FRT, TUG, FIM, glassgow coma

1. FUNCTIONAL
EVALUATION
SCALES
DR. HIMANSHU PATEL (PT) 1

2. OBJECTIVES
 Functional Reach Test (FRT)
 Berg Balance Scale
 Modified Ashworth Scale
 Glasgow Coma Scale
 Timed Up and Go Test (TUG)
 Functional Independence Measure (FIM)
DR. HIMANSHU PATEL (PT) 2

3. FUNCTIONAL REACH TEST (FRT)
 Functional Reach Test (FRT) is a clinical outcome measure and assessment tool for ascertaining
dynamic balance in one simple task.
 FRT was developed by Pamela Duncan and co-workers in 1990; defining functional reach as "the maximal
distance one can reach forward beyond arm's length, while maintaining a fixed base of support in the standing
position".
 FRT is proposed to measure the limit of stability. This test measures the distance between the length of an
outstretched arm in a maximal forward reach from a standing position , while maintaining a fixed base of
support.
 A number of factors exert a major influence on this evaluation. Earlier research revealed that the movement
strategy and a reduced spinal flexibility, both affect the reach distance .
DR. HIMANSHU PATEL (PT) 3

4. METHOD OF USE
 Using a yardstick or tape measure mounted on the wall, parallel to the floor, at the height of the acromion of
the subject's dominant arm, the subject was asked to stand with the feet bare and a comfortable distance
apart, make a fist, and forward flex the dominant arm to approximately 90 degrees; that is Position
themselves close to, but not touching the wall with their arm outstretched and fist.
 Taking note of the starting position by determining what number the metacarpophalangeal (MCP) joints line up
with on the yardstick.
 Take note of the end position of the MCP joints against the ruler, and the distance between the start and end
point was then measured using the head of the metacarpal of the third finger as the reference point.
 The distance between the position of the third metacarpal and the yardstick mounted on the wall
at shoulder height in each position is the Functional Reach.
DR. HIMANSHU PATEL (PT) 4

5. INSTRUCTIONS TO THE PATIENT:
 Please reach as far forward as you can without losing your balance. Keep your feet on the floor. You are not
allowed to touch the wall or the ruler as you reach. You will have two practice trials and then I will record the
distance that you reach forward.
DR. HIMANSHU PATEL (PT) 5

6. CRITERIA TO STOP THE TEST:
 The patient’s feet lifted up from the floor or they fell forward. Most patients fall forward with this test. The
therapist should guard from the front as that is the direction that you reach forward.
 Reduced ability to reach has shown increases in future falls with odds ratios of 8.2 if unable to reach at all and
4 if able to reach < 15.2cm.
DR. HIMANSHU PATEL (PT) 6

7. BERG BALANCE SCALE
 The Berg balance scale is used to objectively determine a patient's ability (or inability) to
safely balance during a series of predetermined tasks. It is a 14 item list with each item consisting of a five-
point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of
function and takes approximately 20 minutes to complete. It does not include the assessment of gait.
 Elderly population with impairment of balance, patients with acute stroke (Berg et al 1995, Usuda et al 1998).
DR. HIMANSHU PATEL (PT) 7

8. METHOD OF USE
 Equipment required
• A ruler
• 2 standard chairs (one with arm rests, one without)
• A footstool or step
• 15 ft walkway
• Stopwatch or wristwatch
DR. HIMANSHU PATEL (PT) 8

9.  The scale
 Name: __________________________________ Date: ___________________
 Location: ________________________________ Rater: ___________________
 ITEM DESCRIPTION SCORE (0-4)
 Sitting to standing ________
Standing unsupported ________
Sitting unsupported ________
Standing to sitting ________
Transfers ________
Standing with eyes closed ________
Standing with feet together ________
Reaching forward with outstretched arm ________
Retrieving object from floor ________
Turning to look behind ________
Turning 360 degrees ________
Placing alternate foot on stool ________
Standing with one foot in front ________
Standing on one foot ________
 Total ________
DR. HIMANSHU PATEL (PT) 9

10. GENERAL INSTRUCTIONS FOR COMPLETING THE SCALE
 Please document each task and/or give instructions as written. When scoring, please record the lowest response
category that applies for each item.
 In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are
deducted if:
• the time or distance requirements are not met
• the subject’s performance warrants supervision
• the subject touches an external support or receives assistance from the examiner
 The subject 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.
 Equipment required for testing is a stopwatch or watch with a second hand, and a ruler or other indicator of 2, 5, and
10 inches. Chairs used during testing should be a reasonable height. Either a step or a stool of average step height
may be used for item # 12.
DR. HIMANSHU PATEL (PT) 10

11.  Cut-off scores for the elderly were reported by Berg et al 1992 as follows :
• A score of 56 indicates functional balance.
• A score of < 45 indicates individuals may be at greater risk of falling.
DR. HIMANSHU PATEL (PT) 11

12. MODIFIED ASHWORTH SCALE
 Modified Ashworth Scale' scores exhibited better reliability when measuring upper extremities than lower[11].
The scale is as below:
 0 No increase in muscle tone
 1 Slight increase in muscle tone, manifested by a catch and release or by minimal resistance at the end of the
range of motion when the affected part(s) is moved in flexion or extension
 1+ Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the
remainder (less than half) of the ROM
 2 More marked increase in muscle tone through most of the ROM, but affected part(s) easily moved
 3 Considerable increase in muscle tone, passive movement difficult
 4 Affected part(s) rigid in flexion or extension
DR. HIMANSHU PATEL (PT) 12

13. ASHWORTH SCALE
The Ashworth scale is the most widely used assessment tool to measure resistance to limb movement in a clinic
setting, although it is unable to distinguish between the neural and non-neural components of increased tone.[12]
The scale is as follows:
 0 No increase in muscle tone
 1 Slight increase in tone giving a catch when the limb is moved
 2 More marked increase in tone but limb easily moved
 3 Considerable increase in tone - passive movement difficult
 4 Limb is rigid in flexion or extensionThe Ashworth scale is the most widely used assessment tool to measure
resistance to limb movement in a clinic setting, although it is unable to distinguish between the neural and
non-neural components of increased tone.[12]
DR. HIMANSHU PATEL (PT) 13

14. GLASGOW COMA SCALE
 The Glasgow Coma Scale (GCS) was first created by Graham Teasdale and Bryan Jennett in 1974. It is a
clinical scale to assess a patient’s “depth and duration of impaired consciousness and coma” following an
acute brain injury. Healthcare practitioners can monitor the motor responsiveness, verbal performance, and
eye-opening of the patient in the form of a simple chart. The GCS is the most commonly used tool
internationally for this assessment and has been translated into 30 languages. It should not, however, be
confused with the Glasgow Outcome Scale (GOS), which evaluates persistent disability after brain damage.
DR. HIMANSHU PATEL (PT) 14

15. METHOD OF USE
 The GCS Assessment Aid has four steps to the assessment process: Check, observe, stimulate, rate.
 The assessor should evaluate each of the subscales as listed in the Assessment Aid. Each subscale has
several components. Based on the level of consciousness, a score is assigned. A higher score indicates a
greater level of consciousness.
DR. HIMANSHU PATEL (PT) 15

16.  The GCS uses three sites for stimulation. This includes fingertip pressure, trapezius pinch and supraorbital
notch. When stimulating these areas, health care practitioners should look for one of two responses: an
abnormal flexion response or a normal flexion response.
DR. HIMANSHU PATEL (PT) 16

17.  The National Institute for Health Care and Excellence (NICE) published Clinical Guidelines on Head Injuries
for Assessment and Early Management. NICE recommends the following Clinical Guidelines:
• Until a patient has achieved a GCS score of 15 on the GCS, patients should be observed every half hour.
• Once the GCS Score has reached 15, the patient should be re-assessed using the GCS every half hour for
two consecutive hours.
• If the patient's GCS score remains above 15, the patient should then be observed once every hour for four
hours and then every 2 hours after that.
• Note: If at any time a patient's GCS score drops below 15, the healthcare practitioners should revert to
observing the patient every half hour.
DR. HIMANSHU PATEL (PT) 17

18. TIMED UP AND GO TEST (TUG)
 To determine fall risk and measure the progress of balance, sit to stand and walking.
 This test was initially designed for elderly persons, but is used for people with:
• Parkinson's - This tool is validated for a population with Parkinson’s Disease.
• Multiple Sclerosis,
• Hip fracture,
• Alzheimers,
• Following a CVA
• Following routine orthopaedic surgery i.e. TKR or THR
• Huntington Disease
• and others conditions
DR. HIMANSHU PATEL (PT) 18

19. METHOD OF USE
Materials Needed:
 One chair with armrest
 Stopwatch
 Tape (to mark 3 meters)
DR. HIMANSHU PATEL (PT) 19

20. 1. The patient starts in a seated position
2. The patient stands up upon therapist’s command: walks 3 meters, turns around, walks back to the chair and
sits down.
3. The time stops when the patient is seated.
4. The subject is allowed to use an assistive device. Be sure to document the assistive device used.
NOTE: A practice trial should be completed before the timed trial
 Cut-off times to classify subjects as high risk for falling vary based on the study and participants.
 If a patient took 14 seconds or longer he or she was classified as high-risk for falling.
DR. HIMANSHU PATEL (PT) 20

21. FUNCTIONAL INDEPENDENCE MEASURE (FIM)
 The Functional Independence Measure (FIM) is an 18-item measurement tool that explores an individual's
physical, psychological and social function.The tool is used to assess a patient's level of disability as well as
change in patient status in response to rehabilitation or medical intervention.
 Patients with functional mobility impairments.
DR. HIMANSHU PATEL (PT) 21

22. METHOD OF USE
 The FIM is used by healthcare practitioners to assess and grade the functional status of a person based on the level
of assistance he or she requires. Grading categories range from "total assistance with helper" to "complete
independence with no helper". Irrespective of the use of any assistive device, the person is considered complete
independence.
 Tasks that are evaluated using the FIM include bowel and bladder control, transfers, locomotion, communication,
social cognition as well as the following six self-care activities:
• Feeding
• Grooming
• Bathing
• Upper Body Dressing
• Lower Body Dressing
• Toileting
The FIM measures what an individual can perform and not what that person could do under certain circumstances.
DR. HIMANSHU PATEL (PT) 22

23. DR. HIMANSHU PATEL (PT) 23

24.  FIM Levels
 No Helper
7. Complete Independence
(Timely, Safety)
6. Modified Independence
(Device)
 Helper - Modified Dependence
5. Supervision
(Subject = 100%)
4. Minimal Assistance
(Subject = 75% or more)
3. Moderate Assistance
(Subject = 50% or more)
DR. HIMANSHU PATEL (PT) 24

25.  Helper - Complete Dependence
 2. Maximal Assistance
(Subject = 25% or more)
 1. Total Assistance or not Testable
(Subject less than 25%)
• Leave no blanks. Enter 1 if not testable due to risk.
DR. HIMANSHU PATEL (PT) 25

26. DR. HIMANSHU PATEL (PT) 26