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STATUS KLINIS GERIATRI

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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 =
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