Assessment tools & Scales

• Modified Ashworth scale,

• Berg balance scale,
• FIM,
• Barthel index,
• Glasgow coma scale,
• Mini mental state examination,
• Rancho Los Amigos Scale for Head injury,
• APGAR score,
• ASIA scale,
• Reflex Grading.
 Modified Ashworth scale
• Original Ashworth Scale:
• Tests resistance to passive movement about a
joint with varying degrees of velocity
– Scores range from 0-4, with 5 choices
– A score of 1 indicates no resistance and 5 indicates
rigidity
• Modified Ashworth Scale :
– Similar to Ashworth,
– but adds a 1+ scoring category
• to indicate resistance through less than half of the
movement.
– Thus scores range from 0-4, with 6 choices
(Bohannon & Smith, 1987)
Score Ashworth Scale (1964) Modified Ashworth Scale Bohannon & Smith
(1987)
0 0 No increase in tone No increase in muscle tone
1 1 Slight increase in toneSlight increase in muscle tone, manifested by a catch
giving a catch when theand release or
limb was moved in flexionby minimal resistance at the end of the range of
or extension motion when the affected part(s) is moved in flexion
or extension
2 1+ Slight increase in muscle tone, manifested by a
catch, followed by minimal resistance throughout the
reminder (less than half) of the ROM (range of
movement)
3 2 More marked increase inMore marked increase in muscle tone through most
tone but limb easily flexed of the ROM, but affected part(s) easily moved

4 3 Considerable increase inConsiderable increase in muscle tone passive,

tone - passive movementmovement difficult
difficult
5 4 Limb rigid in flexion orAffected part(s) rigid in flexion or extension
extension
• Populations Tested
– Adults and children with lesions of the Central
Nervous System
– Cerebral Palsy
– Multiple Sclerosis
– Pediatric Hypertonia
– Spinal Cord Injury
– Stroke
– Traumatic Brain Injury
 Berg balance scale
• Purpose
– A 14-item objective measure designed to assess static
balance and fall risk in adult populations

• Static and dynamic activities of varying difficulty are

performed 
• Item-level scores range from 0-4,
– determined by ability to perform the assessed activity 
• Item scores are summed 
• Maximum score = 56
Area of Balance Non-Vestibular; Functional
Assessment Mobility 
Body Part Lower Extremity 
Domain Motor 
Assessment Type Performance Measure 
Time to Administer15-20 minutes
Number of Items 14-items 
Equipment Stop watch
Required Chair with arm rests
Measuring tape/ruler
Object to pick up off the floor
Step stool
15 ft walkway
Age Range Adult: 18-64 years; Elderly adult: 65+ 
Populations •Brain injury
Tested •Community dwelling elderly
•Multiple sclerosis
•Orthopedic Surgery
•Osteoarthritis
•Parkinson’s Disease
•Spinal Cord Injury
•Stroke
•Traumatic and acquired brain injury
•Vestibular Dysfunction
Scoring: A five-point scale, ranging from 0-4.
“0” indicates the lowest level of function and
“4” the highest level of function.
Total Score = 56
• Interpretation:
 41-56 = low fall risk
 21-40 = medium fall risk
 0–20 = high fall risk

A change of 8 points is required to reveal a

genuine change in function between 2
assessments.
SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand for support.
• ( ) 4 able to stand without using hands and stabilize independently
• ( ) 3 able to stand independently using hands
• ( ) 2 able to stand using hands after several tries
• ( ) 1 needs minimal aid to stand or stabilize
• ( ) 0 needs moderate or maximal assist to stand
 FIM
Functional Independence Measure
• Provides a uniform system of measurement
for disability based on the International
Classification of Impairment, Disabilities and
Handicaps;

• Measures the level of a patient's disability and

– indicates how much assistance is required
• for the individual to carry out activities of daily living.
• Contains 18 items composed of:
– 13 motor tasks
– 5 cognitive tasks (considered basic activities of daily living)

• Tasks are rated on a 7 point ordinal scale that ranges

from complete dependence to complete
independence

• Scores range from 18 (lowest) to 126 (highest)

indicating level of function

• Scores are generally rated at admission and

discharge
• Dimensions assessed include:
Self care
– Eating
– Grooming
– Bathing
– Upper body dressing
– Lower body dressing
– Toileting
Sphincters
– Bladder management
– Bowel management
Mobility
– Bed to chair transfer
– Toilet transfer
– Shower transfer
– Locomotion (ambulatory or wheelchair level)
– Stairs
Communication
– Cognitive comprehension
– Expression
Psychosocial
– Social interaction
Cognition
– Problem solving
– Memory
Area of Assessment Activities of Daily Living 
Domain ADL; Cognition; Motor 
Assessment Type Observer 
Time to Administer 30-45 minutes
Number of Items 18 
Equipment Required May vary based on level and impairment category
measured.
Training Required Yes, certification in administering the FIM instrument
is required prior to use. Training is available through
UDSMR at: www.udsmr.org.
Type of training Reading an Article/Manual 
required
Actual Cost A license to use the FIM instrument may be obtained at:
http://www.udsmr.org.
 
Fees vary depending upon type of use.
Age Range Adult: 18-64 years; Elderly adult: 65+ 
Populations •Brain Injury 
Tested •Geriatrics 
•Multiple Sclerosis 
•Orthopedic Conditions including Low Back Pain 
•Parkinson's Disease
•Spinal Cord Injury 
•Stroke
 Scoring principles
• Function is assessed on the basis of direct observation.

• Admission scoring is done within 10 days of admission.

• Discharge scoring is done during the last week before

discharge.

• Scoring is done by a multi-disciplinary team member.

• Do not leave any score blank.

• Score 1 if the subject does not perform the activity at all, or if

no information is available.

• If function is variable, use the lower score.

No Helper Required
Score Description
7 Complete Independence
6 Modified Independence (patient requires use of a device, but no physical
assistance)

Helper (Modified Dependence)

Score Description
5 Supervision or Setup
4 Minimal Contact Assistance (patient can perform 75% or more of task)

3 Moderate Assistance (patient can perform 50% to 74% of task)

Helper (Complete Dependence)

Score Description
2 Maximal Assistance (patient can perform 25% to 49% of taks)

1 Total assistance (patient can perform less than 25% of the task or
requires more than one person to assist)
 Barthel index
• Purpose
– Assesses the ability of an individual with a
neuromuscular or musculoskeletal disorder to care
for him/herself
Description •10 ADL/mobility activities including:
• Feeding
• Bathing
• Grooming
• Dressing
• Bowel control
• Bladder control
• Toileting
• Chair transfer
• Ambulation
• Stair climbing
•Items are rated based on the amount of assistance required
to complete each activity
Area of Assessment Activities of Daily Living; Functional Mobility; Gait 
Domain ADL; Motor 
Assessment Type Performance Measure 
Time to Administer 2-5 minutes (self-report); 20 minutes (direct observation)
Number of Items 10 items 
Age Range Adult: 18-64 years; Elderly adult: 65+ 
Populations Tested •Stroke
•Neurological Disorders
•Geriatric
•Brain Injury
• The index should be used as a record of what a patient
does,
– not as a record of what a patient could do.

• The main aim is to establish degree of independence.

• The need for supervision renders the patient not

independent.

• A patient's performance should be established using the

best available evidence.

• Asking the patient, friends/relatives and nurses are the

usual sources, but direct observation and common sense
are also important. However direct testing is not needed.
• Usually the patient's performance over the
preceding 24-48 hours is important, but
occasionally longer periods will be relevant.

• Middle categories imply that the patient

supplies over 50 per cent of the effort.

• Use of aids to be independent is allowed.

FEEDING
• 0 = unable
• 5 = needs help cutting, spreading butter, etc., or requires modified diet
• 10 = independent

BATHING
• 0 = dependent
• 5 = independent (or in shower)

GROOMING
• 0 = needs to help with personal care
• 5 = independent face/hair/teeth/shaving (implements provided)

DRESSING
• 0 = dependent
• 5 = needs help but can do about half unaided
• 10 = independent (including buttons, zips, laces, etc.)

BOWELS
• 0 = incontinent (or needs to be given enemas)
• 5 = occasional accident
• 10 = continent
BLADDER
• 0 = incontinent, or catheterized and unable to manage alone
• 5 = occasional accident
• 10 = continent

TOILET USE
• 0 = dependent
• 5 = needs some help, but can do something alone
• 10 = independent (on and off, dressing, wiping)

TRANSFERS (BED TO CHAIR AND BACK)

• 0 = unable, no sitting balance
• 5 = major help (one or two people, physical), can sit
• 10 = minor help (verbal or physical)
• 15 = independent

MOBILITY (ON LEVEL SURFACES)

• 0 = immobile or < 50 yards
• 5 = wheelchair independent, including corners, > 50 yards
• 10 = walks with help of one person (verbal or physical) > 50 yards
• 15 = independent (but may use any aid; for example, stick) > 50 yards ______

STAIRS
• 0 = unable
• 5 = needs help (verbal, physical, carrying aid)
• 10 = independent
 Glasgow Coma Scale
Eye Opening Response
• Spontaneous--open with blinking at baseline 4 points
• To verbal stimuli, command, speech 3 points
• To pain only (not applied to face) 2 points
• No response 1 point

Verbal Response
• Oriented 5 points
• Confused conversation, but able to answer questions 4 points
• Inappropriate words 3 points
• Incomprehensible speech 2 points
• No response 1 point

Motor Response
• Obeys commands for movement 6 points
• Purposeful movement to painful stimulus 5 points
• Withdraws in response to pain 4 points
• Flexion in response to pain (decorticate posturing) 3 points
• Extension response in response to pain (decerebrate posturing) 2 points
• No response 1 point
• Coma: No eye opening, no ability to follow
commands, no word verbalizations (3-8)

Head Injury Classification:

• Severe Head Injury----GCS score of 8 or less
• Moderate Head Injury----GCS score of 9 to 12
• Mild Head Injury----GCS score of 13 to 15
(Adapted from: Advanced Trauma Life Support: Course
for Physicians, American College of Surgeons, 1993).
 Mini mental state examination
• The Mini Mental State Examination (MMSE) is a tool that can be used
to systematically and thoroughly assess mental status.

• It is an 11-question measure

• Tests five areas of cognitive function:

– orientation, registration, attention and calculation, recall, and language.

• The maximum score is 30.

– A score of 23 or lower is indicative of cognitive impairment.

• The MMSE takes only 5-10 minutes to administer and is therefore

practical to use repeatedly and routinely.
• TARGET POPULATION:
• The MMSE is effective as a screening tool for
cognitive impairment with
– older,
– community dwelling,
– hospitalized and
– institutionalized adults.

• Assessment of an older adult’s cognitive function

is best achieved when it is done routinely,
systematically and thoroughly.
 Rancho Los Amigos Scale for Head injury

• Level I: No Response
• Level II: Generalized Response
• Level III: Localized Response
• Level IV: Confused-agitated
• Level V: Confused-inappropriate
• Level VI: Confused-appropriate
• Level VII: Automatic-appropriate
• Level VIII: Purposeful-appropriate
 Level I
• No response
• Total assistance – the patient appears to be in
a deep sleep or coma and does not respond
when presented with visual, auditory, tactile,
proprioceptive, vestibular or painful stimuli
 Level II
• Generalised response
• Total assistance – the patient moves around,
but movement does not seem to have a
purpose or consistency. The reaction may be
due to deep pain. Patient may open their eyes
but do not seem to be focused on anything in
particular.
 Level III
• Localised response
• Total assistance – the patient begins to move
their eyes and look at specific people and
objects. They turn toward or away from loud
voices or noise. The patient at level 3 may
follow a simple command such as, squeeze mu
hand. Responses are inconsistent and directly
related to the type of stimulus.
 Level IV
• Confused and agitated
• Maximal assistance – the patient is very confused
and agitated about where he or she is and what is
happening in the surroundings. At the slightest
provocation, the patient may become very restless,
aggressive or abusive. The patient may enter into
incoherent conversation in reacton to inner
confusion, fear or disorientation. Motor activities
that could be detrimental are attempted. Safety and
deficit awareness are important issues.
 Level V
• Confused inappropriate non agitated
• Maximal assistance – the patient is confused and
does not make sense in conversations, but may
be able to follow simple directions. Stressful
situations may provoke some upset, but agitation
is no longer a major problem. Patient may
experience some frustation as elements of
memory return. Follows tasks for 2-3 minutes
but is easily distracted by environment.
 Level VI
• Confused appropriate
• Moderated assistance- patient’s speech makes
sense and he or she is able to do simple things
such as dressing, eating and teeth brushing.
Although patients know how to perform a specific
activity, they need help discerning when a start and
stop. Learning new things may also be difficult. The
patient’s memory and attention are increasing and
he or she is able to attend to a task for 30 minutes
 Level VII
• Automatic appropriate
• Minimal assistance for daily living skills- the patient
can perform all self-care activities and are usually
coherent. They have difficulty remembering recent
events and discussions. If physically able, can carry
out routine activities. Rational judgments,
calculations, and solving multi-step problems
present difficulties, yet patients may not seem to
realize this. Needs supervision for safety
 Level VIII
• Purposeful appropriate
• Stand by assistance – the patient is
independent for familiar tasks in a distracting
environment for one hour. He or she
acknowledges impairments but has difficulty
self-monitoring. Emotional issues such as
depression, irritability and low frustration
tolerance may be observed.
 Level IX
• Purposeful, appropriate
• Stand by assistance on request – the patient is
able to shift between task for tow hours.
Requires some assistance to adjust to life
demands. Emotional and behavioural issue
may be of concern.
 Level X
• Purposeful appropriate
• Modified independent – the patient is goal
directed handling multiple task and
independently using assistive strategies. Prone
to breaks in attention and may require
additional time to complete tasks
 ASIA scale
• A = Complete.
– No sensory or motor function is preserved in the
sacral segments S4-5
• B = Sensory Incomplete.
• Sensory but not motor function is preserved
below the neurological level and includes the
sacral segments S4-5 (light touch or pin prick
at S4-5 or deep anal pressure) AND no motor
function is preserved more than three levels
below the motor level on either side of the
body
• C = Motor Incomplete.
• Motor function is preserved below the
neurological level, and more than half of key
muscle functions below the neurological level
of injury have a muscle grade less than 3
(Grades 0-2)
• D = Motor Incomplete.
• Motor function is preserved below the
neurological level, and at least half (half or
more) of key muscle functions below the NLI
have a muscle grade >3.
• E = Normal. Both motor and sensory