up to a maximum of 30 seconds) and amount of sway (mild, moderate or severe). Feet apart (eyes open/ eyes closed) Normative data (healthy elderly) eyes open eyes closed = = 30sec+ 30sec+

Feet together (eyes open / eyes closed - Rhomberg's test) Stride stance (eyes open/eyes closed = Sharpened or tandem Rhomberg) Normative data (healthy elderly) eyes open = 48sec eyes closed = 22sec One leg stance test Normative data (mean age 75yrs) eyes open eyes closed = = 14secs 4secs

Clinical Test of Sensory Interaction of Balance Type of Measure Six tests designed to determine what sensory system the patient is most reliant on for orientation information, and to determine the ability of the patient to integrate conflicting information. Equipment Stopwatch, high-density foam, visual conflict dome. Method Involves the testing of six conditions each measured to a maximum of 30 seconds. Testing is done WITHOUT SHOES. The testing position is with hands by sides and feet in a standardised position (eg 10 cm apart). Each task is explained and or demonstrated to the subject.

The subject is instructed to keep as steady as they can during the test procedures. The tester stands close beside the subject and indicates the commencement of each test with the instruction "starting now". If the subject overbalances or requires steadying before the 30 seconds is completed they are allowed two further attempts. The subject's best time is recorded. Note the amount of sway - minimum/moderate /severe. The six test conditions are: 1. 2. 3. 4. 5. 6. Eyes open, firm support surface. All senses operating Eyes closed, firm support surface. Removes vision to determine an over-reliance on this system. Visual conflict dome on firm support surface. Gives false information - as you sway the dome moves with you. If you can't integrate this information, you fall. Eyes open, standing on foam. (4-6" high density foam). Reduces the available proprioceptive input. Eyes closed, standing on foam. This is a test of the integrity of the vestibular system. Visual conflict dome, standing on foam. This condition has two systems giving false/altered information and tests the ability of the vestibular system to integrate information.

Normative data healthy older adults do not show significant differences from young adults in amount of body sway until conditions 5 and 6 (where both ankle joint inputs and visual inputs were distorted or absent), Woollacott, 1986. in these conditions (5 and 6), where both visual and somatosensory inputs were reduced, 30-50% of the older adults lost balance on the first trial and needed the aid of an assistant. young adults sway 40% more in conditions 5 and 6 than in condition 1. Reference Shumway-Cook and Horak (1986) Assessing the influence of sensory interaction on balance. Physical Therapy 66:1548-1550. Woollacott MH, Shumway-Cook A, Nashner LM. Aging and posture control: changes in sensory organisation and muscular coordination. Int J Aging Hum Dev 1986;23:97-144. Functional Reach Type of Measure

The maximal distance reached beyond arms length, in the forward direction. Equipment Required: Tape measure, blue-tac, wall PT pre-requisite: Can stand unaided for ~20sec and can achieve 90 shoulder F Method Subject stands with feet comfortably apart (approximately 10cm) beside the tape measure on the wall. The tape should be at the subject's shoulder height. The test arm is raised to 90 degrees of shoulder flexion and the tester reads off the level of the KNUCKLES on the tape measure (The test arm is the one with the least shoulder pathology). The standardised instruction is given: Keeping your arm out in front of you, I want you to reach as far forward as you can without losing your balance or moving your feet. Trunk flexion can be encouraged. The tester then notes the level of the knuckles at the furthest point of reach. The Functional reach score is the difference in distance (cm) between the starting reach and the maximal reach. Do not allow the subject to lean against the wall as they reach. If overbalancing occurs, the subject should be steadied and the test repeated. Reliability and Validity excellent inter and intrarater reliability (Duncan, 1990) concurrent validity: good with walking speed & st (Weiner, 1992) predictor of falls in frequent fallers (Duncan, 1992)

Normative Data Duncan et al, 1990 Healthy subjects 20 -24 M= 42cm 41-69 M= 38cm 70-87 M= 33cm F= 37cm F= 35cm F= 27cm

A significant difference has been demonstrated between fallers and non fallers healthy elderly mean reach = 25.9 cm fallers = 15cms - poor - fair - good Mean values Young 20-40yrs 41-69yrs Healthy old 70-87yrs Balance- impaired old Isles et al Age 20-29 30-39 40-49 50-59 60-69 70-79 < or = 15cm >6 but < 25cm > or = 25cm Functional Reach Men (cm) Women (cm) 36.74.2 32.14.8 32.84.8 30.44.8 29.13.5 23.17.7 16.4 Adjusted Mean (cm) Left 42.93 40.84 39.99 38.49 36.81 34.29

Adjusted Mean (cm) Right 42.71 41.01 40.37 38.08 36.85 34.13

Reference Duncan P et al (1990). A new clinical measure of Balance. Journal of Gerontology 45:M192 197 Duncan PW, Studenski S, Chandler J, Prescott B (1992) Functional reach: Predictive validity in a sample of elderly male veterans. Journal of Gerontology 47:M93-M98. Isles RC, Low Choy NL, Steer M, Nitz JC Normal values of balance tests in women aged 20 to 80. Submitted to JAGS, 2003. Weiner D, Duncan PW, Chandler J, Studenski SA. Functional Reach: A marker of physical frailty. JAGS. 1992;40:203-207.

Lateral Reach Type of Measure A measure of mediolateral postural stability limits. Equipment Required Laminated grid (40cm long, 30cm high and 1mm graduations) Method The grid is attached to a wall at the height of the subjects acromial process. The subject is asked to stand with their back to (but not touching) the wall. The subjects feet should be 10cm apart at the heel with the foot angled out at 30 degrees. The subject is asked to stand for 10seconds with BOTH arms abducted to 90 degrees and to maintain equal weight bearing. Subjects are given the standardised instruction: Please reach as far as you can to the left / right without overbalancing, taking a step or touching the wall. The contralateral arm remains by their side during the reach. Both the subjects feet must remain fully in contact with the support surface during their reach. No trunk flexion, trunk rotation or knee flexion is permitted during the reach. The perceived maximal reach must be maintained for three seconds before returning to the start position for an accurate result to be recorded. Practice trials are allowed. The tester records the distance travelled by the tip of the third finger in relation to the grid. Lateral reach to both sides is recorded. Reliability and Validity: excellent inter and intrarater reliability (Brauer, 1999) concurrent validity: good with Berg Balance Scale and one leg stance (Brauer, 1999) Normative data: Young women 20-40yrs Healthy old women 70-87yrs Balance- impaired old women Mean values (cm) 27.24.1 20.14.9 12.33.5

Isles et al Age 20-29 30-39 40-49 50-59 60-69 70-79

Adjusted Mean (cm) Right 22.95 23.09 18.96 18.37 17.11 15.71

Adjusted Mean (cm) Left 22.36 22.00 18.44 17.31 16.10 15.58

Reference Brauer S, Burns Y and Galley P (1999). Lateral Reach: a clinical measure of medio-lateral postural stability. Physiotherapy Research International 4 (2):81-88. Isles RC, Low Choy NL, Steer M, Nitz JC Normal values of balance tests in women aged 20 to 80. Submitted to JAGS, 2003. Step Test Type of Measure Performance measure evaluating speed in a dynamic single limb stance task (self generated perturbation). Equipment required Stopwatch, 7.5 cm step test block Method The subject stands unsupported with SHOES REMOVED and feet parallel. The test block is placed 5cm in front of the subject's feet. The subject is advised which leg is to be the step leg. The standardised instruction is given: On the word go I want you to lift your foot up onto this block and then place it back onto the floor as many times as you can in 15 seconds. Do not move the opposite (supporting) foot during the test. A completed step involves placing the foot fully onto the step and then returning it to the floor. The procedure can be demonstrated to the subject and they are allowed to practice several steps. The tester commences the measurement period by saying "go", starting the stopwatch at the same time and indicates the end of the measurement period by saying "stop" indicates the start of the test by saying GO and the end with STOP.

The tester does not provide hands on assistance unless the subject loses their balance during testing. If this occurs, the number of completed steps is recorded. The same procedure is repeated for the opposite leg stepping. Reliability and Validity High test-retest reliability (Hill, 1996) Concurrent validity: good with functional reach, gait velocity and stride length (Hill, 1996) Normative Data Hill K et al (1996): Normal healthy elderly (mean age 73) CVA subjects Isles et al Age 20-29 30-39 40-49 50-59 60-69 70-79 = 17.67 steps in 15 seconds. = 6.5 steps in 15 seconds. Adjusted Mean (no.of steps) Left 20.61 19.87 18.61 17.14 15.87 14.10

Adjusted Mean (no.of steps) Right 20.72 20.17 18.77 17.13 15.59 13.73

Reference Hill K et al (1996). A New Test of Dynamic Standing Balance for Stroke Patients Physiotherapy Canada . Fall. 257-262 Isles RC, Low Choy NL, Steer M, Nitz JC Normal values of balance tests in women aged 20 to 80. Submitted to JAGS, 2003.

Pastor, Day and Marsden Test Type of Measure Test of an ability to withstand an external perturbation Equipment Required None Method The standardised instruction is given: I am going to give you a brief tug from behind. I want you to resist the backward movement. The tester stands behind the subject and delivers a brief tug backward to the subject's shoulders. The subject's eyes remain open throughout the test. The subject's response is rated according to the following scale: Scoring 0 1 2 3 4 Staying upright without taking a step. Staying upright with one step backwards required for stability. Two or more steps backwards required for stability but able to maintain upright. Several steps backwards but unable to steady self thus requiring the tester to steady the subject. Falling backwards without attempting to step.

Normative Data Response recorded as: 0-2 = normal; 3-4 = abnormal. Reference Pastor et al (1993). Vestibular induced postural responses in Parkinson's Disease. Brain 116: 11-17.

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FUNCTIONAL PERFORMANCE TESTS Timed Up and Go Type of Measure: Basic test which demonstrates subject's balance, functional ability and gait speed. Equipment Required: Stopwatch, standard height armchair, 3m marked course. Method The subject begins seated in a standard height armchair with their back against the backrest and arms resting on the armrests. The subject is tested wearing their usual footwear. The subject has their walking aid (if required) within reach. A line is marked on the floor three metres from the chair. One practice trial is given to become familiar with the test. The standardised instruction is given: On the word "go", I want you to walk as fast as you safely can to the line on the floor, turn, walk back to the chair and sit down again. The test is timed from the instruction "go" until the subject achieves sitting again. If the subject can not complete the test without assistance, it is not valid. Dual Task TUG TUG Manual & TUG Cognitive variants of this test have been developed to test the effect of dual tasks. Procedure TUG Manual Subject asked to complete the test as above while carrying a full cup of water TUG cognitive Subject asked to complete the test as above while counting backward by 3s from 100.

Reliability and Validity: - excellent inter and intrarater reliability and good concurrent validity with Berg Balance Scale (Podsiadlo 1991) - able to descriminate between fallers and non fallers

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Normative Data Isles et al Age 20-29 30-39 40-49 50-59 60-69 70-79 Shumway-Cook, 2000 Young Healthy Elderly (65-85) Balance Impaired Elderly Predicts fallers TUG 5.221.07 8.421.66 22.169.34 13.5 sec DTTUGM 6.000.90 9.731.57 27.1411.01 14.5 sec DTTUGC 5.561.02 9.702.25 27.7311.55 15 sec Adjusted Mean (secs) 5.31 5.39 6.24 6.44 7.24 8.54

Reference Podsiadlo and Richardson (1991). Journal of the American Geriatrics Society 39:142-148. Isles RC, Low Choy NL, Steer M, Nitz JC Normal values of balance tests in women aged 20 to 80. Submitted to JAGS, 2003. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the timed up and go test. Phys Ther 2000. 80:9:896903.

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Timed 10 Metre Walk Type of Measure: A measure of gait velocity, cadence and stride length. Equipment Required Stopwatch. 14 metre walkway with markers at 2 metres from each end of walkway to indicate start and finish of measurement area. Method The subject stands at one end of the walkway. The subjects regular gait aid may be used. The standardised instruction is given: I want you to walk to the far line at your comfortable speed. Do not stop or talk until you reach the far line. The tester walks beside or behind the subject without providing hands-on support unless the subject appears to be overbalancing. If overbalancing occurs, repeat the test. The tester commences timing and commences counting strides as the subject crosses the 2-metre mark. The timing and counting are stopped as the subject crosses the 12 metre line. Collecting data over the central 10 metres eliminates the period of acceleration and deceleration from measurements. If the subject can not complete the test without assistance, it is not valid. Calculations Velocity (metres/minute) Stride Length (m) Cadence(steps/minute) Normative Data Healthy older people (mean age 72.5): Velocity: 71 metres/minute Stride length: 1.27m Cadence: 111 steps/minute Signalled road crossings: 1.2 m/sec or 72 m/min (Traffic Signal Guidelines, Austroads) For gait speed reference values presented by sex and decade of age refer to Bohannon (1997). References Wolfson et al (1990). Gait Assessment in the Elderly Journal of Gerontology 45:M12-19. Bohannon RW (1997) Comfortable and maximum walking speed of adults aged 20 79 years: reference values and determinants. Age and Ageing 26: 15 19. = 600/time (secs) = 10/(number of steps/2) = velocity (metres/minute)/step length(m)

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COMPOSITE MEASUREMENT SCALES

The Modified Elderly Mobility Scale Type of Measure A measure of independence in functional mobility tasks. Equipment required Stopwatch, bed, ten metre walkway, functional reach tape measure. Method This scale is suitable for use with all elderly subjects with mobility problems, including CVA's, Parkinson's Disease, Orthopaedic Conditions and Amputees. The subject is observed completing a number of tasks. Standardised instructions are given (see below). Subjects are scored at the level at which they are safe. The scoring instructions are on the testing form (see next page). Independence means that NO physical help or verbal cues are given. For the Functional Reach and the Timed Ten Metre Walk tests, please refer to the relevant sections in this manual for instructions. Instructions Lying to Sitting Sitting to Lying Sit to Stand Standing Please sit up with your legs over the edge of the bed. Please lie down. Please stand up. Please stand as long as you can. Please reach out to touch my hand. (The tester encourages the subject to reach outside the base of support. Support infers the help of one tester) Tester observes normal walking method. Please go up and down the stairs safely.

Gait Steps

Reference Prosser L and Canby A (1997). Further Validation of the Elderly Mobility Scale for Measurement of Mobility of Hospitalised Elderly People. Clinical Rehabilitation 11:338-343. Smith R (1994) Validation and Reliability of the Elderly Mobility Scale. Physiotherapy 80 (11): 744 747.

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Date Modified Elderly Mobility Scale Lying to sitting 2.Independent 1.Needs help of one person 0.Needs help of two + people Sitting to lying 2. Independent 1. Needs help of one person 0. Needs help of two or more people Sit to stand 3. Independent (in less than three seconds) 2. Independent (in greater than three seconds) 1.Needs help of one person (verbal or physical) 0. Needs help of 2+ people Stand 3. Stands without support and able to reach outside BOS 2. Stands without support but needs support to reach outside base 1. Stands but needs support 0. Stands but only with physical assistance Gait 3. Independent (includes use of stick) 2. Independent with frame 1. Mobile with walking aid but erratic or unsafe turning (needs occasional supervision) 0. Needs physical help to walk or constant supervision Timed walk 3. Less than 18 seconds 2. 18-35 seconds 1. Over 35 seconds 0. Unable to cover 10 metres Functional reach 4. Over 16cm 2. 8-16cm 0. Unable to reach 8cm Steps 3. Independent without aid or rail 2. Independent with aid and or rail 1. Needs assistance of one person 0. Needs assistance of two or more people TOTAL /23

Date

Date:

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Motor Assessment Scale A useful measure of function for the physiotherapist with monitoring of tasks that are frequently the focus of rehabilitation after stroke: rolling; sit up over the bed edge; sitting balance; sit to stand; walking; proximal upper limb function; distal upper limb function and advanced hand activities. Zero is completely dependent/ unable to do the task, progressing to level six, which denotes an independent, efficient level of function The tool does not monitor wheelchair skill and transfers which limits the use of the tool for those groups of clients who are unable to walk eg complete spinal cord injury clients; some TBI & Stroke clients. Most appropriate for CVA, as the tool was developed specifically for this group, but can be applied to other groups of ambulant clients. Has been shown to be reliable and a valid predictor of outcome, with sitting ability at six weeks highly predictive of outcome. All rehabilitation units in SE Queensland use this tool. Carr J and Shepherd R, Nordholm L and Lynne D, 1985: A Motor Assessment Scale for Stroke. Physical Therapy. 65: 175-80. Revised version, 1994. GENERAL RULES FOR ADMINISTERING THE MAS 1. The test should preferably be carried out in a quiet private room or curtained-off area, with standardised test procedures and materials (see 13). 2. The test should be carried out when patient is maximally alert. For example, not when under the influence of hypnotic or sedative drugs. Record should be made if patient is under the influence of one of these drugs. 3. Patient should be dressed in suitable day clothes. Items 1 to 3 inclusive may be scored if necessary with patient in nightclothes. 4. Each item is recorded on a scale of 0 to 6. 5. All items are to be performed independently by the patient unless otherwise stated. Stand-by help means that therapist stands by and may steady the patient but must not actively assist. 6. Patient should be scored on the best performance out of three unless other specific instructions are stated. 7. Since the scale is designed to score best performance, the therapist should give general encouragement but should not give specific feedback on whether response is correct or incorrect. Sensitivity to the patient is necessary to enable the production of best performance. 8. Instructions should be repeated and demonstration given to patient if necessary. 9. The order of administration of items 1 to 8 can be varied according to convenience. 10. If patient becomes emotionally labile at any stage during scoring, the therapist should wait 15 seconds before attempting the following procedures: (1) Ask the patient to close the mouth and take a deep breath. (2) Hold patients jaw closed and ask the patient to stop crying. If patient is unable to control behaviour, the examiner should cease testing, and rescore this item and any other items unscored at a more suitable time. 11. If performance is scored differently on left and right side, the therapist may indicate this by dividing the box into L and R.

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12. The patient should be informed when being timed. 13. You will need the following equipment which should be standardised: a low wide plinth, a stopwatch, a polystyrene cup, eight jellybeans, two teacups, a rubber ball approximately 14cm (5 in) diameter, a stool, a comb, a pen top, a table, a dessert spoon and water, a pen, a prepared sheet for drawing lines with one vertical line on the right of the sheet, and a cylindrical object such as a jar.

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CRITERIA FOR SCORING 1. Supine to Side Lying onto Intact Side 1. Pulls self into side lying, (Starting position must be supine lying, legs extended. Patient pulls self into side lying with intact arm, moves affected leg with intact leg.) 2. Move leg across actively and the lower half of the body follows. Starting position as above. Arm is left behind. 3. Arm is lifted across body with other arm. Leg is moved actively and body follows in a block. (Starting position as above.) 4. Moves arm across body actively and the rest of the body follows in a block. (Starting position as above.) 5. Moves arm and leg and rolls to side but overbalances. (Starting position as above. Shoulder protracts and arm flexes forward.) 6. Rolls to side in 3 seconds. (Starting position as above. Must not use hands.) 2. Supine to Sitting over Side of Bed 1. Side lying, lifts head sideways but cannot sit up. (Patient assisted to side lying.) 2. Side lying to sitting over side of bed. (Therapist assists patient with movement. Patient controls head position throughout.) 3. Side lying to sitting over side of bed. (Therapist gives stand-by help [see General Rules item 5] by assisting legs over side of bed.) 4. Side lying to sitting over side of bed. (With no stand-by help.) 5. Supine to sitting over side of bed. (With no stand-by help.) 6. Supine to sitting over side of bed within 10 seconds. (With no stand-by help.) 3. Balanced Sitting 1. Sits only with support. (Therapist should assist patient into sitting.) 2. Sits unsupported for 10 seconds. (Without holding on, knees and feet together, feet can be supported on floor.) 3. Sits unsupported with weight well forward and evenly distributed. (Weight should be well forward with hips flexed, head and thoracic spine extended, weight evenly distributed on both sides.) 4. Sits unsupported, turns head and trunk to look behind. (Feet supported and together on floor. Do not allow legs to abduct or feet to move. Have hands resting on thighs, do not allow hands to move onto plinth. Turn to each side.) 5. Sits unsupported, reaches forward to touch floor, and returns to starting position. Feet supported on floor, do not allow patient to hold on. Do not allow legs and feet to move, support affected arm if necessary. Hand must touch floor at least 10 cm (4 in) in front of feet. Reach with each arm. 6. Sits on stool unsupported, reaches sideways to touch floor, and returns to starting position. (Feet supported on floor. Do not allow patient to hold on. Do not allow legs and feet to move, support affected arm if necessary. Patient must reach sideways not forward. Reach to both sides.)

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4. Sitting to standing 1. Gets to standing with help from therapist. (Any method.) 2. Gets to standing with stand-by help. (Weight unevenly distributed, uses hands for support.) 3. Gets to standing. (Do not allow uneven weight distribution or help from hands.) 4. Gets to standing and stands for 5 seconds with hips and knees extended. (Do not allow uneven weight distribution.) 5. Sitting to standing to sitting with no stand-by help. (Do not allow uneven weight distribution. Full extension of hips and knees.) 6. Sitting to standing to siting with no stand-by help three times in 10 seconds. (Do not allow uneven weight distribution.) 5. Walking 1. 2. 3. 4. 5. 6. Stands on affected leg and steps forward with other leg. (Weight-bearing hip must be extended. Therapist may give stand-by help.) Walks with stand-by help from one person. Walks 3 m (10 ft) alone or uses any aid but no stand-by help. Walks 5 m (16 ft) with no aid in 15 seconds. Walks 10 m (33 ft) with no aid, picks up a small sandbag from floor, turns around and walks back in 25 seconds. (May use either hand.) Walks up and down four steps with or without an aid but without holding on to the rail three times in 35 seconds.

6. Upper Arm Function 1. Supine, protract shoulder girdle with arm in 90 degrees of shoulder flexion. (Therapist places arm in position and supports elbow in extension.) 2. Supine, hold arm in 90 degrees of shoulder flexion for 2 seconds. (Therapist places arm in position and patient must maintain position with some [45 degrees] external rotation. Elbow must be held within at least 20 degrees of full extension.) 3. Supine, hold arm in 90 degrees of shoulder flexion, flex and extend elbow to take palm to forehead. (Therapist may assist supination of forearm.) 4. Sitting, hold extended arm in forward flexion at 90 degrees to body for 2 seconds. (Therapist should place arm in position and patient maintains position. Patient must hold arm in mid-rotation [thumb pointing up]. Do not allow excess shoulder elevation.) 5. Sitting, patient lifts arm to above position, holds it there for 10 seconds and then lowers it. (Patient must maintain position with some external rotation. Do not allow pronation.) 6. Standing, hand against wall. Maintain hand position, while turning body toward wall. (Arm is abducted to 90 degrees with palm flat against the wall.) 7. Hand Movements

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1. 2.

3. 4. 5. 6.

Sitting, extension of wrist. (Patient sits at a table with forearm resting on the table. Therapist places cylindrical object in palm of patients hand. Patient is asked to lift object off the table by extending the wrist. Do not allow elbow flexion.) Sitting, radial deviation of wrist. (Therapist places forearm in mid pronationsupination, i.e., resting on ulnar side, thumb in line with forearm and wrist in extension, fingers around a cylindrical object. Patient is asked to lift hand off table. Do not allow elbow flexion or pronation.) Sitting, elbow into side, pronation and supination. (Elbow unsupported and at a right angle. Three-quarter range is acceptable.) Sitting, reach forward, pick up large ball of 14cm (5 in) diameter with both hands and put it down. (Ball should be placed on table at a distance that requires elbow extension. Palms should be kept in contact with the ball.) Sitting, pick up a polystyrene cup from table and put it on table across other side of body. (Do not allow alteration in shape of cup.) Sitting, continuous opposition of thumb and each finger more than 14 times in 10 seconds. (Each finger in turn taps the thumb, starting with index finger. Do not allow thumb to slide from one finger to the other, or to go backwards.)

8. Advanced Hand Activities 1. Pick up the top of a pen and put it down again. (Patient reaches forward to arms length, picks up pen top, releases it on table close to body.) 2. Pick up one jellybean from a cup and place it in another cup. (Teacup contains eight jellybeans. Both cups must be at arms' length. Left hand takes jellybean from cup on right and releases it in cup on left.) 3. Draw horizontal lines to stop at a vertical line 10 times in 20 seconds. (At least five lines must touch and stop at the vertical line. Lines should be approximately 10cm in length.) 4. Hold a pen, make rapid consecutive dots on a sheet of paper. (Patient must do at least 2 dots a second for 5 seconds. Patient picks pen up and positions it without assistance. Pen must be held as for writing. Dots not dashes.) 5. Take a dessert spoon of liquid to the mouth. (Do not allow head to lower towards spoon. Liquid must not spill.) 6. Hold a comb and comb hair at back of head. (Shoulder must be externally rotated, abducted at least 90. Head erect.)

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Clinical Outcome Variable Scale (COVS): The COVS (Clinical Outcome Variable Scale) is a physiotherapy functional outcome measurement. It is a comprehensive monitor of motor tasks and useful for PT to set targets, monitor progress. Currently being used as part of an outcome study at PAH in the Brain Injury & Spinal Injury Units. These studies are linking the quality of sitting balance at admission to BIRU, to outcome (Low Choy & colleagues, unpublished data). Items include: rolling to R and L, sit up over edge of bed, sitting balance, horizontal transfer, vertical transfer, ambulation (assistance, aids, velocity, endurance), wheelchair skill, R and L upper limb function. Scores are determined at admission and discharge with a score out of 91 given. There is a rating scale from one to seven in each of these categories, indicating increasing functional independence. One is completely dependent, progressing to seven, which is denotes independent, efficient function. A ceiling effect does occur with high level patients scoring full points even at admission to the BIRU. This factor is largely due to the policy of screening all concussed clients who are admitted to the rehabilitation unit prior to discharge. A number of the large teaching hospitals use this outcome scale. If you are in such a hospital you will be expected to become familiar with its use. There are detailed instructions and guidelines for its use. Reference: Seaby L and Torrance G, 1989: Reliability of a Physiotherapy Functional Assessment in a Rehabilitation Setting. Physio Canada. 41 (5): 264-271

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Items and Scores

Item 1a: Roll to right 1. Dependent - 2 assistants required 2. One person assistance, plus device (eg bed rail) 3. One person assistance, no device 4. Rolls unaided/ assistance for comfortable position 5. Independent with device 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 1b: Roll to left 1. Dependent - 2 assistants required 2. One person assistance, plus device (eg bed rail) 3. One person assistance, no device 4. Rolls unaided/ assistance for comfortable position 5. Independent with device 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 2: Supine lying to sitting over bed edge 1. Dependent - require two assistants 2. One person assistance, plus device(eg bed rail) 3. One person assistance, no device 4. Supervision/ Instructions for safety/ verbal cues 5. Independent with device 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 3: Sitting Balance 1. Not able to sit unsupported 2 Able to sit unsupported / no displacement 3. Able to move head/trunk within base of support 4. Able to lift arm/leg within base support 5. Able to move outside base of support and return 6. Tolerates external displacement/ slow reactions 7. Tolerates external displacement / efficient Item 4a: Horizontal Transfer 1. Dependent - requires two assistants 2. One person assistance, plus device (eg sliding board) 3. One person assistance, no device 4. Supervision/ Instructions /cues /may use device 5. Independent with device 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 4b: Vertical Transfer (F/C or F/S) 1. Dependent - requires two assistants or hoist 2. One person assistance, plus device(eg chair) 3. One person assistance, no device 4. Supervision/ Instructions /cues / may use device 5. Independent with/without device, effort+/slow 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 5: Performance of Ambulation 1. No functional ambulation 2. One person continuous assistance 3. One person intermittent assistance 4. Supervision/ verbal cues for safety 5. Independent, level surfaces, assistance other surfaces and stairs 6. Independent with all surfaces/ stairs without rail Efficient Ambulation / normal sped and skill Item 6: Performance of Ambulation - aids 1. Not walking 2. Parallell bars / 2 continuous assist 3. Walker ( Rollator or Hopper) 4. Two aids ( eg Crutches , two 4 point sticks) 5. One aid except a single stick (eg one 4 point stick) 6. Uses a single stick 7. Walks without an aid. Item 7: Performance of Ambulation - Endurance 1. Not walking 2. < 10metres 3. < 50 metres 4. < 100 metres 5. < 200 metres 6. < 5oo metres 7. > 500 metres Item 8: Performance of Ambulation - Velocity 1. Not walking / 0m/sec 2. < .1m/sec 3. < .3m/sec 4. < .5m/sec 5. < .7m/sec 6. < .9m/sec 7. > .9m/sec Item 9: Performance of Wheelchair Mobility 1. Dependent 2. Able to move chair < 10metres/requires assistance. 3. Able to move chair <30 metres / intermittent assistance. 4. Supervision only flat surfaces/ Assistance for barriers 5. Independent indoors all surfaces 6. Independent outdoors, except grass /curbs 7. Independent outdoors, all conditions/surfaces Item 10a and 10b: Left and Right Arm Function 1. Unable to actively move arm 2. Able to move actively / no useful movement 3. Able to use arm as a stabiliser in weight bearing 4. Able to use arm as a stabiliser in function ( eg hold a jar) 5. Able to bring a cup to mouth 6. Functional fine movement but clumsy / awkward ( eg slides coin to table edge to pick up) 7. Efficient fine motor skill (eg pick up a coin/inserts in money box quickly and accurately)

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Berg Balance Scale The Berg Balance Scale is a comprehensive balance assessment designed to assess balance in a range of positions. 14 functional items scored /56. Items include: sit, sit to stand, transfers, standing balance, FR, stepping, trunk rotation in standing, tandem stance, one legged stance, 360 turn. Equipment required BBS scoring sheet - has explanations tape measure/ruler, blue-tac, wall, step 10-15cm high PT pre-requisite can stand unaided for 10sec

Reliability and Validity Repeatable, reliable, strongly correlated with tests of balance and fear of falling Normative Data < 45 considered to indicate a high risk of falling (Berg, 1992) < 49 when used with a history of instability to predict falling risk (Shumway-Cook, 1997). Reference: Berg, K. (1989): Balance and its measure in the elderly: A review. Physio Canada. 41: 240246

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Berg Balance Scale 1. Sitting to standing Instruction: Please stand up. Try not to use your hands for support. Grading: Please mark the lowest category which applies. _____ (4) able to stand, no hands and stabilize independently (3) able to stand independently using hands (2) able to stand using hands after several tries (1) needs minimal assist to stand or to stabilize (0) needs moderate or maximal assist to stand 2. Standing unsupported Instruction: Stand for two minutes without holding. Grading: Please mark the lowest category which applies. _____ (4) able to stand safely 2 min. (3) able to stand 2 min. with supervision (2)able to stand 30 seconds unsupported (1) needs several tries to stand 30 sec unsupported (0) unable to stand 30 sec unassisted If patient able to stand 2mins safely, score full marks for sitting unsupported. Proceed to position change standing to sitting. 3. Sitting unsupported feet on floor Instruction: Sit with arms folded for two minutes. Grading: Please mark the lowest category which applies. _____ (4) able to sit safely and securely 2 minutes (3) able to sit 2 minutes under supervision (2) able to sit 30 seconds (1) able to sit 10 seconds (0) unable to sit without support 10 seconds

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4. Standing to sitting Instruction: Please sit down. Grading: Please mark the lowest category which applies. _____ (4) sits safely with minimal use of hands (3) controls descent by using hands (2) uses back of legs against chair to control descent (1) sits independently but has uncontrolled descent (0)needs assistance to sit 5. Transfers Instruction: Please move from chair to bed and back again. One way toward a seat with armrests and one way toward a seat without armrests. Grading: Please mark the lowest category which applies. _____ (4) able to transfer safely with only minor use of hands (3) able to transfer safely with definite need of hands (2) able to transfer with verbal cueing and/or supervision (1) needs one person to assist (0) needs two people to assist or supervise to be safe 6. Standing unsupported with eyes closed Instruction: Close your eyes and stand still for 10 seconds. Grading: Please mark the lowest category which applies. _____ (4) able to stand 10 sec safely (3) able to stand 10 sec with supervision (2) able to stand 3 sec (1) unable to keep eyes closed 3 sec but stays steady (0) needs help to keep from falling 7. Standing unsupported with feet together. Instruction: Place your feet together and stand without holding. Grading: Please mark the lowest category which applies. _____ (4) able to place feet together indep and stand 1 min. safely (3) able to place feet together indep and for 1 min. with supervision (2) able to place feet together indep but unable to hold for 30 sec (1) needs help to attain position but able to stand 15 sec feet together (0) needs help to attain position and unable to hold for 15 sec

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The following items are to be performed while standing unsupported 8. Reaching forward with outstretched arm Instruction: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position.) Grading: Please mark the lowest category which applies. _____ (4) can reach forward confidently >10 inches (3) can reach forward >5 inches safely (2) can reach forward >2 inches safely (1) reaches forward but needs supervision (0) needs help to keep from falling 9. Pick up object from the floor Instruction: Pick up the shoe/slipper that is placed in front of your feet Grading: Please mark the lowest category which applies. _____ (4) able to pick up slipper safely and easily (3) able to pick up slipper but need supervision (2) unable to pick up but reaches 1-2 inches from slipper and keeps balance indep (1) unable to pick up and needs supervision while trying (0) unable to try/ needs assist to keep from falling 10. Turning to look behind over left and right shoulders. Instruction: Turn to look behind you over toward left shoulder. Repeat to the right. Grading: Please mark the lowest category which applies. _____ (4) looks behind from both sides and weight shifts well (3) looks behind one side only other side shows less weight shift (2) turns sideways only but maintains balance (1)need supervision when turning (0) needs assist to keep from falling 11. Turn 360 degrees Instruction: Turn completely around in a full circle, pause, turn a full circle to the other way. Grading: Please mark the lowest category which applies. _____ (4) able to turn 360 safely in <4 sec each side (3) able to turn 360 safely one side only in <4 sec (2) able to turn 360 safely but slowly (1) needs close supervision or verbal cueing (0) needs assistance while turning

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12. Count number of times step stool is touched Instruction: Place each foot alternately on the stool. Continue until each foot has touched the stool four times. Grading: Please mark the lowest category which applies. _____ (4) able to stand indep and safely and complete 8 steps in 20 sec (3) able to stand indep and complete 8 steps in >20 sec (2) able to complete 4 steps without aid with supervision (1) able to complete >2 steps needs minimal assist (0) needs assistance to keep from falling/ unable to try 13. Standing unsupported, one foot in front Instruction: (Demonstrate to subject) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. Grading: Please mark the lowest category which applies. _____ (4) able to place foot tandem indep and hold 30 sec (3) able to place foot ahead of other indep and hold 30 sec (2) able to take small step indep and hold 30 sec (1) needs help to step but can hold 15 sec (0) loses balance while stepping or standing 14. Standing on one leg Instruction: Stand on one leg as long as you can without holding. Grading: Please mark the lowest category which applies. _____ (4) able to lift leg indep and hold >10sec (3) able to lift leg indep and hold 5-10sec (2) able to lift leg indep and hold =or>3 sec (1) tries to lift leg unable to hold 3 sec but remains standing indep (0) unable to try or needs assist to prevent fall

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Functional Independence Measure (FIM) The FIM (Functional Independence Measure) is a more global functional outcome measure. This scale was introduced as a standard measure for rehabilitation units and enables comparisons to be made between rehabilitation centres. It is a tool designed for all team members to use but training for accreditation is required before administration of this tool is recommended. Assessments include: Personal / Self care: eating; grooming; bathing; dressing upper and lower; toileting Sphincter control: bladder; bowel Mobility: Transfers to bed, chair, wheelchair: toilet; tub, shower Locomotion: Walking / wheelchair; stairs Communication: comprehension; expression Social cognition: social interaction; problem solving; memory. A scale of one to seven is applied, with seven indicating complete independence without any devices, and one indicating total assistance (in this case, the patient is able to assist less than 25% with the task). The occupational therapist attends to personal care & cognition; the physiotherapist assesses mobility & locomotion, the speech pathologist assesses communication, and the nursing staff sphincter control / continence. Reference: Rankin A, 1993: The Functional Independence Measure. Physio. 79(12): 184 Disability Rating Scale (DRS) Another global measures of function is provided by the DRS - mobility, ADL and cognition scores are gathered by the team members with this scale having a high degree of reliability. The DRS is valued as a disability measure. There are limitations for the physiotherapist with mobility measures including walking, transfers and wheelchair skill Reference: Fleming J and Maas F, 1994: Prognosis of rehabilitation outcome in head injury using the disability rating scale. Arch Phys Med Rehabil. 75: 156-163

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Glasgow Outcome Scale This scale has value as a global measure of disability or handicap but the categories are too general for use as a physiotherapy measure of function. 1. Death 2. Vegetative State: not obeying commands or vocalizing, spontaneous eye movements, sucking and chewing reflexes, occasional visual tracking and stereotyped motor responses. 3. Severe Disability: awake and dependent, assisted for activities of daily living, major cognitive or physical problems or both. 4. Moderate Disability: independent but disabled, independent in activities of daily living and some independence in home and community skills, vocational goals limited to lower level of responsibility, and residual problems such as cognitive changes, impaired communication skills, motor skills, or balance problems persist. 5.Good Recovery: able to pursue normal occupational and social activities with minor physical deficits or complaints. Reference: Jennett B, Snoek J, Bond M, Brooks N, 1981: Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol, Neursurg and Psychiatry. 44: 285 - 293.