You are now ready to administer the FIST. Remember the following regarding the FIST items:
- There are 14 items in total
- Aside from the 3 nudge items, these items are ordered by difficulty, so have the patient perform them in order.
- Nudges should be randomly inserted into the test by the therapist.
- Multiple attempts for each item are acceptable.
- Especially if the therapist is providing cues, prompts the patient to attempt with/without hands to improve performance, or to ensure full movement through the task.
- Try to limit the attempts of any particular item to less than 2 or 3 to minimize testing effects interfering with the patient's score on that item.
- It is preferable that you score the patient's first attempt, if possible.
- Prior to each individual item:
- Give the patient instructions, and demonstrate the task if needed.
- Reposition the patient as needed before each item so they are in the standard position.
- Recall the scoring criteria; it is the same for each item.
The following pages review each individual test item, and include:
- Description of the item
- Directions to give patient for that item
- Item-specific examples of performance for each level of scoring
- Common questions about performance and scoring specific to the item
- A video clip showing examples of patient performance for at least 2 scoring levels
- maximum score of 4
- either 0, 1, 2, or 3
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
Description & Directions
"Sit tall with your hands in your lap."
Time the patient for 30 seconds, assign a score.
Static Sitting Scoring
| Score | Description | Selected Example |
4 | Independent | Normal performance |
3 | Verbal cues/increased time | Slouches posture repeatedly during 30 seconds requiring cues to sit tall. |
2 | Upper extremity support | Cannot maintain upright posture without using hand(s) for full 30 seconds, even on second attempt. |
1 | Needs assistance | Requires mod A to sit statically for the full 30 seconds, only able to maintain without assistance for first 9 seconds. |
0 | Dependent | Cannot sit without total assistance. |
Common Questions about Static Sitting
- Does the patient get partial credit for time completed? You you may attempt an item 1 or even 2 additional times. However, if they cannot complete the full 30 seconds at one scoring level, you need to score the item based on their lowest performance.
Video examples
Description & Directions
"Remain sitting steady and tall without using your hands unless you need them for balance. When I tell you to "look right," keep sitting straight, but turn your head to the right. Keep looking right until I tell you "look left," then keep sitting straight and turn your head to the left. Keep your head to the left until I tell you "look straight," then keep sitting straight but return your head to the center."
Ensure the patient has rotated their head in both directions through their available range of motion. Assign a score.
Sitting, Shake 'no' Scoring
| Score | Description | Selected Example |
4 | Independent | Normal performance |
3 | Verbal cues/increased time | Repeatedly needs cueing to rotate head fully, even in just one direction. |
2 | Upper extremity support | Can perform right cervical rotation fully, but for left cervical rotation must use hand, even on 2nd attempt. |
1 | Needs assistance | Requires min A to maintain upright balance during rotation. |
0 | Dependent | Requires total A to perform task. |
Common Questions about Sitting, Shake 'no' item
- Can I ask the patient to perform the task a second time? Yes. Be sure if the patient requires verbal cues to complete the task that this is accounted in the final score you assign.
Video examples
Description & Directions
"Close your eyes and remain sitting still with your hands in your lap."
Time the patient for 30 seconds, assign a score.
Sitting, Eyes Closed Scoring
| Score | Description | Selected Example |
4 | Independent | Normal performance. |
3 | Verbal cues/increased time | Needs cues to keep eyes closed. |
2 | Upper extremity support | Must use hand(s) to maintain upright posture, may attempt 2-3 times to ensure hands are required. |
1 | Needs assistance | Cannot sit for the full 30 seconds with eyes closed without physical assistance. |
0 | Dependent | Total assist required to sit, cannot keep eyes closed even with maximal cueing. |
Common questions about Sitting, Eyes Closed
- Is there partial scoring for timed items? No. You should score the lowest performance of the patient if they cannot complete the time requirement.
Video examples
Description & Directions
"Sit with your hands in your lap, and lift your foot 1 inch off the floor two times."
Perform on the least involved, stronger, or dominant side; ensure they lift the foot twice at least 1 inch. Assign a score.
Sitting, lift foot Scoring
| Score | Description | Selected Example |
4 | Independent | Performance normal. |
3 | Verbal cues/increased time | Performance is slower than normal, even with repeated attempt. |
2 | Upper extremity support | On two attempts, still needs to use hand(s) on second lift attempt to complete. |
1 | Needs assistance | Needs min A to lift foot the prescribed 1 inch off floor. |
0 | Dependent | Requires total assist to perform. |
Common questions about Sitting, lift foot
- If the patient attempts without hands and has a loss of balance, can you perform a second trial where you encourage them to use their hands? Yes. You want the best overall performance you can get from the patient. If you think they might be able to complete the task if they use their hands, you may prompt them to as long as you score them appropriately.
Video examples
Description & Directions
"Turn around and pick up this object that I've placed behind you."
Show the patient the object. Use something lightweight and easy to grasp, like a small retractable tape measure, a watch, or a pen.
Place object one hand's breadth (fingertip to base of palm) posterior to hips.
The purpose of this test item is to have the patient rotate their trunk and move their arm while maintaining their balance. The patient should not be allowed to blindly reach behind to find the object or to use shoulder internal rotation to swipe at the object.
The patient may turn to their preferred side and use either arm to pick up the object. If the patient needs cues to problem solve how to perform the task, adjust the score accordingly.
Turn for Object Behind Scoring
| Score | Description | Selected Example |
| 4 | Independent | Normal performance. |
| 3 | Verbal cues/increased time | Requires cues to rotate trunk to reach item, otherwise performance is normal. |
| 2 | Upper extremity support | Must use hand(s) to stabilize self to achieve trunk rotation. |
| 1 | Needs assistance | Mod A required to turn and reach for object. |
| 0 | Dependent | Cannot fully turn or reach for object without total assistance. |
Common questions for Turn for Object Behind
- Can the patient fish for the object using their hand behind their back without performing trunk rotation? No. The purpose of this item is for the patient to balance with trunk rotation and arm movement. If they require cues or assistance to rotate during this item, their score should be adjusted accordingly.
Video examples
Description & Directions
"Reach forward, keeping your other arm in your lap or at your side. Reach as far as you can while staying balanced."
You may need to perform the motion passively to assess excursion and/or available patient ROM.
Patient must go full ROM or until abdomen contacts anterior thighs.
Have the patient reach with least involved, stronger, or dominant arm. Assign a score.
Forward Reach Scoring
| Score | Description | Selected Example |
| 4 | Independent | Performance normal. |
| 3 | Verbal cues/increased time | Moves tentatively or excessively slowly, but can complete task. |
| 2 | Upper extremity support | Uses hand, even on second attempt with cueing to not use hand, to return to sitting position. |
| 1 | Needs assistance | Min A required to move through full motion. |
| 0 | Dependent | Requires total assist to complete motion. |
Common questions about Forward Reach
- What if patient doesn't use their hand(s) and doesn't need assist, but clearly is limited in reach distance? The patient must move through their full available reach motion. If they need cues to do this, or you have to physically assist them to complete their full reach, the score should reflect this.
Video examples
Description & Directions
"Reach out to the side as far as you can; try to keep your hand at the height of your shoulder. Be sure to get all your weight off the opposite side of your bottom and keep your feet on the floor."
Patient should reach with the least involved, stronger, or dominant side.
Patient must off-weight the opposite buttock, but need not lift it off the surface. The therapist may need to check that weight has been shifted off the opposite buttock.
Lateral Reach Scoring
| Score | Description | Selected Example |
| 4 | Independent | Performance normal. |
| 3 | Verbal cues/increased time | Slow movement or cues required to get patient to move until their buttock clears the surface, even on multiple attempts |
| 2 | Upper extremity support | Must stabilize balance by using hand(s). |
| 1 | Needs assistance | Requires mod A to achieve task or to return to starting position. |
| 0 | Dependent | Cannot complete without total assistance, or cannot be completed if therapist cannot lift buttock. |
Common questions about Lateral Reach
- Can I give the patient more than one opportunity to perform the task? In general, yes. Oftentimes the patient needs cues to sequence the task, so a second attempt with you providing cues is acceptable; just be sure that performance is reflected in the score. It is not recommended to give the patient more than 2-3 attempts so as to not introduce training effects.
Video examples
Description & Directions
"Pick this object up off the floor with your hand."
Show the patient the object. Place object between metatarsalphalangeal joints.
Patient may use either hand to pick up the object. Assign a score.
Pick Object off Floor Scoring
| Score | Description | Selected Example |
| 4 | Independent | Normal performance. |
| 3 | Verbal cues/increased time | Multiple attempts all require prompting to normalize speed of movement. |
| 2 | Upper extremity support | Cannot return to sitting with use of hand(s), even on repeated attempts. |
| 1 | Needs assistance | Min A required to complete task. |
| 0 | Dependent | Cannot complete the task, or only completes with total assistance. |
Common questions about Pick Object off Floor
- My patient lays their trunk in their lap for stability while reaching for the object on the floor. Do I need to adjust their score? No. The scoring criteria relate to completion of the task and often don't account for compensations like this one. You may want to describe this strategy when documenting, but it does not affect their score.
Video examples
Description & Directions
"Move backward 2 inches without using your arms."
Use the tape measure to ensure 2 inches of movement. Assign a score.
Posterior Scoot Scoring
| Score | Description | Selected Example |
| 4 | Independent | Performance normal. |
| 3 | Verbal cues/increased time | Excessive time or excessive scooting motions required. |
| 2 | Upper extremity support | Must use hand(s) to complete scoot, even with multiple attempts. |
| 1 | Needs assistance | Mod A to complete scoot. |
| 0 | Dependent | Cannot complete without total assistance. |
Common questions about Posterior Scoot
- My patient performs the scoot, but they are moving too fast and the movement is not safe without supervision. How do I score them? If safety is the primary problem the patient has, and you feel supervision would be required for the task, you should score the patient a 3 Verbal cues/increased time. This is to account for the verbal cues you would normally give the patient regarding the safety of the movement.
Video examples
Description & Directions
"Move forward 2 inches without using your arms."
Have the patient move back to the starting position on the bed. Use the tape measure to ensure 2 inches of movement. Assign a score.
Anterior Scoot Scoring
| Score | Description | Selected Example |
| 4 | Independent | Performance normal. |
| 3 | Verbal cues/increased time | Unsafe movement requiring cues to slow down, but can complete the task. |
| 2 | Upper extremity support | Cannot complete the task, even on 2nd or 3rd attempt, unless they use their hand(s). |
| 1 | Needs assistance | Max A needed to complete the scoot. |
| 0 | Dependent | Requires total assist to complete task. |
Common questions about Anterior Scoot
- I only need to assist the patient for the last part of the scoot. How do I score them? Patient's don't get partial credit for performance. In this instance, the patient would score 1 Needs Assistance with the level of assistance recorded.
Video examples
Description & Directions
"Move sideways 2 inches without using your arms."
Patient may move in their preferred direction or to stronger or less involved side. Use tape measure to ensure 2 inches of movement. Assign a score.
Lateral Scoot Scoring
| Score | Description | Selected Example |
| 4 | Independent | Normal performance. |
| 3 | Verbal cues/increased time | Impulsive movement deemed unsafe, would require verbal cues to slow down. |
| 2 | Upper extremity support | Must use hand(s) to complete scoot, even on repeated attempt. |
| 1 | Needs assistance | Min A needed to complete the scoot. |
| 0 | Dependent | Requires total assist to scoot. |
Common questions about Lateral Scoot
- I had to provide cues for the patient to try a second time using their hands. On the second attempt, when using their hands, the patient successfully scooted. How to I score the patient? You provided cues (score = 3) but the patient had to use their hands to be successful (score = 2). You select the lower of the scores, a 2, to best reflect their need to use their hands.
Video examples
Now you are familiar with all 14 of the FIST items.