Abigail Spaulding was worried. Her 20-year-old patient seemed to have plateaued, having made little progress during his two weeks at one of the country’s premier brain trauma centers, Spaulding Rehabilitation Hospital in Boston. His accident had left him with a brain injury so severe he couldn’t understand basic commands or sit up on his own.
Spaulding, a doctor of physical therapy and neurologic specialist, knew that if she couldn’t track signs of improvement, the patient’s health insurance company was likely to send him to a skilled nursing facility. Though such in-patient rehabilitation centers can be helpful for patients without specialized needs, Spaulding feared that sending her patient to one might mean months would pass before he could push himself in a wheelchair or walk again—if at all. With her hospital’s advanced care, equipment, and expertise, she was confident he’d be rolling himself in a wheelchair and even walking with some assistance in a matter of weeks. He’d be able to skip the nursing facility altogether and return to his family. She just had to convince the insurance company.
“Our team works with patients three hours a day on rehabilitation. This specialized treatment can make a big difference in just a short amount of time,” says Spaulding, whose grandfather founded the hospital.
It was 2016, and a new measure of patient progress had just been introduced at the hospital. It was called the FIST or Function in Sitting Test. Unlike other tracking methods at the time which measured a patient’s ability to stand and walk, this test was designed by a Bay Area physical therapist for low-functioning patients who had trouble maintaining balance and posture to sit. The FIST proved that despite Spaulding’s patient’s apparent plateau, there had been progress—enough to justify a few more weeks in the hospital’s traumatic brain injury team’s care.
Today, the FIST is a leading tool used worldwide by physical therapists to better understand and treat low-functioning patients who can’t sit upright. And it was created by SMU Professor Sharon Gorman, DPTSc, PT, board-certified geriatric clinical specialist.
Answers are hard to come by
The seed for the FIST took root when Gorman couldn’t get answers. Having worked in ICUs with stroke and accident patients for seven years, she often found herself caring for people who couldn’t sit up. One of Gorman’s major concerns was that her patients might fall trying to get in or out of a wheelchair. Other patients had trouble breathing because of poor posture caused by sitting imbalance. She wanted to know what therapies might improve their ability to sit, turn, and reach without falling or slumping—and how to measure their progress.
In 1999, Gorman flew to Seattle hoping to speak with other experts at the American Physical Therapy Association Combined Sections Meeting, the country’s biggest conference for physical therapists. She arrived early to a lecture on balance, featuring the world’s foremost researchers, including Anne Shumway-Cook and Marjorie Wollacott.
“I remember thinking, ‘This will be fantastic. I’ll finally have answers for my patients,’” Gorman says.
But while the experts had a lot to say about people re-learning how to balance in standing and walking, they had nothing to say about the patients she worked with.
Gorman was surprised. Why was there so little information on this population? She mentioned this to a friend at the conference, who told her: “Sounds like you’re going to have to be the one to do the research.”
Gorman chuckled. “Really?” she thought. But after mulling it over, it made sense. She was in the perfect position.
There’s a science to measuring balance
Gorman later enrolled in the Doctor of Physical Therapy Science program at the University of California, San Francisco (UCSF) and needed a research topic for her dissertation. As a physical therapist at Regional Medical Center in San Jose, Gorman had plenty of professional experience and access to work with low-functioning patients who have trouble sitting and other basic tasks.
At the time, therapists relied on observation and intuition to determine a patient’s sitting balance ability. Patients were rated on a scale of “good,” “fair,” “bad,” and “poor;” definitions varied from facility to facility. “It’s difficult to document progress when you’ve only got four words. A patient may improve in some small way, but still fit the definition of ‘poor.’”
At UCSF, Gorman discovered why so little had been done on the subject. It’s difficult to study patients with sitting imbalance because they are often older and have other problems going on, so it’s hard to isolate the research. Plus, there aren’t as many patients who have trouble sitting. So, researchers naturally chose to study a population that was more readily available: those who have trouble standing.
Gorman took classes on how to write research proposals and launch research studies, as well as courses on geriatric physiology so that she could better understand the typically older patient populations who have trouble with sitting balance. She realized that the ideal research participant would be stroke patients, who are relatively abundant in hospitals. That is why the FIST is still primarily used for stroke patients, though it is also helpful for certain types of brain trauma.
Unlike tests before it, the FIST is an objective method to assess patients with sitting balance issues. Patients complete a series of actions that people do while sitting and are scored on each: turning their head from side to side, lifting a hand, picking up their foot. A physical therapist can determine whether the patient is improving in sitting balance based on their scores and identify where challenges are that can be targeted with improvement exercises.
Gorman finished her doctor of science degree in 2009, and a year later, her FIST research was published in the Journal of Neurologic Physical Therapy. To make the test freely available and accessible to all, Gorman published a guide to using the FIST on Samuel Merritt University’s website, where she had become an assistant professor. Over time, the test gained recognition, and people from all around the world started contacting Gorman to find out how they could implement it in their hospitals.
Looking back, Gorman is amazed by her professional trajectory.
“It’s exciting how weird moments—like that friend telling me at the conference that I’d have to be the person to do the research—can really change your life,” she says.
For physical therapists at Spaulding Rehabilitation Hospital in Boston, the FIST was a game-changer, providing a way to objectively track progress in sitting balance for the first time.
On the second week of treatment with her 20-year-old brain trauma patient, Spaulding saw that just because he didn’t seem to be improving by former measurement methods, the FIST showed small, but significant progress. He scored higher on measures looking at how he could turn his head or move his arm forward.
When she petitioned the insurance company to allow her patient to stay for six weeks, rather than transfer him to a skilled nursing facility, the insurance company agreed. At the end of six weeks, the patient had recovered enough to roll himself in a wheelchair and walk with her assistance.
Spaulding notes that it wasn’t just the FIST test data that proved the patient was improving: There was also data from his speech therapist, occupational therapist, and others. But the FIST was a vital part of the assessment.
“This is why the FIST is so important,” Spaulding says. “If I hadn’t been able to objectively prove even that small amount of progress to the insurance company, my patient might have gone to a nursing facility and never walked again—or at least taken significantly longer to make progress without the kind of specialized care we are able to provide.”
The FIST doesn’t only show whether a patient is improving. It can also act as a warning sign if a patient is in decline. In 2018, one of Spaulding’s patients had brain surgery to implant a ventriculoperitoneal shunt—a device that removes excess fluid. Over the weeks, the patient’s FIST scores dropped lower and lower. Spaulding and her colleagues contacted the patient’s doctor, who determined the shunt was not functioning properly. After an adjustment surgery, the patient quickly improved.
The FIST can be used to make other treatment decisions, as well. For example, if a patient is scoring high in static balance, such as sitting style and typing on a computer, but having trouble with dynamic balance, such as bending over to put on a pair of socks, the physical therapist may choose to focus particularly on exercises that help with dynamic balance.
Can FIST predict the chances of recovery?
When the FIST was rolled out at Spaulding Rehabilitation Hospital in 2016, a group of physical therapists—including Spaulding—connected with Gorman to better understand and use the test.
The group wondered whether the test might have an ability to predict how quickly a patient could recover. For example, if a patient achieved a certain score upon entering the hospital, would that make it more or less likely they might walk again in four weeks?
Gorman didn’t have an answer. That research had never been done. But because the physical therapists were part of a research hospital, they had the resources to conduct the research themselves—and Gorman agreed to help. Spaulding and her colleagues—Debra Clooney, Angela Link, Trina Modoono, Stacey Zalanowski, and Kathryn Quaglia—also wanted to know if the FIST could be modified to work on patients with spinal injuries, on top of stroke and traumatic brain injury patients. The basic test doesn’t work for spinal cord injury patients because their ability to move depends on where the injury is on the spinal cord.
“Some people with very high up injuries don’t have full use of their arms, so some of the items on the FIST are too difficult for them,” explains Gorman. “We’re trying to tweak the test, so it works with people with various spinal cord injuries.”
Not long after Gorman released the FIST in 2010, she was invited to speak at the American Physical Therapy Association Combined Sections Meeting in San Diego.
“I was super nervous because when I saw the schedule, I realized that one of the balance researchers I’d seen all those years before was presenting right before me,” Gorman says. “This is a person I’ve admired my whole career, and I couldn’t believe I was following her presentation.”
But Gorman’s presentation was a hit. An audience member approached her afterward to compliment her work, and the two ended up partnering on some of the first research to improve the FIST. The test is similar to a poll, Gorman explains: There’s a few points wiggle room for statistical error. Gorman and the physical therapist determined the minimum change needed to statistically show patient improvement.
Gorman’s enthusiasm and eagerness to collaborate is another one of the reasons the FIST has been successful.
Alumna Ramona Hignite, DPT ’05, who is now a therapy manager at the Rehabilitation Institute of Michigan in Detroit, learned about the FIST from a colleague while co-teaching a physical therapy class at the University of Michigan, Flint and reached out to Gorman with questions. She’s now working to implement the FIST at her own hospital.
“When I realized Sharon, my former professor, developed the test, it made me really proud of my program at SMU and my profession and how we can help patients,” Hignite says.
The FIST is used by hospitals from Kaiser Permanente in Northern California to Johns Hopkins in Baltimore, and has been translated into at least five languages, including Spanish and Turkish. As Gorman continues collaborating with researchers and practitioners, she sees a bright future for the FIST and the patients it helps—all thanks to a half-joking comment by her friend at a conference.