Postural

Assessment
Scale for Stroke
Patients
Lauren Wu, SPT
Ascension St. John Providence -
Macomb Hospital
Spring 2018
Central Michigan University
What is the PASS?
❖ First scale completely measuring balance
designed specifically for patients post-stroke1

❖ Assess and monitor postural control

❖ Originally adapted from the Fugl-Meyer

assessment balance subscale2
http://www.brooksrehab.org/blog/stroke-patient-sea
n-bretz-comes-full-circle-in-his-recovery/
3 Aims of development1
1) Measure ability to maintain postures and ensure equilibrium with changing
posture
2) Applicable to all patients with stroke of all levels
3) Contains items of increasing difficulty
The PASS...
12 items of graded difficulty in two categories:
Sitting without support
● Maintaining postures Standing with support
● Changing postures Standing without support
Standing on nonparetic leg
Standing on paretic leg
Supine to paretic side
Time Supine to nonparetic side
● 10 minutes (depending on patient) Supine to sitting up to edge of mat
Sitting on edge of mat to supine
Sit to stand
Equipment needed Stand to sit
Standing, picking up pencil from floor
● Stopwatch, pen, 50 cm high examination table
Scoring
Each item has a four point ordinal scale
Higher scores =
Total points possible = 36 MORE FUNCTIONAL
● 0-3 points possible
Pros
❖ Most sensitive for first 3 months ❖ Easier to administer in clinical and
post-stroke - high responsiveness3,4 research settings7

❖ Can be used in variety of settings5 ❖ Don’t need formal training

❖ Highly correlated with Functional ❖ Inexpensive, don’t need a lot of

Independence Measure (FIM)3,6 equipment

❖ Focus on posture and balance,

strong evidence for early trunk
control as predictor for ambulation7
Cons
❖ Not sensitive after 3 months - ceiling effect3

❖ Not based on quality of performance

❖ No standardized set of instructions

x
PASS vs. Chedoke-McMaster
PASS Chedoke-McMaster

Advantages ❖ Cost-effective ❖ Accuracy of severity

❖ Less time-consuming ❖ Comprehensive
❖ Can use for other neuro diagnoses (TBI, etc)
❖ Standardized instructions

Disadvantages ❖ Not validated for clients more than
3 months post stroke
❖ No information on quality of
movement or posture
❖ No standardized instructions
❖ Technical manual, one-day training workshop
❖ Detailed scoring and interpretation
❖ Time consuming (total >45 minutes; complete
in < 2 days)
❖ Need variety of equipment for entire
assessment

Neutral ❖ Doesn’t require highly trained ❖ Clinician should be familiar with manual,
individual administration of test, and be knowledgeable
about impairments
Academy of Neurologic PT- APTA EDGE
Recommendations for Stroke5
Setting Acuity Education

Tool Acute IP Home SNF OP Acute Sub- Chronic Students Students

should should be
Rehab Acute learn to exposed to
administer tool

PASS 4 4 4 4 4 4 3 1 x

Chedoke - 3 3 3 2 3 3 3 3 x
McMaster

FIM 2 4 2 2 2 4 2 2 x

BBS 3 4 4 4 4 3 4 4 x

Fugl-Meyer 4 4 4 4 4 4 4 4 x x
(Motor)

4 = Highly recommended; excellent psychometric properties and clinical utility; 3 = recommended; good psychometrics and good clinical utility
2 = unable to recommend at this time; insufficient information; 1 = not recommended; poor psychometrics and/or poor clinical utility
X = yes
Evidence-Based Literature: Highly Valid3
Validation of a Standardized Assessment of Postural Control in Stroke Patients. (1999)
Benaim C, Perennou DA, Villy J, Rousseaux M, Pellissier JY.

Objective: Determine the validity and reliability of the PASS

Methods:

Prospective study including 70 patients with supratentorial stroke and 30 age-matched healthy participants.

Each was assessed using the PASS, and a variety of outcome measures including the FIM to obtain ceiling effect and
construct validity.

For predictive validity, patients were assessed using the FIM and PASS on Day 30 and Day 90 after stroke onset.

For inter- and intrarater reliability, 2 raters (A = physiotherapist, B = physiatrist) assessed 12 patients with the PASS.
First, both raters A and B assessed on the same day; second, rater B assessed the same patients 3 days later.
Evidence-Based Literature: Highly Valid3
Validation of a Standardized Assessment of Postural Control in Stroke Patients. (1999)
Benaim C, Perennou DA, Villy J, Rousseaux M, Pellissier JY.

Results/Conclusions:

Moderate ceiling effect: Pronounced peak in distribution of scores on day 90 after many patients (38%) reached the
maximum score, suggesting moderate ceiling effect after 90 days.

Construct validity: Pearson correlation coefficient between PASS and FIM found strong correlation with transfers
(=.82) and locomotion (=.73) subscales.

Predictive validity: On Day 30, PASS correlated with total FIM (r=.75), suggesting it is possible to predict functional
prognosis from PASS on Day 30.

Reliability: Pearson correlation coefficient between global scores were .99 and .98 for interrater and intrarater
reliability, demonstrating high reliability.
Evidence-Based Literature: Acute Care
Discharge Recommendations6
Use of the Postural Assessment Scale for Stroke Patients in Determining Acute Care
Discharge Recommendations. (2015)
Lesser M, Borst J, Dekerlegand.

Objective: Assess feasibility of PASS in acute setting and compare score to therapist’s
discharge recommendations, and compare score to other outcomes (i.e., FIM)

Methods:

Patients with acute stroke were assessed with PASS at initial evaluation within 48 hrs of hospital admission, as well
as FIM transfer/ambulation, and therapist DC recommendations
Evidence-Based Literature: Acute Care
Discharge Recommendations6
Use of the Postural Assessment Scale for Stroke Patients in Determining Acute Care
Discharge Recommendations. (2015)
Lesser M, Borst J, Dekerlegand.

Results:
Discharge Recommendation Mean PASS
PASS had strong correlation with FIM transfers and
Acute Rehab 17.3 ±9.2
ambulation ( =.90 and .86 respectively)
SNF 11.4 ± 12.3
PASS was able to differentiate between therapy DC
recommendations, with higher scores (>30) more likely to Home with Home PT 31.0 ± 3.5
be recommended home, and lower scores (<30) more likely
Home with OP PT 32.8 ± 1.7
to be recommended other settings/rehab.
Home without PT 34.6 ± 2.2
Use PASS as a guide for discharge recommendations.
Evidence-Based Literature: Strong
Predictive Ability for Ambulation8
Postural Assessment Scale for Stroke Patients Scores as a Predictor of Stroke Patient
Ambulation at Discharge From the Rehabilitation Ward. (2016)
Huang YC, Wang WT, Liou TH, Liao CD, Lin LF, Huang SW

Objective: Investigate the predictive effect for ambulation in patients with stroke after
inpatient rehabilitation

Methods:

Retrospective study including 341 patients with ischemic stroke recruited from rehab ward of medical university
hospital in Taiwan. All patients were non-ambulatory at baseline. All patients were assessed with the PASS at
baseline, underwent OT/PT 60 min each per day, 5x/wk, and assessed again by the same Physical Therapist at DC.

At DC, patients were categorized as ambulatory (could walk independently with or without an AD for 10 m) or
non-ambulatory.
Evidence-Based Literature: Strong
Predictive Ability for Ambulation8
Postural Assessment Scale for Stroke Patients Scores as a Predictor of Stroke Patient
Ambulation at Discharge From the Rehabilitation Ward. (2016)
Huang YC, Wang WT, Liou TH, Liao CD, Lin LF, Huang SW

Results/Conclusions:

Mean admission to rehab ward = 34 days s/p stroke; mean length of hospitalization = 18 days.

Cut-off scores 3.5 for static PASS; 8.5 for dynamic PASS; 12.5 total PASS determined with statistical analysis using
ROC curve and Youden Index.

Patients with scores for static PASS > 3.5 and dynamic PASS > 8.5 were ~3x more likely to walk at discharge.
Video

https://youtu.be/q4ulbIbyyiw
PASS available online
http://www.brightonrehab.com/wp-content/uploads/2012/02/Postural-Assessmen
t-Scale-for-Stroke-Patients-PASS.pdf
Questions?
References
1. Barnes M, Dobkin B, Bogousslavsky. Balance disorders and vertigo after stroke. In: Recovery After Stroke. 1st ed. New
York, NY: Cambridge University Press; 2005:326-328.
2. Postural Assessment Scale for Stroke Patients. Physiopedia website.
https://www.physio-pedia.com/index.php?title=Postural_Assessment_Scale_for_Stroke&oldid=180333. Updated
November 3, 2017. Accessed April 4, 2018.
3. Benaim C, Perennou DA, Villy J, Rousseaux M, Pellissier, JY. Validation of a standardized assessment of postural control
in stroke patients. Stroke. 1999;30(9):1862-1868. doi: https://doi.org/10.1161/01.STR.30.9.1862
4. Mao HF, Hsueh IP, Tang PF, Sheu CF, Hsieh CL. Analysis and comparison of the psychometric properties of three
balance measures for stroke patients. Stroke. 2002;33(4):1022-1027.
5. APTA Academy of Neurologic Physical Therapy. Final StrokEDGE Recommendations Spreadsheet 2011.
http://www.neuropt.org/docs/edge-documents/finalstroke-edge-recommendations-spread-sheet.pdf?sfvrsn=6.
Accessed April 4, 2018.
6. Lesser M, Borst J, Dekerlegand. Use of the Postural Assessment Scale for Stroke Patients in Determining Acute Care
Discharge Recommendations. J Acute Care Phys Ther. 2015;8(3):79-85. doi: 10.1097/JAT.0000000000000057.
Accessed April 4, 2018.
7. Hsieh CL, Sheu CF, Hsueh IP, Wang CH. Trunk control as an early predictor of comprehensive activities of daily living
function in stroke patients. Stroke. 2002;33:2626-2630. doi: https://doi.org/10.1161/01.STR.0000033930.05931.93
8. Huang YC, Wang WT, Liou TH, Liao CD, Lin LF, Huang SW. Postural Assessment Scale for Stroke patients scores as a
predictor of stroke patient ambulation at discharge from the rehabilitation ward. J Rehabil Med. 2016;48:259-264. doi:
10.2340/16501977-2046