LAPORAN STATUS KLINIK Universitas 'Aisyiyah Yogyakarta Fakultas Ilmu Kesehatan Program Studi Profesi Fisioterapi =========================================================== Tanggal Pembuatan Laporan : Kondisi / kasus : I. KETERANGAN UMUM PENDERITA Nama : Umur : Jenis Kelamin : A g am a : Pekerjaan : Alamat : No RM : Tempat perawatan : II. DATA-DATA MEDIS RUMAH SAKIT A. Diagnosa Medis Tgl B. Catatan Klinis : : : C. TERAPI UMUM (GENERAL TREATMENT ) : Medika mentosa : D. RUJUKAN FISIOTERAPI DARI DOKTER : III. SEGI FISIOTERAPI TANGGAL : 02 Februari 2011 A. ANAMNESIS ( AUTO / HETERO *)) 1. KELUHAN UTAMA : 2. RIWAYAT PENYAKIT SEKARANG : 3. RIWAYAT PENYAKIT DAHULU : 4. RIWAYAT PENYAKIT PENYERTA : 5. RIWAYAT KELUARGA : 6. RIWAYAT PRIBADI DAN STATUS SOSIAL a) kepala dan leher : b) kardiovaskuler : c) respirasi ( tdk ada batas normal ) : d) gastrointestinalis : e) urogenitalis : f) muskuloskeletal : g) nervorum : B. PEMERIKSAAN 1. PEMERIKSAAN FISIK 1.1. TANDA-TANDA VITAL a) Tekanan darah : 140/ 90 mmHg. b) Denyut Nadi : 80 kali/ menit. c) Pernapasan : 26 kali/ menit. d) Temperatur : 370 C. e) Tinggi Badan : 165 cm. f) Berat Badan : 55 kg. 1.2. INSPEKSI : a) Statis : b) Dinamis : 1.3. PALPASI : 1.4. PERKUSI : 1.5. AUSKULTASI : 1.6. GERAKAN DASAR : a) Gerak Aktif : b) Gerak Pasif : c) Gerak Isometrik Melawan Tahanan : 1.7. KOGNITIF, INTRA PERSONAL & INTER PERSONAL : Kognitif : Intra Personal : Inter Personal : 1.8. KEMAMPUAN FUNGSIONAL & LINGKUNGAN AKTIVITAS : a) Kemampuan Fungsional Dasar : b) Aktivitas Fungsional : . c) Lingkungan Aktivitas : . 1.9. 1) PEMERIKSAAN SPESIFIK ( FT A / FT B / FT C /FT D / FT E ) Tes ballottement Tes ini untuk melihat apakah ada cairan di dalam lutut. Pada pemeriksaan posisi tungkai full ekstensi. Prosedurnya, recessus suprapatellaris di kosongkan dengan menekannya satu tangan, dan sementara itu dengan jari tangan lainnya patella ditekan ke bawah. Dalam keadaan normal patella itu tidak dapat ditekan ke bawah: dia sudah terletak di atas kedua condyli dari femur. Bila ada (banyak) cairan di dalam lutut, maka patella sepertinya terangkat, yang memungkinkan adanya sedikit gerakan. Kadang- kadang terasa seolah olah patella mengetik pada dasar yang keras itu. Pada pemeriksaan ini hasilnya positif. 2) Tes laci sorong Tes laci sorong ada dua macam yaitu tes laci sorong ke depan dan tes laci sorong ke belakang, dimana tes ini dapat dikombinasi dengan berbagai posisi kaki baik posisi eksorotasi maupun endorotasi. Tes laci sorong ke depan, posisi kaki eksorotasi ditujukan untuk ligamen cruciatum anterior dan capsul posteromedial dan dengan posisi kaki endorotasi ditujukan untuk ligamen cruciatum anterior dan capsul posterolateral. Untuk posisi kaki sedikit eksorotasi dan endorotasi ditujukan untuk ligamen cruciatum anterior. Tes laci sorong ke belakang posisi kaki eksorotasi ditujukan untuk ligamen cruciatum posterior dan capsul posterolateral dan dengan posisi kaki endorotasi ditujukan untuk ligamen cruciatum posterior dan capsul posteromedial. Untuk posisi kaki sedikit eksorotasi dan endorotasi ditujukan untuk ligamen cruciatum posterior. Cara pemeriksaannya adalah pasien berbaring terlentang dengan satu tungkai lurus dan satu tungkai yang dites dalam keadaan fleksi lutut, dimana telapak kaki masih menapak pada bidang. Kedua tangan terapis memfiksasi pada bagian distal sendi lutut kemudian memberikan tarikan dan dorongan. Hasil yang didapatkan dari pemeriksaan adalah negatif. 3) Hipermobilitas varus. Tes ini ditujukan untuk mengetahui stabilitas dari sendi lutut oleh ligamen collateral lateral. Pada pemeriksaan ini dapat dilakukan dengan cara full ekstensi dan fleksi 300. Cara pemeriksaannya adalah pasien berbaring terlentang dengan salah satu tungkai yang hendak diperiksa berada di luar bed, salah satu tangan terapis berada di sisi medial sendi lutut dan tangan yang lain berada di sisi luar sendi pergelangan kaki untuk memberikan tekanan ke arah dalam. Hasil yang diperoleh adalah positif. 4) Hipermobilitas valgus. Tes ini ditujukan untuk mengetahui lesi ligamen collateral medial. Cara pemeriksaannya sama dengan tes hipermobilitas varus hanya saja posisi salah satu tangan terapis berada di sisi lateral sendi lutut dan tangan yang lain berada di sisi dalam sendi pergelangan kaki yang berfungsi untuk memberikan tekanan ke arah luar. Hasil yang diperoleh adalah negatif. PEMERIKSAAN KEKUATAN OTOT SENDI LUTUT DENGAN MMT Otot Penggerak Kanan Kiri Fleksor Ekstensor PEMERIKSAAN LGS SENDI LUTUT DENGAN GONEOMETER Data Kanan Kiri LGS lutut aktif LGS lutut pasif PEMERIKSAAN PANJANG TUNGKAI DENGAN PITA UKUR Patokan dari sias sampai maleolus medialis Selisih panjang tungkai 2 cm Tungkai kanan Tungkai kiri PEMERIKSAAN NYERI SENDI LUTUT DENGAN VERBAL DESCRIPTIFE SCALE Nyeri Nyeri diam Nyeri gerak Nilai Keterangan Nyeri tekan PEMERIKSAAN AKTIVITAS FUNGSIONAL DENGAN SKALA JETTE Kriteria Nyeri Berdiri dari posisi duduk Berjalan 15 meter Naik tangga 3 trap 2.0. DIAGNOSA FISIOTERAPI Impairment Fungtional Limitations Disability C. PROGRAM / RENCANA FISIOTERAPI 1. TUJUAN a. Jangka Pendek b. Jangka Panjang 2. TINDAKAN FISIOTERAPI : Kesulitan Ketergantungan a. 1) Teknologi Fisioterapi : Teknologi Alternatif : Teknologi yang Terpilih : a) IR Dengan adanya vasodilatasi pembuluh darah maka sirkulasi darah menjadi lancar, sehingga pemberian nutrisi dan oksigen kepada jaringan akan meningkat, dengan demikian kadar sel darah putih dan antibodi didalam jaringan tersebut juga meningkat. Sehingga pemeliharaan jaringan menjadi lebih baik dan perlawanan terhadap agen penyebab proses radang juga semakin baik dan nyeri menjadi berkurang. b) US 2) Tujuan US adalah menimbulkan efek micromassage karena gerakan dari tranduser, mengurangi nyeri dan merileksasikan otot. c) TERAPI LATIHAN (1) Free active exercise : Tujuan yang dicapai dari latihan ini adalah relaksasi otot yang mengalami spasme, mempertahankan dan menambah kekuatan otot, melatih koordinasi gerakan dan menimbulkan kepercayaan penderita terhadap kemampuan penderita dalam melaksanakan dan mengontrol suatu gerakan (2) Resisted exercise : Tujuan dari latihan ini adalah untuk meningkatkan LGS. (3) Hold Relax : Tujuan dari latihan ini adalah mencapai rileksasi dari grup antagonis dan mendorong gerakan aktif dari grup agonis. b. E d u k a s i: 3. RENCANA EVALUASI E. 1. 2. 3. 4. PROGNOSIS : Quo Ad Vitam : Baik. Quo Ad Sanam : Ragu-ragu. Quo Ad Fungsionam Quo Ad Cosmetikam : Ragu-ragu. : Ragu-ragu. F. PELAKSANAAN FISIOTERAPI : Hari : 1. Infra Red a. Persiapan alat Perlu dipersiapkan alat beserta kelengkapannya antara lain : lampu, kabel, besarnya watt. Sebelumnya dilakukan pemanasan selama 5 menit terutama untuk lampu non luminous. b. Persiapan pasien Penderita diposisikan senyaman mungkin, jaringan yang akan diterapi dibuat tegak lurus dengan sinar infra red. Bagian tersebut dibersihkan dari keringat dan diinformasikan kepada pasien bahwa panas yang dirasakan adalah rasa hangat. Jadi apabila pasien merasakan panas harap memberitahukan kepada terapis. c. Pengaturan Dosis Lampu diletakkan tegak lurus dengan jarak 45-60 cm dengan waktu 15 menit. 2. Ultrasonic a. Persiapan alat Meliputi cek kabel apakah ada kabel yang dalam keadaan terbuka. Apabila kabel dalam keadaan terbuka dikhawatirkan akan terjadi burn pada kulit. Kemudian sambungkan kabel dengan aliran listrik. Hidupkan alat, lakukan cek alat, caranya continuos, kemudian naikkan intensitas. Apabila air pada tranduser mendidih ini menandakan US dalam keadaan baik dan siap untuk dipakai dan siapkan media penghantar berupa gel. b. Persiapan pasien Posisi pasien diatur senyaman mungkin, yaitu pasien diposisikan tidur terlentang di atas bed, area yang akan diterapi atau lutut kanan bebas dari pakaian dan dilakukan tes sensibilitas. Terapis harus menjelaskan tentang tujuan terapi dan rasa yang akan dirasakan selama terapi. c. Pelaksanaan terapi Sebelum terapi dimulai tentukan waktu terlebih dahulu dengan cara luas area yang akan diterapi dibagi dengan luas era penampang tranduser (luas area/luas era). Pada kasus ini luas area yang akan diterapi adalah 24 cm, dan luas penampang tranducer 3 cm. Sehingga waktu yang digunakan untuk terapi ini adalah 8 menit. Pelaksanaannya adalah sebagai berikut, area yang diterapi atau lutut kanan diolesi gel kemudian alat dinyalakan dan diatur waktunya selama 8 menit, dengan frekuensi 3MHz, arus continues dan intensitas sebesar 2 w/cm². Transduser digosokkan secara sirkuler pada lutut kanan. Selesai terapi alat dimatikan kemudian lutut kanan pasien serta transduser dibersihkan dari sisa gel. 3. Terapi Latihan Terapi latihan dimulai dari persiapan pasien, posisi sesuai dengan gerakan yang direncanakan, berikan penjelasan tentang program latihan yang akan dilakukan, tujuan dan caranya, bila perlu terapis memberikan contoh dahulu, serta aba-aba harus bisa dipahami pasien. a. Free active movement Posisi pasien : Duduk ongkang-ongkang di tepi bed Posisi terapis : Di samping pasien Pelaksanaan :Pasien disuruh meluruskan lututnya kemudian menekuknya kembali dengan hitungan 1 sampai 8, dengan frekuensi 5 sampai 10 kali pengulangan. b. Hold Relax Posisi Pasien : Tidur tengkurap di bed Posisi terapis : Di samping pasien Pelaksanaan :Satu tangan terapis memfiksasi pergelangan kaki dan satu tangan yang lain memfiksasi di ujung distal femur atau tungkai atas dekat dengan persendian, terapis menginstruksikan kepada pasien untuk menekuk lututnya kea rah pantat danterapis memberi tahanan yang berlawanan dengan gerakan pasien, dan pasien menggerakkan atau menekuk lututnya sampai batas nyeri, kemudian pasien disuruh rileks dan terapis memberi penguluran ke arah fleksi, dengan pengulangan 10 kali. c. Resisted active exercise dengan quadriceps banch Posisi pasien : Duduk bersandar serileks mungkin Posisi terapis Pelaksanaan : Menyesuaikan : Posisikan pasien duduk dengan tepat dan nyaman dalam quadriceps banch kemudian atur beban dan letakkan beban pada ankle. Kemudian lakukan tes sub maksimal 1 RM dan pasiendiminta menggerakkan sendi lututnya (fleksi-ekstensi) apabila pasien sudah merasa lelah dan nyeri padea sendi lutut latihan dapat dihentikan. Dalam tes 1 RM digunakan beban 2 kg dan pasien dapat mengulangi gerakan fleksi-ekstensi sendi lutut sebanyak 10 kali, setelah itu berhenti karena pasien kelelahan. Kemudian RM dihitung dengan menggunakan diagram Holten dengan rumus = a kg x 100% / B%, dimana A adalah berat beban awal perkiraan terapis kepada pasien dan B adalh banyaknya pengulangan yang dapat dilakukan pasien. Perkiraan beban adalah 2 kg dan pasien dapat mengulangi 10 kali pengulangan maka 1 RM adalah : 1 RM = 2 kg x 100% / 80% = 2,5 kg Intensitas = 30-60% dari 1RM = 50% x 2,5 kg = 1,25kg Repetisi = >20 kali Istirahat = 0-30 detik Seri = 1-3 kali G. E V A L U A S I a. hasil evaluasi nyeri dengan VDS Nyeri T1 T2 T3 T4 T5 T6 Nyeri diam Nyeri gerak Nyeri tekan b. hasil evaluasi kekuatan otot dengan MMT Otot Penggerak T1 T2 T3 T4 T5 Fleksor Ekstensor c. hasil evaluasi LGS dengan goneometer Terapi 1 2 3 4 LGS Aktif LGS Pasif T6 5 6 d. hasil evaluasi aktivitas fungsional dengan skala jette No 1 2 3 Kriteria Berdiri dari posisi duduk Nyeri Kesulitan Ketergantungan Berjalan 15 meter Nyeri Kesulitan Ketergantungan Naik tangga 3 trap Nyeri Kesulitan Ketergantungan H. HASIL TERAPI TERAKHIR : T1 T2 T3 T4 T5 T6 SPES/SCOPA A. Evaluasi motorik Pemeriksaan klinis 1. Tremor istirahat menilai setiap lengan secara terpisah selama 20 detik; tangan bertumpu pada paha; Jika tremor tidak terlihat saat istirahat, usahakan pasien tetap memperhatikan, mis. dengan menyuruhnya menghitung mundur dengan mata tertutup 0 = tidak ada 1 = amplitudo kecil (<1 cm) terjadi secara spontan, atau diperoleh hanya dengan menjaga perhatian pasien (amplitudo apa saja) 2 = amplitudo sedang (12. Tremor postural periksa dengan tangan terentang, pronasi dan semipronasi, dan dengan jari telunjuk kedua tangan hampir menyentuh satu sama lain (siku tertekuk); menilai setiap posisi selama 20 detik 0 = absen 1 = amplitudo kecil (< 1cm) 2 = amplitudo sedang (13. Gerakan tangan yang cepat dan bergantian gerakan cepat bergantian pronasi/supinasi tangan bagian atas, setiap kali menepuk telapak tangan bagian bawah yang dipegang secara horizontal selama 20 detik; masing-masing tangan secara terpisah 0 = biasa 1 = eksekusi lambat, atau perlambatan ringan dan/atau pengurangan amplitudo; mungkin sesekali berhenti 2 = perlambatan sedang dan/atau pengurangan amplitudo atau keragu-raguan dalam memulai gerakan atau sering penangkapan dalam gerakan yang sedang berlangsung 3 = hampir tidak dapat melakukan tugas. 4. Kekakuan menilai gerakan pasif siku dan pergelangan tangan dalam jangkauan penuh, dengan pasien rileks dalam posisi duduk; mengabaikan roda gigi; periksa setiap lengan secara terpisah 0 = absen 1 = kekakuan ringan pada rentang penuh, tidak ada kesulitan mencapai posisi akhir 2 = kekakuan sedang, beberapa kesulitan mencapai posisi akhir 3 = kekakuan yang parah, kesulitan yang cukup besar untuk mencapai posisi akhir. 5. Bangkit dari kursi pasien diinstruksikan untuk melipat tangan di dada; gunakan kursi belakang lurus 0 = biasa 1 = perlahan; tidak perlu senjata untuk bangkit 2 = membutuhkan lengan untuk bangun (bisa bangun tanpa bantuan) 3 = tidak dapat berdiri (tanpa bantuan). 6. Ketidakstabilan postural berdiri di belakang pasien dan tarik pasien ke belakang, sementara pasien berdiri tegak dengan mata terbuka dan kaki agak terbuka; pasien tidak siap 0 = normal, mungkin memerlukan hingga 2 langkah untuk pulih 1 = membutuhkan 3 langkah atau lebih; pulih tanpa bantuan 2 = akan jatuh jika tidak ditangkap 3 = kecenderungan spontan untuk jatuh atau tidak mampu berdiri tanpa bantuan. 7. Gaya berjalan menilai pola kiprah; gunakan alat bantu jalan atau tawarkan bantuan, jika perlu 0 = biasa 1 = perlambatan ringan dan/atau pengurangan tinggi atau panjang langkah; tidak mengocok 2 = pelambatan parah, atau mengocok atau memiliki festination 3 = tidak bisa berjalan. 8. Pidato 0 = biasa 1 = sedikit kehilangan ekspresi, diksi dan/atau volume 2 = tidak jelas; tidak selalu dapat dimengerti 3 = selalu atau hampir selalu tidak dapat dipahami. Informasi sejarah 9. Pembekuan selama 'on' Pembekuan ditandai dengan ragu-ragu ketika mencoba untuk mulai berjalan atau 'menempel' ke tanah sambil berjalan. 0 = absen 1 = mulai ragu-ragu saja, kadang-kadang hadir 2 = sering ada, mungkin membeku saat berjalan 3 = sangat membeku saat berjalan. 10. Menelan 0 = biasa 1 = beberapa kesulitan atau lambat; tidak tersedak; diet normal 2 = kadang tersedak; mungkin membutuhkan makanan lunak 3 = sering tersedak; mungkin memerlukan makanan lunak atau metode alternatif asupan makanan. B. Aktivitas Kehidupan Sehari-hari 11. Pidato 0 = biasa 1 = beberapa kesulitan; kadang-kadang diminta untuk mengulang kalimat 2 = kesulitan yang cukup besar; sering diminta untuk mengulang kalimat 3 = hampir selalu tidak dapat dipahami. 12. Memberi makan (memotong, mengisi cangkir, dll.) 0 = biasa 1 = beberapa kesulitan atau lambat; tidak membutuhkan bantuan 2 = kesulitan yang cukup besar; mungkin membutuhkan bantuan 3 = membutuhkan bantuan hampir lengkap atau lengkap. 13. Berpakaian 0 = biasa 1 = beberapa kesulitan atau lambat; tidak membutuhkan bantuan 2 = kesulitan yang cukup besar; mungkin memerlukan bantuan (misalnya mengancingkan, memasukkan lengan ke dalam lengan baju) 3 = membutuhkan bantuan yang hampir lengkap atau lengkap. 14. Kebersihan (mencuci, menyisir rambut, mencukur, menggosok gigi, menggunakan toilet) 0 = biasa 1 = beberapa kesulitan atau lambat; tidak membutuhkan bantuan 2 = kesulitan yang cukup besar; mungkin membutuhkan bantuan 3 = membutuhkan bantuan hampir lengkap atau lengkap. 15. Mengubah posisi (berbalik di tempat tidur, bangun dari tempat tidur, bangun dari kursi, berbalik ketika berdiri) 0 = biasa 1 = beberapa kesulitan atau lambat; tidak memerlukan bantuan dengan perubahan posisi apa pun 2 = kesulitan yang cukup besar; mungkin memerlukan bantuan dengan satu atau lebih perubahan posisi 3 = membutuhkan bantuan hampir lengkap atau lengkap dengan satu atau lebih perubahan posisi. 16. Berjalan 0 = biasa 1 = beberapa kesulitan atau lambat; tidak membutuhkan bantuan atau alat bantu jalan 2 = kesulitan yang cukup besar; mungkin memerlukan bantuan atau alat bantu jalan 3 = tidak dapat berjalan, atau berjalan hanya dengan bantuan dan usaha keras. 17. Tulisan Tangan 0 = biasa 1 = beberapa kesulitan (misalnya lambat, huruf kecil); semua kata terbaca 2 = kesulitan yang cukup besar; tidak semua kata terbaca; mungkin perlu menggunakan huruf balok 3 = sebagian besar kata tidak terbaca. C. Komplikasi Motorik 18. Diskinesia (kehadiran) 0 = absen 1 = menyajikan beberapa waktu 2 = menyajikan sebagian besar waktu 3 = menyajikan sebagian besar atau sepanjang waktu. 19. Diskinesia (keparahan) 0 = absen 1 = amplitudo kecil 2 = amplitudo sedang 3 = amplitudo besar 20. Fluktuasi motor (adanya periode 'mati') Berapa proporsi hari bangun yang rata-rata pasien 'tidak aktif'? 0 = tidak ada 1 = kadang-kadang 2 = sebagian besar waktu 3 = sebagian besar atau sepanjang waktu. 21. Fluktuasi motor (keparahan periode 'mati') 0 = absen 1 = fluktuasi dosis akhir yang ringan 2 = fluktuasi dosis akhir sedang; fluktuasi tak terduga dapat terjadi sesekali 3 = fluktuasi akhir dosis yang parah; osilasi on-off yang tidak terduga sering terjadi. Penggunaan kuesioner ini dalam penelitian harus dikomunikasikan ke International Parkinson and Movement Disorder Society (MDS). Tidak ada perubahan yang dapat dilakukan pada kuesioner tanpa izin tertulis dari MDS. Silakan gunakan referensi berikut dalam publikasi: Marinus J, Visser M, Stiggelbout AM, Rabey JM, Martínez-Martín P, Bonuccelli U, Kraus PH, van Hilten JJ. Skala pendek untuk penilaian gangguan motorik dan disabilitas pada penyakit Parkinson: SPES/SCOPA. J Neurol Neurolsurg Psychiatry 2004;75:388-395. Untuk meminta izin atau mendapatkan lisensi, harap kirimkan Formulir Permintaan Izin Skala Penilaian. Untuk informasi lebih lanjut, silakan kirim email ke [email protected]. Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ( ) Time: : [ ]am [ ]pm Person Administering Scale Mengelola item skala stroke dalam urutan yang tercantum. Rekam kinerja di setiap kategori setelah setiap ujian subskala. Jangan kembali dan mengubah skor. Ikuti petunjuk yang disediakan untuk setiap teknik ujian. Skor harus mencerminkan apa yang dilakukan pasien, bukan apa yang menurut klinisi dapat dilakukan oleh pasien. Dokter harus mencatat jawaban saat memberikan ujian dan bekerja dengan cepat. Kecuali jika diindikasikan, pasien tidak boleh dilatih (yaitu, permintaan berulang kepada pasien untuk melakukan upaya khusus). Instructions Scale Definition 1a. Level of Consciousness: Investigator harus memilih respon jika evaluasi penuh dicegah oleh hambatan seperti pipa endotrakeal, hambatan bahasa, trauma/perban orotrakeal. Skor 3 hanya jika pasien tidak melakukan gerakan (selain postur refleksif) sebagai respons terhadap rangsangan berbahaya. 0 = Waspada; sangat responsif. 1 = Tidak waspada; tetapi terangsang oleh rangsangan kecil untuk mematuhi, menjawab, atau merespons. 2 = Tidak waspada; membutuhkan stimulasi berulang untuk hadir, atau diperoleh dan membutuhkan stimulasi yang kuat atau menyakitkan untuk membuat gerakan (tidak stereotip). 3 = Merespon hanya dengan refleks motorik atau efek otonom atau Score sama sekali tidak responsif, lembek, dan fleksi. 1b. LOC Questions: Pasien ditanya bulan dan usianya. Jawabannya harus benar - tidak ada kredit parsial untuk menjadi dekat. Pasien afasia dan stupor yang tidak memahami pertanyaan akan diberi skor 2. Pasien yang tidak dapat berbicara karena intubasi endotrakeal, trauma orotrakeal, disartria berat karena sebab apapun, hambatan bahasa, atau masalah lain yang bukan sekunder dari afasia diberi nilai 1. Hal ini penting bahwa hanya jawaban awal yang dinilai dan pemeriksa tidak "membantu" pasien dengan isyarat verbal atau non-verbal. 0 = Menjawab kedua pertanyaan dengan benar. 1 = Menjawab satu pertanyaan dengan benar. 2 = Tidak menjawab pertanyaan dengan benar. 1c. LOC Commands: Pasien diminta untuk membuka dan menutup mata dan kemudian menggenggam dan melepaskan tangan non-paretic. Gantikan perintah satu langkah lagi jika tangan tidak dapat digunakan. Kredit diberikan jika upaya tegas dilakukan tetapi tidak selesai karena kelemahan. Jika pasien tidak menanggapi perintah, tugas harus ditunjukkan kepadanya (pantomim), dan hasilnya dinilai (yaitu, tidak mengikuti satu atau dua perintah). Pasien dengan trauma, amputasi, atau hambatan fisik lainnya harus diberikan perintah satu langkah yang sesuai. Hanya upaya pertama yang mencetak gol. 0 = Melakukan kedua tugas dengan benar. 1 = Melakukan satu tugas dengan benar. 2 = Tidak melakukan tugas dengan benar.. 2. Best Gaze: Hanya gerakan mata horizontal yang akan diuji. Gerakan mata sukarela atau refleksif (oculocephalic) akan dinilai, tetapi pengujian kalori tidak dilakukan. Jika pasien memiliki deviasi konjugasi mata yang dapat diatasi dengan aktivitas volunter atau refleksif, skornya adalah 1. Jika pasien memiliki paresis saraf perifer terisolasi (CN III, IV atau VI), skor a 1. Tatapan dapat diuji pada semua pasien afasia. Pasien dengan trauma okular, perban, kebutaan yang sudah ada sebelumnya, atau gangguan ketajaman visual atau bidang lain harus diuji dengan gerakan refleksif, dan pilihan dibuat oleh penyidik. Melakukan kontak mata dan kemudian menggerakkan pasien dari sisi ke sisi kadang-kadang akan memperjelas adanya kelumpuhan pandangan parsial. 0 = Biasa. 1 = Kelumpuhan pandangan sebagian; tatapan tidak normal pada satu atau kedua mata, tetapi tidak ada deviasi paksa atau paresis tatapan total. 2 = Deviasi paksa, atau paresis tatapan total tidak diatasi oleh oculocephalic maneuver. Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ( ) 3. Visual: Visual fields (upper and lower quadrants) are tested by confrontation, using finger counting or visual threat, as appropriate. Patients may be encouraged, but if they look at the side of the moving fingers appropriately, this can be scored as normal. If there is unilateral blindness or enucleation, visual fields in the remaining eye are scored. Score 1 only if a clear-cut asymmetry, including quadrantanopia, is found. If patient is blind from any cause, score 3. Double simultaneous stimulation is performed at this point. If there is extinction, patient receives a 1, and the results are used to respond to item 11. 0 = No visual loss. 4. Facial Palsy: Ask – or use pantomime to encourage – the patient to show teeth or raise eyebrows and close eyes. Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. If facial trauma/bandages, orotracheal tube, tape or other physical barriers obscure the face, these should be removed to the extent possible. 0 = Normal symmetrical movements. 5. Motor Arm: The limb is placed in the appropriate position: extend the arms (palms down) 90 degrees (if sitting) or 45 degrees (if supine). Drift is scored if the arm falls before 10 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic arm. Only in the case of amputation or joint fusion at the shoulder, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. 0 = No drift; limb holds 90 (or 45) degrees for full 10 seconds. 1 = Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support. 2 = Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity. 3 = No effort against gravity; limb falls. 4 = No movement. UN = Amputation or joint fusion, explain: 1 = Partial hemianopia. 2 = Complete hemianopia. 3 = Bilateral hemianopia (blind including cortical blindness). 1 = Minor paralysis (flattened nasolabial fold, asymmetry on smiling). 2 = Partial paralysis (total or near-total paralysis of lower face). 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face). 5a. Left Arm 5b. Right Arm 6. Motor Leg: The limb is placed in the appropriate position: hold the leg at 30 degrees (always tested supine). Drift is scored if the leg falls before 5 seconds. The aphasic patient is encouraged using urgency in the voice and pantomime, but not noxious stimulation. Each limb is tested in turn, beginning with the non-paretic leg. Only in the case of amputation or joint fusion at the hip, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. 0 = No drift; leg holds 30-degree position for full 5 seconds. 1 = Drift; leg falls by the end of the 5-second period but does not hit bed. 2 = Some effort against gravity; leg falls to bed by 5 seconds, but has some effort against gravity. 3 = No effort against gravity; leg falls to bed immediately. 4 = No movement. UN = Amputation or joint fusion, explain: 6a. Left Leg 6b. Right Leg Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days [ ] 3 months [ ] Other ( ) 7. Limb Ataxia: This item is aimed at finding evidence of a unilateral cerebellar lesion. Test with eyes open. In case of visual defect, ensure testing is done in intact visual field. The finger-nosefinger and heel-shin tests are performed on both sides, and ataxia is scored only if present out of proportion to weakness. Ataxia is absent in the patient who cannot understand or is paralyzed. Only in the case of amputation or joint fusion, the examiner should record the score as untestable (UN), and clearly write the explanation for this choice. In case of blindness, test by having the patient touch nose from extended arm position. 0 = Absent. 8. Sensory: Sensation or grimace to pinprick when tested, or withdrawal from noxious stimulus in the obtunded or aphasic patient. Only sensory loss attributed to stroke is scored as abnormal and the examiner should test as many body areas (arms [not hands], legs, trunk, face) as needed to accurately check for hemisensory loss. A score of 2, “severe or total sensory loss,” should only be given when a severe or total loss of sensation can be clearly demonstrated. Stuporous and aphasic patients will, therefore, probably score 1 or 0. The patient with brainstem stroke who has bilateral loss of sensation is scored 2. If the patient does not respond and is quadriplegic, score 2. Patients in a coma (item 1a=3) are automatically given a 2 on this item. 0 = Normal; no sensory loss. 1 = Present in one limb. 2 = Present in two limbs. UN = Amputation or joint fusion, explain: 1 = Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched. 2 = Severe to total sensory loss; patient is not aware of being touched in the face, arm, and leg. 9. Best Language: A great deal of information about comprehension will be obtained during the preceding sections of the examination. For this scale item, the patient is asked to describe what is happening in the attached picture, to name the items on the attached naming sheet and to read from the attached list of sentences. Comprehension is judged from responses here, as well as to all of the commands in the preceding general neurological exam. If visual loss interferes with the tests, ask the patient to identify objects placed in the hand, repeat, and produce speech. The intubated patient should be asked to write. The patient in a coma (item 1a=3) will automatically score 3 on this item. The examiner must choose a score for the patient with stupor or limited cooperation, but a score of 3 should be used only if the patient is mute and follows no one-step commands. 0 = No aphasia; normal. 1 = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. Reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible. For example, in conversation about provided materials, examiner can identify picture or naming card content from patient’s response. 2 = Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener. Range of information that can be exchanged is limited; listener carries burden of communication. Examiner cannot identify materials provided from patient response. 3 = Mute, global aphasia; no usable speech or auditory comprehension. 10. Dysarthria: If patient is thought to be normal, 0 = Normal. an adequate sample of speech must be obtained by 1 = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, asking patient to read or repeat words from the can be understood with some difficulty. attached list. If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be 2 = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the rated. Only if the patient is intubated or has other absence of or out of proportion to any physical barriers to producing speech, the dysphasia, or is mute/anarthric. examiner should record the score as untestable UN = Intubated or other physical barrier, (UN), and clearly write an explanation for this explain: choice. Do not tell the patient why he or she is being tested. 11. Extinction and Inattention (formerly Neglect): Informasi yang cukup untuk mengidentifikasi pengabaian dapat diperoleh selama pengujian sebelumnya. Jika pasien memiliki kehilangan penglihatan yang parah yang mencegah stimulasi simultan ganda visual, dan rangsangan kulit normal, skornya normal. Jika pasien memiliki afasia tetapi tampak hadir di kedua sisi, skornya normal. Kehadiran pengabaian spasial visual atau anosagnosia juga dapat dianggap sebagai bukti kelainan. Karena kelainan hanya dinilai jika ada, item tersebut tidak pernah dapat diuji. 0 = Tidak ada kelainan. 1 = Inatensi atau kepunahan visual, taktil, auditori, spasial, atau pribadi terhadap stimulasi simultan bilateral di salah satu modalitas sensorik. 2 = Hemi-kekurangan perhatian yang mendalam atau kepunahan lebih dari satu modalitas; tidak mengenali tangan sendiri atau hanya berorientasi pada satu sisi ruang. Timed Up and Go (TUG) Test Test Time Up and Go (TUG) Deskripsi: Ukuran fungsi yang berkorelasi dengan risiko keseimbangan dan jatuh Peralatan: Stopwatch, Kursi Standar, Jarak terukur 3 meter (10 kaki) Instruksi Pasien: "Perintah saya untuk tes ini adalah 'siap, siap, mulai'. Ketika saya mengatakan pergi, saya ingin Anda berdiri dari kursi. Anda dapat menggunakan lengan kursi untuk berdiri atau duduk. Setelah Anda bangun, Anda dapat mengambil jalan apapun yang Anda suka, tapi saya ingin Anda bergerak CEPAT saat Anda merasa aman dan nyaman sampai Anda melewati potongan pita ini (atau akhir jalur yang ditandai) dengan kedua kaki. Berbalik dan berjalan kembali ke kursi. Saya akan menghentikan jam ketika punggung Anda menyentuh bagian belakang kursi. Anda akan menyelesaikan satu latihan lari dan dua yang dihitung. ” Instruksi Terapis: Mulai pengaturan waktu pada kata "GO" dan hentikan pengaturan waktu ketika subjek duduk kembali dengan benar di kursi dengan punggung bersandar di sandaran kursi. Subjek memakai alas kaki biasa, dapat menggunakan alat bantu berjalan yang biasa mereka gunakan selama ambulasi, tetapi tidak boleh dibantu oleh orang lain. Tidak ada batasan waktu. Mereka mungkin berhenti dan beristirahat (tetapi tidak duduk) jika perlu. Penafsiran: 10 detik = biasa 20 detik = mobilitas yang baik, bisa keluar sendiri, bergerak tanpa bantuan kiprah 30 detik = masalah, tidak bisa keluar sendiri, membutuhkan bantuan gaya berjalan * Skor 14 detik telah terbukti menunjukkan risiko tinggi jatuh Norma Kesesuaian Usia: Timed Up and Go Age in years 60-‐69 70-‐79 80-‐89 90-‐101 Mean in seconds 7.9 +/-‐ 0.9 7.7 +/-‐ 2.3 No device: 11.0 +/-‐ 2.2 With device: 19.9 +/-‐ 6.4 No device: 14.7 +/-‐ 7.9 With device: 19.9 +/-‐ 2.5 MWT) Description: 6 Minute Walk Test ( 6 The 6 Minute Walk Test is a measure of endurance. Equipment: Stopwatch, rolling tape measure, long hallway or loop walkway Patient Instructions: “I am going to measure how far you can walk in 6 minutes. When I say ‘go’, I want you to walk around the hallway (track) for 6 minutes. Keep walking until I say ‘stop’ or until you are too tired to go any further. If you need to rest, you can stop until you feel ready to go again. You may also lean against the wall if necessary, but you should resume walking as soon as you are able. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes, but don’t run or jog. I will let you know at 2 minutes, 4 minutes, and when you have one minute left. You can begin when I say ‘go’.” Therapist Instructions: Time the subject for 6 minutes, then say “stop.” Measure the distance walked. STOP testing based on the following criteria: C/o angina symptoms (chest pain or tightness) 2. Any of the following symptoms Light-‐headedness Marked dyspnea Confusion Unusual fatigue Ataxia, staggering Signs of peripheral circulatory unsteadiness insufficiency Pallor Claudication or other significant pain Cyanosis Facial expressions signifying distress Nausea 3. Abnormal cardiac responses Systolic BP drops > 10 mmHg Systolic BP rises to >250 mmHg Diastolic BP rises to > 120 mmHg Heart rate drops more than 15 beats per minute (given the subject was walking the last minutes of the test versus resting) 1. * Please notify the physician if the test is terminated for any of these reasons Age Matched Norms: 6 Minute Walk test Age in years 60-‐64 65-‐69 70-‐74 Distance in feet Men 1830-‐2205 1680-‐2100 1635-‐2040 Women 1635-‐1980 1500-‐1905 1440-‐1845 75-‐79 80-‐84 85-‐89 90-‐94 1410-‐1920 1335-‐1885 1401-‐1710 915-‐1500 1290-‐1755 1155-‐1620 1020-‐1530 825-‐1320 Thoracic Society (2002). ATS Statement: Guidelines for the Six-‐Minute Walk Test. American Journal of Respiratory Critical Care Medicine, 166, 111-‐117. 2. RIkli, Roberta, and C. Jessie Jones. Senior Fitness Test Manual. Human Kinetics, 2001. Print. 1. American Single Leg Stance Test Description: A measure of the ability to stand on one leg and maintain balance Equipment: Stopwatch Patient Instructions: “I am going to time how long you can stand on one leg for each leg, keeping your hands on your hips. We will randomly pick one leg to start. I will start the clock when your foot lifts off the floor. You may balance using any method that you like as long as you are on one leg and the other leg is unsupported. I will stop the clock either when your foot touches the ground, your hands come off your hip, you more your standing foot or the opposite foot braces against the standing leg.” Therapist Instructions: The test should, ideally, be performed with the patient’s shoes off. Demonstrate the test for the patient. Use a coin to determine randomly which leg they will do first each time. Repeat three times for each leg. Average the scores. Age Matched Norms: Single Limb Stance Age in years 20-‐29 30-‐39 40-‐49 50-‐59 60-‐69 70-‐79 Mean in seconds 30.0 30.0 29.7 +/-‐ 1.3 29.4 +/-‐ 2.9 22.5 +/-‐ 8.6 14.2 +/-‐ 9.3 Timed single leg stance (SLS) has been correlated with amplitude and speed of sway in people without disease (Billek, 1990). The ability to maintain SLS generally decreases with increasing age (Bohannon et al, 1985; Ekdahl et al, 1989). Single leg stance has been shown to improve over the course of 6 months of rehabilitation (Judge et al, 1993) and during multi-‐site FIXCIT trials. Initial foot position affects the ability to stand in single leg stance (Kirby, Price, and Macleod, 1987). Rossiter and Wolf et al (1995) found that older adults in the community could maintain SLS for 10 sec about 89% of the time and nursing home residents for 45% of the time. Stair Climbing Test Description: A measure of ability to ascend and descend a flight of stairs Equipment: Stopwatch, flight of stairs with rail Patient Instructions: “I am going to ask you to stand at the bottom of the stairs so that your first step is up. My commands will be ‘ready, set, go’. Then you are going to walk as QUICKLY as you feel safe and comfortable to the top of the stairs, turn around, and come back down. I will stop the clock when your second foot touches the landing. You may use the rail but I only want you to use one rail (determine which), if you can go without the rail try to do so.” Therapist Instructions: The patient will perform one practice and two real trials. Average the trials. Age Matched Norms: Stair Climbing Test Age Group in years 50-‐59 60-‐69 70-‐79 All subjects (age range 50-‐82) N 24 21 16 63 Mean in seconds 7.92 10.02 10.9 9.53 SD in seconds 1.31 2.39 1.99 2.47 Range in seconds 5.13 9.10 6.82 11.96 RL, Petterson SC, Stevens JE, Snyder-‐Mackler L (2005). Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. The Journal of Rheumatology, 32(8), 1533-‐1539. 1. Mizner RL, Petterson SC, Snyder-‐Mackler L (2005). Quadriceps strength and the time course of functional recovery after total knee arthroplasty. Journal of Orthopaedic & Sports Physical Therapy, 35(7), 424-‐436. 2. Mizner Single Limb Step Test Description: Measure of time to raise and lower the body 20 times from 6” block Equipment: 6” block, stopwatch, knee immobilizer Patient Instructions: “I am going to time how long it takes for you to lower and raise your body on this 6” block. The leg not being tested will be in a knee immobilizer so it cannot help. You will start by placing your foot of the leg being tested in the center of the 6” block. My commands will be ‘ready, set, go’ and then you will step up and down 20 times in a row as quickly as possible. I will keep track of the number of steps during the test. The heel and toe of the leg with the immobilizer must touch the top of the block and the floor to count as one.” Therapist Instructions: Demonstrate the test for the patient. Use a coin to randomly determine which leg they will do first each time. Explain to the patient why they will wear the immobilizer on the limb opposite that being tested. Age Matched Norms: Single Limb Age Group in years Step Test 50-‐59 60-‐69 70-‐79 All Subjects (age range 50-‐82) N Mean in seconds 48 17.49 40 21.26 32 21.12 122 19.98 SD in seconds Range in seconds 2.83 10.32 8.40 41.26 15.19 15.19 6.12 41.26 EQ-5D Health Questionnair placing a tick in one box in each group below, please indicate which statements best describe your own health state today. Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems with washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain / Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety / Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed Best imaginable health state Visual Analogue Scale Please indicate on this scale how good or bad your own health state is today. The best health state you can imagine is marked 100 and the worst health state you can is marked 0. Your own health state today Please draw a line from the box to the point on the scale that indicates how good or bad your health state is today. Worst imaginable health state Now, please write the number you marked on the scale in the box below. YOUR HEALTH TODAY = ELDERLY MOBILITY SCALE SCORE Patient details…………………………………………………………………………. TASK Date Lying to Sitting 2 Independent 1 Needs help of 1 person 0 Needs help of 2+ people Sitting to Lying 2 Independent 1 Needs help of 1 person 0 Needs help of 2+ people Sitting to Standing 3 Independent in under 3 seconds 2 Independent in over 3 seconds 1 Needs help of 1 person 0 Needs help of 2+ people Standing 3 Stands without support and able to reach 2 Stands without support but needs support to reach 1 Stands but needs support 0 Stands only with physical support of another person Gait 3 Independent (+ / - stick) 2 Independent with frame 1 Mobile with walking aid but erratic / unsafe 0 Needs physical help to walk or constant supervision 3 Under 15 seconds 2 16 – 30 seconds 1 Over 30 seconds 0 Unable to cover 6 metres Recorded time in seconds. 4 Over 20 cm. 2 10 - 20 cm. 0 Under 10 cm. Actual reach SCORES Timed Walk (6 metres) Functional Reach Staff Initials / 20 / 20 / 20 Scores under 10 – generally these patients are dependent in mobility manoeuvres; require help with basic ADL, such as transfers, toileting and dressing. Scores between 10 – 13 – generally these patients are borderline in terms of safe mobility and independence in ADL i.e. they require some help with some mobility manoeuvres. Scores over 14 – Generally these patients are able to perform mobility manoeuvres alone and safely and are independent in basic ADL. Feasibility Practicalities Training Equipment Time taken to complete the test Space Acceptability to Older People Comments Minimal as long as the standard protocol is followed. Stop watch/ metre rule/ access to a bed and chair/ usual walking aid Approximately 15 minutes (less depending on level of expertise / proficiency of the operator) Space for bed and chair plus a suitable walking space to allow observation of a 6 metre walk Good for both staff and patient as seen as very functional The following section is based mostly on the clinical experience of practitioners who are experienced in the use of the tool Case Study for Elderly Mobility Scale (EMS) HPC Mr A. is a frail 83-year-old man with infective exacerbation of COPD. He has been admitted to an elderly medical ward for medical intervention and rehabilitation. His coughing has increased his chronic low back pain and he is finding it hard to cope with the pain. PMH COPD 23 years, Osteoarthritis in (L) knee and (R) hip and in hands L.B.P., Angina DH Reviewed as relevant to his medical history. On antibiotics for current admission. SH Retired miner, ex smoker of 30/day, stopped 5 years ago. Widower of 1 year, lives alone in a bungalow. Son visits weekly to help with heavy shopping, laundry and cleaning. Goes out in a car with son. No social service support; previously independently mobile with no aids indoors. Summary of Problems following Initial Assessment Respiratory assessment conducted and Mr A is self-managing his chest and clearing when appropriate. Lower back assessed and determined as a chronic problem from his working days. Now being treated conservatively with heat and advice on slow, regular, gentle range of movement to prevent stiffness, ¯ pain and range of movement (ROM) Advised on postural maintenance at rest, and expectation is that as cough abates, the L.B.P. will ease. Physically Mr A requires help from nurses in all personal and functional tasks due to back pain and SOBOE. He is generally weak, but motivated to improve. Agreed Physiotherapy Goals Mr A agrees that his back will improve as his cough improves. To return home independent of help with no Social Service support, as before. To have his respiratory problems returned to a level, which he can, self-manage independently at home. Choice of O/M - EMS No LBP measure was used as it seemed appropriate to use a more holistic tool. EMS was chosen as it encompasses functional components, which have been identified as a problem for this patient, e.g. in/out of bed, sitting to standing, walk in excess of 6 metres. Initial Score = 3/20 (see table below) ELDERLY MOBILITY SCALE Lying – sitting (Max score = 2) O/A 1 Sitting – lying (Max score = 2) 1 2 Sit – stand (Max score = 3) 1 2 (Max score = 3) 0 2 Stand O/D 2 Gait Timed walk (over 6m) Functional reach TOTAL MAXIMUM SCORE POSSIBLE = 20 (Max score = 3) (Max score = 3) 0 WZ F 0 3 stic k 2 (Max score = 4) 0 0 3 13 Intervention - Over 3 week period in hospital and daily intervention: Initially ROM and strengthening exercises in lying and sitting, progressing to standing leg and trunk exercises. Specific functional task practise with occupational therapy on lying to sitting, sitting to lying and transfers from chair, bed and toiler. Endurance work on walking to increase distance within levels of breathlessness and as strength improved. Advice for LBP and general energy saving tips to carry out tasks whilst synchronising breathing. Re-measurement score = 13/20 FORM Goal Attainment Scaling Goals Goal 1: Time Line ICF-CY Component Level of Attainment Much less -2 than expected Somewhat less -1 than expected Expected level 0 of outcome Somewhat more +1 than expected Much more +2 than expected Comments: Goal 2: Goal 3: Goal Area: ICF-CY Component: Time Line: -2 -1 0 +1 +2 Description of GAS GAS is an individualized, criterion-referenced measure of change [see King, McDougall, Palisano, Gritzan, & Tucker (1999) for a detailed description of GAS] GAS involves defining a set of unique goals for a client, and then specifying a range of outcomes, which reflect concrete activities Kiresuk et al. (1994) strongly encourage the use of scales consisting of five levels of attainment, represented by scores ranging from -2 to +2 GAS 5-Point Rating Scale Score Predicted Attainment -2 Much less than expected outcome -1 Less than expected outcome 0 Expected outcome after intervention +1 Greater than expected outcome +2 Much greater than expected outcome Using GAS for Program Evaluation For program evaluation purposes, users of GAS need to calculate a summary score to reflect the overall goal attainment of clients o The recommended procedure is to convert clients’ outcome scores on all their goals into aggregate T- scores that can be summarized, using a statistical software package like Statistical Package for the Social Sciences (SPSS) [see Cardillo & Smith (1994) for a discussion of T-scores and other summary scores] o Aggregate T-scores facilitate reliability analyses, comparisons across clients and comparisons with standardized measures o Aggregate T-scores for each client can be computed using the formula developed by Kiresuk and Sherman (1968): (10 T = 50 + (1 - r WiXi) Wi2 Wi2) o In this formula, 50 represents the mean, 10 the standard deviation, Wi the weighting for a particular goal [Cardillo & Smith (1994) strongly recommend against weighting goals], Xi the score for each goal, and r the expected overall intercorrelation among outcome scores (the formula assumes a correlation among goals of .30) o This formula may appear time-consuming and difficult touse, but the need for manual computation is rare (if goals are not weighted and the suggested intercorrelation of .30 is used, tables are available that allow the quick and easy conversion of outcome scores into T-scores (see Kiresuk et al., 1994) Appendix C - Goal Attainment Scaling Checklist Name of Participant: Therapy Goal: Expected Outcome (i.e., a score of 0) As a whole, the scale must meet the following criteria: Criteria Criterion Met Criterion Not Met Comments Criterion Not Met Comments Amount of change between levels is clinically important There are approximately equal intervals between levels There is a set time period for goal achievement Scale reflects a single variable of change (or, if not feasible, each level reflects a single variable of change) Each level on the scale must meet the following criteria: Criteria Be written in concrete behavioral terms Specify an observable behavior Be written in the present tense Be achievable or realistically possible Criterion Met Appendix D - Examples of Goals Written in GAS Format Example 1 of GAS Scale for Physical Therapy Therapy Discipline: Physical Therapy Target Area: Movement Functions Sub-category: Control of Voluntary Movement Functions Functional Level: Impairment Time Line: 5 months Goal Attainment Rating Scale: -2 The client is able to lift his head and right arm when attempting to roll from supine to prone over his left side. -1 The client is able to roll half way from supine to prone over his left side (and attain left-side lying). 0 The client is able to roll from supine to prone over his left side. +1 The client is able to roll from supine to prone and half way back to supine over his left side (and attain left-side lying). +2 The client is able to roll from supine to prone and back to supine over his left side. Example 2 of GAS Scale for Physical Therapy Therapy Discipline: Physical Therapy Target Area: Mobility Sub-category: Moving Around Using Equipment Functional Level: Activity Limitation Time Line: 5 months Goal Attainment Rating Scale: -2 The client walks with walker from library to classroom in 6 minutes, with supervision and verbal cueing. -1 The client walks with walker from library to classroom within 4 to 5 minutes, with supervision and verbal cueing. 0 The client walks with walker from library to classroom in 3 minutes or less, with supervision and verbal cueing. +1 The client walks with walker from library to classroom in 3 minutes or less, with supervision and no verbal cueing. +2 The client walks with walker from library to classroom in 3 minutes or less independently (no supervision and no verbal cueing. Note: if client walks a distance that falls between scale levels (e.g., 5.5 minutes), the client will be rated at the lower scale level Example 3 of GAS Scale for Physical Therapy Therapy Discipline: Physical Therapy Target Area: Mobility Sub-category: Moving Around Functional Level: Participation Time Line: 10 months Goal Attainment Rating Scale: -2 The client takes part in gym class for 10 minutes, with standby assistance. -1 The client takes part in gym class for 15 minutes, with standby assistance. 0 The client takes part in gym class for 20 minutes, with standby assistance. +1 The client takes part in gym class for 25 minutes, with standby assistance. +2 The client takes part in gym class for 30 minutes, with standby assistance. Note: if client takes part for a time that falls between scale levels (e.g., 17 minutes), the client will be rated at the lower scale level Example 1 of GAS Scale for Speech-Language Pathology Therapy Discipline: Speech-Language Pathology Target Area: and Speech Function Sub-category: Articulation Functional Level: Impairment Time Line: 5 months Voice Goal Attainment Rating Scale: -2 The client produces “f” with 90% accuracy at the imitated sound level. -1 The client produces “f” in final word position with 90% accuracy at the imitated word level. 0 The client produces “f” in final word position with 90% accuracy at the spontaneous word level. +1 The client produces “f” in final word position with 90% accuracy at the imitated sentence level. +2 The client produces “f” in final word position with 90% accuracy at the spontaneous sentence level. Example 2 of GAS Scale for Speech-Language Pathology Therapy Discipline: Speech-Language Pathology Target Area: Communication Sub-category: Speaking Functional Level: Activity Limitation Time Line: 10 months Goal Attainment Rating Scale: -2 The client reads a short passage aloud, making 10 or more pronunciation errors. -1 The client reads a short passage aloud, making between 9 and 7 pronunciation errors. 0 The client reads a short passage aloud, making between 6 and 4 pronunciation errors. +1 The client reads a short passage aloud, making between 3 and 1 pronunciation errors. +2 The client reads a short passage aloud, pronouncing all words correctly. Example 3 of GAS Scale for Speech-Language Pathology Therapy Discipline: Speech-Language Pathology Target Area: Communication Sub-category: Conversation Functional Level: Participation Restriction Time Line: 10 months Goal Attainment Rating Scale: -2 The client responds to questions from the teacher by shaking or nodding her head throughout the school day. -1 The client verbally responds to 1 question from the teacher throughout the school day. 0 The client verbally responds to 2 questions from the teacher throughout the school day. +1 The client verbally responds to 3 questions from the teacher throughout the school day. +2 The client verbally responds to 4 or more questions from the teacher throughout the school day. Example 1 of GAS Form for Occupational Therapy Therapy Discipline: Occupational Therapy Target Area: Movement Functions Sub-category: Control of Voluntary Movement Functions Functional Level: Impairment Time Line: 3 months Goal Attainment Rating Scale: -2 The client is able to grasp a small object with dominant hand and hold on to it for no more than 5 seconds. -1 The client is able to grasp a small object with dominant hand and hold on to it for 10 seconds. 0 The client is able to grasp a small object with dominant hand and hold on to it for 15 seconds. +1 The client is able to grasp a small object with dominant hand and hold on to it for 20 seconds. +2 The client is able to grasp a small object with dominant hand and hold on to it for 25 seconds or more. Note: if client grasps object for a period of time between scalelevels (e.g., 22 seconds), the client will be rated at the lower scale level Example 2 of GAS Form for Occupational Therapy Therapy Discipline: Occupational Therapy Target Area: Learning and Applying Knowledge Sub-category: Learning to Write Functional Level: Activity Limitation Time Line: 10 months Goal Attainment Rating Scale: -2 The client forms 5 of the 26 cursive letters correctly during one on one supervision. -1 The client forms between 6 to 10 of the 26 cursive letters correctly during one on one supervision. 0 The client forms between 11 and 25 of the 26 cursive letters correctly during one on one supervision. +1 The client forms between 16 and 20 of the 26 cursive letters correctly during one on one supervision. +2 The client forms between 21 and 26 of the 26 cursive letters correctly during one on one supervision. Example 3 of GAS Form for Occupational Therapy Therapy Discipline: Occupational Therapy Target Area: Mobility Sub-category: Hand and Arm Use Functional Level: Participation Time Line: 5 months Goal Attainment Rating Scale: -2 The client plays “catch” with a classmate at recess for less than 1 minute, without dropping the ball. -1 The client plays “catch” with a classmate at recess for more than 1 and up to 2 minutes, without dropping the ball. 0 The client plays “catch” with a classmate at recess for more than 2 and up to 3 minutes, without dropping the ball. +1 The client plays “catch” with a classmate at recess, for more than 3 and up to 4 minutes, without dropping the ball. +2 The client plays “catch” with a classmate at recess for more than 4 and up to 5 minutes, without dropping the ball. Mini-Mental State Examination (MMSE) Patient’s Name: Date: Instructions: Ask the questions in the order listed. Score one point for each correct response within each question or activity. Maximu Patient’s Questions m Score Score 5 “What is the year? Season? Date? Day of the week? Month?” 5 “Where are we now: State? County? Town/city? Hospital? Floor?” 3 5 3 2 1 3 1 1 The examiner names three unrelated objects clearly and slowly, then asks the patient to name all three of them. The patient’s response is used for scoring. The examiner repeats them until patient learns all of them, if possible. Number of trials: “I would like you to count backward from 100 by sevens.” (93, 86, 79, 72, 65, …) Stop after five answers. Alternative: “Spell WORLD backwards.” (D-L-R-O-W) “Earlier I told you the names of three things. Can you tell me what those were?” Show the patient two simple objects, such as a wristwatch and a pencil, and ask the patient to name them. “Repeat the phrase: ‘No ifs, ands, or buts.’” “Take the paper in your right hand, fold it in half, and put it on the floor.” (The examiner gives the patient a piece of blank paper.) “Please read this and do what it says.” (Written instruction is “Close your eyes.”) “Make up and write a sentence about anything.” (This sentence must contain a noun and a verb.) “Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to draw the symbol below. All 10 angles must be present and two must intersect.) 1 30 TOTAL (Adapted from Rovner & Folstein, 1987) Instructions for administration and scoring of the MMSE Orientation (10 points): Ask for the date. Then specifically ask for parts omitted (e.g., "Can you also tell me what season it is?"). One point for each correct answer. Ask in turn, "Can you tell me the name of this hospital (town, county, etc.)?" One point for each correct answer. Registration (3 points): Say the names of three unrelated objects clearly and slowly, allowing approximately one second for each. After you have said all three, ask the patient to repeat them. The number of objects the patient names correctly upon the first repetition determines the score (0-3). If the patient does not repeat all three objects the first time, continue saying the names until the patient is able to repeat all three items, up to six trials. Record the number of trials it takes for the patient to learn the words. If the patient does not eventually learn all three, recall cannot be meaningfully tested. After completing this task, tell the patient, "Try to remember the words, as I will ask for them in a little while." Attention and Calculation (5 points): Ask the patient to begin with 100 and count backward by sevens. Stop after five subtractions (93, 86, 79, 72, 65). Score the total number of correct answers. If the patient cannot or will not perform the subtraction task, ask the patient to spell the word "world" backwards. The score is the number of letters in correct order (e.g., dlrow=5, dlorw=3). Recall (3 points): Ask the patient if he or she can recall the three words you previously asked him or her to remember. Score the total number of correct answers (0-3). Language and Praxis (9 points): Naming: Show the patient a wrist watch and ask the patient what it is. Repeat with a pencil. Score one point for each correct naming (0-2). Repetition: Ask the patient to repeat the sentence after you ("No ifs, ands, or buts."). Allow only one trial. Score 0 or 1. 3-Stage Command: Give the patient a piece of blank paper and say, "Take this paper in your right hand, fold it in half, and put it on the floor." Score one point for each part of the command correctly executed. Reading: On a blank piece of paper print the sentence, "Close your eyes," in letters large enough for the patient to see clearly. Ask the patient to read the sentence and do what it says. Score one point only if the patient actually closes his or her eyes. This is not a test of memory, so you may prompt the patient to "do what it says" after the patient reads the sentence. Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence; it should be written spontaneously. The sentence must contain a subject and a verb and make sense. Correct grammar and punctuation are not necessary. Copying: Show the patient the picture of two intersecting pentagons and ask the patient to copy the figure exactly as it is. All ten angles must be present and two must intersect to score one point. Ignore tremor and rotation. (Folstein, Folstein & McHugh, 1975) Interpretation of the MMSE Method Score Single Cutoff <24 Abnormal <21 Increased odds of dementia >25 21 Decreased odds of dementia Abnormal for 8th grade education <23 Abnormal for high school education <24 Abnormal for college education Range Education Severity Interpretation 24-30 No cognitive impairment 18-23 Mild cognitive impairment 0-17 Severe cognitive impairment Johns Hopkins Fall Risk Assessment Tool If patient has any of the following conditions, check the box and apply Fall Risk interventions as indicated. High Fall Risk - Implement High Fall Risk interventions per protocol History of more than one fall within 6 months before admission Patient has experienced a fall during this hospitalization Patient is deemed high fall-risk per protocol (e.g., seizure precautions) Low Fall Risk - Implement Low Fall Risk interventions per protocol Complete paralysis or completely immobilized Do not continue with Fall Risk Score Calculation if any of the above conditions are checked. FALL RISK SCORE CALCULATION – Select the appropriate option in each category. Points Add all points to calculate Fall Risk Score. (If no option is selected, score for category is 0) Age (single-select) 60 - 69 years (1 point) 70 -79 years (2 points) greater than or equal to 80 years (3 points) Fall History (single-select) One fall within 6 months before admission (5 points) Elimination, Bowel and Urine (single-select) Incontinence (2 points) Urgency or frequency (2 points) Urgency/frequency and incontinence (4 points) Medications: Includes PCA/opiates, anticonvulsants, anti-hypertensives, diuretics, hypnotics, laxatives, sedatives, and psychotropics (single-select) On 1 high fall risk drug (3 points) On 2 or more high fall risk drugs (5 points) Sedated procedure within past 24 hours (7 points) Patient Care Equipment: Any equipment that tethers patient (e.g., IV infusion, chest tube, indwelling catheter, SCDs, etc.) (single-select) One present (1 point) Two present (2 points) 3 or more present (3 points) Mobility (multi-select; choose all that apply and add points together) Requires assistance or supervision for mobility, transfer, or ambulation (2 points) Unsteady gait (2 points) Visual or auditory impairment affecting mobility (2 points) Cognition (multi-select; choose all that apply and add points together) Altered awareness of immediate physical environment (1 point) Impulsive (2 points) Lack of understanding of one's physical and cognitive limitations (4 points) Total Fall Risk Score (Sum of all points per category) SCORING: 6-13 Total Points = Moderate Fall Risk, >13 Total Points = High Fall Risk Copyright ©2007 by The Johns Hopkins Health System Corporation. Patient name: Date : NHI: Test carried out by: Time: AM/PM The30-SecondChairStandTest Overview: The 30 Second Chair Stand Test, in conjunction with other measures such as the 4-Stage Balance Test, Timed Up and Go (TUG) Test and an assessment of postural hypotension can help to indicate if a patient is at risk of falling. Purpose: To test leg strength and endurance: Equipment: A chair with a straight back, without arm rests, placed against a wall to prevent it moving A stopwatch/timer Instructions to the patient: 1. 2. 3. 4. 5. 6. Sit in the middle of the chair. Place each hand on the opposite shoulder crossed at the wrists. Place your feet flat on the floor. Keep your back straight and keep your arms against your chest. On “Go”, rise to a full standing position and then sit back down again. Repeat this for 30 seconds. On “Go” begin timing. Do not continue if you feel the patient may fall during the test. Count the number of times the patient comes to a full standing position in 30 seconds and record it in the box below. If the patient is over halfway to a standing position when 30 seconds have elapsed, count it as a stand. If the patient must use his or her arms to stand then stop the test and record “0” for the number below. Number: (See over page for what this means) A below average number of stands for the patient’sage group indicates a high risk of falls. Notes: Chair stand – Number of stands by age group1 MEN Age group (years) Below Average Averag e Above Average 60 – 64 < 14 14 – 19 >19 65 – 69 < 12 12 – 18 >18 70 – 74 < 12 12 – 17 >17 75 – 79 < 11 11 – 17 >17 80 – 84 < 10 10 – 15 >15 85 – 89 <8 8 – 14 >14 90 – 94 <7 7 – 12 >12 Below Average Averag e Above Average 60 – 64 < 12 12 – 17 >17 65 – 69 < 11 11 – 16 >16 70 – 74 < 10 10 – 15 >15 75 – 79 < 10 10 – 15 >15 80 – 84 <9 9 – 14 >14 85 – 89 <8 8 – 13 >13 90 – 94 <4 4 – 11 >11 WOMEN Age group (years) Appendix. Functional Gait Assessmenta Requirements: A marked 6-m (20-ft) walkway that is marked with a 30.48-cm (12-in) width. 1. GAIT LEVEL SURFACE Instructions: Walk at your normal speed from here to the next mark (6 m [20 ft]). Grading: Mark the highest category that applies. (3) Normal—Walks 6 m (20 ft) in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.Moderate impairment—Performs head turns with moderate change in gait velocity, slows down, deviates 25.4 –38.1 cm (10 –15 in) outside 30.48-cm (12-in) walkway width but recov- ers, can continue to walk. (2) Severe impairment—Performs task with severe disruption of gait (eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway width, loses balance, stops, or reaches for wall).Mild impairment—Walks 6 m (20 ft) in less than 7 seconds but 2. CHANGE IN GAIT SPEED Instructions: Begin walking at your normal pace (for 1.5 m [5 ft]). When I tell you “go,” walk as fast as you can (for 1.5 m [5 ft]). When I tell you “slow,” walk as slowly as you can (for 1.5 m [5 ft]). Grading: Mark the highest category that applies. (3) Normal—Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. Devi- ates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.Instructions: Walk from here to the next mark (6 m [20 ft]). Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, tip your head down, keep walking straight while looking down. Continue alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) Normal—Performs head turns with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairment—Performs task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.24 –25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway width or uses assistive device. (1) Moderate impairment—Performs task with moderate change in gait velocity, slows down, deviates 25.4 –38.1 cm (10 –15 in) outside 30.48-cm (12-in) walkway width but recovers, can continue to walk. (0) Severe impairment—Performs task with severe disruption of gait (eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway width, loses balance, stops, reaches for wall). (2) Mild impairment—Is able to change speed but demonstrates 3. GAIT WITH HORIZONTAL HEAD TURNS Instructions: Walk from here to the next mark 6 m (20 ft) away. Begin walking at your normal pace. Keep walking straight; after 3 steps, turn Instructions: Begin with walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and stop. Grading: Mark the highest category that applies. (2) Normal—Pivot turns safely within 3 seconds and stops quickly with no loss of balance. (2) Mild impairment—Pivot turns safely in >3 seconds and stops with no loss of balance, or pivot turns safely within 3 seconds and stops with mild imbalance, requires small steps to catch balance. (1) Moderate impairment—Turns slowly, requires verbal cueing, or requires several small steps to catch balance following turn and stop. (0) Severe impairment—Cannot turn safely, requires assistance to turn and stop. your head to the right and keep walking straight while looking to the 4. GAIT WITH VERTICAL HEAD TURNS greater than 5.5 seconds, uses assistive device, slower speed, mild gait deviations, or deviates 15.24 –25.4 cm (6 –10 in) outside of the 30.48-cm (12-in) walkway width. (1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnor- mal gait pattern, evidence for imbalance, or deviates 25.4 – 38.1 cm (10 –15 in) outside of the 30.48-cm (12-in) walkway width. Requires more than 7 seconds to ambulate 6 m (20 ft). (0) Severe impairment—Cannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside of the 30.48-cm (12-in) walkway width or reaches and touches the wall. 5. GAIT AND PIVOT TURN mild gait deviations, deviates 15.24 –25.4 cm (6 –10 in) outside of the 30.48-cm (12-in) walkway width, or no gait deviations but unable to achieve a significant change in velocity, or uses an assistive device. (1) Moderate impairment—Makes only minor adjustments to walk- ing speed, or accomplishes a change in speed with significant gait deviations, deviates 25.4 –38.1 cm (10 –15 in) outside the 30.48-cm (12-in) walkway width, or changes speed but loses balance but is able to recover and continue walking. (0) Severe impairment—Cannot change speeds, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width, or loses balance and has to reach for wall or be caught. 6. STEP OVER OBSTACLE right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continue alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) Normal—Performs head turns smoothly with no change in gait. Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairment—Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.24 –25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway width, or uses an assistive device. (3) Instructions: Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking. Grading: Mark the highest category that applies. (4) Normal—Is able to step over 2 stacked shoe boxes taped together (22.86 cm [9 in] total height) without changing gait speed; no evidence of imbalance. (2) Mild impairment—Is able to step over one shoe box (11.43 cm [4.5 in] total height) without changing gait speed; no evidence of imbalance. (1) Moderate impairment—Is able to step over one shoe box (11.43 cm [4.5 in] total height) but must slow down and adjust steps to clear box safely. May require verbal cueing. (0) Severe impairment—Cannot perform without assistance. 7. GAIT WITH NARROW BASE OF SUPPORT Instructions: Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number of steps taken in a straight line are counted for a maximum of 10 steps. Grading: Mark the highest category that applies. (3) Normal—Is able to ambulate for 10 steps heel to toe with no staggering. (2) Mild impairment—Ambulates 7–9 steps. (1) Moderate impairment—Ambulates 4 –7 steps. (0) Severe impairment—Ambulates less than 4 steps heel to toe or cannot perform without assistance. 8. GAIT WITH EYES CLOSED Instructions: Walk at your normal speed from here to the next mark (6 m [20 ft]) with your eyes closed. Grading: Mark the highest category that applies. (3) Normal—Walks 6 m (20 ft), no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 7 seconds. (2) Mild impairment—Walks 6 m (20 ft), uses assistive device, slower speed, mild gait deviations, deviates 15.24 – 25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway width. Ambulates 6 m (20 ft) in less than 9 seconds but greater than 7 seconds. (1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnor- mal gait pattern, evidence for imbalance, deviates 25.4 –38.1 cm (10 –15 in) outside 30.48-cm (12-in) walkway width. Requires more than 9 seconds to ambulate 6 m (20 ft). (0) Severe impairment—Cannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width or will not attempt task. 9. AMBULATING BACKWARDS Instructions: Walk backwards until I tell you to stop. Grading: Mark the highest category that applies. (3) Normal—Walks 6 m (20 ft), no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width. (2) Mild impairment—Walks 6 m (20 ft), uses assistive device, slower speed, mild gait deviations, deviates 15.24 –25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway width. (1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnor- mal gait pattern, evidence for imbalance, deviates 25.4 –38.1 cm (10 –15 in) outside 30.48-cm (12-in) walkway width. (0) Severe impairment—Cannot walk 6 m (20 ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width or will not attempt task. 10. STEPS Instructions: Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down. Grading: Mark the highest category that applies. (3) Normal—Alternating feet, no rail. (2) Mild impairment—Alternating feet, must use rail. (1) Moderate impairment—Two feet to a stair; must use rail. (0) Severe impairment—Cannot do safely. TOTAL SCORE: MAXIMUM SCORE 30 BESTest- Inter-rater Reliability Balance Evaluation – Systems Test Subjects should be tested with flat heeled shoes or shoes and socks off. If subject must use an assistive device for an item, score that item one category lower. If subject requires physical assistance to perform an item score the lowest category (0) for that item. I. BIOMECHANICAL CONSTRAINTS 1. BASE OF SUPPORT SECTION I ______ /15 POINTS (3) Normal: Both feet have normal base of support with no deformities or pain (2) One foot has deformities and/or pain (1) Both feet has deformities OR pain (0) Both feet have deformities AND pain 2. COM ALIGNMENT (3) Normal AP and ML CoM alignment and normal segmental postural alignment (2) Abnormal AP OR ML CoM alignment OR abnormal segmental postural alignment (1) Abnormal AP OR ML CoM alignment AND abnormal segmental postural alignment (0) Abnormal AP AND ML CoM alignment 3. ANKLE STRENGTH & RANGE (3) Normal: Able to stand on toes with maximal height and to stand on heels with front of feet up (2) Impairment in either foot of either ankle flexors or extensors (i.e. less than maximum height) (1) Impairment in two ankle groups (eg; bilateral flexors or both ankle flexors and extensors in 1 foot) (0) Both flexors and extensors in both left and right ankles impaired (i.e. less than maximum height) 4. HIP/TRUNK LATERAL STRENGTH (3) Normal: Abducts both hips to lift the foot off the floor for 10 s while keeping trunk vertical (2) Mild: Abducts both hips to lift the foot off the floor for 10 s but without keeping trunk vertical (1) Moderate: Abducts only one hip off the floor for 10 s with vertical trunk (0) Severe: Cannot abduct either hip to lift a foot off the floor for 10 s with trunk vertical or without vertical 5. SIT ON FLOOR AND STANDUP Time______________secs (3) Normal: Independently sits on the floor and stands up (2) Mild: Uses a chair to sit on floor OR to stand up (1) Moderate: Uses a chair to sit on floor AND to stand up (0) Severe: Cannot sit on floor or stand up, even with a chair, or refuses II. STABILITY LIMITS 6. SITTING VERTICALITY AND LATERAL LEAN Left (3) Lean Right (3) Maximum lean, subject moves upper shoulders beyond body SECTION II ______ /21 POINTS Verticality Left (3) Right (3) Realigns to vertical with very SMALL or no (2) midline, very stable Moderate lean, subject’s upper (2) (2) (1) (1) shoulder approaches body midline or some instability Very little lean, or significant (1) (1) (0) (0) instability No lean or falls (exceeds limits) (0) (0) (2) OVERSHOOT Significantly Over- or undershoots but eventually realigns to vertical Failure to realign to vertical Falls with the eyes closed 7. FUNCTIONAL REACH FORWARD _______________________________ Distance reached: ______ cm OR inches (3) Maximum to limits: >32 cm (12.5 in ) (2) Moderate: 16.5 cm - 32 cm (6.5 – 12.5 in) (1) Poor: < 16.5 cm (6.5 in) (0) No measurable lean – or must be caught 8. FUNCTIONAL REACH LATERAL ______________________________________________ Distance reached: Left _____ cm (_____in) Right _____ cm ( __________________________________ in) Left Righ t (3) (3) Maximum to limit: > 25.5 cm (10 in) (2) (2) Moderate: 10-25.5 cm (4-10 in) (1) (1) Poor: < 10 cm (4 in) (0) (0) No measurable lean, or must be caught III. TRANSITIONS- ANTICIPATORY POSTURAL ADJUSTMENT _______ SECTION III /18 POINTS 9. SIT TO STAND (3) Normal: Comes to stand without the use of hands and stabilizes independently (2) Comes to stand on the first attempt with the use of hands (1) Comes to stand after several attempts or requires minimal assist to stand or stabilize or requires touch of back of leg or chair (0) Requires moderate or maximal assist to stand 10. RISE TO TOES (3) Normal: Stable for 3 sec with good height (2) Heels up, but not full range (smaller than when holding hands so no balance requirement) -OR- slight instability & holds for 3 sec (1) Holds for less than 3 sec (0) Unable 11. STAND ON ONE LEG Left Time in Sec: __________ (3) Normal: Stable for > 20 s (2) Trunk motion, OR 10-20 s (1) Stands 2-10 s (0) Unable Right Time in Sec: ___________ (3) Normal: Stable for > 20s (2) Trunk motion, OR 10-20 s (1) Stands 2-10s (0) Unable 12. ALTERNATE STAIR TOUCHING # of successful steps: ________ Time in seconds: _________ (3) Normal: Stands independently and safely and completes 8 steps in < 10 seconds (2) Completes 8 steps (10-20 seconds) AND/OR show instability such as inconsistent foot placement, excessive trunk motion, hesitation or arhythmical (1) Completes < 8 steps – without minimal assistance (i.e. assistive device) OR > 20 sec for 8 steps (0) Completes < 8 steps, even with assistive devise 13. STANDING ARM RAISE (3) Normal: Remains stable (2) Visible sway (1) Steps to regain equilibrium/unable to move quickly w/o losing balance (0) Unable, or needs assistance for stability IV. REACTIVE POSTURAL RESPONSE 14. IN PLACE RESPONSE- FORWARD SECTION IV _____ /18 POINTS (3) Recovers stability with ankles, no added arms or hips motion (2) Recovers stability with arm or hip motion (1) Takes a step to recover stability (0) Would fall if not caught OR requires assist OR will not attempt 15. IN PLACE RESPONSE- BACKWARD (3) Recovers stability at ankles, no added arm / hip motion (2) Recovers stability with some arm or hip motion (1) Takes a step to recover stability (0) Would fall if not caught -OR- requires assistance -OR- will not attempt 16. COMPENSATORY STEPPING CORRECTION- FORWARD (3) Recovers independently a single, large step (second realignment step is allowed) (2) More than one step used to recover equilibrium, but recovers stability independently OR 1 step with imbalance (1) Takes multiple steps to recover equilibrium, or needs minimum assistance to prevent a fall (0) No step, OR would fall if not caught, OR falls spontaneously 17. COMPENSATORY STEPPING CORRECTION- BACKWARD (3) (2) (1) (0) Recovers independently a single, large step More than one step used, but stable and recovers independently OR 1 step with imbalance Takes several steps to recover equilibrium, or needs minimum assistance No step, OR would fall if not caught, OR falls spontaneously 18. COMPENSATORY STEPPING CORRECTION- LATERAL Left (3) Recovers independently with 1 step of normal length/width (crossover or lateral OK) (2) Several steps used, but recovers independently (1) Steps, but needs to be assisted to prevent a fall (0) Falls, or cannot step Right (3) Recovers independently with 1 step of normal length/width (crossover or lateral OK) (2) Several steps used, but recovers independently (1) Steps, but needs to be assisted to prevent a fall (0) Falls, or cannot step V. SENSORY ORIENTATION SECTION V _____ /15 POINTS 19. SENSORY INTEGRATION FOR BALANCE (MODIFIED CTSIB) A -EYES OPEN, FIRM SURFACE Trial 1 _____sec Trial 2 _____sec (3) 30s stable (2) 30s unstable (1) < 30s (0) Unable B -EYES CLOSED, FIRM SURFACE Trial 1 _____ sec Trial 2 ____ sec (3) 30s stable (2) 30s unstable (1) < 30s (0) Unable C -EYES OPEN, FOAM SURFACE Trial 1 ______ sec Trial 2 _____ sec (3) 30s stable (2) 30s unstable (1) < 30s (0) Unable D -EYES CLOSED, FOAM SURFACE Trial 1 ____ sec Trial 2 ____ sec (3) 30s stable (2) 30s unstable (1) < 30s (0) Unable 20. INCLINE- EYES CLOSED Toes Up (3) Stands independently, steady without excessive sway, holds 30 sec, and aligns with gravity (2) Stands independently 30 SEC with greater sway than in item 19B -OR- aligns with surface (1) Requires touch assist -OR- stands without assist for 10-20 sec (0) Unable to stand >10 sec -OR- will not attempt independent stance VI. STABILITY IN GAIT 21. GAIT – LEVEL SURFACE SECTION V _____ /21 POINTS Time _______ secs. (3) Normal: walks 20 ft., good s no evidence of imbalance. (2) Mild: 20 ft., slower speed (>5.5 sec), no evidence of imbalance. (1) Moderate: walks 20 ft., evidence of imbalance (wide-base, lateral trunk motion, inconsistent step path) – at any preferred speed. (0) Severe: cannot walk 20 ft. without assistance, or severe gait deviations OR severe imbalance 22. CHANGE IN GAIT SPEED (3) Normal: Significantly changes walking speed without imbalance (2) Mild: Unable to change walking speed without imbalance (1) Moderate: Changes walking speed but with signs of imbalance, (0) Severe: Unable to achieve significant change in speed AND signs of imbalance 23. WALK WITH HEAD TURNS – HORIZONTAL (3) Normal: performs head turns with no change in gait speed and good balance (2) Mild: performs head turns smoothly with reduction in gait speed, (1) Moderate: performs head turns with imbalance (0) Severe: performs head turns with reduced speed AND imbalance AND/OR will not move head within available range while walking. 24. WALK WITH PIVOT TURNS (3) Normal: Turns with feet close, FAST (< 3 steps) with good balance. (2) Mild: Turns with feet close SLOW (>4 steps) with good balance (1) Moderate: Turns with feet close at any speed with mild signs of imbalance (0) Severe: Cannot turn with feet close at any speed and significant imbalance. 25. STEP OVER OBSTACLES Time _______ sec (3) Normal: able to step over 2 stacked shoe boxes without changing speed and with good balance (2) Mild: steps over 2 stacked shoe boxes but slows down, with good balance (1) Moderate: steps over shoe boxes with imbalance or touches box. (0) Severe: cannot step over shoe boxes AND slows down with imbalance or cannot perform with assistance. 26. TIMED “GET UP & GO” Get Up & Go: Time ___________ sec (3) Normal: Fast (<11 sec) with good balance (2) Mild: Slow (>11 sec with good balance) (1) Moderate: Fast (<11 sec) with imbalance. (0) Severe: Slow (>11 sec) AND imbalance. 27. Timed “Get Up & Go” With Dual Task Dual Task: Time _______________ sec (3) Normal: No noticeable change between sitting and standing in the rate or accuracy of backwards counting and no change in gait speed. (2) Mild: Noticeable slowing, hesitation or errors in counting backwards OR slow walking (10%) in dual task (1) Moderate: Affects on BOTH the cognitive task AND slow walking (>10%) in dual task. (0) Severe: Can’t count backward while walking or stops walking while talking Balance Evaluation – Systems Test Fay Horak PhD Copyright 2008 TEST NUMBER/SUBJECT CODE DATE EXAMINER NAME EXAMINER Instructions for BESTest 1. Subjects should be tested with flat heeled shoes or with shoes and socks off. 2. If subject must use an assistive device for an item, score that item one category lower Tools Required Stop watch Measuring tape mounted on wall for Functional Reach test Approximately 60 cm x 60 cm (2 X 2 ft) block of 4-inch, medium-density, Tempur® foam 10 degree incline ramp (at least 2 x 2 ft) to stand on Stair step, 15 cm (6 inches) in height for alternate stair tap 2 stacked shoe boxes for obstacle during gait 2.5 Kg (5-lb) free weight for rapid arm raise Firm chair with arms with 3 meters in front marked with tape for Get Up and Go test Masking tape to mark 3 m and 6 m lengths on the floor for Get Up and Go SUMMARY OF PERFORMANCE: CALCULATE PERCENT SCORE SUMMARY OF PERFORMANCE: CALCULATE PERCENT SCORE Section I: Section II: /15 x 100 = /21 x 100 = Biomechanical Constraints Stability Limits/Verticality Section III: /18 x 100 = Transitions/Anticipatory Reactive Section IV /18 x 100 = Sensory Orientation Section V: /15 x 100 = Section VI: Percent Total /21 x 100 = Stability in Gait TOTAL:108 points =