Neurology Rehabilitation ILP 2006

- History of presenting illness - Any existing medical symptoms that may affect your treatment e.g. dizziness, chest pain, dyspnoea, arthritis, numbness etc. - Oedema - Vision - Sensation - Pain (where, when, how much, what gives relief) - Dominance - Past or present physiotherapy treatment - Social history - family/accommodation/hobbies/occupation Through conversation with your client you should now be able to comment on:- - Communication problems - Your client's attitude, motivation and understanding of his/her present symptoms and situation. - Your client's cognitive status Then, while client is still sitting, quickly note the active movement in arms/ legs (quantity and quality) by asking client to perform specific movements e.g. hip flexion; knee extension; dorsiflexion; arm elevation. These movements, the report from the client about their current method of transfer and the information in the chart should help you decide the appropriate method of transferring this client if in a wheelchair. Key questions: - Do you need one person or two? - What level of assistance are you expecting to provide? IF YOU FEEL UNSAFE – keep the client in sitting and ask another therapist (or tutor) to assist in a two man controlled transfer or if a standing transfer is not possible, do a sliding transfer or use a hoist to transfer the client. At all times you must observe the NO LIFT POLICY of the unit you are working in. IF YOU FEEL SAFE – help the client stand up and before proceeding to transfer, note posture, balance and control at the hip and knee with loading as this will help you make a safe decision re your ability to transfer the client safely. Give the assistance necessary for a safe, controlled transfer. Proceed to transfer the client and while doing so note: posture; balance; weight shift; movement of the affected side; amount of assistance needed (from standby supervision to maximal help); effect of effort on movement. Any increased patterning / tone due to effort? ALL OF THE ABOVE WILL NOW HELP YOU DECIDE WHERE TO START YOUR OBJECTIVE ASSESSMENT 4. FUNCTIONAL TASK ANALYSIS The best guide to the client's function is gained by observing the performance of functional tasks. Deficits in sensation, perception, joint range, apraxia etc. will show up as changes in movement quality and control and will guide you towards a prioritised objective assessment. Functional task analysis involves observation of the functional movement and analysis of the components of the movement present/absent. The primary aim is to observe the movement disorder and to decide why the movement is abnormal. In most cases, it will be the inability of the client to selectively control the desired movement components. In some clients however, there may be the influence of altered tone, particularly with effort; difficulty initiating movement; incoordination; sensory; vision or perceptual problems; loss of flexibility or range of movement and these must be recorded as appropriate. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 101

For each of the functional tasks described below some examples of typical problems and their possible causative factors will be given. An example for an earlier activity may also apply to later activities e.g. a problem in standing could also affect walking. Each functional task is first described qualitatively and then a quantitative score recorded, according to the appropriate outcome measure selected e.g. Motor Assessment Scale is followed in CVA clients i.e. each task/test must be repeated three times or the COVS for Spinal or TBI clients. (Outcome measurement will be discussed later). For each functional task, note and record the following in the client’s physiotherapy chart: (a) Level of independence The level of independence for each activity is described using the following terms: - independent - requires supervision - requires verbal cueing - requires minimal physical assistance x 1 - requires moderate physical assistance x 1 - requires physical assistance x 2 - unable to perform even with maximal assistance (b)Movement components Record any missing movement components and describe any abnormal movements. (c) Causal factors Reasons for the abnormal task performance may include lack of isolated control, abnormal tone, decreased sensation, decreased vision, neglect, decreased ROM, pain etc. Where to begin? You must be flexible about the appropriate functional task with which to commence your assessment. With a higher levelclient you may assess balance and gait first, while lower level clients may be in bed or need to be laid down following the transfer so that the analysis can commence with rolling. Bridging With the client in crook lying (supine with knees flexed and feet on bed) observe the clients ability to bridge (extend the hips). Also observe ability to shift to left and right on the bed. Supine to Side Lying First read description of tests for Motor Assessment Scale so that you may grade the client's response. The client is asked to roll from supine to side lying. This is repeated three times. The best response is graded. Movement analysis is recorded. Describe rolling to left and to right. Describe using movement components: - Rotation and flexion of neck. - Hip and knee flexion. - Flexion and protraction of shoulder. - Rotation of trunk. Problems interfering with task performance may include: - using normal side only - using momentum - lack of awareness of affected arm or side - lack of body rotation as a result of muscle tightness or decreased/ increased tone ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 102

Side Lying to Sitting Over Edge of Bed The client is asked to go from side lying to sitting over edge of bed. The therapist must always be in a position of safety to assist client. The movement should be observed three times if possible. Score on the MAS is noted (An advanced client should start in supine to sitting over edge of bed). Describe movement components from side lying: - Lateral flexion of neck & trunk; - Push up through abducted arm; - Bend up legs & lower legs over side of bed OR Describe how your client achieves supine to sitting. Problems: - inability to activate muscles appropriately or initiate movement components without cues. - immobility in trunk - why? - influence of tone or tonic reflexes (esp. in head injured client with brain stem damage). Balanced Sitting 1) Sitting posture / alignment Record length of time position can be held. Describe components: - weight evenly distributed - adequate anterior pelvic tilt - adequate trunk and neck extension - head balanced on level shoulders. Problems - If client leans or falls - Why? Which direction? - Is he aware of falling? Sensory loss? Spatial neglect? Verticality? - Is client afraid? Eyesight dependent? - Dizziness - reason? 2) Dynamic sitting Observe client's balance reactions i.e. righting, equilibrium and protective reactions during various movements. Are they slow or efficient? (a) Observe client-initiated displacements - Head movements - Rotate body to (R) / (L) - Touch Imaginary Quadrant -i.e. lean approx. 30o to side and cross midline. - Touch (R) toes (reach forwards)/ Touch (L) toes - Reach sideways to touch floor (from a stool) (b) External Displacements - External push applied in ant/post and lateral directions - For a more challenging task assess client reactions to displacement while sitting on balance board Use MAS / COVS scores where relevant. Standing Up and Sitting Down If client is independent, observe sit to stand and stand to sit alone, giving close supervision if necessary. Otherwise assist client to standing and analyse this movement. Remember safety is of prime importance. Give score on MAS if appropriate. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 103

Standing up Describe using movement components: - Foot placement - normal base. - Forward inclination of trunk with anterior pelvic tilt. - Anterior translation of knees, with passive dorsiflexion of the ankle. - Extension of hips and knees together. Problems - lack of appropriate force generation in muscles - lack of dorsiflexion - shortened tendo-achilles or oedema in ankle - overcompensation by unaffected side (Pusher)? unawareness of side; sensory loss; verticality. - lack of forward inclination of trunk - does client lean backwards? extensor tone? positive supporting reaction? Sitting down Describe movement components: - Forward trunk inclination with anterior pelvic tilt - Even weight distribution - Controlled lowering - Base of support Balanced Standing When testing standing balance the physiotherapist should bear in mind the appropriateness of the test according to the client's functional level so as not to compromise the client's safety. In all tests the existence and timing of client's balance reactions should be noted Tests do not always have to be performed in the sequence given. Test results need to be recorded both subjectively and objectively (using the appropriate objective balance scales). (1) Standing alignment (i.e. static balance) Observe and record Describe standing posture - even weight bearing - hips extended - knees extended, (not hyper-extended) - erect trunk - hips over feet - shoulder over hips - head balanced on level shoulders Problems - similar questions as for balanced sitting - Can the client stand unsupported or not? - Qualitatively, note base of support (wide or narrow) and postural alignment. - If client is unstable, note direction and query reason for falling. Is client afraid of falling; does lack of joint range or muscle length affect balance. (2) Dynamic Standing (a) Internal displacement Page 104 Observe movements and reactions as client moves himself. - Stand and turn head to (R) and then to the (L). If any dizziness occurs, note this. - Turn body; - Stand and reach outside base of support. - Stand and cross midline. - Bend down to touch floor or pick up object. - Step and touch - (L) and (R) support. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

(b) Balance reactions forwards and sideways Therapist displaces client and records reactions i.e. equilibrium and stepping reactions (3) High Level Activities (if appropriate) - Can the client walk over a thick mat. - Can the client walk outside over uneven surfaces. - Can the client stand on a moving balance board? - Can the client walk the length of the balance board? - Can the client stand on one leg? Time? - Can the client open a door (both pushing away and pulling - towards themselves) - Can client turn 360o to the left and right (i.e. step around). Note the amount of time taken to perform this activity. Objective and Functional Balance Measures (see Standing Balance Tests in Outcome Measurement section) Gait Assess safety of client to walk alone or with assistance. This requires the client’s balance in standing to have been assessed, to be sure of the client's ability to stand on one leg while stepping with the other. Observe gait and give MAS score under test conditions. Record level of independence and use of aids and/or orthoses. Note effect of footwear. Record type of surfaces walked on and progression to different floor surfaces (e.g. carpet) and outside (concrete. road, grass, gravel). Also stairs, ramp etc. Record an objective measure of gait (e.g. Timed 10 metre walk; Timed Up & Go) Analyse and record in detail under stance and swing headings. Describe general gait observations - Speed, step length and cadence (measure these objectively) - Rhythm/symmetry - Arm swing - Trunk rotation. Describe the gait cycle: Stance phase components - Ant/post hip control - Med/lat hip control - Knee control - knee flexion from heel strike to mid stance - knee extension to toe off - Foot contact (Heel strike) / Rollover / Push off Problems - Lack of hip extension - Weak hip extensors? Tight hip flexors? - Excessive lateral shift - Weak hip abductors? Trendelenberg? - Instability of knee - hyperextension or excessive flexion? Related to hip? Related to ankle? Length of calf muscles? - Instability of ankle/forefoot - inversion? - If not heel strike - whole foot? forefoot only? Why? decreased range? tone? - No push off – plantar-flexors? ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 105

Swing Phase Components - Hip flexion - Knee flexion - Ankle dorsiflexion These give adequate ground clearance - Internal rotation of pelvis - Knee extension with dorsiflexion of ankle Problems: - Hip hitching, circumduction, excessive lateral flexion of trunk. These are compensations for lack of appropriate muscle activation - Lack of dorsiflexion with knee extension - Synergic patterning? Tone? 5. QUALITY OF ACTIVE MOVEMENTS Assess quality of voluntary movement - selectivity of movement, presence of stereotyped patterns of movements, speed, control and endurance Movements are tested in appropriate positions while the client is in that position e.g. sitting, supine, sidelying, prone. TRUNK Sitting - Anterior and posterior pelvic tilt - Weight shift – anterior/posterior and lateral LOWER LIMBS Sitting - Hip & knee flexion - Knee extension - Ankle dorsiflexion; plantarflexion; eversion and inversion Supine - Hip & knee flexion; Hip & knee extension - Hip abduction with the knee in extension - Hip flexion with knee extension - Dorsiflexion with the knee in extension - Ankle inversion / eversion - Toe extension / flexion Prone/ Side-lying - Knee flexion, Hip extension Sidelying -Hip abduction Describe: How much assistance was required? Were these movements performed in an isolated manner i.e. were they normal? Was there an influence of an abnormal pattern? e.g. Dorsiflexion only possible with hip and knee flexion. Remember, if a client tries too hard an abnormal pattern may result. Did loss of muscle length or joint range affect active movement? Did sensory loss (especially proprioception) affect movement? Record these other factors influencing movement on the recording sheet. After the client has attempted active or assisted movement, passively move the limb, feeling for muscle tone changes and for loss of muscle length or joint range. Record these findings also (see section 6 – Flexibility and Muscle Tone). ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 106

UPPER LIMBS The level of assessment will be very variable and will occur at a level appropriate to the client. Only very advanced clients will be tested on all activities. As previously, the general quality of movement is observed. e.g. Is movement smooth? ataxic? weak? patterned? Movement analysis includes a combined functional assessment e.g. Use of cup; Use of knife/fork; Do up buttons; Grasp/ release of various objects; Other bimanual tasks and a specific assessment of active movement components. Assessment of functional movements is based initially on observations of arm and use of the hand. Once movements can be initiated select a scale to enable an objective assessment score using either the MAS or COVS. Assess active or attempted movements in supine and/or sitting as appropriate. Describe movements and problems. Extent of analysis will depend on degree of isolated movement return in upper limb. Supine (arm in 90o flexion) - shoulder protraction; - shoulder horizontal abduction; - shoulder horizontal adduction; - shoulder flexion; - shoulder extension; - elbow flexion; - elbow extension Sitting - hand to mouth; raise arm forward to 90o; - hand to sacrum (behind back); hand to top of head; raise arm over head; - pron/sup. (arm by side 90o); pron/sup. (elbow extended) - radial deviation with wrist extension - wrist extension while holding an object - Release – extension of MCP joints with fingers in slight flexion - Grasp - abduction of thumb with wrist in radial deviation and extension - Opposition, thumb to fingers. Describe exactly what you are observing: - How much assistance was required? - Were these movements performed selectively or was patterned (i.e. was movement performed in an abnormal pattern? e.g. shoulder elevation on attempted shoulder flexion. Remember, if a client tries too hard (i.e. effort tone), an abnormal pattern may result). - Record presence of movements and limiting factors on chart. 6. FLEXIBILITY AND MUSCLE TONE Examine joint range, muscle length, neural length and muscle tone in trunk and limbs. Record findings. Potential problems: - Joint stiffness - Decreased muscle length - Decreased neural length - Increased or decreased muscle tone When assessing muscle tone, note: - Quality and type of muscle tension at rest and during movement - Is there muscle overactivity at rest? - Is tonic motor activity influenced by position of head/body? Is there an influence of abnormal reflexes? - Is there increased muscle tone with effort? Note any associated reactions. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 107

- Effort tone suggests a cortical component to the tension generation while increased tension even at rest suggests sub-cortical mechanisms are contributing to this tonic motor activity. - If tone is persistently a problem at rest and during movement (e.g. in severe presentation of a TBI client), it needs to be recorded as mild, moderate or severe increase or decrease and the effect of position and effort noted on fluctuating tone. - Also note the resistance to passive stretch at rest although this may not correlate with function. - Note effect of abnormal reflex activity in relevant clients - Note tremor, rigidity, chorea or other involuntary movements 7. MUSCLE POWER Where movements are totally isolated in all positions, it is necessary to perform standard muscle strength tests on standard charts. In the presence of abnormal tone or lack of isolated movement, this is inappropriate. 8. SENSATION After assessing functional activities one should have a good idea of sensation because of movement quality. If the presenting movement implies poor sensation then initially test for primary sensory loss (light touch; passive movement sense and joint position sense). If the primary senses are intact, then test for the interpretative aspects of touch and proprioception (e.g. double simultaneous stimulation; stereognosis etc). Add sharp/blunt; hot/cold for added thoroughness if indicated. See Neurological Assessment Procedures for method of assessment of sensation. 9. OTHER ASSESSMENT AREAS Depending on the nature of brain damage e.g. CVA. vs. head injury vs. multiple sclerosis etc, some areas will be more relevant for continued assessment. Some of these areas are: - vision - apraxias - perceptual deficits - cranial nerves including vision/orofacial - coordination - high level balance and walking skills - cardiovascular and respiratory endurance - aids, orthoses, wheelchair Details of assessment methods follow in Neurological Assessment Procedures. 10. OBJECTIVE OUTCOME MEASUREMENT Objective measures of impairment and disability should be selected and applied as appropriate. In practice, these measures should be integrated into the assessment process. In this manual, specific outcome measures will be described in a later section (Physiotherapy Outcome Measures for Neurological and Geriatric Rehabilitation). 11. INFORMATION FROM OTHER THERAPISTS/TEAM MEMBERS From occupational therapist one may obtain details of testing in the following areas: - Perceptual - Memory and Cognition (Neuropsychologist will provide this information if a member of the team). - Some specific ADL problems e.g. related to dressing, bathing and kitchen skills Memory and cognitive dysfunction is particularly relevant with head injured clients. Knowledge of details of management of these problems is of importance, so that overlap in program design does not occur. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 108

From speech pathologist one obtains details of speech impairments and results of specific tests. Hints for management of speech problems present during physiotherapy treatment are important. The speech pathologist will also be involved with the assessment of swallowing disorders and their management From social workerone may obtain details of the client’s family and social situation and likely placement /care arrangements following discharge from hospital. 12. PROBLEM LIST From the initial assessment, the client's major problems must be identified and placed in order of priority. You must relate function to underlying problems e.g. Unable to transfer independently due to poor hip and knee control, poor balance. 13. GOALS (Short And Long Term) Correspond goals to problem list. Remember that the goals should include both client and therapist aims. Goals must be recorded separately as: 1) Short Term 2) Long Term The time frame will vary depending on the severity of the client’s condition and the likelihood of the degree of movement return. Short term goals for one client may change daily whereas for another, they may last over several weeks. These must be recorded on the physiotherapy chart in the appropriate place. To be able to set long term goals, one must be able to attempt to predict the outcome of rehabilitation. From knowledge of the disease/condition, one can establish expected prognoses. It is necessary to consider the positive and negative factors in relation to the client’s prognosis. These can also be recorded on the physiotherapy chart. 14. TREATMENT PLAN A treatment plan can then be formulated. In describing your treatment plan, methods of treatment should be included and must relate directly to your client, not be a list of theoretical possibilities for any client. Factors to be considered in planning treatment are:- - How frequently? - How long each session? - What techniques to include? - What order of treatment of problem areas? - What work client can continue outside formal treatment time, i.e. with relatives or staff help in the ward or at home? - When/how quickly to progress client? eg When to use a walking aid? When client is safe to walk independently? - When to discharge client? - Which follow-up / community services need to be organised? Progress notes should be included in physiotherapy chart in areas provided. These should include: 1. Changes in observations and measurements of function. 2. A re-statement of aims in the light of the above changes. 3. An upgraded treatment plan. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 109

NEUROLOGICAL ASSESSMENT PROCEDURES: This guide gives details of testing procedures for several important areas of neurological testing. It does not imply that tests should be performed in this order but may be referred to, if necessary in conjunction with the neurological assessment guideline. SENSATION All tested with client's eyes closed or blindfolded. Test both sides. Test face, limbs and trunk as appropriate. Use body chart where available. Record as increased (hypersensitive); or decreased or absent. 1. Primary loss of somato-sensation Light Touch Test with cotton wool, tissue or light finger touch. - Test for localisation of stimulus - 'Can you feel where I am touching you? - Comparison with 'normal' side. (give comparable stimuli). You may attempt to assign a number e.g. 6 out of 10, as means of comparison. - Note variations within limb. If the lesion is a SCI, test dermatomal distribution. Pain Pinprick - Test where no contraindications to piercing skin; not a particularly 'functional' modality. Temperature Important for safety considerations. Must be ascertained before any thermal treatment or electrotherapeutic modality. Test with two test tubes (stoppered) containing cold water (may need to add ice in summer) and warm water. Test for differentiation on 'normal' side and then ask if 'hot' or 'cold'. Proprioception Passive movement sense (dynamic): move one joint and ask if client can feel movement. Which joint? and Is joint bending or straightening? Joint position sense (static): ability to copy the position of one limb held by examiner with the other (normal) side. Note proximal - distal variation - ability at specific joints. Be careful with handling not to give tactile clues. Vibration: this sense may need to be tested in a minority of clients where posterior column damage is suspected. Place vibrating tune fork on heel of foot. 2. Testing for the interpretative aspects of somato-sensation Double Simultaneous Stimulation Touch exactly the same place on both sides simultaneously, after touching each side individually and ascertaining that light touch is present. Ask, \"Which side am I touching now?\" Inability to feel two stimuli together denotes sensory inattention. Stereognosis - Test ability to recognise objects of different size, shape and texture. Do not show client testing objects first. Client needs reasonable light touch, proprioception and finger movement to perform this test. Example of objects: small plastic bead or marble; safety pin; screw; piece of cotton wool. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 110

TESTING THE VISUAL SYSTEM VISUAL ACUITY Are corrected lenses worn? (Short or long sight?) Is contrast sensitivity a problem? Is there pre-existing sight deficit - cataract, glaucoma, diabetic retinopathy? EYE MOVEMENTS Eye follow Hold an easily observable object e.g. pen, 40-50cm from subject’s face. Move object slowly across field of vision. Examine movements horizontally, vertically and diagonally. Observe for: eye follow; effect of crossing midline; speed of movement; any nystagmus. Tests for convergence, divergence. (a) Hold object approximately 1-2 metres away. Ask client to focus on object. Slowly, bring object (in midline) close to face. Observe eye and pupil reactions. Move object away slowly and again observe reactions. (b) Ask client to focus on distant object e.g. clock on wall. Then ask him to focus immediately after on object 40-50 cm away. Observe eye movement and pupils. Note diplopia If there is any disorder of eye movement then test for specific cranial nerves III, IV, VI. Nystagmus is a rhythmic oscillation of eyeballs made of slow and fast components. The direction of the quick component is recorded clinically as this is most obvious. Nystagmus at rest or during eye movements may be related to weakness of ocular muscles or may suggest a peripheral vestibular problem or poor control over vestibular signals associated with cerebellar dysfunction. Is nystagmus accompanied by vertigo? Is it present with head motion or only with eye movement? VISUAL FIELD LOSS Hemianopia (primary loss) 1. Stand in front of client and ask him to fix gaze on your nose. Bring your fingers from side of head slowly into field of vision. Ask client to indicate as soon as the finger is seen. Do one side at a time. Assess for quadrantanopia - bring stimuli from high up and then low down. 2. If two people available, one stand in front and observe response and fix gaze while other provides stimuli from behind the client. Visual inattention If no hemianopia, test for visual inattention by providing stimuli to one field and then both together. This is an interpretative test of visual signals. Objective Tests 1. Cancellation Test - cross out all the 'A's (or any chosen letter) in an array of letters that covers whole width of page for e.g. six lines. 2. Line Bisection Task - Client is required to bisect a variety of lines at different angles on the page. TESTING THE VESTIBULAR SYSTEM The Vestibular Contribution to Gaze Stability The vestibular system may be implicated in gaze instability when motion of the head induces the problem. The cervical proprioceptors also contribute to gaze stability so careful interpretation is required. Observe gaze stability with head at rest and during passive and active movements ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 111

1. Passive movements - note saccadic beats at end of range; crossing the midline and decreased ability to maintain a steady gaze with head movement 2. Active movements - note quality of gaze stability while maintaining gaze on a focal point during head movement; during tandem bead / eye movements to two points. Dizziness Motion induced dizziness could be caused by vestibular dysfunction. 1. Record intensity / duration of dizziness when dizziness elicited during functional tasks 2. Perform the Hall-Pike Dix procedure if a specific pattern of dizziness reported (i.e. dizziness when rolling in one, not both directions; dizziness looking overhead to one side only and dizziness bending forward to one side only) CO-ORDINATION TESTING The assessment of balance, movement and co-ordination are entwined especially in high level clients so that some tests may appear under either heading. Movement should be observed for speed, timing, rhythm, smoothness and ability to follow a sequence of actions. Do movements under or overshoot? Ability to perform a learnt skill should be compared with ability to learn a new skill. Possible causes of incoordination to be noted are: hypotonia, weakness, proprioceptive or tactile loss, cerebellar ataxia, and vestibular dysfunction. Compare movements on both sides of body. Tests – perform each movement slowly at first and then increase speed 1. Finger to nose - client touches his nose then therapist's index finger held up in front of client. May do eyes open/closed. If this is normal the therapist may move their finger (client’s eyes open). 2. Pronation/supination - quickly alternating movements. 3. Hand tapping - tap hand on thigh or table; add a particular beat to copy. 4. Finger strumming - tap each finger in order; may add a particular rhythm. 5. Heel/knee/shin - client slides heel up and down shin. May be done in supine or sitting. 6. Alternate hip and knee flexion - observe movement performed slowly and then faster. Client is supine. 7. Cycling of legs - supine - ride a bicycle with hip and knee flexion/extension. 8. Alternate hip flexion - sitting. 9. Foot tapping - client alternately dorsiflexes ankle and taps foot. Initially test one side at a time; then bilateral; then bilateral alternating. High level functions 1. Heel-toe walking - client walks in straight line with one foot directly in front of other and in contact. 2. Braiding - walk forwards crossing one leg over other; walk sideways crossing one leg in front of other and then behind. 3. Running, skipping, hopping. Note speed, rhythm. 4. Star jumps - start with stride jumps and then add arms as well. May clap hands over head. 5. Cross over jumps - stride jumps with legs crossing alternately front and back. 6. Skipping with a rope. 7. Bouncing balls - different combinations of one hand or alternate hands. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 112

PERCEPTUAL DYSFUNCTION AND APRAXIA Observation of client movement or lack of movement may suggest certain perceptual or motor planning problems. Once behaviour has been observed, certain written tests may be applied. In a team setting, formal testing will be done by a psychologist or occupational therapist. PERCEPTUAL DISTURBANCES Unilateral Spatial Neglect Features to note during assessment of function and movement quality: - Client ignores one side of the body or environment - may run into objects and doorways when walking - may leave affected arm behind when rolling - Difficulty crossing midline - Failure to use or attend to one side or limb even when movement and sensation are relatively intact - This is most severe in combination with hemianopia, hemiparesis and hemisensory loss. Formal Testing: Drawing tests like: 'draw a picture of yourself' or 'draw a house or clock' may show evidence of varying dysfunction e.g. hemianopia; unilateral spatial neglect or body image problems. Inattention/Extinction Tactile Inattention: see Assessment of Sensation - Double Simultaneous Stimulation Visual Inattention: see Assessment of Vision - Visual Fields Agnosias Anosognosia: Is client unrealistic about condition; does he deny what has happened. This is a severe form of neglect and may 'impr ove' to leave neglect of body and space. Autotopagnosia: Disturbed perception of body parts; may be unaware of existence of one side of body (usually left). May be unable to distinguish right from left (laterality). Test: Draw a man test may show this problem with drawings either enlarging or diminishing size of one side of body. Other disorders of visuospatial perception Verticality perception: 1. Position of self - observe posture and ask if client feels `straight' or `falling/leaning to one side'. Move client into various positions, especially to affected side. Is there fear of falling? 2. Position of objects in external environment - hold a stick (e.g. pointer; walking stick) against a background with no cues e.g. vertical doorways. Slowly rotate stick and ask client to tell you when it is vertical or horizontal. Distance perception: Point to two objects and ask which is closer or further away. Size, colour or shape perception: ask to compare size (which is bigger/smaller); or compare colour or shape. Figure-ground perception: ask to pick out an object from a cluttered table or shelf Direction sense: test up; down; left; right; forwards; backwards. Page 113 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006

Route finding/ topographical memory: Client may be unable to find his way from his room to toile t or from physiotherapy area to his ward. Ask client if mobile to show you e.g. the way to the ward. Ask to draw a floor plan of his home; ask to draw plan of city streets. Take to shopping centre or on public transport and observe direction finding skills. APRAXIAS Ideomotor Client fully understands the concept of a task but cannot perform it on command. e.g. bend arm; stand up; let go of the ball. Test: A formal test performed by Occupational Therapists or Psychologists is the Goodglass Test for Apraxia (In Zoltan et al 1986). The test consists of a series of tasks that the therapist asks the client to do. If the client fails on command, the therapist asks the client to imitate her doing the tasks. If the client still fails, and where applicable, the therapist asks the client to do the task with real objects. This is believed to be in the descending order of difficulty for apraxia clients. Examples of tests in this battery are brush teeth, use hammer, wave goodbye. Ideational Client cannot carry out a task either automatically or on command as he doesn't understand concept. He can perform individual movements but cannot develop sequence of action e.g. get off mat (from lying); light a match (give box of matches); clean teeth; roll over. Constructional Client cannot copy 2D or 3D drawings or constructions. Tests 2D - draw a man; draw a house; draw a clock; copy stick patterns; 3D - build a tower; copy block designs. Dressing Apraxia Unable to dress due to disorder of body parts or visuospatia l neglect. Client cannot relate a garment to his own body parts. Observe client dressing; ask to put on shirt or cardigan. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 114

CRANIAL NERVE ASSESSMENT I. Olfactory Deficit - loss of sense of smell Test with various substances e.g. ammonia, cloves, coffee II. Optic Nerve Function: visual acuity and visual fields Acuity: Has vision changed? Can client see number of fingers held up? Field deficits: Test for visual fields (see Testing the visual system – visual fields) a) Lesion before optic chiasm - total blindness one eye b) Lesion optic chiasm - bitemporal hemianopia c) Lesion of optic tract - contralateral homonymous hemianopia. III, IV, VI - Oculomotor, Trochlear, Abducens These nerves control ocular movements by controlling external ocular muscles. They work in a co- ordinated fashion to allow eyes to focus images. These eye movements for nerves III, IV and VI are tested as described under Testing the Visual System – Eye movements Oculomotor Nerve (III) Damage to III Nerve may produce: a) Inability to look medially for conjugate gaze b) Lack of convergence for near vision c) Deviation of the eye (strabismus) laterally d) Partial drooping of the eyelid (ptosis) e) Dilated pupil f) Lack of accommodation for near vision g) Double vision (diplopia) Effects are ipsilateral for all muscles except superior rectus (look up and out) where effect is contralateral. If complete paralysis, eye will be turned down and out due to unopposed superior oblique and lateral rectus. If no obvious squints, may have diplopia when looking in these directions. Trochlear Nerve (IV) Damage to IV Nerve may produce: a) Double vision b) Unable to use superior oblique muscle therefore cannot look down or down to the side without diplopia. Effects are entirely contralateral. It is rare to have an isolated palsy without involvement of IIIrd nerve. Abducens Nerve (VI) Damage to VI Nerve may produce: a) Internal strabismus (medially) b) Inability to look laterally in lateral gaze c) Double vision Effects are ipsilateral. V Trigeminal Lesions may produce: a) Ipsilateral anaesthesia (test light touch) of skin of anterior scalp and face. b) Weakness in chewing - paralysis of muscles of mastication (test jaw closure). c) Loss of ipsilateral corneal reflex [touching the cornea carefully with a corner of tissue (V) will cause the eye to blink (VII)). d) More sensitivity to sounds (because of paralysis of tensor tympani muscle). ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 115

e) Sometimes, sharp, agonising pain due to cutaneous distribution of one of branches (Tic douloureux) Testing 1. Sensation of face and scalp. (Ipsilateral) 2. Corneal light reflex - with tissue in corner of eye to assess blink. 3. Motor - Opening and closing mouth; close against resistance; watch for deviation to unaffected side of face when opening mouth (i.e.. to side of brain lesion - fibres crossed) VII Facial Lesions may produce varying symptoms depending on location of the lesion. Two common presentations are: a) Oedema of nerve in facial canal - Bell's palsy - a lower motor neuron lesion - whole side of face affected (ipsilateral) b) Lesion of one motor cortex or internal capsule - upper motor neuron lesion with only contralateral lower facial muscles affected. Symptoms therefore may include: a) Paralysis of ipsilateral facial muscles (LMNL). b) Test facial muscles as described in Facial Assessment Procedure. c) Inability to close eyelid (LMNL). d) Loss of motor limb corneal reflex. e) Increased sensitivity to sound because of paralysis of stapedius muscle in middle ear. f) Loss of taste on ipsilateral anterior 2/3 of tongue - Test with sugar (tip); salt (side), bitter-oil of cloves (back); sour lemon juice (part way back). VIII Vestibulocochlear This consists of two separate nerves with special functions. Damage to nerve or cell bodies can produce: a) Deafness in the ipsilateral ear. b) Ringing in ipsilateral ear (tinnitus) c) Nystagmus and vertigo (dizziness associated with motion) which may lead to nausea, vomiting and disturbances of gait. d) Balance and gait dysfunction. Test a) Hearing – audiology report required (clients report tinnitus/buzzing and reduced hearing ) b) Observe gaze stability with head at rest and during passive and active movements - see Testing the Vestibular System. c) Dizziness - see Testing the Vestibular System. IX Glossopharyngeal Lesion of nerve can produce: a) Loss of sensation and taste on posterior third of tongue and pharynx (ipsilateral) - test as before. b) Unilateral loss of gag reflex with deviation of uvula to uninvolved side of body - test with spatula. (Afferent or sensory component) c) Difficulty in swallowing (dysphagia) d) Disturbance in carotid sinus reflex may cause tachycardia. e) Increase in salivation X Vagus Lesion of vagus nerve can result in: a) Difficulty swallowing; Decreased gag (motor component) b) Deviation of uvula to uninvolved side during phonation (tested by speech pathologist). c) Flaccid soft palate. d) Hoarse voic e reduced to a whisper if vocal cords become fixed (tested by speech pathologist). e) Transient tachycardia. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 116

XI Spinal Accessory Lesion of nerve can result in: Weakness in ipsilateral sternocleidomastoid and upper trapezius muscles - weakness in contralateral head rotation, weakness of ipsilateral shoulder elevation (shrugging) and some weakness of neck extension, flexion and lateral flexion. Possible ipsilateral shoulder sag. XII Hypoglossal Lesion of nerve can result in: a) Ipsilateral paralysis of the tongue (LMNL) - on protrusion of tongue, the tip deviates to the side of the lesion. b) UMNL - Tongue may temporarily deviate away from the side of the lesion (contralateral) - to weak side of body. Test - Run tongue around lips, protrude, push tongue into cheek. Observe mobility and force of movements. Resistance can be applied with a spatula. Note - atrophy if LMNL; fasciculation; dysarthria; direction of deviation on protrusion. ORO-FACIAL ASSESSMENT Facial Movements - observe symmetry -open eyes wide; close eyes tightly. -frown. -wrinkle nose. -smile. -open mouth wide; close mouth. -blow; suck. -make sounds - E,O,OO. Dentures - fitting and comfortable Swallowing - lip closure - drooling? - tongue movements - elevation, depression, protrusion, and lateral. - palate movements - elevation. - sensation of tongue and palate; taste. - breathing control. - gag reflex. - swallowing reflex. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 117

APPENDIX TWO PHYSIOTHERAPY OUTCOME MEASURES FOR NEUROLOGICAL AND GERIATRIC REHABILITATION Testing procedures, normative data and references are provided for the following commonly used outcome measures: 1. 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 2. Functional Performance Tests - Timed Up and Go - Timed 10 metre walk – calculation of gait parameters (velocity, stride length and cadence) 3. Community Ambulation Measure - Dynamic Gait Index 4. Composite Measurement Scales for Measurement of Motor Tasks - The Modified Elderly Mobility Scale - Motor Assessment Scale - The Clinical Outcome Variables scale (COVS) - Berg Balance scale 5. Tools Used By Rehabilitation Team to Monitor General Outcomes from Rehabilitation - 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. Hill K, Denisenko S, Miller K, Clements T and Batchelor F (2005) Clinical Outcome Measurement in Adult Neurological Physiotherapy (3rd Edition) National Neurology Group, Australian Physiotherapy Association: Victoria. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 118

1. 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) 30sec+ Normative data (healthy elderly) eyes open =30sec+ eyes closed = - 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 eyes open = 14secs Normative data (mean age 75yrs) eyes closed = 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 119

The six test conditions are: 1. Eyes open, firm support surface. All senses operating 2. Eyes closed, firm support surface. Removes vision to determine an over-reliance on this system. 3. 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. 4. Eyes open, standing on foam. (4-6\" high density foam). Reduces the available proprioceptive input. 5. Eyes closed, standing on foam. This is a test of the integrity of the vestibular system. 6. 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 120

Functional Reach Type of Measure The maximal distance reached beyond arm’s 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 & ½ st (Weiner, 1992) • predictor of falls in frequent fallers (Duncan, 1992) Normative Data Duncan et al, 1990 20 -24 M= 42cm F= 37cm Healthy subjects 41-69 M= 38cm F= 35cm 70-87 M= 33cm F= 27cm A significant difference has been demonstrated between fallers and non fallers healthy elderly mean reach = 25.9 cm fallers = 15cms - poor < or = 15cm - fair >6 but < 25cm - good > or = 25cm Mean values Functional Reach Men (cm) Women (cm) Young 20-40yrs 36.7±4.2 32.1±4.8 41-69yrs 32.8±4.8 30.4±4.8 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 121

Healthy old 70-87yrs 29.1±3.5 23.1±7.7 Balance- impaired old 16.4 Isles et al (2004) Adjusted Mean (cm) Adjusted Mean (cm) Age Right Left 42.71 42.93 20-29 41.01 40.84 30-39 40.37 39.99 40-49 38.08 38.49 50-59 36.85 36.81 60-69 34.13 34.29 70-79 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, NitzJC (2004) Normal values of balance tests in women aged 20 to 80. Journal of the American Geriatrics Society 52 (8): 1367-1372 Weiner D, Duncan PW, Chandler J, Studenski SA. Functional Reach: A marker of physical frailty. JAGS. 1992;40:203 - 207. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 122

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 subject’s 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. • Subject’s 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 subject’s 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 Mean values (cm) Healthy old women 70-87yrs 27.2±4.1 20.1±4.9 Balance- impaired old women 12.3±3.5 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 123

Isles et al Adjusted Mean (cm) Adjusted Mean (cm) Age Right Left 22.95 22.36 20-29 23.09 22.00 30-39 18.96 18.44 40-49 18.37 17.31 50-59 17.11 16.10 60-69 15.71 15.58 70-79 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, NitzJC (2004) Normal values of balance tests in women aged 20 to 80. Journal of the American Geriatrics Society 52 (8): 1367-1372 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 124

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) = 17.67 steps in 15 seconds. CVA subjects = 6.5 steps in 15 seconds. Isles et al Adjusted Mean (no.of steps) Adjusted Mean (no.of steps) Age Right Left 20.72 20.61 20-29 20.17 19.87 30-39 18.77 18.61 40-49 17.13 17.14 50-59 15.59 15.87 60-69 13.73 14.10 70-79 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, NitzJC (2004) Normal values of balance tests in women aged 20 to 80. Journal of the American Geriatrics Society 52 (8): 1367-1372 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 125

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 subje ct's response is rated according to the following scale: Scoring 0 Staying upright without taking a step. 1 Staying upright with one step backwards required for stability. 2 Two or more steps backwards required for stability but able to maintain upright. 3 Several steps backwards but unable to steady self thus requiring the tester to steady the subject. 4 Falling backwards without attempting to step. Normative Data Response recorded as: 0-2 = normal; 3-4 = abnormal. Reference Pastor et al (1993). Vestibula r induced postural responses in Parkinson's Disease. Brain 116: 11-17. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 126

2. 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, 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 at a comfortable and s afe pace 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. Normative Data Lower Limit (sec) Upper Limit (sec) Average (sec) Age Group 6.18 7.92 7.05 21-30 6.03 8.21 7.12 31-40 6.76 8.46 7.61 41-50 7.20 8.63 7.92 51-60 7.72 9.67 8.70 61-70 8.17 9.70 8.93 71-80 Fallers = 20-30 seconds TUG Manual & TUG Cognitive variants of this test have been developed to test the effect of dual tasks. Reference Podsiadlo and Richardson (1991). Journal of the American Geriatrics Society 39:142-148. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 127

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 the walkway to indicate start and finish of measurement area. Method § The subject stands at one end of the walkway. The subject’s 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) = 600/time (secs) = 10/(number of steps/2) § Cadence(steps/minute) = velocity (metres/minute)/step length(m) 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 age & gender 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 128

3. COMMUNITY AMBULATION MEASURES Dynamic Gait Index Eight Gait Items are scored (Shumway-Cook & Woollacott, 2001; Shumway-Cook et al, 1997) using a 6-metre walkway (width 25cm). The walking tasks include walking at a comfortable speed; walking with a change in gait speed (faster / slower on instruction); walking with horizontal head turns; walking with vertical head turns; walking with a pivot turn & maintain ing balance on stopping; walking and stepping over an obstacle; walking and stepping around obstacles; and management of stairs. The test has good inter-rater and test re-test reliability and can be used to predict falls among the elderly (Shumway-Cooke et al, 1997). Scores for healthy aged: 21 +\\- 3 Scores for aged fallers: 11 +\\- 4 Patla and Shumway-Cook (1999) give emphasis to the importance of tools being applied in less predictable community environs and conditions. In the absence of adverse conditions, it is recommended that the examiner interpret the performance of community ambulant clients with caution as the performance in ideal conditions may under-estimate the ability of community ambulant clients. Patla and Shumway-Cook (1999) have identified 8 dimensions to monitor for efficient community ambulation. No formal scale published to date. • The minimum walking distances required by the person in their environment • The effect of postural transitions • The time constraints that the individual needs to meet (eg traffic lights) • The effect of lighting on mobility • The effect of terrain on mobility eg slopes • The capacity to manage external load eg carrying parcels • The effect of dual / multi-tasks (attentional demands) • The effect of traffic References Patla AE, Shumway-Cook A (1999) Dimensions of mobility: defining the complexity and difficulty associated with community mobility. Journal Aging & Physical Activity 7: 7-19 Shumway-Cook A, Woollacott M (2001) Motor Control: Theory and Practical Applications. Chapter 15 – pp 406-407 Williams and Wilkins. Baltimore. USA Shumway-Cook A, Baldwin M, Pollisar N, Gruber W (1997): Predicting the probability of falls in community dwelling older adults. Physic al Therapy 77: 812-819. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 129

4. COMPOSITE MEASUREMENT SCALES FOR MEASUREMENT OF MOTOR TASKS The Modified Elderly Mobility Scale Type of Measure A measure of independence in functional mobility tasks. Equipment required Stopwatch, bed, ten metre walkway, tape measure for functional reach. 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 Life-span lectures (3130). Instructions Lying to Sitting Please sit up with your legs over the edge of the bed. Sitting to Lying Please lie down. Sit to Stand Please stand up. Standing Please stand as long as you can. Please reach out to touch my hand. (The tester encourages the subject to Gait reach outside the base of support. Support infers the help of one tester) Steps Tester observes normal walking method. Please go up and down the stairs safely. 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 130

Date Date Date: Modified Elderly Mobility Scale Score Sheet 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 Functiona l 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 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 131

Motor Assessment Scale A useful measure of motor function for the physiotherapist with tasks that are frequently the focus of rehabilitation after stroke being monitored. It includes measures for 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 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 stroke rehabilitation units in SE Queensland use this tool. Limitation: The tool does not monitor wheelchair skill and transfers which limits the use of the tool with clients who are unable to walk e.g. complete spinal cord injury clients; some TBI & Stroke clients. Reference: 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 132

GUIDELINES FOR USING THE MOTOR ASSESSMENT SCALE 1. The test should preferably be carried out in a quiet private room or in a curtained off area. 2. The test should be carried out when the patient is maximally alert. For example, not when he is under the influence of hypnotic or sedative drugs. Record should be made if the patient is under the influence of one of these drugs. 3. Patients should be dressed in suitable street clothes with sleeves rolled up and without shoes and socks. Items 1-3 inclusive may be scored if necessary with patient in his night clothes. 4. All items are to be assessed and recorded on a scale of 0-6. 5. All items are to be performed independently by the patient unless otherwise stated. \"Stand by\" help means that the therapist stands by and may steady the patient but must not actively assist. 6. Items 1-8 are recorded according to the patient's response to specific instructions. 7. Patient should be scored on his best performance. Repeat 3 times unless other specific instructions are stated. 8. Since the scale is designed to score his best performance, the therapist should give general encouragement but should not give specific feedback as to whether correct or incorrect. Sensitivity to the patient is necessary to enable him to produce his best performance. 9. Instructions should be repeated and demonstrations given to the patient if necessary. 10. The order of administration of items 1-9 can be varied according to convenience. 11. If the patient becomes emotionally labile at any stage during scoring, the therapist should wait 15 seconds before attempting the following procedures: (a) ask the patient to close his mouth and take a deep breath, (b) hold jaw closed and ask patient to stop crying. If patient is unable to control behaviour the examiner should cease testing him and score the unscored items at a more suitable time. 12. If performance is scored differently on left and right side, therapist may indicate this with L in one box and R in another box. 13. The patient should be informed when he is being timed. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 133

CRITERIA FOR SCORING USING THE MAS 1. SUPINE TO SIDE LYING ONTO INTACT SIDE 1. Pulls himself into side lying (Patient pulls himself into side lying with intact arm, moves affected leg with intact leg. Starting position must be supine lying, not knees flexed). 2. Moves leg across actively and the lower half of the body follows (Starting position is 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 actively and the rest of 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 forward). 6. Rolls to side in three seconds (Starting position as above. Must not use hands). 2. SUPINE TO SITTING OVER SIDE OF BED 1. Side lying, lifts head sideways but can not 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 by assisting legs over side of bed). 4. Side lying to sitting over side of bed (With 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 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 at the hips, 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). 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 10cm in front of foot). 6. Sits on stools 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). 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 stand 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 sitting with no stand by help 3 times in 10 seconds (Do not allow uneven weight distribution). 5. WALKING 1. Stands on affected leg and steps forward with other leg (Weight-bearing hip must be extended. Therapist may give stand by help). 2. Walks with stand by help from 1 person. 3. Walks 3 metres alone or using any aid but with no stand by help. 4. Walks 5 metres with no aid in 15 seconds. 5. Walks 10 metres with no aid, turns around, picks up a small sand bag from floor, and walks back in 25 seconds (May use either hand). 6. Walks up and down 4 steps with or without an aid but without holding on to the rail 3 times in 35 seconds. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 134

6. UPPER ARM FUNCTION 1. Lying, protract shoulder with arm in elevation (Therapist places arm in position and supports it with elbow in extension). 2. Lying, hold extended arm in elevation for 2 seconds (Physiotherapist should place arm in position and patient must maintain position with some external rotation. Elbow must be held within 200 of full extension). 3. Flexion and extension of elbow to take palm to forehead with arm as in 2 (Therapist may assist supination of forearm). 4. Sitting, hold extended arm in forward flexion at 900 to body for 2 seconds (Therapist should place arm in position and patient must maintain position with some external rotation and elbow extension. Do not allow excess shoulder elevation). 5. Sitting, patient lifts arm to above position and holds it there for 10 seconds, then lowers it (Patient must maintain position with some external rotation. Do not allow pronation). 6. Standing, hand against wall. Maintain arm position while turning body towards wall (Have arm abducted to 900 with palm flat against the wall). 7. HAND MOVEMENTS 1. Sitting, extension of wrist (Therapist should have patient sitting at a table with forearms resting on the table. Therapist places cylindrical object in palm of patient's hand. Patient is asked to lift therapist's hand off the table by extending the wrist. Do not allow elbow flexion). 2. Sitting, radial deviation of wrist (Therapist should place forearm in mid supination/pronation 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). 3. Sitting, elbow to side, pronation and supination (Elbow unsupported at a right angle. Three quarter range is acceptable). 4. Reach forward, pick up a large ball of 14cm diameter with both hands and put it down (Ball should be on table so far in front of patient that he has to extend arms fully to reach it. Shoulders must be protracted, elbows extended, wrist neutral or extended. Palms should be kept in contact with the ball). 5. Pick up a polystyrene cup from table and put it down on table across other side of body (Do not allow alteration in shape of cup). 6. 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 1 finger to the other, or to go backwards). 8. ADVANCED HAND ACTIVITIES 1. Picking up the top of a pen and putting it down again (Patient stretches arm forward, picks up pen top, releases it on table close to body). 2. Picking up 1 jellybean from a cup and placing it in another cup (Teacup contains 8 jelly beans. Both cups must be at arms’ length. Left hand takes jellybean from cup on right and releases it in cup on left). 3. Drawing horizontal lines to stop at a vertical line 10 times in 20 seconds (At least 5 lines must touch and stop at the vertical line). 4. Holding a pencil, making rapid consecutive dots on a sheet of paper (Patient must do at least 2 dots per second for 5 seconds. Patient picks pencil up and positions it without assistance. Patient must hold pen as for writing. Patient must make a dot not a stroke). 5. Taking a desert spoon of liquid to the mouth (Do not allow head to lower towards spoon. Do not allow liquid to spill). 6. Holding a comb and combing hair at back of head. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 135

Clinical Outcome Variable Scale (COVS): Seaby & Torrance, 1989 The COVS (Clinical Outcome Variable Scale) provides a measure of functional motor ability and is often selected by physiotherapists when the type of patient undertaking rehabilitation includes a stage or permanent use of a wheelchair to ambulate (Spinal cord injuries / Amputees / some TBI / Stroke clients). It provides a comprehensive monitor of motor tasks and can be used to set targets, monitor progress, measure outcomes etc. Currently being used as part of outcome studies at PAH in the Brain Injury & Spinal Injury Units. (Low Choy et al, 2002). 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 – more regularly if required - 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. Limitation: A ceiling effect does occur with high level patients scoring full points even at admission to rehabilitation. 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. An outline of the scoring system is included in this resource – see reference for detailed instructions and guidelines for its use (Seaby & Torrance, 1989). Reference: Seaby L and Torrance G, 1989: Reliability of a Physiotherapy Functional Assessment in a Rehabilitation Setting. Physio Canada. 41 (5): 264-271 Low Choy N, Richards M, Kuys S, Isles R (2002) Measurement of functional outcome following Traumatic Brain Injury using the Clinical Outcome Variable Scale: a reliability study. Australian Journal of Physiotherapy 48: 35-39. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 136

COVS Items and Scores / 91 Item 5: Performance of Ambulation 1. No functional ambulation Item 1a: Roll to right 2. One person continuous assistance 1. Dependent - 2 assistants required 3. One person intermittent assistance 2. One person assistance, plus device (eg bed rail) 4. Supervision/ verbal cues for safety 3. One person assistance, no device 5. Independent, level surfaces, assistance other surfaces and 4. Rolls unaided/ assistance for comfortable position stairs 5. Independent with device 6. Independent with all surfaces/ stairs without rail 6. Independent, no device, slow/awkward, effort + Efficient Ambulation / normal sped and skill 7. Independent, no effort, coordinated and efficient Item 6: Performance of Ambulation - aids 1. Not walking Item 1b: Roll to left 2. Parallell bars / 2 continuous assist 1. Dependent - 2 assistants required 3. Walker ( Rollator or Hopper) 2. One person assistance, plus device (eg bed rail) 4. Two aids ( eg Crutches , two 4 point sticks) 3. One person assistance, no device 5. One aid except a single stick (eg one 4 point stick) 4. Rolls unaided/ assistance for comfortable position 6. Uses a single stick 5. Independent with device 7 Walks without an aid. 6. Independent, no device, slow/awkward, effort + 7. Independent, no effort, coordinated and efficient Item 7: Performance of Ambulation - Endurance Item 2: Supine lying to sitting over bed edge 1. Not walking 1. Dependent - require two assistants 2. < 10metres 2. One person assistance, plus device(eg bed rail) 3. < 50 metres 3. One person assistance, no device 4. < 100 metres 4. Supervision/ Instructions for safety/ verbal cues 5. < 200 metres 5. Independent with device 6. < 5oo metres 6. Independent, no device, slow/awkward, effort + 7. > 500 metres 7. Independent, no effort, coordinated and efficient Item 3: Sitting Balance Item 8: Performance of Ambulation - Velocity 1. Not able to sit unsupported 1. Not walking / 0m/sec 2 Able to sit unsupported / no displacement 2. < .1m/sec 3. Able to move head/trunk within base of support 3. < .3m/sec 4. Able to lift arm/leg within base support 4. < .5m/sec 5. Able to move outside base of support and return 5. < .7m/sec 6. Tolerates external displacement/ slow reactions 6. < .9m/sec 7. Tolerates external displacement / efficient 7. > .9m/sec Item 4a: Horizontal Transfer 1. Dependent - requires two assistants Item 9: Performance of Wheelchair Mobility 2. One person assistance, plus device (eg sliding board) 1. Dependent 3. One person assistance, no device 2. Able to move chair < 10metres/requires assistance. 4. Supervision/ Instructions /cues /may use device 3. Able to move chair <30 metres / intermittent assistance. 5. Independent with device 4. Supervision only flat surfaces/ Assistance for barriers 6. Independent, no device, slow/awkward, effort + 5. Independent indoors all surfaces 7. Independent, no effort, coordinated and efficient 6. Independent outdoors, except grass /curbs Item 4b: Vertical Transfer (F/C or F/S) 7. Independent outdoors, all conditions/surfaces 1. Dependent - requires two assistants or hoist 2. One person assistance, plus device(eg chair) Item 10a and 10b: Left and Right Arm Function 3. One person assistance, no device 1. Unable to actively move arm 4. Supervision/ Instructions /cues / may use device 2. Able to move actively / no useful movement 5. Independent with/without device, effort+/slow 3. Able to use arm as a stabiliser in weight bearing 6. Independent, no device, slow/awkward, effort + 4. Able to use arm as a stabiliser in function 7. Independent, no effort, coordinated and efficient ( 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) ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 137

The Berg Balance Scale The Berg Balance Scale is a comprehensive balance assessment designed to assess balance in a range of positions, from sitting, through functional movements such as sit to stand, transfers through to standing. A score out of 56 is given. Reference: Berg, K. (1989): Balance and its measure in the elderly: A review. Physio Canada. 41: 240–246 Guidelines: Total Score / 56 Instruction: For each item, circle the lowest category which applies. 1. SITTING TO STANDING (Instruction: Please stand up. Try not to use your hands for support) (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 assistance to stand or stabilize 2. STANDING UNSUPPORTED (Instruction: Stand for two minutes without holding) (4) Able to stand safely 2 minutes (3) Able to stand 2 minutes with supervision (2) Able to stand 30 seconds unsupported (1) Needs several tries to stand 30 seconds unsupported (0) Unable to stand 30 seconds IF SUBJECT ABLE TO STAND FOR 2 MINUTES SAFELY, SCORE FULL MARKS FOR SITTNG UNSUPPORTED. PROCEED TO POSITION CHANGE STANDING TO SITTING 3.SITTING UNSUPPORTED FEET ON FLOOR (Instruction: Sit with arms folded for 2 minutes) (4) Able to sit safely and securely for 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 for 10 seconds 4.STANDING TO SITTING (Instruction: Please sit down) (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. Do one transfer with a seat with armrests and one transfer with a seat without armrests) (4) Able to transfer safely with minor use of hands (3) Able to transfer safely, 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 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 138

6.STANDING UNSUPPORTES WITH EYES CLOSED (Instruction: Close your eyes and stand still for 10 seconds) (4) Able to stand 10 seconds safely (3) Able to stand 10 seconds with supervision (2) Able to stand 3 seconds (1) Unable to keep eyes closed 3 seconds 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) (4) Able to place feet together independently and stand for 1 minute safely (3) Able to place feet together independently and stand for 1 minute with supervision (2) Able to place feet together independently but unable to hold for 30 seconds (1) Needs help to attain position but able to stand 15 seconds feet together (0) Needs help to attain position but unable to hold for 15 seconds 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 the most forward lean position.) (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 FLOOR (Instruction: Pick up the shoe/slipper which is placed in front of your feet.) (4) Able to pick up slipper safely and easily (3) Able to pick up slipper but needs supervision (2) Unable to pick up, but reaches 1 – 2 inches from slipper and keeps balance independently (1) Unable to pick up and needs supervision while trying (0 ) Unable to try/needs assistance to keep from falling 10.TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS (Instruction: Turn to look behind you toward left shoulder. Repeat to the right.) (4) Looks behind from both sides and shifts weight well (3) Looks behind one side only, other side shows less weight shift (2) Turns sideways only but maintains balance (1) Needs supervision while turning (0) Needs assistance to keep from falling 11.TURN 360 DEGREES (Instruction: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.) (4) Able to turn 360 safely in < 4 seconds each side (3) Able to turn 360 safely one side only <4 seconds (2) Able to turn 360 safely and slowly (1) Needs close supervision or verbal cueing (0) Needs assistance while turning 12.PLACING ALTERNATE FOOT ON STOOL (DYNAMIC WEIGHT SHIFT WHILE STANDING UNSUPPORTED) (Instruction: Place each foot alternately on the stool. Continue until each foot has touched the stool four times.) (4) Able to stand independently and safely and complete 8 steps in 20 seconds (3) Able tot stand independently and safely and complete 8 steps > 20 seconds (2) Able to complete 4 steps without aid with supervision ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 139

(1) Able to complete >2 steps needs minimal assistance (0) Needs assistance to keep from falling/unable to try 13. STANDING UNSUPPORTED 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.) (4) Able to place foot tandem independently and hold for 30 seconds (3) Able to place foot ahead of other and hold 30 seconds (2) Able to take small step and hold 30 seconds (1) Needs help to step but can hold 15 seconds (0) Looses balance while stepping or standing 14. STANDING ON ONE LEG (4) Able to lift leg independently and hold > 10 seconds (3) Able to lift leg independently and hold 5 – 10 seconds (2) Able to lift leg independently and hold = or > 3 seconds (1) Tries to lift leg, unable to hold 3 seconds but remains standing independently (0) Unable to try/assistance needed to prevent fall TOTAL SCORE ( ) Maximum = 56 ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 140

5. TOOLS USED BY REHABILITATION TEAM TO MONITOR GENERAL OUTCOMES FROM REHABILITATION 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 occupationaltherapist 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 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. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 141

APPENDIX THREE STRATEGIES FOR ASSISTING LEARNING ASSESSMENT Problem: Difficulty interpreting chart. Strategy: • Reading extra charts. • Review theory, so that the student knows what they need to get out of chart. • Completing and discussing findings in a clinical reasoning sheet. Problem: Poor subjective. Strategy: Review theory as above. Use of clinical reasoning sheet. Practice on family/friend. Do in a time frame. Write out subjective and review with tutor prior to subjective. Problem: Decreased observational skill - therefore can’t assess. Need to work out if it’s a problem of not seeing in the first place. Strategy: • Review theory à what they expect to see in a condition. • Review normal movement à then it is easier to work out what is not normal. • Do assessment with tutor, and tutor points out things missed. • Practice more assessments, and get tutor to check if observations are accurate. • Student observes other clients and tells tutor what they see. • Video analysis à student is videoed assessing a client à take home and analyze. Problem: Decreased accuracy à this is usually based on decreased accuracy. Strategy: It is imperative students are accurate in initial assessment, but particularly in on-going assessment, so that they can modify what they doing, based from what they are seeing. • As for observations. • Student to ask for immediate feedback from tutor on performance. • Get tutor to do assessment à student does it à tutor corrects. Problem: Knowing which assessments to perform and then interpreting the results of assessment. Interpretation is often a problem à have to work out WHY the student is not able to interpret. Strategy: Often based on – -Poor theory of conditions. -Decreased knowledge and understanding of normal movement. -Decreased observation skills à haven’t seen the movement to be corrected to be able to interpret it. So, try the strategies for these problems (i.e. observation/accuracy/knowledge). If they still can’t interpret, you will probably have to do some extra one on one assessments and walk them through it. • Practice assessments with feedback (extra session with tutor). • Use of video analysis. • Extra movement analysis sessions. • Careful review of Carr and Shepherd MRP to learn movement components (or other suitable literature, such as 3rd year notes etc, to review gaps in theory). • Use of clinical reasoning sheet and/or problem solving models in 3rd year manual. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 142

Problem: Unable to conduct an efficient assessment. Strategy: Plan the night before, write out plan with timetable of what to assess and how long the student will spend on each assessment and stick to it. Practice extra assessment. Review theory so know what has to be assessed à what is appropriate. Also do this if problems prioritizing assessment. Problem: Inability to reassess – objective/ongoing analysis. Strategy: Inability to use on-going analysis (ability to change/modify treatment, handling, instruction, feedback) is usually based on poor observation, or poor interpretation, or poor theory, or understanding and setting of goals. Thus, use strategies for each of these problems. Problem: Unable to get an accurate client proble m list from assessment. Strategy: • Usually based on – - Decreased observation/accuracy. - Decreased interpretation. - Poor theory. Thus, first try strategies for these problems, and work out the basis of the problem. TREATMENT PLANNING Problem: Inability to set appropriate goals. Strategy: Need to have an accurate problem list (based on accurate assessment etc à so see if it is based on any of these problems). • Need to do tutorial in independent learning manual on goal setting. • Review goals with tutor. • Practice scenarios (eg. Another client, or a made up client). Problem: Unable to select appropriate plan/treatment ideas/ decreased comprehensiveness. Strategy: Will be based on decreased interpretation and goal setting (which in turn may be based on decreased assessment etc), therefore need to work out if they have an appropriate problem list etc à use the strategies dependent on where the problem originates. You have to work out if the student has an appropriate problem list etc à use strategies dependent on the base of the problem. • Write out client problem list and a treatment idea for each client problem, so that all problems are addressed in each treatment session. • Written daily treatment plans to be reviewed by tutor. Problem: Decreased variety. Strategy: • Write out problem list and list 5 treatment ideas for each client problem. Problem: Poor ability to modify techniques/ inability to progress clients. Strategy: Usually based on poor observation, poor interpretation, and not knowing what they are trying to achieve with a specific idea or overall plan. Thus, use strategies for these problems. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 143

Problem: Time management/inability to effectively overlap clients. Strategy: • Write out treatment plan with time frame (specifically in 10 minute blocks) for each client + problem. • Write out contingency plan – eg if Mrs. X come ½ hour late àwhat would you do etc. • Reprioritize goals and check with tutor. • Write out what client can do alone, and with family while waiting. Problem: Poor discharge planning, ward carry over. Strategy: • May be based on poor interpretation/goal setting à use strategies for these problems. • Write out ward programs and review with tutor. • Write out discharge plan, review and discuss with tutor. TREATMENT APPLICATION Problem: Handling – rough, insensitive, poor hand placement. Strategy: 3. Video analysis. 4. Practice with peers, friends or family. 5. Need to know where they should be placing hands à need to review theory of conditions/normal movement so can anticipate where to place hands. Problem: Execution of techniques (is usually accuracy and handling skill which is the problem). Strategy: • As for handling, and for accuracy in assessment. • Tutor demonstrations. • Immediate feedback on handling. • Practice with other clients, with feedback. • Video analysis. Problem: Execution of feedback/instruction. Strategy: May be based on not knowing what they want to achieve in the execution of the exercise à need to work out if they know what they are trying to achieve. Often students whose native language is not English will say they don’t have the English skills to change the instructions when they need to. If this is the case, it helps to write out a few phrases for the one instruction. Usually, however, it is based on the fact that the student does not know exactly what they are trying to achieve. • Write out alternative instructions. • Think of other ways of giving feedback à non-verbal, handling. • Video. • Immediate feedback from tutor. • Practice on other students/clients. Problem: Modification of techniques/evaluate effectiveness of intervention. Strategy: This is based on effective use of on-going analysis in assessment. If the student hasn’t got this, they can’t evaluate what is going on, so they can’t modify it or workout if the treatment is effective. Thus, you have to work out if they cannot use on-going analysis because of poor observations skills, +/- difficulty interpreting. • Immediate feedback with tutor. • Demonstration with tutor, then student tries it + feedback. • Student should do the following exercise, which is time consuming but very helpful. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 144

Exercise What trying to achieve What client may do to How student will correct it compensate Eccentric Even WB, activation of Verbal input to increase loading Quads quads, alignment etc. Lateral trunk flexion, on affected leg, change BOS if with uneven WB on affected still asymmetrical à as will lunge leg etc. make it easier to WB etc. An exercise similar to this is also very useful for interpretation and observation. Instead of what trying to achieve, put in observation, next column interpretation etc. ©Division of Physiotherapy, The University of Queensland – Rehabilitation ILP 2006 Page 145