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Nudges

Description & Directions

The nudge items are intended to examine the patient's ability to react to an unknown disruption of their balance.  Therefore it is important that you do not tell the patient immediately before the nudge and that you nudge them only once.  This will accurately allow you to see how an unknown balance perturbation affects the patient's ability to maintain their sitting balance.

During your general FIST directions and explanation you should have stated that you will occasionally lightly push the patient during the test in a variety of directions without warning to see how well they react.  At that time be sure to reinforce that you will be present to ensure they do not lose their balance.  You should not tell the patient immediately before you nudge them; rather the directions for the nudges are embedded in the general FIST description given before testing occurs.

Three nudges are included in the FIST: an anterior nudge, a posterior nudge, and a lateral nudge on the dominant or stronger side. These nudges should be randomly inserted during the FIST by the therapist so they will be unexpected by the patient.

Nudge Locations

  • Anterior nudge: At sternum
  • Posterior nudge: Between scapular spines
  • Lateral nudge: At acromion on dominant or stronger side

In summary, nudges should be

  • RANDOMLY inserted throughout test
  • Given WITHOUT immediate warning
  • Use LIGHT pressure, enough to require a balance reaction
  • ONE push only, for each direction

Scoring Nudges

 Score  Description  Selected Example

4

Independent

Normal performance

 3

Verbal cues/increased time

Puts hand down to perserve balance, on second attempt after cueing to not use hand can perform without the use of their hand.

 2

Upper extremity support
Must put hand down to support self after 1-2 repeated attempts after cueing patient to not use hands.

 1

Needs assistance

Generates insufficient balance reaction and requires min A to maintain upright balance

 0

Dependent

Cannot generate balance reaction and requires total A when nudged.

Common Questions about Nudge Items

  • How hard do I nudge someone? You only want to displace the patient enough to generate a balance reaction.  You may have to practice on a variety of 'normal' persons (family, colleagues) to get an idea of how much pressure is required to generate a balance reaction.

Video examples

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