Informal and Formal/Standardized Assessment Instruments
For Physical Therapy
Cognition Informal Assessment Instruments
• Cognitive Informal Evaluation
Cognition Formal Standardized Assessment Instruments
• Mini-Mental State Exam—measures cognitive aspects of mental functioning
• Brief Cognitive Rating Scale (BCRS)—used to stage a person diagnosed with primary
degenerative dementia
• Global Deterioration Scale (GDS)—provides caregivers with an overview of the stages of
cognitive function for those diagnosed with a primary degenerative dementia
• Functional Staging Assessment—used to stage a person diagnosed with primary
degenerative dementia
Depression Informal Assessment Instruments
• Observe for the following:
o Patient does not want to go to therapy
o Patient’s progress begins to slow down
o Patient loses interest in therapy and/or has slowed progress
o Patient quits doing certain things that were previously important, (e.g., drinking coffee,
turning on the TV, reading the newspaper)
o Limited support system
o Ageist attitude exhibited by caregiver(s) or patient (e.g., “of course you’re depressed,
you’re old”)
o Family members deny symptoms
Depression Formal Assessment Instruments
• Zung Self-Rating Depression Scale—quantifies symptoms of depressive disorders in adults
• Geriatric Depression Scale—rates depression in the elderly
• The Mini-Mental State Exam (MMSE)—screening tool for cognitive impairment with older
adult population, separates patients with cognitive impairment from those without it
• Cornell Scale for Depression in Dementia (CSDD)—assesses five specific categories
reflecting depression: mood-related signs, behavioral disturbance, physical signs, cyclic
functions and ideational disturbances
Safety Judgment Informal Assessment Tools
• Observe the patient throughout the evaluation to determine answers to the following
questions:
o Does the patient initiate safe behaviors?
o Does the patient stop himself/herself if encountering an unsafe situation?
o Does the patient scan the environment to ensure safety?
o Does the patient realize the limits of his/her functional/cognitive abilities and ask for
help accordingly?
o Does the patient use unstable surfaces for support during functional mobility tasks?
• Ask the following types of questions to determine the patient’s safety awareness:
o Can you show me how to lock the brakes on your wheelchair?
o Do you know how to use the call bell?
o When should you call the nurse for help?
o Is it OK to take yourself to the bathroom?
Neuromotor Informal Assessment Instruments
• Equilibrium Coordination Tests
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Nonequilibrium Coordination Tests
Tests for Selected Motor Deficits Contributing to Coordination Problems
Spasticity/Tone Assessment Scales
Brunnstrom Muscle Tone Scale
Brunnstrom Stages of Recovery
Synergies Associated with Hemiplegia
Nerves to Muscles: Motor and Sensory or Motor
Deep Tendon Reflexes
Neuromotor Formal/Standardized Assessment Instruments
• Vestibular System Evaluation & Training—useful for both evaluation and treatment of
patients who suffer from dizziness, lightheadedness and/or unsteadiness brought on by
rapid movement
ROM Informal Assessment Instruments
• AROM/PROM measurements obtained through visual inspection without the use of a
goniometer including evaluation for presence of contractures through the performance of
functional movements
ROM Formal/Standardized Assessment Instruments
• AROM/PROM goniometric measurements including evaluation for presence of contractures
• MACTAR: Patient Preference Questionnaire—evaluates a patient’s change in function and
disability as a result of arthritis
• WOMAC—measures disability of patients with osteoarthritis of the hip or knee
• Functional Knee Evaluation—measures knee function in adults with rheumatoid arthritis and
mild deformity or joint replacements; 85+ points = excellent, 70-84 points = good, 60-69
points = fair, <60 points = failure
• Harris Hip Score—designed to assess the level of pain and functional impairment of hip
replacement patients
• Wolfgang’s Criteria—measures pain, motion, strength and function in patients with rotator
cuff tears
• Special Tests
o Apley Scratch Test
o Ober Test
o Thomas Test
o Modified Ober Test
o “Bounce Home” Test
o Bunnel-Littler Test
o Retinacular Test
o Ankle Dorsiflexion Test
Posture Informal Assessment Instruments
• Four Types of Postural Alignment—side view assessment with plumb line
• Good and Faulty Posture: Summary Chart
• Faulty Posture, Side View: Analysis and Treatment
• Faulty Head and Shoulder Positions: Analysis and Treatment
• Faulty Posture, Back View: Analysis and Treatment
• Faulty Leg, Knee and Foot Positions: Analysis and Treatment
• Informal Posture Evaluation, observe for:
o Head and neck extended forward
o Sunken chest
o Rounded shoulders
o Leaning to one side
o Protruding abdomen
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Slouched lower back with no lumbar support
Knees extending beyond support of seat
Strength Informal Assessment Instruments
• Manual muscle testing (MMT)—use:
o Numeric Grading System For Strength Assessment
o Key to Muscle Grading
o Basic Rules to Muscle Strength Testing
• Dynamometric Methods to Test Muscle Strength
• Tip Pinch to Test Muscle Strength
• Speech Therapy Informal Strength Assessment
Strength Formal/Standardized Assessment Instruments
• Special Tests
• Lysholm Knee Rating Scale—designed to measure functional limitations as a result of knee
ligament injuries
• Functional Knee Evaluation—measures knee function in adults with rheumatoid arthritis and
mild deformity or joint replacements; 85+ points = excellent, 70-84 points = good, 60-69
points = fair, <60 points = failure
• Harris Hip Score—designed to assess the level of pain and functional impairment of hip
replacement patients
• Wolfgang’s Criteria—measures pain, motion, strength and function in patients with rotator
cuff tears
• Jebsen Test of Hand Function—measures functional use of the hand
Sensorimotor Informal Assessment Instruments
• Gross Sensory Assessment Form
• Dermatome Distribution Chart
• Semmes Weinstein Monofilaments
Skin Informal Assessment Instruments
• Wound Assessment—designed to provide descriptive measurements of existing wounds
Skin Formal/Standardized Assessment Instruments
• Pressure Sore Status Tool—designed to evaluate the severity of an existing pressure sore
and to track movement between pressure sore stages
• Braden Scale—used to identify patients who are at risk for the development of pressure
sores
Pain Informal Assessment Instruments
• Pain Rating Scale—designed to measure pain based on facial expression or a patientassigned numeric value
• Geriatric Pain Assessment—designed to summarize the pain assessment in the elderly
Pain Formal/Standardized Assessment Instruments
• Pain Disability Index—designed to measure pain-related disability during activities of daily
living
• Short-Form McGill Pain Questionnaire—designed to depict the sensory and affective
dimensions of pain as well as pain intensity
• Functional Interference Estimate—designed to assess pain-related impairment in the
patient’s level of everyday functioning
• Oswestry Low Back Pain Disability Questionnaire—designed to quantify the degree of
functional impairment as a result of low back pain
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Neck Disability Index—designed to quantify the degree of functional impairment as a result
of neck pain
Balance Informal Assessment Instruments
• Balance Documentation Scale—quantifies static/dynamic sitting/standing balance with an
ordinal scale (e.g., Normal, Good, Fair, Poor)
Balance Formal/Standardized Assessment Instruments
• Berg Balance Measure—designed to test levels of balance in the elderly
• Tinetti Assessment Tool—designed to measure gait and balance
• Functional Reach—measures the maximal distance one can reach outside his/her base of
support while maintaining a fixed base of support in standing
• Get Up and Go/Timed Up and Go—measures the patient’s sense of balance
• Postural Dyscontrol Evaluation—tests for balance control using three visual and two support
surface conditions (Note: Amount and direction of sway)
• Rhomberg/Sharpened Rhomberg—measures balance in static standing
Gait Informal Assessment Instruments
• Observe the patient during gait and utilize the above criteria to evaluate including:
o Description of gait pattern and variables (e.g., assistive device, assistance required)
o Identification and description gait deviations
o Analysis of deviations and identification of mechanism responsible for gait abnormality
o Assessment of energy expenditure
o Determine functional abilities of patient and demands of home/community environment
Gait Formal/Standardized Assessment Instruments
• Functional Ambulation Profile—designed to measure the time/steps it takes to complete
certain functional mobility tasks, specifically static weight-bearing capacity, dynamic weight
transfer rate and basic ambulation efficiency in patients with neuromuscular or
musculoskeletal disorders
• GARS-M: Gait Assessment Rating Score Modified—designed to measure the relationship of
gait abnormalities to falls in the elderly population
• Dynamic Gait Index—designed to assess the likelihood of falls in older adults during gait
• Tinetti Assessment Tool—designed to measure gait and balance
Functional Mobility Informal Assessment Instruments
• Observe the patient during functional mobility tasks and utilize the above criteria to
evaluate performance
Functional Mobility Formal/Standardized Assessment Instruments
• Functional Status Index—measures functional performance in three areas: assistance,
difficulty and pain
• Physical Performance Test—assesses a patient’s level of physical function during activities
of daily living
• PULSES Profile—quantifies functional independence of the chronically ill
• Barthel Index—quantifies improvement in rehabilitation of the chronically ill
• Geriatric Functional Rating Scale—measures the level of the patient’s physical and mental
disability in relation to ability to function and the availability of social networks for support
• Structural Assessment of Independent Living Skills (SAILS)—measures functional ability
during ADL performance for patients with dementia
• Motor Assessment Scale—measures eight areas of function/one area of muscle tone in
stroke patients
• Self-Report Questionnaire—measures the patient’s level of difficulty during ADLs as result of
rheumatoid arthritis
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(MOSES) Multidimensional Observation Scale for Elderly Subjects
Functional Independence Measure
Functional Activity Tolerance Informal Assessment Tools
• Time the patient during functional tasks
• Document the amount of time it takes to complete a specific task
• Identify and list barriers to performance
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