Outcome Measures, Classifications, Scales

What does the ASIA Impairment Scale classify?

Severity of spinal cord injury based on sensory and motor function.

What does ASIA A indicate?

Complete spinal cord injury.

What sensory and motor function is present in ASIA A?

No sensory or motor function is preserved in sacral segments S4-S5.

What does ASIA B indicate?

Sensory incomplete spinal cord injury.

What sensory and motor function is present in ASIA B?

Sensory but not motor function is preserved below the neurologic level and includes the sacral segments S4-S5.

What does ASIA C indicate?

Motor incomplete spinal cord injury.

How are key muscles graded in ASIA C?

More than half of the key muscles below the neurological level have a muscle grade less than 3.

What does ASIA D indicate?

Motor incomplete spinal cord injury.

How are key muscles graded in ASIA D?

At least half of the key muscles below the neurological level have a muscle grade of 3 or more.

What does ASIA E indicate?

Normal sensory and motor function.

What does the Modified Ashworth Scale measure?

Spasticity (muscle tone).

What does a Modified Ashworth Scale score of 0 indicate?

No increase in muscle tone.

What does a Modified Ashworth Scale score of 1 indicate?

Slight increase in muscle tone manifested by a catch and release or by minimal resistance at the end of the ROM when the affected part is moved in flexion or extension.

What does a Modified Ashworth Scale score of 1+ indicate?

Slight increase in muscle tone manifested by a catch followed by minimal resistance throughout the remainder (less than half) of the ROM.

What does a Modified Ashworth Scale score of 2 indicate?

More marked increase in muscle tone through most of the ROM, but the affected part is easily moved.

What does a Modified Ashworth Scale score of 3 indicate?

Considerable increase in muscle tone; passive movement is difficult.

What does a Modified Ashworth Scale score of 4 indicate?

The affected part is rigid in flexion or extension.

What does the Functional Independence Measure (FIM) assess?

The amount of assistance required to complete a functional task.

How many levels are on the Functional Independence Measure (FIM)?

Seven.

What does a FIM score of 7 indicate?

Independent.

What does a FIM score of 6 indicate?

Modified independent; patient requires an assistive or adaptive device.

What does a FIM score of 5 indicate?

Supervision; patient requires verbal cues, setup, or standby assistance.

What does a FIM score of 4 indicate?

Minimal assistance; patient performs greater than 75% of the effort.

What does a FIM score of 3 indicate?

Moderate assistance; patient performs 50% to 74% of the effort.

What does a FIM score of 2 indicate?

Maximal assistance; patient performs 25% to 49% of the effort.

What does a FIM score of 1 indicate?

Total assistance; patient performs less than 25% of the effort.

What does the Berg Balance Scale assess?

Risk of falling.

What types of activities are included in the Berg Balance Scale?

Everyday living tasks including static, dynamic, and transitional movements in sitting and standing.

How many tasks are included in the Berg Balance Scale?

14.

How is each Berg Balance Scale task scored?

0 to 4.

What is the maximum Berg Balance Scale score?

56.

What Berg Balance Scale score indicates an increased risk of falling?

Less than 45.

What does the Fugl-Meyer Assessment assess?

Physical performance and balance in patients with hemiplegia.

How many balance items are included in the Fugl-Meyer Assessment?

Seven.

How is each Fugl-Meyer item scored?

0 to 2.

What is the maximum total Fugl-Meyer Assessment score?

226.

What is the maximum Upper Extremity score on the Fugl-Meyer Assessment?

66.

What is the maximum Lower Extremity score on the Fugl-Meyer Assessment?

34.

What is the maximum Balance score on the Fugl-Meyer Assessment?

14.

What does the Functional Reach Test assess?

Standing balance and risk of falling.

How is the Functional Reach Test performed?

Measure the maximum distance a person can reach forward beyond arm's length while maintaining a fixed base of support in standing.

What does a Functional Reach distance below age-related norms indicate?

Increased risk of falling.

What does the Romberg Test assess?

Balance and ataxia.

How is the Romberg Test initially performed?

The patient stands unsupported with feet together, arms folded, looking straight ahead with eyes open.

Which three systems contribute to balance during the Romberg Test with eyes open?

Visual, vestibular, and somatosensory systems.

How long must a patient maintain the Romberg position with eyes closed to be considered normal?

30 seconds.

What is considered a positive Romberg Test?

Inability to maintain balance with feet together and eyes closed.

What does a positive Romberg Test with ataxia indicate?

Sensory ataxia rather than cerebellar ataxia.

What does the Timed Up and Go (TUG) assess?

Mobility and balance.

Describe the Timed Up and Go procedure.

The patient begins seated in a supported chair, stands, walks approximately 10 feet, turns around without assistance, walks back to the chair, and sits down.

What should the examiner observe during the Timed Up and Go?

Sway, excessive movements, reaching for support, sidestepping, or other signs of loss of balance.

What Timed Up and Go score is normal for healthy adults?

Less than 10 seconds.

What Timed Up and Go score is typical for frail elderly or individuals with a disability?

11 to 20 seconds.

What Timed Up and Go score indicates impaired functional mobility and high fall risk?

Greater than 30 seconds.

What does the Tinetti Performance Oriented Mobility Assessment (POMA) assess?

Risk of falling through assessment of balance and gait.

What activities are assessed during the Tinetti POMA?

Sit to stand, stand to sit, immediate standing balance, standing with eyes open and closed, response to a slight push, and turning 360 degrees.

What is the maximum score on the original Tinetti POMA?

28.

For whom was the original Tinetti POMA developed?

Frail elderly individuals, especially nursing home residents with a propensity to fall.

What Tinetti POMA score indicates high fall risk?

Less than 19.

What Tinetti POMA score indicates moderate fall risk?

19 to 24.

What Tinetti POMA score indicates low fall risk?

Greater than 24.

What does the Walkie-Talkie Test assess?

Dual-tasking.

What does the Glasgow Coma Scale (GCS) assess?

Level of consciousness.

What are the three components of the Glasgow Coma Scale?

Eye opening, Best motor response, and Verbal response.

What Eye Opening score on the GCS indicates spontaneous eye opening?

4.

What Eye Opening score on the GCS indicates eye opening to speech?

3.

What Eye Opening score on the GCS indicates eye opening to pain?

2.

What Eye Opening score on the GCS indicates no eye opening?

1.

What Best Motor Response score on the GCS indicates the patient follows motor commands?

6.

What Best Motor Response score on the GCS indicates the patient localizes pain?

5.

What Best Motor Response score on the GCS indicates the patient withdraws from pain?

4.

What Best Motor Response score on the GCS indicates abnormal flexion?

3.

What Best Motor Response score on the GCS indicates an extensor response?

2.

What Best Motor Response score on the GCS indicates no motor response?

1.

What Verbal Response score on the GCS indicates the patient is oriented?

5.

What Verbal Response score on the GCS indicates confused conversation?

4.

What Verbal Response score on the GCS indicates inappropriate words?

3.

What Verbal Response score on the GCS indicates incomprehensible sounds?

2.

What Verbal Response score on the GCS indicates no verbal response?

1.

What GCS score indicates a severe brain injury?

8 or less.

What GCS score indicates a moderate brain injury?

9–12.

What GCS score indicates a mild brain injury?

13–15.

What does the Rancho Los Amigos Levels of Cognitive Functioning (LOCF) assess?

Level of cognitive functioning following brain injury.

What does Rancho Level I indicate?

No Response. Patient appears to be in a deep sleep and is completely unresponsive to any stimuli.

What does Rancho Level II indicate?

Generalized Response. Patient reacts inconsistently and non-purposefully to stimuli in a nonspecific manner.

What does Rancho Level III indicate?

Localized Response. Patient reacts specifically but inconsistently to stimuli and may inconsistently follow simple commands.

What does Rancho Level IV indicate?

Confused-Agitated. Patient is in a heightened state of activity with bizarre, nonpurposeful behavior, poor attention, impaired memory, and inappropriate verbalizations.

What does Rancho Level V indicate?

Confused-Inappropriate. Patient follows simple commands fairly consistently but becomes nonpurposeful with complex commands. Highly distractible with severely impaired memory.

What does Rancho Level VI indicate?

Confused-Appropriate. Patient shows goal-directed behavior but depends on external direction. Follows simple directions consistently and demonstrates carryover for relearned tasks.

What does Rancho Level VII indicate?

Automatic-Appropriate. Patient is appropriate and oriented in familiar settings, performs daily routines automatically, demonstrates new learning with decreased rate, but judgment remains impaired.

What does Rancho Level VIII indicate?

Purposeful-Appropriate. Patient recalls and integrates past and recent events, demonstrates carryover for new learning, and no longer requires supervision after activities are learned.

What does the Hoehn and Yahr Scale classify?

Disability associated with Parkinson disease.

Describe Hoehn and Yahr Stage I.

Minimal or absent disability; unilateral involvement if present.

Describe Hoehn and Yahr Stage II.

Minimal bilateral or midline involvement. Balance is not impaired.

Describe Hoehn and Yahr Stage III.

Impaired righting reflexes. Unsteadiness when turning or rising from a chair. Some activities are restricted, but the patient can live independently.

Describe Hoehn and Yahr Stage IV.

All symptoms are present and severe. Standing and walking are possible only with assistance.

Describe Hoehn and Yahr Stage V.

Patient is confined to bed or wheelchair.

What is the goal of Initial Mobility PNF techniques?

Initiate movement and improve mobility.

Which PNF techniques are classified under Initial Mobility?

Contract-relax, Hold-relax, Hold-relax active movement, Joint distraction, Rhythmic initiation, and Rhythmical rotation.

What is the goal of Stability PNF techniques?

Improve stability through co-contraction and isometric control.