Examination and Treatment of Postural and Locomotor Control

Examination and Treatment of Postural and Locomotor Control Not to be copied without permission. 1

15-minute Bedside Balance Systems Tests Contents FIVE TIMES SIT TO STAND TEST... 3 SINGLE LEG STANCE... 4 ROMBERG AND TANDEM ROMBERG... 4 IN PLACE RESPONSES... 5 COMPENSATORY STEPPING... 6 FUNCTIONAL REACH TEST... 7 MODIFIED CLINICAL TEST OF SENSORY INTERACTION IN BALANCE... 8 FOUR SQUARE STEP TEST... 10 TIMED UP AND GO TEST... 12 DYNAMIC GAIT INDEX... 14 4-ITEM DYNAMIC GAIT INDEX... 17 FUNCTIONAL GAIT ASSESSMENT... 18 10-METER WALK TEST... 24 Not to be copied without permission. 2

FIVE TIMES SIT TO STAND TEST Cauka & McCarty (1985) Purpose: Measures functional LE strength and provides information about postural control during transitions to/from standing. Original Population: Older adults Special Populations: Vestibular disorders, stroke, arthritis, and renal failure WHO ICF Components: Activity Limitation Time to Complete: < 5 minutes Equipment Needed: Stopwatch and chair (43.5cm) Patient Instructions: Start with your back against the backrest, arms folded, and both feet flat on the floor. Stand [all the way] up and sit back down 5 times as quickly and as safely as possible when I say, Go! Your arms should remain folded at all times. Your back should not touch the backrest of the chair between repetitions. Therapist Considerations: Whitney et al. (2005) 1) Chair height = 43 cm height and 47.5 cm depth 2) The chair should not be secured against a support (wall) 3) Allow one full practice test before recording the official trial 4) For patients who may fatigue, demonstrate the task and ask for two repetitions of practice before recording 5) Inability to complete any repetition as directed indicates a failed test 6) Start timing on Go! and stop when buttocks touches the chair after the fifth attempt 7) Avoid talking to patients during testing as this may affect speed 8) Switch to the 30-second Chair Stand Test for patients who need to use upper extremity assistance to stand Not to be copied without permission. 3

SINGLE LEG STANCE Whitney (1999) Therapist Considerations: 1. Difficult test for older adults to perform 2. Requires significant lower extremity strength 3. Criteria for stopping test need to be established and followed consistently by all clinic staff 4. Right and left timed scores are usually very consistent in normal individuals 5. Though often timed for 30 seconds, this is an artificial ceiling for young adults 6. Foot, head, and eye position is important, both initially and during the test 7. Ideally the test is performed with shoes off about 3 from any wall Patient Instructions: (Eyes Open) Stand on one leg, place your arms across your chest with your hands touching your shoulders and do not let your legs touch each other. Look straight ahead at the object in front of you. Criteria for Stopping the Test Legs touch each other, Stance foot moves on the floor, Raised foot touches down, Arms moved from the start position Patient Instructions: (Eyes Closed) Stand on one leg, place your arms across your chest with your hands touching your shoulders and do not let your legs touch each other. Close your eyes once you have gotten in position. Criteria for Stopping the Test Legs touch each other, Stance foot moves on the floor, Raised foot touches down, Arms moved from the start position, Eyes open during the test ROMBERG AND TANDEM ROMBERG Whitney (1999) Patient Instructions: (Eyes Open) Stand with both ankle bones and big toes touching each other (one foot directly in front of the other-sharpened Romberg) with your arms crossed and your hands touching the opposite shoulder. Look straight ahead. Try to hold this position for 30 seconds. Criteria for Stopping the Test Feet are moved on the floor or arms are moved from the crossed position Patient Instructions: (Eyes Closed) Stand with both ankle bones and big toes touching each other (one foot directly in front of the other-sharpened Romberg) with your arms crossed and your hands touching the opposite shoulder. Close your eyes once you have achieved this position. Hold for 30 seconds. Criteria for Stopping the Test Feet are moved on the floor, arms are moved from the crossed position, eyes open during test Not to be copied without permission. 4

IN PLACE RESPONSES Horak, from the BESTest 10. IN PLACE RESPONSE - FORWARD Patient: Stand in your normal posture with your feet shoulder width apart, arms at your sides and resist my push. Try to keep your balance without taking a step, but step if you have to. Examiner Instructions: Stand in front of the patient, place one hand on each shoulder and lightly push the patient backward until their anterior ankle muscles contract, then suddenly release. You may score only the second trial (best response) if the patient is unprepared or you pushed too hard. (1) Recovers stability with ankles, no added arms or hips motion (2) Recovers stability with arm or hip motion (0) Takes a step to recover stability (0) Would fall if not caught OR requires assist OR will not attempt 11. IN PLACE RESPONSE - BACKWARD Patient: Stand with your feet shoulder width apart, arms at your sides and resist my push. Try to keep your balance without taking a step. Examiner Instructions: Stand behind the patient, place one hand on each shoulder and isometrically hold against the patient s backward lean until their posterior ankle muscles contract, then suddenly release. You may score only second trial (best response) if patient is unprepared or you push too hard. (3) Recovers stability with ankles, no added arms or hips (1) Recovers stability with arms or hip motion (1) Takes a step to recover stability (0) Would fall if not caught OR requires assist OR will not attempt Not to be copied without permission. 5

COMPENSATORY STEPPING Horak, from the BESTest 12. COMPENSATORY STEPPING CORRECTION- FORWARD Patient: Lean forward to your limits. Stand with your feet shoulder width apart, arms at your sides and resist my push. Try to keep your balance. Do not fall. Examiner Instructions: Stand in front of the patient with one hand on each shoulder and allow them to lean forward to their limits of stability and then resist, pushing backwards until there is tibialis anterior recruitment (enough to cause a step), then suddenly release. (2) Recovers independently with a single, large step (2) Small step or more than one step used but stable and recovers independently (1) Takes sideways steps to recover equilibrium, needs assistance to prevent a fall (0) No steps so would fall if not caught 13. COMPENSATORY STEPPING CORRECTION - BACKWARD Patient: Stand with your feet shoulder width apart, arms at your sides, lean backward to your limits, and resist my push. Try to keep your balance. Do not allow yourself to fall. Examiner Instructions: Stand behind the patient with one hand on each shoulder and allow them to lean backward to their limits of stability and then resist, pushing forwards until there is triceps surae recruitment (enough to cause a step), then suddenly release. (3) Recovers independently with a single, large step (2) More than one step used but stable and recovers independently (1) Takes sideways steps to recover equilibrium, needs assistance (even light touch) to prevent a fall (0) No steps so would fall if not caught 14. COMPENSATORY STEPPING CORRECTION - LATERAL Patient: Stand with your feet close together, arms at your sides, and resist my push. Try to keep your balance. Do not allow yourself to fall. Examiner Instructions: Stand behind the patient, place one hand on the side of each pelvis and allow them to lean into your hand beyond their limits of stability and then suddenly release your hold. Right Left (3) Recovers independently with 1 step of normal length and width (3) (2) Several small steps used, but recovers independently (2) (1) Steps but needs to be assisted to prevent a fall (1) (0) Falls (0) Not to be copied without permission. 6

FUNCTIONAL REACH TEST Duncan, et al. (1990) Purpose: Measures unsupported dynamic standing balance impairment in adults Original Population: Community dwelling elderly Special Populations: Vestibular, elderly, PD, Stroke, SCI WHO ICF Components: Activity Limitation Time to Complete: < 5 minutes Equipment Needed: Yardstick Therapist Considerations: 1. Yardstick is mounted on the wall at patient s shoulder height. 2. Starting line is marked so patient s flexed UE enters the first half of the yardstick. 3. May be performed with or without shoes. 4. Patients are allowed to use various reaching techniques, but cannot step. 5. Position patient with the UE closest to the wall in 90 shoulder flexion, hand is fisted. 6. Patient s feet should be shoulder distance apart. 7. Recordings are made where the MCP joint of the third digit is aligned with the ruler. 8. Patient s shoulder should not be protracted. 9. Patient should be standing erect at the start of the test. 10. Patients must be guarded at all times. 11. Patients with certain musculoskeletal problems may have difficulty performing the task. 12. Decrease anxiety by allowing the patient to lightly touch your hand (guide the reach). 13. Perceived limits of stability impact the test Patient Instructions Reach as far as you can without losing your balance. Keep your feet on the floor. You are not allowed to touch the wall or the ruler. You are not allowed to take a step. You are allowed two practice trials before I record how far you can reach. Photograph: Whitney, SL & Herdman, SJ. Ch 15: Physical Therapy Assessment of Vestibular Hypofunction. In: Vestibular Rehabilitation. Ed: Herdman, SJ. FA Davis (2000) Not to be copied without permission. 7

MODIFIED CLINICAL TEST OF SENSORY INTERACTION IN BALANCE Adopted from Shumway-Cook & Horak (1986 and 1987) by Cohen & Blatchly (1993) Purpose: Measures the functional use of somatosensory, visual, and vestibular feedback for quasi-static, standing postural control in normal and sensory conflict conditions. Original Population: Adults Special Populations: Vestibular, pediatrics, elderly, stroke, Alzheimer s disease WHO ICF Components: Impairment Time to Complete: < 5 minutes Equipment Needed: Stopwatch and low-memory foam that prevents orientation via the surface Therapist Considerations: 1. The test may be performed with or without shoes without impact in reliability, but should be assessed and documented in a consistent manner across each administration for a given patient 2. Testing the patient with feet together (medial maleoli touching) and arms folded across shoulders increases the correlation with computerized platform posturography 3. Patient should look straight ahead (visual fixation is allowed, but not necessarily encouraged) 4. Test duration is 30 seconds or until patient loses balance. Additional criteria to stop testing: 1. Patient s arms or feet move from starting position 2. Patient opens eyes during condition 2 or 4. Research has shown that neither the position of the feet nor the footwear influence the scores (Whitney and Wrisley 2004, Wrisley and Whitney 2004). Weber and Cass, 1993, used the Sensory Organization Test (SOT) as the gold standard for the mctsib with patients with complaints of dizziness or imbalance. The mctsib condition 4, standing on foam with the eyes closed had a sensitivity of 95%, and a specificity of 90% compared to SOT condition 5. Not to be copied without permission. 8

Patient Instructions: For each condition: Stand with your feet touching and arms folded across your shoulders. Try to keep your balance for at least 30 seconds. Whitney, SL & Herdman, SJ. Ch 15: Physical Therapy Assessment of Vestibular Hypofunction. In: Vestibular Rehabilitation. Ed: Herdman, SJ. FA Davis (2000) Condition 1: Normal vision non-compliant surface Condition 2: Absent vision non-compliant surface Condition 3: Normal vision compliant surface (6 Sunmate T-foam) Condition 4: Absent vision compliant surface (6 Sunmate T-foam) Not to be copied without permission. 9

FOUR SQUARE STEP TEST Dite & Temple (2002) Purpose: Measures postural stability in multi-directional stepping Original Population: Community-living older adults Special Populations: Vestibular, PD, stroke, transtibial amputations, geriatric WHO ICF Components: Activity Limitation Time to Complete: < 5 minutes Equipment Needed: Stopwatch and four t-handle style canes Patient Instructions: Try to complete the sequence as quickly and as safely as possible without touching the canes. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence. Therapist Considerations: 1. Four canes are arranged on the floor in the shape of a plus sign. 2. T-handle style cane should be used to limit the chance of the patient rolling over a cane. 3. Each cane should be 90 cm in length. 4. Demonstrate the test first 5. Allow one practice trial and then record the fastest time for the next two trials. 6. Begin timing when the right foot contacts the floor in square 2. 7. Repeat a trial if the patient: falls, loses balance, makes contact with a cane. 8. Patients are encouraged to face forward during the entire test, but timed accordingly if they turn. 40-62% of participants had unsuccessful trials at least once during testing, Participants found the test more difficult to perform than the Step Test. However, FSST was preferred by participants because they felt it was relevant to daily life and examined challenging skills (Blennerhassett and Jayalath, 2008). The Four Square Step Test may be helpful in identifying individuals (older adults > 65 y/o) with vestibular disorders who have difficulty changing directions (Whitney 2007). Not to be copied without permission. 10

Not to be copied without permission. 11

TIMED UP AND GO TEST Podsiadlo et al, (1991) Purpose: Measures the dynamic postural control during transitions to/from standing, walking with/without a device, and during turning while walking. Original Population: Neurologically intact adults, independent in balance & mobility skills Special Populations: Numerous! WHO ICF Components: Activity Limitation Time to Complete: < 5 minutes Equipment Needed: Stopwatch, 3m walkway, standard height chair Patient Instructions: When I say go, I want you to stand up and walk just past the line, turn and then walk back to this chair and sit down again. Walk at your normal pace. Additional Modifications: Patient walks at fast pace to show how quickly they can ambulate Patient turns head left, right, up, or down to show if performance changes with head turns TUG Dual-task: interference by having patient perform a secondary task while walking Not to be copied without permission. 12

Therapist Considerations: The patient sits in the chair with his/her back against the chair back On the command go, the patient rises from the chair, walks 3 meters at a comfortable and safe pace, turns, walks back to the chair and sits down Timing begins at the instruction go and stops when the patient is seated Scores range from 1 to 5 based on the observer's perception of the patient s risk of falling (Mathias et al, 1986). We typically score based on timing as the 1 to 5 scale introduces greater chance of measurement error. Podsiadlo & Richardson, 1991, quantified the test by recommending timing (sec) the time between the command to start, till the buttocks touch the chair The patient should have one practice trial that is not included in the score (Podsiadlo & Richardson, 1991) Patient must use the same assistive device each time he/she is tested to be able to compare scores In the vestibular population it is suggested to test with both right and left turning (Whitney and Herdman, chapter 19 in Herdman, 2007:pg. 293) The TUG may demonstrate less reliability among patients suffering from cognitive impairment Chairs with armrests and a seating height of 44-47 cm should be used (Siggeirsdottir et al, 2002) Results suggest using age-related normative data for adults between the ages of 60 and 90 years. (Steffen et al, 2002) Intrarater reliability may be affected by subject performance when completing multiple assessments indicating patients quickly become familiar with this test resulting in the first test affecting the second test (vanhedel et al, 2005). TUG was designed to be tested with people walking at a comfortable speed, yet at times is tested with the walking at a quick yet safe speed. Clinically it is important that the chair is free standing, and not placed against a wall Not to be copied without permission. 13

DYNAMIC GAIT INDEX Shumway-Cook (1995) Purpose: Measures the dynamic postural control required for proactive and reactive gait. Original Population: Older adults Special Populations: Vestibular, TBI, stroke, MS, PD, geriatrics WHO ICF Components: Activity Limitation Time to Complete: < 15 minutes Equipment Needed: 20 x16 walkway, shoe box, 2 cones, and standard stairs Therapist Considerations: 1. Test should be performed in a quiet hallway 2. Patient should ambulate between two strips of tape, 15 apart 3. Test with or without shoes 4. Test with or without orthotics 5. Test with or without assistive devices 6. Reading glasses should not be worn during the test 7. Busy environments may increase motion intolerance 8. Record any symptoms the patient experiences during the test Scoring: Indicate the lowest category that applies. Not to be copied without permission. 14

1. Gait on level surface Instructions: Walk at your normal speed from here to the next mark (20 ) 3 Normal: Walks 20 without assist. device, good speed, no evidence for imbalance, normal gait pattern 2 Mild Impairment: Walks 20, uses assistive device, 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 assistive device, severe gait deviations or imbalance 2. Gait with changes in speed Instructions: Begin walking at your normal speed. (5 ) When I say go, walk as fast as you can. (5 ) When I say slow walk as slowly as you can. (5 ) 3 Normal: Able to smoothly change walking speed without loss of balance or gait deviations. Shows a significant difference in walking speeds between normal, fast, and slow speed. 2 Mild Impairment: Is able to change speeds, but demonstrates mild gait deviations or shows no gait deviations, but is unable to significantly change velocity, or uses an assistive device. 1 Moderate Impairment: Makes only minor adjustments in walking speed or accomplishes a change in speed with significant gait deviations or changes speed and 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 needs to be caught. 3. Gait with horizontal head turning Instructions: Begin walking at your normal pace. When I tell you 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 you head to the left until I tell you, look straight, then keep walking straight, but return your head to the center. 3 Normal: Performs full head turns smoothly with no change in gait pattern. 2 Mild Impairment: Performs full head turns smoothly with slight change in gait velocity or pattern, or uses assistive device. 1 Moderate Impairment: Performs head turns with moderate change in gait velocity or pattern, slows down, staggers, but recovers and continues to walk. 0 Severe Impairment: Performs task with severe disruption in gait, staggers outside 15 path; loses balance, stops, reaches for wall, or must be caught. 4. Gait with vertical head turning Instructions: Begin walking at your normal pace. When I tell you to look up, keep walking straight, but turn your head up. Keep looking up until I tell you, look down, then keep walking straight and turn your head down. Keep you head down until I tell you, look straight, then keep walking straight, but return your head to the center. 3 Normal: Performs full head turns smoothly with no change in gait pattern. 2 Mild Impairment: Performs full head turns smoothly with slight change in gait velocity or pattern, or uses assistive device. 1 Moderate Impairment: Performs head turns with moderate change in gait velocity or pattern, slows down, staggers, but recovers and continues to walk. 0 Severe Impairment: Performs task with severe disruption in gait, staggers outside 15 path; loses balance, stops, reaches for wall, or must be caught. Not to be copied without permission. 15

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. 3 Normal: Pivot turns slowly within 3 seconds and stops quickly with no loss of balance. 2 Mild Impairment: Pivot turns safely in greater than 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 obstacles Instructions: Begin walking at your normal speed. When you come to the obstacle, step over it, not around it, and keep walking. 3 Normal: Is able to step over obstacles without changing speed or evidence of imbalance. 2 Mild Impairment: Able to step over obstacle, but must slow down and adjust steps to clear safely. 1 Moderate Impairment: Able to step over obstacle, but must stop, then step over. May require verbal cues 0 Severe Impairment: Cannot perform without assistance. 7. Step around obstacles Instructions: Begin walking at your normal speed. When you come to the first obstacle (about 6 feet away), walk around the right side of it. When you come to the second obstacle (6 past the first obstacle), walk around it to the left. Obstacles are 4-6 in height and width. 3 Normal: Able to walk around obstacles without changes in speed or gait pattern (continuous steps), no evidence of imbalance. 2 Mild Impairment: Able to step around both obstacles safely, but must slow down slightly, adjust steps to clear obstacles. 1 Moderate Impairment: Able to step around both obstacles, but must slow down significantly or requires verbal cueing. 0 Severe Impairment: Unable to clear obstacles, walks into one or both obstacles, or requires physical assistance. 8. Steps 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. 3 Normal: Ascends and descends using alternating stair pattern. Does not use a rail. 2 Mild Impairment: Ascends and descends using alternating stair pattern. Must use a rail. 1 Moderate Impairment: Step to gait pattern on either ascending or descending or both. Must use rail. 0 Severe Impairment: Cannot do safely. Not to be copied without permission. 16

4-ITEM DYNAMIC GAIT INDEX Marchetti & Whitney (2006) 1. Gait on level surface Instructions: Walk at your normal speed from here to the next mark (20 ) 3 Normal: Walks 20 without assist. device, good speed, no evidence for imbalance, normal gait pattern 2 Mild Impairment: Walks 20, uses assistive device, 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 assistive device, severe gait deviations or imbalance 2. Gait with changes in speed Instructions: Begin walking at your normal speed. (5 ) When I say go, walk as fast as you can. (5 ) When I say slow walk as slowly as you can. (5 ) 3 Normal: Able to smoothly change walking speed without loss of balance or gait deviations. Shows a significant difference in walking speeds between normal, fast, and slow speed. 2 Mild Impairment: Is able to change speeds, but demonstrates mild gait deviations or shows no gait deviations, but is unable to significantly change velocity, or uses an assistive device. 1 Moderate Impairment: Makes only minor adjustments in walking speed or accomplishes a change in speed with significant gait deviations or changes speed and 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 needs to be caught. 3. Gait with horizontal head turning Instructions: Begin walking at your normal pace. When I tell you 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 you head to the left until I tell you, look straight, then keep walking straight, but return your head to the center. 3 Normal: Performs full head turns smoothly with no change in gait pattern. 2 Mild Impairment: Performs full head turns smoothly with slight change in gait velocity or pattern, or uses assistive device. 1 Moderate Impairment: Performs head turns with moderate change in gait velocity or pattern, slows down, staggers, but recovers and continues to walk. 0 Severe Impairment: Performs task with severe disruption in gait, staggers outside 15 path; loses balance, stops, reaches for wall, or must be caught. 4. Gait with vertical head turning Instructions: Begin walking at your normal pace. When I tell you to look up, keep walking straight, but turn your head up. Keep looking up until I tell you, look down, then keep walking straight and turn your head down. Keep you head down until I tell you, look straight, then keep walking straight, but return your head to the center. Not to be copied without permission. 17

FUNCTIONAL GAIT ASSESSMENT Wristley et al. (2004) Purpose: Measures the dynamic postural control required for proactive and reactive gait, particularly with higher level performance Original Population: Vestibular Special Populations: Older adults, PD, SCI, stroke WHO ICF Components: Activity Limitation Time to Complete: < 15 minutes Equipment Needed: 20 x12 walkway, 1-2 shoe box(es), and stairs Position of therapist did not make difference in interrater reliability (Wrisley et al, 2004) Addressed the ceiling effect of the DGI in persons with vestibular dysfunction. (Wrisley et al, 2004) Not to be copied without permission. 18

FUNCTIONAL GAIT ASSESSMENT Score Task Grading Criteria: Mark the highest category that applies (i.e. the highest category in which the subject meets all criteria) 1. Score: Time: 2. Score: 3. Score: 1. Gait Level Surface: Walk from here to the wall at your normal speed (time for 20 ) 2. Change In Gait Speed Begin walking at your normal pace [5 ft]. When I tell you go, walk as fast as you can [5 ft]. When I tell you slow, walk as slowly as you can [5 ft]. 3. Gait With Horizontal Head Turns Walk from here to the next mark 20 ft away. When I tell you look right, turn your head right and keep walking straight, when I tell you look left, turn your head left and keep walking straight. Have subject turn head every 3 steps. (3) Normal: Walks 20 ft in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside of the 12-in walkway. (2) Mild impairment: Walks 20 ft in less than 7 seconds but greater than 5.5 seconds, uses assistive device, slower speed, mild gait deviations, or deviates 6 10 in outside of the 12-in walkway width. (1) Moderate impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, or deviates 10 15 in outside of the 12-in walkway. Requires more than 7 seconds to ambulate 20 ft. (0) Severe impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside of the 12-in walkway width or reaches and touches the wall. (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 in outside of the 12-in walkway width. (2) Mild impairment: Is able to change speed but demonstrates mild gait deviations, deviates 6 10 in outside of the 12-in walkway width, or no 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, deviates 10 15 in outside the 12-in 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 outside 12-in walkway width, or loses balance and has to reach for wall or be caught. (3) Normal: Performs head turns smoothly with no change in gait. Deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 10 in outside 12-in walkway width, or uses an assistive device. (1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down, deviates 10 15 in outside 12-in walkway width but recovers, can continue to walk. (0) Severe impairment: Performs task with severe disruption of gait i.e., staggers 15 in outside 12-in walkway width, loses balance, stops, or reaches for wall. Not to be copied without permission. 19

4. Score: 5. Score: 6. Score: 4. Gait With Vertical Head Turns Walk from here to the next mark 20 ft away. When I tell you look up, tip your head up and keep walking straight, when I tell you look down, tip your head down and keep walking straight. Have subject turn head every 3 steps. 5. Gait And Pivot Turn 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. 6. Step Over Obstacle Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking. (3) Normal: Performs head turns with no change in gait. Deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment: Performs task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 10 in outside 12-in walkway width or uses assistive device. (1) Moderate impairment: Performs task with moderate change in gait velocity, slows down, deviates 10 15 in outside 12-in walkway width but recovers, can continue to walk. (0) Severe impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12-in walkway width, loses balance, stops, reaches for wall). (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. (3) Normal: Is able to step over 2 stacked shoe boxes taped together (9 in total height) without changing gait speed; no evidence of imbalance. (2) Mild impairment: Is able to step over one shoe box (4.5 in total height) without changing gait speed; no evidence of imbalance. (1) Moderate impairment: Is able to step over one shoe box (4.5 in total height) but must slow down and adjust steps to clear box safely. May require verbal cueing. (0) Severe impairment: Cannot perform without assistance Not to be copied without permission. 20

7. Score: # steps: 8. Score: Time: 9. Score: 8. Gait With Narrow Base Of Support Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem. The number of steps taken in a straight line are counted for a maximum of 10 steps. 9. Gait With Eyes Closed Walk at your normal speed from here to the next mark [20 ft] with your eyes closed. 10. Ambulating Backwards Walk backwards until I tell you to stop. (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 6 steps. (0) Severe impairment: Ambulates less than 4 steps heel to toe or cannot perform without assistance. (3) Normal: Walks 20 ft, no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 6 in outside 12-in walkway width. Ambulates 20 ft in less than 7 seconds. (2) Mild impairment: Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6 10 in outside 12-in walkway width. Ambulates 20 ft in less than 9 seconds but greater than 7 seconds. (1) Moderate impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 15 in outside 12-in walkway width. Requires more than 9 seconds to ambulate 20 ft. (0) Severe impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12-in walkway width or will not attempt task. (3) Normal: Walks 20 ft, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6 10 in outside 12-in walkway width. (1) Moderate impairment Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 15 in outside 12-in walkway width. (0) Severe impairment Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12-in walkway width or will not attempt task. 10. Score: 11. Steps Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down. (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. FGA modified from Wrisley DM et al. Reliability, Internal Consistency, and Validity of Data Obtained with the Functional Gait Assessment. Physical Therapy 2004;84:906-918. Reprinted with permission: Personal communication: Wrisley, DM (2007) Not to be copied without permission. 21

FUNCTIONAL GAIT ASSESSMENT VS. DYNAMIC GAIT INDEX Subject Code: Date: Rater: Combined Dynamic Gait Index/Functional Gait Assessment Score Task Grading Criteria: Mark the highest category that applies (i.e. the highest category in which the subject meets all criteria) 1. FGA: DGI: Time: 2. FGA: DGI: 3. FGA: DGI: 4. FGA: DGI: 5. FGA: DGI: 1. Gait Level Surface: Walk from here to the wall at your normal speed (time for 20 ) 2. Change In Gait Speed Begin walking at your normal pace [5 ft]. When I tell you go, walk as fast as you can [5 ft]. When I tell you slow, walk as slowly as you can [5 ft]. 3. Gait With Horizontal Head Turns Walk from here to the next mark 20 ft away. When I tell you look right, turn your head right and keep walking straight, when I tell you look left, turn your head left and keep walking straight. Have subject turn head every 3 steps. 4. Gait With Vertical Head Turns Walk from here to the next mark 20 ft away. When I tell you look up, tip your head up and keep walking straight, when I tell you look down, tip your head down and keep walking straight. Have subject turn head every 3 steps. 5. Gait And Pivot Turn 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. FGA (3) Normal: Walks 20 ft in less than 5.5 seconds, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside of the 12-in walkway. (2) Mild impairment: Walks 20 ft in less than 7 seconds but greater than 5.5 seconds, uses assistive device, slower speed, mild gait deviations, or deviates 6 10 in outside of the 12-in walkway width. (1) Moderate impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, or deviates 10 15 in outside of the 12-in walkway. Requires more than 7 seconds to ambulate 20 ft. (0) Severe impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside of the 12-in walkway width or reaches and touches the wall. (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 in outside of the 12-in walkway width. (2) Mild impairment: Is able to change speed but demonstrates mild gait deviations, deviates 6 10 in outside of the 12-in walkway width, or no 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, deviates 10 15 in outside the 12-in 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 outside 12-in walkway width, or loses balance and has to reach for wall or be caught. (3) Normal: Performs head turns smoothly with no change in gait. Deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 10 in outside 12-in walkway width, or uses an assistive device. (1) Moderate impairment: Performs head turns with moderate change in gait velocity, slows down, deviates 10 15 in outside 12-in walkway width but recovers, can continue to walk. (0) Severe impairment: Performs task with severe disruption of gait i.e., staggers 15 in outside 12-in walkway width, loses balance, stops, or reaches for wall. (3) Normal: Performs head turns with no change in gait. Deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment: Performs task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 6 10 in outside 12-in walkway width or uses assistive device. (1) Moderate impairment: Performs task with moderate change in gait velocity, slows down, deviates 10 15 in outside 12-in walkway width but recovers, can continue to walk. (0) Severe impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12-in walkway width, loses balance, stops, reaches for wall). (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. DGI (3) Normal: Walks 20 ft; no assistive devices, good speed, no evidence for imbalance, normal gait pattern. (2) Mild impairment: Walks 20 ft; uses assistive device, slower speed, mild gait deviations. (1) Moderate impairment: Walks 20 ft; slow speed, abnormal gait pattern, evidence for imbalance. (0) Severe impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance (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 no 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 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) Normal: Performs head turns smoothly with no change in gait. (2) Mild impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), or uses an assistive device. (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 in path, loses balance, stops, or reaches for wall. (3) Normal: Performs head turns smoothly with no change in gait. (2) Mild impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), or uses an assistive device. (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 in path, loses balance, stops, or reaches for wall. (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, or requires several small steps to catch balance following turn and stop. (0) Severe impairment: Cannot turn safely, requires assistance to turn and stop. Not to be copied without permission. 22

6. FGA: DGI: 7. DGI: 8. FGA: # steps: 9. FGA: Time: 6. Step Over Obstacle Begin walking at your normal speed. When you come to the shoe box, step over it, not around it, and keep walking. 7. Step Around Obstacles Begin walking at your normal speed. When you come to the first cone walk around the right side, when you come to the second cone walk around it to the left. 8. Gait With Narrow Base Of Support Walk on the floor with arms folded across the chest, feet aligned heel to toe in tandem. The number of steps taken in a straight line are counted for a maximum of 10 steps. 9. Gait With Eyes Closed Walk at your normal speed from here to the next mark [20 ft] with your eyes closed. (3) Normal: Is able to step over 2 stacked shoe boxes taped together (9 in total height) without changing gait speed; no evidence of imbalance. (2) Mild impairment: Is able to step over one shoe box (4.5 in total height) without changing gait speed; no evidence of imbalance. (1) Moderate impairment: Is able to step over one shoe box (4.5 in total height) but must slow down and adjust steps to clear box safely. May require verbal cueing. (0) Severe impairment: Cannot perform without assistance (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 6 steps. (0) Severe impairment: Ambulates less than 4 steps heel to toe or cannot perform without assistance. (3) Normal: Walks 20 ft, no assistive devices, good speed, no evidence of imbalance, normal gait pattern, deviates no more than 6 in outside 12-in walkway width. Ambulates 20 ft in less than 7 seconds. (2) Mild impairment: Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6 10 in outside 12-in walkway width. Ambulates 20 ft in less than 9 seconds but greater than 7 seconds. (1) Moderate impairment: Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 15 in outside 12-in walkway width. Requires more than 9 seconds to ambulate 20 ft. (0) Severe impairment: Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12-in walkway width or will not attempt task. (3) Normal: Is able to step over 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 (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: Cannot perform without assistance. 10. FGA: 10. Ambulating Backwards Walk backwards until I tell you to stop. (3) Normal: Walks 20 ft, no assistive devices, good speed, no evidence for imbalance, normal gait pattern, deviates no more than 6 in outside 12-in walkway width. (2) Mild impairment Walks 20 ft, uses assistive device, slower speed, mild gait deviations, deviates 6 10 in outside 12-in walkway width. (1) Moderate impairment Walks 20 ft, slow speed, abnormal gait pattern, evidence for imbalance, deviates 10 15 in outside 12-in walkway width. (0) Severe impairment Cannot walk 20 ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside 12-in walkway width or will not attempt task. 11. DGI: FGA: 11. Steps Walk up these stairs as you would at home (ie, using the rail if necessary). At the top turn around and walk down. (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. (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. DGI Total Score (Items 1-7 & 11): Scores of 19/24 indicates increased risk of falling FGA Total Score (Items 1-6, 8-11): DGI modified from Shumway-Cook A, Woollacott MH. Motor control: theory and practical applications. Baltimore: Williams & Wilkins; 1995. p 323 4. FGA modified from Wrisley DM et al. Reliability, Internal Consistency, and Validity of Data Obtained with the Functional Gait Assessment. Physical Therapy 2004;84:906-918. Reprinted with permission: Personal communication: Wrisley, DM (2007) Not to be copied without permission. 23

10-METER WALK TEST Source: rehabmeasures.org Purpose: Assesses walking speed in m/sec over a short distance Original Population: Adults Special Populations: Numerous WHO ICF Components: Activity Limitation Time to Complete: < 5 minutes Equipment Needed: 10 meter (32.8 feet) walkway, stopwatch, start and stop lines Scoring: Normative data General Information: individual walks without assistance 10 meters (32.8 feet) and the time is measured for the intermediate 6 meters (19.7 feet) to allow for acceleration and deceleration Therapist Instructions: Start timing when the toes of the leading foot crosses the 2-meter mark Stop timing when the toes of the leading foot crosses the 8-meter mark Assistive devices can be used but should be kept consistent and documented from test to test If physical assistance is required to walk, this should not be performed Can be performed at preferred walking speed or fastest speed possible Documentation should include the speed tested (preferred vs. fast) Collect three trials and calculate the average of the three trials Set-up: (derived from the reference articles): Measure and mark a 10-meter walkway Add a mark at 2-meters Add a mark at 8-meters Patient Instructions: (derived from the reference articles): Normal comfortable speed: I will say ready, set, go. When I say go, walk at your normal comfortable speed until I say stop Maximum speed trials: I will say ready, set, go. When I say go, walk as fast as you safely can until I say stop References: \ Bohannon, R. W. Comfortable and maximum walking speed of adults aged 20-79 years: reference values and determinants." Age Ageing. 1997;26(1): 15-9. Bohannon RW, Andrews AW, Thomas MW. Walking speed: reference values and Not to be copied without permission. 24

correlates for older adults. J Orthop Sports Phys Ther. 1996;24(2):86-90. Wolf SL, Catlin PA, Gage K, Gurucharri K, Robertson R, Stephen K. Establishing the reliability and validity of measurements of walking time using the Emory Functional Ambulation Profile. Phys Ther. 1999;79(12):1122-33. Not to be copied without permission. 25

Decreased Base of Support Decreased Base of Support: These exercises are used to treat abnormal reactive balance and sensory organization when used in conjunction with manipulation of sensory inputs. Stimulus: Position Speed: Stable (unless including head movement, then start slow) Duration: 4 reps x 30 seconds each, total of 2 minutes Frequency: 1-2 times a day Symptoms: Avoid pain and more than 2/10 dizziness Progression: Start with the most difficult position in which patient is unstable, but able to independently self-correct and still feels safe, then progress as tolerated Not to be copied without permission. 26

Postural Strategies: Hip Postural Strategies - Hip: These exercises are used to develop the appropriate use of the hip strategy. Postural strategies are often intact for patients with vestibular dysfunction, but are poorly controlled. Stimulus: Combination of foot position and surface (compliant or narrow) Speed: Fast, controlled movements of the hips Duration: 4 reps x 30 seconds each, total of 2 minutes Frequency: 1-2 times a day Symptoms: Avoid pain and more than 2/10 dizziness Progression: Alter BOS, surface, activity, or visual input Not to be copied without permission. 27

Sensory Organization Sensory Organization: These exercises are used to treat impaired functional use of sensory input for postural control. The sample is an example of treatment of impaired use of vestibular input for balance. This is an example of a vestibular adaptation exercise since the patient is trained to change the use of remaining vestibular input. Stimulus: Position in combination with surface and visual manipulation Speed: Stable (unless including head movement, then start slow) Duration: 4 reps x 30 seconds each, total of 2 minutes Frequency: 1-2 times a day Symptoms: Avoid pain and more than 2/10 dizziness Progression: Start with the most difficult position in which patient is unstable, but able to independently self-correct and still feels safe, then progress as tolerated Not to be copied without permission. 28