Neuro Outcome Measures Eran Gerstein

Test Purpose Area of Assessment

Populations Considerations Reliability Validity Normative Values

Standardized Instructions

Berg Balance Scale

Assess static balance and fall risk in adult populations

Balance – non-vestibular Functional Mobility

-Vestibular Disorders -Stroke -Spinal Injuries -Parkinson -OA -Older adults and Geriatric care -Brain Injury

- Better suited for use with acute stroke -Limited use in Parkinson’s middle stages (ceiling effects) -Not best for vestibular dysfunction when identifying individuals at risk of falling

- TBI: Excellent test-retest reliability - ELDERLY Excellent test-retest, interrater, and intrarater reliability PARKINSON’S - Excellent test-retest, intrarater, and interrater reliability SCI - Excellent interrater reliability STROKE - Excellent test-retest, interrater, and intrarater reliability

ELDERLY - High Specificity for predicting non fallers - Low sensitivity in positive prediction of falls STROKE - Excellent predictive validity of BBS at 14, 30, and 90 days at predicting MAS scores -

PARKINSON’S - Mean BBS Score = 40.22; Range = 21-53 SCI - Mean BBS score: 47.9; range 17-56 - Mean BBS for Paraplegia: 44.8; Range 17-50 -Mean BBS score for Tetraplegia: 50.7; range 31-56

See Appendix A:BBS

CTSIB Provides clinicians with a means to

Balance – Vestibular

-Vestibular Disorders -Stroke

Conditions and Dysfunctions

HEALTHY YOUNG ADULTS

See Appendix B: CTSIB

quantify postural control under various sensory conditions

and non-vestibular Functional Mobility

-Parkinson’s Disease -Brain Injury -MS

1) Patients dependent on vision become unstable in conditions 2, 3, 5, 6 with either eyes close or conflict between vision and vestibular 2) Patients depend on surface/somatosensory in conditions 4, 5, 6 because they stand on a soft surface 3) Patients with vestibular loss become unstable in conditions 5 & 6 because they can’t rely on vision/surface 4) Patients with sensory selection problems become unstable in conditions 3-6

- High test-retest, inter-rater reliability STROKE - High inter-rater reliability

Dynamic Gait Index

DGI assess individual’s ability to modify balance while walking in the presence of external demands

Balance – Vestibular and non-vestibular Functional Mobility Gait

-MS -Parkinson’s -Stroke -Vestibular Disorders

- Performed with a marked distance of 20 feet and it can be performed with or without an assistive device - Scores based on 4 point scale 3) No Gait dysfunction 2) Minimal impairment

OLDER ADULTS - Hospital + Outpatient Reliability: Excellent intrarater and interrater reliability STROKE

OLDER ADULTS - Excellent criterion validity STROKE - Excellent concurrent validity with Berg Balance

Cut off scores ELDERLY: < 19 indicative of increased falls STROKE Median scores: 13 PARKINSON’S

See Appendix C DGI

1) Moderate impairment 0) Severe impairment - Highest possible score is 24 points, and tasks include 1) Steady state walking 2) Walking with Changing speeds 3) Walking with head turns horizontally and vertically 4) Walking while stepping over and around obstacles 5) Pivoting while walking 6) Stair climbing

- Excellent test-retest, interrater reliability PARKINSON’S - Excellent test-retest reliability MS - Excellent test-retest, interrater, and intrarater VESTIBULAR - Excellent test-retest, adequate inter-rater reliability

Scale, DGI, 10 MWT PARKINSON’S - Excellent correlation with falls history in PD MS - Excellent concurrent validity with BBS, TUG VESTIBULAR - Excellent concurrent Validity

- Baseline: 16.3 median - Outcome: 16.54 median MS - <12 indicative of falls risk VESTIBULAR - Subjects with scores of <19/24 are more likely to have reported fall in last 6 months

10 MWT Assesses walking speed in m/s over a short duration

-Functional Mobility -Gait -Vestibular

- Brain Injury -MS - PD - SCI - Stroke

- Individual is instructed to walk a set distance - Time is measured while individual walks set distance at their own walking speed - Distance covered is divided by the time it took individual to walk that distance

PARKINSON’S - Excellent test-retest reliability for comfortable and fastest gait speeds SCI - Excellent test-retest, intrarater,

MS - Excellent correlation with dependence in self-care at comfortable speed - Adequate to excellent correlation with

PARKINSON’S -Comfortable Gait speed: 0.18 m/s -Fastest gait speed: 0.25 m/s SCI - Paraplegia: 0.08-1.43 - Tetraplegia: 0.34-1.43

See Appendix D: TenMWT

- Collect 3 trials and calculate the average - Assistive devices may be used but kept consistent - Test is not appropriate if individual requires assistance to ambulate - Test can be performed at preferred walking speed or fastest speed possible

and interrater reliability STROKE - Excellent test-retest, interrater, and intrarater reliability BRAIN INJURY - Excellent test-retest and interrater reliability

dependence in mobility and domestic life SCI - Excellent correlation with TUG and 6MWT (Excellent construct validity) STROKE - Excellent criterion and construct validity BRAIN INJURY - Poor Face validity

STROKE Cut off scores - <0.4 m/s: household ambulators - 0.4-0.8 m/s: limited community - >0.8 m/s community Normative Data - Mean: 0.84 +/- 0.3 m/s

Modified Ashworth Scale

Measure spasticity in patients with lesions of the CNS

Spasticity -Brain Injury -Cerebral Palsy -MS -SCI -Stroke

- Reliability differs from muscle to muscle - Assessment technique must be standardized - Better descriptor of resistance to passive movement; measuring only one aspect of spasticity – not comprehensive

STROKE - Excellent intrarater reliability for the elbow - Adequate intra-rater reliability in lower extremity SCI

STROKE - Excellent construct validity - Adequate Content validity SCI

Normal Joint Ranges

See Appendix E: Ashworth

- Produces global assessment of the resistance to passive movement of an extremity not just stretch-reflex hyper-excitability - Modified measures muscle tone intensity at one unspecified velocity which can make comparisons difficult

- Adequate test-retest reliability - Poor to adequate interrater reliability depending on muscle group BRAIN INJURY - Adequate test-retest reliability for shoulder, elbow, wrist, hip, and knee - Excellent test-retest for ankle - Adequate interrater reliability for PF spasticity CEREBRAL PALSY - Adequate to excellent test-retest reliability for hamstrings and hip adductors

- Excellent Construct validity BRAIN INJURY - Adequate concurrent validity CEREBRAL PALSY -

- Poor to adequate test-retest reliability for calf - Poor to adequate Inter-rater reliability

TUG Assesses mobility, balance, walking ability, and fall risk

-Balance – non-vestibular - Functional Mobility - Gait - Vestibular

- Joint conditions - Cerebral Palsy - MS - PD - SCI - Stroke - Vestibular

- Patient should have 1 practice trial not included in score - With vestibular populations, test both right and left turning - Less reliability with patients suffering cognitive impairments - Chairs with armrests should be used - TUG was designed to be tested with people walking at a comfortable speed

STROKE - Excellent test-retest reliability PD - Excellent test-retest, inter-rater reliability SCI - Excellent intrarater and interrater reliability TBI - Excellent test-retest reliability

STROKE - Excellent criterion and construct validity PD - Excellent Criterion and convergent Validity SCI - Excellent Convergent validity VESTIBULAR - Bilateral: Excellent criterion validity - Unilateral: Weak to moderate

Cut-off Scores STROKE - >14 PD - >11.5 VESTIBULAR - >11.1 Normative PARKINSON’S - Fallers: 16.8s - Non-fallers: 11.2s SCI - Paraplegia: 19.7 mean - Tetraplegia: 14.6 mean VESTIBULAR - Unilateral vestibular

See Appendix F: TUG

criterion validity

hypofunction: 19.5 s - Bilateral vestibular hypofunction: 23.33s

MAS Assess everyday Motor function in stroke patients

-ADL - Functional Mobility

- Stroke - General tonus item may be difficult to assess because there are no guidelines to it - Reliability only been established in stable patients

STROKE - Excellent test-retest reliability for chronic stroke - Excellent interrater reliability for chronic and acute stroke

STROKE - Excellent validity overall - Poor concurrent validity for sitting balance - Adequate convergent validity for sitting arm raise and forward reach (balance)

STROKE 1) Rolling 3.3 2) Lie to sit 4.8 3) Balanced Sitting 5.4 4) Sit to stand 3.6 5) Walking 1.8 6) Upper arm function 7) Hand movements 2.5 8) Advanced hand activities 1.2

See Appendix G: MAS

Functional Reach Test

Assesses a patient’s stability by measuring the maximum distance they can reach forward while

- Balance: vestibular and non-vestibular - Functional Mobility

-PD -SCI -Stroke -Vestibular

- Patient is instructed to stand close to, but not touching a wall and position the arm that is closer at 90 degrees flexion with closed fist assessor records starting position at the 3rd metacarpal head

STROKE - Excellent test-retest and intra rater reliability overall PD

STROKE - High face validity in stroke patients PD - Good predictive

STROKE Cut-off: <15 cm indicates fall risk Normative Hemiplegic - With arm sling: 16.8 cm

See Appendix H: FRT

standing in a fixed position.

after reach, 3rd metacarpal distance is recorded - Test allows 4 total trials: 2 practice and 3 test trials that are averaged

- Excellent test-retest reliability for patients with falls history - Poor test-retest for patients with no falls history VESTIBULAR - Excellent intrarater reliability SCI - Excellent test-retest reliability

validity at predicting maximum top, middle, and bottom reaches VESTIBULAR - Poor construct validity SCI

- Without arm sling: 15.2 cm Subacute stroke - 25.6 cm Chronic Hemiplegic Post-stroke - 27.11 cm Chronic Hemiplegic post-stroke with AFO - 28.50 cm PD Cut-off: <31.75 cm indicates falls risk Normative - 33.54 cm; range: 22-50 cm VESTIBULAR - Mean: 31.7 cm

STREAM Designed to provide a quantitative

Coordination

- Stroke - 30 items across 3 domains

STROKE - Excellent test-retest,

STROKE Acute (within 1 week, 4

See Appendix I: STREAM

evaluation of motor functioning for stroke patients

Functional Mobility ROM

1)Upper limb movements 2)Lower limb movements 3)Basic mobility items

interrater, and intrarater reliability

weeks, 3 months) - Total: 86 UL: 85 LL: 90 MOB: 83 - Total: 94 UL:100 LL: 95 Mob:97 - Total: 97 UL:100 LL:100 Mob:97

5x STS Measure of functional LL muscle strength that may also be useful in quantifying functional change of transitional movements

- Functional Mobility - Strength

- Cerebral palsy - PD - Stroke - Vestibular

- It is okay if patient does not touch the back of the chair but it is not recommended - Try to not talk to the patient during the test - Quick and easy to administer - DGI is more sensitive

CEREBRAL PALSY - Excellent test-retest reliability PD - Excellent test-retest and interrater reliability STROKE - Excellent test-retest, interrater, and intrarater reliability

PD - Adequate predictive validity for mobility, freezing, balance confidence, balance, quadriceps maximal voluntary contraction, endurance, and falls risk VESTIBULAR - Adequate concurrent and

PD Cut-off: >16s indicates risk of falls Normative - Baseline: 9.67s - Retest: 9.48s VESTIBULAR Cut-off: 15s Normative: - Young (14-59):15.3s - Older (61-90): 16.4s STROKE Cut-off: 12s

See Appendix J: FiveSTS

construct validity for balance STROKE - Excellent predictive validity for muscle strength

Tardieu Assesses the muscle’s response to stretch at various given velocities

Functional Mobility

- Brain Injury - Cerebral Palsy - Stroke

- Takes into account resistance to passive movement at both slow and fast speed - Measures quality of muscle reaction and angle of muscle reaction - 3 speed definitions 1)V1 is slow as possible 2) V2 speed of limb falling under gravity 3) V3 moving as fast as possible - Quality of muscle reaction: 0 is no resistance to passive ROM to 5 indicating joint is immobile - Joint angle: angle of full ROM (R2) is taken at V1; angle of muscle reaction (R1) is defined as angle in which a

STROKE - Excellent test-retest reliability - Adequate interrater reliability for R2-R1 and MTS quality BRAIN INJURY - Adequate intrarater reliability for muscle groups except shoulder external rotation (poor) - Poor interrater reliability

STROKE - Excellent convergent validity

BRAIN INJURY -Ischemic Stroke: 7 - ICH: 11 - TBI: 5 - Cerebral Hypoxia: 7

See Appendix K:Tardieu

catch or clonus is found during a quick stretch (V3) R1 is subtracted from R2 and that represents dynamic tone component of the muscle

CEREBRAL PALSY - Adequate to excellent test-retest reliability for MTS at hamstrings - Poor-excellent test-retest reliability for MTS at gastroc - Adequate interrater reliability

Function in Sitting Test

Bedside evaluation of sitting balance that evaluates sensory, motor, proactive, reactive, and steady state balance factors

Balance- Non-vestibular

-Brain Injury -Stroke

- 14 items on 4 pt scale for each test items 4)Independent 3)Needs cues 2)UL support; unable to complete with support 1)Needs assistance 0)Complete assistance - 1 trial of each item allowed - Verbal directions and demonstrations given - Individual seated at edge of hospital bed with half of upper leg supported, hips and

VESTIBULAR - Excellent test-retest, intra-rater, and interrater reliability

VESTIBULAR - Good to excellent concurrent validity with Berg

See Appendix L: FIST

knees at 90 degrees and feet flat - Hands placed in lap unless supported

Step Test Measures dynamic balance during an activity requiring weigh-shift and movement while in single-leg stance as well as paretic-lower extremity motor control in patients with stroke

- Stroke - Assesses individual’s ability to place one foot onto a 7.5 cm high step and then back down to the floor repeatedly for 15 seconds - Score is the number of steps completed in the 15 second period for each leg - Fast and easy to conduct - ST counts can distinguish subjects with chronic stroke from healthy adults older than 50 years - Cut-off scores can accurately classify falls risk

STROKE - Excellent test-retest, interrater, and intrarater reliability

STROKE - Adequate predictive validity

STROKE - Chronic Stroke Non-paretic side: 11 Paretic side: 8.1 - Acute Affected Side: 12-14

4-Square Test of dynamic balance that clinically assesses the person’s ability to step over objects forward,

-ADLs -Balance – vestibular, non-vestibular

-Vestibular Disorders -Stroke -PD

- 1 practice trial is allowed - 2 trials are performed, and the better time is taken as the score - Timing starts when right foot contacts floor in square

PD - Excellent test-retest and interrater reliability STROKE

PD - Poor concurrent validity STROKE - Adequate predictive validity

PD Cut-off: >9.68s = increased falls risk Normative - On meds: 9.6s

See Appendix M: FSST

sideways, and backwards

- Repeat trial if patient fails to complete sequence successfully Loses balance Makes contact with cane - Patients start in the upper left square and go clockwise first then counter clockwise

- Excellent test-retest reliability VESTIBULAR - Excellent test-retest reliability

VESTIBULAR - Poor to adequate concurrent validity

- Off meds: 11.02 STROKE Cut-off: failed or >15s = increased falls risk Normative - Initial: 20.8s - 2 weeks: 17.9s - 4 weeks: 17.5s VESTIBULAR Cut-off: >12s = falls risk

BESTest Assesses balance impairments across 6 contexts of postural control

-Balance – Non-vestibular Gait Strength

- Stroke - PD - MS

- 6 postural control contexts 1) Biomechanical constraints 2) Stability limits/verticality 3) Anticipatory postural adjustments 4) Postural Responses 5) Sensory Orientation 6) Stability in gait - Total score of 108 points is calculated into a percentage score

PD - Excellent test-retest reliability for total BEST score, Anticipatory postural adjustments, and postural adjustments - Adequate to excellent test retest reliability for biomechanical

MS - Adequate to excellent concurrent validity - High predictive validity for identifying patients at falls risk PD - Excellent concurrent validity with

PD Cut-off: 69% to predict fallers (poor-adequate reliability) STROKE Cut-off: >49% indicates those with high functional ability Normative

See Appendix N: BESTest

- Item scores range from 0-3 - Suitable for assessing balance in individuals with subacute stroke across many levels of functional ability - BESTest may be more preferable than other balance scales due to its lack of floor and ceiling effects -

constraints, stability, sensory orientation, and stability in gait - Excellent interrater reliability for all components of the BESTest STROKE - Excellent interrater and intrarater reliability

other functional assessments - Excellent construct validity STROKE - Adequate predictive validity in classifying high or low functional ability - Moderate positive and negative likelihood ration in classifying high or low functional ability - Excellent construct validity

- Low functional ability mean: 23.89 - High functional ability mean: 59.52

HiMAT A unidimensional scale designed to assess high-level motor performance in TBI patients

- Functional Mobility - Vestibular

- Brain Injury - PD

- Designed to assess patients who suffer from high-level balance and mobility problems - minimum mobility requirement is

BRAIN INJURY - Excellent test-retest and interrater reliability

BRAIN INJURY - Adequate concurrent validity with FIM

See Appendix O:

independent walking over 20m without gait aids - Patients allowed trial session prior to scored assessment - Performed at max safe speed - 13 items on 5 point scales - Best for Acute stages of TBI when patient can ambulate unaided

ASIA Scale Classifies motor and sensory impairment that results from an SCI

- Functional Mobility - Strength - Upper extremity function

- SCI - ASIA A: complete with absence of motor and sensory function in sacral segments - ASIA B: incomplete with preserved sensation below neurological level of injury and at S4-S5; no motor preserved more than 3 levels below motor level on either side - ASIA C: Incomplete with half the key muscles below neurological injury graded <3/5 - ASIA D: incomplete with half or more of the key muscles below

CHRONIC SCI - Excellent intrarater reliability for all aspects ACUTE TO CHRONIC SCI - Excellent interrater reliability for total motor scores, pin prick, and light touch - Adeuqate interrater reliability for motor scores for the 10 key msucles and

ACUTE AND CHRONIC SCI - Excellent predictive validity of motor score for hand function and ambulatory capacity - Adequate predictive validity of sensory scores for ambulatory capacity in acute and chronic individuals for pin prick

See Appendix P:

neurological level have >/= 3/5 - Also classify into 1 of 5 types Central Cord: greater loss of upper vs. lower limb function Brown-Sequard Anterior spinal tract Conus Medullaris Cauda-Equina syndrome

sensory and motor levels

and light tough - Excellent construct validity of total motor score and separate upper and lower motor scores

12-Item MS Walking Scale

Self-report measure of impact of MS on individual’s walking ability

- Gait - MS - 3 items are scored 1-3 and the other 9 are scored 1-5 - Scores on the 12 items are summed - To transform to a 0-100 scale, minimum score of 12 is substracted from the sum; the result is divided by 42 and multiplied by 100

MS - Excellent test/retest reliability when test was taken twice within 10 day interval and after a period of 6 and 12 months

MS - Excellent concurrent validity with other walking tests - Adequate concurrent validity with balance scales

MS - Average score: 28.2

See Appendix Q:

Activities-Specific Balance Confidence Scale

ABC is a subjective measure of confidence in performing various ambulatory activities without falling or

- Balance – Vestibular and non-vestibular - Functional Mobility

- MS - PD - Stroke - Vestibular - Brain injury

- 16 item self-report measure in which patients rate balance confidence for performing activities - Items rated from 0-100 (0 is no confidence) - Overall score is calculated by adding

PD - Excellent test-retest STROKE - Excellent test/retest reliability

PD - Excellent predictive validity of predicting recurrent falls STROKE

PD Cut-off: 69%; predictive of recurrent falls Normative - 73.6% STROKE

experiencing a sense of readiness

item scores and dividing by total number of items

- Adequate construct validity correlation between ABC and BBS and gait speed

Cut-off: 81.1 can provide certainty the individual did not have a history of multiple falls Normative - 68.3

9 Hole Peg Measures finger dexterity

- Dexterity - Upper Extremity Function

- Brain injury - Stroke - PD - MS

- Ask patient to take pegs from a container 1 by 1 and place them into holes on the board as quickly as possible - Participants then remove pegs from holes and replace them into container - Board should be placed at pateitn’s midline with container holding pegs oriented towards hand being tested - Only hand being evaluated should perform test - Scores based on time taken to complete task

STROKE - Excellent test-retest and interrater reliability - Adequate intrarater reliability PD - Excellent test-retest reliability

STROKE - Adeuqate concurrent validity with Stroke Impact Scale Hand Function pretreatment

STROKE - 1Month: 88.8 - 3 months: 67.8 - 6 months: 60.8 MS - 17.81 mean (dominant side - 18.49 mean (non-dominant)

See Appendix R:

Glasgow Coma Scale

Assess’s a person’s level of consciousness after injury.

- Cognition - Brain Injury

- Assess motor, verbal, and eye opening response - Eyes

BRAIN INJURY

BRAIN INJURY Cut-off scores -

Can be used as part of an initial assessment or to monitor changes in consciousness over time.

1) does not open eyes 2) Opens eyes in response to painful stimuli 3) Opens eyes in response to voice 4) Opens eyes spontaneously - Verbal 1) Makes no sounds 2) Incomprehensible sounds 3) Utters inappropriate words 4) Confused, disoriented 5) Oriented, converses normally - Motor 1) Makes no movements 2) Extension to painful stimuli 3) Abnormal flexion to painful stimuli 4) Flexion/Withdrawal to painful stimuli 5) Localizes painful stimuli 6) obeys commands

- Scores summed across and ranges from 3-15

Figure 1 Berg Balance Scale Instructions

Appendix A

Appendix B

Figure 2 CTSIB

Appendix C

Dynamic Gait Index (original 8-item test) Description:

Developed to assess the likelihood of falling in older adults. Designed to test eight facets of gait.

Equipment needed: Box (Shoebox), Cones (2), Stairs, 20’ walkway, 15” wide

Completion:

Time: 15 minutes

Scoring: A four-point ordinal scale, ranging from 0-3. “0” indicates the lowest level of function and “3” the highest level of function.

Total Score = 24

Interpretation: < 19/24 = predictive of falls risk in community dwelling elderly

1. Gait level surface _____

Instructions: Walk at your normal speed from here to the next mark (20’)

Grading: Mark the lowest category that applies.

(3) Normal: Walks 20’, no assistive devices, good sped, no evidence for imbalance, normal gait pattern

(2) Mild Impairment: Walks 20’, uses assistive devices, slower speed, mild gait deviations.

(1) Moderate Impairment: Walks 20’, slow speed, abnormal gait pattern, evidence for imbalance.

(0) Severe Impairment: Cannot walk 20’ without assistance, severe gait deviations or imbalance.

2. Change in gait speed _____

Instructions: Begin walking at your normal pace (for 5’), when I tell you “go,” walk as fast as you can (for 5’). When I tell you “slow,” walk as slowly as you can (for 5’).

Grading: Mark the lowest category that applies.

(3) Normal: Able to smoothly change walking speed without loss of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast and slow speeds.

(2) Mild Impairment: Is able to change speed but demonstrates mild gait deviations, or not gait deviations but unable to achieve a significant change in velocity, or uses an assistive device.

(1) Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, or changes speed but has significant gait deviations, or changes speed but loses balance but is able to recover and continue walking.

(0) Severe Impairment: Cannot change speeds, or loses balance and has to reach for wall or be caught.

3. Gait with horizontal head turns _____

Instructions: Begin walking at your normal pace. When I tell you to “look right,” keep walking straight, but turn your head to the right. Keep looking to the right until I tell you, “look left,” then keep walking straight and turn your head to the left. Keep your head to the left until I tell you “look straight,“ then keep walking straight, but return your head to the center.

Grading: Mark the lowest category that applies.

(3) Normal: Performs head turns smoothly with no change in gait.

(2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid.

(1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.

(0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers

outside 15” path, loses balance, stops, reaches for wall.

4. Gait with vertical head turns _____

Instructions: Begin walking at your normal pace. When I tell you to “look up,” keep walking straight, but tip your head up. Keep looking up until I tell you, “look down,” then keep walking straight and tip your head down. Keep your head down until I tell you “look straight,“ then keep walking straight, but return your head to the center.

Grading: Mark the lowest category that applies.

(3) Normal: Performs head turns smoothly with no change in gait.

(2) Mild Impairment: Performs head turns smoothly with slight change in gait velocity, i.e., minor disruption to smooth gait path or uses walking aid.

(1) Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, staggers but recovers, can continue to walk.

(0) Severe Impairment: Performs task with severe disruption of gait, i.e., staggers

outside 15” path, loses balance, stops, reaches for wall.

5. Gait and pivot turn _____

Instructions: Begin walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and stop.

Grading: Mark the lowest category that applies.

(3) Normal: Pivot turns safely within 3 seconds and stops quickly with no loss of balance.

(2) Mild Impairment: Pivot turns safely in > 3 seconds and stops with no loss of balance.

(1) Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop.

(0) Severe Impairment: Cannot turn safely, requires assistance to turn and stop.

6. Step over obstacle ____

Instructions: Begin walking at your normal speed. When you come to the shoebox, step over it, not around it, and keep walking.

Grading: Mark the lowest category that applies.

(3) Normal: Is able to step over the box without changing gait speed, no evidence of imbalance.

(2) Mild Impairment: Is able to step over box, but must slow down and adjust steps to clear box safely.

(1) Moderate Impairment: Is able to step over box but must stop, then step over. May require verbal cueing.

(0) Severe Impairment: Cannot perform without assistance.

7. Step around obstacles _____

Instructions: Begin walking at normal speed. When you come to the first cone (about 6’ away), walk around the right side of it. When you come to the second cone (6’ past first cone), walk around it to the left.

Grading: Mark the lowest category that applies.

(3) Normal: Is able to walk around cones safely without changing gait speed; no evidence of imbalance.

(2) Mild Impairment: Is able to step around both cones, but must slow down and adjust steps to clear cones.

(1) Moderate Impairment: Is able to clear cones but must significantly slow, speed to accomplish task, or requires verbal cueing.

(0) Severe Impairment: Unable to clear cones, walks into one or both cones, or requires physical assistance.

8. Steps _____

Instructions: Walk up these stairs as you would at home, i.e., using the railing if necessary. At the top, turn around and walk down.

Grading: Mark the lowest category that applies.

(3) Normal: Alternating feet, no rail.

(2) Mild Impairment: Alternating feet, must use rail.

(1) Moderate Impairment: Two feet to a stair, must use rail.

(0) Severe Impairment: Cannot do safely.

TOTAL SCORE: ___ / 24 References:

1. Herdman SJ. Vestibular Rehabilitation. 2nd ed. Philadelphia, PA: F.A.Davis Co; 2000. 2. Shumway-Cook A, Woollacott M. Motor Control Theory and Applications, Williams and Wilkins Baltimore, 1995: 323-324

Appendix D

Appendix E

Appendix F

Appendix G

Appendix H

Appendix I

Appendix J

Appendix K

Appendix L

Appendix M

Appendix N