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 6
GAIT SPEED (preferred and maximal)
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Landers, PT, DPT, OCS2 ABSTRACT INTRODUCTION Purpose: The Physical Mobility Scale (PMS) is used to evalu- One of the primary focuses of physical therapy in long-term ate the functional ability of aged adults. It has been shown to care is to improve the functional mobility of a resident. be reliable and has evidence to support its validity; however, there has been only 1 study performed to date that has Many times the resident is admitted at a very low function- addressed its responsiveness. The purpose of this study was al level, unable to complete the most basic tasks such as bed to evaluate the responsiveness of the PMS using residents of mobility and transfers. Because of these generalized deficits a long-term care facility. in mobility, it is difficult to objectively measure functional Methods: Seventy participants who were permanent residents mobility and to identify improvement with treatment of a long-term care facility were recruited for this study. To because many of the current functional scales are not determine minimal detectable changes at the 95% confidence designed for use with residents of long-term care. level (MDC95), each participant was assessed using the PMS on 2 occasions. To determine the clinically important differ- Functional scales that are typically used for residents of ence, participants were also tested on 2 separate occasions long-term care can be categorized by method of adminis- 3 months apart. The treating physical therapist then used a tration as a self-report instrument completed by the patient 7-point Likert scale to rate the participants’ change in function. or as a performance-based measure requiring observation Results: Intrarater reliability for the pre- and post-PMS scores and rating of movement by a physical therapist or other for all 70 participants was excellent (intraclass correlational health care professional. For example, self-report question- coefficients [3,1] 0.982). At the individual level, the MDC 95 naires that address mobility include the California was 3.98 points. At the group level, the MDC95 for the 70 par- 1 ticipants was 0.476 points. Minimal clinically important differ- Functional Evaluation instrument, the Movement Ability ence results suggest that a positive change of 5 points is Measure,2,3 the Health Assessment Questionnaire,4,5 and “improved” clinically whereas a 4-point decrease in score is the Functional Status Questionnaire.6 Although these ques- considered “worsened” clinically. tionnaires are easy to administer and appear to adequately Conclusions: The psychometric properties of the PMS in an address mobility, they are inherently subject to response aging adult population of long-term residents are excellent, bias. In addition, self-report questionnaires can be prob- demonstrating good reliability and responsiveness. These results also offer some support to the validity of the PMS in lematic in patient populations with a high incidence of cog- this patient population. The utility of the PMS in the long-term nitive impairment, as is commonly found in long-term care care setting for assessing patient status and positive and/or facilities. Sinoff and Ore7 report that self-report question- negative functional outcomes is of value to both researcher naires are problematic when used with persons older than and clinician. 75 years. They found inconsistency between self-report and Key Words: mobility, psychometrics, reliability, reproducibility, actual performance of questionnaire tasks, suggesting that transfers older adults may not accurately perceive their physical func- (J Geriatr Phys Ther 2010;33:92-98.) 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 1Nevada State Veterans’ Home, Boulder City. Functional Independence Measure16) or are disease-specific 2Department of Physical Therapy, School of Allied Health in looking at functional mobility (eg, Motor Assessment Sciences, University of Nevada, Las Vegas. Scale for persons with stroke17 and the Parkinson Activity 18 Address correspondence to: Eric Pike, PT, DPT, MS, NFA, Scale ). Other scales test specific aspects of mobility, such Nevada State Veterans’ Home, 100 Veteran’s Memorial Dr, as balance and gait (eg, Berg Balance Scale19 and Boulder City, NV 89005 ([email protected]). Performance Oriented Mobility Assessment20). Many of 12a Volume 33 • Number 2 • April-June 2010 Research Report these performance-based scales include items that are unre- veterans nursing facility. The most common diagnoses lated to mobility (eg, continence or communication), items included hypertension (64.3%), dementia (42.9%), chronic that would be inappropriate for the majority of long-term obstructive pulmonary disease (28.6%), diabetes mellitus care facility residents (eg, running), or items specific to a dis- (27.1%), coronary artery disease (25.7%), and cerebrovas- ease process (eg, hand movements or gait akinesia). Because cular accident (22.9%). Initial recruitment consisted of a of this, many are not appropriate for the general long-term verbal invitation to participate from the lead author to res- care facility population. In their place, physical therapists idents. Inclusion criteria were (1) ability to follow verbal may use subjective ratings to evaluate the resident’s func- instructions and (2) no medical contraindications to per- tional ability. Although these subjective ratings are usually forming basic mobility tasks. Those who did not meet the performance-based, they are not standardized and may inclusion criteria were excluded from the study. All partici- reflect unwanted bias or excessive error in the rating. pants provided informed consent under the University of Nitz and Hourigan21 and Barker et al22 reported on a Nevada, Las Vegas institutional review board approval scale, the Physical Mobility Scale (PMS), that was developed prior to participation in the study. by physical therapists and seems to be an appropriate tool to evaluate the functional mobility of aging adults in long-term Procedure and Data Collection care. Nitz and Hourigan21 found the PMS to have good reli- To determine the responsiveness of the PMS, participants ability in participants ranging in age from 35 to 90 years. were assessed by the same physical therapist on 2 separate Interrater reliability using intraclass correlational coefficients occasions. The PMS includes measures of 9 basic move- (ICC) for individual items ranged from 0.68 to 0.94 and was ments, including supine to side-lying, supine to sitting, sit- not affected by the physical therapists’ level of experience. ting balance, sitting to and from standing, standing balance, Intrarater reliability was also established with an ICC level transferring, and ambulating (Appendix).21 Each of the 9 of more than 0.9. The PMS demonstrated concurrent valid- measures is scored on a scale of 0 to 5, with 0 being depend- ity (Spearman’s rank order agreement 0.69 to 0.90) with ent and 5 independent. Total scores range from 0 to 45, the performance scoring outcomes of the Clinical Outcomes with 45 indicating independent mobility functioning and 0 Variable Scale and the Rivermead Mobility Index. Barker indicating very low mobility functioning. et al22 also reported good interrater reliability ( .60 for The original PMS does not have formal instructions most items) and evidence to support construct validity. on how to implement the test or definitions of the items. While the PMS seems to have good reliability and good No specific instructions in the original PMS regarding support for validity for use with adults, the responsiveness single limb balance time and wheelchair mobility dis- of this performance-based scale has been reported in only 1 tance were provided in either article on the PMS.21,22 In study.22 Responsiveness allows the clinician to make deci- this study, some clarifications were made to ensure con- sions about a change in a patient’s outcome as detected by sistency and instructions were added to the scoring the scale. In addition, it allows for inference about the effec- sheet. The clarifications that were made are italicized in tiveness of treatment, economic appraisals, and other pro- the Appendix. The first 5 items and the item on transfers are gram evaluations.23 Two types of responsiveness have been well described in the scoring sheet and are self-explanatory. commonly used in the physical therapy literature, minimal The standing balance item was clarified to state that the detectable change (MDC) and minimal clinically important single limb balance must be maintained for 10 seconds difference (MCID). Barker et al22 determined the MDC of to receive a score of 5. This follows the same guidelines the PMS to be 4.39 at the 90% confidence level. To our as the Berg Balance Scale,19 in which the participant knowledge, no study has reported the MCID of the PMS. must maintain a single leg stand for 10 seconds to The MDC is the minimal amount of change required to receive full marks for that item. Springer et al deter- be considered a statistically significant change. The MDC mined normative values of the single leg stand by decade allows inference about how much change has actually as follows: 60- to 69-year-old participants could perform occurred beyond error of measurement of the scale. a single leg stand for a mean of 26.9 seconds, 70- to Although the MDC is an indication of statistically signifi- 79-year-old participants for 15.0 seconds, and 80- to cant change, this change may not be clinically meaningful. 99-year-old participants for 6.2 seconds.24 Because the Therefore, it is also important to establish the MCID. In population with which we are concerned are in these contrast to the MDC, which is statistically determined, ranges and are not considered healthy, the 10-second MCID is based on subjective ratings of change by the cutoff seemed reasonable. We also clarified the wheel- patient, caregiver, or health care provider. The purpose of chair mobile score of wheelchair mobility to be defined the present study is to determine the responsiveness of the as able to move 50 ft without assistance, because that PMS based on the MDC and the MCID. length is a reasonable distance to get to most immediate areas in a nursing facility (eg, room to dining room). METHODS Calculation of Minimal Detectable Change Participants For calculation of the MDC, 70 participants were tested For our study, 70 participants (mean age 81.4 years [SD twice within the same week. The MDC is determined by 6.3]; 12 women and 58 men) were recruited from a state performing a test and a retest within a relatively short time Journal of GERIATRIC Physical Therapy 12b Research Report frame so that the condition being investigated is unlikely to ities were variable on the basis of individual preferences and have changed.25 To determine the MDC, one must first treatments; thus, no limitations were put on activity levels. assign a reliability change index value. The reliability Minimal clinically important difference, which by defini- change index expresses the confidence level at which this tion is the smallest difference in a score of a measurement tool change could be considered significant. For instance, if one that the patient, caregiver, or health care provider perceives as were to measure at a 95% confidence interval, then change beneficial, can be calculated from data of participants who above this level would be confidently considered (at a 95% have minimally improved or minimally worsened as ranked confidence level) greater than measurement error and, from a Likert scale. Prior to the final assessment, the thera- therefore, likely a true change.23 Once the reliability is pist provided a rating of the patient’s change (or lack there- determined, the Standard Error of Measurement (SEM) is of) in functional mobility since the initial assessment. The found by the following equation23,25,26: therapist’s assessment was standardized by using the Clinical Global Impression-Global Improvement (CGI-I) √ 26 SEM baseline standard deviation 2 (1 rxx) scale, a typical 7-point Likert scale. The anchors for the CGI-I were 7 (very much worsened), 6 (much worsened), 5 where rxx test-retest reliability. (minimally worsened), 4 (no change), 3 (minimally The MDC at a 95% confidence level (MDC95) for the improved), 2 (much improved), or 1 (very much improved). individual is found by multiplying the SEM by 1.96 (repre- This scale has been used to determine MCID in previous senting 95% of the area under the curve of a normal distri- studies.27-30 To determine whether there was a difference in bution) and 1.41 (the square root of 2, to control for possi- the pre- and post-test scores for participants rated into each ble error associated with calculating the coefficient from 2 of the CGI-I anchors, paired-samples t tests were used. data sets (ie, test and retest))23: