ASSESSMENTS
Balance and Falls Screening:
The Timed Up and Go (TUG) Test
The TUG is a simple test used to measure basic mobility and detect balance problems affecting daily mobility in older adults. Materials needed to administer this assessment include a stop watch, a standard height chair with arms, and a marked distance of 3 meters. This assessment uses the time that a person takes to rise from a chair, walk 3 meters, turn around, walk back to the chair, and sit down. Walking aids can be used (note this for subsequent trials). This test was introduced to me in OT 881 and I had the opportunity to administer it in one of our lab sessions. The TUG is particularly useful for determining fall risks and measuring progress of balance, sit to stand, and walking. Norms in performance indicate that neurologically intact individuals who are independent in balance and mobility skills complete the test in 10 seconds or less. Individuals with a score of 13.5 or greater are at risk of falls (90% correct prediction rate). Individuals who took 20 seconds or more required assistance with basic transfers and required assistance when going outside. This test is impactful because it is very quick and easy to administer and will assist in determining whether or not a client may need a mobility aid.
The Berg Balance Scale
The Berg Balance Scale consists of 14 items to assess an individual’s balance. Items are typical tasks that an individual must perform in their daily routines. Testing is completed in a quiet room. Each of the 14 items involves a different set-up (described on test form). Individuals begin with the most simple tasks and progress to those requiring a higher level of balance. Materials needed include: a stopwatch, ruler, chair (standard height), and a step/stool.
To administer this assessment, the tester first demonstrates each task and gives instructions as written. When scoring, record the lowest response category that applies for each item. In most items, the subject is asked to maintain a given position for specific time. Progressively more points are deducted if the time or distance requirements are not met, if the subject's performance warrants supervision, or if the subject touches an external support or receives assistance from the examiner. Clients should understand that they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will adversely influence the performance and the scoring.
Podsaidlo, D., Richardon, S. (1991). The timed “up and go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatric Society, 39, 142-148.
Sumway-Cook, A, Brauer, S., &Woollacott, M. (2000). Predicting the probability for falls in the community-dwelling older adults using the timed up and go test. Physical Therapy, 80. 896-903.
Disabilities of the Arm, Shoulder, and Hand (DASH) Questionnaire
The Disabilities of the Arm, Shoulder, and Hand (DASH) is an assessment tool that I was introduced to in my Physical Determinants of Occupation course in first semester. The DASH outcome measure is a free 30-item, self-report questionnaire.The DASH The items enquire about the degree of difficulty in performing different activities because of arm, shoulder and hand problems (21 items), the severity of each of the symptoms of pain, activity-related pain, tingling, weakness and stiffness (five items) and the impact of the problem on social functioning, work, sleep and self-image (four items). Each item has five response options. The scores are then used to calculate a scale score ranging from 0 (no disability) to 100 (most severe disability)—this is called the DASH score. The DASH questionnaire is used as an indicator of the impact of an impairment on the level and type of disability. It assesses the whole person’s ability to function, even if the person is compensating with the other limb.
This assessment would be appropriate for clients with arthritis, chronic pain, joint pain and fractures, multiple sclerosis, and other musculoskeletal conditions.
Many times in rehabilitation OTs will work with clients that have impairments in the upper extremity, while physical therapists will focus more on the lower extremity. While this is by no means absolute, it does highlight the importance of the upper extremity for OTs. The DASH is very commonly used in OT practice, and has been used as an assessment by many of my classmates for case studies and presentations. It has high test-retest reliability, internal consistency, and convergent validity when compared to other assessments of similar measures. Given its ease of use and psychometric properties, the DASH is a must for my toolbox.
Jamar Hand Dynamometer
The Jamar Hand Dynamometer is a tool that I was introduced to in my Physical Determinants clinical skills labs as well as my placement. Occupational therapists are often involved in helping clients by diagnosing and treating hand impairments caused by injury or other situations. The hand dynamometer is ideal for routine screening of grip strength with its purpose being to measure the maximum isometric strength of an individual’s hand and forearm muscles. It can also be used as an outcome measure for ongoing evaluation of clients with hand dysfunction.
This tool could be used in an initial assessment of the client’s hand function. Also, it could be used as an outcome measure to track improvements during rehabilitation. There are many values to this tool that support why I liked this assessment tool and why I would use it in practice. First of all, it is very quick and easy to administer as a therapist and is easy to understand and use as a client. It can be adjusted for hand size in order to use with all clients and gives accurate and repeatable grip strength readings. The maximum strength indicator remains after each reading until you reset it so you can always ensure you are able to record the reading and that you get the correct reading. The dynamometer also has a dual scale so that the strength can be read in either kilograms or pounds. I also like that there are norms provided for this tool so you can assess whether your client is within the normal range for their age or gender group, and these results can be shown to the client as well. This way clients can see for themselves where they sit in terms of normal range or observe their own improvements. A potential disadvantage to the hand dynamometer is that it must be calibrated regularly for consistent results and depending on the position of the arm and hand, different results can be achieved. Therefore, to achieve the best and accurate results it is best for the same therapist to do each assessment to ensure reliability. Overall, due to its simplicity to use, time efficiency, and relatively low cost to purchase, I would use this in practice as an initial and follow up assessment if looking at clients hand strength in an outpatient setting or a hand clinic.
Range of Motion/Goniometers
Joint Range of Motion (ROM)
ROM= the arc of motion through which a joint passes
Passive range of motion (PROM) = movement performed by external forces
Active range of motion (AROM) = movement performed by the muscles acting on a joint
Why Measure ROM?
To determine the functional limitations arising from loss of movement
To determine the presence or risks of deformities developing
To establish treatment goals
To assist in the selection of treatment modalities, including splinting
To assess the need for assistive devices
To establish a baseline for monitoring status and or progress
To evaluate the need for education re:adaptive methods
Some will argue that physical assessment such as goniometry is assessing only impairments rather than function, and I don’t disagree…I think there is a clear place for both. But as always, we need to understand the functional impact of impairments; someone who goes from having no AROM at their PIP joint to having 30 degrees of flexion has made significant gains in movement, but will still likely be dropping their change in the grocery store.
Assessing ROM is a relatively simple task, requiring that the assessor owns a goniometer (potentially a few of different sizes depending on the ROM being measured) and that the assessor has the knowledge of how to properly assess the ROM of the joint in question. Learning this skill takes practice, and there are many resources available online to help train the assessor.
Understanding normal ROM and being able to correctly measure it are important things that many OTs might come across in practice.
Muscle Testing
Why Measure Muscle Strength?
To determine functional limitations related to weakness
To prevent deformities that may result from imbalances of muscle power
To determine the need for assistive devices and splints
To plan treatment goals and strategies
To evaluate the effectiveness of treatment
To aid in evaluating diagnosis, prognosis
How do you measure muscle strength?
Manual Muscle Testing (MMT)
Grip
Pinch
Principles of MMT:
Client considerations
1.Explain to the client what and why
2.Position the client to allow (a) maximal stability for testing from surface or the action of other muscles and (b) to allow for desired resistance ie against gravity
3. Ensure comfort
Testing considerations
1.Assess ROM prior to assessing strength to know what range is available
2. Allow the client to complete motion before applying resistance
3.Demonstrate the expected movement
MMT PROCEDURE
Determine whether group or individual muscle testing is required.
Position the client appropriately.
Stabilize the limb to be tested.
Observe muscle function against gravity; palpate as necessary.
Apply resistance to muscle if tolerated (make or break).
Score and record.
MUSCLE GRADING SYSTEM
0 = ABSENT;NO MUSCLE CONTRACTION CAN BE SEEN OR FELT
1 = FLICKER;CONTRACTION CAN BE FELT, BUT THERE IS NO MOTION
2- =INCOMPLETE ROM WITH GRAVITYELIMINATED
2 = COMPLETE AVAILABLE ROM WITH GRAVITYELIMINATED (LESSENED)
2+ = INCOMPLETE ROM (<50%) AGAINSTGRAVITY
3- = INCOMPLETE ROM (>50%) AGAINST GRAVITY
3 = COMPLETE AVAILABLE ROM AGAINST GRAVITY
3+ = COMPLETE AVAILABLE ROM AGAINST GRAVITY AND SLIGHT RESISTANCE
4- = INCOMPLETE ROM (>50%) AGAINST GRAVITY AND MODERATE RESISTANCE
4 = COMPLETE AVAILABLE ROM AGAINST GRAVITY AND MODERATE RESISTANCE
5 = COMPLETE AVAILABLE ROM AGAINST GRAVITY AND FULL RESISTANCE
Pain Visual Analogue Scale (VAS)
The Pain Visual Analogue Scale (VAS) is a unidimensional measure of pain intensity, which has been widely used in diverse adult populations, including those with rheumatic diseases. The VAS consists of a line that has the descriptions "no pain at all" and "worst pain possible" at each end. The client will mark an intersecting line to address where on the spectrum of pain they feel they are. The OT can then measure using a ruler the distance of the line from each end to gauge the pain intensity. The VAS is commonly delivered often as a way of tracking progress throughout the rehabilitation process.
The VAS is a great tool that also can be applied across different practice environments. Pain is entirely subjective, and the VAS allows for the client to get to chart their pain based on their experience. Additionally, pain might not always be obvious. It may be that pain is interfering with occupational experience but the client's affect does not show it. By charting pain, the OT can decipher whether pain is limiting the client in any way, and if it is, whether interventions are effectively addressing the pain when the VAS is administered at a future time point. I plan to use the VAS if there is any physical impairments that a client presents, and if there is any indication that a client might be in pain. It is simple to check in and ensure the client is not uncomfortable, and therefore should be done in most contexts. The VAS presents as an easy way of checking in about pain.
Katz Index of Independence in Activities of Daily Living (ADL)
The Katz Index of Independence in Activities of Daily Living, commonly referred to as the Katz ADL, is an instrument that can be used to assess functional status as a measurement of the client’s ability to perform activities of daily living independently. Clinicians typically use the tool to assess function and detect problems in performing activities of daily living and to plan care accordingly. The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored yes/no for independence in each of the six functions. A score of 6 indicates full function, 4 indicates moderate impairment, and 2 or less indicates severe functional impairment.
This instrument is used effectively among older adults in the community and all care settings. The tool is most useful when baseline measurements are taken when the client is well and compared to periodic or subsequent measures.
Barthel Index for Activities of Daily Living (ADL)
The Barthel Index (BI) measures the extent to which somebody can function independently and has mobility in their activities of daily living (ADL) i.e. feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation and stair climbing. The index also indicates the need for assistance in care.
The BI is a widely used measure of functional disability. The index was developed for use in rehabilitation patients with stroke and other neuromuscular or musculoskeletal disorders, but may also be used for oncology patients.