APTA Combined Sections Meeting 2008

Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

FUGL- MEYER ASSESSMENT OF PHYSICAL PERFORMANCE PROCEDURE

Description: This assessment is a measure of upper extremity (UE) and lower extremity (LE) motor and sensory impairment. Equipment: A chair, bedside table, reflex hammer, cotton ball, pencil, small piece of cardboard or paper, small can, tennis ball, stop watch, and blindfold. Administration: Perform the assessment in a quiet area when the patient is maximally alert. The complete assessment usually requires 45 minutes.
GENERAL RULES Perform the assessment in a quiet area when the patient is maximally alert. Volitional movement assessment: This includes flexor synergy, extensor synergy, movement combining synergies, movement out of synergy, wrist, hand, and coordination/speed. For all tests of volitional motion, these guidelines are to be followed: 1. Give clear and concise instructions. Mime as well as verbal instructions permissible. 2. Have subject perform the movement with non-affected extremity first. 3. Repeat each movement 3x on the affected side and score best performance. If full score is attained on trials 1 or 2, do not have to repeat 3 times. Only test Coordination/speed, one time. 4. Do not assist subject, however verbal encouragement is permitted. 5. Test the wrist and hand function independently of the arm. During the wrist tests (items 7a-e), support under the elbow may be provided to decrease demand at the shoulder; however, the subject should be activating the elbow flexors during the elbow at 90 degree tests and activating the elbow extensors during the elbow at 0 degree tests. In contrast, assistance can be provided to the arm at the elbow and just proximal to the wrist in order to position the arm during the hand tests (items 8a-g).

Fugl-Meyer Motor Assessment Lower Extremity

I. Reflex activity (1a and 1b) Subject is supine or sitting. Attempt to elicit the Achilles and patellar reflexes. Assess the unaffected side first. Test affected side. Scoring (Maximum possible score = 4): (0) - No reflex activity can be elicited; (2) - Reflex activity can be elicited. Items to be scored are Achilles and patellar reflexes.

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

IIA. Flexor synergy (2a, 2b, 2c) Subject is supine. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM at each joint to be tested. Start with leg fully extended at hip, knee, and ankle. Instruct the subject to bring your knee to your chest (therapist is observing for evidence of hip, knee, ankle flexion in order to assess the presence of all components of the flexor synergy). Therapist can cue the patient to move any missing component. Test 3x on the affected side and score best movement at each joint. Scoring (Maximum possible score = 6): (0) - Cannot be performed at all (1) Partial motion (2) Full motion Items to be scored are: Hip flexion, knee flexion, ankle dorsiflexion. IIB. Extensor synergy (2d, 2e, 2f, 2g) Subject is sidelying. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM at each joint to be tested. Start in 90 degrees hip flexion, 90 degrees knee flexion and ankle dorsiflexion. Instruct the subject to "push your foot down and kick down and back. (Ankle plantarflexion, knee extension, hip adduction and hip extension.) Slight resistance should be applied in adduction which is gravity-assisted in this position to ensure subject is actively doing it. Test 3x on the affected side and score best movement at each joint. Scoring (Maximum possible score = 8): (0) No motion (1) Partial motion (2) Full motion Items to be scored are: Hip extension, hip adduction, knee extension, ankle plantarflexion. III. Movement combining synergies (in sitting) (3a, 3b) 3a. Knee flexion beyond 90 : Subject is sitting, feet on floor, with knees free of chair. Knee to be tested is slightly extended beyond 90 knee flexion. Calf muscles should not be on stretch. To decrease friction, subjects shoes can be removed, but socks should remain on. Have patient perform movement with unaffected side first. Subject is instructed to "pull your heel back and under the chair." Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2):

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

(0) No active motion (1) From slightly extended position, knee can be flexed but not beyond 90 (2) Knee flexion beyond 90 3b. Ankle Dorsiflexion: Subject is sitting, feet on floor, with knees free of chair. Calf muscles should not be on stretch. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM at the ankle joint. Subject is instructed to "keeping your heel on the floor, lift your foot." Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) No active motion (1) Incomplete active flexion (heel must remain on floor with medial and lateral borders of the forefoot clearing the floor during dorsiflexion) (2) Normal dorsiflexion (full within available ROM, heel remains on the floor) IV. Movement out of synergy (Standing, hip at 0 degrees) (4a, 4b) 4a. Knee Flexion: Subject is standing, hip at 0 degrees (or full available ROM up to 0 degrees). On leg that is being tested, hip is at 0 degrees (or full available ROM up to 0 degrees), but the knee is flexed, and the subjects toes are touching the floor slightly behind. Evaluator can provide assistance to maintain balance and subject can rest hands on a table. Have patient perform movement with unaffected side first. Subject is instructed to "keeping your hip back, kick your bottom with your heel." Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Knee cannot flex without hip flexion (1) Knee flexion begins without hip flexion but does not reach to 90 or hip begins to flex in later phase of motion (2) Knee flexion beyond 90 (Knee flexion beyond 90 degrees with hip maintained in extension) 4b. Ankle Dorsiflexion: Subject is standing, hip at 0 degrees. If subjects calf muscle length is limiting active dorsiflexion in this starting position, then leg that is being tested can be positioned forward, so the hip is at approximately 5 degrees of flexion, and calf muscles are in lengthened position. Knee must stay fully extended. Evaluator can provide assistance to maintain balance and subject can rest hands on a table. Have patient perform movement with unaffected side first. On the affected side, check subjects available dorsiflexion PROM.

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

Subject is instructed to "keeping your knee extended and your heel on the floor, lift your foot." Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) No active motion (1) Partial motion (less than full available range with knee extended; heel must remain on floor with medial and lateral borders of the forefoot clearing the floor during dorsiflexion) (2) Full motion (within available dorsiflexion range with knee extended and heel on the floor)

V. Normal Reflexes (sitting) (5) ONLY DONE IF THE SUBJECT ATTAINS A SCORE OF 4 ON SECTION IV (i.e., if the subject does not score a 2 on each of the previous items, then score this item 0). The examiner shall elicit patellar and Achilles phasic reflexes with a reflex hammer and knee flexors with quick stretch of the affected leg and note if the reflexes are hyperactive or not. Scoring (Maximum possible score = 2): (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 VI. Coordination/speed - Sitting: Heel to opposite knee repetitions in rapid succession. (6a, 6b, 6c) Subject positioned in sitting with eyes open. Have patient perform movement with unaffected side first. Subject is instructed to "Bring your heel from your opposite ankle to your opposite knee, keeping your heel on your shin bone, move as fast as possible." Use a stopwatch to time how long it takes the subject to do 5 full (ankle to knee to ankle) repetitions. Use the full achieved active ROM in the unaffected limb as the comparison for the affected limb. If active ROM of affected limb is significantly less than that of affected limb, patient should be scored 0 for speed. Repeat the same movement with the affected leg. Record the time for both the unaffected and affected sides. Observe for evidence of tremor or dysmetria during the movement. Scoring Tremor (Maximum possible score = 2): (0) - Marked tremor (1) Slight tremor (2) No tremor Scoring Dysmetria (Maximum possible score = 2): (0) - Pronounced or unsystematic dysmetria

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

(1) Slight or systematic dysmetria (2) No dysmetria Scoring Speed (Maximum possible score = 2): (0) - Activity is more than 6 seconds longer than unaffected leg (1) 2-5.9 seconds longer than unaffected leg (2) - less than 2 seconds difference NOTE: This item attempts to discriminate between basal ganglia, thalamic, or cerebellar strokes in which tremor or dysmetria may result as a direct result of lesion to these areas. The majority of stroke cases are in the middle cerebral artery or basilar artery where we expect to observe paralysis that affects movement speed but does not cause tremor or dysmetria. In cases of complete paralysis, observe for any indication of tremor or dysmetria that may be evident in face, voice, arms or legs. If there are no indicators of tremor or dysmetria, then score these items 2 and score speed 0.

Upper Extremity
I. Reflex activity (1a, 1b) Subject is sitting. Attempt to elicit the biceps and triceps reflexes. Test reflexes on unaffected side first. Test affected side. Scoring (Maximum possible score = 4): (0) - No reflex activity can be elicited (2) - Reflex activity can be elicited II. Flexor synergy (2a, 2b, 2c, 2d, 2e, 2f) Subject is sitting. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM at each joint to be tested. Instruct the patient to fully supinate his/her forearm, flex the elbow, and bring the hand to the ear of the affected side. The shoulder should be abducted at least 90 degrees. The starting position should be that of full extensor synergy. If the patient cannot actively achieve the starting position, the limb may be passively placed extended towards opposite knee in shoulder adduction/internal rotation, elbow extension, and forearm pronation. Test 3x on the affected side and score best movement at each joint. Scoring (Maximum possible score = 12): (0) - Cannot be performed at all (1) - Performed partly (2) - Performed faultlessly Items to be scored are: Elevation (scapular), shoulder retraction (scapular), shoulder abduction (at least 90 degrees) and external

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

rotation, elbow flexion, and forearm supination. III. Extensor synergy (3a, 3b, 3c) Subject is sitting. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM at each joint to be tested. Instruct the patient to adduct & internally rotate the shoulder, extend his arm towards the unaffected knee with the forearm pronated. The starting position should be that the limb is passively placed at patients side in elbow flexion and supination. The examiner must ensure that the patient does not rotate and flex the trunk forward, thereby allowing gravity to assist with the movement. The pectoralis major and triceps brachii tendons may be palpated to assess active movement. Test 3x on the affected side and score best movement at each joint. Scoring (Maximum possible score = 6): (0) - Cannot be performed at all (1) - Performed partly (2) - Performed faultlessly Items to be scored are: Shoulder adduction/internal rotation, elbow extension, and forearm pronation. IV. Movement combining synergies (4a, 4b, 4c) The patient is asked to perform three separate movements: 4a. Hand to lumbar spine: Subject is sitting with hand resting on lap. Have patient perform movement with unaffected side first. Subject is instructed to actively position the affected hand on the lumbar spine by asking them to put your hand behind your back. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) No specific action is performed (or patient moves but does not reach ASIS) (1) - Hand must pass anterior superior iliac spine (performed partly) (2) - Performed faultlessly (patient clears ASIS and can extend arm behind back towards sacrum; full elbow extension is not required to score a 2) 4b. Shoulder flexion to 90 elbow at 0 , : Subject is sitting with hand resting on lap. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM for shoulder flexion to 90 and full elbow extension. Subject is instructed to flex the shoulder to 90 keeping the elbow , extended. The elbow must be fully extended throughout the shoulder flexor movement; the forearm can be in pronation or in a mid-position

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

between pronation and supination. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Arm is immediately abducted, or elbow flexes at start of motion (1) - Abduction or elbow flexion occurs in later phase of motion (2) - Performed faultlessly (patient can flex shoulder keeping elbow extended)

4c. Pronation/supination of forearm, elbow at 90 shoulder at 0 , : Subject is sitting with arm at side, elbow flexed, and forearm in supination. Have patient perform movement with unaffected side first. On the affected side, check subjects available PROM for end range of pronation and supination. Subject is instructed to actively flex the elbow to 90 and pronate/supinate the forearm through the full available ROM. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Correct position of shoulder held in adduction at side of body and elbow flexion cannot be attained, and/or pronation or supination cannot be performed at all (1) Active pronation or supination can be performed even within a limited range of motion, and at the same time the shoulder and elbow are correctly positioned. (2) - Complete pronation and supination with correct positions at elbow and shoulder. V. Movement out of synergy (5a, 5b, 5c) The patient is asked to perform three separate movements: 5a. Shoulder abduction to 90 elbow at 0 and forearm pronated: , , Subject is sitting with arm and hand resting at side. Have patient perform movement with unaffected side first. Subject is instructed to abduct the shoulder to 90 in a pure abduction , motion, with the elbow fully extended and the forearm pronated. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Initial elbow flexion occurs, or any deviation from pronated forearm occurs (1) - Motion can be performed partly, or, if during motion, elbow is flexed, or forearm cannot be kept in pronation; (2) - Performed faultlessly (patient can fully abduct shoulder, keeping forearm pronated with no elbow flexion) 5b. Shoulder flexion from 90 -180 elbow at 0 and forearm in mid-position: , , Subject is sitting with elbow extended, hand resting on knee.

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

Have patient perform movement with unaffected side first. Subject is instructed to flex the shoulder above 90 with the elbow fully , extended and the forearm in the midposition between pronation and supination. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Initial flexion of elbow or shoulder abduction occurs (arm is immediately abducted, or elbow flexes at start of motion) (1) Elbow flexion or shoulder abduction occurs during shoulder flexion (in later phases of motion) (2) - Performed faultlessly (patient can flex shoulder above, with forearm in mid-position and no elbow flexion)

5c. Pronation/supination of forearm, elbow at 0 and shoulder at 30 , -90 of flexion: Subject is sitting with elbow extended, hand resting on knee. Have patient perform movement with unaffected side first. Subject is instructed to pronate and supinate the forearm as the shoulder is flexed between 30-90 and the elbow is fully extended. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Supination and pronation cannot be performed at all, or elbow and shoulder positions cannot be attained (1) Elbow and shoulder properly positioned and supination performed in a limited range (2) - Performed faultlessly (complete pronation and supination with correct positions at elbow and shoulder) VI. Normal Reflexes (sitting) (6) ONLY DONE IF THE SUBJECT ATTAINS A SCORE OF 6 ON SECTION V (i.e., if the subject does not score a 2 on each of the 3 previous items, then score this item 0). The examiner shall elicit biceps and triceps phasic reflexes with a reflex hammer and finger flexors with quick stretch to the affected arm and note if the reflexes are hyperactive or not. Scoring (Maximum possible score = 2): (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 VII. Wrist (7a, 7b, 7c, 7d, 7e) Remember: During the wrist tests (items 7a-e), support under the elbow to may be provided to decrease demand at the shoulder; however, the subject should be activating the elbow flexors during the elbow at 90 degree tests and activating the elbow extensors during the elbow at 0 degree tests.

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

The patient is asked to perform five separate movements: 7a. Stability, elbow at 90 and shoulder at 0 , : Subject is sitting with arm and hand resting at side. Have patient perform movement with unaffected side first. Subject is instructed to dorsiflex (extend) the wrist to the full range of 15 (or full available range) with the elbow at 90 flexion and the shoulder at 0 If full range of dorsiflexion is attained, slight resistance is given. . Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) - Patient cannot dorsiflex wrist to required 15 (1) Dorsiflexion is accomplished, but no resistance is taken (2) - Position can be maintained with some (slight) resistance 7b. Flexion/extension, elbow at 90 and shoulder at 0 , : Subject is sitting with arm and hand resting at side. Have patient perform movement with unaffected side first. Subject is instructed to perform repeated smooth alternating movements from 15 degrees of dorsiflexion (wrist extension) to 15 degrees of volar flexion with the fingers somewhat flexed. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) - Volitional movement does not occur (1) Patient cannot actively move through the wrist joint throughout the total range of motion (2) Faultless, smooth movement (repetitive through full available ROM) 7c. Stability, elbow at 0 and shoulder at 30 flexion: , Subject is sitting with elbow extended, hand resting on knee and forearm pronated. Have patient perform movement with unaffected side first. Subject is instructed to dorsiflex (extend) the wrist to the full range of 15 (or full available range) with the elbow fully extended and the shoulder at 30 flexion. If full range of dorsiflexion is attained, slight resistance is given. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) - Patient cannot dorsiflex wrist to required 15 (1) Dorsiflexion is accomplished, but no resistance is taken (2) - Position can be maintained with some (slight) resistance 7d. Flexion/extension, elbow at 0 and shoulder at 30 flexion: , Subject is sitting with elbow extended, hand resting on knee and forearm pronated. Have patient perform movement with unaffected side first. Subject is instructed to perform repeated smooth alternating movements

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

from maximum dorsiflexion to maximum volar flexion with the fingers somewhat flexed to the full range of 15 (or full available range) with the elbow fully extended and the shoulder at 30 flex. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) - Volitional movement does not occur (1) Patient cannot actively move throughout the total range of motion; (2) Faultlessly, smooth movement (repetitive through full ROM)

7e. Circumduction: Subject is sitting with arm at side elbow flexed to 90 and forearm , pronated. Have patient perform movement with unaffected side first. Subject is instructed to circumduct the wrist with smooth alternating movements throughout the full range of circumduction. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Cannot be performed (volitional movement does not occur) (1) Jerky motion or incomplete circumduction (2) Complete motion with smoothness (performs faultlessly, smooth, repetitive movement through full ROM) VIII. Hand (8a, 8b, 8c, 8d, 8e, 8f, 8g) Remember: During the hand tests (items 8a-g), assistance can be provided to the arm at the elbow and just proximal to the wrist in order to position the arm for the grasp tasks. The patient is asked to perform seven separate movements: 8a. Finger mass flexion:

Subject is sitting with arm on bedside table or lap. Have patient perform movement with unaffected side first. Starting from the position of finger extension (this may be attained passively if necessary), instruct the patient to fully flex all fingers. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) No flexion occurs (1) Some flexion, but not full motion (2) Completed active flexion (compared to unaffected hand)

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

8b. Finger mass extension:

Subject is sitting with arm on bedside table or lap. Have patient perform movement with unaffected side first. Starting from the position of finger flexion (this may be attained passively if necessary), instruct the patient to fully extend all fingers. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) No extension occurs (1) Patient can release an active mass flexion grasp (2) Full active extension (compared to unaffected side)

8c. Grasp I: Subject is sitting with arm on bedside table. Have patient perform movement with unaffected side first. Instruct the patient to extend the metacarpophalangeal joints of digits II-V and flex the proximal & distal interphalangeal joints. Test this grip against resistance. You can tell the patient pretend you are holding the handle of a briefcase. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Required position cannot be attained (1) Grasp is weak (2) Grasp can be maintained against relatively great resistance

8d. Grasp II:

Subject is sitting with arm on bedside table. Have patient perform movement with unaffected side first. Instruct the patient to abduct the thumb to grasp a piece of paper (tester may insert the paper). Then ask the patient to perform pure thumb adduction with the scrap of paper interposed between the thumb and first digit (as in figure). Test this grip against resistance by asking the patient to hold as you attempt to pull the paper out with a slight tug. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Function cannot be performed (1) Scrap of paper interposed between the thumb and index finger can be kept in place, but not against a slight tug

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

8e. Grasp III:

(2) Paper is held firmly against a tug

Subject is sitting with arm on bedside table. Have patient perform movement with unaffected side first. Instruct the patient to grasp a pen (preferred pen with cap) by opposing the thumb and index finger pads around the pen. The tester may support the patients arm but may not assist with the hand function required for the retrieval task. The pen may not be stabilized by the therapist or the patients other hand. To minimize excessive movement, however, a pen with a pocket clip that prevents rolling more than 180 may be used. Once the pencil is retrieved, instruct the patient to oppose the thumb pad against the pad of the index finger with a pencil interposed. Test this grip against resistance by asking the patient to hold as you attempt to pull the pencil out with a slight tug. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Function cannot be performed (1) A pencil interposed between the thumb pad and the pad of the index finger can be kept in place, but not against a slight tug (2) Pencil is held firmly against a tug

8f. Grasp IV: Note: This is a SUPERIOR view of the hand grasping a small can. Subject is sitting with arm on bedside table. Have patient perform movement with unaffected side first. Instruct the patient to grasp a small can (placed upright on a table without stabilization) by opening the fingers and opposing the volar surfaces of the thumb and digits. The arm may be supported but the tester may not assist with hand function. Once the can is grasped, test this grip against resistance by asking the patient to hold as you attempt to pull the can out with a slight tug. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Function cannot be performed (1) A can interposed between the thumb and index finger can be kept in place, but not against a slight tug (2) Can is held firmly against a tug NOTE: the hand must open and close on the can; it is not acceptable to have the patient grasp can by coming down from the top of the can.

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

8g. Grasp V:

Subject is sitting with arm on bedside table. Have patient perform movement with unaffected side first. Instruct the patient to perform a spherical grasp by grasping a tennis ball The tester may support the patients arm but may not assist with the hand function required for the retrieval task. The ball may not be stabilized by the therapist or the patients other hand. To minimize excessive movement, the ball can be placed on an object that reduces rolling. An inverted medium-sized bottle cap or other small bowl shaped object that fits under the ball to prevent rolling is acceptable. (A Snapple-type bottles cap works well).Once the tennis ball is grasped, test this grip against resistance by asking the patient to hold as you attempt to pull the ball out with a slight tug. Test 3x on the affected side and score best movement. Scoring (Maximum possible score = 2): (0) Function cannot be performed (1) A tennis ball can be kept in place with a spherical grasp, but not against a slight tug (2) Tennis ball is held firmly against a tug

IX. Coordination/speed - Sitting: Finger to nose (5 repetitions in rapid succession) (9a, 9b, 9c) Subject positioned in sitting with eyes open. Have patient perform movement with unaffected side first. Subject is instructed to "bring your finger from your knee to your nose, as fast as possible." Use a stopwatch to time how long it takes the subject to do 5 repetitions. Repeat the same movement with the affected arm. Record the time for both the unaffected and affected sides. Observe for evidence of tremor or dysmetria during the movement. Scoring Tremor (Maximum possible score = 2): (0) - Marked tremor (1) Slight tremor (2) No tremor Scoring Dysmetria (Maximum possible score = 2): (0)- Pronounced or unsystematic dysmetria (1) Slight or systematic dysmetria (2) No dysmetria Scoring Speed (Maximum possible score = 2): (0) Activity is more than 6 seconds longer than unaffected hand (1) (2-5.9) seconds longer than unaffected side

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

(2) less than 2 seconds difference NOTE: This item attempts to discriminate between basal ganglia, thalamic, or cerebellar strokes in which tremor or dysmetria may result as a direct result of lesion to these areas. The majority of stroke cases are in the middle cerebral artery or basilar artery where we expect to observe paralysis that affects movement speed but does not cause tremor or dysmetria. In cases of complete paralysis, observe for any indication of tremor or dysmetria that may be evident in face, voice, arms or legs. If there are no indicators of tremor or dysmetria, then score these items 2 and score speed 0. If active ROM of affected limb is significantly less than that of affected limb, patient should be scored 0 for speed.

SENSORY ASSESSMENT
a) Light touch: Procedure: The procedure can be tested in the sitting or supine positions. Explain to the patient with their eyes open, I am going to touch you with this cotton ball and I would like you to tell me if you can feel that you are being touched. Lightly touch patient with cotton ball over the unaffected muscle belly. Ask them, Can you feel that you are being touched? This part of the procedure confirms that the patient understands the test. Explain to the patient, I am going to ask you to close your eyes. Then I am going to touch you with the cotton ball on your right/left (unaffected) side followed by your right/left (affected) side. When I ask you, tell me if you can feel the touch. Ask the patient to close their eyes. Lightly touch unaffected area with cotton ball and ask, Do you feel this? Lightly touch affected area with cotton ball and ask Do you feel this? If the patient says they feel the touch on both sides, then repeat the procedure by touching first the unaffected side immediately followed by the affected side and ask the following question. Does this (unaffected area touch) feel the same as this (affected area touch)? The intent is to determine if there are differences in the characteristics of the touch between the two sides. If the tester is not confident that the patient understands this procedure or that the response is inconsistent, the tester may confirm their impression by using the following procedure. With the eyes closed, touch the patient on the affected side and ask them to point to where they were touched with the unaffected side. If the patient does not recognize that they are being touched, the score would be absent. If they recognize the touch but are not accurate on the localization, the score will be impaired. If they recognize the touch and are accurate on the localization, the score will be intact. Upper Extremity (1a, 1b) Upper arm: Follow above procedure by touching patient over the unaffected

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Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

and affected biceps muscle belly. Palmar surface of the hand: Follow above procedure by touching patient over the unaffected and affected palmar surface of the hand. Lower Extremity (1c, 1d) Thigh: Follow above procedure by touching patient over the unaffected and affected thigh of the leg. Sole of foot: Follow above procedure by touching patient over the unaffected and affected sole of the foot. Scoring : (0) Absent - If the patient states that he does not feel the touch on the affected side, the score is absent. (1) Impaired - If the patient states that he feels the touch on the affected side and the touch does not feel the same between affected and unaffected sides or the response is delayed or unsure, the score is impaired. (2) Intact - If the patient states that he feels the touch on the affected side and the touch feels the same between affected and unaffected sides, the score is intact.

b) Proprioception:
Procedure: Proprioception can be tested in the sitting or supine positions for the upper extremity and in supine for the lower extremity. Start with the unaffected limb. Explain to the patient with their eyes open, I am going to move your arm. This is up; this is down (demonstrate test). I want you to close your eyes and tell me if I am moving you up or down. Use the hand positions described below for each joint movement. Move the joint through a small range of motion (approximately 10 degrees for the limb joints and 5 degrees for the digit joints of the hand and foot). Move the limb at least 3 times in random directions. If the subject is wrong on any direction, then add several more repetitions to determine if the accuracy is great than 75% (score 2) or 75% or less (score 1). Start with the most proximal limb joint on the unaffected side. Move to the same joint on the affected side. The intent is to determine if there are differences in the perception of proprioception between the two sides. For example, if the subject identifies the movement stimulus with the same accuracy and responsiveness of the unaffected side then the score would be 2. However, if the subject is accurate but responses are delayed or unsure then the score would be 1. (At this point, you could ask the subject if the movement on this side feels the same as the other side). No perception of joint movement is scored 0.

Adapted from LEAPS Manual of Procedures Property of the LEAPS Clinical Trial not to be reproduced without permission

APTA Combined Sections Meeting 2008

Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

Upper Extremity (2a, 2b, 2c, 2d) Shoulder: Therapist supports patients arm by the medial and lateral epicondyles of the humerus and at the distal ulnar and radius. Have patient look at arm. Move shoulder, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your shoulder in either direction. I want you to tell me up or down. Randomly move arm approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Elbow: Therapist supports patients arm by the medial and lateral epicondyles and the distal ulnar and radius. Have patient look at elbow. Move elbow, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your elbow in either direction. I want you to tell me up or down. Randomly move elbow approximately 10 degrees, 4 times (more if needed) keeping track of correct responses. Wrist: Therapist supports patients wrist at the distal ulna and radius and the heads of the 2nd and 5th metacarpal. Have patient look at wrist. Move wrist, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your wrist in either direction. I want you to tell me up or down. Randomly move wrist approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Thumb: Therapist supports patients thumb proximal to the interphalangeal joint and either side of the most distal aspect of the thumb. Have patient look at thumb. Move thumb at interphalangeal joint, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your thumb in either direction. I want you to tell me up or down. Randomly move thumb approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Lower Extremity (2e, 2f, 2g, 2h) The hip and knee should be tested in the supine position. The ankle and toe can be tested in the supine or sitting position. Hip: Therapist supports patients leg at the femoral condyles and the medial and lateral malleolus. Have patient look at leg. Move hip, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your hip in either direction. I want you to tell me up or down. Randomly move hip approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Knee: Therapist supports patients leg at the femoral condyles and the medial and lateral malleolus. Have patient look at knee. Move knee, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your knee in either direction. I want you to tell me up or down. Randomly move knee approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Ankle: Therapist supports patients leg at the medial and lateral malleoli and the heads of the 1st and 5th metatarsal. Have patient look at ankle. Move ankle,

Adapted from LEAPS Manual of Procedures Property of the LEAPS Clinical Trial not to be reproduced without permission

APTA Combined Sections Meeting 2008

Incorporating valid and reliable outcome measures into care for patients with stroke: Suggestions from the LEAPS Clinical Trial

saying This is up. This is down. I am now going to have you close your eyes and Im going to move your ankle in either direction. I want you to tell me up or down. Randomly move ankle approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Toe: Therapist supports patients toe at the interphalangeal joint and either side of the most distal aspect of the great toe. Have patient look at great toe. Move interphalangeal joint, saying This is up. This is down. I am now going to have you close your eyes and Im going to move your big toe in either direction. I want you to tell me up or down. Randomly move great toe approximately 10 degrees, 4 times (more if needed), keeping track of correct responses. Scoring: (0) Absent (no sensation) (1) Impaired (three quarters of answers are correct, but considerable difference in sensation compared with unaffected side) (2) Intact (all answers are correct, little or no difference). References 1. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand J Rehabil Med 1975; 7:13-31. 2. Fugl-Meyer AR. Post-stroke hemiplegia assessment of physical properties. Scand J Rehabil Med 1980; 7(Suppl): 85-93.

Adapted from LEAPS Manual of Procedures Property of the LEAPS Clinical Trial not to be reproduced without permission