Table of Contents

Date Collection………………………………………………………….. 1
Balance and Gait………………………………………………………………… 5
Gait Speed………………………………………………………………. 6
Tinetti Assessment Tool: Description………………………………….. 7
Tinetti Mobility Scale-Balance Performance…………………………… 8
Tinetti Mobility Scale-Gait Performance……………………………….. 9
Performance-Oriented Assessment of Gait……………………………... 10
Performance-Oriented Assessment of Balance…………………………. 11
Physical Mobility Scale…………………………………...…………….. 12a - 12g
Berg Balance Scale……………………………………………………… 13
Dynamic Gait Index…………………………………………………….. 16
Romberg Test…………………………………………………………… 19
Balance Assessment: a Modified Romberg test………………………... 20
Get-Up-and-Go Test……………………………………………………. 22
Timed Up and Go………………………………………………………. 23
Elderly Mobility Scale………………………………………………….. 24
30 Second Chair Stand Test……………………………………………. 25
Rivermead Mobility Index……………………………………………… 27
Sensory and Functional Reach…………………………………………………. 30
Functional Reach Test………………………………………………….. 31
Functional Reach Information………………………………………….. 33
Modified Sensory Integration Test……………………………………... 34
Dix-Hallpik Maneuver………………………………………………….. 35
Dix Hallpik Maneuver with Epley Partide Repositioning…………….. 36
Pain Assessment Tools………………………………………………………… 38
Wong-Baker FACES Pain Rating Scale……………………………….. 39
Assessing Pain in Older Adults with Dementia……………………….. 40
Comprehensive Pain Assessment Form………………………………. 41
Pain Rating Scales……………………………………………………… 45
Short-Form McGill Pain Questionnaire……………………………….. 46
Brief Pain Inventory…………………………………………………… 47
Pulmonary and Cardiac Assessments…………………………………………. 49
Borg Scale Rating of Perceived Dyspnea/ Exertion………………….. 50
Timed Ergometer Assessment………………………………………… 51
 Metabolic Equivalent…………………………………………………. 52
GXT Stress Test………………………………………………………. 56
Breathing Techniques…………………………………………………. 57
Progressive Muscle Relaxation…….…………………………………. 58
Important Phone Numbers……………………………………………. 59
Angina Log……………………………………………………………. 60
Activity Log…………………………………………………………… 61
Medicine Chart………………………………………………………... 62
Blood Pressure Tracker-Instructions…………………………………. 63
Blood Pressure Tracker………………………………………………. 64
Blood Pressure Tracker-Wallet Card…………………………………. 65
ADL Assessment Tools………………………………………………………. 66
Modified Barthel Index - Self Care Assessment…………………….... 66a - 66d
The Barthel Index……………………................................................... 67
Frenchay Activities Index…………………………………………….. 71
Northwick Park Index of Independence in ADL…………………….. 75
Katz Index of Independence in Activities of Daily Living (ADL)…... 78
Lawton Instrumental ADL Scale (IADL)…………………………….. 80
Fine Motor, Dexterity and Coordination Assessments………………………. 82
Nine-Hole Peg Test…………………………………………………… 83
Bowel and Bladder Incontinence Assessments……………………………… 85
Bowel and Bladder Incontinence Assessment………………………. 86
Seating Assessment and Power Chairs………………………………………. 89
Resident Ergonomic Assessment Profile for Seating (REAPS)……... 90
Power Mobility Device (PMD)………………………………………. 95
Power Mobility Device Assessment (PMD)………………………… 96
Motorized Wheelchair Assessment………………………………….. 97
Power Operated Vehicle Assessment……………………………….. 99
Body Mass Index…………………………………………………………….. 100
BMI…………………………………………………………………... 101
Visual Perceptual Assessments……………………………………………… 102
Line Bisection Test…………………………………………………… 103
Dementia Staging and Cognition Assessments……………………………… 105
Comparison of Cognitive Scales…………………………………….. 106
Time and Change Test………………………………………………. 107
 Instructions for the Clock Drawing Test……………………………. 109
Clock Drawing Test…………………………………………………. 110
Global Deterioration Scale…………………………………………… 111
Montreal Cognitive Assessment (MOCA)…………………………… 115
Normative Data………………………………………………………. 116
Montreal Cognitive Assessment Instructions………………………... 117
Mini-Mental State Examination (MMSE)…………………………… 121
Short Portable Mental Status Questionnaire (SPMSQ)……………… 123
Brief Cognitive Rating Scale (BCRS)……………………………….. 124
Confusion Assessment Method (CAM)……………………………… 126
Confusion Assessment Method (CAM) Diagnostic Algorithm……… 128
VAMC SLUMS Examination………………………………………… 129
Function, Reason, Orientation, Memory, Arithmetic, Judgment and
Emotional Status (FROMAJE)………………………………………. 132
FAST Scale Administration…………………………………………. 135
Swallowing Assessments…………………………………………………….. 137
Modified Barium Swallow Study……………………………………. 138
Fiberoptic Endoscopic Evaluation of Swallowing…………………… 139
Mann Assessment of Swallowing Ability (MASA)…………………. 140
MASA Modified Instructions………………………………………… 143
Speech-Language Assessment Tools…………………………………………. 150
Assessment of Aphasia Form…………………………………………. 154
Wound Assessments…………………………………………………………… 159
Wound Assessment/ Progress Report…………………………………. 160
Vascular Assessment in Older Adults………………………………… 162
Vascular Risk Assessment of the Older Cardiovascular Patient……… 163
Braden Scale for Predicting Pressure Sore Risk………………………. 165
Stroke Assessment Scales……………………………………………………… 167
Stroke Impact Scale (SIS)……………………………………………… 168
National Institutes of Health Stroke Scale……………………………... 176
NIH Stroke Scale……………………………………………………….. 178
References………………………………………………………………………. 186
 1

Data Collection

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Balance and Gait

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GAIT SPEED (preferred and maximal)

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Tinetti Assessment Tool: Description

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Tinetti Mobility Scale-Balance Performance

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Date Date Date Date

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Balance Task Score Score Score Score

Sitting Balance:
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 9

Tinetti Mobility Scale-Gait Performance

Procedures: Subject stands with examiner then walks down

hallway or across room, first at “usual” pace, then back at Patient Name: ____________________________
“rapid” pace using usual walking aids
Date Date Date Date
The Tinetti Scale is recommended for ACL of 2.4 or greater.

Gait Component Score Score Score Score

Initiation of Gait (Immediately after told to go):
0=any hesitancy or multiple attempts start
1=no hesitancy
Step Length and Height:

Right 0=does not pass left stance foot with step

Swing 1=passes left stance foot
Foot:
0=right foot does not completely clear floor with
step
1=right foot completely clears floor

Left 0=does not pass right stance foot with start

Swing 1=passes right stance foot
Foot:
0=left foot does not completely clear floor with
step
1=left foot completely clears floor
Step Symmetry:
0=right and left step length are not equal (estimate)
1=right and left step appear equal
Step Continuity:
0=stopping or discontinuity between steps
1=steps appear continuous
Path Deviation::
0=marked deviation
1=mild/moderate deviation or uses walking aid
2=straight without walking aid
(Estimate in relation to floor tiles 12” length; observe excursion
of one foot over about 10 feet of the course)
Trunk:
0=marked sway or walking aid
1=no sway, but flexion of knew/back, or spreads
arms out while walking
2=no sway, no flexion, no use of arms or assistive
device
Walking Stance:
0=heels apart
1=heels almost touching while walking
Total /12 /12 /12 /12

Therapist Signature:________________________________________ PT OT (Circle one.)

 10
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11
 Patient Response to Maneuver
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12
 Research Report
Responsiveness of the Physical Mobility Scale
in Long-term Care Facility Residents
Eric Pike, PT, DPT, MS, NFA1; Merrill R. Landers, PT, DPT, OCS2
ABSTRACT
Purpose: The Physical Mobility Scale (PMS) is used to evalu-
ate the functional ability of aged adults. It has been shown to
be reliable and has evidence to support its validity; however,
there has been only 1 study performed to date that has
addressed its responsiveness. The purpose of this study was
to evaluate the responsiveness of the PMS using residents of
a long-term care facility.
Methods: Seventy participants who were permanent residents
of a long-term care facility were recruited for this study. To
determine minimal detectable changes at the 95% confidence
level (MDC95), each participant was assessed using the PMS
on 2 occasions. To determine the clinically important differ-
ence, participants were also tested on 2 separate occasions
3 months apart. The treating physical therapist then used a
7-point Likert scale to rate the participants’ change in function.
Results: Intrarater reliability for the pre- and post-PMS scores
for all 70 participants was excellent (intraclass correlational
coefficients [3,1]  0.982). At the individual level, the MDC95
was 3.98 points. At the group level, the MDC95 for the 70 par-
ticipants was 0.476 points. Minimal clinically important differ-
ence results suggest that a positive change of 5 points is
“improved” clinically whereas a 4-point decrease in score is
considered “worsened” clinically.
Conclusions: The psychometric properties of the PMS in an
aging adult population of long-term residents are excellent,
demonstrating good reliability and responsiveness. These
results also offer some support to the validity of the PMS in
this patient population. The utility of the PMS in the long-term
care setting for assessing patient status and positive and/or
negative functional outcomes is of value to both researcher
and clinician.
Key Words: mobility, psychometrics, reliability, reproducibility,
transfers
(J Geriatr Phys Ther 2010;33:92-98.)
1Nevada State Veterans’ Home, Boulder City.
2Department of Physical Therapy, School of Allied Health
Sciences, University of Nevada, Las Vegas.
Address correspondence to: Eric Pike, PT, DPT, MS, NFA,
Nevada State Veterans’ Home, 100 Veteran’s Memorial Dr,
Boulder City, NV 89005 (ecpike00@yahoo.com).
12a
INTRODUCTION
One of the primary focuses of physical therapy in long-term
care is to improve the functional mobility of a resident.
Many times the resident is admitted at a very low function-
al level, unable to complete the most basic tasks such as bed
mobility and transfers. Because of these generalized deficits
in mobility, it is difficult to objectively measure functional
mobility and to identify improvement with treatment
because many of the current functional scales are not
designed for use with residents of long-term care.
Functional scales that are typically used for residents of
long-term care can be categorized by method of adminis-
tration as a self-report instrument completed by the patient
or as a performance-based measure requiring observation
and rating of movement by a physical therapist or other
health care professional. For example, self-report question-
naires that address mobility include the California
Functional Evaluation instrument,1 the Movement Ability
Measure,2,3 the Health Assessment Questionnaire,4,5 and
the Functional Status Questionnaire.6 Although these ques-
tionnaires are easy to administer and appear to adequately
address mobility, they are inherently subject to response
bias. In addition, self-report questionnaires can be prob-
lematic in patient populations with a high incidence of cog-
nitive impairment, as is commonly found in long-term care
facilities. Sinoff and Ore7 report that self-report question-
naires are problematic when used with persons older than
75 years. They found inconsistency between self-report and
actual performance of questionnaire tasks, suggesting that
older adults may not accurately perceive their physical func-
tion. Brach et al8 suggest that instruments based on per-
formance are more likely to identify deficits in physical
function than questionnaires that are based on self-report.
Performance-based scales can be subclassified into those
that test mobility skills alone (eg, Rivermead Mobility
Index9 and Clinical Outcome Variables Scale10) or mobility
and activities of daily living (eg, Edmonton Functional
Assessment Tool,11-13 Barthel Index,14 Katz Index of
Independence in Activities of Daily Living,15 and the
Functional Independence Measure16) or are disease-specific
in looking at functional mobility (eg, Motor Assessment
Scale for persons with stroke17 and the Parkinson Activity
Scale18). Other scales test specific aspects of mobility, such
as balance and gait (eg, Berg Balance Scale19 and
Performance Oriented Mobility Assessment20). Many of
Volume 33 • Number 2 • April-June 2010

these performance-based scales include items that are unre-
lated to mobility (eg, continence or communication), items
that would be inappropriate for the majority of long-term
care facility residents (eg, running), or items specific to a dis-
ease process (eg, hand movements or gait akinesia). Because
of this, many are not appropriate for the general long-term
care facility population. In their place, physical therapists
may use subjective ratings to evaluate the resident’s func-
tional ability. Although these subjective ratings are usually
performance-based, they are not standardized and may
reflect unwanted bias or excessive error in the rating.
Nitz and Hourigan21 and Barker et al22 reported on a
scale, the Physical Mobility Scale (PMS), that was developed
by physical therapists and seems to be an appropriate tool to
evaluate the functional mobility of aging adults in long-term
care. Nitz and Hourigan21 found the PMS to have good reli-
ability in participants ranging in age from 35 to 90 years.
Interrater reliability using intraclass correlational coefficients
(ICC) for individual items ranged from 0.68 to 0.94 and was
not affected by the physical therapists’ level of experience.
Intrarater reliability was also established with an ICC level
of more than 0.9. The PMS demonstrated concurrent valid-
ity (Spearman’s rank order agreement  0.69 to 0.90) with
the performance scoring outcomes of the Clinical Outcomes
Variable Scale and the Rivermead Mobility Index. Barker
et al22 also reported good interrater reliability (  .60 for
most items) and evidence to support construct validity.
While the PMS seems to have good reliability and good
support for validity for use with adults, the responsiveness
of this performance-based scale has been reported in only 1
study.22 Responsiveness allows the clinician to make deci-
sions about a change in a patient’s outcome as detected by
the scale. In addition, it allows for inference about the effec-
tiveness of treatment, economic appraisals, and other pro-
gram evaluations.23 Two types of responsiveness have been
commonly used in the physical therapy literature, minimal
detectable change (MDC) and minimal clinically important
difference (MCID). Barker et al22 determined the MDC of
the PMS to be 4.39 at the 90% confidence level. To our
knowledge, no study has reported the MCID of the PMS.
The MDC is the minimal amount of change required to
be considered a statistically significant change. The MDC
allows inference about how much change has actually
occurred beyond error of measurement of the scale.
Although the MDC is an indication of statistically signifi-
cant change, this change may not be clinically meaningful.
Therefore, it is also important to establish the MCID. In
contrast to the MDC, which is statistically determined,
MCID is based on subjective ratings of change by the
patient, caregiver, or health care provider. The purpose of
the present study is to determine the responsiveness of the
PMS based on the MDC and the MCID.
METHODS
Participants
For our study, 70 participants (mean age  81.4 years [SD 
6.3]; 12 women and 58 men) were recruited from a state
Journal of GERIATRIC Physical Therapy
Research Report
veterans nursing facility. The most common diagnoses
included hypertension (64.3%), dementia (42.9%), chronic
obstructive pulmonary disease (28.6%), diabetes mellitus
(27.1%), coronary artery disease (25.7%), and cerebrovas-
cular accident (22.9%). Initial recruitment consisted of a
verbal invitation to participate from the lead author to res-
idents. Inclusion criteria were (1) ability to follow verbal
instructions and (2) no medical contraindications to per-
forming basic mobility tasks. Those who did not meet the
inclusion criteria were excluded from the study. All partici-
pants provided informed consent under the University of
Nevada, Las Vegas institutional review board approval
prior to participation in the study.
Procedure and Data Collection
To determine the responsiveness of the PMS, participants
were assessed by the same physical therapist on 2 separate
occasions. The PMS includes measures of 9 basic move-
ments, including supine to side-lying, supine to sitting, sit-
ting balance, sitting to and from standing, standing balance,
transferring, and ambulating (Appendix).21 Each of the 9
measures is scored on a scale of 0 to 5, with 0 being depend-
ent and 5 independent. Total scores range from 0 to 45,
with 45 indicating independent mobility functioning and 0
indicating very low mobility functioning.
The original PMS does not have formal instructions
on how to implement the test or definitions of the items.
No specific instructions in the original PMS regarding
single limb balance time and wheelchair mobility dis-
tance were provided in either article on the PMS.21,22 In
this study, some clarifications were made to ensure con-
sistency and instructions were added to the scoring
sheet. The clarifications that were made are italicized in
the Appendix. The first 5 items and the item on transfers are
well described in the scoring sheet and are self-explanatory.
The standing balance item was clarified to state that the
single limb balance must be maintained for 10 seconds
to receive a score of 5. This follows the same guidelines
as the Berg Balance Scale,19 in which the participant
must maintain a single leg stand for 10 seconds to
receive full marks for that item. Springer et al deter-
mined normative values of the single leg stand by decade
as follows: 60- to 69-year-old participants could perform
a single leg stand for a mean of 26.9 seconds, 70- to
79-year-old participants for 15.0 seconds, and 80- to
99-year-old participants for 6.2 seconds.24 Because the
population with which we are concerned are in these
ranges and are not considered healthy, the 10-second
cutoff seemed reasonable. We also clarified the wheel-
chair mobile score of wheelchair mobility to be defined
as able to move 50 ft without assistance, because that
length is a reasonable distance to get to most immediate
areas in a nursing facility (eg, room to dining room).
Calculation of Minimal Detectable Change
For calculation of the MDC, 70 participants were tested
twice within the same week. The MDC is determined by
performing a test and a retest within a relatively short time
12b
 Research Report

frame so that the condition being investigated is unlikely to
have changed.25 To determine the MDC, one must first
assign a reliability change index value. The reliability
change index expresses the confidence level at which this
change could be considered significant. For instance, if one
were to measure at a 95% confidence interval, then change
above this level would be confidently considered (at a 95%
confidence level) greater than measurement error and,
therefore, likely a true change.23 Once the reliability is
determined, the Standard Error of Measurement (SEM) is
found by the following equation23,25,26:
SEM  baseline standard deviation  √ 2  (1  rxx)
where rxx  test-retest reliability.
The MDC at a 95% confidence level (MDC95) for the
individual is found by multiplying the SEM by 1.96 (repre-
senting 95% of the area under the curve of a normal distri-
bution) and 1.41 (the square root of 2, to control for possi-
ble error associated with calculating the coefficient from 2
data sets (ie, test and retest))23:
ities were variable on the basis of individual preferences and
treatments; thus, no limitations were put on activity levels.
Minimal clinically important difference, which by defini-
tion is the smallest difference in a score of a measurement tool
that the patient, caregiver, or health care provider perceives as
beneficial, can be calculated from data of participants who
have minimally improved or minimally worsened as ranked
from a Likert scale. Prior to the final assessment, the thera-
pist provided a rating of the patient’s change (or lack there-
of) in functional mobility since the initial assessment. The
therapist’s assessment was standardized by using the
Clinical Global Impression-Global Improvement (CGI-I)
scale,26 a typical 7-point Likert scale. The anchors for the
CGI-I were 7 (very much worsened), 6 (much worsened), 5
(minimally worsened), 4 (no change), 3 (minimally
improved), 2 (much improved), or 1 (very much improved).
This scale has been used to determine MCID in previous
studies.27-30 To determine whether there was a difference in
the pre- and post-test scores for participants rated into each
of the CGI-I anchors, paired-samples t tests were used.

MDC95  SEM  1.96  1.41 RESULTS

Although the MDC95 for the individual is typically used
as a statistical cutoff for change in individual patients or
participants, the group MDC95 is typically used by
researchers or clinicians to determine whether a statistically
significant change has occurred in the mean of a group of
patients or participants. To determine the MDC95 for a
group, the MDC95 for the individual is divided by the
square root of the number in the group:
MDC95  MDC95 / U n
Calculation of Minimal Clinically
Important Difference
For calculation of the MCID, 60 of the 70 original participants
were assessed twice approximately 3 months apart. Ten of the
original participants were lost to follow-up because of
declining to participate (n  4), medical contraindications
(n  3), discharge from the facility (n  2), and death (n 
1). During the 3-month period between tests, resident activ-
Intrarater reliability for the pre- and post-PMS scores for all
70 participants was excellent (ICC [3,1]  0.98). Using this
reliability statistic, the MDC95 was calculated for the indi-
vidual and group levels. At the individual level, the MDC95
was 3.98 points. At the group level, the MDC95 for the 70
participants was 0.48 points.
Results of the MCID are found in Table 1. While all of
the differences in means for the pre- and post-PMS values
trended in the correct direction based on their CGI-I anchor
(Figure 1), low power (most likely small sample size) ren-
dered some of these differences nonsignificant. Because
there were not enough participants and power in the mini-
mally improved and minimally worsened categories, these
categories were combined with the much-improved and
much-worsened categories, respectively (Table 2). Based on
the combined categories, the MCID for improvement was
5 scale points, rounded up from 4.68 (95% confidence
interval  2.66–8.09), and for worsening, it was 4 scale
points, rounded up from 3.82 (95% confidence interval 
0.68–6.95).

Table 1. Therapist Rating of Participants’ Pre- and Posttest Scores (3 Months Apart) With Accompanying t Test Values to Determine
Minimal Clinically Important Difference
Therapist rating Number of Participants Pretest Mean (SD) Posttest Mean (SD) Mean Difference t Value P Value Power

Very much improved 2 9.95 (0.7) 19.5 (2.1) 9.6 10.0 .063 100

Much improved 4 29.5 (9.0) 37.3 (7.7) 7.8 8.188 .004 26

Minimally improved 4 29.0 (14.7) 32.0 (14.4) 3.0 2.449 .092 6

Unchanged 34 34.3 (9.4) 34.3 (10.2) 0 .0005 1.00 5

Minimally worsened 6 26.8 (11.0) 25.8 (10.1) 1.0 1.074 .332 5.3

Much worsened 5 25.2 (9.9) 18.0 (7.4) 7.2 3.456 .026 25.5

Very much worsened 5 34.0 (8.3) 16.2 (4.7) 17.8 4.590 .010 98.7

12c Volume 33 • Number 2 • April-June 2010

 Research Report

Figure 1. Mean difference (pre-post) over 3 months on the Physical Mobility Scale for each level of therapist-rated change
for mobility function using the Clinical Global Impression-Global Improvement scale.

DISCUSSION
A tool that is able to accurately measure mobility change in
long-term care facility residents would be an asset for phys-
ical therapists responsible to monitor resident function. It
allows therapists to make inference about the resident’s
progress with treatment and helps guide clinical decision
making about whether the implemented treatment has been
successful. In addition, scales like the PMS can help deter-
mine when a long-term care facility resident may be in need
of physical therapy. Many residents of long-term care facil-
ities do not have regular physical therapy but do have reg-
ular, often biannual, evaluations to determine whether
physical therapy or other treatments are needed or appro-
priate. A scale with scientifically validated responsiveness
properties could be a valuable tool for a therapist doing
these evaluations because it allows them to make sound evi-
dence-based decisions on when a patient has worsened or
improved.
Results from the present study suggest that the PMS is
reliable and offers good value in determining change over
time in aging adult residents living in a long-term care facil-
ity. A 4-point change in the PMS scale was determined to be
the MDC at a 95% confidence interval on an individual
level. The MDC at the individual level is the typical thresh-
old used by clinicians in determining whether an individual
patient has improved or worsened over time. Therefore, if
a patient improves or worsens by 4 PMS scale points, under
statistical parameters, health care providers can be confi-
dent that there has been true change in mobility status.
A change of at least 0.5 points was determined to be the
MDC at the 95% confidence interval at the group level.
Therefore, if a group of patients has realized a mean change
of 0.5 PMS scale points, then researchers or health care
providers can confidently conclude that this group of
patients has had a statistically significant change in their
mobility status. Although the MDC at the group level is

Table 2. Therapist Rating of Participants’ Pre- and Posttest Scores to Determine Minimal Clinically Important Difference

Therapist Rating Number of Participants Pretest Mean (SD) Posttest Mean (SD) Mean Difference t Value P Value
Minimally or much improved 8 29.25 (11.25) 34.62 (11.07) 5.375 t (7)  4.680 .002

Minimally or much worsened 11 26.09 (10.05) 22.27 (9.47) 3.82 t (10)  2.714 .022

Journal of GERIATRIC Physical Therapy 12d

 Research Report
not typically used by health care providers, it can be used
to determine whether the mean of a group of participants
with a similar diagnoses has changed significantly from a
previous measurement. In the case of the PMS, it could be
used to determine whether all patients with a similar pro-
file (eg, dementia) at a long-term care facility were experi-
encing a significant change in their functional mobility
from 1 year to the next by comparing mean difference
over the 2 years.
Although only 3 of the 6 CGI-I anchors had results that
were significant in the MCID portion of the study, these
results suggest that the PMS is able to detect a meaningful
change with very little score change (Table 1). An increase
of 5 scale points was enough to show an improvement rated
“improved” and a decrease of 4 points was determined to
be “worsened.” On the basis of these data, in combination
with the MDC95 value, it is safe to assume that a change of
5 scale points is both meaningful from a clinical perspective
and statistically significant from a measurement error per-
spective. Therefore, the authors recommend that the con-
servatively estimated 5 scale point change, incorporating
the 4 scale points from the MDC95 and the 5 scale points
from the MCID, in either direction on the scale is important
in determining change between the ranges of 5 and 40 scale
points on the scale. These results are consistent with those
of Barker et al,22 which found an MDC90 of 4.39. Because
the scoring system on the PMS incrementally increases or
decreases by whole numbers, this 4.39 would be appropri-
ately rounded up to 5 scale points.
Because the PMS is performance-based, it affords a clos-
er approximation to the actual functional mobility of
patients than a self-report measure that is influenced by
responder bias. The performance-based aspect of the PMS
is not affected by limitations associated with cognitive dys-
function common in nursing facilities. The strength of a
performance-based tool like the PMS is limited only by
rater error and inherent variability of the subject and the
tasks that the participant is performing. Because the
intrarater reliability of the PMS in our study was high
(ICC  0.98), the amount of rater error was relatively
small. While the PMS seems to have excellent reliability,
based on our results and that of Nitz and Hourigan,21 more
evidence is needed to support its validity. Therefore, future
studies should move beyond reliability to aspects that
would support its validity in this and other populations.
A challenge in determining MCID is that it has been
shown to vary across patients and patient groups and,
therefore, has limited generalizability to other popula-
tions.31 This is partially because patients are prone to bias
and influenced by memory, emotional status, and cognitive
ability. Using a performance-based, therapist-rated tool
with clinical-based anchors, the results are less likely to be
affected by patient subjectivity and bias and would, there-
fore, be more accurate and generalizable; however, there
may also be some bias by the rater. Ferreira and Herbert32
discuss another possible weakness when attempting to
interpret the MCID of an intervention; that is, the focus
should be on whether the patient feels that the effect of or
12e
difference made by the intervention is sufficient enough to
outweigh the costs, inconvenience, and harms of the inter-
vention itself. Even though the MCID is typically based on
the patient’s perception of change, we feel that the therapist
rating used in the present study was appropriate because of
the high incidence of dementia (present in 42.9% of partic-
ipants) as well as the absence of an intervention.
One limitation of this study was the underpowered clin-
ically important change analyses. The most likely contrib-
utor to low power was the small number of participants in
the “minimally improved” (4 participants) or “minimally
worsened” (6 participants) categories (Table 1). Repeating
the study with larger sample size would detect a more
accurate value of the MCID. Because of the low power in
these 2 categories, it was decided to combine them with
the “much improved” and the “much worsened” cate-
gories. Although this is not ideal for analysis of MCID, it
does provide meaningful information for clinicians in deter-
mining when patients have had a “clinically important
difference.”
Another weakness was the female-to-male ratio of
participants. Because this study was performed on residents
living in a state veterans home, there were far more men
than women. This may not be consistent with other long-
term care facilities, in which the majority of residents are
female.
CONCLUSION
The PMS demonstrated excellent reliability and had an
MDC of 4 scale points for patients residing in a long-term
care facility. The MDC of the PMS at the group level was
determined to be 0.5 scale point change. It was also shown
that an increase of 5 scale points in score was considered
“improved” clinically, whereas a decrease of 4 points in
score could be considered “worsened.”
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12f
 Research Report

Appendix

Physical Mobility Scale

Physical Mobility Scale Date

Supine to side-lying (0) No active participation in rolling R

Note: Indicate R and L directions separately (1) Requires facilitation at shoulder and lower limb but actively turns head to roll
Patient in supine. (2) Requires facilitation at shoulder or at lower limb to roll
Instructions: Please roll onto your left/right (3) Requires equipment (eg, bedrail) to pull into side-lying. Specify: L
side. (4) Requires verbal prompting to roll—does not pull to roll
(5) Independent—no assistance or prompting

Supine to sit Patient in supine. (0) Maximally assisted, no head control

Instructions: (1) Fully assisted but controls head position
Please sit up at the edge of the bed. (2) Requires assistance with trunk and lower limbs or upper limbs
(3) Requires assistance with lower limbs or upper limbs only
(4) Supervision required only
(5) Independent and safe

Sitting balance (0) Sits with total assistance, requires head support
Patient sitting at the edge of the bed, feet on (1) Sits with assistance, controls head position
the floor. (2) Sits using upper limbs for support
Instructions: (3) Sits unsupported for at least 10 seconds
(If able to maintain balance without support) (4) Sits unsupported, turns head and trunk to look behind, to (L) and (R)
Please turn and look over your shoulder/ (5) Sits unsupported, reaches forward to touch floor and returns to sitting position
reach forward and touch the floor. independently

Sitting to Standing (0) Unable to weight bear

Patient sitting at the edge of the bed.
Instructions:
Please stand up. Try not to use your hands for
support.
Standing to sitting
Patient starts standing near the edge of the
bed.
Instructions:
Please sit down. Try not to use your hands for
support.
Standing balance
Patient starts standing supported/unsupported
Instructions:
Please turn and look over your shoulder/pick
(the object) up from the floor/stand on your
left/right leg for as long as you can.
(1) Gets to standing with full assistance from therapist, describe:
(2) Requires equipment (eg, handrails) to pull to stand. Specify equipment/method used:
(3) Pushes to stand, weight unevenly distributed, stand-by assistance required
(4) Pushes to stand, weight evenly distributed, may require frame or bar to hold onto once
standing
(5) Independent, even weight bearing, hips and knees extended, does not use upper
limbs
(0) Unable to weight bear
(1) Gets to sitting with full assistance from therapist, describe:
(2) Can initiate flexion, requires help to complete descent, holds arms of chair, weight
evenly/unevenly distributed
(3) Poorly controls descent, stand-by assistance required, holds arms of chair, weight
evenly/unevenly distributed
(4) Controls descent, holds arms of chair, weight evenly distributed
(5) Independent and does not use upper limbs, weight evenly distributed
(0) Unable to stand without hands-on assistance
(1) Able to safely stand using an assistive device
(2) Able to stand independently for 10 seconds without an assistive device
(3) Stands and turns head and trunk to look behind (L) and (R)
(4) Able to bend forward to pick up object from floor safely
(5) Single limb stand for 10 seconds. (L)__________seconds; (R)__________seconds

Transfers (0) Non—weight-bearing hoist (full hoist)

Patient starts sitting at the edge of the bed. (1) Weight bearing hoist (standing hoist)
Instructions: (2) Assistance required by 2 persons, describe:
Please stand up and sit in your wheelchair/ (3) Assistance required by 1 person, describe:
chair. (4) Stand-by assistance(prompting required only
(5) Independent

Ambulation/mobility (0) Bed/chair bound

Patient starts standing with or without assistive (1) Wheelchair mobile (50 feet without assistance)
device or sitting in wheelchair. (2) Ambulant with assistance of two
Instructions: (3) Ambulant with assistance of one
Please walk/push your wheelchair. (4) Stand-by assistant/prompting required only
(5) Ambulates independently, aid required: Aids/assistance. Specify equipment used:

Total (Out of 45 points)

12g Volume 33 • Number 2 • April-June 2010

 13

Berg Balance Scale

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 14

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 XQDEOHWRVWDQGVHFRQGVXQDVVLVWHG
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(Instructions: “Sit with arms folded for two minutes.”)
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(Instructions: “Please sit down.”)
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7UDQVIHUV
(Instructions: “Please move from chair to chair/mat and back again. One way
toward a seat with armrests and one way toward a seat without armrests.”)
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(Instructions: “Close your eyes and stand still for 10 seconds.”)
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(Instructions: “Place your feet together and stand without holding.”)
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 15
%HUJ%DODQFH6FDOH3DJH
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The following items are to be performed while in the standing unsupported position: 
5HDFKLQJ)RUZDUGZLWK2XWVWUHWFKHG$UP    
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(Instruction: “Lift arm to 90 . Stretch out your fingers and reach forward
as far as you can.”)
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 FDQUHDFKIRUZDUG!LQFKHVVDIHO\
 FDQUHDFKIRUZDUG!LQFKHVVDIHO\
 UHDFKHVIRUZDUGEXWQHHGVVXSHUYLVLRQ
 QHHGVKHOSWRNHHSIURPIDOOLQJ
3LFN8S2EMHFW)URP WKH)ORRU    
(Instruction: “Pick up the shoe which is placed in front of your feet.”)
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 LVDEOHWRSLFNXSREMHFWEXWQHHGVVXSHUYLVLRQ
 XQDEOHWRSLFNXSEXWUHDFKHV´´IURPREMHFWDQGNHHSVEDODQFH
LQGHSHQGHQWO\
 XQDEOHWRSLFNXSDQGQHHGVVXSHUYLVLRQZKLOHWU\LQJ
 XQDEOHWRWU\DQGRUQHHGVDVVLVWWRNHHSIURPIDOOLQJ
7XUQLQJWR/RRN%HKLQG2YHU/HIWDQG5LJKW6KRXOGHUV    
(Instruction: “Turn to look behind you, over toward left shoulder. Repeat
to the right.”)
 ORRNVEHKLQGIURPERWKVLGHVDQGZHLJKWVKLIWVZHOO
 ORRNVEHKLQGRQHVLGHRQO\RWKHUVLGHVKRZVOHVVZHLJKWVKLIW
 WXUQVVLGHZD\VRQO\EXWPDLQWDLQVEDODQFH
 QHHGVVXSHUYLVLRQZKHQWXUQLQJ
 QHHGVDVVLVWWRNHHSIURPIDOOLQJ
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(Instructions: “Turn completely around in a full circle. Pause. Then turn a
full circle in the other direction.”)
R
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R
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R
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 QHHGVFORVHVXSHUYLVLRQRUYHUEDOFXHLQJ
 QHHGVDVVLVWDQFHZKLOHWXUQLQJ
The following items measure dynamic weight shifting while standing unsupported: 
&RXQW1XPEHURI7LPHV6WHS7RXFK0HDVXUHG6WRRO    
(Instructions: “Place foot alternately on the stool (6” - 8”). Continue until
each foot has touched the stool four times.”)
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VHFRQGV
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 QHHGVDVVLVWDQFHWRNHHSIURPIDOOLQJDQGRUXQDEOHWRWU\
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(Instructions: “Place one foot directly in front of the other. If you feel that
you cannot place your foot directly in front, try to step far enough ahead
that the heel of your forward foot is ahead of the toes of the other foot.”)
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(Instructions: “Stand on one leg as long as you can without holding.”)
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 16

Dynamic Gait Index

Description:
'HYHORSHGWRDVVHVV WKHOLNHOLKRRGRIIDOOLQJLQROGHU DGXOWV'HVLJQHGWRWHVWHLJKWIDFHWVRI
JDLW
Equipment needed: %R[6KRHER[&RQHV6tairs, 20’ ZDONZD\5” ZLGH
Completion:
Time: PLQXWHV
Scoring: $ IRXUSRLQWRUGLQDOVFDOHUDQJLQJIURP“0” LQGLFDWHVWKHORZHVW
OHYHORIIXQFWLRQDQG “3”WKHKLJKHVWOHYHORIIXQFWLRQ
7RWDO 6FRUH 
Interpretation:  19/24 = predictive of falls in the elderly
> 22/24 = safe ambulators

1. Gait level surface

Instructions: :DONDW\RXUQRUPDOVSHHGIURPKHUHWRWKHQH[W PDUN20’)
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO:Dlks 20’, noDVVLVWLYHGHYLFHVJRRGVSHGQRHYLGHQFHIRULPEDODQFHQRUPDO
JDLW SDWWHUQ
 0LOG,PSDLUPHQW:Dlks 20’, usHVDVVLVWLYHGHYLFHVVORZHUVSHHGPLOGJDLWGHYLDWLRQV
 0RGHUDWH,PSDLUPHQW :Dlks 20’, slow spHHGDEQRUPDOJDLWSDWWHUQHYLGHQFHIRU
LPEDODQFH
 6HYHUH,PSDLUPHQW &DQQRWZDlk 20’ without DVVLVWDQFHVHYHUHJDLW GHYLDWLRQVRU
LPEDODQFH

2. Change in gait speed

Instructions: %HJLQZDONLQJDW\RXUQRUPDOSDFHIRU5’ZKHQ,WHOO\RX“go,” ZDONDV IDVWDV
\RXFDQIRU’:KHQ,WHOO\RX“slow,” ZDONDVVORZO\DV\RXFDQIRU5’
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO$EOHWRVPRRWKO\FKDQJHZDONLQJ VSHHGZLWKRXWORVVRIEDODQFHRUJDLW
GHYLDWLRQ6KRZVDVLJQLILFDQWGLIIHUHQFHLQZDONLQJVSHHGVEHWZHHQQRUPDOIDVWDQG
VORZVSHHGV
 0LOG,PSDLUPHQW,VDEOHWRFKDQJHVSHHGEXWGHPRQVWUDWHVPLOGJDLW GHYLDWLRQVRUQRW
JDLW GHYLDWLRQVEXWXQDEOHWRDFKLHYHDVLJQLILFDQWFKDQJHLQYHORFLW\RUXVHVDQ
DVVLVWLYHGHYLFH
 0RGHUDWH,PSDLUPHQW 0DNHVRQO\PLQRUDGMXVWPHQWVWRZDONLQJVSHHGRU
DFFRPSOLVKHVDFKDQJHLQVSHHGZLWKVLJQLILFDQWJDLW GHYLDWLRQVRUFKDQJHVVSHHGEXW
KDVVLJQLILFDQWJDLWGHYLDWLRQVRUFKDQJHVVSHHGEXWORVHVEDODQFHEXWLVDEOHWRUHFRYHU
DQG FRQWLQXHZDONLQJ
 6HYHUH,PSDLUPHQW &DQQRWFKDQJHVSHHGVRUORVHVEDODQFHDQGKDVWRUHDFKIRUZDOO RU
EHFDXJKW

3. Gait with horizontal head turns

Instructions: %HJLQZDONLQJDW\RXUQRUPDOSDFH:KHQ,WHOO\ou to “look ULJht,” NHHSZDONLQJ
VWUDLJKWEXWWXUQ\RXUKHDGWRWKHULJKW.HHSORRNLQJWRWKHULJKWXQWLO,WHOO\RX“ORRN OHft,”
WKHQNHHSZDONLQJVWUDLJKWDQGWXUQ\RXUKHDGWRWKHOHIW.HHS\RXUKHDGWRWKHOHIWXQWLO,WHOO
\RX“ORRNVWUDLJKW“ WKHQNHHSZDONLQJVWUDLJKWEXWUHWXUQ\RXUKHDGWRWKHFHQWHU
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO3HUIRUPVKHDGWXUQVVPRRWKO\ZLWKQRFKDQJHLQJDLW
 17

 0LOG,PSDLUPHQW3HUIRUPVKHDGWXUQVVPRRWKO\ZLWKVOLJKWFKDQJHLQ JDLWYHORFLW\LH
PLQRUGLVUXSWLRQWRVPRRWKJDLW SDWKRUXVHVZDONLQJDLG
 0RGHUDWH,PSDLUPHQW 3HUIRUPVKHDGWXUQVZLWKPRGHUDWHFKDQJHLQJDLWYHORFLW\VORZV
GRZQVWDJJHUVEXWUHFRYHUVFDQ FRQWLQXHWRZDON
 6HYHUH,PSDLUPHQW 3HUIRUPV WDVNZLWKVHYHUHGLVUXSWLRQRIJDLWLHVWDJJHUV
RXWVLGH 15”SDWKORVHVEDODQFHVWRSVUHDFKHVIRUZDOO

4. Gait with vertical head turns

Instructions: %HJLQZDONLQJDW\RXUQRUPDOSDFH :KHQ,WHOO\ou to “look up,” NHHSZDONLQJ
VWUDLJKWEXWWLS\RXUKHDGXS.HHSORRNLQJXSXQWLO,WHOO\RX“ORRNGRZQ” WKHQNHHSZDONLQJ
VWUDLJKWDQGWLS\RXUKHDGGRZQ.HHS\RXUKHDGGRZQXQWLO,WHOO\RX“ORRNVWUDLJht,“ tKHQNHHS
ZDONLQJVWUDLJKWEXWUHWXUQ\RXUKHDGWRWKHFHQWHU
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO3HUIRUPVKHDGWXUQVVPRRWKO\ZLWKQRFKDQJHLQJDLW
 0LOG,PSDLUPHQW3HUIRUPVKHDGWXUQVVPRRWKO\ZLWKVOLJKWFKDQJHLQ JDLWYHORFLW\LH
PLQRUGLVUXSWLRQWRVPRRWKJDLW SDWKRUXVHVZDONLQJDLG
 0RGHUDWH,PSDLUPHQW 3HUIRUPVKHDGWXUQVZLWKPRGHUDWHFKDQJHLQ JDLWYHORFLW\VORZV
GRZQVWDJJHUVEXWUHFRYHUVFDQ FRQWLQXHWRZDON
 6HYHUH,PSDLUPHQW 3HUIRUPVWDVNZLWKVHYHUHGLVUXSWLRQRIJDLWLHVWDJJHUV
RXWVLGH15”SDWKORVHVEDODQFHVWRSVUHDFKHVIRUZDOO

5. Gait and pivot turn

Instructions: %HJLQZDONLQJDW\RXUQRUPDOSDFH :KHQ,WHOO\RX“WXUQDQd stop,” WXUQDV
TXLFNO\DV\RXFDQWRIDFHWKHRSSRVLWHGLUHFWLRQDQGVWRS
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO3LYRWWXUQVVDIHO\ ZLWKLQVHFRQGVDQGVWRSVTXLFNO\ZLWKQRORVVRIEDODQFH
 0LOG,PSDLUPHQW3LYRWWXUQVVDIHO\LQ!VHFRQGVDQGVWRSVZLWKQRORVVRIEDODQFH
 0RGHUDWH,PSDLUPHQW 7XUQVVORZO\UHTXLUHVYHUEDOFXHLQJUHTXLUHVVHYHUDOVPDOO VWHSV
WRFDWFKEDODQFHIROORZLQJWXUQDQGVWRS
 6HYHUH,PSDLUPHQW &DQQRWWXUQVDIHO\UHTXLUHV DVVLVWDQFHWRWXUQDQGVWRS

6. Step over obstacle

Instructions: %HJLQZDONLQJDW\RXUQRUPDOVSHHG :KHQ\RXFRPHWRWKHVKRHER[VWHSRYHULW
QRWDURXQGLWDQGNHHSZDONLQJ
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO,VDEOHWRVWHSRYHUWKHER[ZLWKRXWFKDQJLQJ JDLW VSHHGQRHYLGHQFHRI
LPEDODQFH
 0LOG,PSDLUPHQW,VDEOHWRVWHSRYHUER[EXWPXVWVORZGRZQDQGDGMXVWVWHSVWRFOHDU
ER[ VDIHO\
 0RGHUDWH,PSDLUPHQW,VDEOHWRVWHSRYHUER[EXWPXVWVWRSWKHQVWHSRYHU0D\
UHTXLUHYHUEDOFXHLQJ
 6HYHUH,PSDLUPHQW &DQQRWSHUIRUPZLWKRXWDVVLVWDQFH

7. Step around obstacles

Instructions: %HJLQZDONLQJDWQRUPDOVSHHG:KHQ\RXFRPHWRWKHILUVWFRQHDbout 6’DZD\
ZDONDURXQGWKHULJKWVLGHRILW:KHQ\RXFRPHWRWKHVHFRQGFRQH6’ SDVWILUVWFRQHZDON
DURXQGLW WRWKHOHIW
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO,VDEOHWRZDONDURXQGFRQHVVDIHO\ZLWKRXWFKDQJLQJJDLW VSHHGQRHYLGHQFH
RILPEDODQFH
 18

 0LOG,PSDLUPHQW,VDEOHWRVWHSDURXQGERWKFRQHVEXWPXVWVORZGRZQDQGDGMXVW
VWHSVWRFOHDU FRQHV
 0RGHUDWH,PSDLUPHQW,VDEOHWRFOHDU FRQHVEXWPXVWVLJQLILFDQWO\VORZVSHHGWR
DFFRPSOLVKWDVNRUUHTXLUHVYHUEDOFXHLQJ
 6HYHUH,PSDLUPHQW 8QDEOHWRFOHDUFRQHVZDONVLQWRRQHRUERWKFRQHVRUUHTXLUHV
SK\VLFDODVVLVWDQFH

8. Steps
Instructions: :DONXSWKHVH VWDLUVDV\RXZRXOGDWKRPHLHXVLQJWKHUDLOLQJLIQHFHVVDU\$W
WKHWRSWXUQDURXQGDQGZDONGRZQ
Grading: 0DUNWKHORZHVWFDWHJRU\WKDWDSSOLHV
 1RUPDO$OWHUQDWLQJIHHWQRUDLO
 0LOG,PSDLUPHQW$OWHUQDWLQJIHHW PXVWXVHUDLO
 0RGHUDWH,PSDLUPHQW7ZRIHHW WRDVWDLUPXVWXVH UDLO
 6HYHUH,PSDLUPHQW&DQQRWGRVDIHO\

TOTAL SCORE: / 24
5HIHUHQFHV
+HUGPDQ6-Vestibular Rehabilitation QG HG3KLODGHOSKLD3$)$'DYLV&R
6KXPZD\&RRN$:RROODFRWW 0 Motor Control Theory and Applications :LOOLDPV
DQG:LONLQV%DOWLPRUH
 19

ROMBERG TEST

7KH5RPEHUJ7HVWLVDQHXURORJLFDO WHVWWRGHWHFWSRRUEDODQFH6SHFLILFDOO\LW GHWHFWVWKH

LQDELOLW\WRPDLQWDLQDVWHDG\VWDQGLQJSRVWXUHZLWKWKHH\HVFORVHG7KHWHVW LVQDPHG
DIWHUWKHWKFHQWXU\*HUPDQ(DU6SHFLDOLVW0RULW]+HLQULFK5RPEHUJ

7KHWHVWFRQVLVWVRIVWDQGLQJZLWK\RXUIHHW WRJHWKHU DQG\RXUH\HVFORVHG7KHQHXURORJLVW

ZLOORIWHQSXVK\RXVOLJKWO\WRFKHFNZKHWKHU\RXDUHDEOHWRFRPSHQVDWHDQGUHJDLQ\RXU
SRVWXUH+HRUVKHVKRXOGDOVRVWDQGFORVHE\WRFDWFK\RXLI\RXVZD\H[FHVVLYHO\RUIDOO$
SRVLWLYH5RPEHUJLVH[FHVVLYHVZD\LQJRU HYHQIDOOLQJRYHUDQGLVVRPHWLPHVFDOOHG
5RPEHUJ
VVLJQ7KHUH DUHVHYHUDOYDULDQWVRI5RPEHUJ
V7HVWVRPHLQYROYHGLIIHUHQW
SRVLWLRQVRIWKHIHHWIRUH[DPSOH VWDQGLQJKHHOWRWRHRWKHUVXVHPHFKDQLFDOGHYLFHVWR
TXDQWLI\WKHG\VIXQFWLRQ

6RPHSHRSOHZLWKRXWQHXURORJLFDORUEDODQFHSUREOHPVKDYHVRPHSUREOHPV
PDLQWDLQLQJDVWHDG\SRVWXUH

$SRVLWLYH5RPEHUJ
VVLJQLQGLFDWHVRQHRUPRUHRIWKHVH SUREOHPV

• 9HUWLJRRU 9HVWLEXODU$WD[LDSUREOHPVZLWKWKHEDODQFHRUJDQVLQWKHLQQHU HDU

RU VHQVRU\IHHGEDFN7KHVH FDQEHFDXVHGE\
• 3UREOHPVZLWKWKHLQQHUHDULWVHOI
• 3UREOHPVLQWKHFUDQLDOQHUYHVXSSO\LQJWKHHDU &1 9,,,
• /HVLRQVLQWKH3RQVUHJLRQRIWKHEUDLQVWHPZKHUH&19,,,DULVHV
• 'DPDJHWRRWKHUFHQWUDOQHUYRXVV\VWHPSDWKZD\VZKLFKFRQQHFW WRWKH3RQV

• &HUHEHOODU$WD[LDWKLVLVDG\VIXQFWLRQFDXVHGE\GDPDJHWRDEUDLQUHJLRQFDOOHG
WKH FHUHEHOOXPRUWRQHUYRXVV\VWHPSDWKZD\VFRQQHFWLQJWRLW 7KHFHUHEHOOXPLV
UHVSRQVLEOHIRUDVVLPLODWLQJVHQVRU\GDWDIRU H[DPSOH OLPESRVLWLRQDQGYLVXDO
GDWDDQGFRFRRUGLQDWLQJPRYHPHQWVUHVXOWLQJIURP WKDW

• 3URSULRFHSWLYH'\VIXQFWLRQ3URSULRFHSWLYHVHQVRUVDUH ORFDWHGQWKHPXVFOHV DQG

MRLQWVDQGIHHGEDFNSRVLWLRQDOGDWDWRWKHFHUHEHOOXP'DPDJHDQ\ZKHUHDORQJWKH
SDWKZD\IURPWKHSURSULRFHSWLYHVHQVRUVWRWKHFHUHEHOOXPFDQJLYHULVHWR
FHUHEHOODUDWD[LD

%\HOLPLQDWLQJYLVXDOIHHGEDFNWKH5RPEHUJ7HVWFDQGHWHFW G\VIXQFWLRQLQRWKHUSDWKZD\V
WRDQGIURPWKHFHUHEHOOXP7KH5RPEHUJ7HVWLVDQRQVSHFLILFWHVWRIQHXURORJLFDORULQQHU
HDU G\VIXQFWLRQDQGLVQRWLQGLFDWLYHRIDVSHFLILFFRQGLWLRQ,W LVXVXDOO\FRPELQHGZLWKRWKHU
WHVWVLQFOXGLQJILQHUWRQRVHWHVWV9HUWLJRYHVWLEXODU DQGFHUHEHOODU DWD[LDDQGSURSULRFHSWLYH
G\VIXQFWLRQDUHDOO UHODWLYHO\FRPPRQO\VHHQLQPXOWLSOH VFOHURVLV

)DLOXUHWRFRPSHQVDWHLQDSDUWLFXODUGLUHFWLRQLVLQGLFDWLYHRIGDPDJH RQDSDUWLFXODUVLGHRI
WKH FHQWUDO QHUYRXVV\VWHP
 20

Balance Assessment: a
Modified Romberg test
A test for gait/ambulation

7KHVWDQGLQJSDWLHQWSHUIRUPV tasks of
increasing difficultyREVHUYLQJWKHUHVSRQVH
WRSRVLWLRQDOVWUHVVWRVVRIYLVXDOLQSXWDQG
GLVSODFHPHQW7KHSDWLHQWDVVXPHVGLIIHUHQW
VWDQGLQJSRVLWLRQVILUVWZLWKH\HVRSHQWKHQ
ZLWK H\HVFORVHGWith each successive
maneuverVWDELOLW\LVREVHUYHGDQGWKH
SDWLHQWLVDVNHG'R\RXIHHOVWHDG\"$
OLJKWQXGJHWRWKHVWHUQXPFDQEHKHOSIXOLQ
DVVHVVLQJWKHUHVSRQVHWRGLVSODFHPHQW
7KLVDOORZVDURXJKHVWLPDWHRIEDODQFHDQG
FDQKHOSLGHQWLI\FDXVDWLYHIDFWRUVHJ
RVWHRDUWKULWLVSHULSKHUDOQHXURSDWK\IRRW
SUREOHPVDWKHURVFOHURVLVZHDNQHVV
VWURNHSDLQRUFRQWUDFWXUHV

)HHWFRPIRUWDEO\DSDUW
)HHW WRJHWKHU
)HHWVHPLWDQGHPKHHOWRLQVWHS
 )HHW WDQGHPKHHOWRWRH
 21

Romberg Test

$VNWKHSDWLHQWWRVWDQGZLWKWKHLUIHHW WRJHWKHU WRXFKLQJHDFKRWKHU7KHQDVNWKH

SDWLHQWWRFORVHWKHLUH\HV5HPDLQFORVHDWKDQGLQFDVH WKHSDWLHQWEHJLQVWRVZD\RUIDOO

67. Romberg Test

:KDW LV %HLQJ7HVWHG"

:LWKWKHH\HVRSHQWKUHHVHQVRU\V\VWHPVSURYLGHLQSXWWRWKHFHUHEHOOXPWRPDLQWDLQ
WUXQFDOVWDELOLW\7KHVHDUHYLVLRQSURSULRFHSWLRQDQGYHVWLEXODUVHQVH,I WKHUHLVDPLOG
OHVLRQLQWKHYHVWLEXODURUSURSULRFHSWLRQV\VWHPVWKHSDWLHQWLVXVXDOO\DEOHWR
FRPSHQVDWHZLWKWKHH\HVRSHQ:KHQWKHSDWLHQWFORVHVWKHLUH\HVKRZHYHUYLVXDO LQSXW
LVUHPRYHGDQGLQVWDELOLW\ FDQEHEURXJKWRXW,IWKHUHLVDPRUHVHYHUHSURSULRFHSWLYHRU
YHVWLEXODUOHVLRQRULIWKHUHLVDPLGOLQHFHUHEHOODUOHVLRQFDXVLQJWUXQFDO LQVWDELOLW\WKH
SDWLHQWZLOOEHXQDEOHWRPDLQWDLQWKLVSRVLWLRQHYHQZLWKWKHLUH\HVRSHQ1RWHWKDW
LQVWDELOLW\FDQDOVREHVHHQZLWKOHVLRQVLQRWKHUSDUWVRIWKHQHUYRXVV\VWHPVXFKDVWKH
XSSHURUORZHUPRWRUQHXURQVRUWKHEDVDOJDQJOLDVRWKHVH VKRXOGEHWHVWHGIRUVHSDUDWHO\
LQRWKHUSDUWVRIWKHH[DP
 22

*HW8SDQG*R7HVW
Procedure: Guide the subject to stand up from a chair, walk a short distance (3 meters), tum
around, return, and sit down again. Scoring of the test is based on a rating scale between 1
and 5 points. The scores are defined as follows:

This test can be used with ACL of 2.4 or greater.

Score
Date Date Date Date

 1RUPDO
The subject gave no evidence of being at risk of falling
during the test or at any other time

 9HU\ VOLJKWO\ DEQRUPDO The scores of 2, 3, and 4 are based on

 0LOGO\ DEQRUPDO the presence of undo slowness,
 0RGHUDWHO\ DEQRUPDO hesitancy, abnormal movements of
the trunk, upper limbs, staggering
and stumbling.

 6HYHUHO\ DEQRUPDOā
The subject appeared at risk of falling during the test
performance.

TIME (optional):

Timed Get-Up-and-Go Test: Podisiadlo, D. and Richardson, 6 reported that subjects who performed the
test in less than 20 seconds tended to be independent in mobility. Those subjects that performed the test in
30 seconds or more tended to need assistance of others for mobility tasks. The authors also described D
"gray zone" in which 25% of the subjects performed the test in 20- 29 seconds. This group of subjects
varied widely with respect to balance, gait speed, and functional capacity. The authors reported that the
Timed Get-Up-and-Go correlated well with the subject's balance, gait speed and functional capacity with r
72, r=.55, r =.51 respectively.
The Timed portion is useful for patients with Allen Cognitive Levels of 4.0 or greater.
 23
Timed Up and Go

Description Scoring

0HDVXUHVG\QDPLFEDODQFHJDLWVSHHGDQG < 10 seconds &OLHQWVDUHIUHHO\PRELOH

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PRELOLW\ FRPPXQLW\EDVHGH[HUFLVHSURJUDP

Estimated Time of Test &OLHQWVDUHLQGHSHQGHQWZLWKEDVLFWUDQVIHUV

 PLQXWHV < 20 seconds 0RVWJRRXWVLGHDORQHDQGFOLPEVWDLUV0DQ\
DUHLQGHSHQGHQWZLWKWXEDQGVKRZHUWUDQVIHUV
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Instructions for Timed Up and Go SULRUWR 37LQWHUYHQWLRQ

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 24
ELDERLY MOBILITY SCALE

1. Purpose
This scale provides physiotherapists with a standardised validated scale for assessment of mobility in more frail elderly
patients. The scale has good validity and inter-rater reliability.

2. Content
The scale assesses 7 dimensions of functional performance. These include locomotion, balance and key position changes,
all of which are intrinsic skills that permit the performance of complex activities of daily living. Total score is from a
maximum of 20, higher scores indicating better performance.

3. Assessment
ELDERLY MOBILITY SCALE
Lying to sitting Gait
2 Independent 3 Independent (incl. use of sticks)
1 Needs help of 1 person 2 Independent with frame
0 Needs help of 2+ people 1 Mobile with walking aid but erratic/
unsafe turning
0 Requires physical assistance or constant
supervision
Sitting to lying Timed walk
2 Independent 3 Under 15 seconds
1 Needs help of 1 person 2 16-30 seconds
0 Needs help of 2+ people 1 over 30 seconds
Sit to stand Functional Reach
3 Independent in under 3 seconds 4 Over 20cm
2 Independent in over 3 seconds 2 10-20cm
1 Needs help of 1 person (verbal or physical) 0 Under 10cm or unable
0 Needs help of 2 + people
Standing
3 Stands without support & reaches within arms
length
2 Stands without support but needs help to reach
1 Stands, but requires support
0 Stands, only with physical support (1 person)
Support = uses upper limbs to
steady self
Total

Interpretation of scores*
14 – 20 Manoeuvres alone and safely. Independent in basic ADLs. These patients are generally safe to go home
but may need home help
10 – 13 Borderline in terms of safe mobility and independence in ADLs. These patients will require some help
with mobility manoeuvres.
< 10 Dependent in mobility manoeuvres & requiring help with basic ADLs (transfers, toileting, dressing etc.).
May require Home Care Package/Long Term Care depending on patients’ wishes and circumstances.
* Please note that these are general interpretations. They do not take into account cognition, safety awareness and other
factors that may impact on mobility e.g. postural hypotension.

References
Proser L et al (1997) Further validation of EMS for measurement of mobility of hospitalised elderly people Clinical
Rehabilitation 11, 4, 338-343

Smith R (1994) Validation and Reliability of the Elderly Mobility Scale Physiotherapy 80, 744-747

Spilg, E. G., B. J. Martin, et al. (2001). A comparison of mobility assessments in a geriatric day hospital. Clinical
Rehabilitation 15(3): 296-300

Mabel S. W. Yu (2007) Usefulness of the Elderly Mobility Scale for classifying residential placements. Clinical Rehabilitation,
Vol. 21, No. 12, 1114-1120
 25
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 26
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 PATIENT'S NAME:
RIVERMEAD MOBILITY 27

INDEX
&23<5,*+75,9(50($'5(+$%,/,7$7,21&(175(
$%,1*'2152$'2;)25'2;,;' HOSPITAL NUMBER:
(Reproduce freely but acknowledge source.)

Score 0 = No 1 = Yes DATE

'R\RXWXUQRYHUIURP\RXUEDFNWR\RXUVLGHZLWKRXWKHOS"

)URPO\LQJLQEHGDUH\RXDEOHWRJHWXSWRVLWRQWKHHGJHRI
WKHEHGRQ\RXURZQ"

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VHFRQGV"

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DFKDLULQOHVVWKDQVHFRQGVDQGVWDQGWKHUHIRUVHFRQGV

2EVHUYHSDWLHQWVWDQGLQJIRUVHFRQGVZLWKRXWDQ\DLG

$UH\RXDEOHWRPRYHIURPEHGWRFKDLUDQGEDFNZLWKRXW
DQ\KHOS"

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VWDQGE\KHOS"

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RULFHZLWKRXWKHOS"

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$IDVWZDONLVDFFHSWDEOH
TOTAL
 28

5LYHUPHDG0RELOLW\,QGH[50,


Q1. What does the Rivermead Mobility Index test?

0RELOLW\GLVDELOLW\IRFXVHGRQIXQGDPHQWDODVSHFWVRIPRELOLW\WKDWLVDVSHFWVRIPRELOLW\
LQGHSHQGHQWRIRQH¶VVRFLDOHQYLURQPHQW&ROOHQHWDO:DGH

Q2. Describe the Rivermead Mobility Index

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)RXUWHHQLWHPVDUHTXHVWLRQVDERXWWKHSHUIRUPDQFHRIIXQFWLRQDODFWLYLWLHVDVVHVVHGE\
VHOIUHSRUWDQGRQHDFWLYLW\LVDVVHVVHGE\GLUHFWREVHUYDWLRQ$OOLWHPVJHQHUDWHD
GLFKRWRPRXV\HVQRUHVSRQVHZLWK³\HV´JHWWLQJDVFRUHRI

Q3. Describe some of the key Rivermead Mobility Index numbers

7KHWRWDOVFDOHVFRUHUDQJHVIURP±ZKHUHDVFRUHRIZRXOGLQGLFDWHFRPSOHWH
LQDELOLW\WRSHUIRUPDQ\RIWKHIXQFWLRQDODFWLYLWLHVLQFOXGHGLQWKHDVVHVVPHQW

Q4. What are the Advantages of the Rivermead Mobility Index?

$VVHVVPHQWWDNHVDSSUR[LPDWHO\±PLQXWHVDQGUHTXLUHVQRVSHFLDOHTXLSPHQWRU
WUDLQLQJ&ROOHQHWDO)RUODQGHU %RKDQQRQ
7KH50,LVDUHOLDEOHLQVWUXPHQW

Q5. What are the Disadvantages of the Rivermead Mobility Index?

,QFUHDVHVLQPRELOLW\DFKLHYHGWKURXJKHQYLURQPHQWDOPRGLILFDWLRQVWKHXVHRIDVVLVWLYH
GHYLFHVRUZLWKKHOSIURPDQRWKHUSHUVRQLVQRWWDNHQLQWRDFFRXQW&ROOHQHWDO
3RWHQWLDOGLIILFXOWLHVLQWKHRUGHURIWKHILUVWVFDOHLWHPV


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4XHVWLRQV $QVZHU
:KDWGRHVLW 0RELOLW\GLVDELOLW\IRFXVHGRQIXQGDPHQWDODVSHFWVRIPRELOLW\
PHDVXUH" WKDWLVDVSHFWVRIPRELOLW\LQGHSHQGHQWRIRQH¶VVRFLDO
HQYLURQPHQW&ROOHQHWDO:DGH
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 29

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,2
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NOTE: Excellent;  Adequate;  Poor; QD insufficient information; 75 Test re-test; ,&
Internal consistency; ,2 Interobserver; YDULHG(re floor/ceiling effects; mixed results)

References

Collen FM, Wade DT, Robb GF, Bradshaw CM. The Rivermead Mobility Index: A further
development of the Rivermead Motor Assessment. Int Disabil Stud 1991;13:50- 54.

Wade DT. Measurement in neurological rehabilitation. New York: Oxford University Press, 1992.

Forlander DA, Bohannon RW. Rivermead Mobility Index: a brief review of research to date. Clin
Rehabil 1999;13:97-100.



 30

Sensory and
Functional Reach
 31

Functional Reach Test

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Average Values for Scores:

$Q\WKLQJXQGHU 8” LVDWrisk IRUIDOOV

$Q\WKLQJXQGHU 6” LVDWhigh risk IRUIDOOV

Men Women
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 32

Functional Reach
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 38

Pain Assessment Tools

 39

Therapist Signature:__________________________________ PT OT ST (Circle one.)

 40

Assessing Pain in Older Adults with Dementia

By: Ann L. Horgas, RN, PhD, FGSA, FAAN, University of Florida College of Nursing

Why: Pain in older adults is very often undertreated, and it may be especially so in older adults with severe
dementia. Changes in a patient’s ability to communicate verbally present special challenges in treating
pain, since self-report is considered the gold standard of pain assessment.
As with older adults, those with dementia are at risk for multiple sources and types of pain, including
chronic pain from conditions such as osteoarthritis and acute pain from surgery, injury, and infection.
Untreated pain in cognitively impaired older adults can delay healing, disturb sleep and activity patterns,
reduce function, reduce quality of life, and prolong hospitalization.
The American Medical Directors Association has endorsed the Pain Assessment in Advanced Dementia
Scale (PAINAD) (Warden, Hurley, & Volicer, 2003).
The American Society for Pain Management Nursing’s Task Force on Pain Assessment in the Nonverbal
Patient recommends a comprehensive hierarchical approach to pain assessment that incorporates the
following steps:
x Ask older adults with dementia about their pain. Even older adults with mild to moderate
dementia can respond to simple questions about their pain.
x Use a standardized tool to assess pain intensity, such as the numerical rating scale (NRS) (0-10) or a
verbal descriptor scale (VDS) (Herr, Coyne, et al., 2006). The VDS asks participants to select a word
that best describes their present pain (e.g., no pain to worst pain imaginable) and may be more
reliable than the NRS in older adults with dementia.
x Use an observational tool (e.g., PAINAD) to measure the presence of pain in older adults with
dementia.
x Ask family or usual caregivers as to whether the patient’s current behavior (e.g., crying out,
restlessness) is different from their customary behavior. This change in behavior may signal pain.
x If pain is suspected, consider a time-limited trial of an appropriate type and dose of an analgesic
agent. Thoroughly investigate behavior changes to rule out other causes. Use self-report and
observational pain measure to evaluate the pain before and after administering the analgesic.
 41
Comprehensive Pain Assessment Form
&RJQLWLYHO\,PSDLUHG

Name       ID #      Room #     

Assessment Date       Time        Physician 


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Current Pain-related Diagnosis(es):      

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 42
Additional Pain BehaviorsIURP0'66HFWLRQ-
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8QNQRZQ 2WKHUGHVFULEH    

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Family Report about Pain/Pain History:      

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Comments:      

Signature/Title of person completing assessment:      'DWH     
 43
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 44
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 45

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 46
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 47
BRIEF PAIN INVENTORY
7) What treatments or medications are you
Date / / Time: receiving for your pain?

Name: ________________________________________________
Last First Middle Initial

________________________________________________
1) Throughout our lives, most of us have had pain from
time to time (such as minor headaches, sprains, and
toothaches). Have you had pain other than these 8) In the last 24 hours, how much relief have pain
everyday kinds of pain today? treatments or medications provided? Please circle
1. Yes 2. No the one percentage that shows how much RELIEF
you have received.
2) On the diagram, shade in the areas where you feel 0% 10 20 30 40 50 60 70 80 90 100%
pain. Put an X on the area that hurts the most.
No Complete
relief relief

Right Left Left Right

9) Circle the one number that describes how, during
the past 24 hours, pain has interfered with your:

A. General activity
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

B. Mood
0 1 2 3 4 5 6 7 8 9 10
Does not Completely
interfere interferes

3) Please rate your pain by circling the one number C. Walking ability
that best describes your pain at its WORST in the 0 1 2 3 4 5 6 7 8 9 10
last 24 hours. Does not Completely
interfere interferes
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad
Pain as you can D. Normal work (includes both work outside the
imagine
home and housework)
4) Please rate your pain by circling the one number 0 1 2 3 4 5 6 7 8 9 10
that best describes your pain at its LEAST in the Does not Completely
last 24 hours. interfere interferes

0 1 2 3 4 5 6 7 8 9 10
No Pain as bad E. Relations with other people
Pain as you can
imagine 0 1 2 3 4 5 6 7 8 9 10
Does not Completely
5) Please rate your pain by circling the one number interfere interferes
that best describes your pain on the AVERAGE.
0 1 2 3 4 5 6 7 8 9 10 F. Sleep
No Pain as bad
Pain as you can
0 1 2 3 4 5 6 7 8 9 10
imagine Does not Completely
interfere interferes
6) Please rate your pain by circling the one number
that tells how much pain you have RIGHT NOW. G. Enjoyment of life
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
No Pain as bad
Pain as you can Does not Completely
imagine interfere interferes

Brief Pain Inventory (Short Form). Source: Pain Research Group, Department of
Neuro-Oncology, The University of Texas MD Anderson Cancer Center. Provided as an educational service by
Used with permission. Adapted to single page format.
 48

In addition to completing the Brief Pain Inventory, Talking About Your Pain
to help your doctor better manage your pain,
please tell us: It’s important to remember that each person’s pain
is different. The pain that you experience can’t be
What does the pain feel like? Circle compared to another person’s pain. ONLY YOU know
how and when you hurt, and how the pain affects
those words that describe your pain. your life.
aching throbbing shooting It is important to describe what you are feeling to those
who are trained to help you. Don’t be embarrassed to
stabbing gnawing pricking talk to your doctor, nurse, or pharmacist. They need to
sharp tender burning know as much as possible about your pain in order to
develop the best plan to control it. The questions on
exhausting tiring penetrating this form can help you describe your pain.
nagging numb miserable
Why Is Pain Relief So Important?
unbearable dull radiating
Proper treatment for pain is not only a matter of
squeezing cramping deep comfort. Unrelieved pain can lead to nausea, loss of
sleep, depression, loss of appetite, weakness, and other
How long have you had this pain? problems. Pain can also affect your life at home and at
(Circle one) work. Relieving your pain means that you can continue
to do the day-to-day things that are important to you.
less than a week 1 to 2 weeks
2 to 4 weeks more than a month Most Pain Can Be Controlled
It is important to know that most pain CAN be relieved.
What kinds of things make your pain feel Your doctor will work with you to find the treatment
better (for example, heat, medicine, rest)? that may be best for your pain.

________________________________________________ The key to effective pain control is to take the RIGHT

________________________________________________
What kinds of things make your pain worse
(for example, walking, standing, lifting)?
________________________________________________
________________________________________________
AMOUNT, of the RIGHT MEDICINE, at the RIGHT TIME.
You should take your pain medicine on a regular sched-
ule, as your doctor, nurse, or pharmacist tells you. Don’t
wait until the pain becomes severe. Pain is easier to con-
trol when it is mild than when it has reached full force.
If your pain medicine wears off too soon, is not relieving
the pain, or causes problems with side effects, you
should call your doctor because you may need to have
your treatment plan changed.

Do you have any other symptoms?

Comments: Write down any questions or
Circle any that apply:
information you need to share with your
nausea vomiting doctor, nurse, or pharmacist about your pain.
constipation diarrhea
_________________________________________________________
lack of appetite indigestion
_________________________________________________________
difficulty sleeping feeling drowsy
_________________________________________________________
nightmares dizziness
tiredness itching _________________________________________________________

urinary problems sweating _________________________________________________________

weakness headaches _________________________________________________________

Provided as an educational service by 3056HSWHPEHU

 49

Pulmonary and
Cardiac Assessments
 50

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 52

Metabolic Equivalent
Pick the best exercises by fitness level and calories burned.
Metabolic Equivalent (MET)* can tell you the amount of energy burned
with just about any type of physical activity or exercise. Below are
MET charts for sports/hobbies, at home activities and formal
exercises. The charts compare the calories burned for 30 minutes of
each activity.

Definition of metabolic equivalent

*1 MET
The energy burned at rest, which is 30-38 calories for every 30
minutes

3-6 MET
The energy burned with moderate exercise: 90-225 calories per 30
minute workout. (Moderate exercise is intense enough to meet health
standards for the U.S. Physical Activity Guidelines.)

Calories are calculated for the average adult in the US, weighing 165-
190 lbs, Your exact calories burned during exercise may vary due to
differences in muscle mass or level of effort during the activity.
 53

More sports and leisure activities

Softball / baseball-- (5.0 MET)-- 150-188 calories Hiking

without a heavy pack-- (6.0 MET)-- 180-225 cal Downhill
skiing, moderate effort-- (6.0 MET)-- 180-225 cal
Horseback riding, trotting-- (6.5 MET)-- 195-244 cal
Tennis, singles-- (7.0 MET)-- 210-263 cal
Raquetball, casual-- (7.0 MET)-- 210-263 cal
Volleyball, competitive-- (8.0 MET)-- 240-300 cal
Touch or flag football-- (8.0 MET)-- 240-300 cal
Mountain biking--(8.5 MET)-- 255-323 cal
Rock climbing-- (11.0 MET)-- 330-413 cal

More 'At Home' Activities

Light gardening--(2.3 MET)-- 69-87 cal

General cleaning and straightening up--(2.5 MET)-- 75-95 cal
Washing dishes, clearing table--(2.5 MET)--75-95 cal
Putting away groceries--(2.5 MET)--75-95 cal
Scrubbing floors-- (3.8 MET) -- 114-143 calories
Multiple household tasks all at once.
vigorous effort (4.0 MET)-- 120-150 cal
 54

Gardening / weeding-- (4.0 MET) -- 120-170 cal

Mowing the lawn-- (5.5 MET) -- 165-206 cal
Shoveling, moderate-- (7.0 MET) -- 210-263 cal

More 'Formal Exercise' Routines

Walking 2.0 mph-- (2.8 MET) -- 84-106 cal

Walking 3.0 mph-- (3.3 MET) -- 99-124 cal
Walking in sand-- (4.5 MET)-- 135-171 cal
Water aerobics-- (5.3 MET) -- 159-201 cal
Health club exercise
(stairclimber, elliptical trainer)--(5.5 MET) 165-206 cal
Stationary bike, 100 watts-- (5.5 MET)-- 165-206 cal
Walking 3.5 mph uphill-- (6.0 MET) -- 180-225 cal
Circuit training-- (8.0 MET) -- 240-304 cal
Swimming freestyle, vigorous-- (12.0 MET) -- 360-450 cal
Running 8 min/mile (7.5 mph)-- (12.5 MET) -- 375-469 cal

Still missing the metabolic equivalent for your activity? Find the most complete list here.
 55

Think of the calories burned on the Metabolic Equivalent charts as an average. Raking the lawn
can be done at a slow pace, which burns less energy, or it can be done more vigorously which
burns more calories. In the same way, a light game of 2-on-2 basketball is a lighter workout
than a highly competitive game of 5-on-5.

Need more guidance in picking activities? Take the Rockport walking test. Once you have your
fitness rating (VO2 Max),you can pick the activities that best match your fitness level. Click the
chart to take the test. As you become more fit, you'll be able to add higher calorie- burning
activities to your routine.

With this in mind, during whichever type of exercise or physical activity you choose for your
workout, pace yourself according to your ability level. If you are a beginner, or if you need a
lighter workout today, keep your effort moderate. If you are a (well-rested) fit person looking for
a harder workout then you can work at a high intensity. The Exercise Effort Scale will help you
maintain the best level of effort for your next workout.

Using metabolic equivalent allows you to include all kinds of activities in your workout plans.
Sports, playing with children, yard work and dancing can all be part of your plans to get in
shape. All you need to do is keep moving and maintain a moderate effort during the exercise.

Refer to the pages below for further info. They will open in a separate window so you can flip
between pages.

Related articles
VO2 Max A key health and fitness measurement. Improve your score and improve your
cardiovascular health! Rockport walking test

Calculate your VO2 Max with this 1 mile walking test.

Free workout plans

Build a workout routine you can commit to using physical activities that fit your lifestyle.
 56

GXT Stress Test

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 58
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 59

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60
 Activity Log
DATE TYPE OF ACTIVITY TOTAL MINUTES HOW I FELT
61

Personal Goals: ____________________________________________________________________________________________________________________________________________

 Medicine Chart
Name: ____________________________

Date: ____________________________

HOW OFTEN & PRESCRIBING PHARMACY

NAME OF MEDICINE COLOR WHAT S IT FOR? DOSE SPECIAL INSTRUCTIONS REFILL DATE
WHAT TIME DOCTOR PHONE NO.

Aspirin white blood thinner 1 pill once daily at night Dr. Jones 650-555-1234 Take with food 9/1/12
62
 BLOOD PRESSURE TRACKER - INSTRUCTIONS
63

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64

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professional recommends. the Instructions page of this tracker for a
picture, or check your monitor’s instructions,
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flat on the floor.
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the upper arm at heart level.
Cut this card out, fold it and keep in your wallet for use when
you are traveling or away from home.

BLOOD HEART BLOOD HEART BLOOD HEART

PRESSURE RATE (PULSE) PRESSURE RATE (PULSE) PRESSURE RATE (PULSE)
DATE/TIME DATE/TIME DATE/TIME
READING 1 READING 1 READING 1
READING 2 READING 2 READING 2
READING 3 READING 3 READING 3
COMMENTS COMMENTS COMMENTS
DATE/TIME DATE/TIME DATE/TIME
READING 1 READING 1 READING 1
READING 2 READING 2 READING 2
READING 3 READING 3 READING 3
COMMENTS COMMENTS COMMENTS
DATE/TIME DATE/TIME DATE/TIME
READING 1 READING 1 READING 1
READING 2 READING 2 READING 2
READING 3 READING 3 READING 3
COMMENTS COMMENTS COMMENTS
DATE/TIME DATE/TIME DATE/TIME
READING 1 READING 1 READING 1
READING 2 READING 2 READING 2
READING 3 READING 3 READING 3
COMMENTS COMMENTS COMMENTS

fold
fold

Blood pressure higher than 180/110 is an emergency. Call 9-1-1 immediately. If 9-1-1 is not available to you, have someone drive you to the nearest emergency facility immediately.
65

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 66

ADL Assessment Tools

Appendix 3
MODIFIED BARTHEL INDEX (SHAH VERSION) : SELF CARE ASSESSMENT
INDEX ITEM
CHAIR/BED TRANSFERS
AMBULATION
AMBULATION/WHEELCHAIR
* (If unable to walk)
Only use this item if the
patient is rated “0” for
Ambulation, and then
only if the patient has
been trained in
wheelchair management.
SCORE DESCRIPTION
0 Unable to participate in a transfer. Two attendants are required to transfer the
patient with or without a mechanical device.
3 Able to participate but maximum assistance of one other person is require in all
aspects of the transfer.
8 The transfer requires the assistance of one other person. Assistance may be
required in any aspect of the transfer.
12 The presence of another person is required either as a confidence measure, or to
provide supervision for safety.
15 The patient can safely approach the bed walking or in a
wheelchair, lock brakes, lift footrests, or position walking aid, move safely to bed,
lie down, come to a sitting position on the side of the bed, change the position of
the wheelchair, transfer back into it safely and/or grasp aid and stand. The patient
must be independent in all phases of this activity.
0 Dependent in ambulation.
3 Constant presence of one or more assistant is required during ambulation.
Assistance is required with reaching aids and/or their manipulation. One person is
8 required to offer assistance.
The patient is independent in ambulation but unable to walk 50 metres without
12 help, or supervision is needed for confidence or safety in hazardous situations.
The patient must be able to wear braces if required, lock and unlock these braces
assume standing position, sit down, and place the necessary aids into position for
15 use. The patient must be able to crutches, canes, or a walkarette, and walk 50
metres without help or supervision.
0 Dependent in wheelchair ambulation.
1 Patient can propel self short distances on flat surface, but assistance is required for
all other steps of wheelchair management.
3 Presence of one person is necessary and constant assistance is required to
manipulate chair to table, bed, etc.
4 The patient can propel self for a reasonable duration over regularly encountered
terrain. Minimal assistance may still be required in “tight corners” or to negotiate
a kerb 100mm high.
5 To propel wheelchair independently, the patient must be able to go around corners,
turn around, manoeuvre the chair to a table, bed, toilet, etc. The patient must be
able to push a chair at least 50 metres and negotiate a kerb.
66a
 INDEX ITEM SCORE DESCRIPTION
0 The patient is unable to climb stairs.

2 Assistance is required in all aspects of chair climbing, including assistance with

walking aids.

5 The patient is able to ascend/descend but is unable to carry walking aids and needs
supervision and assistance.
STAIR CLIMBING
8 Generally no assistance is required. At times supervision is required for safety due
to morning stiffness, shortness of breath, etc.

10 The patient is able to go up and down a flight of stairs safely without help or
supervision. The patient is able to use hand rails, cane or crutches when needed
and is able to carry these devices as he/she ascends or descends.

0 Fully dependent in toileting.

2 Assistance required in all aspects of toileting.

5 Assistance may be required with management of clothing, transferring, or

washing hands.

TOILET TRANSFERS 8 Supervision may be required for safety with normal toilet. A commode may be
used at night but assistance is required for emptying and cleaning.

10 The patient is able to get on/off the toilet, fasten clothing and use toilet paper
without help. If necessary, the patient may use a bed pan or commode or urinal at
night, but must be able to empty it and clean it.

0 The patient is bowel incontinent.

2 The patient needs help to assume appropriate position, and with bowel movement
facilitatory techniques.

5 The patient can assume appropriate position, but cannot use facilitatory techniques
or clean self without assistance and has frequent accidents. Assistance is required
BOWEL CONTROL with incontinence aids such as pad, etc.

8 The patient may require supervision with the use of suppository or enema and has
occasional accidents.

10 The patient can control bowels and has no accidents, can use suppository, or take
an enema when necessary.

0 The patient is dependent in bladder management, is incontinent, or has indwelling

catheter.

2 The patient is incontinent but is able to assist with the application of an internal or
external device.

BLADDER CONTROL 5 The patient is generally dry by day, but not at night and needs some assistance
with the devices.

8 The patient is generally dry by day and night, but may have an occasional accident
or need minimal assistance with internal or external devices.

10 The patient is able to control bladder day and night, and/or is independent with
internal or external devices.

66b
 INDEX ITEM SCORE DESCRIPTION
0 Total dependence in bathing self.

1 Assistance is required in all aspects of bathing, but patient is able to make some
contribution.

3 Assistance is required with either transfer to shower/bath or with washing or

drying; including inability to complete a task because of condition or disease, etc.
BATHING
Supervision is required for safety in adjusting the water temperature, or in the
4 transfer.

The patient may use a bathtub, a shower, or take a complete sponge bath. The
5 patient must be able to do all the steps of whichever method is employed without
another person being present.

0 The patient is dependent in all aspects of dressing and is unable to participate in

the activity.

2 The patient is able to participate to some degree, but is dependent in all aspects of
dressing.

DRESSING 5 Assistance is needed in putting on, and/or removing any clothing.

8 Only minimal assistance is required with fastening clothing such as buttons, zips,
bra, shoes, etc.

10 The patient is able to put on, remove, corset, braces, as prescribed.

0 The patient is unable to attend to personal hygiene and is dependent in all aspects.

Assistance is required in all steps of personal hygiene, but patient able to make
1 some contribution.

PERSONAL HYGIENE Some assistance is required in one or more steps of personal hygiene.
3
(Grooming) Patient is able to conduct his/her own personal hygiene but requires minimal
4 assistance before and/or after the operation.

The patient can wash his/her hands and face, comb hair, clean teeth and shave. A
5 male patient may use any kind of razor but must insert the blade, or plug in the
razor without help, as well as retrieve it from the drawer or cabinet. A female
patient must apply her own make-up, if used, but need not braid or style her hair.

0 Dependent in all aspects and needs to be fed, nasogastric needs to be administered.

Can manipulate an eating device, usually a spoon, but someone must provide
2 active assistance during the meal.

Able to feed self with supervision. Assistance is required with associated tasks
5 such as putting milk/sugar into tea, salt, pepper, spreading butter, turning a plate or
other “set up” activities.
FEEDING
Independence in feeding with prepared tray, except may need meat cut, milk
8 carton opened or jar lid etc. The presence of another person is not required.

The patient can feed self from a tray or table when someone puts the food within
reach. The patient must put on an assistive device if needed, cut food, and if
10 desired use salt and pepper, spread butter, etc.

66c
 SCORE INTERPRETATION
00 - 20 Total Dependence

21 - 60 Severe Dependence

61 - 90 Moderate Dependence

91 - 99 Slight Dependence

- 100 Independence

SCORE PREDICTION
Less Than 40 Unlikely to go home
- Dependent in Mobility
- Dependent in Self Care

60 Pivotal score where patients move from dependency to assisted independence.

60 - 80 If living alone will probably need a number of community services to cope.

More Than 85 Likely to be discharged to community living

- Independent in transfers and able to walk or use wheelchair independently.

REFERENCES
1. Shah, S., Vanclay, F., & Cooper, B. (1989a). Improving the sensitivity of the Barthel Index for stroke
rehabilitation. Journal of Clinical Epidemiology, 42, 703 - 709.

2. Shah, S., & Cooper, B. (1991). Documentation for measuring stroke rehabilitation outcomes.
Australian Medical Records Journal, 21, 88 - 95.

3. Shah, S., Cooper, B., & Maas, F. (1992). The Barthel Index and A D L evaluation in stroke
rehabilitation in Australia, Japan, the U K and the U S A. Australian Occupational Therapy Journal,
39, 5 - 13.

4. Granger, V., Dewis, L., Peters, W., Sherwood, C., & Barrett, J. (1979). Stroke rehabilitation
analysis of repeated Barthel Index measures. Archives of Physical and Medical
Rehabilitation, 60, 14 - 17.

5. Hasselkus, B., (1982). Barthel self-care index and geriatric home care patients. Physical and
Occupational Therapy in Geriatrics, 1, 11 - 22.

6. Leonard, R., & McGovern, L. (1992). The Barthel Index in an acute geriatric setting.
American Journal of Occupational Therapy, 39, 41 - 43.

66d
 67

THE Patient Name BBBBBBBBBBBBBBBBBBBBBBBBBB

BARTHEL Rater Name: __________________________
INDEX Date: ___________________________

Activity Score

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 68

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References

McDowell I, Newell C. Measuring Health. A Guide to Rating Scales and Questionnaires., 2nd ed.
New York: Oxford University Press, 1996.

Duncan PW, Samsa G, Weinberger M, et al. Health status of individuals with mild stroke. Stroke
1997; 28:740-745.

Roberts L, Counsell R. Assessment of clinical outcomes in acute stroke trials. Stroke 1998; 28:986-
991.
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References

Wade DT. Measurement in neurological rehabilitation. New York: Oxford University Press, 1992.

Segal ME, Schall RR. Determining funcitonal/health status and its relation to disability in stroke
survivors. Stroke 1994;25:2391-2397.

Holbrook M, Skilbeck CE. An activities index for use with stroke patients. Age and Aging
1983;12:166-170.

Han CW, Yajima Y, Nakajima K, Lee EJ, Meguro M, Kohzuki M. Construct validity of the Frenchay
Activities Index for community dwelling elderly in Japan. Tohoku J Exp Med 2006;210:99-107.

Appelros P. Characteristics of the Frenchay Activities Index one year after a stroke: a population-
based study. Disabil Rehabil 2007;29:785-790.

Piercy M, Carter J, Mant J, Wade DT. Interrater reliability of the Frenchay Activities Index in
patients with stroke and their carers. Clin Rehabil 2000;14:433-440.

Post MWM, de Witte LP. Good inter-rater reliability of the Frenchay Activities Index in stroke
patients. Clinical Rehabilitation 2003; 17: 548-552.
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Fine Motor, Dexterity

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Assessments
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Q1. What does the Nine-Hole Peg Test test?

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Q4. What are the Advantages of the Nine-Hole Peg Test?

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Q5. What are the Disadvantages of the Nine-Hole Peg Test?

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References

Mathiowetz V, Volland G, Kashman N, Weber K. Adult Norms for the Box and Block Test of Manual
Dexterity. The American Journal of Occupational Therapy 1985;39:386-391
 85

Bowel and Bladder

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Bowel and Bladder Incontinence Assessment

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Bowel and Bladder Incontinence Assessment

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Bowel and Bladder Incontinence Assessment

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Seating Assessments
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 96

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 97
MOTORIZED WHEELCHAIR ASSESSMENT

Resident Name: ________________________________________ Room No. _____________

Assessor: _____________________________________________ Date: _________________
Equipment trialed (brand/features): ________________________________________________

Check boxes below if “yes” or “acceptable.” Comments

Meets Criteria – all must be checked to qualify

Ƒ The resident is unable to functionally ambulate.

Ƒ The resident is unable to operate a manual wheelchair.
Ƒ The resident has sufficient cognitive skills to understand
directionality, i.e., left, right, front, and back and is able
to demonstrate these skills.
Ƒ The resident can transfer safely in and out of the
motorized wheelchair (except in HCC where assistance is
available), and has trunk stability to be able to safely ride
in the wheelchair (may have assistance).
Ƒ The resident is capable of safely operating the controls
for the motorized wheelchair.
Ƒ The resident is able to independently move away from
potentially dangerous or harmful situations.
Ƒ The resident has sufficient eye/hand perceptual
capabilities to safely operate the motorized wheelchair.
Ƒ The resident demonstrates the ability to start, stop, and
guide the motorized wheelchair within a reasonable
confined area.

Perception

Ƒ Eyesight
Ƒ Hearing

Seating/Positioning

Ƒ Posture in chair
Ƒ Dynamic sitting balance
Ƒ Need for trunk or head supports
Ƒ Upper limb position
 98
Transfers

Ƒ Ability to get in and out of chair

Ƒ Ability to put footplates up/down
Ƒ Ability to alter joystick/armrest
Ƒ Ability to reach walking aid to assist transfer

Use of Controls

Ƒ Turning motor on/ff

Ƒ Joystick
Ƒ Speed control
Ƒ Horn
Ƒ Ability to see battery level indicator

Driving Skills

Ƒ Forwards (maintains straight line)

Ƒ Turning left & right on cue
Ƒ Reverse
Ƒ “U” Turn
Ƒ 3-point turn
Ƒ Circles, figure 8
Ƒ Start/stop reaction time
Ƒ Maneuvers around obstacles
Ƒ Negotiates doors
Ƒ Parks chair
Ƒ Approaches corners safely
Ƒ Maintains safe following/passing distance
Ƒ Enters and exits elevator
 99
Power Operated Vehicle Assessment

Resident Name: ______________________________ Date of Incident: ___________

† Reviewed attached incident report for further information

When assessing to see if further training/testing is necessary, please complete the following and then
determine outcome:

Is resident currently on caseload with physical or occupational therapy?

† Yes (report incident to therapy and discontinue assessment) † No (continue)

Has resident had other reported power operated vehicle incidents in the past 6 months?

† Yes † No

Has the resident recently had a change of mental status?

† Yes † No

Outcome
† Refer to therapy for training
† Screen request given to therapy
† Copy of assessment attached
† Refer to therapy for further testing
† Screen request given to therapy
† Copy of assessment attached
† Referral not necessary – isolated incident (give to Medical Records for Resident’s file)

Assessment completed by: ____________________________ Date: ______________

 100

Body Mass Index

 101

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 102

Visual Perceptual
Assessments
 103
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 104

Line Bisection Test

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____________________________________________________________
 105

Dementia Staging and

Cognition Assessments
 106

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 107

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 108

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 111

GLOBAL DETERIORATION SCALE FOR ASSESSMENT OF PRIMARY

DEGENERATIVE DEMENTIA

STAGE 1: No Cognitive Decline

No subjective complaints of memory deficit. No memory deficit evident on clinical interview.

STAGE 2: Very Mild (Forgetfulness)

Subjective complaints of memory deficit, most frequently in following areas: forgetting
where one has placed familiar objects; forgetting names one formerly knew well. No
objective evidence of memory deficit on clinical interview. No objective deficits in
employment or social situations. Appropriate concern with respect to symptomatology.

STAGE 3: Mild Cognitive Decline (Early Confusional)

Earliest clear-cut deficits. Manifestations in more than one of the following areas: patient
may have gotten lost when traveling to an unfamiliar location; co-workers become aware of
patient’s relatively poor performance; word and name finding deficit becomes evident to
intimates; patient may read a passage or a book and retain relatively little material; patient
may demonstrate decreased facility in remembering names upon introduction to new people;
patient may have lost or misplaced an object of value; concentration deficit may be evident
on clinical testing. Objective evidence of memory deficit obtained only with an intensive
interview. Decreased performance in demanding employment and social settings. Denial
begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.

STAGE 4: Moderate Cognitive Decline (Late Confusional)

Clear-cut deficit on careful clinical interview. Deficit manifests in following areas: decreased
knowledge of current and recent events; may exhibit some deficit in memory of one’s
personal history; concentration deficit elicited on serial subtractions; decreased ability to
travel, handle finances, etc. Frequently no deficit in the following areas: orientation to time
and person; recognition of familiar persons and faces; ability to travel to familiar
locations/inability to perform complex tasks. Denial is dominant defense mechanism.
Flattening of affect and withdrawal from challenging situations occur.

STAGE 5: Moderately Severe Cognitive Decline (Early Dementia)

Patient can no longer survive without some assistance. Patient is unable during interview to
recall a major relevant aspect of their current lives; e.g., an address or telephone number of
many ears, the names of close family members (such as grandchildren), the name of the high
school or college from which they graduated. Frequently, some disorientation to time (date,
day of week, season, etc.) or to place. An educated person may have difficulty counting back
from 40 by 4’s or from 20 by 2’s. Persons at this stage retain knowledge of many major facts
regarding themselves and others. They invariably know their own names and generally
know their spouses’ and children’s names.
They require no assistance with toileting and eating, but may have some difficulty choosing
the proper clothing.
 112

STAGE 6: Severe Cognitive Decline (Middle Dementia)

May occasionally forget the name of the spouse upon whom they are entirely dependent for
survival. Will be largely unaware of all recent events and experiences in their lives. Retain
some knowledge of their past lives but this is very sketchy. Generally unaware of their
surroundings, the year, the season, etc. May have difficulty counting from 10 both backward
and sometimes forward. Will require some assistance with activities of daily living; e.g., may
become incontinent, will require travel assistance but occasionally will display ability to
familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their own
name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their
environment. Personality and emotional changes occur. These are quite variable and include:
(1) delusional behavior; e.g., patients may accuse their spouse of being an impostor, may talk
to imaginary figures in the environment, or to their own reflection in the mirror; (2)
obsessive symptoms; e.g., person may continually repeat simple cleaning activities; (3)
obsessive symptoms, agitation, and even previously nonexistent violent behavior may occur;
(4) cognitive abula: i.e., loss of willpower because an individual cannot carry a thought long
enough to determine a purposeful course of action.

STAGE 7: Very Severe Cognitive Decline (Late Dementia)

All verbal abilities are lost. Frequently there is no speech at all – only grunting. Incontinent
of urine, requires assistance toileting and feeding. Lose basic psychomotor skills; e.g., ability
to walk. The brain appears to no longer be able to tell the body what to do. Generalized and
cortical neurologic signs and symptoms are frequently present.

Reisberg, B., Ferris, S.H, Leon, M.J. & Crook, T. The global deterioration scale for
assessment of primary degenerative dementia. American
Journal of Psychiatry, 1982, 139:1136-1139.

Reprinted with permission from the American Journal of Psychiatry, (Copyright 1982).
American Psychiatric Association.



 
 113

Global Deterioration Scale for Assessment Of Primary Degenerative Dementia

Level Clinical Characteristics


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 117

Montreal Cognitive Assessment

(MOCA)
Administration and Scoring Instructions

Š‡‘–”‡ƒŽ‘‰‹–‹˜‡••‡••‡–ȋȌ™ƒ•†‡•‹‰‡†ƒ•ƒ”ƒ’‹†•…”‡‡‹‰‹•–”—‡–ˆ‘”‹Ž†
…‘‰‹–‹˜‡†›•ˆ—…–‹‘Ǥ–ƒ••‡••‡•†‹ˆˆ‡”‡–…‘‰‹–‹˜‡†‘ƒ‹•ǣƒ––‡–‹‘ƒ†…‘…‡–”ƒ–‹‘ǡ‡š‡…—–‹˜‡
ˆ—…–‹‘•ǡ‡‘”›ǡŽƒ‰—ƒ‰‡ǡ˜‹•—‘…‘•–”—…–‹‘ƒŽ•‹ŽŽ•ǡ…‘…‡’–—ƒŽ–Š‹‹‰ǡ…ƒŽ…—Žƒ–‹‘•ǡƒ†‘”‹‡–ƒ–‹‘Ǥ
‹‡–‘ƒ†‹‹•–‡”–Š‡‹•ƒ’’”‘š‹ƒ–‡Ž›ͳͲ‹—–‡•ǤŠ‡–‘–ƒŽ’‘••‹„Ž‡•…‘”‡‹•͵Ͳ’‘‹–•Ǣƒ•…‘”‡‘ˆ
ʹ͸‘”ƒ„‘˜‡‹•…‘•‹†‡”‡†‘”ƒŽǤ

1. Alternating Trail Making:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‹•–”—…–•–Š‡•—„Œ‡…–ǣ"Please draw a line, going from a number to a letter in

ascending order. Begin here ȏ’‘‹––‘ȋͳȌȐand draw a line from 1 then to A then to 2 and so on. End here
ȏ’‘‹––‘ȋȌȐǤ̶…‘”‹‰ǣŽŽ‘…ƒ–‡‘‡’‘‹–‹ˆ–Š‡•—„Œ‡…–•—……‡••ˆ—ŽŽ›†”ƒ™•–Š‡ˆ‘ŽŽ‘™‹‰’ƒ––‡”ǣͳΫǦʹǦ
Ǧ͵ǦǦͶǦǦͷǦǡ™‹–Š‘—–†”ƒ™‹‰ƒ›Ž‹‡•–Šƒ–…”‘••Ǥ›‡””‘”–Šƒ–‹•‘– ‹‡†‹ƒ–‡Ž›•‡ŽˆǦ…‘””‡…–‡†
‡ƒ”•ƒ•…‘”‡‘ˆͲǤ

2. Visuoconstructional Skills (Cube):

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•ǡ’‘‹–‹‰–‘–Š‡cubeǣDzCopy this drawing as

accurately as you can, in the space below”Ǥ
…‘”‹‰ǣ‡’‘‹–‹•ƒŽŽ‘…ƒ–‡†ˆ‘”ƒ…‘””‡…–Ž›‡š‡…—–‡††”ƒ™‹‰Ǥ

Ȉ”ƒ™‹‰—•–„‡–Š”‡‡Ǧ†‹‡•‹‘ƒŽ
ȈŽŽŽ‹‡•ƒ”‡†”ƒ™
Ȉ‘Ž‹‡‹•ƒ††‡†
Ȉ‹‡•ƒ”‡”‡Žƒ–‹˜‡Ž›’ƒ”ƒŽŽ‡Žƒ†–Š‡‹”Ž‡‰–Š‹••‹‹Žƒ”ȋ”‡…–ƒ‰—Žƒ”’”‹••ƒ”‡
ƒ……‡’–‡†Ȍ

’‘‹–‹•‘–ƒ••‹‰‡†‹ˆƒ›‘ˆ–Š‡ƒ„‘˜‡Ǧ…”‹–‡”‹ƒƒ”‡‘–‡–Ǥ

3. Visuoconstructional Skills (Clock):

†‹‹•–”ƒ–‹‘ǣ†‹…ƒ–‡–Š‡”‹‰Š––Š‹”†‘ˆ–Š‡•’ƒ…‡ƒ†‰‹˜‡–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•ǣ“Draw a clockǤPut

in all the numbers and set the time to 10 past 11”.
…‘”‹‰ǣ‡’‘‹–‹•ƒŽŽ‘…ƒ–‡†ˆ‘”‡ƒ…Š‘ˆ–Š‡ˆ‘ŽŽ‘™‹‰–Š”‡‡…”‹–‡”‹ƒǣ

Ȉ‘–‘—”ȋͳ’–ǤȌǣ–Š‡…Ž‘…ˆƒ…‡—•–„‡ƒ…‹”…Ž‡™‹–Š‘Ž›‹‘”†‹•–‘”–‹‘
ƒ……‡’–ƒ„Ž‡ȋ‡Ǥ‰Ǥǡ•Ž‹‰Š–‹’‡”ˆ‡…–‹‘‘…Ž‘•‹‰–Š‡…‹”…Ž‡ȌǢ
Ȉ—„‡”•ȋͳ’–ǤȌǣƒŽŽ…Ž‘…—„‡”•—•–„‡’”‡•‡–™‹–Š‘ƒ††‹–‹‘ƒŽ
—„‡”•Ǣ—„‡”•—•–„‡‹–Š‡…‘””‡…–‘”†‡”ƒ†’Žƒ…‡†‹–Š‡
ƒ’’”‘š‹ƒ–‡“—ƒ†”ƒ–•‘–Š‡…Ž‘…ˆƒ…‡Ǣ‘ƒ—‡”ƒŽ•ƒ”‡ƒ……‡’–ƒ„Ž‡Ǣ
—„‡”•…ƒ„‡’Žƒ…‡†‘—–•‹†‡–Š‡…‹”…Ž‡…‘–‘—”Ǣ


x ƒ†•ȋͳ’–ǤȌǣ–Š‡”‡—•–„‡–™‘Šƒ†•Œ‘‹–Ž›‹†‹…ƒ–‹‰–Š‡…‘””‡…––‹‡Ǣ–Š‡Š‘—”Šƒ†
—•–„‡…Ž‡ƒ”Ž›•Š‘”–‡”–Šƒ–Š‡‹—–‡Šƒ†ǢŠƒ†•—•–„‡…‡–‡”‡†™‹–Š‹–Š‡…Ž‘…
ˆƒ…‡™‹–Š–Š‡‹”Œ—…–‹‘…Ž‘•‡–‘–Š‡…Ž‘……‡–‡”Ǥ
x 
’‘‹–‹•‘–ƒ••‹‰‡†ˆ‘”ƒ‰‹˜‡‡Ž‡‡–‹ˆƒ›‘ˆ–Š‡ƒ„‘˜‡Ǧ…”‹–‡”‹ƒƒ”‡‘–‡–Ǥ
 118
4. Naming:

†‹‹•–”ƒ–‹‘ǣ‡‰‹‹‰‘–Š‡Ž‡ˆ–ǡ’‘‹––‘‡ƒ…Šˆ‹‰—”‡ƒ†•ƒ›ǣ“Tell me the name of this

animal”.

…‘”‹‰ǣ‡’‘‹–‡ƒ…Š‹•‰‹˜‡ˆ‘”–Š‡ˆ‘ŽŽ‘™‹‰”‡•’‘•‡•ǣȋͳȌŽ‹‘ȋʹȌ”Š‹‘…‡”‘•‘””Š‹‘ȋ͵Ȍ…ƒ‡Ž‘”
†”‘‡†ƒ”›Ǥ

5. Memory:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡””‡ƒ†•ƒŽ‹•–‘ˆͷ™‘”†•ƒ–ƒ”ƒ–‡‘ˆ‘‡’‡”•‡…‘†ǡ‰‹˜‹‰–Š‡
ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•: “This is a memory test. I am going to read a list of words that you
will have to remember now and later on. Listen carefully. When I am through, tell me
as many words as you can remember. It doesn’t matter in what order you say them”Ǥ
ƒ”ƒ…Š‡…‹–Š‡ƒŽŽ‘…ƒ–‡†•’ƒ…‡ˆ‘”‡ƒ…Š™‘”†–Š‡•—„Œ‡…–’”‘†—…‡•‘–Š‹•ˆ‹”•––”‹ƒŽǤŠ‡–Š‡•—„Œ‡…–
‹†‹…ƒ–‡•–Šƒ–ȋ•ȌŠ‡Šƒ•ˆ‹‹•Š‡†ȋŠƒ•”‡…ƒŽŽ‡†ƒŽŽ™‘”†•Ȍǡ‘”…ƒ”‡…ƒŽŽ‘‘”‡™‘”†•ǡ”‡ƒ†–Š‡Ž‹•–ƒ
•‡…‘†–‹‡™‹–Š–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•ǣ“I am going to read the samelist for a second time. Try to
remember and tell me as many words as you can, including wordsyou said the first time.” —–ƒ…Š‡…‹–Š‡
ƒŽŽ‘…ƒ–‡†•’ƒ…‡ˆ‘”‡ƒ…Š™‘”†–Š‡•—„Œ‡…–”‡…ƒŽŽ•ƒˆ–‡”–Š‡•‡…‘†–”‹ƒŽǤ

––Š‡‡†‘ˆ–Š‡•‡…‘†–”‹ƒŽǡ‹ˆ‘”–Š‡•—„Œ‡…––Šƒ–ȋ•ȌŠ‡™‹ŽŽ„‡ƒ•‡†–‘”‡…ƒŽŽ–Š‡•‡™‘”†•ƒ‰ƒ‹„›
•ƒ›‹‰ǡ“I will ask you to recall those words again at the end of the test.”

…‘”‹‰ǣ‘’‘‹–•ƒ”‡‰‹˜‡ˆ‘””‹ƒŽ•‡ƒ†™‘Ǥ

6. Attention:

‘”™ƒ”†‹‰‹–’ƒǣ†‹‹•–”ƒ–‹‘ǣ
‹˜‡–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣDzI am going to say some
numbers and when I am through, repeat them to me exactly as I said themdzǤ‡ƒ†–Š‡ˆ‹˜‡
—„‡”•‡“—‡…‡ƒ–ƒ”ƒ–‡‘ˆ‘‡†‹‰‹–’‡”•‡…‘†Ǥ

ƒ…™ƒ”†‹‰‹–’ƒǣ†‹‹•–”ƒ–‹‘ǣ
‹˜‡–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣDzNow I am going to saysome more
numbers, but when I am through you must repeat them to me in the backwardsorder.dz‡ƒ†–Š‡–Š”‡‡
—„‡”•‡“—‡…‡ƒ–ƒ”ƒ–‡‘ˆ‘‡†‹‰‹–’‡”•‡…‘†Ǥ

…‘”‹‰ǣŽŽ‘…ƒ–‡‘‡’‘‹–ˆ‘”‡ƒ…Š•‡“—‡…‡…‘””‡…–Ž›”‡’‡ƒ–‡†ǡȋN.B.ǣ–Š‡…‘””‡…–”‡•’‘•‡ˆ‘”–Š‡
„ƒ…™ƒ”†•–”‹ƒŽ‹•ʹǦͶǦ͹ȌǤ

‹‰‹Žƒ…‡ǣ†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡””‡ƒ†•–Š‡Ž‹•–‘ˆŽ‡––‡”•ƒ–ƒ”ƒ–‡‘ˆ‘‡’‡”•‡…‘†ǡ
ƒˆ–‡”‰‹˜‹‰–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣDzI am going to read a sequence of letters. Every time I
say the letter A, tap your hand once. If I say a different letter, do not tap your handdzǤ

…‘”‹‰ǣ
‹˜‡‘‡’‘‹–‹ˆ–Š‡”‡‹•œ‡”‘–‘‘‡‡””‘”•ȋƒ‡””‘”‹•ƒ–ƒ’‘ƒ™”‘‰Ž‡––‡”‘”ƒ
ˆƒ‹Ž—”‡–‘–ƒ’‘Ž‡––‡”ȌǤ

‡”‹ƒŽ͹•ǣ†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣ“Now, I will ask you to count by
subtracting seven from 100, and then, keep subtracting seven from your answer until I tell you to stop.”
‹˜‡
–Š‹•‹•–”—…–‹‘–™‹…‡‹ˆ‡…‡••ƒ”›Ǥ

…‘”‹‰ǣŠ‹•‹–‡‹••…‘”‡†‘—–‘ˆ͵’‘‹–•Ǥ
‹˜‡‘ȋͲȌ’‘‹–•ˆ‘”‘…‘””‡…–•—„–”ƒ…–‹‘•ǡͳ
’‘‹–ˆ‘”‘‡…‘””‡…–‹‘•—„–”ƒ…–‹‘ǡʹ’‘‹–•ˆ‘”–™‘Ǧ–‘Ǧ–Š”‡‡…‘””‡…–•—„–”ƒ…–‹‘•ǡƒ†͵’‘‹–•‹ˆ–Š‡
’ƒ”–‹…‹’ƒ–•—……‡••ˆ—ŽŽ›ƒ‡•ˆ‘—”‘”ˆ‹˜‡…‘””‡…–•—„–”ƒ…–‹‘•Ǥ‘—–‡ƒ…Š…‘””‡…–•—„–”ƒ…–‹‘‘ˆ͹
 119
„‡‰‹‹‰ƒ–ͳͲͲǤƒ…Š•—„–”ƒ…–‹‘‹•‡˜ƒŽ—ƒ–‡†‹†‡’‡†‡–Ž›Ǣ–Šƒ–‹•ǡ‹ˆ–Š‡’ƒ”–‹…‹’ƒ–”‡•’‘†•™‹–Šƒ
‹…‘””‡…–—„‡”„—–…‘–‹—‡•–‘…‘””‡…–Ž›•—„–”ƒ…–͹ˆ”‘‹–ǡ‰‹˜‡ƒ’‘‹–ˆ‘”‡ƒ…Š…‘””‡…–•—„–”ƒ…–‹‘Ǥ
‘”‡šƒ’Ž‡ǡƒ’ƒ”–‹…‹’ƒ–ƒ›”‡•’‘†DzͻʹȂͺͷȂ͹ͺȂ͹ͳȂ͸Ͷdz™Š‡”‡–Š‡Dzͻʹdz‹•‹…‘””‡…–ǡ„—–ƒŽŽ
•—„•‡“—‡–—„‡”•ƒ”‡•—„–”ƒ…–‡†…‘””‡…–Ž›ǤŠ‹•‹•‘‡‡””‘”ƒ†–Š‡‹–‡™‘—Ž†„‡‰‹˜‡ƒ•…‘”‡‘ˆ͵Ǥ

7. Sentence repetition:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•ǣ“I am going to read you a

sentence. Repeat it after me, exactly as I say it ȏ’ƒ—•‡ȐǣI only know that John is the one to
help today.” ‘ŽŽ‘™‹‰–Š‡”‡•’‘•‡ǡ•ƒ›ǣ“Now I am going to read you another sentence.
Repeat it after me, exactly as I say it ȏ’ƒ—•‡ȐǣThe cat always hid under the couch when dogs were in the
room.”

…‘”‹‰ǣŽŽ‘…ƒ–‡ͳ’‘‹–ˆ‘”‡ƒ…Š•‡–‡…‡…‘””‡…–Ž›”‡’‡ƒ–‡†Ǥ‡’‡–‹–‹‘—•–„‡‡šƒ…–Ǥ‡
ƒŽ‡”–ˆ‘”‡””‘”•–Šƒ–ƒ”‡‘‹••‹‘•ȋ‡Ǥ‰Ǥǡ‘‹––‹‰̶‘Ž›̶ǡ̶ƒŽ™ƒ›•̶Ȍƒ†•—„•–‹–—–‹‘•Ȁƒ††‹–‹‘•ȋ‡Ǥ‰Ǥǡ̶ ‘Š
‹•–Š‡‘‡™Š‘Š‡Ž’‡†–‘†ƒ›Ǣ̶•—„•–‹–—–‹‰̶Š‹†‡•̶ˆ‘”̶Š‹†̶ǡƒŽ–‡”‹‰’Ž—”ƒŽ•ǡ‡–…ǤȌǤ

8. Verbal fluency:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣ“Tell me as many words as you can think of

that begin with a certain letter of the alphabet that I will tell you in a moment. You can say any kind of word
you want, except for proper nouns (like Bob or Boston), numbers, or words that begin with the same sound
but have a different suffix, for example, love, lover, loving. I will tell you to stop after one minute. Are you
ready? ȏƒ—•‡ȐNow, tell me as many words as you can think of that begin with the letter F. ȏ–‹‡ˆ‘”͸Ͳ•‡…ȐǤ
Stop.”

…‘”‹‰ǣŽŽ‘…ƒ–‡‘‡’‘‹–‹ˆ–Š‡•—„Œ‡…–‰‡‡”ƒ–‡•ͳͳ™‘”†•‘”‘”‡‹͸Ͳ•‡…Ǥ‡…‘”†–Š‡
•—„Œ‡…–ǯ•”‡•’‘•‡‹–Š‡„‘––‘‘”•‹†‡ƒ”‰‹•Ǥ

9. Abstraction:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”ƒ••–Š‡•—„Œ‡…––‘‡š’Žƒ‹™Šƒ–‡ƒ…Š’ƒ‹”‘ˆ™‘”†•Šƒ•‹
…‘‘ǡ•–ƒ”–‹‰™‹–Š–Š‡‡šƒ’Ž‡ǣ“Tell me how an orange and a banana are alike”. ˆ–Š‡
•—„Œ‡…–ƒ•™‡”•‹ƒ…‘…”‡–‡ƒ‡”ǡ–Š‡•ƒ›‘Ž›‘‡ƒ††‹–‹‘ƒŽ–‹‡ǣ“Tell me another way in which
those items are alike”. ˆ–Š‡•—„Œ‡…–†‘‡•‘–‰‹˜‡–Š‡ƒ’’”‘’”‹ƒ–‡”‡•’‘•‡(fruit)ǡ sƒ›ǡ“Yes, and they are
also both fruit.” ‘‘–‰‹˜‡ƒ›ƒ††‹–‹‘ƒŽ‹•–”—…–‹‘•‘”…Žƒ”‹ˆ‹…ƒ–‹‘Ǥˆ–‡”–Š‡’”ƒ…–‹…‡–”‹ƒŽǡ•ƒ›ǣ“Now,
tell me how a train and a bicycle are alike”. ‘ŽŽ‘™‹‰–Š‡”‡•’‘•‡ǡƒ†‹‹•–‡”–Š‡•‡…‘†–”‹ƒŽǡ•ƒ›‹‰ǣ
“Now tell me how a ruler and a watch are alike”Ǥ‘‘–‰‹˜‡ƒ›ƒ††‹–‹‘ƒŽ‹•–”—…–‹‘•‘”’”‘’–•Ǥ

…‘”‹‰ǣŽ›–Š‡Žƒ•––™‘‹–‡’ƒ‹”•ƒ”‡•…‘”‡†Ǥ
‹˜‡ͳ’‘‹––‘‡ƒ…Š‹–‡’ƒ‹”…‘””‡…–Ž›
ƒ•™‡”‡†ǤŠ‡ˆ‘ŽŽ‘™‹‰”‡•’‘•‡•ƒ”‡ƒ……‡’–ƒ„Ž‡ǣ

”ƒ‹Ǧ„‹…›…Ž‡α‡ƒ•‘ˆ–”ƒ•’‘”–ƒ–‹‘ǡ‡ƒ•‘ˆ–”ƒ˜‡ŽŽ‹‰ǡ›‘—–ƒ‡–”‹’•‹„‘–ŠǢ
—Ž‡”Ǧ™ƒ–…Šα‡ƒ•—”‹‰‹•–”—‡–•ǡ—•‡†–‘‡ƒ•—”‡Ǥ
Š‡ˆ‘ŽŽ‘™‹‰”‡•’‘•‡•ƒ”‡not ƒ……‡’–ƒ„Ž‡ǣ”ƒ‹Ǧ„‹…›…Ž‡α–Š‡›Šƒ˜‡™Š‡‡Ž•Ǣ—Ž‡”Ǧ™ƒ–…Š
α–Š‡›Šƒ˜‡—„‡”•Ǥ

10. Delayed recall:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘ǣ“I read some words to you

earlier, which I asked you to remember. Tell me as many of those words as you can
remember.” ƒ‡ƒ…Š‡…ƒ”ȋξȌˆ‘”‡ƒ…Š‘ˆ–Š‡™‘”†•…‘””‡…–Ž›”‡…ƒŽŽ‡†•’‘–ƒ‡‘—•Ž›
 120
™‹–Š‘—–ƒ›…—‡•ǡ‹–Š‡ƒŽŽ‘…ƒ–‡†•’ƒ…‡Ǥ

…‘”‹‰ǣAllocate 1 point for each word recalled freely without any cues.

Optional:
‘ŽŽ‘™‹‰–Š‡†‡Žƒ›‡†ˆ”‡‡”‡…ƒŽŽ–”‹ƒŽǡ’”‘’––Š‡•—„Œ‡…–™‹–Š–Š‡•‡ƒ–‹……ƒ–‡‰‘”›…—‡
’”‘˜‹†‡†„‡Ž‘™ˆ‘”ƒ›™‘”†‘–”‡…ƒŽŽ‡†Ǥƒ‡ƒ…Š‡…ƒ”ȋξȌ‹–Š‡ƒŽŽ‘…ƒ–‡†•’ƒ…‡‹ˆ–Š‡•—„Œ‡…–
”‡‡„‡”‡†–Š‡™‘”†™‹–Š–Š‡Š‡Ž’‘ˆƒ…ƒ–‡‰‘”›‘”—Ž–‹’Ž‡Ǧ…Š‘‹…‡…—‡Ǥ”‘’–ƒŽŽ‘Ǧ”‡…ƒŽŽ‡†™‘”†•‹
–Š‹•ƒ‡”Ǥˆ–Š‡•—„Œ‡…–†‘‡•‘–”‡…ƒŽŽ–Š‡™‘”†ƒˆ–‡”–Š‡…ƒ–‡‰‘”›…—‡ǡ‰‹˜‡Š‹ȀŠ‡”ƒ—Ž–‹’Ž‡…Š‘‹…‡
–”‹ƒŽǡ—•‹‰–Š‡ˆ‘ŽŽ‘™‹‰‡šƒ’Ž‡‹•–”—…–‹‘ǡ“Which of thefollowing words do you think it was, NOSE,
FACE, or HAND?”
•‡–Š‡ˆ‘ŽŽ‘™‹‰…ƒ–‡‰‘”›ƒ†Ȁ‘”—Ž–‹’Ž‡Ǧ…Š‘‹…‡…—‡•ˆ‘”‡ƒ…Š™‘”†ǡ™Š‡ƒ’’”‘’”‹ƒ–‡ǣ

ǣ…ƒ–‡‰‘”›…—‡ǣ’ƒ”–‘ˆ–Š‡„‘†›—Ž–‹’Ž‡…Š‘‹…‡ǣ‘•‡ǡˆƒ…‡ǡŠƒ†
ǣ…ƒ–‡‰‘”›…—‡ǣ–›’‡‘ˆˆƒ„”‹…—Ž–‹’Ž‡…Š‘‹…‡ǣ†‡‹ǡ…‘––‘ǡ˜‡Ž˜‡–
ǣ…ƒ–‡‰‘”›…—‡ǣ–›’‡‘ˆ„—‹Ž†‹‰—Ž–‹’Ž‡…Š‘‹…‡ǣ…Š—”…Šǡ•…Š‘‘ŽǡŠ‘•’‹–ƒŽ
ǣ…ƒ–‡‰‘”›…—‡ǣ–›’‡‘ˆˆŽ‘™‡”—Ž–‹’Ž‡…Š‘‹…‡ǣ”‘•‡ǡ†ƒ‹•›ǡ–—Ž‹’
ǣ…ƒ–‡‰‘”›…—‡ǣƒ…‘Ž‘”—Ž–‹’Ž‡…Š‘‹…‡ǣ”‡†ǡ„Ž—‡ǡ‰”‡‡
…‘”‹‰ǣNo points are allocated for words recalled with a cue. …—‡‹•—•‡†ˆ‘”…Ž‹‹…ƒŽ
‹ˆ‘”ƒ–‹‘’—”’‘•‡•‘Ž›ƒ†…ƒ‰‹˜‡–Š‡–‡•–‹–‡”’”‡–‡”ƒ††‹–‹‘ƒŽ‹ˆ‘”ƒ–‹‘ƒ„‘—––Š‡–›’‡‘ˆ
‡‘”›†‹•‘”†‡”Ǥ ‘”‡‘”›†‡ˆ‹…‹–•†—‡–‘”‡–”‹‡˜ƒŽˆƒ‹Ž—”‡•ǡ’‡”ˆ‘”ƒ…‡…ƒ„‡‹’”‘˜‡†™‹–Šƒ…—‡Ǥ
‘”‡‘”›†‡ˆ‹…‹–•†—‡–‘‡…‘†‹‰ˆƒ‹Ž—”‡•ǡ’‡”ˆ‘”ƒ…‡†‘‡•‘–‹’”‘˜‡™‹–Šƒ…—‡Ǥ

11. Orientation:

†‹‹•–”ƒ–‹‘ǣŠ‡‡šƒ‹‡”‰‹˜‡•–Š‡ˆ‘ŽŽ‘™‹‰‹•–”—…–‹‘•ǣDz‡ŽŽ‡–Š‡†ƒ–‡–‘†ƒ›dzǤˆȏyear, month,

exact date, and day of the week].” Š‡•ƒ›ǣ“Now, tell me the name of this
place, and which city it is in.”

…‘”‹‰ǣ
‹˜‡‘‡’‘‹–ˆ‘”‡ƒ…Š‹–‡…‘””‡…–Ž›ƒ•™‡”‡†ǤŠ‡•—„Œ‡…–—•––‡ŽŽ–Š‡‡šƒ…–†ƒ–‡ƒ†–Š‡‡šƒ…–
’Žƒ…‡ȋƒ‡‘ˆŠ‘•’‹–ƒŽǡ…Ž‹‹…ǡƒ†‘ˆˆ‹…‡ȌǤ‘’‘‹–•ƒ”‡ƒŽŽ‘…ƒ–‡†‹ˆ•—„Œ‡…–ƒ‡•ƒ‡””‘”‘ˆ‘‡†ƒ›ˆ‘”
–Š‡†ƒ›ƒ††ƒ–‡Ǥ

TOTAL SCORE: —ƒŽŽ•—„•…‘”‡•Ž‹•–‡†‘–Š‡”‹‰Š–ǦŠƒ†•‹†‡Ǥ††‘‡’‘‹–ˆ‘”ƒ

‹†‹˜‹†—ƒŽ™Š‘Šƒ•ͳʹ›‡ƒ”•‘”ˆ‡™‡”‘ˆˆ‘”ƒŽ‡†—…ƒ–‹‘ǡˆ‘”ƒ’‘••‹„Ž‡ƒš‹—‘ˆ͵Ͳ’‘‹–•Ǥˆ‹ƒŽ–‘–ƒŽ
•…‘”‡‘ˆʹ͸ƒ†ƒ„‘˜‡‹•…‘•‹†‡”‡†‘”ƒŽǤ
 121

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Instructions: Ask the questions in the order listed. Score one point for each correct
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 122
Interpretation of the MMSE:

Method Score Interpretation

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Score Day-to-Day Functioning
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x Folstein MF, Folstein SE, McHugh PR: “MiniPHQWDOVWDWH$3UDFWLFDOPHWKRGIRUJUDGLQJWKH

cognitive state of patients for the clinician.” J Psychiatr Res 1975;12:189
 123

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 124

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SLUMS EXAMINATION
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BB 1 1. What day of the week is it?

BB 1 2. What is the year?
BB 1 3. What state are we in?
4. Please remember these five objects. I will ask you what they are later.
 $SSOH  3HQ  7LH  +RXVH  &DU
5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.
1 How much did you spend?
BB 2 How much do you have left?
6. Please name as many animals as you can in one minute.
BB  0 DQLPDOV  1 DQLPDOV  2 DQLPDOV 3DQLPDOV
BB 7. What were the five objects I asked you to remember? 1 point for each one correct.
8. I am going to give you a series of numbers and I would like you to give them to me
backwards. For example, if I say 42, you would say 24.
BB   0   1   1 
9. This is a clock face. Please put in the hour markers and the time at
ten minutes to eleven o’clock.
2  +RXUPDUNHUVRND\
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1 10. Please place an X in the triangle.

BB 1 Which of the above figures is largest?

11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask
you some questions about it.
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2 What was the female’s name? 2 What work did she do?
BB 2 When did she go back to work? 2 What state did she live in?

TOTAL SCORE

SCORING
HIGH SCHOOL EDUCATION LESS THAN HIGH SCHOOL EDUCATION
      1250$/     
    0,/'1(852&2*1,7,9(',625'(5    
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0LQL0HQWDO6WDWXV([DPLQDWLRQ006($SLORWVWXG\Am J Geriatr Psych
 130

VAMC Saint Louis University Mental Status Examination

Form Details
Who Can Complete the Form: Social Services, Reflections/Passages Program Coordinators, Licensed Nurses,
MDs, NPs, OTs, PTs, Residence Supervisors and Other Qualified Healthcare Professional who have been trained
(and retrained annually) by viewing the VA-produced DVD (available upon request to tumosan@slu.edu).

Purpose of the Form: To screen individuals to look for the presence of cognitive deficits, and to identify changes in
cognition over time.

Instructions for Use:

1. Complete resident demographics at the top of the page.

2. We recommend that you put the date and the name of the evaluator on the bottom of the page as well (see
#19).

3. Administration should be conducted privately and in the examinee’s primary language. Be prepared with the
items you need to complete the exam. You will need a watch with a second hand on it.

4. Record the number of years the patient attended school. If the patient obtained an Associates, Bachelor’s,
Master’s or Doctorate degree, note the degree achieved instead of actual years of school attended.

5. Determine if the patient is alert. Do not answer “yes” or “no”, but indicate level of alertness. Alert indicates that
the individual is fully awake and able to focus. Other descriptors include: drowsy, confused, distractible,
inattentive, preoccupied.

6. Begin by asking the patient the following:

“Do you have any trouble with your memory?” “May I ask you some questions about your memory?”
Then proceed with the exam questions.

7. Read the questions aloud clearly and slowly to the examinee. It is not usually necessary to speak loudly but it
is necessary to speak slowly.

8. Begin by asking the patient something similar to the following:

“Do you have any trouble with your memory?” “May I ask you some questions about your memory?”
“I’d like to see how good your memory is by asking you some questions.” You may need to reassure
patients by telling them that this is not a test that they can fail but merely a tool much like a
thermometer that takes temperature is a tool. What this does is checks for the amount of memory they
have.
Then begin to administer the exam questions.

9. Score the questions as indicated on the examination.

10. On question #4, read the statement as listed on the exam. Ask the patient to repeat each of the five objects
(Apple, Pen, Tie, House, Car) that you recite to make sure that the patient heard and understood what you said.
Repeat them as many times as it takes for the patient to repeat them back to you correctly.

09/03/09
 131

VAMC Saint Louis University Mental Status Examination

Form Details
11. On question #5, make sure the patient is focused on you prior to reciting the information. Obtain an answer for
the first part of the question (“How much did you spend”) before moving on to part two (“How much do you have
left?”). Do not prompt or give hints, but do give ample time to the patient to answer the questions. If the patient
asks you to repeat the question you may do so once.

12. Redirect the patient’s attention if necessary back to you to answer question #6. Give them one minute to
complete the question. Be sure to time them.

13. Continue with the exam questions in the order that they are listed.

14. On question #8, state each number by its individual name. 87 is pronounced eight, seven; 649 is pronounced
six, four, nine; 8537 is pronounced eight, five, three, seven.

15. On question #9, either draw a large circle on the back of the examination form or provide the patient with a
separate piece of paper with a larger circle printed on it and attach it to the original examination form. When
scoring, give full credit for either all 12 numbers or all 12 ticks. If the patient puts only 4 ticks on the circle,
prompt them once to put numbers next to those ticks (12, 3, 6, and 9) for full credit. When scoring the correct
time, make sure the hour hand is shorter than the minute hand and that the minute hand points at the 10 and
the hour hand points at the 11.

16. You may also provide a separate sheet with larger examples of the forms listed on question #10 for those with
vision impairment. This sheet should be created by enlarging the figures on the examination form and can also
be attached to the original form.

17. Read question #11 as written, and provide ample time to answer each question. Do not repeat the story but do
make sure they are paying attention the first time you read it to them. Do not prompt or give hints. The answer
of Chicago as the state she lives in gets no credit but you may prompt them once by repeating the question.

18. Score the examination as listed at the bottom of the page, circling the level based on the score.

19. Sign and date the form.

20. Upon Completion of the Form:

Record the score in the patient’s record and comment on any indicated changes
Depending upon office protocols, either put the sheet in the patient’s record, place it in a separate identified
location, or destroy the worksheet once the score is recorded in the patient record (Specify based on Office Center Policy)
21. Form Status: (Varies by office)
0RUH)UHH&RJQLWLYH7HVWV$YDLODEOHDWZZZP\EUDLQWHVWRUJ
Mandatory for (e.g., patients with diagnoses or indicators of cognitive loss

Mandatory for _________________________________________

09/03/09
 132

FUNCTION, REASON, ORIENTATION, MEMORY, ARITHMETIC,

JUDGEMENT AND EMOTIONAL STATUS
(FROMAJE)

Scope: Š‡FROMAJE ƒ••‡••‡••‡˜‡ƒ•’‡…–•‘ˆ‡–ƒŽ•–ƒ–—•ǣ

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•…‘”‡•Ǥ

Š‡’—”’‘•‡‘ˆ–Š‡FROMAJE ‹•–‘…Žƒ••‹ˆ›‹†‹˜‹†—ƒŽ•‹–‘‘‡‘ˆˆ‘—”…ƒ–‡‰‘”‹‡•ƒ•†‡–‡”‹‡†„›–Š‡
‘˜‡”ƒŽŽ”ƒ–‹‰ƒ•ˆ‘ŽŽ‘™•ǣ

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 ‡•‹†‡–

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Function:

ͳᇐ–ƒŽˆ—…–‹‘‹•ƒ†‡“—ƒ–‡
ʹα‡…ƒ—•‡‘ˆ‡–ƒŽ‹’ƒ‹”‡–ǡ”‡•‹†‡–™‹ŽŽ‡‡†•‘‡ƒ–Š‘‡•—’’‘”–ǡƒ–Ž‡ƒ•–’ƒ”–‘ˆ–Š‡†ƒ›‘”
™‡‡Ǥ
͵α‡…ƒ—•‡‘ˆ‡–ƒŽ‹’ƒ‹”‡–ǡ”‡•‹†‡–‡‡†•ʹͶŠ‘—”•—’’‘”–ƒ†•—’‡”˜‹•‹‘͹†ƒ›•Ȁ™‡‡

Reasoning: ‡…‹–‡ƒ’”‘˜‡”„ƒ†ƒ•–Š‡”‡•‹†‡––‘‡š’Žƒ‹–Š‡‡ƒ‹‰Ǥšƒ’Ž‡ǣDzŠ‡‡ƒ”Ž›„‹”†
…ƒ–…Š‡•–Š‡™‘”dzƒ†Dzƒ•–‹–…Š‹–‹‡•ƒ˜‡•‹‡dzǤ

ͳᇕ‹†‡–‡š’Žƒ‹‡†’”‘˜‡”„™‡ŽŽǢ‰ƒ˜‡‰‡‡”ƒŽ…‘‘–ƒ–‹‘•‘ˆ’”‘˜‡”„Ǥ
ʹᇕ‹†‡–‰ƒ˜‡•‘‡•‡„Žƒ…‡‘ˆ‡ƒ‹‰„—–™‹–Š•‘‡‹…‘’Ž‡–‡‡••‘”™ƒ•—ƒ„Ž‡–‘
‰‡‡”ƒŽ‹œ‡Ǥ
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Orientation: •ˆ‘”ǣ
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Ǧ‘–Šǡ†ƒ–‡ǡƒ†›‡ƒ”
 133

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Š‘‡ǫ
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ʹᇕ‹†‡–ƒ†‡•‹‰‹ˆ‹…ƒ–‡””‘”‹‘‡ƒ”‡ƒǣ–‹‡’Žƒ…‡ǡ‘”•‡ŽˆǤ
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Memory:

‹•–ƒ–ǣ

ǦŠ‘™ƒ•–Š‡”‡•‹†‡–‘ˆ–Š‡ǤǤ†—”‹‰ƒ†™ƒ•‹ƒ™Š‡‡Ž…Šƒ‹”ǫ
ǦŠ‡”‡™‡”‡›‘—„‘”ǫ™Šƒ–›‡ƒ”™‡”‡›‘—„‘”ǫ

‡…‡–ǣ

ǦŠƒ–†‹†›‘—Šƒ˜‡ˆ‘”„”‡ƒˆƒ•––‘†ƒ›ǫ
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‡†‹ƒ–‡ǣ

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 Ǧ‡‡„‡”–Š‡—„‡”•Ͷǡͳʹǡƒ†ͳͺǤ™‹ŽŽ„‡ƒ•‹‰›‘—–‘”‡’‡ƒ––Š‡‹–Š‡‡š–ˆ‡™
‹—–‡•ǤȋŠ‡ƒ•–‘”‡’‡ƒ–Ȍ

ͳᇕ‹†‡–™ƒ•‰‡‡”ƒŽŽ›ƒ……—”ƒ–‡ƒ†ƒ†‡‘Ž›‹‘”‡””‘”•‹†‹•–ƒ–ǡ”‡…‡–‘”‹‡†‹ƒ–‡
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͵ᇕ‹†‡–ƒ†‡ƒ•‹‰‹ˆ‹…ƒ–‡””‘”‹–™‘‘”–Š”‡‡ƒ”‡ƒ•ǣ†‹•–ƒ–ǡ”‡…‡–ǡ‹‡†‹ƒ–‡‡‘”›Ǥ

Arithmetic: •”‡•‹†‡––‘ǣ

Ǧ‘—–„ƒ…ˆ”‘ͳͲͲ–‘ͻͲǤ
Ǧ—„–”ƒ…–͹ǯ•ˆ”‘ͳͲͲǤ
Ǧ‘—–ˆ”‘ͳ–‘ʹͲǤ

ͳᇕ‹†‡–™ƒ•‰‡‡”ƒŽŽ›ƒ……—”ƒ–‡ƒ†ƒ†‡‘Ž›‹‘”‡””‘”•Ǥ
ʹᇕ‹†‡–ƒ†‡‘Ž›‘‡•‹‰‹ˆ‹…ƒ–‡””‘”Ǥ
͵ᇕ‹†‡–ƒ†‡–™‘‘”‘”‡•‹‰‹ˆ‹…ƒ–‡””‘”•

Judgment: •”‡•‹†‡–ǣ

Ǧ–‹‰Š–‹ˆ›‘—‡‡†•‘‡Š‡Ž’ǡŠ‘™…ƒ›‘—‘„–ƒ‹‹–ǫ
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Ǧˆ›‘—•‡‡•‘‡‹ƒ™ƒ•–‡’ƒ’‡”„ƒ•‡–ǡ™Šƒ–•Š‘—Ž†›‘—†‘ǫ

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ʹᑏ‡’‘‘”Œ—†‰‡–†‡‘•–”ƒ–‡†Ǥ
 134

͵αš–”‡‡Ž›’‘‘”Œ—†‰‡–†‡‘•–”ƒ–‡†Ǥ

Emotional State: „•‡”˜‡†—”‹‰‹–‡”˜‹‡™ǣ

Ǧ•ƒ„‘—–…”›‹‰ǡ•ƒ†‡••ǡ†‡’”‡••‹‘ǡ‘’–‹‹•ǡ‡–…Ǥ
Ǧ‘•‹†‡”„‡Šƒ˜‹‘”ƒ……‘”†‹‰–‘Ž‹ˆ‡•‹–—ƒ–‹‘Ǥ

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ʹαš–‡•‹˜‡‘”‹ƒ’’”‘’”‹ƒ–‡†‡’”‡••‹‘‘”‰”ƒ†‹‘•‹–›Ǥ
͵αš–”‡‡Ž›—”‡ƒŽ‘”‹ƒ’’”‘’”‹ƒ–‡‹†‡ƒ•ȋ†‡Ž—•‹‘ƒŽ‘”ŠƒŽŽ—…‹ƒ–‘”›ǡ‡š–”‡‡†‡’”‡••‹‘‘”
•—‹…‹†ƒŽ‹†‡ƒ–‹‘Ȍ

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 OR, FROMAJE* Staging Formula:

‘–ƒŽ•…‘”‡‘ˆƒŽŽ•—„–‡•–•†‹˜‹†‡†„›͵ȋƒ˜‰Ǥ͓‘ˆ’‘••‹„Ž‡”‡•’‘•‡•‹‡ƒ…Š•—„–‡•–α–ƒ‰‡‘ˆ
†‡‡–‹ƒȌ

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 135

FAST SCALE ADMINISTRATION

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Functional Assessment Staging of Alzheimer's Disease (FAST)©

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Swallowing
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 138

Modified Barium Swallow Study

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 142
The Mann Assessment of Swallowing Ability (MASA; 2002)

The MASA (Mann, 2002) is a brief bedside examination of swallowing ability in patients 18 years of age and
older. It can be administered in 15-20 minutes with a patient who is moderately impaired. The minimal
supporting materials necessary include: a tongue depressor; flashlight; gloves; different food consistencies;
or water. The examination covers 24 clinical items that evaluate oromotor/ sensory components of
swallowing, prerequisite learning skills, such as cooperation and auditory comprehension, baseline cranial
nerve function, and functional assessment of swallow.

Each item in the scale is scored according to severity. All scores from the different subskills are tallied and a
composite score out of 200 is given. Normative data has been established for subjects who experienced their
first stroke. However, the author believes that administering the MASA to patients with other neurological
disorders may be appropriate to determine their level of swallowing ability.

MASA Score Cutoff for Severity Groupings of Dysphagia and Aspiration (p. 9)

Severity Grouping MASA Score-dysphagia MASA Score-aspiration

No abnormality detected ч 178-200 ч 170-200
Mild ч 168-177 ч 149-169
Moderate ч 139-167 ч 148
Severe ч 138 ч 140

In addition to determining a severity rating, the examiner can indicate a diet recommendation and a swallow
integrity rating.

Some administrative pointers:

x The patient should be evaluated in the most comfortable position possible

x Feeding trials should be given in a semi-upright position with adequate limb support
x There should be access to suctioning equipment and medical staff
x Always begin with item 1; if the patient cannot complete this item, discontinue assessment and
repeat at a later date.
x Proceed with each item in the order outlined, trying to identify the rating that best describes the
patient’s behavior in each area
x If a patient’s responses to any of the skills examined are delayed or incomprehensible, the entire
stimulus may be repeated once, and the repetition noted in the scoring
 143
MASA MASLP2004 Modified Instructions

Alertness
Awareness of the environment and self, sensitivity to stimuli, focusing thought or attention
Task: Observe and evaluate patient’s response to speech, movement, or pain. May incorporate
information from medical or nursing staff.

Rating: 10=Alert
8=Drowsy-fluctuating awareness/alert level
5=Difficult to rouse by speech or movement
2=No response to speech or movement

Cooperation
Patient is able to direct his or her attention and interact in activity.

Task: To gain patient’s attention and attempt to initiate communication or activity

Rating: 10=Cooperative-engages in some form of exchange (verbal/nonverbal)

8=Fluctuating cooperation; distracted by multiple simultaneous stimuli
5=Reluctant; unwilling to permit interaction
1=Unable to cooperate with interaction or activity

Auditory Comprehension
Ability to understand basic verbal communication

Task: Informally engage patient in conversation; ask patient to follow single and two-stage commands.
Utilize both high and low-probability instructions.

Grade: 10=No abnormality detected on screening

8=Follows ordinary conversation with little difficulty
6=Follows simple conversation/ instructions with repetition
4=Occasional motor response if cued
2=No/minimal response to speech

Respiration
Status of the patient’s respiratory/ pulmonary system

Task: Consult physician, respiratory therapist or nursing staff regarding the current condition of the
patient’s pulmonary system. Also note activity level of the patient’s pulmonary system. Also note
activity level of the patient.
10=Chest clear, no evidence of clinical/ radiographic abnormality
8= Sputum in the upper airway or other respiratory condition, such as asthma/ bronchospasm,
chronic obstructive airway disease
6=Fine basal rales/ self-clearing
4=Course basal rales, receiving respiratory therapy/ physical therapy
2=Frequent suctioning/ respiratory therapy/ suspected infection/ respirator dependent
 144

Respiratory Rate for Swallow

Respiratory-swallow coordination

Task: Observe respiratory rate at rest. Observe mode of breathing (nasal/oral). Observe the timing of
patient’s saliva swallows in relation to inhalation/exhalation. Note pattern or return from swallow,
that is, returns to exhalation or not. Observe timing or cough (if present) in relation to swallow. Ask
patient to close mouth to breathe and then hold breath (comfortably); record duration.

Rating: 5=Able to control breath rate for swallow. Patient returns to exhalation post-swallow and can
comfortably hold breath 5 seconds.
3=Some control/incoordination. Patient can achieve nasal breathing and breath hold for a short
period. Patient returns to inhalation on occasion after swallow.
1=No independent control. Patient mouth breathes predominantly. Patient is unable to hold breath
comfortably. Rate of breath is variable.

Aphasia
Language impairment crossing different language modalities: speaking, listening, reading

Task: Formally assess the patient’s verbal expression. Ask patient to repeat sounds, words, sequences,
name objects, numbers, body/parts, answer simple questions, etc. NB: If formal assessment of
language completed, results may be rated

Rating: 5=No abnormality detected on screening

4=Mild difficulty finding words/ expressing ideas
3=Expresses self in a limited manner/ short phrases or words
2=No functional speech sounds or undecipherable single words
1=Unable to assess

Apraxia
Impairment in the capacity to order the positioning of the speech musculature or sequence the movements
for volitional production of speech. Not accompanied by weakness, slowness, or incoordination of these
muscles in reflex or automatic acts.

Task: Informally assess as above. Include repetition of phrases of increasing syllabic length and
performance of a range of oral movement to command. Record accuracy, agility, and spontaneous
versus imitative productions.

Rating: 5=No abnormality detected on screening

4=Speech accurate after trial and error, minor searching movements
3=Speech crude/ detective in accuracy or speed on command
2=Significant groping/inaccuracy, partial or irrelevant responses
1=Unable to assess
Dysarthria
Impairment of articulation characterize by disturbance in muscular control over the speech musculature.
Includes features such as paralysis, weakness, or incoordination of the speech musculature.

Task: Informally assess as above. Include articulation tasks of increasing length, that is sentence repetition,
 145
reading, and monologue. Engage in conversation. Request patient count to 5, whispering and
increasing volume. Diadochokinetic rate may be utilized.

Rating: 5=No abnormality detected on screening

4=Slow with occasional hesitation and slurring
3=Speech intelligible but obviously detective in rate/ range/ strength/ coordination
2=Speech unintelligible
1=Unable to assess

Saliva
Ability to manage oral secretions

Task: Observe the patient’s control of saliva. Note any escape of secretions from the side of mouth, and
check corners of mouth for wetness. Ask the patient if he/she has noticed undue saliva loss during
the day, at night, or while side lying.

Rating: 5= No abnormality detected on screening

4=Frothy/expectorated into cup
3=Drooling at times, during speech while side lying, when fatigues
2=Some drool consistently
1=Gross drooling. Unable to control drooling, open mouth posture, needing bib protection

Lip Seal
Ability to control labial movement and closure

Task: Observe lips at rest. Note tone at corners of mouth. Ask patient to spread lips widely on the vowel /i/
and round for the vowel /u/. Ask patient to alternate lip movement between the two vowels.
Observe bilabial function on earlier sound repetition and speech tasks, e.g., /pˆ/ and “Paul prefers
pink petunias.” Observe patient’s ability to close mouth around an empty spoon. Ask patient to blow
air into cheeks and maintain closure.

Rating: 5=No abnormality detected on screening

4=Mild impairment, occasional leakage
3=Unilaterally weak, poor maintenance, restricted movement
2=Incomplete closure, limited movement
1=No closure, unable to assess

Tongue Movement
Lingual mobility in both anterior and posterior aspects

Task: Anterior Aspect

Protrusion-Have patient extend tongue as far forward as possible and then retract similarly.
Lateralization-Have patient touch each corner of the mouth, then repeat alternating lateral
movements.
With tongue, have patient attempt to clear out lateral sulci on each side of mouth.
Elevation-With mouth open wide, have patient raise tongue tip to ridge. Alternate elevation and
depression in this way.
 146
Posterior Aspect
Elevation-Have patient raise back of tongue to meet palate and hold the position (like you’re going to
say /kˆ/.

Rating: 10=Full range of movement/ no abnormality detected

8=Mild impairment in range
6=Incomplete movement
4=Minimal movement
2=No movement

Tongue Strength
Bilateral lingual strength on resistance tasks

Task: Have patient push laterally, against a tongue depressor or gloved finger. Have patient push
anteriorly, against a tongue depressor or gloved finger. Have patient push during elevation and
depression of the tongue. Ask patient to elevate back of tongue against a tongue depressor or gloved
Note tone and strength to resistance.

Rating: 10:No abnormality detected on screening

8=Minimal weakness
5=Obvious unilateral weakness
2=Gross weakness

Tongue Coordination
Ability to control lingual movement during serial repetitious activity or speech

Task: Ask patient to lick around lips, slowly and then rapidly, touching all parts. Have patient rapidly repeat
tongue tip alveolar syllables /ta/. Repeat a sentence including tongue tip alveolar consonants (e.g.,
Take Time to tea). Ask patient to rapidly repeat velar syllables /ka/. Repeat a sentence including velar
consonants (e.g. Can you keep Katie clean?).

Rating: 10: No abnormality detected on screening

8=Mild incoordination
5=Gross incoordination
2=No movement/ unable to assess

Oral Preparation
Ability to break down food, mix with saliva, and form a cohesive bolus ready to swallow

Task: Observe patient while eating or chewing. Ask to observe how bolus is prepared prior to swallowing.
Check for loss from mouth, position of food bolus, spread throughout oral cavity, and loss of material
into lateral or anterior sulci. Note chewing movements and fatigue.

Rating: 10=No abnormality detected on screening

8=Lip or tongue seal, bolus escape
6=Minimal chew/ tongue thrust bolus projected forward limited preparation gravity assisted/ spread
throughout mouth/ compensatory head extension
4=No bolus formation/ no attempt
 147
2=Unable to assess

Gag
Reflex motor response triggered in response to noxious stimuli. It measures response of surface tactile
receptors and afferent information travels by way of CN X (and possibly some portion of IX).

Task: Using a laryngeal mirror (size 00) (introduction of cold is optional), contact the base of the tongue or
posterior pharyngeal wall. Note any contractions of the pharyngeal wall or soft palate.

Rating: 5=No abnormality detected, strong symmetrical response/ hyperreflexive

4=Diminished bilaterally
3=Diminished unilaterally
2=Absent unilaterally
1=No gag response noted

Palate
Function of the velum in speech reflexively

Task: Ask the patient to produce a strong /ah/ and sustain for several seconds. Ask the patient to
repeat/ah/ several times. Note action of elevation. Observe any hypernasality from earlier speech
tasks. Test palatal reflex-make contact with cold laryngeal mirror at juncture of hard and soft palates.

Rating: 10=No abnormality detected on screening

8=Slight asymmetry noted, mobile
6=Unilaterally weak, inconsistently maintained
4=Minimal movement, nasal regurgitation, nasal air escape
2=No spread or elevation

Bolus Clearance
Ability to move a bolus effectively through the oral cavity

Task: Observe patient eating/ swallowing a bolus. Check oral cavity for residue following a swallow.

Rating: 10=Bolus fully cleared from mouth

8=Significant clearance, minimal residue
5=Some clearance, residue
2=No clearance

Oral Transit*
Time from initiation of lingual movement until bolus head reaches point where lower edge of mandible
crosses the tongue base. In clinical measurement, this duration must be timed from the initiation of lingual
movement until the initiation of hyoid and laryngeal rise. Thus, the measurement is a crude estimate of time
from tongue movement initiation to the trigger of the pharyngeal swallow. Exact oral transit time cannot be
separated.

Task: The clinician will position a hand under the patient’s chin, with fingers spread as per manual
palpitation method (Logemann, 1983). Use only a light touch. Ask the patient to swallow. Compare
time elapsed between the initiation of lingual movement until the initiation of hyoid and laryngeal
 148
rise. (Normal time for triggering of the pharyngeal swallow is approximately 1 second.)

Rating: 10=No abnormality detected on screening, triggers rapidly within 1 second

8=Delay greater than 1 second
6=Delay greater than 5 seconds
4=Delay greater than 10 seconds
2=No movement observed/ unable to assess

*In the elderly, this may not be an appropriate assessment task

Cough Reflex
Spontaneous cough in response to an irritant

Task: Observe any spontaneous coughing during the examination. Cough may be elicited in combination
with a respiratory or physical therapist.

Grading: 5=No abnormality detected on screening, strong reflexive cough

3=Weak reflexive cough
1=None observed/ unable to assess

Voluntary Cough
Cough response to command

Task: Ask the patient to cough as strongly as possible. Observe strength and clarity of cough.

Rating: 10=No abnormality detected on screening, strong clear cough

8=Cough attempted but bovine, hoarse in quality
5=Attempt inadequate
2=No attempt/ unable to assess

Voice
Evaluation of laryngeal functioning with specific emphasis on vocal quality

Task: Ask the patient to prolong an /ah/ sound for as long as possible. Ask the patient to slide up and down
a scale. Ask the patient to prolong /s/ and /z/. Observe clarity of production, pitch, phonation breaks,
huskiness, uneven progression, uncontrolled volume (as in previous dysarthria tests), and voice
deterioration.

Rating: 10=No abnormality detected on screening, strong clear cough

8=Mild impairment, slight huskiness
6=Hoarse, difficulty with pitch/ volume control
4=Wet/ gurgling vocal quality
2=Aphonic/ unable to assess

Trach
Tracheostomy tube to provide ventilator support, facilitate aspiration of tracheobronchial secretions, and/ or
to bypass a respiratory obstruction
 149
Task: Observed the presence of tracheostomy tube; identify reason for insertion. Information may be
gathered from medical chart, physiatrist, respiratory therapist, or nursing staff.

Rating: 10=No trach required

5=Fenestrated trach in situ or uncuffed
1=Cuffed trach in situ (including those with periods of cuff deflation)
 150

Speech-Language
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Interpretation:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
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___________________________________________________________________________________________
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 159

Wound Assessments
 160

Wound Assessment/ Progress Report

Patient: Room # Time: Date:

Wound 1 Wound 2 Wound 3
Level
Length (cm)
Width (cm)
Depth (cm)
Wound Type: L AB L AB L AB
Laceration=L Perineum Abcess=AB SW PU SW PU SW PU
Surgical Wound=SW Pressure Ulcer=PU A T A T A T
Arterial=A Trauma=T D Other__________ D Other__________ D Other__________
Diabetic=D Other=O_________ V V V
Venous=V

Tunneling/Undermining _______o’clock______cm _______o’clock______cm _______o’clock______cm

_______o’clock______cm _______o’clock______cm _______o’clock______cm
_______o’clock______cm _______o’clock______cm _______o’clock______cm
_______o’clock______cm _______o’clock______cm _______o’clock______cm

Exposed Muscle, Tendon, or Bone Yes_____ No______ Yes_____ No______ Yes_____ No______
Exposed Subcutaneous Yes_____ No______ Yes_____ No______ Yes_____ No______
Stage: II III IV P F Un II III IV P F Un II III IV P F Un
Tissue %: 25%, 50%, 75% 100%
N=Necrotic (Eschar or Slough) N=_____% N=_____% N=_____%
G=Granulation G=_____% G=_____% G=_____%
E=Epithelialization E=_____% E=_____% E=_____%
Color: Red, Yellow, Brown _____%R ______%Y _____%R ______%Y ______%B _____%R ______%Y ______%B
______%B
Related Conditions: (Circle if Present)
Hemorrhage=H Inflammation=Infl H Infl H Infl H Infl
Maceration=M Circulatory Deficit=CD M CD M CD M CD
Induration=I Sensation Loss=SL I SL I SL I SL
Edema=E E E E
Drainage: (Circle) Min Mod Heavy Min Mod Heavy Min Mod Heavy
Drainage: (Circle if Present)
None=N Serous=S N S N S N S
Sanguineous=B Purulent=P B P B P B P
Odor: (Circle if Present)
None=N Mild=M Foul=F N M F N M F N M F
Periwound:
Pink/Normal=P Blanchable=B P B P B P B
Reddened=R White, Grey, Pale=W R W R W R W
Macerated=M Induration=I M I M I M I
Purple & Nonblanchable=PNB PNB PNB PNB
Wound Edge:
Well Defined=WD Scissors=S WD J WD J WD J
Rolled=R Chemical=CM R C R C R C
Debrided With:
Curette=C Scissors=S C S C S C S
Lavage=L Chemical=CM L CM L CM L CM
Tissue Type:
Devitalized=D Foreign Material=FM D FM D FM D FM
Contaminated=C C C C
Patient Response:
Tolerated Well=TW Unable to Tolerate=UT TW TP UT TW TP UT TW TP UT
Tolerated w/Pain=TP
Pain:
Wong Scale: 0-10 Level___________ Level___________ Level___________
 161

Wound Assessment/ Progress Report

Name: Page 2
Wound 1 Wond 2 Wound 3
Patient Dressing: (Specify Brand) Primary Dressing:____________ Primary Dressing:____________ Primary Dressing:____________
Alginate=A Ag Alginate=SA Secondary Dressing__________ Secondary Dressing__________ Secondary Dressing__________
Honey Alginate=HA Collagen=C Secondary Dressing__________ Secondary Dressing__________ Secondary Dressing__________
Collagen Powder=CP Hydrogel=H Secondary Dressing__________ Secondary Dressing__________ Secondary Dressing__________
Packing Strip=PS Iodine Packing Strip=IPS ___________________________ ____________________________ ___________________________
Oil Emulsion=OE Xeroform=X ___________________________ ____________________________ ___________________________
Ag Foam=AF Foam=F ___________________________ ___________________________ ___________________________
Hydrocolloids=HC Transparent Film=TF ___________________________ ___________________________ ___________________________
Non-Adherent=NA ABD=ABD ___________________________ ___________________________ ___________________________
Conforming Gauze=CG Gauze Roll=GR ___________________________ ___________________________ ___________________________
AMD Gauze Roll=AGR AMD Gauze=AG ___________________________ ____________________________ ___________________________
Paper Tape=PT Coban Roll=CR ___________________________ ____________________________ ___________________________
Fabric Tape=FT ___________________________ ____________________________ ___________________________
___________________________ ____________________________ ___________________________
Type of Specialty Bed: Type: Type: Type:
Positioning Needs/Equipment:

Modality:
HVPC=H Ultrasound Continuous-US H US H US H US
Pulse Ultrasound=PU_____% duty cycle PU PS PU PS PU PS
Thermal SWD=TS Pulse SWD=PS TS WP TS WP TS WP
Whirlpool=WP
(Minutes)
Ultrasound (face to face)___________minutes for__________________________ Ultrasound_________________@_______________________Volts
Elicrical Stimulation_______________minutes for__________________________ E-Stim Pads_________________@_______________________Volts
Heat Therapy____________________minutes for__________________________ E-Stim Pads_________________@_______________________Volts
Therapy________________________ minutes for__________________________ E-Stim Polarity_______________Negative_______________Positive
Other__________________________minutes for___________________________ Location__________________________________________________
Other__________________________ minutes for__________________________

Comments: Discharge: Yes or No

_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________

Therapist Signature:________________________________________________ License #______________ Date:__________________________

Red=clean healthy tissue; Yellow= presence of exudate that needs removal, It can be whitish yellow, creamy yellow, yellowish green, or light
brown; Black=presence of eschar
 162

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 163

Vascular Risk Assessment of the Older Cardiovascular Patient: The Ankle-Brachial

Index (ABI)
By: Lola A. Coke, PhD, ACNS-BC, Rush University College
of Nursing and Preventive Cardiovascular Nurse’s
Association

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Stroke Assessment
Scales
 168

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Q1. What does the Stroke Impact Scale test?

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Q2. Describe the Stroke Impact Scale

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Q3. Describe some of the key Stroke Impact Scale numbers

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Q4. What are the Advantages of the Stroke Impact Scale?

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Q5. What are the Disadvantages of the Stroke Impact Scale?

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 169

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References

Duncan PW, Jorgensen HS, Wade DT. Outcome measures in acute stroke trials. A systematic
review and some recommendations to improve practice. Stroke 2000;31:1429-1438.

Duncan PW, Wallace D, Lai SM, Johnson D, Embretson S, Laster LJ. The Stroke Impact Scale
version 2.0. Evaluation of reliability, validity and sensitivity to change. Stroke 1999;30:2131-2140.
 170

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 171

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These questions are about the physical problems which may have occurred as a
result of your stroke.

1. In the past week, how would A lot of Quite a bit Some A little No
you rate the strength of strength of strength strength strength strength at
your.... all
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These questions are about your memory and thinking.

2. In the past week, how difficult Not A little Somewhat Very Extremely
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difficult difficult difficult difficult difficult
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 172

These questions are about how you feel, about changes in your mood and
about your ability to control your emotions since your stroke.

3. In the past week, how often None of A little of Some of Most of All of the
did you... the time the time the time the time time
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The following questions are about your ability to communicate with other
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and what you hear in a conversation.

4. In the past week, how difficult Not A little Somewhat Very Extremely
difficult difficult difficult difficult difficult
was it to...
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 173

The following questions ask about activities you might do during a typical day.

5. In the past 2 weeks, how difficult Not A little Somewhat Very Could
was it to... difficult at difficult difficult difficult not do at
all all
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The following questions are about your ability to be mobile, at home and in
the community.

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 174

The following questions are about your ability to use your hand that was
MOST AFFECTED by your stroke.

7. In the past 2 weeks, how difficult Not A little Somewhat Very Could not
difficult difficult difficult difficult do at all
was it to use your hand that was
most at all
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The following questions are about how stroke has affected your ability to
participate in the activities that you usually do, things that are meaningful
to you and help you to find purpose in life.

8. During the past 4 weeks, how None of A little of Some of Most of All of the
much of the time have you been the time the time the time the time time
limited in...
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 175

9. Stroke Recovery

On a scale of 0 to 100, with 100 representing full recovery and 0 representing no recovery,
how much have you recovered from your stroke?

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Q1. What does the National Institutes of Health Stroke Scale test?

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Q2. Describe the National Institutes of Health Stroke Scale

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Q3. Describe some of the key National Institutes of Health Stroke Scale numbers

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Q4. What are the Advantages of the National Institutes of Health Stroke Scale?

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Q5. What are the Disadvantages of the National Institutes of Health Stroke Scale?

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 177

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References

Brott T, Adams HP, Jr., Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale.
Stroke 1989;20:864-870.

Heinemann AW, Harvey RL, McGuire JR, et al. Measurement properties of the NIH Stroke Scale during acute
rehabilitation. Stroke 1997;28:1174-1180.

Anemaet WK. Using standardized measures to meet the challenge of stroke assessment. Top
Geriatr Rehabil 2002;18:47-62.

Schlegel DJ, Tanne D, Demchuk AM, Levine SR, Kasner SE. Prediction of hospital disposition after thrombolysis
for acute ischemic stroke using the National Institutes of Health Stroke Scale. Arch Neurol 2004;61:1061-1064.

Goldstein LB, Chilukuri V. Retrospective assessment of initial stroke severity with the Canadian
Neurological Scale. Stroke 1997;28:1181-1184.

Dewey HM, Donnan GA, Freeman EJ, et al. Interrater reliability of the National Institutes of Health Stroke Scale:
rating by neurologists and nurses in a communitybased stroke incidence study. Cerebrovasc Dis 1999;9:323-327.
Josephson SA, Hills NK, Johnston SC. NIH Stroke Scale reliability in ratings from a large sample of clinicians.
Cerebrovasc Dis 2006;22:389-395.

Schmulling S, Grond M, Rudolf J, Kiencke P. Training as a prerequisite for reliable use of NIH Stroke Scale.
Stroke 1998;29:1258-1259.
Muir KW, Weir CJ, Murray GD, Povey C, Lees KR. Comparison of neurological scales and scoring systems for
acute stroke prognosis. Stroke 1996;27:1817-1820.
 178
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Instructions Scale Definition Score

1a. Level of Consciousness: The investigator must choose a
response if a full evaluation is prevented by such obstacles as an
endotracheal tube, language barrier, orotracheal
trauma/bandages. A 3 is scored only if the patient makes no
movement (other than reflexive posturing) in response to
noxious stimulation.
1b. LOC Questions: The patient is asked the month and his/her
age. The answer must be correct - there is no partial credit for
being close. Aphasic and stuporous patients who do not
comprehend the questions will score 2. Patients unable to speak
because of endotracheal intubation, orotracheal trauma, severe
dysarthria from any cause, language barrier, or any other
problem not secondary to aphasia are given a 1. It is important
that only the initial answer be graded and that the examiner not
"help" the patient with verbal or non-verbal cues.
0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is
obtunded and requires strong or painful stimulation to make
movements (not stereotyped).
3 = Responds only with reflex motor or autonomic
0 = Answers both questions correctly.
1= Answers one question correctly.
2 = Answers neither question correctly.

1c. LOC Commands: The patient is asked to open and dose the 0 = Performs both tasks correctly.
eyes and then to grip and release the non-paretic hand.
Substitute another one step command if the hands cannot be 1= Performs one task correctly.
used. Credit is given if an unequivocal attempt is made, but not
completed due to weakness. If the patient does not respond 2 = Performs neither task correctly.
to command, the task should be demonstrated to him or her
(pantomime), and the result scored (i.e., follows none, one or
two commands). Patients with trauma, amputation, or other
physical impediments should be given suitable one-step
commands. Only the first attempt is scored.

5HY
 179

1,+
Patient Identification__ __-__ __ __-__ __ __
6752.( Pt. Date of Birth ________________ /______ /
6&$/( Facility______________________________________

Date of Exam __ __/__ __/__ __

Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other_____________________________________________ (____ ____)

2. Best Gaze: Only horizontal eye movements will be tested.

0= Normal.
Voluntary or reflexive (oculocephalic) eye movements will be
scored, but caloric testing is not done. If the patient has a
1= Partial gaze palsy; gaze is abnormal in one or both eyes, but
conjugate deviation of the eyes that can be overcome by
forced deviation or total gaze paresis is not present.
voluntary or reflexive activity, the score will be 1. If a patient
has an isolated peripheral nerve paresis (CN III, IV or VI), score a
2 = Forced deviation, or total gaze paresis not overcome
1. Gaze is testable in all aphasic patients. Patients with ocular
by the oculocephalic maneuver.
trauma, bandages, pre-existing blindness, or other disorder of
visual acuity or fields should be tested with reflexive movements,
and a choice made by the investigator. Establishing eye contact
and then moving about the patient from side to side will
occasionally clarify the presence of a partial gaze palsy.

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.
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.
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 tum, 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 visual loss.
1= Partial hemianopia.
2 = Complete hemianopia.
3 = Bilateral hemianopia (blind including cortical blindness).
0= Normal symmetrical movements.
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).
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 effor1against gravity.
3= No effort against gravity; limb falls.
4= No movement.
UN=Amputation or joint fusion, explain:____________________

5a. Left Arm

5b. Right Arm

5HY

1,+
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Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other_____________________________________________ (____ ____)
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 tum, 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.
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-nose-finger
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.
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.
5HY
180
Patient Identification__ __-__ __ __-__ __ __
Pt. Date of Birth ________________ /______ /
Facility______________________________________
Date of Exam __ __/__ __/__ __
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 effor1against 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
0= Absent
1= Present in one limb.
2= Present in two limbs.
UN= Amputation or joint fusion, explain:
0 = Normal no sensory loss.
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.

1,+
6752.(
6&$/(
Interval: [ ] Baseline [ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes [ ] 7-10 days
[ ] 3 months [ ] Other_____________________________________________ (____ ____)
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.
10. Dysarthria: If patient is thought to be normal an
adequate sample of speech must be obtained by asking patient
to read or repeat words from the attached list. If the patient
has severe aphasia, the clarity of articulation of spontaneous
speech can be rated. Only if the patient is intubated or has other
physical barriers to producing speech, the examiner should record
the score as untestable (UN), and clearly write an explanation for
this choice. Do not tell the patient why he or she is being tested.
11. Extinction and Inattention (formerly Neglect): Sufficient
information to identify neglect may be obtained during the
prior testing. If the patient has a severe visual loss preventing
visual double simultaneous stimulation, and the cutaneous
stimuli are normal, the score is normal. If the patient has aphasia
but does appear to attend to both sides, the score is normal. The
presence of visual spatial neglect or anosagnosia may also be taken
as evidence of abnormality. Since the abnormality is scored only if
present, the item is never untestable.
5HY
181
Patient Identification__ __-__ __ __-__ __ __
Pt. Date of Birth ________________ /______ /
Facility______________________________________
Date of Exam __ __/__ __/__ __
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.
0= Normal.
1= Mild-to-moderate dysarthria; patient slurs at least some
words and, at worst, can be understood with some
difficulty.
2= Severe dysarthria; patient's speech is so slurred as to be
unintelligible in the absence of or out of proportion to any
dysphasia, or is mute/anarthric.
UN= Intubated or other physical barrier,
explain:_________________________________________
0 = No abnormality.
1= Visual tactile, auditory, spatial, or personal inattention
or extinction to bilateral simultaneous stimulation in one of
the sensory modalities.
2 = Profound hemi-inattention or extinction to more than
one modality; does not recognize own hand or orients to
only one side of space.
182
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References
Impairment Test Description Format Population Interpretation How to access: Cost:
Activity Tolerance Walk Test Assess exercise Performance- Patients with chronic A greater distance Guyatt, GH, Thorax
(2-minute) tolerance in patients based test airflow limitation and/or indicates a better 1984;39:818-22
with chronic airflow chronic heart failure, performance
limitation COPD, frail elderly,
Parkinson’s neurologically
impaired adults
Walk Test Assess exercise Performance- Patients with COPD A greater distance Guyatt, GH. Can
(6-minute) tolerance in patients based test and/or heart failure, indicates a better Med Assoc J
with respiratory fibromyalgia, respiratory performance 1985;132:919-23
disease disease
Walk Test Used to assess exercise Performance- Patients with COPD A greater distance McGavin, CR. BMJ
(12-minute) tolerance in patients based test indicates a better 1976;1:822-3
with chronic bronchitis performance
Walk Test Used to evaluate Performance- Healthy adults, elderly Faster walking Bassey EJ. Clin Sci
(Self-Paced) walking efficiency in the based test patients, cardiac patients speed and lower Mol Md
elderly and functional heart rates indicate 1976;51:609-12.
performance better performance
ADL/ Functional Canadian An individualized Interview- Patients with a variety of Scores are used to Canadian
Assessment Occupational client-centered based rating disabilities and across all compare patient’s Association of
Performance outcome measure, scale developmental stages elf-perceptions Occupational
Measure designed to detect against their own Therapist. 416-487-
(COPM) change in a patients eassessment scores; 5404
self-perception of hanges of 2 points
occupational are clinically
performance over time ignificant
Comprehensive Provides a standard Behavior rating Adult acute psychiatric Provides a daily American Journal <$10
Occupational and objective method scale patients summary of client’s of Occupational
Therapy of observing and rating behavior over the Therapy, 30 (2), 94-
Evaluation behaviors of psychiatric entire acute care 100
(COTE) patients on a regular hospitalization
basis
Barthel Index Simple index of Performance Patients with Total score yields Maryland State <$10
independence reflects index based on neuromuscular or categories of Medical Journal,
the functional status of observation, musculoskeletal disorders. functioning 14,61-65. (1965)
hospital patients in interview or Adults indicating intact,
ADL’s and assess records limited, helper and
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change null
Impairment Test Description Format Population Interpretation How to access: Cost:


Functional Designed to provide Checklist-type Any hospitalized or Yields a single level Geri-Rehab, Inc.,
Assessment uniform, simple rating scale institutionalized patient of function assigned 908-735-8918
Scale (FAS) method of rating the to the patient
level of self-care
function/ dysfunction
ADL/ Functional Kitchen Task A practical and Standardized Adults with Senile The final score American Journal <$10
Assessment- Assessment objective measure of performance- Dementia of the ranges from 0-18, of Occupational
continued (KTA) organizational, based Alzheimer’s type the higher the Therapy, 47, 431-
planning and judgment score, the more 436. (1993)
skills as performed in a impaired
common task performance
Kohlman Designed to provide a Interview and Short term psychiatric Yields a single cutoff AOTA Bethesda,
Evaluation of quick and simple task adolescent and adult score indicating MD 301-652-2682
Living Skills evaluation of an performance inpatients, geriatric, brain capability to live
(KELS) individual’s ability to tests injured, or cognitively independently in
perform basic living impaired the community
skills
Balance Berg Balance Monitor functional Performance- Older adults and patients Maximum score is www.chcr.brown.e <$10
Scale (BBS) balance over time and based test receiving rehab services 56. Higher scores du/BALANCE.htm
response to treatment indicate greater
balance
Functional Assess dynamic Performance- Community living elderly, Length of horizontal Duncan PW. J <$10
Reach postural control based test frail elderly, CVA, MS, TBI, reach over base of Gerentol
low back pain, Parkinson’s support indicator of 1990;45M192-7
risk for fall
Timed Stands Measure lower Performance- Healthy males and Shorter time Csuka, M. AM J
test extremity muscle based measure females, patients with indicates better Med 1985; 78:77-
strength pulmonary, cardiology, performance 81
metabolic
Timed Up and Measure mobility, Performance Elderly patients with Used to measure Podsiadlo D. J AM
Go (TUG) balance and locomotor task balance disturbances risk of fall Geriatr Sco 1991;
performance 39:142-8
Tinetti Test that measure the Performance Adult and elderly patients Maximum score is Tinetti ME. PT
patients gait and task 28, with the higher Bulletin 1993; 2:9,
188

balance scores a predictor of 40.

falls
Impairment Test Description Format Population Interpretation How to access: Cost:


Get Up and Go Measures the sense of Performance Elderly population A score of severely Mathias, S. Arch
balance that the task abnormal meant the Phys Med Rehabil
patient has patients appeared 1986;67:387-389
at a serious risk of
falling
Behavior Geriatric Rating Designed to assess all Observation- Geriatric institutionalized Each scale yields a The Stockton <$10
Scale/ Stockton behaviors of patients based patients, including total summed score Geriatric Rating
Geriatric Rating that contribute to their behavioral functional psychotic with higher scores Scale, Journal of
Scale ability to leave the rating scale disorders and organic indicating greater Gerontology, 21,
hospital. The GRS is a mental disease improvement 392-403. (1996)
revision of the
Stockton
Cognition Allen Cognitive A clinical instrument to Task analysis Any psychiatric or The assigned S&S Worldwide
Level (ACL) assess cognitive with standard cognitively impaired cognitive level PO Box 513
disability and suggest demonstration- population indicates the level of Colchester, CT
treatment approach. instruction cognitive function 06415
Using a routine task. the patient is 1-800-243-9232
expected to perform
Allen Standardized craft Rating scale Adolescents and adults of The outcome of the S&S Worldwide $$-
Diagnostic activities are used to based on the both sexes who are at a patient’s PO Box 513 $$$
Model (ADM) evaluate and treat patients task cognitive level of 3 or performance Colchester, CT
patients with cognitive performance higher indicates the 06415
disabilities functional cognitive 1-800-243-9232
level
Blessed Attempts to quantify Rating scale Elderly people with Total score ranges http://www.stroke <$10
Dementia the degree of and checklist Dementia from 0-28 (fully center.org/trials/sc
Rating Scale intellectual and based on semi- preserved capacity- ales/blessed_deme
personality structured extreme incapacity) ntia.pdf
deterioration in people interview and
with Dementia. mental tasks
Cognitive identifies general Screening test Adults who have Raw scores are Therapy Skill
Assessment of cognitive problem using Q & A sustained a brain injury or plotted on a scoring Builders
Minnesota areas to guide the and CVA and who are at a profile. Mild-Severe 800-228-0752
(CAM) selection of specific performance rancho level IV and above rating
tasks
189

treatment activities
Cognitive A functional Standardized Adults With mild- Scores range from AOTA, <$10
Performance assessment of ADL graded task moderate Alzheimer's Level1(lowest) -6 Bethesda, MD.
Test(CPT) tasks, based on the performance on each task
ACL
Impairment Test Description Format Population Interpretation How to access: Cost:


Global The scales were Behavior-based Patients with primary Describes the Or. Barry <$10
Deterioration developed to assess rating scales degenerative dementia cognitive skills and Reisberg, MD Dept
Scale (GDS)/ the clinically resulting ADL status of Psychiatry, New
Brief Cognitive identifiable and of the subject over York University
Rating Scale ratable-stages of the long disease Medical Center,
(BCRS)/ primary degenerative course 550 First
Functional dementia and age- Avenue, New
Assessment associated memory York, NY 10016
staging (FAST) impairment. BCRS and
FAST were derived
from GDS
Mini-Mental A short and simple Standardized Neuro-geriatric Mean score for the Journal of $1.10
State (MMSE) qualitative measure of oral patients, good for those normal sample was Psychiatric
Cognitive performance questionnaire patients who can 27.6 with range of Research, 12,
cooperate for short 24-30 18g..198. (1975)
Routine Task A measurement of Performance Adults who may have Ratings describe AOTA, Bethesda, $
Inventory (RI- impairment as it rating cognitive impairments behavior according MD Claudia Allen
2). Based on relates scale based on to the level of (1992)
the ACL to the performance of observation, cognitive ability
ADL. self- report,
and/or
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Cognition Severe Assesses the low-level Performance Severely demented older Severity of Thames Valley $$$
Impairment patient with severe test and rating adults impairment is Test Co.
Battery cognitive deficits. scale graded as reflected 517-732-3866
Demonstrates by the score
performance on tow-
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patterns of
deterioration over time
Dysphagia Dysphagia Designed to provide Checklist based Adults with a wide Yields a summary of Therapy Skill $$
Evaluation an objective and on observation variety of diagnoses that findings, indicating Builders
Protocol reliable measure of and may be associated with degree of assistance 800-228-0752
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swallowing function performance acute or chronic dysphagia needed and

recommendations
for diet, therapy or
additional referrals
Impairment Test Description Format Population Interpretation How to access: Cost:


Dyspnea Baseline/ Used to determine Interview COPO, asthma, CHF Lower score Mahler CA.
Transitional the severity of indicates Chest
Dyspnea Index dyspnea at a single Greater severity of 1984;85:751-8
point in time dyspnea
Gait Gait Speed Developed to Performance Acute and chronic Allows to quantify Salbach NM.
assess patients based on stroke, MS, OA, one aspect of Arch Phys Med
exercise timed walk Alzheimer's, Parkinson's normal and Rehabil
tolerance test pathologic gait 2001;82:1204-12
Gait Measures the Performance Elderly patients In long The higher the Wolfson L.
Assessment relationship of gait based term care GARS score the Journal of
Rating Score abnormalities to falls task more impaired the Gerontology
patients gait is 1990;45(1):M12-
19
Functional Provides a clinical test Task Adult population, As the patient Nelson AJ.
Ambulation of locomotor skill performance neuromuscular or improves the time Physical Therapy
Profile exam musculoskeletal the patient takes 1974;54(10):105
disorders to complete the 9-1064
task decreases
/HLVXUH Activity Index: Both instruments Structured Elderly, age 65 and over Both instruments AJOT, 37, 548-553 <$10
Activity examine the meaning interview and yield a summed (1983)/AJOT, 28,
Patterns and and significance of self-report score for 337-345 (1974)
Leisure activity and activity questionnaire participation in
Concepts patterns among the activities, as well as
Among the elderly listings of preferred
Elderly/ activities
Occupational
Behavior and
Life
Satisfaction
Among
Retirees
Motor Deuel’s Test of Designed to identify Motor Older patients with senile Total apraxia score Education Institute, <$10
Manual the presence, type and performance dementia of the (0-160), with a Inc. 310-940-7165
Apraxia severity of apraxia in rating scale alzheimer’s type cutoff score of 31
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function achieved
Impairment Test Description Format Population Interpretation How to access: Cost:


Functional Test Designed to evaluate Battery of Adults with hemiparesis Yields a single score, Education Institute, <$10
for the the integrated function performance indicating level of Inc. 310-940-7165
Hemiparetic of the total tasks function achieved
Upper hemiparetic upper
Extremity extremity of the adult
Jebsen Hand Designed to assess the Standardized Children and adults, over Item scores are Sammons Preston, <$10
Function Test effective use of the norm-based 5 years of age compared to Inc. 800-323-5547
hands in everyday performance normative values
activity by performing test according to age
tasks similar to and sex
functional manual
activities
Minnesota Tests are designed to Standardized Adults General American Guidance MRM
Rate of measure manual speed tests interpretation of Service, Inc. T-
Manipulation dexterity or speed of speed 800-428-7545 $$$M
Tests (MRMT)/ gross arm and hand MDT-
Minnesota movements during $$
Manual rapid eye-hand
Dexterity Test coordination tasks
(MMDT)
Motor-Continued Motor Designed to Standardized Stroke patients Provides a visual Carr, J.H., <$10
Assessment quantitatively measure performance score on a graph, Shephard, R.B.,
Scale the motor recovery of scale indicating Nordholm, L
stroke patients by motor/function
using functional tasks recovery and tone. Physical Therapy,
Offers immediate 65, 175-180 (1985)
feedback to the
patient

Purdue Designed to measure Standardized Adults Timed testing of fine Lafayette $$

Pegboard fingertip dexterity and performance motor manipulation Instrument Co.
finger/hand/arm tasks of pins and 800-428-7545
activity compared with
192

norms
Impairment Test Description Format Population Interpretation How to access: Cost:


Pain McGill Pain Provides a consistent Questionnaire Adult patients with pain A qualitative index Pain, 1, 277-299. <$10
Questionnaire method of measuring consists of 3 of pain and indicate (1975) Melzack, R.
(MPQ) subjective pain groups of pains the extent of change (1983). Pain
experience. descriptor in quality and measurement and
words intensity of pain assessment. New
(sensory, York. Raven Press.
affective and
evaluative)
Disability Short and simple Self-rated Patients with low back Score ranges from 0 Roland, M., Morris, <$10
Questionnaire questionnaire that questionnaire pain (no disability) to 24 R.A. Spine, 8, 141-
measures self-rated (severe disability) 144 (1983)
disability due to back
pain
Oswestry Low Designed to measure Questionnaire Patients with low back Expressed as Physiotherapy, <$10
Back Pain the level of function as pain percentage: 0-20% 66,271-273
Disability an indication of min disability
Questionnaire disability, limitations of 20-40% mod
performance when disability
compared to a fit 40-60% severe
person disability
60-80% crippled
80-100% bed bound
Pain Assess the AD patients Observation Advanced Dementia Higher score Warden 2003 <$10
Assessment in for nonverbal pain patients indicates greater
Advanced indicators pain
Dementia
(PANAID)
Numeric Pain Assess the patients 11 point scale Patients with orthopedic Scale of 0-10 and Jensen MP. Paon <$10
Rating Scale self-report of pain (0-100) dysfunction, acute and can vary 1986;27:117-26
(NPRS) chronic conditions and RA
Pain-continued Roland Morris Assess functional status 24 item self- Patients with low back Scores can vary Roland M. Spine <$10
Questionnaire and pain-related report pain, acute, chronic from 0-24, highest 1983;8:141-4
disability status questionnaire to lowest functional
state
193

Visual Subjective Self-report Patients with acute pain, 100 mm straight Scott, J. Pain <$10
Analogue Scale measurement of pain chronic pain, RA, cancer, horizontal/ vertical 1976;2:175-84
(VAS) intensity orthopedic pain, TMJ line indicating
intensity of pain
Impairment Test Description Format Population Interpretation How to access: Cost:


Western To assess pain, stiffness Questionnaire Hip and knee OE and The total score form www.clinicmetrics. <$10
Ontario and disability in arthroplatsy patients the 3 subtests will net
McMaster patients with determine the
Osteoarthritis Osteoarthritis of the impact of pain on
Index hip or knee function and
(WOMAC) disability
Perceived Exertion Borg’s rating Provides a measure of Self-report Children, young and older 15 grade rating scale Shop Kindred <$10
Scale of the patients perceived adults, healthy individuals, will assist in exercise
Perceived exertion during work or respiratory conditions prescription
Exertion (RPE) leisure activities
COPD Self- Assess self-efficacy, Self-report Adults with chronic Higher scores Wigal JK. Chest
Efficacy Scale condition-specific bronchitis and/or indicate higher 1991;99:1193-6
(CSES) measure emphysema efficiency
Oxygen Cost Self-assessment tool Self- Patients with mild-severe 100 mm vertical line McGavin CR. BMJ
Diagram (OCD) designed to allow assessment airflow limitation and with descriptions of 1978;2:241-3
patients to report their restrictive lung disease daily activities on
functional exercise either side
limitation
Quality of Life Sickness Behaviorally based Self-rated Applicable to all types of Total score offers Sickness Impact <$10
impact Scale measure of perceived checklist severity of illnesses assistance to Profile, John
(SIP) health status to detect determine health Hopkins University,
changes of differences care planning and Baltimore, MD
in health status that evaluation
occurs over time
Chronic Assess physical and Interview Patients with chronic Identifies the www.atsqol.org
Respiratory emotional aspects of airflow limitation, COPD patients perceived
Disease quality of life limitation of activity
Questionnaire base on SOB
Fibromyalgia Assess the current Questionnaire Patients with A higher score Burckhardt CS. J
Impact health status of women fibromyalgia, RA indicates a poorer Rheumatol
Questionnaire health status 1991;19:728-33
(FIQ)
Nottingham Tool to evaluate the Self-report Patients with arthritis and Total core is used to McDowell I. Oxford
Health Profile patients quality of life variety of acute and determine impact of University Press;
194

(NHP) measures chronic illnesses illness on quality of 1996. P 438-46

life
Impairment Test Description Format Population Interpretation How to access: Cost:


Quality of Life- SF-36 (Medical Uses as an indicator of 36-item short General populations, Estimates disease www.sf-36.com <$10
continued Outcomes perceived health status form health elderly patients burden in more than
Study 36-item survey 130 diseases and
short form conditions
health survey)
SF-12 (12-ite Generic measure of Questionnaire Adult patients with www.sf-36.com <$10
short-form health status chronic conditions
Health survey
195