BI | stroke & Complications Barthel Index (BI) lidity and reliability, standard sca| ed for stroke, excellent val Strengths: Widely us: in clinical trials ion it tly and hag i ebody can function independen: is i measures the extent to which som D n n nn aa on their activities of daily living (ADL) i.e. aay ran ee a i indi for assistance in care. The 2 wide The index also indicates the need fo a Sasloped tar ee ar sure of functional disability. The index was develops Ir Sea stroke and other neuromuscular or musculoskeletal disorders, but may also be used for oncology patients. Instructions: The original 10-item form of the BI consists of 10 common ADL activities including: fee ding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair transfer, ambulation and stair climbing. Items are rated in terms of whether individuals can per form activities independently, with some assistance, or are dependent (scored as 0, 5, or 10). Items are weighted according to the level of nursing care required. The index should be used as a a patient could do, The main aim is to establish a degree of in bal, howev record of what a patient does, not as a record of what dependence from any help, on. lent not independent. ; Physical or ver- er minor and for whatever reas + The need for supervision renders the pati& Complications Feeding ~The patient can feed himself a meal from a tray or table day [10 mdere ‘ id within reach, He must put on an assistive ‘someone puts the foo msi this is needed, cut up the food, use salt and pepper, spread but- S mplish this in a reasonable time. _ He must acco! faa ceca ignecessary (with cutting up food, etc. as listed above) an} Helpless-Hemustbefed._ pele erp nal | of bility, ‘Moving from wheelchair to bed and return maya | 46 ndependent in all phases of this activity, Patient can safely approach Ire ped in is wheelchair, lock brakes, lift footrests, move safely to bed, Jie down, come to 2 sitting position on tl jon of the wheelchair, if necessary, eturn to the wheelchair. 10 Either some minimal help is needed in some step of this activity or the needs to be reminded or supervised for safety of one or more ‘parts of this activity. 5 Patient can come toa sitting position without the help of a second person ‘butneeds to be lifted out of bed, or if he transfers with a great deal of he side of the bed, change the to transfer back into it safely and trans can pe 50,5) -He cannot come to a sitting position. toilet | Score sh hands and face, comb hair, clean teeth and shave. He / of razor but must put in blade or plug in razor without t from drawer or cabinet. Female patients must put on need not braid or style hair. | Score fasten and unfasten clothes, prevent | without help. He may use a wall bar | d. If itis necessary to use a bed iton a chair, empty it and clothes or in usingBI | stroke & COMPNCS” , 9 self take a complete sponge bath. He ub, a shower 0 | Patient may use Periha ~ieps involved in whichever method isemplo- | Je to do cs ing present. | yed without another person being P! 0 Heneeds hele, a ra | surface SS aiaah at least 50 meters without help or supervision. He may eee or prostheses and use crutches, canes or a walkerette but not Meare emia! He must be able to lock and unlock braces if used, assume the standing position and sit down, get the necessary mechanical aides into position for use, and dispose of them when he sits. (Putting on and taking off braces is scored under dressing.) 40 Patient needs help or supervision in any of the above but can walk at least 50 meters with a little help. if 6a. Propelling a wheelchair (Do not score this item if patient gets score for | walking) 5 Ifa patient cannot ambulate but can propel a wheelchair independently. He must be able to go around corners, turn around, maneuver the chair to a table, bed, toilet, etc. He must be able to push a chair at least 50 meters. 0 _Unmoved - Patient needs help to propel a wheelchair. 7. Ascending and descending stairs 10 eee to.go up and down a flight of stairs safely without help or _— supervis pases ond should use handrails, canes or crutches when needed. Boe able to carry canes or crutches as he ascends or Patient needs help wit i Ip with or supervision of any one of the above items. Put f a una and fasten all clothing, and tie shoe ae adaptations for this), The activity inclu- ny ing corset or braces when these Suspenders, loafer shoes, dresses _ necessary+ Continence of bowels patient isable to control his bowels and have no accidents. He can use a suppository oF take an enema when necessary (as for spinal cord injury | tients who have had bowel training). ttneeds help in using a suppository or taking an enema or has ‘occasional accidents. incontinent. 0. Controlling bladder 10 Patient is able to control his bladder day and night. Spinal cord injury who wear an external device and leg bag must put them on independently, clean and empty bag, and stay dry day and night. 5 Patient has occasional accidents or cannot wait for the bed pan or get to the toilet in time or needs help with an external device. the Barthel Index is used by official care organizations to assess the assistance to perform activities of daily living. Higher rating score independency. e assistance by healthcare professionals is a Barthel| Stroke & Complications montreal Cognition Assessment (MOCA) jo ins: The most itive Assessment (MoCA) was designed as a rapid screening instrument Te Mont Sanction, Itassesses different cognitive domains: attention and con- form oa eutive functions, memory, language, visuoconstructional skills, conceptual centration sjations, and orientation. Time to administer the MoCA is approximately 10 neat total possible score is 30 points; a score of 26 or above is considered normal. mi instructions: please find some examples of MOCA-templates at page 32. widely used scale to detect post-stroke-cognition problems 1.Alternating Trail Makin: The examiner instructs the subject: ‘please drawa line, going from a number to a letter in ascending order. Begin here [point to (and draw a line from 1 then to A then to 2.and so on. End here [point to (E)].” Scoring: Allocate one point if the subject successfully draws the following pattern: 1-A-2-B-3-C—4-D-5—E, without drawing any lines that cross. Any error that is not immediately self-corrected earns a score of 0. 2.Visuoconstructional Skills (Cube): ‘Theexaminer gives the following instructions, pointing to the cube: ing as accurately as you can, in the space below” is allocated for a correctly executed drawing. be three-dimensional parallel and their length is similar (rectangular prisms are accepted) if any of the above-criteria are not met. and give the following instructions: rs and set the time to 10 past 11MOCA | Stroke & Complications of the following three criteria: located for each criteria eS be a circle with only minor distortion ); the clock face must ing the circl (e.g. slight imperfection on closing , / Numbers (1 pt):all clock numbers must be present with no additional nui bers must be in the correct order and placed in the approximate quadi clock face; Roman numerals are acceptable; numbers can be placed o contour + Hands (1 pt): there must be two hands jointly indicating the correct time; hand must be clearly shorter than the minute hand; hands must be tred clock face with their junction close to the clock centre. A point is not assigned for a given element if any of the above-criteria are not Scoring: One poi + Contour (1 pt. 4. Naming: Scoring: One point each is given for the foll lowin ) rhino (3) camel or dromedary. 9 espns 5.Memory: The examiner reads a list of 5 words second, instructions: “This isa memorytes lam gol tesa remember now and later on. Listen careflly. When lam PReaeoEa you can remember. It doesn't matter in what order Mark a check in the allocated space for each word ; trial. When the subject indicates that (s)he has recall no more words, read the list a second time going (0 read the same list for a second time, Try to as you can, including words you said the first time: each word the subject recalls after the At the end of the second trial, inform the words again by saying, “I will ask you to Scoring: No points are given for 6. Attention: Forward Digit Span: Give the |_ | Stroke & Complications Sey gt Span: Give the following instruction: “Now lam going to say some more | pk Seeement or through you must repeat them to me in the backwards order. bee sequence at a rate of one digit per second, peadthe tree number seq heat. Allocate one point for each sequence correctly repeated, (N.B.: the correct res- Cig geortng? n 4 Some forthe backwards trial is 2-4-7) he hy thing —— The examiner reads the list of letters at a rate of one per second, after giving following instruction: “lam going to read a sequence of letters. Every time I say the Saemnpyeutfand once Iilsay a different letter, do not tap your hand” ¢ Give one point if there is zero to one errors (an error is a tap on a wrong letter or a —_ Scoring: |" fgilureto tap on letter A). Serial 7s: The examiner gives the following instruction: “Now, | will ask you to count by | subtracting seven from 100, and then, keep subtracting seven from your answer until | tell you to stop” Give this instruction twice if necessary. ing Scofing: This item is scored out of 3 points. Give no (0) points for no correct subtractions, 1 7. pointfor one correction subtraction, 2 Points for two-to-three correct subtractions, and 3 A points ifthe participant successfully makes four or five correct subtractions, Count each comrect subtraction of 7 beginning at 100. Each subtraction is evaluated independently; s,_ thatis ifthe participant responds with an incorrect number but continues te correctly bac fom it, give a point for each correct subtraction. For example, a Participant may 7 ‘spond"92-85-78-71 - 64" where the’92"is incorrect, but all subsequent numbers are i ‘Correctly. This is one error and the item would be given a score of 3. am going to read you a sentence. Repeat ; y a5 | say it (pause): | ‘only know that John is the one to help today.” say: “Now | am going to read you another sentence. Repeat it ‘it [pause]: The cat always hid under the couch when dogs were in etition must be exact. ‘only’, "always") and substitutions/ Substituting "hides" for "hid" alteringMOCA | Stroke & Complications 8. Verbal fluency: The examiner gives the following instruction: the any that be will tell “Tell me as many words as yOu begin with a certain letter of the alphabet that | will tell you in a moment. Yo ’d of word you want, except for proper nouns (like Bob or Boston), in with the same sound but have a different suffix, for example, lo you to stop after one minute. Are you ready? [Pause] Now, tell meas, you can think of that begin with the letter F. {time for 60 sec], Stop” . Scoring: Allocate one point if the subject generates 11 words or more i the subject's response in the bottom or side margins. 9. Abstraction: The examiner asks the subject to explain what each pair of words ting with the example: “Tell me how an orange and a banana are: answers in a concrete manner, then say only one additional tin in which those items are alike’ If the subject does not give th (fruit), say, "Yes, and they are also both fruit.” Do not give any ad clarification. After the practice trial, say: “Now, tell me how a tr | Following the response, administer the second trial, a watch are alike’ Do not give any additional instru Only the last two item pairs are scored. answered. «The following responses are acceptable: Ruler-watch The following responses are not Train-bicycle = they have Lasked you to rel check mark ( ¥) for| Stroke & Complications a optional: Following the delayed free recall trial, prompt the subject with the semantic yj cate category cue provided below for any word not recalled, Make a check means (4 )in the ‘On. allocated space if the subject remembered the word with the help of a category or "Woe juultiple-choice cue. Prompt all non-recalled words in this manner. If the subject does Ving pot recall the word after the category cue, give him/her a multiple cheice trial, using ras, the following example instruction, “Which of the following words do you think it wan NOSE, FACE, or HAND?” > Use the following category and/or multiple-choice cues for each word, when appro- Recy priate: FACE: category cue: part of the body multiple choice: nose, face, hand VELVET: category cue: type of fabric multiple choice: denim, cotton, velvet CHURCH: category cue: type of building multiple choice: church, school, hospital DAISY: category cue: type of flower multiple choice: rose, daisy, tulip RED: category cue: a colour multiple choice: red, blue, green Scoring: No points are allocated for words recalled with a cue. A cue is used for clinical information purposes only and can give the test interpreter additional information about the type of memory disorder. For memory deficits due to retrieval failures, per- nc formance can be improved with a cue. ‘11, 0rientation: The examiner gives the following instructions: “Tell me the date today” If the subject ‘doesnot give a complete answer, then Prompt accordingly by saying: “Tell me the [year, date, and day of the week].” Then say: “Now, tell me the name of this place, city it is in.” one point for each item correctly answered. The su bject must tell the exact ‘place (name of hospital, clinic, office). No points are allocated if subject ‘day for the day and date. res listed on the right-hand side. Add one point for an ‘fewer of formal education, for a possible maximum of 26 and above is considered normal.a_i MOCA | stroke & Complications NAME .NITIVE ASSESSMENT (MOCA) Education| version Sex XTREAL COG! Rest Original ‘Draw CLOCK (Ten past (3 points) be CII a rorya anaes“Moca | Stroke & Complications soe COGNITIVE ASSESSMENT (Moca) Y MONTREAL Salternative Version tay oF Contour __ Numbers ead ist of words, subject must VIOUN ‘epatterDo2 tial event til success, ‘oar ater Smits RewdNl dots (i cig sec}. Subject has orepeatiheminthefornacdroer ‘Subject has to repeat them in the backward order chleter A No pons 2 enon []_FBACMNAAJKLBAFAKDEAAAJAMOFAAS [183 (176 [168 sors ‘eel eters The sibject must tap with Ris hand aca ST ae aT I gana pare C 23 (Normal) 13 - 23 (Mild deme 5-12 (Moderate d <5 (Severe det Approximate time of the test: 10 minutesDn) tion) —J functional Independence Measure (FIM) «: Widely used for stroke scale was developed to address the issues of sensitivity and comprehensiveness that The st cized as being problematic with the Barthel Index. were Instructions: ‘The FIM offers auniform system of measurement for disability based on the International Chssifcation of Impairment, Disabilities and Handicaps for use in the medical system in theUnited States. The level of a patient's disability indicates the burden of caring for them anditemsare scored on the basis of how much assistance is required for the individual to carry out activities of daily living. items: The FIM consists of 18 items assessing 6 areas of function. The items fall into two do- mains: Motor (13 items) and Cognitive (5 items). The motor items are based on the items of the Barthel Index. These domains are referred to as the Motor-FIM and the Cognitive-FIM. Eating Grooming Bathing Dressing-upper body Dressing-lower body Toileting ‘Bladder management _Bowel managementFIM | Stroke & Com plications Comprehension Expression ee | Socal cognition Social interaction Problem solving Memory Grooming items are known tol Bowel management, and é whereas Locomotion, Tub th stroke to accomplish, ‘hallenging items For the Motor-FIM, the Eating, the easiest items for patients wit fers, and Stair climbing are the most cl FIM Scoring Criteria: e Description sess | Complete Independence | No helper required Modified Independence (patient requires | 6 use of a device, but no physical assistance) Supervision or Setup Minimal Contact Assistance (patient can 4 | Helper perform 75% or more of task) | (Modified dependance) | Moderate Assistance (patient can perform 50% to 74% of task) Maximal Assistance (patient can perform 25% to 49% of taks) ; Total assistance (patient can perform less than 259% of the task or more uires one person to assist) os om Activity does not occur | HelperInterpretation: Scores range from 18-126. Higher scores represent more independence. Beoroms crn complete dependence, while a score of 126 represents complete independence. "Approximate time of the test: 40 minutesaloheimer’s Disease Assessment Scale - cognitive section (ADAS-COG) strengths: Covers all cognitive areas in dementia, has good sensitivity to change jrisone ofthe most frequently used tests to measure cognition in clinical trials. Instructions: the patient is given three trials to learn a list of 10 words. The words are printed in block Jetters on cards. Each card is presented for 2 seconds. The patient then recalls the words ‘aloud. Three trials of reading and recall are administered. The score equals the mean num not recalled. 53 ‘patient: “am going to show you some words, one ata time. Please read each word |try to remember it because | will later ask you to try to remember all of the words Trial 3 | [picture _ CIRCLE - [ CIRCLE SKY SKY FACTORY | [MARKET PICTURE —_| [House HOUSE SLAVE nc WaTER DOLLAR MARKET | FACTORY a [ eiRo #not recalled SCORE: (moor fof words not recalled)i | Stroke & Rehabilitation Fugl-Meyer Assessment (FMA) strengths: The FMA is a lengthy measure but very thorough and c 1 complete The Fugl-Meyer Assessment (FMA) is a stroke-specific, index. It is designed to assess motor functioning, in patients with post-stroke hemiplegia. be Performance-based impairment alance, sensation and joint functioning Instructions: The FMA requires a mat or bed, a few small objects and several different tools for the as- sessment of sensation, reflexes, and range of motion: Materials needed: + Scrap of paper + Goniometer + Ball + Stopwatch + Cotton ball + Blindfold + Pencil + Chair + Reflex hammer + Bedside table + Gjlinder (small can or jar) The scale is comprised of five domains and there are 155 items in total: + Motor functioning (in the upper and lower extremities) + Sensory functioning (evaluates light touch on two surfaces of the arm and leg, and Position sense for 8 points) + Balance (contains 7 tests, 3 seated and 4 standing) + Joint range of motion (8 points) * Joint pain ints are divided among the domains as follows: * Motor score: Coen om 0 (hemiplegia) to 100 points (normal motor sees into 66 points for upper extremity and 34 points for the lowe’ Tanges from 0 to 24 points. . 8 points for light touch and 16 points for position sense for sitting and 8 points Jes from 0 to 44 points. 44 points.—_——— FMA | stroke & Rehabilitation EYER ASSESSMENT -UE) eMITY (FMA-U! i f sensorimotor function FUGL-MI UPPER EXT! Assessment Ca finger flexors (at least one) Flexors: biceps and Examiner: Extensors: triceps 1. Volitional movement within synerg _without gravitational help Flexor synergy: Hand from contralateral | Shoulder _| retraction 0 synergy: knee to ipsilateral ear. From extensor elevation o synergy (shoulder adduction/ internal 5 rotation, elbow extension, forearm shu : pronation) to flexor synergy (shoulder externalrotation | 0 abduction/ external rotation, elbow Fibs fledon! 0O flexion, forearm supination). Forearm | supination 0 Extensor synergy: Hand from ipsilateral earto the contralateral knee Shower _|scsuctonl aa nal rotation Elbow extension Forearm pronationNo pronation/supination, starting position | 9 | — Ipow at 90° impossible Sa ider at 0° limited pronation/supination, maintains ‘ starting position full pronation/supination, maintains starting position 4 LE ———____*“_—srrrervrer—_____ Subtotal ll (max 6) eae or no synergy ] te | ‘Shoulder abduction 0-90° | immediate supination or elbow flexion 0 ‘elbow at 0° supination or elbow flexion during 1 forearm pronated movement | abduction 90°, maintains extension and | 2 pronation ‘Shoulder flexion 90°-180° | immediate abduction or elbow flexion 0 elbow at 0° abduction or elbow flexion during 1 pronation-supination 0° movement flexion 180°, no shoulder abduction or 2 elbow flexion : immediate abduction or elbow flexion 0 elbow at 0° abduction or elbow flexion during | 1 ‘shoulder at 30°-90° flexion | movement | flexion 180°, no shoulder abduction or 2 Se elbow flexion Subtotal IV (max 6) Piiac=§ ] triceps, | 2 of 3 reflexes markedly hyperactive or 0 points in part |V kg . markedly hyperactive or at least 2 reflexes lively of 1 reflex lively, none hyperactive Subtotal V (max 2)FMA | stroke & Rehabilitation 'B. WRIST support may be provided at the elbow to take or hold the starting position, no support at wrist, check the passive range of motion prior testing | Stability at 15° dorsiflexion elbow at 90°, forearm pronated shoulder at 0° Repeated dorsifexion / volar flexion elbow at 90°, forearm pronated shoulder at 0°, slight finger flexion less than 15° active dorsiflexion dorsiflexion 15°, no resistance tolerated maintains dorsiflexion against | resistance cannot perform volitionally limited active range of motion full active range of motion, smoothly Stability at 15° dorsiflexion elbow at 0°, forearm pronated slight shoulder flexion/abduction less than 15° active dorsiflexion dorsiflexion 15°, no resistance tolerated maintains dorsiflexion against resistance Repeated dorsiflexion / volar flexion elbow at 0°, forearm pronated slight shoulder flexion/abduction cannot perform volitionally limited active range of motion full active range of motion, smoothly Circumduction elbow at 90°, forearm pronated shoulder at 0° Hook grasp flexion in PIP and Dip 4 (digit: extension in MCP iy. me cannot perform volitionally jerky movement or incomplete complete and smooth circumduction TOTAL B (max 10)ilitation cannot be performed “fingers in abduction/flexion, can hold ball but not against tug Thumb adduction Oa Thum IPatO, scrapof | can hold paper but not against tug tial | 13tN Menthumb and 2nd | canhold paper against atug | -] cP joint —__—__—. | __| pincer grasp, opposition cannot be performed Oak eines Fetnumbagainstthe | can hold pencl but not against tug 1 “Ripa of 2nd finges, pencil, tug can hold pencil against a tug 2 | upward | “q.oylinder grasp cannot be performed ° | “ofindershaped object (small can) | can hold cylinder but not against tug hes _tugupward opposition ofthumb | can hold cylinder against a tug | 2 ‘and fingers | L "|e. Spherical grasp cannot be performed o | | thumb opposed, tennis ball, tug can hold ball against a tug away at least slight ar pronounced or unsystematic trial with both arms, eyes 1 completed movement nd systematic no dysmetria rose, 5 times as fast as possible ae TOTAL C (max 14) atleast 6 seconds slower than unaffected side 2-5 seconds slower than unaffected side less than 2 seconds difference a) rormavinxsss[ idFMA | stroke & Rehabilitation jo] _ anesthesia 7 SATION, upper extremity eyes P H. SENS ared withthe unaffected side ‘upper arm, forearm 0 Lighttouch | palmary surface of 0 1 the hand : suet a less than 3/4 | 3/4 correct or correct or considerable Se __absence_ | difference Position shoulder 0 1 small altera- ors hnthe al come o 1 position wrist 0 thumb (IP-joint) 0| wrist = Flexion Y 9 1 2 Extension S 0 2 Fingers | Flexion 0 0 1 2 | Extension ia 2 TOTAL (max 24) ‘TOTAL (max a ey | A.UPPER EXTREMITY /36 | B.WRIST 0 C.HAND ‘4 D.COORDINATION / SPEED /6 D 166 HSENSATION N2 4.PASSIVE JOINT MOTION 124 4.JOINT PAIN 124FMA | stroke & Rehabilitation FUGL-MEYER ASSESSMENT 1D: LOWER EXTREMITY (FMA-LE) Date: Assessment of sensorimotor function Examiner: | Reflex activity, supine position Flexors: knee flexors Extensors: patellar, Achilles Subtotal | (max 4) [.Votitional movement within synergies, supine position Flexor synergy: Maximal hip flexion Hip flexion (abduction/external rotation), maximal | Knee ‘foroe flexion in knee and ankle joint (palpate distal tendons to ensure activeknee _| Ankle doris | flexion). Extensor synergy: From flexor synergy [yj ; tothe hip extension/adduction, knee |"? oe adduction extension and ankle plantar flexion. Resistance is applied to ensure active Knee extension movement, evaluate both movement sade Ankle —_| plantar flexion& Rehabilitation jmovement with little or no synergy, standing position, none | partial | full | jon to 90° no active motion /immediate and simulta.) 9 | = | | | Rar anee support is | neous hip flexion | new less than 90° knee flexion or hip flexion 1 “. a during movement | at least 90° knee flexion without simulta- 2 | neous hip flexion | le dorsiflexion no active motion 0 | compare with unaffected side | limited dorsiflexion 1 complete dorsiflexion 2 Subtotal IV (max 4) jrefiex activity supine position, evaluated only if full score of 4 [on earlier part IV, compare with unaffected side Reflex activity | 0 points on part IV or 2 of 3 reflexes markedly hyperac- 0 ‘nee flexors, | tive Achilles, 1 reflex markedly hyperactive or at least 2 reflexes lively 1 patellar maximum of 1 reflex lively, none hyperactive 2 Subtotal V (max 2) Pronounced or unsystematic slight and systematic no dysmetria pew than 5 seconds slower than unaffected 25 seconds slower than unaffected side ‘Maximum difference of 1 second betweenFMA | Stroke & Rehabilitation Cannot maintain sitting without support | Can sit unsupported less than 5 minutes can sit longer than 5 minutes ‘Sit without support Parachute reaction in| Does not abduct shoulder or extend elbow non-affected side Imparied reaction Normal reaction "Parachute reaction in | Does not abduct shoulder or extend elbow affected side Imparied reaction Normal reaction Stand with support Cannot stand Stands with maximum support Stands with minimum support for 1 minute Stand without support | Cannot stand without support Stands less than 1 minute or sways Stands with good balance more than 1 minute Stand on non-affected | Cannot be maintained longer than 1-2 side seconds Stands balanced 4-9 seconds Stands balanced more than 10 seconds == Stand on affected side _ | Cannot be maintained longer than 1-2 seconds Stands balanced 4-9 seconds Stands balanced more than 10 seconds Light touch Position | small alterations in the position ‘eat toe (P-joint) No