Valorar la funcionalidad en sedestacin: FIST

Los diferentes estudios de investigacin indican que la capacidad de mantener el control

de tronco en sedestacin despus de sufrir un ACV es un factor de prediccin
importante en la recuperacin funcional del paciente. En Terapia Ocupacional es
importante poder valorar la funcionalidad en sedestacin. La mayora de escalas como
la Berg, Tinetti, Trunk Control Test, Trunk Impairment Scale, etc valoran el equilibrio
en sedestacin, en bipedestacin, el paso de sedestacin a bipedestacin, etc. Pero no es
fcil encontrar escalas que valoren el control de tronco en sedestacin mientras se
realizan actividades.
La Universidad Samuel Merritt de California, ha creado la Function in Sitting Test
(FIST), una prueba estandarizada para valorar la funcionalidad en sedestacin durante la
realizacin de actividades en la fase aguda del ACV.
Diseada para poder realizarse en la misma cama del hospital, est indicada para
pacientes con:

Falta de control de tronco en sedestacin

Dificultades para pasar otras pruebas de equilibrio.

Incapaces de ponerse de pie o deambular sin ayuda o con dispositivos.

Capacidad de seguir instrucciones simples (verbales o no verbales).

Con problemas de seguridad

Movimientos lentos

La prueba se compone de 14 actividades cotidianas funcionales tales como recoger un

objeto que est colocado detrs del paciente, realizar alcances frontales con una mano
mientras q la otra debe permanecer apoyada en la pierna, realizar alcances laterales,
recoger objetos del suelo
Es una prueba muy sencilla de pasar, se puede completar en menos de 10 minutos y solo
necesita para llevarse a cabo un cronmetro o reloj con segundero, una cinta mtrica,
un escaln para posicionar las extremidades inferiores de los pacientes en funcin de la
altura del paciente y la altura de la cama y una silla para el terapeuta.

Function in Sitting Test (FIST)

Welcome to the Function in Sitting Test (FIST) Web-based Training
This website will train rehabilitation and medical professionals on how to administer a
standardized test of sitting balance, the Function In Sitting Test or FIST, intended to be
used in patients/clients who are suspected of having problems with balance and/or

safety in a seated position. Thank you to the Department of Physical Therapy and
Information Techonology Services at SMU for hosting this training on their website.
This online module consists of an overview of the FIST, specifics related to each of the
14 FIST items, and documentation information. All FIST items have video examples
showing different levels of performance. There is a brief quiz to assess competency
available after you complete this tutorial.
First, some general information about the FIST.
What is the FIST?

Useful: The FIST is a clinical examination of sitting balance, designed

to be conducted at the patient's bedside

Practical: Consists of 14 functional, everyday activities as test items

Easy: Performance is scored by therapist using a single set of scoring

criteria for all 14 items

Quick: Most patients can easily complete the FIST in under 10

minutes

Purposes of the FIST

The FIST can be useful for a variety of clinical uses including:

Assess functional sitting abilities

Describe sitting balance dysfunction

Focus interventions

Track changes in sitting balance over time

Assessment of lower level patients, especially if other balance tests

may be too difficult for the patient

Is my patient appropriate for testing with the FIST?

The FIST is best suited for patients with:

The ability to follow simple directions, either verbal or nonverbal

Known or suspected sitting balance deficits

Impulsiveness

Safety issues in sitting

Slow movement

Poor seated motor control

Lower level patients who...

o

cannot tolerate other balance tests

are unable to stand or ambulate without excessive assistance

or devices

Patients who may benefit from other types of balance testing include:

Patients who can...

o

stand or perform more complex ADLs

ambulate

Patients who aren't yet...

o

medically stable for sitting

cleared for the motions or tasks on the FIST

Creation of the FIST

Please see the paper published in the Journal of Neurologic Physical Therapy detailing
the development and validation of the FIST for more details, or view the abstract at
PubMed.
Psychometrics of the FIST

FIST reliability
o

Functional sitting balance ability explains 83.33% of score

variance between persons

Cronbach's alpha = 0.98

Person separation reliability = 0.978

Standard error of measurement = 2.03

Minimal detectable change (95% confidence) = 5.63

Studies to determine inter- and intra- rater reliability, evaluative

validity in other applicable patient populations, and responsiveness
are underway and/or in planning stages. See our Research
Collaboration page if you would like to participate in
current/upcoming studies.

FIST Instructions & Setup

The FIST was designed as a bedside clinical measure, so the required equipment is
simple and readily available in clinics and hospitals.
Equipment for FIST testing:
1. Stopwatch, or watch with second hand--to time 30 seconds of
performance (2 items)
2. Tape measure--to measure 2 inches required to scoot (3 items), and
to use as a lightweight object for patient to pick up (2 items)

You may also need:

1. Small lightweight object, if not using the tape measure. A pen or
cone could be used.
2. Stool or step to position the patients lower extremities depending on
patient height and bed height.
3. Chair for therapist positioning.

Position the patient:

Before having the patient perform any of the 14 items on the FIST, they should be
positioned in the standard starting position. The therapist may help the patient and
reposition them between items as needed.

Note the patient is on a normal hospital bed without a mattress overlay and the bed is
fully flattened. The patient's feet are flat on the floor, with the hips and knees at
approximately 90 degrees of flexion. You should use a step or stool to position the
lower extremities and feet if the patient is shorter. The hips are positioned so that hip
rotation is neutral and they are not in hip abduction or adduction. The patient's hands
are in the lap.
Position yourself:
Therapist positioning is determined by patient safety requirements to guard the patient
appropriately and to allow the therapist to provide physical assistance to the patient
should they need it during testing. Common positions for the therapist include sitting in
front of the patient or to the side of the patient. The therapist can move between these
positions as needed during testing.

Describe the FIST to the patient:

It is important that prior to beginning testing you describe the FIST to the patient. Not
only does this help confirm informed consent for testing with the FIST, but it allows the
patient to better understand what you will be doing and why. It also allows you to
review some of the general principles of the FIST and FIST scoring prior to starting the
FIST. You may choose to read the following prepared description to your patients:
"I will be conducting a test with you today to see how well you balance yourself
in a sitting position. It will involve you sitting with your best posture and
balance, as well as moving in a seated position to reach and scoot. I might lightly
push you to see how well your balance reactions work. I will be right here next to
you to make sure you are safe if you lose your balance. I would prefer if you
could perform the test without using your hands for balance, but if you need to
use your hands, you can. I will remind you to try to not use your hands during the
test. If you need a break, just let me know and we can pause to let you rest. Do
you have any questions? [Pause, answer questions] Let's start."
If you choose the paraphrase the directions for the FIST, be sure you include the
following points:

The FIST tests balance in seated position

The patient should perform items with their best posture and
balance, and while moving in a seated position

The therapist will give them occasional light pushes to test for
balance reactions

The therapist will make sure they won't lose their balance

The patient should try not to use their hands, but they can if they
must

The therapist will remind the patient to try to not use their hands

Breaks are allowed-if the patient needs one, they should tell the
therapist

The therapist should ask the patient if they have questions, and
answer them before proceeding

Now you should be able to set up FIST testing, including what equipment is required,
patient positioning, therapist positioning, and general FIST description to use when
testing.

FIST Scoring
The scoring criteria on the FIST are the same for each item. The FIST was designed
this way to make learning and using the scoring scale easy and to decrease the need to
constantly refer to written directions when scoring each item. The items are scored on a
5 point ordinal scale ranging from 0 to 4, with 0 representing the lowest ability and 4
representing normal ability.
0 Dependent
1 Needs assistance
2 Upper extremity support
3 Verbal cues/increased time
4 Independent
Let's take a look at each point on the scale.
0 Dependent: Patient requires complete physical assistance to perform task
successfully, patient is unable to complete task successfully even with physical
assistance, or dependent

Without complete assistance, cannot complete the task successfully

or safely

1 Physical Assistance: Patient is unable to complete task successfully without

physical assistance

Cannot complete the task safely or completely without physical

assistance of the therapist

Documentation of level of physical assistance needed by the patient

is also required for this score
o

minimal assistance or min A (25% or less effort provided by

therapist)

moderate assistance or mod A (26-74% of the effort provided

by the therapist)

maximal assistance or max A (75% or more of the effort

provided by the therapist)

2 Upper Extremity Support: If the patient requires the use of one or both of their
upper extremities to support themselves or to maintain their balance during the
performance of the task, they score a 2. Items involving grasping or picking up items
should be scored a 2 if the patient uses their upper extremity for support or balance, not
as a score of how they pick up the item. Items that involve a movement and require the
patient return to the starting position should be scored a 2 if the patient requires the use
of their hands for any part of the task. You may prompt the patient to try again without
using their hands to see if they are able to successfully complete the task without their
hands.

Must use hands for successful completion of task or to maintain

balance during task

3 Verbal Cues/ Increased Time: A score of 3 indicates the patient required verbal
cueing or an increased amount of time to complete the task. Otherwise, their
performance was complete and they successfully completed the task. If a patient is
unsafe but can otherwise complete the task, and providing verbal cueing would improve
safety (i.e.,"slow down"), the patient is scored as a 3.

Performance is normal but cues are needed or longer than normal

time is needed

4 Independent: 4 is the highest score attainable for any individual item and represents
performance that is normal. It also accounts for speed and safety.

Reaction and performance you would expect as normal

Speed and safety also normal

Now you should be familiar with the scoring scale used for all the FIST items.

FIST Item Overview

You are now ready to administer the FIST. Remember the following regarding the FIST
items:

There are 14 items in total

Aside from the 3 nudge items, these items are ordered by difficulty,
so have the patient perform them in order.

Nudges should be randomly inserted into the test by the therapist.

Multiple attempts for each item are acceptable.

Especially if the therapist is providing cues, prompts the patient

to attempt with/without hands to improve performance, or to
ensure full movement through the task.

Try to limit the attempts of any particular item to less than 2 or

3 to minimize testing effects interfering with the patient's score
on that item.

It is preferable that you score the patient's first attempt, if

possible.

Prior to each individual item:

o

Give the patient instructions, and demonstrate the task if

needed.

Reposition the patient as needed before each item so they are

in the standard position.

Recall the scoring criteria; it is the same for each item.

The following pages review each individual test item, and include:

Description of the item

Directions to give patient for that item

Item-specific examples of performance for each level of scoring

Common questions about performance and scoring specific to the

item

A video clip showing examples of patient performance for at least 2

scoring levels
o

maximum score of 4

either 0, 1, 2, or 3

Nudges
Description & Directions
The nudge items are intended to examine the patient's ability to react to an unknown
disruption of their balance. Therefore it is important that you do not tell the patient
immediately before the nudge and that you nudge them only once. This will accurately
allow you to see how an unknown balance perturbation affects the patient's ability to
maintain their sitting balance.
During your general FIST directions and explanation you should have stated that you
will occasionally lightly push the patient during the test in a variety of directions
without warning to see how well they react. At that time be sure to reinforce that you
will be present to ensure they do not lose their balance. You should not tell the patient
immediately before you nudge them; rather the directions for the nudges are embedded
in the general FIST description given before testing occurs.
Three nudges are included in the FIST: an anterior nudge, a posterior nudge, and a
lateral nudge on the dominant or stronger side. These nudges should be randomly
inserted during the FIST by the therapist so they will be unexpected by the patient.
Nudge Locations

Anterior nudge: At sternum

Posterior nudge: Between scapular spines

Lateral nudge: At acromion on dominant or stronger side

In summary, nudges should be

RANDOMLY inserted throughout test

Given WITHOUT immediate warning

Use LIGHT pressure, enough to require a balance reaction

ONE push only, for each direction

Scoring Nudges
Sco
Description
re

Selected Example

Independent

Normal performance

Verbal
cues/increased
time

Puts hand down to perserve balance, on second attempt after

cueing to not use hand can perform without the use of their
hand.

Must put hand down to support self after 1-2

Upper extremity
repeated attempts after cueing patient to not use
support
hands.

Needs assistance

Generates insufficient balance reaction and requires

min A to maintain upright balance

Dependent

Cannot generate balance reaction and requires total

A when nudged.

Common Questions about Nudge Items

How hard do I nudge someone? You only want to displace the patient
enough to generate a balance reaction. You may have to practice on
a variety of 'normal' persons (family, colleagues) to get an idea of
how much pressure is required to generate a balance reaction.