LiFE Assessment Tool

LiFE Assessment Tool (LAT) Name: ________________________ Date ______________ Musculoskeletal History Do you have any arthritis in your knees or hips circle which applies Y/N Details: If yes, which knee / hip has arthritis? Do you have any joint replacements in your knees or hips? Y/N Details: Do you get, or have you ever had bursitis or tendonitis in your leg or legs? Y/N Details: Do you get or have you ever had low back pain? Y/N Details: Functional Balance Questions Do you sit or stand when dressing? If both, do you mostly sit or mostly stand? Sit Do you sit down to put on your shoes and socks? Sit Stand Do you sit down to put on your pants/bra or singlet Sit Stand Do you sit down or stand up to shower? If bath, do you sit in bottom of bath? Sit Stand Sit down in bath During your shower do you hold onto anything for support? Yes How confident are you that you can get dressed without losing your balance? Not at all confident A little confident Fairly confident Very confident If yes, which ones do you have? Mostly Sit Mostly Stand No Do you use a walking stick or walking frame? Yes No If yes, when do you use it? Always When going out Are you able to step down a curb or gutter without assistance? Yes No Clemson, Munro & Fiatarone Singh Varies Assessment Tool: balance activities Decreased base of support Instructions 1. Tandem stand Heel-to-toe stand. Support available. Weight transferred in a forwards / backwards direction. 2. Tandem walk Have support available. Distance walked should be approximately 1.5 metres. 3. One-leg stand Record the leg that is least stable. Level 0 Level 1 Tandem stand with constant support. OR Unable to perform. Tandem stand Tandem stand Tandem stand with intermittent with no support. with no support support. while brushing hair OR with eyes shut. Tandem walk with constant support. OR Unable to perform. Single-leg stand with constant support. Least stable leg: Left / Right OR Unable to perform. Tandem walk Tandem walk Tandem walk with intermittent with no support. with no support with eyes shut. support. Single-leg stand with intermittent support. Least stable leg: Left / Right Level 2 Single-leg stand with no support. Least stable leg: Left / Right Level 3 Single-leg stand with no support while doing something else such as getting object from cupboard at shoulder height. Least stable leg: Left / Right Level 4 Notes Record where activity is done: Single-leg stand with no support with eyes shut. Least stable leg: Left / Right Shifting weight and moving to the limits of stability 4. Leaning forwards and backwards Stepping over objects 5. Forwards and backwards Instructions Level 0 Level 1 Level 2 Level 3 Stand on both feet. Lean as far as possible forward, shifting the weight onto the toes. Do not bend at the waist or neck. Aim to hold for 10 seconds. Stand with feet shoulderwidth apart; use constant support. Hold for 10 seconds. OR Unable to perform. Stand with feet shoulder-width apart; use no support. Time position held: Stand with feet together; use no support. Hold for 10 seconds. Stand with feet together; use no support. Hold for 10 seconds while using a mental distractor OR hold for 10 seconds with eyes closed. Instructions Level 0 Level 1 Level 2 Level 3 Place an A4-size marker on the floor. The subject should step forward and then backwards over the marker. Ensure that support is available, e.g. the door frame. Step in both directions using a support. OR Unable to perform. Step in both directions without using support. Step over foam block without using support. Step over foam block without using support while doing another task such as carrying a dinner plate OR with eyes shut. Level 4 Notes Record which mental distractor was used: Level 4 Notes Assessment Tool: strength activities Bend the knees Instructions Level 0 Level 1 Level 2 Level 3 Level 4 Notes 6. Squatting Have support available. The exercise should be pain free. Do not aim for a full squat. Partial squat with support. OR Unable to perform. Partial squat with no support. Hold for five seconds. Half squat with no support. Hold for five seconds. OR Get something from below the sink using a squat. On your toes Instructions Level 0 Level 1 Level 2 Level 3 Level 4 Notes Walk on toes 7. Walking on toes Heels must be off Unable to perform Level 1. using constant the ground for support. entire distance walked. Distance should be approximately 1.5 metres. Walk on toes using intermittent or no support. Walk on toes Record where Walk on toes using no support using no support activity done: with eyes shut. while doing something else such as carrying a plate with a biscuit on it. On your heels Instructions Level 2 Level 3 8. Walking on heels Walk on heels Toes must be off Unable to perform Level 1. using constant the ground for support. entire distance walked. Distance should be approximately 1.5 metres. Walk on heels using intermittent support. Record where Walk on heels Walk on heels using no support using no support activity done: with eyes shut. while doing something else such as carrying. a plate with a biscuit on it. Level 0 Level 1 Level 4 Notes Sit to stand / stand to sit Instructions Level 0 Level 1 9. Standing up from a seated position Assessor demonstrates correct technique: Sit with bottom to front of chair. Lean forward. Push up from legs. Avoid rocking. Use hand support as required. Rising from standard chair with hand support. OR Unable to perform. Rising from Rising from a low standard chair chair No hand support. With hand support Rising from a low chair slowly. No hand support Must take at least 5 seconds Move sideways Instructions Level 0 Level 1 Level 2 Level 3 Sideways walk with steps that are shoulderwidth or less apart, using support. OR Unable to perform. Sideways walk with steps that are wider than shoulder-width apart, using support. Sideways walk with steps that are wider than shoulder-width apart, using no support. 10. Move sideways. Walk by stepping sideways. Support should be available. Subjects should aim to take the widest step they can safely perform. Assessor may need to demonstrate. Level 2 Level 3 Level 4 Notes Record the chair used in the assessment: Level 4 Notes If support is required, record where activity was assessed: