PNCR Network

for SMA

March 29

2019
Hammersmith
Functional Motor Scale
Expanded for SMA
(HFMSE)
 Hammersmith Functional Motor Scale Expanded for SMA (HFMSE)

Introduction to this collaboration

Back in 2008 physiotherapists in the UK and part of the Smartnet network (neuromuscular network aimed
at improving the management of individuals with SMA) were working on establishing a written manual for
the Hammersmith Functional Motor Scale (HFMS). At the same time, yet independently, in the U.S. the
Pediatric Neuromuscular Clinical Research Group (PNCR) had been aiming to achieve the same thing for
their Expanded version of the Hammersmith Functional Motor Scale (HFMSE) which combines the
original HMFS with an add-on module, consisting of items adapted from the Gross Motor Function
Measure (GMFM). The 13 add-on items were selected based on their ability to distinguish motor skills
among individuals with SMA II and III and has been shown to do this successfully. These groups came
together to create one common manual and proformas for both the HFMS and the HFMSE (2009 version).

After 10 years of administration and experience, the International Spinal Muscular Atrophy Consortium
(iSMAC) collaboration between SMA REACH UK, the Italian SMA Network and the Pediatric
Neuromuscular Clinical Research Network (PNCR) for SMA (USA) has led the effort to revise this manual
to provide further clarification and refinement of item description and scoring details based on lessons
learned from clinical use and therapeutic trials. This updated manual version 2019 supports the original
2009 manual without any changes in scoring criteria. We are confident testing conducted using the
original 2009 manual is still valid and comparable. This updated manual provides further explanations and
descriptions to support clinical evaluators across the world to maintain consistency of administration and
scoring of the HFMSE for both ambulant and non-ambulant SMA.

Notes on Testing Procedure

1. Intended Population
The HFMSE is intended to be used in accessing the functional motor abilities of people with SMA who are
able to sit and walk. This manual clarifies the procedures and scoring. The HFMSE is intended for clinical
use (natural history and treated patients) and for clinical research trial use.

2. Motor Scale Evaluators

HFMSE assessments should be performed by individuals who have experience in the handling of children
and adults with SMA, such as physical or occupational therapists. Any use of this scale for research
purposes should be predicated by the understanding of the scales’ starting positions, operational
definitions and scoring criteria. The reliability and validity of the HFMSE have been documented, however
if the scale is utilized for clinical research, evaluators are encouraged to undergo training to establish
reliability prior to beginning data collection.

3. Scoring System and Positional Definitions

The HFMSE was designed with a 3 point scoring system:
Score 2 = performs without modification/adaptation/compensation
Score 1 = performs with modification/adaptation/compensation
Score 0 = unable to perform
Specific scoring criteria per item is outlined in detail in this manual. In general, a score of 0 means the
subject did not meet the criteria for a score of 1 or 2.

- Supine = Hips and shoulders facing upwards towards the ceiling.

- Prone = Hips and shoulders facing downwards towards the floor.
- Sitting = Sitting up with bottom in contact with mat. Legs should be positioned in front of body,
however precise position does not matter. Can include floor sitting (long sit, ring sit, cross-legged sit)
or 90/90 over edge of plinth (not ‘w’ sitting).
- Four-point kneeling = Hands and knees should be roughly positioned under the shoulders and hips
respectively. Perfect alignment is not required.
- Half kneeling = Weight taken on one knee and the opposite foot and the buttocks are clear of the
lower leg. Alignment is not a consideration.
- Standing = Upright on both feet, taking full weight independently, posture is not important.

Additional specific positioning criteria per item is outlined in detail in this manual.

4. Instructions to the subject & demonstration

This gross motor measure should reflect the subject’s best ability and best performance on the day. If
after verbal instructions are given, the subject does not understand the command, or if clarification is
needed, the evaluator may demonstrate the item. To make the demonstration uniform, the highest
scoring for the item (most difficult) may be demonstrated. When the item is to be tested, the item
instructions are given verbally followed by an optional demonstration. Any subject especially younger
ones may require encouragement to complete the task. Use what is appropriate and works for the
individual in order to capture their best abilities.

5. Order of tests
Ideally, all centres would follow the same test order and for research purposes this would be essential, as
fatigue can be an issue with these children. However, in the clinic setting it may be appropriate to alter the
order to suit the needs of the patient.

6. Clinical evaluation
It is recommended that when using the test for clinical use that all the items should be attempted, even
though you may have seen the child you are assessing before and think you know their level of motor
ability. Their ability to score 1 or even 2 points may be unexpected. At subsequent assessments, you may
feel it is clearly unnecessary to test the child on some items but they should be attempted once or twice.

7. Trials/ number of attempts to achieve items

The subject is allowed three valid trials for each item. The best-performed trial will be scored.

8. Orthotic use
During the testing, no orthoses are to be used. This includes scoliosis jackets, Lycra suits/garments,
AFOs, socks and shoes. If the subject cannot perform the item without the use of orthotics, the score
should be recorded as a zero.

9. Attaining /maintaining starting position

Ideally the subject should get into the starting position themselves. If they are unable to do so they may
be placed into the starting position by the therapist where indicated. In order to score an item the correct
starting position must be achieved either by the individual or with the assistance of the therapist. If placed
by the therapist, they must be able to maintain the position independently.

Contractures: If the subject is unable to maintain the starting or end position of an item, it may often be
due to the fact that many children with SMA are prone to soft tissue contractures, specifically of the
tendoachilles, hamstrings, and hip flexors. Example positions that may be impacted include long sitting,
prone, kneeling, and standing. The impact of contractures on some items needs to be established,
therefore please detail on the proforma by ticking the “limited by contracture” column (LBC) and provide
any extra information if you perceive it to be a confounding factor. An example for item 11 – prop on
forearms, you would score LBC + 0 if the hips or pelvis are not in contact with mat due to contractures.

10. Clothing
Testing should be done with as minimal amount of clothing as is comfortable and does not restrict
movement. This will allow the evaluator to assess posture and compensations. T-shirts and shorts are
recommended. No socks or shoes.
 11. Previous assessments
Please do not examine previous results prior to reassessing a patient as this is likely to bias your current
assessment.

12. Compliance issues

When gaining and maintaining compliance is an issue, therapists are asked to make a value judgment as to
whether test results give a true value of the patient’s ability. If it is felt that data is poor this should be clearly
noted on the assessment sheet. Distractions should be kept to a minimum wherever possible during testing.

13. Rest breaks

Rest breaks are allowed if required but should be included in the overall timing of the test.

14. Clinical environment

Ideally the clinical environment should be kept as free of distractions as possible.

15. Time taken to complete

Timing of administration should begin after the test is explained to the subject and parents and the
subject is in the starting position for item 1. The subject should not be informed of the timed aspect of the
test as it may result in a sped up effort and unnecessary fatigue. Once the final task is attempted, timing
should cease. The time taken should be recorded in whole minutes (round up half minutes).

16. Timing tasks

Several tasks depend on being able to hold a position for 3 seconds. In the text this is called “for the count
of 3”. It is unnecessary to use a stopwatch for this amount of time when involved in a clinical assessment.
When counting to 3, time for 3 seconds by saying: “and 1 - and 2 - and 3” so that three seconds is
achieved on the word of 3. “For the count of 10” also utilize this approach.

17. Safety
For some tests having the evaluator available to guard the subject whilst attempting the task will be a
necessary safety precaution. For some items, such as “standing unsupported” or “stand to sitting on the
floor”, it may be advisable to have a bench/plinth nearby as well.

18. Equipment
- Plinth/Mat table or floor-mat
- Bench/Height adjustable plinth (mat table)
- Stairs, at least 4 (6 inch/15 cm in height) with a railing (or standard therapy stairs)
- Tape and ruler (see item 29)
Test item 1: Plinth /chair sitting
Starting Best attainable independent sitting position on floor/plinth. Sitting on edge of plinth
position or chair (feet unsupported).
Not in wheelchair. Back unsupported.
Finish Sitting with arms up, arms not in contact with body
position
Instruction Can you sit on the plinth/chair without using your hands for support for a count of 3?

Scoring Score 0: If subject uses both hands on mat or body for support including elbows
detail / resting/bracing/contacting on trunk, or holding onto a toy.
Diagram

Activity 2 1 0
Plinth / chair Able to sit using no hand Needs one hand support Needs two hand support to
sitting support for a count of 3 or to maintain balance for a maintain balance
more count of 3 Unable to sit
Photographs
/ Notes

Figure 1a Score 2 Subject

able to sit without hand Figure 1b Score 1 Subject Figure 1c Score 0 Subject
support for more than a able to maintain sitting unable to sit without
count of 3. Arms need to with one hand support for support externally, or
be clear of floor and body a count of 3. One hand unable to maintain a
for more than a count of support may be in contact sitting position for a count
3. with the surface or their of 3 without the use of
body. both hands.

Test item 1: Additional postural information

Starting Sitting on floor / plinth. Bottom in contact with mat. Legs should be positioned in front of
position body; however precise position does not matter.
You can record on the proforma predominant postures seen in the spine and in the legs.
This does not affect the scoring but is for clinical use to monitor change over time.
1 Predominant spinal posture

Details
of
posture 2 Predominant leg Ring sitting – ‘frog’ sitting with hips abducted and externally rotated, or cross-legged
posture sitting.

Long sit – with legs straight = knees may be flexed, knee caps pointing upwards, ankles
<10cm apart.

90/90 sitting – hips and knees at 90° on the edge of the plinth, feet unsupported (not in
Circle predominant spinal posture and wheelchair)
leg position
Test item 2: Long sitting
Starting Sitting on floor / plinth with the legs in maximal extension and kneecaps pointing
position to the ceiling. Back unsupported.

Finish Long sitting with legs straight and arms up, arms not in contact with body
position
Instruction Can you sit on the floor/plinth without using your hands for support and with your legs
straight for a count of 3? Don’t let your legs roll out.

Scoring Legs straight = knees may be flexed but knee caps must be pointing upwards,
detail / ankles no more than 10cm apart. This defines neutral hip rotation. If contractures
Diagram limit scoring mark in “limited by contracture” (LBC) column.

Activity 2 1 0
Long sitting Able to sit on floor/plinth Able to sit on floor/plinth Able to long sit using two
with legs straight without with legs straight hands for a count of 3
hand support for a count propping with one hand Or unable to sit with
of 3 support for a count of 3 straight legs

Photographs
/ Notes

Figure 2c Score 0 Subject

unable to maintain neutral
Figure 2a Score 2 Figure 2b Score 1 Subject hip rotation in long sitting
Subject able to maintain able to maintain long and/or requires both arms
long sitting with neutral sitting with neutral hip to support.
hip rotation without the rotation using one hand
use of hands for a count support for a count of 3.
of 3. Note Hand support may be in
accommodation of knee contact with the surface
contractures. or their body.
Test item 3: One hand to head in sitting
Starting Sitting on floor / plinth or over edge of chair/plinth. The sitting position used should
position be their best unsupported sitting position for use of their arms. Bottom in contact
with mat. Legs should be positioned in front of body; however, precise position
does not matter. Arms may be resting on mat or lap.
Not tested in wheelchair. No back support.

Finish All the fingertips of one hand above ear level (may or may not be in contact with
position head)
Instruction Can you get one hand to your head (above your ear) without bending your neck?
Scoring Ear level is an imaginary line made around the circumference of the head from the
detail / superior tip of the left ear, across the face to the eyebrow line, to the superior tip of
Diagram the right ear and behind their head back to the starting point.
Mark right or left arm in comments column
Arms free from side = visible space between arms and body, may be using
abduction or a combination of abduction and flexion.
Score 1: If uses any neck flexion or side tilt. If you observe minimal head flexion, ask
them to repeat the test to see if they can score 2. Able to place hand on head by
crawling hand up.

Score 0: Using two hands clasped together or supporting thumb/finger on body.

Activity 2 1 0
One hand to Able to bring one hand to Can only bring hand to Unable to bring hand to
head head – arms free from head by flexing head even using head and
side. Head and trunk head/trunk or by crawling trunk movement
remain stable hand up to top of head

Photographs
/ Notes

Figure 3c Score 0 Subject

attempts to reach the
head above level of ear
Figure 3a Score 2 Figure 3b Score 1 Subject but is unable to reach to
Subject able to touch able to touch head above ear line.
head above ear level ear level, however
whilst maintaining stable requires neck flexion to
trunk and head position. achieve the movement.
Repeat the movement if it
is not clear whether neck
flexion occurred.
Test item 4: Two hands to head in sitting
Starting Sitting on floor / plinth or over edge of chair/plinth. The sitting position used should
position be their best unsupported sitting position for use of their arms. Bottom in contact
with mat. Legs should be positioned in front of body; however, precise position
does not matter.
Not tested in wheelchair. No back support.

Finish All the fingertips (does not include thumbs) of both hands above ear level (may or
position may not be in contact with head)

Instruction Can you lift both hands up at the same time, to your head, without bending your neck?

Scoring Must bring hands up to head together (at the same time)
detail / Arms free from side = visible space between arms and body, may be using
Diagram abduction or a combination of abduction and flexion.
Score 1: If uses any neck flexion or side tilt. If you observe minimal head flexion, ask
them to repeat the test to see if they can score 2. Able to place hands on head by
crawling hands up.
Score 0: Using two hands clasped together or supporting thumb/finger on body.

Activity 2 1 0
Hands to Able to place both hands Able to place hands on Unable to place both
head in on head at the same time head but only using head hands on head
sitting – arms free from side. flexion or side tilt or
Head and trunk remain crawling hands up or one
stable at a time

Photographs
/ Notes

Figure 4a Score 2 Subject Figure 4b Score 1 Subject Figure 4c Score 0 Subject

can touch both hands to lifts both hands to his touches his face with both
head above the ear line head at the same time hands but is unable to
whilst maintaining stable and makes contact above reach above the ear line,
trunk and head position. ear line but flexes head. despite use of neck
flexion.
Test item 5: Supine to side lying
Starting Supine arms by side or in mid-position (see diagram), hips and shoulders facing
position upwards towards the ceiling

Finish Shoulders must be perpendicular to the floor, and the trunk and hips are to be in line
position with the shoulder and body. The lower leg position is not important but the thighs
are stacked on top of each other.

Instruction Can you roll onto your side in both directions?

Scoring Can use any strategy to achieve ½ roll except grabbing edge of the mat to help
detail /
Diagram Score 1: Mark right or left ½ roll in column scoring 1

Activity 2 1 0
Supine to Able to ½ roll onto side Can ½ roll onto side only Unable to ½ roll onto side
side lying from supine both ways one way either way
R/L

Photographs Score 1 If subject can ½

/ Notes roll to one side but not the
other. Right or left side
roll should be circled on
the score sheet.

Figures 5a Score 2 Figure 5b Score 0 Subject

Subject is able to achieve rolls his upper trunk but is
a ½ roll to both sides. His unable to bring hips in line
hips roll enough to be in with shoulders and
line with his shoulders and perpendicular to the mat.
perpendicular to the mat.
Test item 6: Rolls prone to supine over R
Starting Prone, arms in mid position (see diagram) or by side, hips and shoulders facing
position downwards towards the floor

Finish Supine with arms out from underneath body, hips and shoulders facing upwards
position towards the ceiling

Instruction Can you roll from your tummy to your back in both directions? Try not to use your
hands.

Scoring Score 2: Momentum is allowed as long as not pushing or pulling with arms. Can use
detail / legs.
Diagram Score 1: Locking hands together or using elbows. Can use legs.
Score 0: If unable to bring hips and shoulders into supine or grabs the edge of mat
to help. This may be due to limitations as a result of contractures. You would score
LBC + 0 if patient unable to achieve start/finish position (ie. hips or pelvis are not in
contact with mat due to contractures).

Activity 2 1 0
Rolls prone Rolls fully into supine Rolls fully into supine by Unable to roll into supine.
to supine with free arms to the pulling /pushing on arms Does not initiate or
over R right complete final supine
position

Photographs
/ Notes

Figure 6a Score 2
Subject rolls from prone
to supine over his right Figure 6b Score 1 Subject
side without using his moves from prone to Figure 6c Score 0
arms to help. supine independently Movement to full supine is
using one arm to push/pull attempted but not
them through the achieved. If due to
movement using the contractures mark 0 and
surface or on the other note this in the LBC
arm. Note subject is using column.
two arms locked together.
Test item 7: Rolls prone to supine over L
Starting Prone, arms in mid position or by side, hips and shoulders facing downwards
position towards the floor

Finish Supine with arms out from underneath body, hips and shoulders facing upwards
position towards the ceiling

Instruction Can you roll from your tummy to your back in both directions? Try not to use your
hands.

Scoring Score 2: Momentum is allowed as long as not pushing or pulling with arms. Can use
detail / legs.
Diagram Score 1: Locking hands together or using elbows. Can use legs.
Score 0: If unable to bring hips and shoulders into supine or grabs the edge of mat to
help. This may be due to limitations as a result of contractures. You would score
LBC + 0 if patient unable to achieve start/finish position (ie. hips or pelvis are not in
contact with mat due to contractures).

Activity 2 1 0
Prone to Rolls fully into supine with Rolls fully into supine by Unable to roll into supine.
supine over free arms to the left pulling /pushing on arms Does not initiate or
L complete final supine
position

Photographs See item 6

/ Notes
Test item 8: Rolls supine to prone over R
Starting Supine on mat/plinth with arms in mid position (see diagram) or by side,
position hips and shoulders facing upwards towards the ceiling

Finish Prone, with arms out from underneath the body, hips and shoulders facing
position downwards towards the floor

Instruction Can you roll from your back to your tummy in both directions? Try not to use your
hands.

Scoring Score 2: Momentum is allowed as long as not pushing or pulling with arms. Can use
detail / legs.
Diagram Score 1: Locking hands together. Can use legs.
Score 0: If unable to bring hips and shoulders into prone, if one shoulder/hip is
raised, or grabs the edge of mat to help. This may be due to limitations as a result
of contractures. You would score LBC + 0 if patient unable to achieve start/finish
position (ie. hips or pelvis are not in contact with mat due to contractures).

Activity 2 1 0
Rolls supine Rolls fully into prone with Rolls fully into prone by Unable to roll into prone.
to prone over free arms to the right pulling /pushing on arms Does not initiate or
R complete final prone
position

Photographs
/ Notes

Figure 8b Score 1 Subject

Figure 8a Score 2 able to achieve the task Figure 8c Score 0 If there
Subject able to roll from but uses elbows to push is an attempt to transition
supine to prone over his on the mat. from supine towards, but
right side without not achieving full prone.
pulling/pushing on his Subject grabs the edge of
hands. mat to help.
Test item 9: Rolls supine to prone over L
Starting Supine on mat/plinth with arms in mid position or by side, hips and shoulders facing
position upwards towards the ceiling

Finish Prone, with arms out from underneath the body, hips and shoulders facing
position downwards towards the floor

Instruction Can you roll from your back to your tummy in both directions? Try not to use your
hands.

Scoring Score 2: Momentum is allowed as long as not pushing or pulling with arms. Can use
detail / legs.
Diagram Score 1: Locking hands together. Can use legs.
Score 0: If unable to bring hips and shoulders into prone, if one shoulder/hip is
raised, or grabs the edge of mat to help. This may be due to limitations as a result of
contractures. You would score LBC + 0 if patient unable to achieve start/finish
position (ie. hips or pelvis are not in contact with mat due to contractures).

Activity 2 1 0
Rolls supine Rolls fully into prone with Rolls fully into prone by Unable to roll into prone.
to prone free arms to the left pulling / pushing on arms Does not initiate or
over L complete final prone
position

Photographs See item 8

/ Notes
Test item 10: Sitting to lying
Starting Sitting on plinth / floor, bottom in contact with mat. Legs should be positioned in
position front of body, however precise position does not matter.
Not 90/90 sitting over edge of bed.

Finish Supine, hips and shoulders facing upwards towards the ceiling
position
Instruction Can you lie down in a controlled/safe way from sitting?

Scoring Score 2: Controlled fashion can mean through side-lying or by lowering themselves
detail / in midline through their arms and legs to a supine position.
Diagram Score 1: May use one of the techniques above but lacks some control or flops
forward/rolls sideways. However remains safe – does not risk injury.
Score 0: Unable, needs assistance. May need guarding to not risk hitting head.

Activity 2 1 0
Sitting to Able to lie down through Able to lie down by Unable or completes in
lying side-lying or midline flopping forwards and uncontrolled/unsafe way
using clothes in a rolling sideways, or
controlled/safe way through prone in a
controlled/safe way

Photographs
/ Notes

Figure 10a Score 2

Subject moves from
Figure 10b Score 1
sitting to supine, through
Subject moves from
side-lying, or with use of
sitting to prone by
hands in a
flopping
controlled/safe fashion
forward/collapsing
without collapsing.
(controlled/safe) and
rolling sideways to get to
supine.
Test item 11: Props on forearms
Starting Prone with forehead resting on mat/plinth, hips and shoulders facing downwards
position towards the floor (pelvis in contact with mat) – arms down by side

Finish Prone and propping on forearms. Forearms should be on the surface and hands not
position clasped together. Pelvis must be in contact with the mat.

Instruction Can you prop yourself on your forearms with your head up (not holding your head) and
hold for a count of 3?

Scoring Score 2: If head is level with trunk or above it

detail / score 2
Diagram

Score 1: If can only achieve when placed and head is level with trunk or above it
Score 0: If unable to achieve prone position (if hips or pelvis not in contact with the
mat due to contractures). You would score LBC + 0 if hips or pelvis are not in contact
with mat due to contractures.

Activity 2 1 0
Props on Able to achieve prop on Holds position for a count Unable or holds for less
forearms forearms and hold head of 3 when placed than a count of 3
up independently for a
count of 3

Photographs Score 1 The subject is

/ Notes unable to attain this
position independently
but can maintain it for a
count of 3 when placed.

Figure 11a Score 2 Figure 11b Score 0

Subject able to Subject is unable to prop
independently transition on forearms and maintain
from prone to prop on head up. When placed,
forearms and maintain the subject supports the
this position with head up head with his hands by
for a count of 3. propping on elbows.
Forearms are not in
contact with the surface
area.
Figure 11c Score 0
Subject is unable to
achieve prone position
(hips are not in contact
with mat). Tick LBC.
Test item 12: Lifts head from prone
Starting Prone with forehead resting on mat/plinth, hips and shoulders facing downwards
position towards the floor - arms down by side. Pelvis does not need to be in contact with
the mat.

Finish Prone with chin clear of the mat. With arms either by side (score 2) or in mid
position position (abduction between 70° and 110° (score 1))

Instruction Can you lift your head up keeping your arms by your side for a count of 3?

Scoring Score 2: Chin needs to be clear of the mat and held for a count of 3. Achieves neck
detail / extension purely in the sagittal plane, no compensations.
Diagram Score 1: Chin must be clear of the mat and held for a count of 3. Arm positioned
between 70° and 110° shoulder abduction. Can use compensatory movements such
as side extension to lift head.

Activity 2 1 0
Lifts head Able to lift head upright Lifts head upright with Unable or lifts head for less
from prone through midline in arms in a mid position for a than a count of 3
prone, arms down by count of 3
side for a count of 3

Photographs
/ Notes

Figure 12c Score 0 Subject

is unable to lift head to
Figure 12b Score 1 The break contact with the mat
subject can only lift his with arms by the side or in
Figure 12a Score 2 head off the mat when his the mid position.
Subject able to lift head arms are in the mid
and break contact with position but can do this for
the mat for a count of 3 a count of 3.
with arms resting by
sides.
Test item 13: Prop on extended arms
Starting Prone with forehead resting on mat/plinth, hips and shoulders facing downwards
position towards the floor (pelvis in contact with mat) - arms down by side

Finish Prone with elbows extended and trunk in extension - umbilicus must be clear of
position surface.
Head must be above neutral position (neutral position means in line with neck
represented by the dotted line).
The position of the hands on the mat and the angle of the hands is not important
(can still score 1 or 2) but they should be within a radius of the shoulder joint.

Instruction Can you prop yourself up with straight arms for a count of 3?

Scoring Score 2: Hyperextension of elbows does not influence score. Strategy to get to final
detail / end position independently does not matter.
Diagram Score 1: Hyperextension of elbows does not influence score.
Score 0: If umbilicus is not clear of surface (belly button touches the surface) or if
hands are too far forward.
You would score LBC + 0 if hips or pelvis are not in contact with mat due to
contractures.

Activity 2 1 0
Prop on Able to prop on extended Can prop on extended Unable
extended arms, head up for a count arms if placed for a count
arms of 3 of 3

Photographs
/ Notes

Figure 13a Score 2 Figure 13b Score 1 Figure 13c Score 0

Subject able to transition Subject can maintain this Subject is unable to
from prone to prop on position when placed and maintain the position with
extended arms then hold for a count of 3 head above neutral for a
independently and hold without assistance. count of 3.
for a count of 3. (Operator hands present
for safety reasons
however operator support
is not allowed during
scoring of actual item).
Test item 14: Lying to sitting
Starting Supine arms by side, hips and shoulders facing upwards towards the ceiling
position
Finish Sitting up with bottom in contact with mat. Legs should be positioned in front of
position body; however, precise position does not matter.
Instruction Can you get from lying (supine) to sitting without rolling to your tummy?

Scoring Score 2: Able to get into sitting by using side-lying or supine – not turning into
detail / prone or towards floor.
Diagram Supine: Utilizes flexion in the sagittal plane (full sit-up), may use arms to assist.
Side: Able by using side lying / pushing up through side
Score 1: Turns into prone or towards floor and pushes up into sitting
Score 0: Requests to get close to edge of mat to throw legs off to help with
transition, or requires assistance from caregiver to complete the transition

Activity 2 1 0
Lying to Able by using Turns into prone or Unable
sitting supine/side-lying towards floor

Photographs Score 0 If the subject is

/ Notes unable to transition from
lying to sitting
independently.

Figure 14a Score 2 Figure 14b Score 1

Subject moves from lying Subject can
to sitting through side- independently move from
lying. lying to sitting by turning
into prone and pushing up
into sitting.
Test item 15: Four–point kneeling
Starting Prone on mat/plinth, arms in mid position (see diagram) or by side, hips and
position shoulders facing downwards towards the floor

Finish Four-point kneeling position with head extended and looking forward. Hands and
position knees should be roughly positioned under the shoulders and hips respectively.
Perfect alignment is not required.

Instruction Can you get onto your hands and knees with your head up and hold for a count of 3?

Scoring Score 2: Head extended, looking forwards

detail / Score 1: Head may be in line with body or extended beyond neutral when placed in
Diagram four-point kneeling.
Score 0: Head falls below the line of the body.

Activity 2 1 0
Four-point Achieves four-point Holds position when Unable
kneeling kneeling. Head up for a placed for a count of 3
count of 3

Photographs
/ Notes

Figure 15a Score 2

Subject is shown in
independent transition
from prone to four-point Figure 15c Score 0
kneeling, able to Figure 15b Score 1 Subject was unable to
maintain this position, Subject unable to maintain the position
with head up for a count independently achieve when placed. Head falls
of 3. position but once placed below the line of the
can maintain four-point body.
kneeling with head in line
with body or above for a
count of 3.
Test item 16: Crawling
Starting From four-point kneeling
position
Finish Remains in four-point kneeling but has moved forwards. Distance moved not
position important.

Instruction Can you crawl forwards?

Scoring Score 1 or 2: A point equals a hand or a knee. Moving all four points means moving
detail / both right and left arm, and both right and left leg (one arm, one leg, one arm and
Diagram one leg) in any order and does not need to be synchronous.
Score 2: Must be able to move both hands and knees at least two times
Score 1: Must be able to move both hands and knees at least once
Score 0: Moves both arms, but legs are dragged

Activity 2 1 0
Crawling Able to crawl forwards Moves all four points only Unable
Moves all four points once
twice or more

Photographs
/ Notes

Figure 16a Score 2 Clear

movement of all 4 limbs
at least 2 times in a row
(any pattern).
Test item 17: Lifts head from supine
Starting Supine on plinth/mat with arms crossed over chest (elbows clear from mat)
position
Finish Supine with head flexed using neck flexion (score 2) or off surface of the mat (score
position 1). Elbows clear from mat.

Instruction Can you lift your head to look at your toes keeping your arms folded for a count of 3?
Can demonstrate action passively. Useful to assess range of movement.

Scoring If the subject is unable to cross their arms over their chest due to arm weakness you
detail / can help fold their arms across their chest.
Diagram Score 2: Must be true neck flexion to lift head off floor, not just protraction.
Achieves neck flexion purely in the sagittal plane, no compensations.
Score 1: Uses compensatory movements such as side flexion and or protraction to
lift head
Score 0: Moves arms down by side or pushes elbows on surface to lift head

Activity 2 1 0
Lifts head In supine, can lift head Head is lifted but through Unable
from supine through neck flexion in side flexion, using
mid-line. Chin moves protraction, or with no
towards chest. Held for a neck flexion. Held for a
count of 3. count of 3.

Photographs Score 0 Head remains in

/ Notes contact with plinth.

Figure 17b Score 1

Subject able to flex head,
Figure 17a Score 2 breaking contact with the
Subject able to flex her mat for a count of 3 with
neck and break contact no neck flexion.
with the mat, holding the
position for a count of 3.
Test item 18: Supported standing
Starting Standing barefoot on the floor. No use of orthotics.
position The evaluator should be nearby to guard the subject in order to ensure safety.
A table, plinth, bench should be nearby at about hip height if ability is uncertain.

Finish Standing upright on both feet using one hand for support
position
Instruction Can you stand using one hand for support for a count of 3?

Scoring Scoring is not based on qualitative nature of stance.

detail / Definition of support
Diagram
- Subject uses one hand support on plinth/surface. Plinth is at level of umbilicus.
- Trunk, hip and knees must not be supported.
- Subject must be able to control hip, knee and pelvis independently.
- Can be placed in this position as long as they are able to maintain it.
Score 2: Using their hand as support
Score 1: If assessor needs to place hand on chest to prevent loss of control
Score 0: If needs hip and/or knee support or unable to stand or if leans trunk on
support surface or uses two hands
When counting to 3 – Use “and 1 - and 2 - and 3” so that three seconds is achieved
on the word of 3
Activity 2 1 0
Supported Can stand with one hand Able to stand with one Can stand with one hand
standing support for a count of 3. hand support and minimal support but needs
trunk support (not hip) for knee/hip support in
a count of 3. addition for a count of 3.
Or unable to stand
supported

Photographs
/ Notes

Figure 18a Score 2 Figure 18b Score 1 Able Figure 18c Score 0
Subject able to stand with to stand for a count of 3 Subject unable to achieve
the support of one hand but requires minimal standing without
for a count of 3. Trunk trunk support. additional support at hip
support not required. and trunk.
Test item 19: Stand unsupported
Starting Standing barefoot on the floor, feet should be approximately 10cm/hip width apart
position (place hand between feet to get approx. 10cm). No use of orthotics.
A table, plinth, bench could be nearby and at about hip height if ability is uncertain.

Finish Standing upright on both feet, taking full weight independently, posture is not
position important

Instruction Can you stand without holding onto anything for a count of 3?

Scoring Can be placed in this position as long as they are able to maintain it without
detail / support.
Diagram Scoring is not based on qualitative nature of stance. Scoring is based on time.
When counting to 3 – Use “and 1 - and 2 - and 3 - and” so that more than three
seconds is achieved on the last word “and”
Score 0: Momentarily means less than a count of 3 therefore scores 0 if stands
independently for less than a count of 3 or if needs hands on legs to maintain
position (counts as support).

Activity 2 1 0
Stand Can stand independently Stands independently for Stands only momentarily
unsupported for more than a count of 3 a count of 3 (less than a count of 3)
Or unable

Photographs Score 1 Subject able to Score 0 Subject is able to

/ Notes stand independently for a stand only momentarily or
count of 3. not at all.

Figure 19a Score 2

Subject is able to stand
independently for more
than a count of 3.
Test item 20: Stepping
Starting Standing barefoot on a level floor. Tested without orthotics, socks and shoes.
position Walking aides are not permitted.

Finish Remains in standing but has moved forwards. Distance moved not important.
position
Instruction Can you walk without using any help or aids? Show me

Scoring Score 1 or 2: Any independent gait pattern is acceptable i.e. waddling, no heel strike.
detail / Scoring is based on number of independent steps.
Diagram
Score 0: Requires hand-held for support, hands on knees for support, or if needs aids
(including any orthotics) to take steps.

Activity 2 1 0
Stepping Able to take more than 4 steps Able to take 2 – 4 steps Unable
unaided unaided

Photographs Score 1 Subject may

/ Notes require close
supervision, able to keep
balance for at least two
steps, may have limited
movement.

Must be a clear step –

foot must leave contact
with the floor.

Figure 20a Score 2

Able to take more than 4
independent steps.
Test Item 21 and 22: Right and Left hip flexion in supine
Starting Supine on mat/plinth with hips and knees in maximal available extension.
position Assess passive range for hip AND knee flexion prior to testing item.
*Note level of hip/knee flexion contracture in comments section as it may place
them at an increased mechanical advantage. Whilst conducting tests do not hold
down opposite leg.
Finish Full active range of hip and knee flexion is achieved and remains in supine.
position Maximum hip flexion = normal AROM or full available ROM. The thigh should
approximate the subject’s chest and the posterior calf should approximate the
thigh. Approximate does not necessarily mean touch.
Instruction Can you bring your right knee to your chest? Try to go as far as you can.
Now can you bring your left knee to your chest? Try to go as far as you can.
Individuals should not use their arms to assist this activity
Scoring Any strategy to gain hip flexion is permitted (i.e. anti-gravity movement in hip
detail / external rotation) however encourage the movement to be in vertical alignment.
Diagram Scoring is based on range of movement, not qualitative movement of lower limb.
Score 2: The subject is able to perform full flexion of unilateral hip and knee. They
can use any method to get there including hip external rotation, contacting the
other leg. Allow hip range with dissociation, when the opposite leg comes up, that
is the end of the range.
Score 1: The subject initiates unilateral hip and knee flexion or flexes through
partial range (defined as between 10% of flexion ROM to sub-full range). They can
use external rotation at hip or contact the other leg.
Score 0: The subject is unable to initiate unilateral hip and knee flexion or uses
ankle dorsi/plantarflexion only to move heel up the mat or rolls to side (raise pelvis)
to help pull leg up. Severe hip and knee flexion contractures putting the leg at a
mechanical advantage scores a 0.
Activity 2 1 0
Right and Full hip flexion achieved Able to initiate unilateral Unable
Left hip Full range is defined as > hip and knee flexion >10%
flexion in but does not achieve full
110°
supine range (<110°)
Photographs
/ Notes

Figure 21a Score 2 Figure 21b Score 1

Subject is able to Subject initiates hip and
perform full flexion of hip knee flexion or flexes Figure 21c Score 0
and knee (i.e. beyond through partial range- Subject can only flex at
110°). The thigh visible knee and hip hip and knees with both
approximates the flexion > 10% from legs moving at same time.
subject’s chest. starting position. The foot Subject also has severe
may/may not leave the hip and knee flexion
surface of the bed. contractures putting leg at
mechanical advantage.
Test item 23: High kneeling to right half kneel
Starting High kneeling, arms free. The evaluator should be nearby to guard the subject in
position order to ensure safety.
Arms may be used to assist with transition or subject is able to use one arm on a
bench to support themselves when placed in this position. It is permitted to use a
therapy bench/plinth/their own body for support. This item may require a few "test
trials" to determine whether or not the subject will require a bench for support.

Finish Half kneeling defined as weight taken on one knee and the opposite foot and the
position buttocks are clear of the lower leg. Right half kneeling is with the weight bearing
on the right knee and left foot forwards. Alignment is not a consideration.
Instruction Can you bring your left leg up so that your foot is flat on the ground without using
your arms and hold for a count of 10?
Scoring Scores 2: The subject transitions from high kneeling to half kneeling on right knee,
detail / with or without the use of arm support, and then maintains right half kneel for a
Diagram count of 10 without arm support. Leg may be in any position.
Scores 1: When placed in right half kneel, or gets there by any method, the subject
can maintain the position for a count of 10 with the use of one arm support for
balance only. Leg may be in any position. Once in right half kneel, any use of the
bench for maintaining this position restricts the subject to a score of 1 or less.
Scores 0: The subject is unable to maintain right half kneeling, even when placed,
for a count of 10 with the use of one arm support or if leans trunk or hips on support
surface.
Activity 2 1 0
High Able to achieve half kneel Maintains half kneel with Unable
kneeling to (with or without arm one arm support for a
right half support) and maintains count of 10
kneel position without arm
support for a count of 10
Photographs
/ Notes

Figure 23a Score 2 Figure 23b Score 1 Figure 23c Score 0

Able to complete without Subject requires use of Unable to get into half
need of arms for one hand on the bench to kneeling or maintain
transition or to maintain get into the position of position.
half kneeling. half kneel or to maintain
half kneeling.
Subject able to be placed
into half kneel and
maintain one arm support
for a count of 10.
Test item 24: High kneeling to left half kneel
Starting High kneeling, arms free. The evaluator should be nearby to guard the subject in
position order to ensure safety.
Arms can be used to assist with transition or subject is able to use one arm on a
bench to support themselves in this position. It is permitted to use a therapy
bench/plinth/their own body for support. This item may require a few "test trials" to
determine whether or not the subject will require a bench for support.

Finish Half kneeling defined as weight taken on one knee and the opposite foot and the
position buttocks are clear of the lower leg. Left half kneeling is with the weight bearing on
the left knee and right foot forwards. Alignment is not a consideration.

Instruction Can you bring your right leg up so that your foot is flat on the ground without using
your arms and hold for a count of 10?

Scoring Scores 2: The subject transitions from high kneeling to half kneeling on left knee,
detail / with or without the use of arm support, and then maintains left half kneel for 10
Diagram seconds without arm support. Leg may be in any position.

Scores 1: When placed in left half kneel, or get there by any method, the subject
can maintain the position for 10 seconds with the use of one arm support for
balance only. Leg may be in any position. Once in left half kneel, any use of the
bench for maintaining this position restricts the subject to a score of 1 or less.

Scores 0: The subject is unable to maintain left half kneeling, even when placed for
10 seconds with the use of one arm support or if leans trunk or hips on support
surface.

Activity 2 1 0
High Able to achieve half kneel Maintains half kneel with Unable
kneeling to (with or without arm one arm support for a
left half support) and maintains count of 10
kneel position without arm
support for a count of 10

Photographs See 23
/ Notes
Test item 25: High kneeling to standing, leading with left leg (through right half kneel)
Starting High kneeling, arms free
position
Finish Standing upright on both feet, taking full weight independently, posture is not
position important

Instruction Can you stand up from this position starting with your left leg without using your
hands?

May need demonstration

Have a bench nearby in case the subject requires support for balance or strength

Scoring Scores 2: The subject independently transitions from high kneeling to standing via
detail / right half kneel without arm support. Contact with subject’s own body, i.e. hands on
Diagram thigh, is considered arm support and therefore cannot be given a score of 2. Half
kneeling on the right knee must be used in the transition from high kneeling to
stand.

Scores 1: Stands up through half kneeling with arm support (1 or 2 hands) or

initiates transition to standing by un-weighting the weight bearing knee, with or
without arm support, or leans trunk on bench, but trunk not weight bearing through
top of bench.

Scores 0: The subject is unable to initiate standing.

Activity 2 1 0
High kneel Able to stand with arms Able to shift weight off Unable
to stand free both knees (with or
through without arm support)
right half
kneel

Photographs
/ Notes

Figure 25a Score 1

Subject uses arms to
initiate standing.
Test item 26: High kneeling to standing leading with right leg (through left half kneel)
Starting High kneeling, arms free
position
Finish Standing upright on both feet, taking full weight independently, posture is not
position important

Instruction Can you stand up from this position starting with your right leg without using your
hands?
May need demonstration
Have a bench nearby in case the subject requires support for balance or strength

Scoring Scores 2: The subject independently transitions from high kneeling to standing via
detail / left half kneel without arm support. Half kneeling on the left knee must be used in
Diagram the transition from high kneeling to stand.

Scores 1: Stands up through half kneeling with arm support or initiates transition to
standing by un-weighting the weight bearing knee, with or without arm support, or
leans trunk on bench, but trunk not weight bearing through top of bench.

Scores 0: The subject is unable to initiate standing.

Activity 2 1 0
High kneel Able to stand with arms Able to shift weight off Unable
to stand free both knees (with or
through left without arm support)
half kneel

Photographs
/ Notes

Figure 26b Score 1

Subject moves from high Figure 26c Score 0
Figure 26a Score 2 kneel to left half kneel and Subject unable to initiate
Subject stands from high uses arm support to standing from a high
kneeling through left half stand. kneeling position.
kneel without the use of
arm support.
Test item 27: Stand to sitting on the floor
Starting Standing barefoot on a level floor or mat. In order to attempt this item, the subject
position must be able to maintain independent standing without arm support. Guard
patient for safety.

Finish Sitting up with bottom in contact with mat. Legs should be positioned in front of
position body, however precise position does not matter.
Instruction Can you sit on the floor in a controlled/safe way from standing? Try not to use your
arms.

Scoring Scores 2: The subject is able to lower themselves to sitting on the floor with control
detail / and without using their arms. "With control" implies that the movement is regulated
Diagram or directed, no fast movements or collapse permitted.

Scores 1: The subject is able to lower to sitting on floor with the use of arms or
crashes during the transition.
“Crash" indicates a loss of control.
Contact with the subject’s own body, i.e. hands on thighs for support is considered
arm support and therefore a score of 2 cannot be given.
Scores 0: The subject does not transition to the floor or requires any use of furniture
to assist.

Activity 2 1 0
Stand to Able to sit down with Sits on floor using hands Unable
sitting on arms free and no collapse on floor/body or crashes
floor in a controlled manner

Photographs
/ Notes

Figure 27a Score 1

Subject able to sit down
using hands on floor.
Test item 28: Squat
Starting Standing barefoot independently on a level floor or mat. Guard patient for safety.
position No orthotics used.

Finish Squat position defined as hips and knees flexed to greater than 90°
position
Instruction Can you squat? Pretend you are going to sit in a very low seat-only go as far down as
you are able to get up from on your own

Scoring Scores 2: The subject attains a full squat position without arm or external support.
detail / Subject does not need to return to standing position. If the subject attains the full
Diagram squat position but requires the use of arm support (hands on their own body) in
order to do so, a score of 2 cannot be given.

Scores 1: The subject crouches more than 10% of the motion (achieves 100 of knee
flexion only, hip flexion not required) to less than 900 hip and knee flexion (mid-
range squat) with or without the use of arm support. External support (aides and the
mat) are not allowed. Subject does not need to return to standing position.

Scores 0: The subject is unable to initiate the squat, only unlocking the knees, or
only exhibiting trunk/hip flexion. Subject uses external support.

Activity 2 1 0
Squat Squats hips and knees Initiates squat in both Unable to control or
flexed to greater than 90° knees (10° to <90°), uses initiate
with arms free arm support

Photographs
/ Notes

Figure 28b Score 1

Figure 28a Score 2 Subject using arms to
Subject able to attain a squat greater than 10° but
full squat without using does not reach 90°
arms - hips and knees degrees of hip and knee
flexed greater than 90°. flexion.
Test item 29: Jumps 12 inches forward
Starting Standing barefoot on a level floor.
position Position the standing subject comfortably in front of two parallel lines [taped 12” (30
cm) apart on the floor].
Guard patient for safety.

Finish Must have landed without use of arm support and without falling forward
position
Instruction Can you jump as far as you can, with both feet, from this line all of the way to the other
line?

Scoring The distance jumped is from the starting line to the back of the heels. In the case
detail / that the distance travelled by two feet is uneven, the lesser distance should be
Diagram considered.

Scores 2: The subject jumps 12” (30 cm) with both feet simultaneously

Scores 1: The subject jumps with both feet simultaneously (clearing both feet from
the ground) but travels 2-11” (5-28 cm)

Scores 0: The subject is unable to initiate jumping forward with both feet
simultaneously. This includes one foot leading in a jump. If falls on landing or if uses
hands to land.

Activity 2 1 0
Jumps Jumps at least 12” (30 Jumps between 2- 11” (5- Unable to initiate jump
forward 12” cm), both feet 28 cm), both feet with both feet
simultaneously simultaneously simultaneously

Scoring Detail for Item 29

Photographs / Notes

Figure 29a Starting Figure 29c Shows how

Position. Subject is Figure 29b Subject the distance of the
placed with toes jumping with both feet jump is measured,
touching the starting simultaneously leaving from the starting line
line. the floor. to the back of the
heels.
Test item 30: Ascends 4 stairs with railing
Starting Standing independently, barefoot at the base of the four stairs
position
Finish Standing at the top of the stairs, both feet on top step. May still use rail for support
position if required.
Instruction Can you walk up the steps? You can use one railing (can use two hands to one rail).

Scoring Using a set of standard steps (each step 15cm/6 inches in height, therapy stairs if
detail / possible), goal is to ascend 4 steps, must complete all 4 steps to score a 2.
Diagram Alternating pattern = Step-through pattern, one foot to a step, reciprocal
movement with alternate leg on each step
Marking time = Step-to pattern, two feet to a step
1 rail = hand(s) on body and/or rail, 2 hands on 1 rail, providing support of any kind

Scores 2: The subject ascends four steps, holding one rail and utilizes an alternating
stepping pattern. Two hands on one rail are acceptable. *If the subject ascends 4
steps using an alternating pattern and without the use of a rail, a score of 2 should
be given. Widening base of support is acceptable.

Scores 1: The subject ascends at least 2 steps, holding one rail utilizing a alternating
or step-to pattern. Subjects who demonstrate a step-to pattern (moving one leg up
one step and then bringing the opposite leg up to the same step) at any time during
the four steps would only meet the criterion for a score of 1. This includes subject
facing the railing and side-stepping up the steps.

Scores 0: The subject is unable to ascend 2 steps with the use of one rail
Activity 2 1 0
Ascends 4 Ascends 4 steps with Ascends 2-4 steps, one Unable to ascend 2 steps
stairs, with railing, alternating feet rail, any pattern using one rail
railing
Photographs
/ Notes

Figure 30b Score 1 Figure 30c Score o

Subject ascends at least 2 Subject ascends 4 steps
Figure 30a Score 2 steps, holding one rail using two rails or unable
Subject ascends 4 steps using an alternating or
with alternating steps, “step to” pattern. Holds
holding onto one rail with one railing with two
one hand (two hands on hands.
one railing would still
score 2).
Test item 31: Descends 4 stairs with railing
Starting Standing independently barefoot at the top of the four stairs
position
Finish Standing at the base of the four stairs, both feet on floor. May still use rail for
position support if required.

Instruction Can you walk down the steps? You can use one railing (can use two hands to one rail).

Scoring Using a set of standard steps (each step 15cm/6 inches in height, therapy stairs if
detail / possible), goal is to descend 4 steps, must complete all 4 steps to score a 2
Diagram Alternating pattern = Step-through pattern, one foot to a step, reciprocal
movement with alternate leg on each step
Marking time = Step-to pattern, two feet to a step
1 rail = hand(s) on body and/or rail, 2 hands on 1 rail, providing support of any kind

Scores 2: The subject descends four steps, holding one rail and utilizes an
alternating stepping pattern. Two hands on one rail are acceptable.
If the subject descends 4 steps using an alternating pattern and without the use of a
rail, a score of 2 should be given.

Score 1: The subject descends at least 2 steps, holding one rail utilizing an
alternating or step-to pattern.
Subjects who demonstrate a step-to pattern (moving one leg down one step and
then bringing the opposite leg down to the same step) at any time during the four
steps would only meet the criterion for a score of 1. This includes subject facing the
railing and side-stepping down the steps.

Score 0: The subject is unable to descend 2 steps with the use of one rail.
Activity 2 1 0
Descends 4 Descends four steps, with Descends 2-4 steps, one Unable to descend 2 steps
stairs, with railing, alternating feet rail, any pattern using one rail
railing
Photographs
/ Notes

Figure 31c Score 0 Two

Figure 31a Score 2 Figure 31b Score 1 railings are required to
Subject can descend 4 Subject can descend at descend steps or unable.
steps holding onto one least 2 steps holding onto
railing with one (or two) one railing with two hands
hand and stepping but requires both feet on a
alternately. step to move down to the
next step.
Test item 32: Ascends 4 stairs without arm support
Starting Standing independently, barefoot at the base of the four stairs
position
Finish Standing at the top of the four stairs, both feet on top step
position
Instruction Can you walk up the steps? This time try not to use the railing.

Scoring The subject may not touch the rail or the steps with either hand (i.e. must remain
detail / arms free). Arm support includes contact with the rail or steps or subjects own
Diagram body.
Alternating pattern = Step-through pattern, one foot to a step, reciprocal
movement with alternate leg on each step

Marking time = Step-to pattern, two feet to a step

Scores 2: The subject ascends 4 steps and utilizes an alternating foot pattern
without the use of arm support.

Scores 1: The subject ascends at least 2 steps utilizing either an alternating or step-
to pattern without arm support. If, at any time, a step-to pattern (one leg up one
step followed by bringing the opposite leg up to the same step) is used, a maximum
score of 1 should be given.

Scores 0: The subject is unable to ascend 2 steps without arm support. If the subject
touches the railing, their body, or the evaluator for balance or support, a score of 0
should be given.

Activity 2 1 0
Ascends Independently (without Ascends 2-4 steps, arms Unable to ascend 2 steps
fours stairs support/rail) ascends four free, any pattern arms free
arms free steps using alternating
feet

Photographs Score 1 Subject climbs at

/ Notes least 2 steps with either
an alternating or a step-to
pattern without touching
rails.

Figure 32a Score 2

Ascending steps hands- Figure 32c Score 0 A
free with alternating step- requirement to touch or
through pattern. hold the rails scores 0.
Test item 33: Descends 4 stairs without arm support
Starting Standing independently, barefoot at the top of the four stairs
position
Finish Standing at the base of the four stairs, both feet on floor
position
Instruction Can you walk down the steps? This time try not to use the railing.

Scoring The subject may not touch the rail or the steps with either hand (i.e. must remain
detail / arms free). Arm support includes contact with the rail or steps or subjects own
Diagram body.
Alternating pattern = Step-through pattern, one foot to a step, reciprocal
movement with alternate leg on each step

Marking time = Step-to pattern, two feet to a step

Scores 2: The subject descends 4 steps utilizing an alternating foot pattern without
the use of arm support.

Scores 1: The subject descends at least 2 steps and utilizes either an alternating or
step-to pattern without arm support. If, at any time, a step-to pattern (one leg
down one step followed by bringing the opposite leg down to the same step) is
used, a maximum score of 1 should be given.

Scores 0: The subject is unable to descend 2 steps without arm support. If the
subject touches the railing, their body, or the evaluator for balance or support, a
score of 0 should be given.

Activity 2 1 0
Descends 4 Independently (without Descends 2-4 steps, arms Unable to descend 2 steps
stairs arms support/rail) descends free, any pattern arms free
free four steps using
alternating feet

Photographs
/ Notes

Figure 33a Score 2

Descends hands-free
using alternating step- Figure 33b Score 1
through pattern. Descends hands-free
using step-to, marking
time pattern.
 Acknowledgements

This manual is the result of the International Spinal Muscular Atrophy Consortium (iSMAC) collaboration between SMA
REACH UK, the Italian SMA Network and the Pediatric Neuromuscular Clinical Research Network (PNCR) for SMA
(USA). We are also grateful to Marion Main for the creation of the original Hammersmith Functional Motor Scale (HFMS)
and her support for its use worldwide. We also would like to acknowledge previous authors for their work in development
of the HFMSE 2009 manual upon which this 2019 manual is based. We also thank the previous authors of the manuals
for their permission to reproduce their original photographs for this manual. This manual was made possible through
generous support by The SMA Trust (UK) who has funded SMA REACH UK, from the Italian Telethon and Famiglie
SMA to the Italian SMA network, and the support of the SMA Foundation (USA). We acknowledge Spinal Muscular
Atrophy Support UK (formerly The Jennifer Trust for SMA) for the development of previous scales. We are grateful to
all of the clinicians and investigators that have provided feedback and input. Finally, we thank those affected with SMA
and their families who have given us their time and their permission to use their photographs to illustrate this assessment
tool successfully.

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