North Star Ambulatory Assessment

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Objective

The North Star Ambulatory Assessment (NSAA) is a 17-item rating scale that is used to measure functional motor abilities in ambulant children with Duchenne Muscular Dystrophy (DMD). It is usually used to monitor the progression of the disease and treatment effects.

Intended Population

Ambulant children with DMD.

Method of Use

Equipment Required:

• a size-appropriate chair or height adjustable plinth
• box step, approximately 15 cm high
• a mat
• a stopwatch
• a clear, straight, and marked 10 metres pathway

Test Details and Instruction:

The test must be completed without the use of any thoracic brace or leg orthoses. Therapist asks the patient to complete activities listed in the table below.

The activities are graded as follows:

2 - "Normal" - no obvious modification of activity

1 - Modified method but achieves goal independent of physical assistance from another

0 - Unable to achieve independently

Range of score: 0 - 34

Activity	Instructions to patient	Starting position / test detail	Comments
1. Stand	Can you stand up tall for me for as long as you can and as still as you can?	Feet should be close together and heels on the ground if possible. Arms by sides. NO shoes should be worn.	Best done on the floor rather than on a mat. Whichever is chosen maintain consistency through repeated testing sessions. Minimum count of 3 seconds to score 2.
2. Walk	Can you walk from A to B (state to and where from) for me?	Walk without shoes/socks on. Should be enough of a distance to observe ‘normal gait’ for that subject.	A value judgement needs to be made in scoring – if the patient generally toe walks but occasionally gets heels flat, or can on request but doesn’t usually, they should score 1
3. Stand up from chair	Stand up from the chair keeping your arms folded if you can	Starting position 90º hips and knees, feet on floor/supported on a box step.	A size-appropriate chair or height adjustable plinth should be used. Arms should be kept crossed throughout the activity to score 2.
4. Stand on one leg - Right	Can you stand on your right leg for as long as you can?	Minimum count of 3 seconds to score 2. NO shoes should be worn.	Best done on the floor rather than on a mat. Whichever is chosen maintain consistency through repeated testing sessions.
5. Stand on one leg - Left	Can you stand on your left leg for as long as you can?	Minimum count of 3 seconds to score 2. NO shoes should be worn.	Best done on the floor rather than on a mat. Whichever is chosen maintain consistency through repeated testing sessions.
6. Climb box step - right	Can you step onto the top of the box using your right leg first?	Stands facing the box step. Step should be approximately 15cm high	Support may be provided by the use of a height adjustable plinth, or, if not available a ‘neutral’ hand from the therapist.
7. Climb box step - left	Can you step onto the top of the box using your left leg first?	Stands facing the box step. Step should be approximately 15cm high	Support may be provided by the use of a height adjustable plinth, or, if not available a ‘neutral’ hand from the therapist.
8. Descend box step - Right	Can you step down from the box using your right leg first?	Stands on top of the box step facing forwards. Step should be approximately 15cm high	Support may be provided by the use of a height adjustable plinth, or, if not available a ‘neutral’ hand from the therapist.
9. Descend box step - Left	Can you step down from the box using your left leg first?	Stands on top of the box step facing forwards. Step should be approximately 15cm high	Support may be provided by the use of a height adjustable plinth, or, if not available a ‘neutral’ hand from the therapist.
10. Gets to sitting	Can you get from lying to sitting?	Starting position supine on a mat. No pillow should be used under head	If patient turns into prone or towards the floor to work their way into sitting 1 should be scored
11. Rise from floor	Get up from the floor using as little support as possible and as fast as you can (from supine)	Starting position supine with arms by sides, legs straight. No pillow to be used	Activity should be attempted without use of furniture in the first instance. Do not note time if a chair has to be used.
12. Lifts head	Lift your head to look at your toes keeping your arms folded	Supine on a mat. No pillow should be used.	Ask patient to keep arms crossed over chest during the activity to avoid self-assist. Also ask to look at toes to ensure neck is flexed – should be a chin to chest manoeuvre.
13. Stands on heels	Can you stand on your heels?	Standing on the floor. No shoes to be worn.	Watch for inversion. If substantial inversion but forefeet are still lifted – score 1. If only inversion with lateral border of foot still on the ground score 0.
14. Jump	How high can you jump?	Standing on the floor, feet fairly close together.	Want height, not forward movement. Small amount of forward movement acceptable
15. Hop right leg	Can you hop on your right leg?	Starting position standing on floor on right leg. No shoes should be worn.	Needs obvious floor clearance to score 2
16. Hop left leg	Can you hop on your left leg?	Starting position standing on floor on right leg. No shoes should be worn.	Needs obvious floor clearance to score 2
17. Run (10m)	Run as fast you can to……(give point)	A straight 10m walkway should be clearly marked in a quiet department or corridor. A stopwatch should be used to time the walk. Be consistent as to whether shoes are worn or not. Ensure safety of patient. They should self select speed after being asked to go ‘as fast as they can’.	‘Duchenne jog’ - not a true run (there probably IS a double support phase), but more than a walk. Typically characterized by excessive use of arms, trunk rotation, substantial ’waddle’. No real ‘pushoff’

Links

North Star Ambulatory Assessment