1. North Star Ambulatory Assessment (NSAA) – Version 2.0 Test Description The NSAA is a 17-item scale that grades performance of various functional skills on a scale from 0 (unable), 1 (completes independently but with modifications), and 2 (completed without compensation). NOTE: The order has been modified to enable more efficient conduct of the assessment. a. Climb and Descend stairs: climb box step is performed step up right, step down right, step up left, step down left. b. Lifts head is performed before ‘gets to sitting’ and ‘rise from floor’ to avoid fatigue. Test Guidelines • Performance of upright activities must not be completed if a lower limb injury exists. However, the subject may perform the head lift and gets-to-sitting items if he is able. Provide ‘comments’ on the source worksheet. • Complete the NSAA in the order provided (Please note this has been modified from previous trials for a smoother administration). • Do NOT use a mat. • Please note the time in seconds rounded to the nearest tenth of a second for all timed tests (eg, rise from floor and 10 m ‘run’). • Generally, activities are graded in the following manner: Score of 2 = ‘Normal’ – no obvious modification of activity Score of 1 = Modified method but achieves goal with no physical assistance Score of 0 = Unable to achieve goal independently • If you think the subject is capable of a better performance, due to non-compliance or improved understanding of task, it is acceptable to ask the subject to repeat the item and re-score if appropriate. • If unsure if the performance on a particular item meets the higher criteria, give the subject the lower score.
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1. NorthStarAmbulatoryAssessment(NSAA)–Version2.0
TestDescription
TheNSAAisa17-itemscalethatgradesperformanceofvariousfunctionalskillsonascalefrom0(unable),1(completesindependentlybutwithmodifications),and2(completedwithoutcompensation).
NOTE:Theorderhasbeenmodifiedtoenablemoreefficientconductoftheassessment.
a. ClimbandDescendstairs:climbboxstepisperformedstepupright,stepdownright,stepupleft,stepdownleft.
b. Liftsheadisperformedbefore‘getstositting’and‘risefromfloor’toavoidfatigue.
TestGuidelines
• Performanceofuprightactivitiesmustnotbecompletedifalowerlimbinjuryexists.However,thesubjectmayperformtheheadliftandgets-to-sittingitemsifheisable.Provide‘comments’onthesourceworksheet.
• CompletetheNSAAintheorderprovided(Pleasenotethishasbeenmodifiedfromprevioustrialsforasmootheradministration).
• DoNOTuseamat.
• Pleasenotethetimeinsecondsroundedtothenearesttenthofasecondforalltimedtests(eg,risefromfloorand10m‘run’).
• Generally,activitiesaregradedinthefollowingmanner:
Scoreof2=‘Normal’–noobviousmodificationofactivity
Scoreof1=Modifiedmethodbutachievesgoalwithnophysicalassistance
Scoreof0=Unabletoachievegoalindependently
• Ifyouthinkthesubjectiscapableofabetterperformance,duetonon-complianceorimprovedunderstandingoftask,itisacceptabletoaskthesubjecttorepeattheitemandre-scoreifappropriate.
• Ifunsureiftheperformanceonaparticularitemmeetsthehighercriteria,givethesubjectthelowerscore.
Set-Up
• Markoffa10-metrecourseinalong,quiethallwayorroom.Providea‘finish’lineatapproximately11metrestoensurethesubjectmoves‘through’the10-metreline,ratherthanslowingdownpriortofinishing.
• Ensureaclearfloorspace,measuringapproximately10feetx12feet,isavailableforremainingassessments(i.e.,risefromfloor).
ConductingtheTest
Testitem1:Standing
Startingposition
Feetmustbenofurtherthan10cmapartandheelsonthegroundifpossible.Armsbysides.
Instruction Canyoustanduptallformeforaslongasyoucanandasstillasyoucanforthreesecondswithyourheelsflatontheground?
Scoringdetail Whencountingto3–Use“And1,and2,and3”sothatthreesecondsisachievedonthewordof3.Score2-Minimumcountof3seconds.
Activity 2 1 0
Standing Standsupright,still,symmetrical,withoutcompensation(heelsflatandhipsinneutralrotation)forminimumcountof3seconds
Standsstillbutwithcompensation(e.g.ontoesorwithlegsabductedorwithbottomstuckout/hipflexion,etc)forminimumcountof3seconds
Cannotstandstillorcannotstandindependently,needssupport(evenminimal)
Photographs/
Notes
Score2-Symmetricalheelsflat
Score1–Asymmetricorcompensation
Testitem2:WalkStartingposition Standing.Observewalkforatleast10stepsinbothsagittalandcoronal
planes.
Instruction CanyouwalkfromAtoB(statetoandwherefrom–approximately8-10feet)forme?
Scoringdetail
Score1-Ifthepatientgenerallytoewalksbutoccasionallygetsheelsflat,orcanonrequest,theymustscore1
Activity 2 1 0
Walk Walksconsistentlywithheel-toeorflat-footedgaitpattern
Persistentorhabitualtoewalker,unabletoheel-toeconsistently
Lossofindependentambulation–mayuseknee-ankle-footorthosis(KAFO)orwalkshortdistanceswithassistance
Score1–habitualtoewalker
Testitem3:StandupfromchairStartingposition
Sittinginchair,benchorplinthwitharmsfoldedacrosschestwithhishandupbyhisshouldersandwithfeetabletoreachfloororsupportedonsecurebox.Adjusttheseatheightsothatthehipsandkneesareata90ºanglefromthefloor.Feetnomorethanshoulderwidthapart.
Instruction Canyoustandupfromthechairkeepingyourarmsfolded?
Scoringdetail
Asize-appropriatechair(withoutarm-rests)orheightadjustableplinthmustbeused.Alternatively,aboxstepunderthefeettoachievethecorrectstartingpositionmaybeused.
Score2-Armsmustbekeptcrossedwiththehandsupbytheshouldersthroughouttheactivitytoscore2
Activity 2 1 0
Standupfromchair
Abletostandupkeepingarmsfolded
Withhelpfromthighs/pushonchair/proneturnoraltersstartingpositionbywideningbase
Unable
Photographs/notes
Score2–keepsarmsfoldedandstandsupwithoutwideningbase
Score1-Needstwohandstopushand/or
Widenedbase
Score0-Unabletorisefromstartingposition
Score0-Needstochangebodyposition;and/orhipsextendedtoslideforwardfromchair(not90/90)
Testitem4&5:StandononelegRight&LeftStartingposition
Standing.
Instruction Showmehowlongyoucanstandonyourright/leftlegwithyourarmsatyourside.
Count“And1,and2,and3”
Scoringdetail
Score2–Minimumcountof3secondsrequired
Activity 2 1 0
Standononeleg
Abletostandinarelaxedmanner(nofixation)foracountof3seconds
Standsbuteithermomentarilyorwithtrunkside-flexionorneedsfixatione.g.bythighsadducted
Unable
Photographs/notes
Score2–Relaxedandnofixation
Score1-Hookslegbehindstandingleg
Score1-Posturalcompensation/leaningtoside
Score0-Ifneedstoholdontoatableorpersonforsupport
Testitem6&8:ClimbboxstepRight&LeftStartingposition
Standinginfrontofboxstep,toesnomorethan20cm(~8in)awayfromboxstep.
Instruction Canyoustepontothetopoftheboxusingyourright/leftleg.
Scoringdetail Boxstepmustbe15cmhigh.Score1:Iftheyneedahandforbalanceonly–evaluatorshandshouldbekeptrelativelyhigh.Score1:Iftheyuseahandontheirthigh.Ifindoubtwhetherthisisusedforbalanceorsupportofferthemyourhandandrepeattest.Score0:Iftheyputweightthroughtheevaluatorshand(withoneortwohands)orunabletoclimbstep
Theyshouldnothavetheirhandsintheirpocket.
Activity 2 1 0
Climbsboxstep
Facesstep–nosupportneeded
Goesupsideways/rotatestrunk/circumductshiporneedshandforbalance
Unabletoperformindependently
Photographs/notes
Score1–Needshandforbalanceonly
Score2–Facesstep
Score1-Rotatestrunkoruseshandonthigh
Testitem7&9:DescendboxstepRight&LeftStartingposition
Standingonboxstep
Instruction Canyoustepdownfromtheboxusingyourright(orleft)leg?
Scoringdetail Boxstepmustbe15cmhigh.
Score1:Iftheyneedahandforbalanceonly–evaluatorshandshouldbekeptrelativelyhigh.Iftheyuseahandontheirthigh.Ifindoubtwhetherthisisusedforbalanceorsupportofferthemyourhandandrepeattest.Usesmethodthatavoidsflexingsupportingknee(oneontheboxstep)Score0:Iftheyputweightthroughtheevaluatorshand(withoneortwohands)orunabletodescendstep
Theyshouldnothavetheirhandsintheirpocket.
Activity 2 1 0
Descendsboxstep
Facesforward,stepsdowncontrollingweight-bearingleg.Nosupportneeded
Sideways,skipsdownorneedshandforbalance
Unablewithoutmorethanminimalsupport,orrequireshandsforsupport
Photographs/notes
Score2–facesforward
Score1–Needshandforbalance.Noweighttakenthroughhand.
Score1–Turningtosidetodescend
Testitem10:LiftsheadfromsupineStartingposition
Supineonaplinthorfloor,armsfoldedacrosschestandthehandsupbytheshoulders.Nopillowmustbeused.
Instruction Canyouliftyourheadandtouchyourchintoyourchestkeepingyourarmsfolded?
Scoringdetail
Askpatienttokeeparmscrossedoverchestduringtheactivitytoavoidself-assistance.
Activity 2 1 0
Liftsheadfromsupine
Insupine,fullneckflexion,headmustbeliftedinmid-line.Chinmovestowardschest
Headisliftedthroughsideflexion,partialneckflexion,orwithprotraction.
Unable.Noclearanceofheadfromsurface
Photographs/Notes
Score2–Chinonchest
Score1-Didn’tachievefullrangeofflexion
Testitem11:GetstosittingStartingposition
Startingpositionsupineonthefloor,orlargeplinthwitharmsbyside.Nopillowmustbeusedunderhead.
Instruction Canyougetfromlyingintositting?
Scoringdetail Aimistomoveintolongsittingratherthansittingovertheedgeofaplinth.Useofonehandorarmisacceptabletoachieveascoreof2.
Score1ifpatientturnsintoproneortowardsthefloortoworktheirwayintosittingorifusestwoarms.Alsoscoreaoneifthechilduseslegmomentum/rockingtogettositting.
Activity 2 1 0
Getstositting Startsinsupine–mayuseonehand/armtopushup
Usestwoarms/pullsonlegsorturnstowardsfloororusesmomentum/rocking
Unable
Photographs
/notes
Score2-Onlyneedsonearmtositup
Score1-Pullswithbothhandsonlegs
Testitem12:RisefromfloorStartingposition
Startingpositionsupinewitharmsbysides,legsstraight.Nopillowtobeused.
Instruction • Givethefollowingverbalinstructionstothepatient:• “WhenIsayGOcanyougetupasfastasyoucanandstandupstraight
withyourarmsbyyoursidelikeasoldierusingaslittlesupportaspossible”.Givethecommand“Ready,Set,GO!”andstartthestopwatchwhensaying“GO”.
• Stopthetimerwhenthepatientassumesanuprightpositionwithhisarmsbyhisside.
Scoringdetail/Diagram
Activitymustbeattemptedwithoutuseoffurnitureinthefirstinstance.Score1:Ifthepatientgetstostandingindependentlyofanyfurniturebutdemonstratesanypartofthemaneuverdescribedbelow.ComponentsofGower’smanoeuvre:Turnstowardsthefloor(intoafour-pointkneelingpositionorrollstoprone).Placeshandsonthefloortoassistrisingfromfloorandwalkshandsbackintowardshim.Usesoneorbotharmstopushuponlegstoachieveuprightstanding.Largebaseofsupportbyabductinghipsandextendingknees.
Activity 2 1 0
Risefromfloor NoevidenceofGower’smaneuver.
Exhibitsatleastoneofthecomponentsdescribedabove–inparticularrollstowardsfloor,and/orusehand(s)onlegs
(a)NEEDStouseexternalsupportobjecte.g.chair,wall–stillrecordtimeOR(b)Unable(timemustbeenteredasN/Aifthepatientscores0)
Photographs/Note
Score2-Doesn’troll.Only1handonfloortomoveintositting
Score1–Rollstoprone
Score1-Useshandonthigh
Score0–Useschair
Testitem13:StandsonheelsStartingposition Standingonthefloor.Noshoestobeworn.
Instruction Canyoustandonyourheels?Count‘And1,and2,and3.”
Scoringdetail Score2:Mustclearbothfeetatthesametimeusingcleardorsiflexion
Score1:Ifbothforefeetarelifted-allmetatarsalheadsoffloorevenifinversionisevidentorcleardorsiflexionofonefoot.
Score0:Ifusesinversionwithlateralborder(fifthmetatarsal)offootstillonthegroundorifjustliftstoes.
Activity 2 1 0
Standonheels Bothfeetatthesametime,clearlystandingonheelsonly(acceptabletomoveafewstepstokeepbalance)forcountof3
Raisesforefootonbothfeet–allmetatarsalheadsoffground–orclearlydorsiflexesonefootonly
Unable
Photograph/Notes
Score2–Bothfeetraised
Score1-Bothfeetraisedbutonlyforefeet
Score0–Unabletoraiseevenforefeet
Testitem14:JumpStartingposition
Standingonthefloor,feetcomfortablyclosetogether
Instruction Howhighcanyoujump?
Scoringdetail Wantheight,notforwardmovement.Smallamountofforwardmovementacceptable
Activity 2 1 0
Jump Bothfeetatthesametime,clearthegroundsimultaneously
Onefootaftertheother(skip)ordoesnotfullyclearbothfeetatthesametime
Unable
Photographs/Notes
Score2–Clearsfloor
Score1-Onestepaftertheother(skip)
Score0-Feetdonotleavefloor
Testitem15&16:HopRight&LeftlegStartingposition
Startingpositionstandingonflooronright/leftleg.
Instruction Canyouhoponyourright/leftleg?
Scoringdetail Score2:Needsobviousfloorclearance.Mustlandononefoot.Ifleavesfloorbutlandswithtwofeetthisisnotahop.
Activity 2 1 0
Hop Clearsforefootandheelofffloor
AbletobendkneeANDraiseheel,nofloorclearance
Unableoronlyraisesheel
Photographs/Notes
Score2–Clearsfootofffloor
Score1-Bendskneebutfootdoesnotleavefloor
Testitem17:Run(10metres)Startingposition
Standing
Instruction Givethefollowingverbalinstructionstothepatient:“WhenIsayGO,yougoasfastasyousafelycanallthewaytome.Ifyoucanrun,thenrun.Ifyoucan’tthenwalktomeasfastasyoucan.”(Encouragechildtorunpastthe10-metremark)bystandingatleastonemetrebehindtheline.Givethecommand“Ready,Set–GO”.Continuouslyencouragethepatientuntilhecrossesthefinishline.
Startthetimerwhenyousay“GO”.Stopthetimerwhenthesecondfootclearsthefinishline.
Scoring
detail
Astraight12-mwalkwaymustbeclearlymarkedat10-minaquietdepartmentorcorridor.Astopwatchmustbeusedtotimethewalk.Theymustself-selectspeedafterbeingaskedtogo‘asfastastheycan’.Score1-‘Duchennejog’-notatruerun(Thereisadoublesupportphase),butitisfasterthanawalk.Characterisedbyexcessiveuseofarms,trunkrotation,substantial’waddle’.Noreal‘push-off’.
Activity 2 1 0
Run Bothfeetofftheground(nodoublestancephaseduringrunning)
‘Duchennejog’orfastwalk
Walk(Noacceleration)
Photographs/Notes
Score2-Bothfeetofftheground
Definite‘run’
Score1-Picksupspeedbutwaddlesandhasonefootincontactwithflooratalltimes
NSAABriefTestDetailActivity 2 1 0 Score
1.Stand Standsupright,stillandsymmetrically,withoutcompensation(withheelsflatandlegsinneutral)forminimumcountof3seconds
Standsstillbutwithsomedegreeofcompensation(e.g.ontoesorwithlegsabductedorwithbottomstuckout)forminimumcountof3seconds
Cannotstandstillorindependently,needssupport(evenminimal)
2.Walk Walkswithheel-toeorflat-footedgaitpattern
Persistentorhabitualtoewalker,unabletoheel-toeconsistently
Lossofindependentambulation–mayuseKAFOsorwalkshortdistanceswithassistance
3.Standupfromchair
Keepingarmsfolded.Startingposition90ºhipsandknees,feetonfloor/supportedonaboxstep.
Withhelpfromthighs/pushonchair/proneturnoraltersstartingpositionbywideningbase.
Unable
4.Standononeleg–right
Abletostanduprightinarelaxedmanner(nofixation)forcountof3seconds
Standsbuteithermomentarilyorwithtrunkside-flexionorneedsfixatione.g.bythighsadducted
Unable
5.Standononeleg-left
Abletostanduprightinarelaxedmanner(nofixation)forcountof3seconds
Standsbuteithermomentarilyorwithtrunkside-flexionorneedsfixatione.g.bythighsadducted
Unable
6.Climbboxstep-right
Facesstep–nosupportneeded
Goesupsideways/rotatestrunk/circumductshiporneedshandforbalance
Unable
7.Descendboxstep–right
Facesforward,stepsdowncontrollingweight-bearingleg.Nosupportneeded
Sideways,skipsdownorneedshandforbalance
Unable
8.Climbboxstep-left
Facesstep–nosupportneeded
Goesupsideways/rotatestrunk/circumductshiporneedshandforbalance
Unable
9.Descendboxstep-left
Facesforward,stepsdowncontrollingweight-bearingleg.Nosupportneeded
Sideways,skipsdownorneedshandforbalance
Unable
Activity 2 1 0 Score10.Liftshead
Insupine,headmustbeliftedinmid-line.Chinmovestowardschest
Headisliftedbutthroughsideflexionorwithnoneckflexion(protracts)
Unable
11.Getstositting
Startsinsupine–mayuseonehand/armtopushup
Usestwoarms/pullsonlegsorturnstowardsfloor.
Unable
12.Risefromfloor
NoevidenceofGower’smaneuver.
ExhibitsatleastoneoftheGower’scomponentsdescribed–inparticularrollstowardsfloor,and/orusehand(s)onlegs
(a)NEEDSexternalsupportofobjecte.g.chairOR(b)Unable
Timed
13.Standsonheels
Bothfeetatthesametime,clearlystandingonheelsonly(acceptabletomoveafewstepstokeepbalance)forcountof3
Raisesforefootonbothfeet–allmetatarsalheadsoffground–orclearlydorsiflexesonefootonly
Unable
14.Jump Bothfeetatthesametime,clearthegroundsimultaneously
Onefootaftertheother(skip)ordoesnotfullyclearbothfeetatthesametime.
Unable
15.Hoprightleg
Clearsforefootandheelofffloor
Abletobendkneeandraiseheel,nofloorclearance
Unable
16.Hopleftleg
Clearsforefootandheelofffloor
Abletobendkneeandraiseheel,nofloorclearance
Unable
17.Run(10m)
Bothfeetofftheground(nodoublestancephaseduringrunning)
‘Duchennejog’orfastwalk Walk Timed
TOTAL=/34
2. TimedGradedFunctionalactivities
RiseFromFloor
Placetheparticipantinasupinepositionwithhisarmsbyhissidesandhislegstogether.Noshoesorsocksshouldbeworn.
Givethefollowingverbalinstructionstotheparticipant:“WhenIsayGOyougetupasfastasyoucanandstandupstraightwithyourarmsbyyoursidelikeasoldier”.
Givethecommand“Readysteady–GO”andstartthestopwatchwhensaying“GO”.
Stopthetimerwhentheparticipantassumesanuprightpositionwithhisarmsbyhisside.
Onlyprovideachairaftertheparticipanthasattemptedtostandfromthefloorfor30secondsandfailed.
Recordthefastesttimeandthemethodtheyusedtoachievethisfastesttime.Youcanrepeatifyouthinktheycandoitfasterorthegradewasnotrepresentativeoftheirusualability.
Assignoneofthefollowinggrades:
NSAAequivalent
grade
FunctionalGrade
Description
0 1 Unabletostandfromsupine,evenwithuseofachair DONOTRECORDTIME
0 2 Requiresfurnituretostandupfromsupinetofulluprightposture
DONOTRECORDTIME*
1 3 Rollsover,standsupwithbothhands“climbingup”thelegstoachievefulluprightposture.
TIME
1 4 Rollsover,standsupwith1handsupportonleg TIME
1 5 Rollstothesideandstandsupwithoneorbothhandsonthefloortostarttorisebutdoesnottouchlegs
TIME
2 6 Standsupwithoutrollingoverorusinghandsonlegs TIME
*Usingfurnituretogetupmakesiteasier/fasterandiftheyhavenotusedfurniturebeforeafastertimewithfurniturewouldnotreflectprogressionaccurately
10-MetreRun/Walk
10mrunisgradedduringtheperformanceofthetestfortheNSAA.Youcanrepeatthetesttocheckthetimeorthegrade.
Thistestmeasureshowfastthesubjectcanrun/walk10metres.
• Askthesubjecttostanduprightwithbothfeetbehindthestartinglineandtoestouchingthestartingline.
• Theevaluatorshouldstandata12-metremark.Youstand2metrespastthe“finishline”
• Givethefollowingverbalinstructionstothesubject:WhenIsayGO,yougoasfastasyousafelycanallthewaytome
• Givethecommand“readyset–GO”andstartthestopwatchwhensaying“GO”.
• Continuouslyencouragethesubjectuntilhecrossesthefinishline.
• Stopthetimerwhenthesecondfootclearsthefinishline.
Note:Encouragethechildtokeeprunningacrossthefinishlineandnottoslowdownbeforethe10-metremark.
Scorethefastesttimeandrecordthemethodtheyusedtocompleteitinthefastesttime.
Assignoneofthefollowinggrades:
NSAAequivalentgrade
FunctionalGrade
Description
0 1 Unabletowalkindependently
0 2 Unabletowalkindependentlybutcanwalkwithknee-ankle-footorthosis(KAFO)orsupportfromaperson
0 3 Cannotincreasewalkingspeed,highlyadapted,wide-basedlordoticgait
1 4 Canpickupspeedbutcannotrun,moderatelyadaptedgait
1 5 Nearlyrunning,butrunswithadoublestancephase,i.e.,cannotachievebothfeetofftheground
2 6 Runsandgetsbothfeetofftheground(achievesflight)
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