Outcome Measures Flashcards
Hunt and Hess Scale
- Used with __ population
- Scored from __-__, with high scores being [better / worse]
Hunt and Hess Scale
- Used with SUBARACHNOID HEMORRHAGE
- Scored from 1-5, higher score = WORSE
1: No or Minimal HA, mild neck stiffness (70% survival)
2: Mod/Severe HA, Neck stiff, ?CN palsy (60% survival)
3: Drowsy, min neuro deficit (50% survival)
4: Stupor, Mod/severe hemiparesis (20% survival)
5: Deep coma, Decerebrate posturing, (10% survival)
Modified Fisher Scale
- Used with __ population
- Scored from __-__, with high scores being [better / worse]
Modified Fisher Scale
- Used with SUBARACHNOID HEMORRHAGE, severity scale based on imaging
- Scored from GRADE 0 - GRADE 4 with high scores being WORSE
Grade 0:
No SAH
No IVH
0% incidence of symptomatic vasospasm
Grade 1:
Thin focal or diffuse SAH
No IVH
24% incidence of symptomatic vasospasm
Grade 2:
Thin focal or diffuse SAH
+IVH
33% incidence of symptomatic vasospasm
Grade 3:
Thick focal or diffuse SAH
No IVH
33% incidence of symptomatic vasospasm
Grade 4:
Thick focal or diffuse SAH
+IVH
40% incidence of symptomatic vasospasm
Glasgow Coma Scale
Scoring from __-__, with higher score = [more / less] impaired.
What’s on it?
Give scores suggestive of…
Severe = ____
Moderate = ___
Mild = ___
What score denotes coma?
Glasgow Coma Scale
Scoring from 3-15 with higher score = LESS impaired.
Severe: <=8
Moderate: 9-12
Mild: 13-15
What’s on it?
Eye opening (max 4)
- –> Spontaneous - 4
- –> To Speech - 3
- –> To pain - 2
- –> None - 1
Verbal response (max 5)
- –> Oriented - 5
- –> Confused conversation - 4
- –> Words (inapprop) - 3
- –> Sounds (incomprehensible) - 2
- –> None - 1
Best motor Response (max 6)
- –> Obeys commands - 6
- –> Localizes to pain - 5
- –> Flexion - Normal - 4
- –> Flexion - abnormal - 3
- –> Extensor posturing - 2
- –> None - 1
COMA = <8
Coma Recovery Scale - Revised (CRS-R)
Who is it used with / why to use it?
What’s on it?
Score range?
What qualifies as a …
… Vegetative State?
… Minimally conscious state?
… Emergence from minimally conscious state (MCS+)?
Coma Recovery Scale - Revised (CRS-R)
Who is it used with/ why to use it?
- Assists with DDx, prognosticating, and treatment planning in patients with DOCs
- Can discern between VS, MCS, and emerging from MCS!
- 26 items, 6 subscales: Auditory, Visual, Motor, Oral Motor, Communication, Arousal
Scored from 0 (Severe Vegetative State) -> 23 (Normal fxning) Lowest scored items for each are reflexive activity, higher scores require cognitive mediation
What qualifies as a …
… Vegetative State?
Requires ALL of the following:
—–> NO command following; can localizes or startles to sound (<=2 auditory)
—-> NO visual fixation (<=1 visual)
—-> NO localization to noxious stim; can be posturing or have +flexor withdrawal (reflexive; <=2 motor)
—-> NO intelligent verbalization (though can have vocalization; <=2 oral motor/verbal)
—-> NO attempts to communicate (0)
—-> Arousal doesn’t matter much for this
… Minimally conscious state?
Any one of the following would qualify:
—> Reproducible (>75% of trials) or consistent movement to command
—-> Visual fixation, pursuit, localizing + reaching to or recognizing objects
—-> Localizing to noxious stim, manipulating object, automatic motor responses (e.g. waves when I wave, opens mouth when spoon approaches) (but NOT yet using objects functionally)
—-> Intelligible verbalizations
—-> Non-functional but intentional communication (head shake/nod, thumbs up/down in response to a ?, regardless of accuracy)
… Emergence from minimally conscious state (eMCS)?
Needs higher scores in motor and communication subscales, including:
- FUNCTIONAL object use…
OR…
- Accurate functional communication (yes/no answers to questions)
Rancho Los Amigos Levels of Cognition
- No response: No response to external stim
- Generalized response: Reacts to external stim in non-specific and inconsistent ways, not purposeful
- Localized Response : Responds specifically and inconsistently to stim, may follow simple commands for motor actions
- Confused, Agitated : Bizarre, non-purposeful, incoherent or inappropriate behaviors and has no short-term recall, attention is short and non-selective
- Confused, Inappropriate, Not Agitated : Random, fragmented responses to stimuli, simple commands followed consistently, new info not retained, memory and attention impaired
- Confused, Appropriate response: Gives appropriate responses that are depended on external input. Carry over for relearned but not for new things.
- Automatic, Appropriate response : Daily routine automatic, appropriate behaviors in familiar settings, shows carryover for new learning, judgment impaired.
- Purposeful, Appropriate Response: Oriented and responds to the environment, abstract reasoning abilities lower than before injury
Modified Ashworth Scale
Scoring (taken from Bohannon and Smith, 1987):
0 = No increase in muscle tone
1 = Slight increase in muscle tone; catch and release or MIN resistance at the end ROM when the affected part(s) is moved in
flexion or extension
1+ = Slight increase in muscle tone, manifested by a catch -> minimal resistance
throughout the remainder (<50%) of the ROM
2 = More marked increase in muscle tone through >50% of the ROM, but affected part(s) easily moved
3 = CONSIDERABLE increase in muscle tone, passive movement difficult
4 = Affected part(s) rigid in flexion or extension
Prognostic indicators surrounding CRS-R:
Patients in a vegetative state who clear to MCS in ___ weeks to resolve MCS
>___ weeks to clear confusional state/post traumatic amnesia
- Mean CRS-R change > [#] /week = high likelihood of resolving MCS
- Mean CRS-R change > [#] /week = high likelihood of clearing confusional state/post traumatic amnesia
CRS-R related prognostic indicators:
*Used in TBI!
Patients in a vegetative state who clear to MCS in < 8 weeks are more likely to recover to higher levels of function (including household independence)
POOR chance of recovery to household independence or better if it takes:
> 12 weeks to resolve MCS
> 16 weeks to clear confusional state/post traumatic amnesia
- Mean CRS-R change >2/week = high likelihood of resolving MCS
- Mean CRS-R change >3/week = high likelihood of clearing confusional state/post traumatic amnesia
Motor and communication subscale score at 3 months post injury is most predictive of outcome at 12 months; auditory subscale is most predictive at 6 months post
Source: Katz 2009: Natural history of recovery from brain injury after prolonged disorders of consciousness: outcome of patients admitted to inpatient rehabilitation with 1–4 year follow-up
Galveston Orientation and Amnesia Test (GOAT)
Measure of __ and __, especially to see if a patient has recovered
from ___ after a TBI.
Scoring?
A score >___ for 3 consecutive days is considered the threshold for emergence from __.
Measure of ATTENTION and ORIENTATION, especially to see if a patient has recovered
from post-traumatic amnesia (PTA) after a TBI (first measure created to test PTA and is still the most widely used test). Used in TBI.
Maximum Score (100 – Error Score) this number can be a negative (deduct points for each error)
○ <66 is Impaired,
○ 66-75 is Borderline,
○ 75-100 Normal
o A score > 78 for three consecutive days is considered the threshold for emergence from PTA (vs score of > 60 for two consecutive days is considered
emergence from PTA on the modified GOAT for individuals with expressive language difficulties or those who are intubated).
Agitated Behavior Scale (ABS)
Purpose: Developed to assess the nature and extent of agitation during the acute phase of recovery from ____
14 items, scored from 1-4, with lower scores meaning [ more / less] agitated.
Score range: \_\_\_ Cutoff scores: \_\_\_\_: normal \_\_\_: mild agitation \_\_\_: moderate agitation \_\_\_: severe agitation
Predictors? Can predict change in ___ status and differentiate between __ and ___
Agitated Behavior Scale (ABS)
Purpose: Developed to assess the nature and extent of agitation during the acute phase of recovery from ABI
14 items, scored from 1-4
Low score = NO agitation
Higher score = HIGH agitation
Score range: 14 (not agitated) -> 56 (v agitated) Cutoff scores: <21: normal 22-28: mild agitation 29-35: moderate agitation >35: severe agitation
Predictors? Can predict change in COGNITIVE status and differentiate between CONFUSION and INATTENTION
- Short attention span, easy distractibility, inability to concentrate.
- Impulsive, impatient, low tolerance for pain or frustration.
- Uncooperative, resistant to care, demanding.
- Violent and or threatening violence toward people or property.
- Explosive and/or unpredictable anger.
- Rocking, rubbing, moaning or other self-stimulating behavior.
- Pulling at tubes, restraints, etc.
- Wandering from treatment areas.
- Restlessness, pacing, excessive movement.
- Repetitive behaviors, motor and/or verbal.
- Rapid, loud or excessive talking.
- Sudden changes of mood.
- Easily initiated or excessive crying and/or laughter.
- Self-abusiveness, physical and/or verbal.
Moss Attentional Rating Scale (MARS)
Observational rating scale, quantitative measure of attention-related behavior after ___
Appropriate for what level of functioning in patients? [ VS / MCS / MCS+ / Rancho Level(s) ___] ??
Scoring: 22 items, 5pt likert scale (but some are flipped, so weird scoring), but range is 22-110, with higher scores indicating [better / worse ] attention
Observational rating scale, quantitative measure of attention-related behavior after TBI
NOT appropriate for use with patients in MCS or VS; validation studies have been in patients at Rancho level IV or higher
Scoring: 22 items, 5pt likert scale (but some are flipped, so weird scoring), but range is 22-110, with higher scores indicating BETTER attention
Disability Rating Scale (DRS)
Observer rated, 30-point continuous scale
that provides quantitative information to
document the progress of patients with
___ injury from coma to ___.
What does it look at (subscales)? Impairment, activity, participation?
High score = [better / worse]?
DRS can predict outcomes in [what settings?] as well as return to ___!
Disability Rating Scale (DRS)
Observer rated, 30-point continuous scale
that provides quantitative information to
document the progress of patients with
moderate-severe head injury from coma to community reintegration
Valid and reliable. DRS can predict inpatient and long-term outcomes and return to work!
8 Subscales:
○ Eye Opening (0-3)
○ Communication Ability (0-3)
○ Motor Response (0-5)
○ Feeding (Cognitive Ability Only) (0-3)
○ Toileting (Cognitive Ability Only) (0-3)
○ Grooming (Cognitive Ability Only) (0-3)
○ Level of Functioning (Physical, Mental, Social, Emotional) (0-5)
○ Employability (as Full-time worker, homemaker, student) (0-3)
Scoring: low is better, 0 (Normal Functioning) to 29 (Severe Vegetative State)
This scale does not distinguish MCS from VS because it was constructed prior to the development of MCS criteria (Whyte 2009)
Determinants of independent walking ability at 6 months post stroke?
- 25 points on Trunk Control Test (TCT) AND
-Motricity Index ≥25 OR
-Fugl-Meyer Assessment for LE ≥19
(above assessed 1-2 days post-CVA)
*Per Veerbeck Guidelines
*Patients with unfavorable outcomes should continue to be assessed;
-weekly for the first month
-monthly for first 6 months
However, only Level 4 evidence
- Also: (Smith, Barber, Stiner 2017: TWIST Algorithm)
- Trunk Ctrl Test score >40 at 1 week = walking indep at 6 wks
- Trunk Ctrl Test <40 ONLY achieved indep walking at 12wks IF HIP EXTENSION STRENGTH >=3/5
Determinants of UE Dexterity at 6 months post stroke?
Functional recovery is highly associated with:
-finger extension of the Fugl-Meyer ≥1
-Shoulder ABD on Motricity Index ≥9
-initial dexterity
-motor evoked potentials w/TMS
-somatosensory-evoked potentials
(Above should be recorded 1-2 days post-stroke)
*Patients with unfavorable outcomes should continue to be assessed;
-weekly for the first month
-monthly for first 6 months
However, only Level 4 evidence
Independence with Basic ADL Activities 6 months post-stroke?
Barthel Index, day 5
Factors associated with poor outcomes in individuals after CVA?
- Coma at onset
- Poor cognitive fxn
- Severe aphasia
- Severe hemiparesis/no motor return within 1 month of onset
- Visual perceptual spatial disorders
- Inability to sit unsupported
- Depression
- Incontinence 2 wks post CVA
6MWT
Description: Measure of gait velocity and endurance; distance walked in 6 minutes. Sub max, can use asst device.
ICF Domain: Activity
Populations: MS, PD, SCI (higher level), Stroke, HD (may modify to 2MWT in stages IV and V)
MDC: Geri 34m, PD 82 m, SCI 46 m, Chronic CVA: 36; Subacute CVA: 61
MCID 50 meters for geriatrics and CVA
Scoring based on age (averages exist, look em up! No real cutoffs, but…) <200m associated with increased mortality in COPD pts
Normal values (healthy)
- 60-69 yrs: M 572 m, F 538 m
- 70-79 yrs: M 527 m, F 471 m
- 80-89 yrs: M 417 m, F 392 m
Berg Balance Scale
Description: 14 item test (each scored 0-4) of static balance, 20 minutes to administer
ICF Domain: Activity
Scoring: 0 (worst) -> 56 (best)
Cutoff:
Elderly and CVA:
- <45= greater risk of falling
- <51 and +Hx of falls is predictive of falls vs…
- <42 and NO Hx falls predictive of falls
- <40 = almost 100% fall risk
(Not great predictive value in SCI; has ceiling effects; <40 is also fall risk cutoff in HD)
MDC/MCID:
Elderly: ranges from 3.3-6.3
Parkinson: 5
Stroke: ranges from 6-8.1 (MCID is at least 7, MDC 6); other study chronic stroke 2.5-4.6
Fugl-Meyer Assessment of Motor Performance
Description: 45 mins (good test, takes a while); looks at UE and LE motor, sensation, balance (sitting and standing) and joint mobility/pain; uses chair, bedside table, reflex hammer, cotton ball, stop watch, blindfold, tennis ball, scrap of paper, pencil, small can.
ICF domain: Body function/structure
Scoring: 0 - 226 points, higher = independent / less impaired. Each item scored 0-2 (0=cannot perform, 1=performs partially, 2=performs fully)
Cutoffs: (Fugl-Meyer et al 1975 and 1980) <50 = Severe 50-84 = Marked 85-95 Moderate, hemiplegia 95-99 = Slight discoordination
(More recent data Duncan 1994 suggests: 0-35 Very severe 35-55 Severe 56-79 Moderate >79 Mild) UE Motor: standardized response mean =1.42; MDC=5.2 LE Motor: MDC = >5 pts Balance: critical value of change = 4pts
Functional Reach Test
Description: with shoulder flexed to 90 deg and hand fisted, “Reach as far as you can forward without taking a step,” measured at 3rd metacarpal.
ICF: Activity level
MDC: 6.79cm, no MCID for CVA
Cutoffs:
Stroke: <15cm (5.9”) = falls
Community-dwelling elderly: < 7 inches (other studies say <6”) are unable to leave neighborhood without help, limited in mobility skills, and most restricted in ADLs; <7.2” = fall risk
Motor Activity Log
(IPR & OP)
Description: Semi-structured interview, pts rate the quality of movement (QOM) and amount of Movement (AOM) during daily tasks – original version is 30 tasks, but there are shorter versions with 28 or 14 items.
Includes object manipulation (fork, comb, cup) and gross motor use of UE (car tf, pulling up a chair while standing). 20 minutes to administer original 30 item test. Examines pt’s PERCEPTION of arm function.
ICF: Activity level
Scoring: Scored on a 6 point ordinal scale; 0=weaker arm is NEVER used for the task to
5=the weaker arm functions at pre-morbid levels
MCID/MDC: not established for stroke
Postural Assessment Scale for Stroke Patients
Postural Assessment Scale for Stroke Patients
Description: Quick/easy test to assess basic sitting and standing balance (static sit, stand, SLS) and ability to complete transitional movements (rolling, supine<>sit, sit<>stand, pick up object off floor)
ICF: Activity
Scoring: 0 to 3 for 12 items, quality of movement matters; points = 0-36 max (total; higher = better performance). Mean in healthy older adults is 35.7.
Cutoff:
<3.5 on static PASS, <8.5 on dynamic pass, and <12.5 total PASS predicts non-ambulatory on d/c from rehab (positive predictive value of these is ~0.6, which is meh)
MDC: 3.2 points
Stroke Rehabilitation Assessment of Movement (STREAM)
Description: 15-20 mins, 30 total items with subscales of UE, LE, and basic mobility items (includes supine limb movements, sitting, standing, toe tap on step, and walking backward/sideways, down stairs)
Look at QUALITY and EXCURSION of movement between involved vs uninvolved sides
No cutoff scores available
ICF: Body structure/fxn
Scoring: 3 pt ordinal scale, max = 70
MCID: UE: 2.2, LE: 1.9, Mobility: 4.8
Timed Up and Go (TUG)
Description: from sitting in chair, time to stand up, walk 3m, turn around, walk back to chair and sit.
Can be performed with cognitive or manual dual task (counting backwards by 3’s, walk holding glass of water)
Scoring: Timed
MCID: not established for stroke
MDC: 2.9sec
CUTOFF: >15 seconds to complete in elderly subjetucts indicates high fall risk
- One study shows >13.5 as cut off score to predict falling in community dwelling adults
- Older stroke patients, ALS, HD >14
- Older stroke patients in fall clinic >15
- Frail elderly 32.6 s
- PD >7.95 s
- Vestibular >11.1 s
If TUG Manual (carrying cup of water) is >4.5 sec slower= increased risk of falls next 6 months
<10 sec completely indep
10-20 sec independent for most transfers
>20 dependent in most activities
10MWT
Description: gait velocity at preferred and fast speeds (average 3 trials)
ICF: Activity
Populations: Recommended in CVA, SCI, and TBI (also ok with TBI, Geriatrics, Hip fx, Amputee, Movement disorders, MS, PD, SCI, CVA)
Scoring: Timed
MDC:
- PD: Comfortable gait speed: 0.18; Fast speed 0.25m/s
- SCI: 0.09, 0.16
- TBI: 0.05
MCID: SCI 0.06; Stroke 0.16m/s; TBI 0.15-0.25m/s
CUTOFFS: in Stroke population: <0.4m/s were more likely to be household ambulators 0.4-0.8m/s limited community ambulators >0.8m/s community ambulators 1.2m/s to cross a street
Functional Independence Measure
(CVA Quality recommendations: IPR 4, acute and OP 2)
Description: 18 items assessing domains of motor (self care, sphincter control, transfers, locomotion) and cognition (communication and social cognition). 30-45 minutes to complete, but required in IPR setting for Medicare reimbursement.
ICF: Activity
Scoring: 7 point ordinal scale, 1= total assistance and 7 = independence. Range of 18-128.
**Scores of…
37-40: Not likely to gain independence; likely not to benefit from IPR, typically DCed to nursing home type setting
41-79: Most likely to benefit from IPR
80-96: Most likely to be DCed home/to community to receive home health/OP services
MCID: In stroke population, MCID for:
Total FIM score: 22 point
FIM Motor subscale: 17 points
FIM cognitive subscale: 3 points
Orpington Prognostic Scale
Description: Copyrighted, 15 min test, 4 domains:
- Motor (MMT in affected limb, but simplified w/no +/-)
- Proprioception (find your thumb)
- Balance (walks 10ft > stands > sits)
- Cognition (orientation ?s).
Population: Best for patients <2weeks post stroke (acute and rehab; NOT OP). Requires training to administer.
Scoring: from 1.6 to 6.8; higher = GREATER DEFICIT
MCD/MCID: not established for stroke
**Cutoffs:
<3.2 = high likelihood of returning home, mild to moderate deficit
Score from 3.2 -5.2 respond better to rehabilitation; moderate to severe deficit
>5.2 dependent; increased risk of institutionalization
Stroke Impact Scale
Description: Self report questionnaire that evaluates disability and health-related QOL after stroke (with higher scores = “I’m functioning 100% at my normal! Stroke not affecting me!”) May be completed by mail or phone. 15-20 mins to administer the 59 items, 8 domains:
- Strength
- Hand function
- ADL
- Mobility
- Communication
- Emotion
- Memory and thinking
- Participation/role function
SIS-16 assesses only strength, hand function, mobility and ADLs for physical dimension score.
ICF: Activity
Scoring: 5 point ordinal scale; scoring follows SF-36. Low summative score for each domain is 0 (high impact of stroke/ more impaired) -> 100 (low impact of stroke impairment)
Predictive of QoL post CVA; well correlated with Barthel Index
MDC: (Strength subscale: 24, ADL: 17.3, Mobility: 15.1, Hand function 25.9)
MCID: (Strength subscale: 9.2, ADL: 5.9, Mobility: 4.5, Hand function: 17.8)
EuroQOL
Description: Simple descriptive profile and index value for health status. Domains: - Mobility - Self-care - Usual activities - Pain/discomfort - Anxiety/depression
Population: Stroke (rehab, SNF, OP; but NOT acute)
Scoring: pts rate each item as “none” mild/mod” and “severe”, which then yields an index score from 0.000 (Death) -> 1.000 (perfect health)
No cutoffs; fair to good predictive validity w/FIM and Stroke Impact Scale
5x Sit to Stand
(CVA: 3 in acute, IPR, and OP)
Description: 5 time sit to stand from chair with armrest (43-45 cm) not against wall, arms across chest, if use arms then failure of test. Designed to measure an individual’s LE strength and endurance to go from sit to stand. NOT great for someone who is really low level (use 30 sec sit<>stand)
ICF: Activity
Populations: CP, Geriatrics, PD, Stroke, vestibular (NOT tested for MS), HD (most stages)
CUTOFFS:
>12 = need further assessment of fall risk in elderly
>15 = risk of recurrent/ predicts falls in elderly
PD: >16 = risk of falls
CVA: >12 divides stroke from healthy elderly; correlates with mm strength in CVA!
Vestibular: >13 balance dysfunction
Young Adults: >10sec differentiates btwn those w/ and w/out balance dysfunction
MDC Healthy elderly: 4.2 sec, Stroke: 3.6 sec, CP 0.06
MCID vestibular: >/= 2.3 sec
Tardieu Spasticity Scale (Modified Tardieu)
Description: Measures spasticity, takes into account resistance to passive movement at slow and fast speeds. Looks at full ROM (“R2” when done slowly) and angle of “catch” or clonus (R1; found w/quick stretch/mvmt).
ICF: Body Structure/fxn
Populations: Recommended (3) in CVA (3 in acute, IPR, and OP); NOT MS
Scoring:
Grade 0 = No resistance t/o mvmt
1 = Slight resistance t/o, followed by release
2 = Clear catch, then release
3 = Fatiguable clonus (<10 sec) at precise angle
4 = Non-fatiguing clonus (>10 sec)
Dynamic Gait Index
Description: 8 gait tasks; even surface, changing speed, head turns, stepping over and around objects, pivot turns, stairs; 10-15 minutes to administer
ICF: Activity
Population: CVA, PD, vestibular, MS
Scoring: each item 0-3, 0 (severe impairment) -> 24 (normal)
Cutoff: <19 = increased risk for falls
Chedoke McMaster Stroke Assessment
Description: 45-60 min, copyrighted test. 2 big parts:
(1) Impairment inventory. Looks at recovery stage based on 7-point scale (corresponds with Brunnstrom’s stages of recovery!). Stage/# assigned based on motor control in that arm, or pain. 6 dimensions, each look at movement in/out of synergy then more functional movements (e.g. supine->sit, standing, decreasing support, hopping!, rolling, pouring water, etc)
Recovery stage of the…
- Arm, hand, leg, foot
- Postural control ( Sitting static -> leaning/dynamic; Standing: static bilaterally then SLS -> stepping/weight shifts, karaoke, tandem walking, walking on toes)
- Shoulder Pain
Activity Inventory:
- Gross motor fxn index (supine<>sit, rolling to/from strong side, sit<>stand, transfers)
- Walking index (walking indoors; outdoors over varied surfaces/ramps, outdoors several blocks; stairs; walking distance in 2 mins)
ICF: Impairment + Activity level
Scoring: 14 (greatest disability) -> 100 (Maximum Activity Inventory score)
*Remember, each Impairment item is scored based on Brunnstrom 7 stages of motor recovery:
1= flaccid paralysis
2= spasticity present (“resistance to passive mvmt”)
3= Marked spasticity, voluntary mvmt within synergistic patterns
4=Spasticity decreases
5= Spasticity wanes, but is evident w/rapid movements at extreme ranges
6= Near normal coordination and mvmt patterns
7= Normal mvmt
Each Activity Item is scored like the FIM! 1= dependent/total asst 2=MaxA 3=ModA 4=MinA 5=Supervision 6=ModI (device asst) 7=Safe, timely, independent!
CUTOFFS: >9 on combined leg + postural control score = independent ambulation!
MCID: 7
MDC: not established for stroke
NIH Stroke Scale
(CVA: 3 acute, IPR and OP)
Description: Measures severity of symptoms post-stroke including LOC, ability to answer questions, follow commands, gaze deviation, hemianopsia, facial palsy, UE/LE motor strength, limb ataxia, sensory loss, visual neglect, dysarthria, and dysphagia.
ICF: Body structure/fxn
Scoring: 0 (normal) -> 42 (SEVERE stroke). Each item graded on ordinal scale of 0 to 3 or 4
Interpretation/Cutoffs: >25 very severe 15-24 severe 5-14 mild to moderate 1-5 mild
<5: 80% of CVA survivors will d/c home
6-13: Typically need acute IRF
>14: Frequently require long-term skilled care
Favorable outcomes in pts with NIHSS <=5 for posterior circulation stroke vs <=8 for anterior circulation stroke
MCID/MDC: not established for stroke
Rivermead Motor Assessment
Description: Assesses gross function, UE and LE w/trunk function. Have to complete 1 item to make it to the next item, otherwise test is stopped.
Gross function ex: sit unsupported, transfers, amb
LE/trunk: roll over, sit<>stand, toe taps in standing
UE: supine arm flexion, seated reaching, pinch grasp, patty-cake
ICF: Body structure/fxn
Population: CVA (IPR and OP)
Scoring: each item 1=yes, 0=no. Goes from easy -> more difficult tasks, test stops when pt can no longer complete the tasks. Higher scores = better.
- NO Cutoff, but low RMA score at 6wks post CVA Predicts poor prognosis to ambulate.
- *Large ceiling effect in higher level TBI (HIMAT better for that group)
MCID/MDC: not established for stroke
SF-36
Description: Copyrighted, self-reported survey of health-related QoL; 30 min to complete. Scoring system is…unpleasant.
ICF: Participation
Population: CVA (just not acute care), SCI, MS (only OP)
Scoring: Nominal (yes/no) scale; 0 (negative/poor health QoL) -> 100% is optimum health
- NO cutoffs
- MCID/MDC: not established for stroke
Looks at 8 domains:
(1) Physical fxn
(2) Role limitations d/t physical problems
(3) General health perceptions
(4) Vitality
(5) Social fxning
(6) Fole limitations d/t emotional problems
(7) general mental health
(8) Health transition
**SF-12 is shorter version with only 12 items; gives summary physical and mental health, but not specific to each of the above 8 dimensions. Beginning to be used more w/TBI populations
Trunk Impairment Scale
Description: Assesses trunk activities in:
- Static sitting balance
- Dynamic sitting balance
- Coordination.
ICF: Activity
Population: CVA
Scoring: 17 items, 0->23, higher = better
Predictive Validity:
- *Total TIS (and sitting balance subscale) were most important factors to predict Barthel Index score at 6mo post CVA
- *Excellent validity btwn TIS at rehab admission and FIM scores at discharges; lower TIS at admission predicted transfer to an institutional setting rather than home post acute rehab
MCID/MDC: not established for stroke
Wolf Motor Function Test
Description: TIMED (quantitative) measure of UE ability through timed functional and strength tasks.
*Think: “Fast as a wolf!”
Takes ~1 hour for each UE tested. Yields a timed score and a functional abilities score.
ICF: Activity
Population: CVA
Scoring:
Timed portion: how long to complete each of 15 tasks (cuts you off after 2 mins).
Fxn’l ability score: 0-5 ordinal scale (0 = does not attempt w/affected arm; 5 is affected arm moves normally). Total score 0 (bad) -> 75 (normal).
NO CUTOFFS
MCID:
WMFT-Time: 1.5-2 seconds
WFMT-Functional Ability Scale: .2-.4
MDC:
WMFT-Time: range of .7 seconds to 4.36 seconds
WFMT-Functional Ability Scale: range .1 to .37
Scale for Assessment and Rating of Ataxia (SARA)
Description: SARA was developed by combining the most reliable components of the ICARS with shorter and more specific instructions. SARA is better for clinic use, ICARS may be better for research purposes. 8 items: - Gait - Stance - Sitting - Speech disturbance - Finger chase* - Nose-finger test* - Fast alternating movement* - Heel-shin slide* (Does NOT include oculomotor function, which ARE on the ICARS) *Scores taken for each side, then take mean
ICF: Body structure/fxn + Activity
Scoring: 0 (no ataxia) to 40 (severe ataxia) CUTOFFS: based on the ataxic score... Performance of ADLs: ≤5.5 total independence ≤10 minimal dependence ≤14.25 moderate dependence ≥23 maximal dependence
Gait:
<8 independent gait
<11.5 quad cane
<12.25 walker
Norms/Mean scores for... Spinocerebellar ataxia: 15.9+/-8.5 Ischemic: 11.7+/-6.75 Hemorrhagic: 9.3+/-5.73 ACA: 7.00+/-0.00 MCA: 13.42+/-7.9 PCA: 13.74+/-1.06 Brainstem: 12.91+/-7.12 Cerebellum: 8.34+/-4.45
Functional Gait Assessment
Description Modification of Dynamic Gait Index that decreases ceiling effect by adding narrow base of support, eyes closed and backwards ambulation tasks. 5 – 10 minutes to perform.
ICF: Activity
Populations: Geriatrics, Parkinson’s, Stroke, Vestibular
Scoring: 0 (most impaired) to 3 (highest level of function). Range 0-30.
CVA: MCID: not established, MDC: 4.2 points (clinically 5 points)
Vestib: 8 pt MCID
Geriatrics and PD: 4 pts
CUTOFFS:
Scores ≤22/30 indicate increased fall risk in community dwelling older adults
= 20/30 = community dwelling adults would sustain unexplained falls in next 6 months
PD: <=18/30
International Cooperative Ataxia Rating Scale (ICARS)
Description: 19-item scale with subscales of:
- Posture/gait disturbances
- Kinetic fxn
- Speech disorder
- Oculomotor disorders
ICF: Activity
Scoring: 0 (no ataxia) to 100 (severe ataxia) (HIGHER is WORSE!)
Norms:
SEM: 4.18
MDC: 11.58 (Spinocerebellar ataxia)
Morton 2010: ICARS able to distinguish between subjects with static lesions and those with degenerative disorders; it was sensitive to increases in ataxia severity over one year; and it correlated well with specific instrumented measures of gait in persons with cerebellar degeneration
Higher ICARS correlated with more variability in joint angles during gait
Activity Specific Balance Confidence Scale
Description: 16 item self report (10-20 mins), rates balance confidence w/several activities.
Scoring: 0-100% confidence (higher = better fxn), add and average items (Can have a ceiling effect for high level older adults)
Norm: Community-dwelling older adults: 79.89% (MDC 13-14%)
Populations: For subacute to chronic stroke, TBD for SCI CD, TBD for higher level TBI, recommended for MS
CUTOFFS:
Fallers vs non-fallers:
<67%= risk for falls, correctly identifies people who fall 84% of the time
PD: <=69% - very sensitive, moderately specific to identify fallers
Stroke: > 81% = relative certainty individual NOT at risk for falls
Mini-BESTest
Mini Balance Evaluation Systems Test
Description: Targets/identifies 6 different balance and control systems. Helpful w/goal setting and pre/post testing. 14 items addressing:
- Anticipatory postural adjustments (sit->stand; stand on toes; SLS)
- Reactive postural ctrl (reactive stepping fwd, side, and back)
- Sensory orientation (feet together EO firm surface; feet together EC foam, incline EC)
- Dynamic gait (change gait speed, walk w/horizontal head turns, pivot turn, step over obstacles, **TUG + TUG cog)
Scoring: max score of 28 although score of 32 used often in research (includes both scores for bilateral extremities tested)
ICF: Body structure/fxn + Activity
Populations: TBI, MS, PD (HIGHLY recommended across all PD phases except H&Y V), (NOT on stroke edge), Vestibular disorders
CUTOFFS:
Stroke: <17.5 identified fall risk, excellent correlation w/TUG and BERG
PD:
<19 identified recurrent fallers
<20 adequately predicts fallers in the next 6-12 mo
<23 maximizes sensitivity to detect fallers
**In early PD, reactive balance and slowed TUG/TUG cog tend to be impacted first, then see all areas impacted by mid-stage PD
MDC/MCID: 3.5-5.5ish (MCD: Vestib: 3.5, PD: 5.52; Vestib MCID 4)
Four Square Step Test
Description: Steps over 4 canes set up on floor like a cross, with cane tips pointing inward starting in upper left quadrant and stepping clockwise then counter clockwise
Population: Vestib, PD (Stages II-IV), MS (4.0-7.5 on EDSS), Geriatrics, CVA, HD (early stage)
CUTOFFS: Geriatrics: >15 sec = fall risk PD: >9.68 sec fall risk Stroke: failed attempt or >15sec Vestib: >12sec
Friedreich’s Ataxia Rating Scale (and Disease Staging)
Description: includes functional disease staging, ADLs, and Neurological Exam
Components are supplemented by quantitative performance on 8-meter walk test, 9-hole peg test, PATA rate (measure of speech coordination), and low-contrast letter acuity
Total score 0-159, with higher scores reflecting greater disability
Staging:
Stage 0 = NORMAL
Stage 1.0: Min signs detected by physician during screening. Runs and jumps without LOB. No disability
Stage 2: Symptoms present, pt recognizes them, but still mild. CANNOT run or jump without LOB. Physically able to lead indep life, but restricted activities. Min disability
Stage 3: Overt and significant symptoms. Needs regular or periodic holding onto wall/furniture or use of cane for stability and walking. Mild disability.
Stage 4: Needs BUE support to walk (RW, loftstrands, or 2 canes). Or walking dogs. Can perform several ADLs, but mod disability
Stage 5: Navigates with a w/c, but confined. Can do some ADLs that don’t need standing or walking. Severe disability
Stage 6: Confined to wheelchair or bed with total dependency for all ADLs. Total disability.
Dizziness Handicap Index
Description: Self assessment of impairment d/t dizziness. 25-item self-assessment across 3 domains:
- Functional (36pt)
- Emotional (36pt)
- Physical (28pt)
Populations: TBI, MS, Vestibular disorders
ICF: Body structure/fxn + Participation
(fall risk) CUTOFFS: MS: <59 Vestib: - mild 0-30 - moderate 31-60 - severe 61-100
From Scoring Instructions:
16-34 Mild
36-52 Moderate
54+ Severe
ALS Functional Rating Scale (original and revised versions)
Description:
Disease-specific measure of global function, comparing present function vs prior function to the onset of ALS symptoms. *This is the big one most clinics use.
Subscales:
Speech, salvation, swallowing, handwriting, cutting food, dressing and hygiene, turning in bed, walking, climbing stairs, dyspnea, orthopnea, and respiratory insufficency (this last one wasn’t on the original)
Population: ALS
ICF: Participation
**Correlates with survival, QOL, mm strength, and timed function tests
**Average rate of decline is 0.95 points per month
MDC = 6.74 points MCID = 20% change (4 pts) is somewhat meaningful; >50% change (>7 points) is very meaningful
Scoring: 12 items, measured on 5-point scale from 0 (unable to do) to 4 (normal); scored from 0 (worst fxn) to 48 (best fxn/normal)
ALS Assessment Questionnaire (ALSAQ-40)
Description: QOL measure, answer depending on past 2 weeks; 40 items, 5pt Likert scale
5 domains: mobility, ADL, eating/drinking, communication, emotional fxn
ICF: Participation
Tinetti Mobility Test POMA (Tinetti Performance Oriented Mobility Assessment) (TMT)
Description: Screen for older adults for balance and gait impairments. 10-15 mins to do. 18 items = total scored on a 3 pt ordinal scale (0-1 or 2), 0 - 28 with higher score = indep.
Populations: HD, PD (H&Y 2-4), ALS (NOT great w/CVA, MS, TBI)
ICF: Activity
HD: MDC= 4.44, ICC= 0.83
Kloos et al, Gait and Posture. 2014: 40:647-651
- Correlated with UHDRS motor scores
- Moderately to strongly r/t LE muscle weakness and activity limitations in ALS
CUTOFFS:
General population:
<=18 = HIGH fall risk
19-23 = MOD fall risk
>=24 = LOW fall risk
HD = < 21 = fall risk (Sn 74% and Sp 60%)
PD <20 vs <17.5 (depends on the study)
*In older adults, cutoff <19 vs <21 (depends on the study) predicts falls
LOWER Tinetti score + younger age (maybe because they’re moving fast and doing a lot of things; vs older people intentionally slowing down?) = significant predictors of falls in HD
Unified Huntington’s Disease Rating Scale (UHDRS)
Used to monitor dz progressions and effects of therapy
Scored 0 (normal) - 4 (severe)
Assesses motor, cognition, behavior, and function
- Occular pursuit, saccade initiation and velocity
- Dysarthria, tongue protrusion (pts have difficulty maintaining force to keep tongue out)
- Maximal dystonia (trunk and extremities)
- Maximal chorea (face, mouth, trunk, extremities)
- Retropulsion pull test (reactive balance when pulled backwards)
- Finger taps (looks at bradykinesia; normal = 15 in 5 sec)
- Pronate/supinate hands
- Luria (looks at motor sequence of fist-hand-palm test)
- Rigidity-arms (R and L)
- Bradykinesia (body)
- Gait (looks at speed, BOS)
- Tandem walking
Cognitive battery includes:
- Verbal fluency test (max words in 60 sec for F or P - shows frontostriatal fxn)
- Symbol Digit modalities Test (pairing #s with geometric figures in 90 sec; looks at complex scanning and visual processing) - highly associated with falls!
- Stroop Test (color naming, word reading, intereference test; looks at executive functions (selective attention, cognitive flexibility, processing speed)
Functional assessment (yes/no): - Looks at Activity and Participation level (e.g. can pt manage finances? handle money? engage in employment? prepare meals/laundry? Get in/out of ed? Walk w/out falling? Use toilet without help?)
Total functional capacity scale
Used to divide HD into early, (TFC stage I), middle (TFC stage II and III) and late (TFC stages IV and V) stages
- Able to live at home through stage III (TFC 3-6), home vs SNF at stage IV, full time SNF at stage V (unable to do job, finances, chores, or ADLs)
Nine (9) -hole Peg Test
Description: Pt has to place 9 pegs into holes on a peg board, 1 at a time with 1 hand, then remove each peg and place it back in starting container
Norms are ~16-25 seconds (increase with age, a touch faster in older F vs M)
Populations: PD, subacute to chronic stroke, and highly rec’d in MS! Can also use w/HD
CUTOFF:
- MS: >33.3 sec = severe hand dysfunction
POOR predictive validity - 9 hole peg test at 1 month post CVA did NOT predict functional outcomes at 6mo in stroke
30 Second Sit to Stand
30-second chair stand test
Description: Designed to measure LE strength and endurance to rise from a chair, most appropriate to use with someone who is very low functioning and would have difficulty performing the 5x reps required for the 5x sit to stand test.
Norms:
F: 60s: 15; 70s: 14->13; 80s: 12->11; 90s: 9
M: 60s: 17->16; 70s: 15->14; 80s: 13->11; 90s: 9
Walking While Talking Test
Description: A test of dual task demands. Assesses time taken to walk a set distance (40ft in Verghese study)
(1) Walk
(2) Walk while reciting alphabet (simple dual task)
(3) Walk while reciting every other letter of the alphabet (Complex)
Cutoffs:
>=20 sec for WWT simple = HIGH sensitivity for identifying fallers (89%), modest specificity (46%) to r/o falls
>=33 sec for WWT complex = HIGH sensitivity for identifying falls (95.6%), modest specificity to r/o fall (38.5%)
Movement Disorder Society -Sponsored Unified Parkinson’s Disease Rating Scale - Revision
(MDS - UPDRS)
Needs training/certification.
3 Parts:
Part I: Non-motor Aspects of Daily life, some self-report vs some PT assessment (w/pt input). It’s a general scan for symptoms:
- Cognition, hallucinations, mood, sleepiness, bowel/bladder, fatigue, lightheadedness in standing
Part II: ADLs. Self report, general scan for symptoms:
- Speech, saliva/drooling, chew/swallow, eating, dressing, hygiene, tremor, handwriting, ability to do hobbies, get in/out of bed, up/down from chair, walking and balance, freezing
Part III: Therapist grades motor fxn:
- Speech volume/diction, resting and action tremor, rigidity in neck/arms/legs, finger taps, RAM, heel taps, rising from chair, posture, gait, pull test to look at reactive balance, dyskinesia
- **UPDRS does NOT examine gait/balance in any detail, but DOES track change over time at a GROSS level.
Each item scored 0 (normal) to 4 (severe); high score = more impaired
PD
Part 1 and 3 are Body structure/Function
Part 2 is Activity level
Montreal Cognitive Assessment (MoCA)
Description: Screening tool for cognitive function (looks like the single page with the connect the dots of #s/letters, lion/rhino/camel pictures, etc.). Takes 10 mins, no training required, valid for screening for mild cognitive impairment (and BETTER to identify MILD cognitive impairment than the MMSE!)
***Assesses executive function, memory, attention, language, abstraction
Populations: PD, vascular dementia, vascular cognitive impairment (anything w/significant frontal lobe pathology), Huntington’s, brain tumors and mets, MS, TBI, depression, heart failure
Body structure/Function
Scoring: 30 points
***Cutoff: <26 = possible dementia, warrants further w/u
Psychometrics:
100% Sn, 87% Sp for detecting early Alzheimer’s (vs 78% Sn and 100% Sp for the MMSE)
Includes trailmaking (sequentially connecting 1 - A - 2 - B…) - issues here indicate issues with executive function and visuospatial awareness
Folstein Mini-Mental State Exam
Description: SCREENING tool for cognition (e.g. dementia; but NOT sensitive or specific for diagnostic purposes). MMSE equivalent is free (vs the original MMSE is licensed/$)
Areas assessed:
- Concentration (count backward by 3s; WORLD backward)
- Memory (3 word recall)
- Visuospatial function (copy a picture of 2 overlapping pentagons)
- Language (a tiny bit; naming items; following written instruction; writing a sentence; “no ifs ands or buts”)
Considerations:
- Influenced by the person’s cultural and educational background; it is the most commonly used test in the USA
- ** Does NOT measure executive function! Often clinicians will add the “clock task” to assess executive fxn
Cutoff:
<24 = possible dementia, needs more in-depth assessment
24-30: No cog impairment
18-23: Mild cog impairment
0-17: Severe cog impairment
25-30: Trace deficit, any deficit would likely impact only most demanding ADLs
20-25: May need S/support w/day to day fxn
10-20: Clear impairment, may need 24/7 supervision
0-10: Not likely to be able to engage well w/testing; will likely need 24/7 supervision and assist w/ADLs
Psychometrics:
78% Sn and 100% Sp for detecting early Alzheimer’s (vs 100% Sn, 87% Sp for the MoCA)
Clock Task
Description: Assesses executive function. Ask pt to draw the face of a clock with the numbers on it, and place the hands at a specified time (11:10 or 1:45).
Often reveals problems w/executive function in the very old (>85yo), diabetics, HIV, and those w/uncontrolled HTN. Difficulty performing complex tasks and putting all of the elements of a task together.
*Often added on to the MMSE since that test does NOT assess executive fxn
Mini-Cog
Faster, easier to administer cognitive screening tool
(1) 3-word registration (give 3 words, “I want you to remember those words, I’m going to ask you for them later”
(2) Clock drawing (have pre-drawn circle; “First, use this circle and put the numbers in where they go. Now I want you to draw the hands on the clock and indicate [11:10 or 1:45])
(3) 3 word recall (“now I want you to recall the 3 words I told you earlier”)
Assesses attention, memory, and executive fxn
Craig Handicap Assessment and Reporting Technique (CRAIG)
Description: Assesses physical independence (need for unpaid vs occasional paid care) , cognitive independence (need help to make decisions, judgements in home or outside; remembering; money mgmt; communication), mobility (leave house during day or night, hours OOB, enter/exit house indep, use of transportation w/out advance notice and indep to places you want to go?), occupation (homemaking, work, school, self-improvement, home improvement, recreation, volunteering), social integration (family or romantic relationships), and economic self-sufficiency
Scoring: 0 (low independence/ fxn) to 100 (most independent / functional) on each of the 6 domains
Populations: SCI, TBI (outpatient only), MS, post CVA
ICF Level: Activity + Participation
*It is combined with the Community Integration Questionnaire (participation level) as a joint measure called the “PART-O” for use in TBI
Brunnstrom Stages of Motor Recovery after Cortical Stroke
What is it? Classification system/common stage of motor recovery, in patients who have sustained a cortical stroke. Based on predictable synergistic movement patterns
How it works: UEs and LEs are classified as being in one or more of these stages (e.g. the stage for the UE can be different than that of the LE). Patterns are ONLY more predictable after cortical stroke, but variations of them are seen in other CNS lesions, especially brain injury. NOT used anymore in clinic, but still useful when first learning about cortical stroke (though doesn’t totally agree with current understanding of neuroplasticity
STAGE 1 - Flaccidity, no movement present (reflex or voluntary)
STAGE 2 - Weak associated reactions appear or minimal voluntary movement responses are present in limb synergies. Spasticity begins to develop.
STAGE 3 - All movement are in synergy although synergies may not be through full ROM. Spasticity peaks.
STAGE 4 - Some mvmt combinations out of synergy are possible & mastered w/ difficulty. Spasticity decreasing.
STAGE 5 - Synergies lose dominance; can master more difficult mvmt combos. Spasticity further decreases.
STAGE 6 - No synergies; full isolated joint movements are possible but decreased coordination present. Spasticity present only during active rapid movements.
STAGE 7 - Normal movements performed; normal muscle tone.
- Good to assess gross stage of recovery s/p CVA and for developing broad treatment goals.
..BUT not all pts fit exactly into described stages of recovery. Lacks # scores; less sensitive to change than more detailed test (can’t track changes in scores well). Limited use in quantitative analysis. Not so helpful for clinical decision making re: specific treatment planning.
Trunk Control Test
Description: 4 items:
- Roll to weak side
- Roll to strong side
- Balance in sitting
- Supine->sit
**Not recommended by any of the EDGE groups (Use Trunk Impairment Scale [TIS], or Postural Assessment Scale for Stroke Patients [PASS])
Score: 0 (min) to 100 (max, normal)
0 = Unable without asst
12= able, but modified (uses weird approach, assist from environment/clothes)
25 = Completes movement normally
CUTOFF:
At 18 wks post CVA (4.5 mo)…
>50 associated with ambulators
<40 were non-ambulatory
*Better initial trunk control on TCT = longer walking distance and faster speed at hospital d/c
Higher/better TCT = shorter LOS
Clinical Staging of ALS:
Describe the stages.
I: Ambulatory, no problem with ADLs, mild weakness (normal activities, moderate exercise in unaffected mm, AROM)
II: Ambulatory, moderate weakness in certain mm (need modification in living, still can do modest exercise and AAROM; needs assistive devices e.g. beginning to use rollator)
III: Ambulatory, severe weakness in certain muscles, mild/mod limitation of function (goal to promote an active life with A/AAROM and PROM, joint pain, mgmt; needs assistive devices, adaptive devices, home equipment, and wheelchair)
IV: Wheelchair mobility, but almost independent. Severe BLE weakness. (PROM, modest exercise in uninvolved mm; needs assistive devices, adaptive devices, home equipment)
V: Wheelchair, dependent. Pronounced weakness in BLE. Severe weakness in UEs (PROM, pain management, decubitus prevention; needs adaptive devices, home equipment, power wheelchair)
VI: Bedridden, cannot do ADLs, maximal assist required (PROM, pain mgmt, decubitus prevention, DVT prevention, pulmonary hygiene; needs adaptive devices and home equipment)
- Stages based off of Del Bello Haas 1998
- Begin equipment needs at ~10% of disease duration; max equipment needs arise around 25-50% of disease duration
Clinical Staging of Parkinson’s is done with the ___.
Describe the stages.
Modified Hoehn and Yahr Scale:
0: no signs of disease
1: mild disease, unilateral: symptoms on one side only
1. 5: unilateral w/ axial involvement
2: bilateral involvement without loss of balance/postural instability
2. 5: (mild) bilateral disease with early signs of postural instability (recovery on pull test)
3: (mild to moderate) bilateral disease with postural instability (no recovery on pull test), physically independent
4: severe disability, but still able to walk or stand unassisted
5: Confined to wheelchair or bed
Predictors for more rapid decline in Parkinson’s?
Predictors for more rapid decline in Parkinson’s:
- Late onset
- Male
- Postural instability (predominant gait difficulty; e.g. PIGD subtype)
- Rigidity or bradykinesia as 1st symptom
- Dementia
- Poor response to Levadopa
- Associated comorbidities (e.g. CVA)
Predictors of a more benign course/slower decline in Parkinson’s?
Predictors of slower/more benign PD course:
- Early onset
- Tremor predominant
- Female
Clinical Staging of Huntington’s Disease is done with the ___, which is part of the __.
Describe the stages.
Staging of HD done with the Total Functional Capacity scale, which is part of the Unified Huntington Disease Rating Scale (UHDRS)
Clinically, we divide into:
(1) Pre-manifest stage (no symptoms)
(2) Early (TFC stage I)
- Mild motor chorea, voluntary saccadic deficits
- Difficulty organizing/sequencing w/daily activities
- Remain relatively functionally independent
(3) Middle (TFC stage II and III)
- Increased involuntary movements, presentation fo dystonias, increased variability in gait -> frequent falls
- Impaired motor skill learning
- Voluntary motor tasks become more difficult
- Psych symptoms: impulsve, apathy, perseveration, antisocial/suicidal behaviors, paranoia, delusions, hallucinations
- May no longer be able to work/drive, may need assist w/some ADLs by TFC stage III but still living at home
(4) Late (TFC stages IV and V)
- Motor symptoms progress, severely limiting mobility. Chorea and dystonic movement may further increase, but often overshadowed by Parkinsonian symptoms (bradykinetic, rigidity)
- Deteriorating swallow, dysarthria
- Cognitive deficits progres to global dementia
- Delirum may occur d/t meds or medical problems (e.g. dehydration, infections)
- Unable to do any IADLs (occupation, finances, chores)
- Require assist w/aspects of ADLs (Stage IV: performing gross ADL tasks only, borderline home vs facility; by stage V pt is total care and requires full time skilled nursing care)
- Able to live at home through stage III (TFC 3-6), home vs SNF at stage IV, full time SNF at stage V (unable to do job, finances, chores, or ADLs)
- Choreas peak in middle stage
How is disease severity categorized in MS? Name the scale and give the ranges for each level of disability.
Expanded Disability Status Scale (EDSS)
0-10 scale, 0 = normal, 10 = death
0-3.5: Normal to mild disability 4-5.5: Mild to mod disability 6.0-7.5: Mod to severe disability 8-9.5: severe disability, restricted to bed or w/c 10: Death
Fatigue Impact Scale
Description: Assesses perceived impact of fatigue via physical, cognitive, and psychosocial subscales
MS
40 items, each scored 0 (never) - 4 (almost always)
Total = 0 (no fatigue) - 84 (MORE fatigued) (*modified version 0-40)
Norms ~33
Twelve-Item MS Walking Scale (MSWS-12)
Description: Self report measure, rates the impact of MS on the pt’s ability to walk
Scoring: 0 (normal) -> 100 (worse, very impaired)
Cutoff: >75/100 indicates fall risk
Discuss electrodiagnostic findings which are predictive of outcomes in GBS?
Electrodiagnostic findings which are predictive of outcomes in GBS:
Distal compound motor action potential (CMAP) <20% of normal at 3-5 weeks post onset of symptoms = suggests prolonged or poor outcome
Gross Motor Function Measure (GMFM-88)
GMFM-88
Description: Evaluates change in gross motor skills in children with CP. Help to establish treatment goals. Takes 45 mins. Emphasizes child’s USUAL (not best) performance and the quantity of movement (not quality).
Ages: 6mo - 18yo (best for 2-9yo)
Criterion referenced (NO normative data)
5 dimensions:
- Lying and rolling
- Sitting
- Crawling
- Standing
- Walking and running (OK to use assistive device)
Scoring: 4 point ordinal scale, higher score = better
Cutoff on GMFM-66 (% of total score fo GMFM-66) relative to GMFCS Level: GMFCS I = 81.48 II = 75.98 III = 53.33 IV = 40.92 V = not determined
Gross Motor Function for Children with Cerebral Palsy (GMFCS)
GMFCS
Description: System for categorizing severity of movement in CP (has descriptions for movement based on age group, starting at 1 yo).
Level I: Walks without restrictions. Limitation sin more advanced gross motor skills.
Level II: Walks without assistive mobility devices, but limitations in walking outdoors and in community
Level III: Walks with assistive mobility devices; limitations walking outdoors and in community
Level IV: Self mobility in w/c without limitations; children are transported or use power mobility outdoors and in community
Level V: Self mobility severely limited, even w/use of assistive technology
Denver Developmental Screening Tool
Denver Developmental Screening Tool
Description: SCREENING TOOL to assess fine motor, gross motor, social contact, and language.
Age: 0-5yo
Scoring: Norm referenced. Reflects what % of a certain age group can perform X task
APGAR scores
APGAR
Used with newborns in acute setting (at 1 and 5 mins post birth)
Appearance Pulse Grimace Activity Respiration
Scoring: 0 (worst) to 10 (max) points
<3 critically low
4-6 fairly low
7-10 generally normal
Alberta Infant Motor Scale (AIMS)
AIMS
Description: Includes 58 GROSS motor items in prone, supine, sit, and stand (whether or not the skill is observed)
Age: 0-18months (best from 4-10 mo)
Scoring: Norm referenced. Primarily an observational screening tool. Each item scored 0 (not observed) or 1 (observed) with higher scores = better
Peabody Developmental Motor Scale - 2 (PDMS-2)
PDMS-2 Description: Gross and fine motor tasks, does not look at quality of movement. Long to administer. Reflexes Stationary Locomotor Object manipulation Grasping Visual/motor integration
Age: 0-72 mo (6yo)
Scoring: Norm and criterion reference. Gives raw score, age equivalent. Higher score = better.
Test for Gross Motor Development (TGMD-2)
TGMD-2
Description: Gross motor skills in locomotion (run, gallop, hop, leap, jump, slide) and object control (bat a ball, dribble, catch, kick, throw, roll). Looks at quality of movement - sensitive to detect even mild issues.
Age: 3-10yo
Scoring: Norm referenced - can give %ile and age equivalent
Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)
BOT-2 Description: Assesses motor skills in 8 subtests: Gross motor: - Bilateral coordination - Balance - Running speed/agility - Gross motor strength Fine motor: - Precision - Visual motor integration - UE manual dexterity - UE coordination
Age: 4-21yo
Scoring: Gives scaled scores, %ile rank, age equivalents etc. Higher scaled scores are better: 25+: well above avg 20-25: above avg 10-20: avg 5-10: below avg <5: well below avg
School Functional Assessment
Description: Assesses function of students w/disabilities in educational environments. Can identify needs, help w/IEP development (identifies strengths/ weaknesses) facilitate collaborative planning, and document progress over time
Looks at participation in school settings, amount of support needed for tasks, and performance on activities
Age: Grade K-6th with disabilities
Scoring: Criterion referenced, standardized. Higher score = more independent /better
Wee FIM (Functional Independence Measure for Children)
Description: Helps to track disability, measure impact of developmental strengths/ difficulties on independence at home, school, and community in areas of: - Transfers - Locomotion (walk, w/c, crawl, stairs) - Self-care (ADLs) - Sphincter control (bowel/ bladder) - Communication - Social Age: 6mo - 7yo with disabilities
Scoring: criterion referenced, observational, and report. Scored like the FIM 7 = total indep 6 = Mod I 5 = Supervision or modified performance 4 = MinA 3 = ModA 2 = MaxA 1 = Dep
*Used mostly in rehab settings
Pediatric Evaluation of Disability Inventory (PEDI)
PEDI
Description: Assess functional capacities, evidence of mastery, progress. Can eval therapeutic outcomes / interventions.
Functional skills:
- Self care (ADLs
- Mobility (transfers, indoor/outdoor mobility)
- Social function: communication, interaction, household / community tasks
Caregiver assistance (I to dep)
Amount of environmental modification + equipment used in daily activities
Age: 6mo = 7.5 years with disabilities
Scoring: Norm and criterion referenced, standardized, parent report, structured interview, professional observation. Gives a raw score, normative standard score, and scaled score for each domain out of 100 total (high score is better), normal distribution (50 is average for typically-developing kids)
Hawaii Early Learning Profile (HELP)
Description: Lets you assess, monitor progress, and plan/target interventions
Skills: - Gross motor (from reflexes to running/jumping) - Fine motor - Cognitive - Language - Self-help - Social Age: 0-3yo
Scoring: criterion referenced checklist of skills
Action Research Arm Test (ARAT)
Looks at grasp, grip, pinch, & gross arm movement.
Scoring: 0 (bad) - 57 (normal).
19 items; each item 0 (unable) - 3 (normal),
