Assessments. BLAST Study (Backward Locomotion After STroke) Forms. Funded by VA RR&D

Transcription

1 Assessments Forms BLAST Study (Backward Locomotion After STroke) Funded by VA RR&D

2 Blinded Assessments 1. C1.Ten Meter Walk Test (initial) 2. C2.Three meter Backward Walk Test (initial) 3. C3.Modified Falls Efficacy Scale (initial) 4. C4.Functional Gait Assessment (initial) 5. C5.LE Fugl Meyer Motor and Sensory Assessment (initial) 6. C6.Four-Step Square Test (initial) 7. C7.Berg Balance Scale (initial) 8. C8.Activities-Specific Balance Confidence Scale (initial) 9. C9.Six minute walk test (initial) 10. C10 Modified Rankin Scale (initial)

3 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C1. 10 Meter Walk Test INSTRUCTIONS TO PATIENT You are going to walk a distance of about 40 feet. We will repeat this distance four times, two times at your comfortable walking pace two times as fast as possible. Do you have any questions? Resting Pulse 1. _ 2. Systolic 3. Diastolic Resting BP Comfortable Pace Trial 1 (seconds) Comfortable Pace Trial 2 (seconds) As Fast as Possible Pace Trial 1 (seconds) As Fast as Possible Pace Trial 2 (seconds) You will walk at a comfortable pace to the chair *. (*Use appropriate descriptor of chair/location as needed but DO NOT refer to the tape on the floor). The start command will be Ready and Go. Ready and Go. Walk as fast as you can to the chair *. (*Use appropriate descriptor of chair/location as needed but DO NOT refer to the tape on the floor). The start command will be Ready and Go. Ready and Go. Assistive Device Used Type of AFO Functional Ambulation Category 1. Non functional ambulator 2. Ambulator - Dependent for Physical Assistance Level II 3. Ambulator - Dependent for Physical Assistance level I 4. Ambulator - Dependent for Supervision 5. Independent, level surfaces only 6. Independent Assistive Device 0. None Single Point Cane 2. Quad Cane 3. Hemi Walker 4. 2-wheeled walker 5. Standard Walker 6. 4-wheeled Walker 7. Other (Specify Type of AFO 0. None 1. Rigid plastic (no joint) 2. Rigid plastic (with joint) 3. Metal double upright with joint 4. Posterior spring (flexible) 5. External ankle support 6. Other (Specify) Evaluator Name FBW_ _v4. Data Entry Person Name (Date) / / 1 of 1

4 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C2. 3 Meter Backward Walk Test INSTRUCTIONS TO PATIENT You are going to walk backwards at a distance of about 16 feet. We will repeat this distance two times at your comfortable pace. I will be with you as you walk, assisting you as needed. Do you have any questions? Trial 1 (seconds) Trial 2 (seconds) Assistive Device Used Type of AFO Functional Ambulation Category 1. Non functional ambulator 2. Ambulator - Dependent for Physical Assistance Level II 3. Ambulator - Dependent for Physical Assistance level I 4. Ambulator - Dependent for Supervision 5. Independent, level surfaces only 6. Independent 1a.. 1b.. 2a.. 2b You will walk at a comfortable pace to the chair. The start command will be Ready and Go. Ready and Go. Walk at a comfortable pace to the chair. Ready and Go. Comments: Assistive Device Type of AFO 0. None 0. None 1. Single Point Cane 1. Rigid plastic (no joint) 2. Quad Cane 2. Rigid plastic (with joint) 3 Hemi Walker 3. Metal double upright with joint 4. 2-wheeled walker 4. Posterior spring (flexible) 5. Standard Walker 5. External ankle support 6. 4-wheeled Walker 6. Other (Specify 7. Other (Specify) Evaluator Name Data Entry Person Name / / Month/ Day/ Year BLAST_ _v1. 1 of 1

5 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C3. Modified Falls Efficacy Scale Subjects are asked: How confident/sure are you that you can do each of the activities without falling? This is a survey, 0-10, there is no right or wrong answer. Whatever is right for you is right. (If participant asks, this refers to with their customary orthotic/assistive device. )(Show participant answer template and explain range of scores) Activity 1 Light housekeeping (e.g. sweep, dust) 2 Getting dressed or undressed 3 Preparing simple meals 4 Taking a bath or shower 5 Simple shopping 6 Getting in/out of bed 7 Getting in/out of a chair 8 Walking around the inside of your house 9 Reach into a cabinet or closet 10 Answer the door or telephone 11 Using public transportation 12 Crossing roads 13 Light gardening or hanging out the wash 14 Using front or rear steps at home Score Each item is scored from 0 to 10 with: 0 = not confident/not sure at all 5 = fairly confident/fairly sure 10 = completely confident/completely sure Evaluator Name Data Entry Person Name (Date) / / BLAST_ _v1

6 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C4. Functional Gait Assessment Item 1. Gait, Level Surface 2. Change in Gait Speed 3. Gait with horizontal head turns 4. Gait with vertical head turns 5. Gait and pivot turn 6. Step over obstacle 7. Gait with Narrow Base of Support 8. Gait with Eyes Closed 9. Ambulation Backwards 10. Stairs Total Score Evaluator Name Data Entry Person Name (Date) / / FBW_ _v3.

7 Pt. ID: BLT- Date: / / Assessment #: Evaluator: Functional Gait Assessment Procedures Set Up: Look for BLAST FGA START and BLAST FGA END tape on the floor. This is the participant s walking path. Orient yourself to START/END before you begin. A marked 20 ft (6- m) walkway that is marked with a 12 inch (30.48 cm) width. A chair is placed at either end of the walkway, a meter beyond the 6-meter path. There is no acceleration or deceleration distance for this assessment. Note that for some test items, participant automatically scores < 3 if they use assistive device, but this is not the case for each item. Review scoring of each item carefully. Participants are to complete the assessment in the least restrictive fashion (i.e. without assistive/orthotic devices). The intent is to assess participant s actual ability. Devices are permitted if the assessor determines the participant would be unsafe and/or prone to injury if not used. Demonstrate each task to the participant. 1. Gait Level Surface Instructions: Walk at your normal speed from here to the chair (20'). Grading: Mark the highest category that applies. (3) Normal: Walks 20' (6 m) in less than 5.5 seconds (good speed) No assistive devices No evidence for imbalance Normal gait pattern, Deviates no more than 6 in (15.24 cm) outside of the 12-in (30.48 cm) walkway width (2) Mild impairment: Walks 20' (6 m) in less than 7 seconds but greater than 5.5 seconds (slower speed) Uses assistive devices, slower speed Mild gait deviations or Deviates 6-10 in ( cm) outside of the 12-in (30.48 cm) walkway width (1) Moderate impairment: Walks 20' (6 m), requires greater than 7 seconds, (slow speed) Abnormal gait pattern, Evidence for imbalance, or Deviates in ( cm) outside of the 12-in (30.48 cm) walkway width. (0) Severe impairment: Cannot walk 20' (6 m) without assistance, Severe gait deviations or imbalance, Deviates greater than 15 in (38.1 cm) outside of the 12-in (30.48 cm) walkway width, or reaches and touches the wall. BLAST_ _v2.

8 Pt. ID: BLT- Date: / / Assessment #: Evaluator: 2. Change in gait speed Instructions: Begin walking at your normal pace. (for 5' (1.5 m)). When I say "fast," walk as fast as you can (for 5' (1.5 m)). When I say "slow," walk as slowly as you can (for 5' (1.5 m)). Note: Give instructions to participant such that he walks at normal pace for 5 feet, fast for 5 feet and slow for 5 feet. Grading: Mark the highest 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. Deviates no more than 6 inches (15.24 cm) outside of the 12-in (30.48 cm) walkway width. (2) Mild impairment: Is able to change speed but demonstrates mild gait deviations, deviates 6-10 in ( cm) outside of the 12-in (30.48 cm) walkway width, or No gait deviations but unable to achieve a significant change in velocity, or uses and assistive device. (1) Moderate impairment: Makes only minor adjustments to walking speed, or Accomplishes a change in speed with significant gait deviations, deviates in ( cm) outside the 12-in (30.48 cm) walkway width, or Changes speed but loses balance but is able to recover and continue walking. (0) Severe impairment: Cannot change speeds, Deviates greater than 15 in (38.1 cm) outside 12-in (30.48 cm) walkway width, or Loses balance and has to reach for wall or be caught. 3. Gait with horizontal head turns Instructions: Walk from here to the chair 20 ft (6 m) away. Begin walking straight ahead at your normal pace. When I say turn right, turn your head to the right and keep walking straight while looking to the right. When I say turn left, turn your head to the left and keep walking straight while looking left. Keep walking straight head and listen for me to say turn right or turn left Note: Have participant alternating looking right and left every 3 steps until they have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) Normal: Performs head turns smoothly with no change in gait Deviates no more than 6 in (15.24 cm) outside 12-in (30.48 cm) walkway width BLAST_ _v2.

9 Pt. ID: BLT- Date: / / Assessment #: Evaluator: (2) Mild impairment: Performs head turns smoothly with slight change in gait velocity (eg. minor disruption to smooth gait path) Deviates 6-10 in ( cm) outside 12-in (30.48 cm) walkway width, or Uses assistive device (1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down, Deviates in ( cm) outside 12-in (30.48 cm) walkway width but recovers, can continue to walk (0) Severe impairment: Performs task with severe disruptions of gait (i.e., staggers 15 in (38.1 cm) outside 12-in (30.4 cm) walkway width) loses balance, stops, or reaches for wall 4. Gait with vertical head turns Instructions: Walk from here to the chair (20 ft (6 m). Begin walking straight ahead at your normal pace. When I say look up, tip your head up and keep walking straight while looking up. When I say look down, tip your head down, keep walking straight while looking down. Keep walking straight ahead and listen for me to say look up or look down. Note: Have participant alternating looking up and down every 3 steps until they have completed 2 repetitions in each direction. Grading: Mark the highest category that applies. (3) Normal: Performs head turns with no change in gait. Deviates no more than 6 in (15.24 cm) outside 12-in (30.48 cm) walkway width (2) Mild impairment: Performs task with slight change in gait velocity (i.e., minor disruption to smooth gait path) Deviates 6-10 in ( cm) outside 12-in (30.48 cm) walkway width or Uses assistive device (1) Moderate impairment: Performs tasks with moderate change in gait velocity, slows down Deviates in ( cm) outside 12-in (30.48 cm) walkway width but recovers, can continue to walk. (0) Severe impairment: Performs task with severe disruption of gait (i.e., staggers 15 in (38.1 cm) outside 12-in (30.48 cm) walkway width Loses balance, stops, reaches for wall BLAST_ _v2.

10 Pt. ID: BLT- Date: / / Assessment #: Evaluator: 5. Gait and pivot turn Instructions: Begin with 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 and don t move. Grading: Mark the highest 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, or Pivot turns safely within 3 seconds and stops with mild imbalance, requires small steps to catch balance. (1) Moderate impairment: Turns slowly, requires verbal cueing, or 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 shoe box, step over it, not around it, one leg at a time and keep walking. You can step over it with either leg first, whichever you prefer. Grading: Mark the highest category that applies. If participant is unable to step over 2 stacked shoe boxes, they are then to attempt to step over one shoe box. Can only score a 3 if able to step over two stacked shoe boxes. (3) Normal: Able to step over 2 stacked shoe boxes taped together (9 in [22.86 cm] total height) without changing gait speed No evidence of imbalance (2) Mild impairment: Able to step over one shoe box (4.5 in [11.43 cm] total height) without changing gait speed No evidence of imbalance (1) Moderate impairment: Able to step over one shoe box (4.5 in [11.43 cm] total height) but must slow down and adjust steps to clear box safely May require verbal cueing (0) Severe impairment: BLAST_ _v2.

11 Pt. ID: BLT- Date: / / Assessment #: Evaluator: Cannot perform without assistance 7. Gait with Narrow Base of Support Instructions: Walk straight ahead with your arms folded across your chest, heel to toe. You can begin with either foot first. (If UE is plegic, participant should support plegic UE with intact UE). If unable to attempt/complete task without an assistive device, score is 0. Grading: Participant should walk such that feet are aligned heel to toe in tandem for a distance of 12 feet (3.6 m). The number of steps taken in a straight line are counted for a maximum of 10 steps. Mark the highest category that applies. (3) Normal: Is able to ambulate for 10 steps heel to toe with no staggering (2) Mild impairment: Ambulates 7-9 steps (1) Moderate impairment: Ambulates 4-7 steps (0) Severe impairment: Ambulates less than 4 steps heel to toe or cannot perform without assistance 8. Gait with Eyes Closed Instructions: Walk at your normal speed from here towards the chair (20 feet [6 m]) with your eyes closed. I will walk beside you and will tell you when to stop. Grading: Mark the highest category that applies. (3) Normal: Walks 20 ft (6 m) in less than 7 seconds (good speed) No assistive devices No evidence of imbalance Normal gait pattern Deviates no more than 6 in (15.24 cm) outside 12-in (30.48 cm) walkway width. (2) Mild impairment: Walks 20 ft (6 m) in less than 9 seconds but greater than 7 seconds (slower speed) Uses assistive device Mild gait deviations Deviates 6-10 in ( cm) outside 12-in (30.48 cm) walkway width (1) Moderate impairment: Walks 20 ft (6 m), slow speed (requires more than 9 seconds) Abnormal gait pattern Evidence for imbalance Deviates in ( cm) outside 12-in (30.48 cm) walkway width (0) Severe impairment: Cannot walk 20 ft (6 m) without assistance Severe gait deviations or BLAST_ _v2.

12 Pt. ID: BLT- Date: / / Assessment #: Evaluator: Imbalance, deviates greater than 15 in (38.1 cm) outside 12-in (30.48 cm) walkway width or Will not attempt task 9. Ambulating Backwards Instructions: Walk backwards until I tell you stop. I will be behind you as you walk. Grading: Mark the highest category that applies. (3) Normal: Walks 20 ft (6 m), good speed No assistive devices No evidence for imbalance Normal gait pattern Deviates no more than 6 in (15.24 cm) outside 12-in (30.48 cm) walkway width (2) Mild impairment: Walks 20 ft (6 m) Uses assistive device Slower speed Mild gait deviations Deviates 6-10 in ( cm) outside 12-in (30.48 cm) walkway width (1) Moderate impairment: Walks 20 ft (6 m), slow speed Abnormal gait pattern Evidence for imbalance Deviates in ( cm) outside 12-in (30.48 cm) walkway width (0) Severe impairment: Cannot walk 20 ft (6 m) without assistance Severe gait deviations or imbalance Deviates greater than 15 in (38.1 cm) outside 12-in (30.48 cm) walkway width or Will not attempt task. 10. Stairs Instructions: Walk up these stairs as you would at home (i.e., using the rail if necessary). At the top, turn around and walk down. At top of stairs, hands on rail to assist in turning is permitted. Can still score a 3 on this task. Grading: Mark the highest 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. BLAST_ _v2.

13 Pt. ID: BLT- Date: / / Assessment #: Evaluator: BLAST_ _v2.

14 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C5. FUGL-MEYER ASSESSMENT OF PHYSICAL PERFORMANCE Motor Function- Lower Extremity TEST ITEM SCORE SCORING CRITERIA I. Reflex Activity Achilles Patellar 0-No reflex activity can be elicited 2-Reflex activity can be elicited II. A. Flexor Synergy (in supine) Hip flexion 0-Cannot be performed at all Knee flexion 1-Partial motion 2-Full motion Ankle dorsiflexion II. B. Extensor Synergy (in sidelying) III. Movement combining synergies (sitting: knees free of chair) IV. Movement out of synergy (Standing, hip at 0 ) Hip extension Adduction Knee extension Ankle plantar flexion A. Knee flexion beyond 90 V. Normal Reflexes (sitting) Knee flexors, Patellar, Achilles (This item is only tested if the patient achieves a maximum score on all previous LE items. If the person has not achieved a full score to this point, enter 0) VI. Coordination/speed - Sitting: Heel to opposite knee (5 repetitions in rapid succession) 0-Cannot be performed at all 1-Partial motion 2-Full motion BLAST_ _v2. Adapted from Fugl-Meyer, of 2 0-No active motion 1-From slightly extended position, knee can be flexed, but not beyond Knee flexion beyond 90 B. Ankle dorsiflexion 0-No active flexion 1-Incomplete active flexion 2-Normal dorsiflexion A. Knee flexion 0-Knee cannot flex without hip flexion 1-Knee begins flexion without hip flexion, but does not reach to 90, or hip flexes during motion 2-Full motion as described B. Ankle dorsiflexion 0-No active motion 1-Partial motion 2-Full motion 0-At least 2 of the 3 phasic reflexes are markedly hyperactive 1-One reflex is markedly hyperactive, or at least 2 reflexes are lively 2-No more than one reflex is lively and none are hyperactive A. Tremor 0-Marked tremor 1-Slight tremor 2-No tremor B. Dysmetria 0-Pronounced or unsystematic dysmetria 1-Slight or systematic dysmetria 2- No dysmetria C. Speed 0-Activity is more than 6 seconds longer than unaffected side 1-(2-5.9) seconds longer than unaffected side 2-Less than 2 seconds difference Lower Extremity Total Maximum = 34

15 Pt. ID: BLT- Date: / / Assessment #: Evaluator: Sensation TYPE OF SENSATION AREA SCORE SCORING CRITERIA I. Light Touch a.thigh 0-Anesthesia b.sole of Foot 1-Hyperesthesia / dysesthesia 2-Normal II. Proprioception a.hip 0-No Sensation b.knee c.ankle d.toe 1-75% of answers are correct, but considerable difference in sensation relative to unaffected side 2- All answers are correct, little or no difference Comments Total Sensation Score Maximum = 12 Total Motor and Sensory Score Maximum = 46 Evaluator Name Data Entry Person Name (Date) / / BLAST_ _v2. Adapted from Fugl-Meyer, of 2

16 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C6. Four Square Step Test INSTRUCTIONS TO PATIENT Try to complete the sequence as fast as possible without touching the sticks. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence. The start command will be Ready and Go. Do you have any questions? Trial 1 (seconds) Trial 2 (seconds) Assistive Device Used Type of AFO Comments: Assistive Device Type of AFO 0. None 0. None 1. Single Point Cane 1. Rigid plastic (no joint) 2. Quad Cane 2. Rigid plastic (with joint) 3 Hemi Walker 3. Metal double upright with joint 4. 2-wheeled walker 4. Posterior spring (flexible) 5. Standard Walker 5. External ankle support 6. 4-wheeled Walker 6. Other (Specify 7. Other (Specify) Evaluator Name Data Entry Person Name / / Month/ Day/ Year

17 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C7. BERG BALANCE SCALE INSTRUCTIONS: Demonstrate each task and/or give instructions as written. When scoring, record the lowest response category for each item. Patient can not use an assistive device for this test. ITEM INSTRUCTIONS SCORE SCORING CRITERIA 1. Sitting to Standing 2. Standing Unsupported 3. Standing to Sitting 4. Sitting Unsupported with Feet on Floor 5. Transfers 6. Standing Unsupported with Eyes Closed 7. Standing Unsupported with Feet Together 8. Reaching Forward with Outstretched Arm Please stand up. Try not to use your hands for support. Stand for 2 minutes without holding onto anything. Please sit down. Try to use your hands as little as possible. Sit with arms folded across chest for 2 minutes. Please move from the chair you are sitting in to the other chair (place chairs at 45 angle, one chair with arm rests, one without). Stand with feet shoulderwidth apart. Close your eyes and stand still for 10 seconds Place your feet together and stand without holding. Hold for 1 minute. Raise your arm to shoulder height and reach forward with your fist as far as you can. 4 - Able to stand independently, does not use hands and is stable 3 - Able to stand independently using hands 2 - Able to stand using hands after several tries 1 - Needs min assistance to stand or stabilize 0 - Needs mod-max assistance to stabilize 4 - Stands safely for 2 minutes 3 - Stands for 2 minutes with supervision 2 - Stands unsupported for 30 seconds 1 - Needs several tries to stand 30 seconds 0 - Unable to stand 30 seconds unassisted 4 - Sits with minimal use of hands 3 - Controls descent with hands 2 - Uses back of legs against chair to control descent 1 - Sits independently but has uncontrolled descent 0 - Needs assistance to sit 4 - Sits safely for 2 minutes 3 - Sits 2 minutes with supervision 2 - Sits 30 seconds 1 - Sits 10 seconds 0 - Unable to sit for 10 seconds unsupervised 4 - Transfers safely with minimal use of hands 3 - Transfers safely with definite need of hands 2 - Transfers with verbal cues or supervision 1 - Needs 1 person assist or supervision for safety 0 - Needs 2 person assist 4 - Stands for 10 seconds safely 3 - Stands for 10 seconds with supervision 2 - Stands 3 seconds 1 - Unable to keep eyes closed for 3 seconds but stays steady 0 - Needs help to keep from falling 4 - Able to place feet together independently and stand 1 minute safely 3 - Places feet together independently and stands for 1 min with supervision 2 - Places feet together independently but unable to hold for 30 seconds 1 - Needs help to attain position but able to stand for 15 seconds 0 - Needs help to attain position and unable to hold for 15 seconds 4 - Greater than 10 inches 3 - Greater than 5 inches 2 - Greater than 2 inches 1 - Reaches forward but needs supervision 0 - Needs help to keep from falling Adapted from Berg, of 2

18 Pt. ID: BLT- Date: / / Assessment #: Evaluator: TEST INSTRUCTIONS SCORE SCORING CRITERIA Please pick up plastic cup. (Place on floor 6-12 inches in front of feet.) 9. Pick Up Object from Floor 4 - Able to pick up safely and easily 3 - Able to pick up but needs supervision 2 - Unable to pick up but reaches 1-2 inches from object and keeps balance independently 1 - Unable to pick up and needs supervision while trying 0 - Unable to try or tries and needs assist to keep from falling 10. Turn to Look Behind over Left and Right Shoulders 11. Turning Dynamic Weight Shifting While Standing Unsupported 13. Standing Unsupported One Foot in Front 14. Standing on One Leg Comments Turn to look behind you over toward the left shoulder without moving your feet. Repeat with the right. Turn completely around in full circle. Pause. Now turn in the other direction. Place each foot alternately on the stool for a count of 8 (demonstrate with foot flat; count touches). Place one foot directly in front of other as close as possible and hold for 30s Stand on one leg for as long as you can without holding 4 - Looks behind from both sides and weight shifts well 3 - Looks behind one side only, other side shows less weight shift 2 - Turns sideways only but maintains balance 1 - Needs supervision while turning 0 - Needs assistance to keep from falling 4 - Turns full circle in < 4 seconds each side. 3 - Turns safely to only one side in < 4 seconds 2 - Turns safely but slowly 1 - Needs close supervision or verbal cuing 0 - Needs assist while turning 4 - Completes 8 steps in 20 seconds safely 3 - Completes 8 steps in > 20 seconds 2 - Completes 4 steps without aid and with supervision 1 - Able to complete > 2 steps, needs min assist 0 - Needs assist to keep from falling / unable to try 4 - Places foot in tandem independently and holds 30 seconds 3 - Places one foot in front of other independently and holds for 30 seconds 2 - Takes small step independently and holds for 30 seconds 1 - Needs help to place foot, holds 15 seconds 0 - Loses balance while stepping or standing 4 - Lifts leg independently and holds > 10 seconds 3 - Lifts leg independently and holds 5-10 seconds 2 - Lifts leg independently and holds 3 seconds 1 - Tries to lift leg, unable to hold 3s but remains standing independently 0 - Unable to try or needs assist to prevent fall Adapted from Berg, of 2

19 Pt. ID: BLT- - Date: / / Assessment #: Evaluator: C8. ACTIVITIES-SPECIFIC BALANCE CONFIDENCE SCALE For each of the following, please indicate your level of confidence in doing the activity without losing your balance or becoming unsteady by choosing one of the percentage points on the scale from 0% to 100%. If you do not currently do the activity in question, try and imagine how confident you would be if you had to do the activity. If you normally use a walking aid to do the activity or you hold on to someone, rate your confidence as if you were using these supports. For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following scale: 0% % No confidence Completely confident How confident are you that you will not lose your balance or become unsteady when you ITEM 1. walk around the house? 2. walk up or down stairs? 3. bend over and pick up a slipper from the front of a closet? 4. reach for a small can off a shelf at eye level? SCORE 5. stand on tip toes and reach for something above your head? 6. stand on a chair and reach for something? 7. sweep the floor? 8. walk outside the house to a car parked in the driveway? 9. get into or out of a car? 10. walk across a parking lot to a mall? 11. walk up or down a ramp? 12. walk in a crowded mall where people rapidly walk past you? 13. are bumped into by people as you walk through the mall? 14. step onto or off of an escalator while you are holding onto a railing? 15. step onto or off of an escalator while holding onto parcels such that you cannot hold onto the railing? 16. walk outside on icy sidewalks? Evaluator Name Data Entry Person Name / / Month/Day/Year BLAST_ _v1

20 Pt. ID: BLT- Date: / / Assessment #: Evaluator: C9. 6 Minute Walk Test Pre-test Heart Rate ITEM Pre-test Blood Pressure Instructions to Patient I want you to walk for six minutes, covering as much ground as possible. Keep going continuously if possible, but don't be concerned if you have to slow down and stop to rest. You can rest either standing or sit down in one of the chairs. The aim at the end of six minutes is for you to feel you could not have covered more ground. I will stay with you as we walk and you are allowed to use any assistive device (walker, cane, etc.) or brace that your normally use. We will not talk during the walk as this may affect your performance. I will inform you of the time elapsed. Please let me know if you are uncomfortable or have pain. The idea is for you to walk at a comfortable, safe, pace but to cover as much ground as possible in the six minutes. I will give you input every minute. You will start when I say "GO". Do you have any questions? At one minute intervals, provide the following encouragement: 1 minute: "It has been one minute. You're doing well, keep up the good work." 2 minutes: "You're doing a good job, keep it up. That s two minutes" 3 minutes: "You're doing fine with this test, and you're half-way through." 4 minutes: "You're continuing to do well, that's four minutes." 5 minutes: "Keep up the good work, you've got one more minute to go." If the participant is resting when it is time to provide encouragement change the encouragement statement to: "It's been minute(s). Rest as long as you need to and let me know when we can get started again." If the participant continues to rest through the next minute, state: " minute(s) is/are left in the test. You may continue to rest or resume walking when you feel able." Repeat this statement at each minute if the participant continues to rest. You may assist the patient with transitions from standing to sitting and sitting to standing. Total Distance Walked (meters) Number of Rests during 6 Minute Walk Post-test Heart Rate Post-test Blood Pressure ( # of laps x 13 m) + m = Total m) Comments: Assistive Device Used Type of AFO Functional Ambulation Category 1. Non functional ambulator 2. Ambulator - Dependent for Physical Assistance Level II 3. Ambulator - Dependent for Physical Assistance level I 4. Ambulator - Dependent for Supervision 5. Independent, level surfaces only 6. Independent Adapted from Salbach of 2

21 Evaluator Name Data Entry Person Name (Date) / / Adapted from Harada

22 Pt. ID: BLT- Date: / / Assessment #: Evaluator: 01, 03, 05 C10. Modified Rankin Scale Today, Post-Stroke Modified Rankin Scale: 1. Modified Rankin Scale 0 No symptoms at all 1 No significant disability: despite symptoms, able to carry out all usual duties and activities 2 Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance. 3 Moderate disability: requiring some help, but able to walk without assistance. 4 Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance. 5 Severe disability: bedridden, incontinent and requiring constant nursing care and attention. From interview Engages fully in all previous activities but may have residual symptoms of stroke. Change in social roles related to work or social engagement. May use assistive device but no physical assistance. Assistance includes physical assistance or verbal instruction by another person. Constant care: usually bedridden, moving from bed to sitting requires major assistance. Evaluator Name Data Entry Person Name (Date) / / BLAST_ _v1