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RehabilitationMeasures

Neuromuscular Recovery Scale

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Purpose

The NRS is used to measure quality of movement without compensatory movement patterns using a body weight support system and a treadmill.

Link to Instrument

Acronym NRS

Area of Assessment

Functional Mobility
Gait
Range of Motion
Seating
Strength

Administration Mode

Paper & Pencil

Cost

Not Free

Actual Cost

$250.00

Cost Description

$250 course through NeuroRecoveryLearning.org and cost of equipment

Populations

Key Descriptions

  • ● 11-item scale that compares sitting, standing, walking, and transfers to typical movement
    ● Items are ordinal on a bounded scale with a small range of available scores
    ● Administration of the phasing tool occurs during one evaluation period
    ● Testing is sequential and begins with over ground items and moves to a body weight support treadmill
    ● Scores are on a continuum from unable to complete the task to full recovery with the ability to complete tasks at preinjury level
    ● Items (sit, reverse sit-ups, sit -up, trunk extension in sitting, sit to stand, stand, walking, stand and step adaptability and retraining) are rated on a 10 item scale over four phases of ability 1 through 4 with subphases a-c and phase 4 with no subphase, receiving a point for each phase.
    ● Utilizes a hierarchy of performance with lower phase achieved before moving to the next phase
    ● Lower of two scores should be selected

Number of Items

11

Equipment Required

  • Treadmill
  • Bodyweight supported system
  • 4 personnel

Time to Administer

30-50 minutes

Required Training

Training Course

Required Training Description

Therapists utilizing the NRS for the Christopher and Dana Reeve Foundation NeuroRecovery Network (NRN) complete formal training. The training includes: review of each item, demonstration of each task by persons with and without spinal cord injury, and practice scoring the items. The NRN requires ongoing therapist training to ensure standardization.
NeuroRecoveryLearning.org has an Adult Neuromuscular Recovery Scale course for purchase.

Age Ranges

Adult

18 - 64

years

Instrument Reviewers

Instrument reviewed in 2019 by:

  • Tracy Bentley-Root, MS, OTR/L
  • Jennifer Cline PT, MS
  • Karen Walsh, MS, MBA 

Body Part

Back
Lower Extremity

ICF Domain

Body Structure
Body Function
Activity
Participation

Measurement Domain

Motor

Professional Association Recommendation

NINDS CDE Status as of 9/29/19:

  • Exploratory: Spinal Cord Injury (SCI) and SCI-Pediatric (over 12 years old)

Considerations

  • Treadmill and bodyweight support system required.
  • Up to four staff are required to assist with body weight supported treadmill assessment to ensure safety with patient’s varying level of paralysis.
  • Limited power in studies due to low numbers of therapists studied for reliability and validity
  • Unrealistic time to complete the assessment in clinical setting
  • Recovery phases are correlated to Berg Balance, six-minute walk test, and ten-meter walk test.
  • A pediatric NRS is also available (13-items on a 12-point scale)
  • A modified NRS that includes upper extremity (UE) function is also available (additional four items to measure UE function, one treadmill item removed, and new scoring for upper extremity motor score (UEMS) and lower extremity motor score (LEMS)
  • Conflicts of interest noted with Drs. Behrman, Ardolino, and Harkema as they founded NeuroRecovery Ed Inc. and authored the majority of the research articles.

Spinal Injuries

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Cut-Off Scores

Adult Spinal Cord Injury: (Behrman et al, 2012; n=95,Mean age=43(17) Mean time post SCI 1 year (0.1,25.8) Severity: AIS level  D=64 C= 31),  Phases listed below indicate progression of motor function and are not cutoff scores.

 

  • Phase I ( scores a-c) 50-60% Body weight support for stand retraining, <60%,>20% for treadmill training .27-.54 m/s, >40% to 20% for stand retraining
  • Phase II (scores a-c) <10% and >20% body weight support for stand retraining, <20% body weight support for treadmill speed .27-.54m/s, <20% and >10% for stand retraining
  • Phase III (scores a-c) 0-9% body weight support for stand retraining, <20% body weight support treadmill speed .58-.89m/s, 0-9% for stand retraining
  • Phase IV (only)Independent stepping and <10% body weight support for speeds >1.52 m/s

Test/Retest Reliability

Adult Spinal Cord injury: (Behrman, Velozo, Suter, Lorenz, & Basso, 2015; n = 69; mean age = 36(15); AIS level: A = 18, B = 17, C = 13, D = 21; time since injury = 3.3 years (7 years); 13 raters: PT = 1, MPT = 2, DPT = 10)

  • Excellent Test-retest reliability of NRS items 10/11 items had Spearman correlation coefficients of > .92. Measurement model-derived summary score was (ρ=.99; 95% CI, .96–.99).

Interrater/Intrarater Reliability

Interrater Reliability:

Adult Spinal Cord Injury: (Basso, Velozo, Lorenz, Suter, & Behrman, 2015; n = 10; mean age = 43(18); AIS level: A = 1, B = 1, C = 2, D = 6; time since injury = 36 months(3-119); 15 raters: PT = 1; MPT = 2, DPT = 11, PhD = 1)

  • Excellent Reliability Kendall Coefficient of concordance (W) Interrater reliability generally strong W=.91-.98 C.I.=.65-.99 
  • Excellent Lower reliability for treadmill stand retraining W= .87 C.I. + .06-1
  • Excellentseated trunk extension: W=.82 C.I. .28-.94

Construct Validity

Construct Validity:

Adult Spinal Cord Injury: (Velozo et al., 2015; n = 188; mean age = 39.3; AIS level: A = 20, B = 19, C = 49, D = 98; time since injury = 1.2 years))

 

Acceptable overall construct validity for this study.  Areas of opportunity are described below.

  • NRS met many Rasch model criteria for construct validity. There were five different components to construct validity for this study:

(1) dimensionality;

(2) item rating structure;

(3) fit of items and patients to the Rasch model;

(4) item difficulty hierarchy; and

(5) person ability-item difficulty match (Velozo et al., 2015).

  • Confirmatory Factor Analysis (CFA) was utilized for dimension analysis assessment of the NRS.  Within CFA, principal component analysis was used for dimension reduction.  Instead of traditional psychometric analysis that focuses on test level psychometrics, Rasch analysis was utilized which is more of a probability focused method at the item level (Velozo et al., 2015). Infit and outfit statistics were utilized to validate items and patient fit. (Velozo et al., 2015).  Overall fit was assessed as well to look at observed over expected variance; the ideal for this measurement would be 1.0 (Velozo et al., 2015).
  • Results of the CFA chi-squared root mean square error (RMSE) test failed at .217; however results of the CFI were met at .955. (Velozo et al.,2015). The PCA from the Rasch model explained 76.9% of the item and person variance (Velozo et al.,2015). When looking at the finer results of the CFA it appears some of the eigenvalues were over 2.0.  In addition, the variance explained by the first component was 5.3%; the remaining items explained 43.4%, which shows the strength of the measurement construct (Velozo et al., 2015).
  • Some model fit statistics include: ten of the eleven items met the criteria for model outfit and infit and 91% of the patients fit the measurement model (Velozo et al., 2015). Precision was assessed using Person separation reliability and results were .92 which is similar to Cronbach’s alpha; and item separation reliability was .90. (Velozo et al, 2015).  It is no surprise based on these results that 9 of the 11 items were highly discriminatory.
  • Regarding the person ability-item difficulty match, the distribution of patients according to AIS classifications is adequate ( Velozo et al., 2015).
  • Overall these results show a lot of strong characteristics of solid construct validity for the NRS.  However, there is an opportunity for improvement.  CFA criteria was not completely met for unidimensionality and there were a few items in NRS that were not discriminatory (Velozo et al., 2015)

Content Validity

Adult Spinal Cord Injury: (Behrman et al, 2012)

  • The NRS was developed between 2000 and 2008 by a team of scientists and physical therapists within the NRN.

Floor/Ceiling Effects

Adult Spinal Cord Injury: (Velozo et al., 2015)

  • Excellent Rasch analysis identified that the NRS did not show ceiling or floor effects.

Responsiveness

Adult Spinal Cord Injury: (Tester et al., 2015; n = 72; mean age = 36 (15); AIS level: A = 17, B = 10, C = 20, D = 25; time since injury = 1.2 yrs (0.1-53.1))

  • The NRS was significantly responsive for SCI outpatients (ARM = 1.05; CI = 0.75-1.35).

Bibliography

Basso, D. M., Velozo, C., Lorenz, D., Suter, S., & Behrman, A. L. (2015). Interrater reliability of the Neuromuscular Recovery Scale for spinal cord injury. Archives of Physical Medicine and Rehabilitation, 96(8), 1397–1403.

 

 

Behrman, A. L., Ardolino, E., Vanhiel, L. R., Kern, M., Atkinson, D., Lorenz, D. J., & Harkema, S. J. (2012). Assessment of functional improvement without compensation reduces variability of outcome measures after human spinal cord injury. Archives of Physical Medicine and Rehabilitation, 93(9), 1518–1529.

 

Behrman, A. L., Trimble, S. A., Argetsinger, L. C., Roberts, M. T., Mulcahey, M. J., Clayton, L., . . . Ardolino, E. M. (2019). Interrater Reliability of the Pediatric Neuromuscular Recovery Scale for Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation, 25(2), 121-131. doi:10.1310/sci2502-121

 

Behrman, A. L., Velozo, C., Suter, S., Lorenz, D., & Basso, D. M. (2015). Test-retest reliability of the Neuromuscular Recovery Scale. Archives of Physical Medicine and Rehabilitation, 96(8), 1375–1384.

 

Harkema, S. J., Shogren, C., Ardolino, E., & Lorenz, D. J. (2016). Assessment of functional improvement without compensation for human spinal cord injury: Extending the neuromuscular recovery scale to the upper extremities. Journal of Neurotrauma, 33(24), 2181-2190. doi:10.1089/neu.2015.4213

 

Jones, M. L., Evans, N., Tefertiller, C., Backus, D., Sweatman, M., Tansey, K., & Morrison, S. (2014). Activity-based therapy for recovery of walking in chronic spinal cord injury: Results from a secondary analysis to determine responsiveness to therapy. Archives of Physical Medicine and Rehabilitation, 95(12), 2247–2252.

 

Lorenz DJ, Datta S, Harkema SJ. Longitudinal patterns of functional recovery in patients with incomplete spinal cord injury receiving activity-based rehabilitation. Arch Phys Med Rehabil. 2012  Sep;93(9):1541–52. doi: 10.1016/j.apmr.2012.01.027. [] [] []

Tester, N. J., Lorenz, D. J., Suter, S. P., Buehner, J. J., Falanga, D., Watson, E., … Michele Basso, D. (2016). Responsiveness of the Neuromuscular Recovery Scale during Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury. Neurorehabilitation and Neural Repair, 30(6), 1–11.

 

Velozo, C., Moorhouse, M., Ardolino, E., Lorenz, D., Suter, S., Basso, D. M., & Behrman, A. L. (2015). Validity of the Neuromuscular Recovery Scale: A measurement model approach. Archives of Physical Medicine and Rehabilitation, 96(8), 1385–1396.