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RehabMeasures Instrument

Postural Assessment Scale for Stroke

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Purpose

The PASS is a 12-item performance-based scale used for assessing and monitoring postural control following stroke.

Link to Instrument

Instrument Details

Acronym PASS

Area of Assessment

Balance – Non-vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Cost of equipment

Diagnosis/Conditions

  • Stroke Recovery - Draft 2

Key Descriptions

  • The scale comprises of 12 items with increasing difficulty which measure balance in lying, sitting and standing.
  • It is specially designed for individuals with stroke regardless of their postural competence.
  • It is especially sensitive for assessment of postural control in the first 3 months and can discriminate between right and left brain damage in individuals with stroke.
  • It measures the ability of an individual with stroke to maintain stable postures and equilibrium during positional changes.
  • It consists of a 4-point scale where the items are scored from 0 to 3, and the total scoring ranges from 0 to 36.
  • Test activities include:
    1) Sitting without support (sitting on the edge of an 50-cm-high examination with the feet touching the floor)
    2) Standing with support (feet position free, no other constraints)
    3) Standing without support (feet position free, no other constraints)
    4) Standing on non-paretic leg (no other constraints)
    5) Standing on paretic leg (no other constraints)
    6) Supine to affected side lateral
    7) Supine to non-affected side lateral
    8) Supine to sitting up on the edge of the table
    9) Sitting on the edge of the table to supine
    10) Sitting to standing up
    11) Standing up to sitting down
    12) Standing, picking up a pencil from the floor
  • Modified versions of the PASS include the PASS trunk control items (PASS-TC) and the Short-Form PASS (SFPASS). Both have 5 items instead of the original 12 included with the PASS.

Number of Items

12

Equipment Required

  • 50 cm-high examination table (e.g. Bobath plane)
  • Stop watch
  • Pen

Time to Administer

10 minutes

Required Training

No Training

Age Ranges

Adults

18 - 64

years

Older Adults

65 +

years

Instrument Reviewers

Reviewed by the StrokEDGE Task Force, Neurology Section, APTA , 2011; Reviewed by Shweta Subramani on 12/4/2014; Updated by Heather Anderson and Rie Yoshida from the StrokEdge II Task Force, Neurology Section, APTA on 4/11/16

Body Part

Lower Extremity

ICF Domain

Activity

Measurement Domain

Motor

Professional Association Recommendation

American Physical Therapy Association (APTA) Neurology section’s Stroke Taskforce (StrokEDGE) recommendations on a 4 point scale:

  • 4 = highly recommended; the outcome has excellent psychometric properties and clinical utility

  • 3 = recommended; the outcome measure has good psychometric properties and good clinical utility

  • 2 = unable to recommend at this time; there is insufficient information to support a recommendation of this outcome measure

  • 1 = not recommended; the outcome measure has poor psychometric properties and/or poor clinical utility

Practice setting

Measure

Acute

IP Rehab

Home

SNF

OP

PASS

4

4

4

4

4

 

Patient Acuity

Measure

Acute2

Sub-acute

Chronic

PASS

4

3

1

 

Education

Measure

Students should learn to administer tool

Students should be exposed to tool

PASS

x

 

Considerations

  • This scale is easy to administer with no special requirement.

  • Any clinician can easily, rapidly and confidently administer the scale.

  • However, the clinician must have the understanding of balance impairments and safety issues that are seen following stroke.

  • It is more sensitive for assessment of stroke in the first 3 months and can discriminate between patients with right and left brain damage.

Older Adults and Geriatric Care

back to Populations

Normative Data

Healthy Older Adults: (Benaim et al, 1999; n = 30; mean age = 63.3 (1.5) years)

  • Mean PASS score = 35.7 points, range = 32 to 36 points

Stroke

back to Populations

Standard Error of Measurement (SEM)

Chronic Stroke: (Liaw et al, 2008; n = 52; mean age = 60.4 (13.4) years; time since stroke onset = 6 to 292 months)

  • 1.14 points for PASS

Chronic Stroke: (Liaw et al, 2012; n = 52; mean age = 60.4 (13.4) years; time since stroke onset = 13.3-53.5 months)

  • 0.78 point for SFPASS

Acute Stroke: (Chien et al, 2007b; n = 287; mean age = 65.5 (11.3); 14 days post stroke)

  • 2.4 points (+ 4.7 points, 95% CI)

Minimal Detectable Change (MDC)

Subacute Stroke: (Chien et al, 2007a; n = 40; mean age = 58.6 (12.0) years)

  • MDC at an individual score level: 2.22 points

  • MDC at a group score level: 0.50 points

Chronic Stroke: (Liaw et al, 2008)

  • MDC of PASS: 3.2 points

Chronic Stroke: Liaw et al, 2012)

  • MDC of SFPASS: 2.2 points

Acute Stroke: (Hsuen et al, 2013; n = 251; mean age 67.3 (10.9) years; 14 and 30 days post stroke)

  • MDC mean individual ratio of PASS = 1.8 (1.7)

Cut-Off Scores

Acute Stroke: (Huang et al, 2016; n = 341; mean age = 63 (13.28) for ambulatory group and 69 (13.83) for non-ambulatory group; mean time since stroke = 26.22 (30.30) day s for ambulatory group and 31.05 (39.42) days for non-ambulatory group; Taiwanese study)

  • 3.5 points for static PASS (sensitivity 77.9%, specificity 82.1%)

  • 8.5 points for dynamic PASS (sensitivity 77.9%, specificity 82.5%)

  • 12.5 points for total PASS (sensitivity 78.9%, specificity 83.7%)

Test/Retest Reliability

Chronic Stroke: (Chien et al, 2007a)

  • Excellent test-retest reliability (Intra Class Coefficient (ICC) = 0.84)

Chronic Stroke: (Liaw et al, 2008)

  • Excellent relative test-retest reliability (ICC = 0.97) over 7 days

Chronic Stroke: (Liaw et al, 2012)

  • Excellent test-retest reliability in SFPASS (ICC = 0.93)

Interrater/Intrarater Reliability

Interrater reliability:

Acute/Subacute Stroke: (Benaim et al, 1999; n = 12; 30 and 90 days post stroke)

  • Adequate to Excellent inter-rater reliability for individual items (average alpha = 0.88, range 0.64-1)

  • Excellent inter-rater reliability for total score (r = 0.99, p < 0.001)

Acute Stroke: (Mao et al, 2002; n = 112; mean age = 69.3 (11.2); 14 days post stroke)

  • Adequate to Excellent inter-rater reliability for individual items (median alpha = 0.88, range 0.61-0.96)

  • Excellent inter-rater reliability (ICC = 0.97, 95% confidence interval (CI 0.95-0.98)) for total score.

Acute Stroke: (Hsieh et al, 2002; n = 169; mean age = 66.8 (11.3))

  • Excellent inter-rater reliability of the trunk control items (PASS-TC: items 1, 6, 7, 8, 9; ICC = 0.97)

Intrarater reliability:

Acute/Subacute Stroke: (Benaim et al, 1999)

  • Good intrarater reliability for individual items (average k = 0.72, range 0.45-1.00)

  • Excellent intrarater reliability for total score (r = 0.98, p < 0.001)

Internal Consistency

Acute/Subacute Stroke: (Benaim et al, 1999)

  • Excellent internal consistency: Cronbach’s Alpha = 0.95

Stroke: (Mao et al, 2002)

  • Excellent internal consistency: Cronbach’s Alpha = 0.94-0.96 at 14, 30, 90, and 180 days post stroke

Acute Stroke: (Hsieh et al, 2002)

  • Excellent internal consistency: Cronbach’s Alpha = 0.93-0.94

Acute Stroke: (Chien et al, 2007b)

  • Excellent internal consistency: Cronbach’s Alpha = 0.96

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Acute Stroke: (Mao et al, 2002)

  • Excellent relationship with Fugl-Meyer Assessment modified balance scale (FMA-B) (p = 0.95-0.97) and Berg Balance Scale (BBS) (p = 0.92-0.95)

Acute/Subacute Stroke: (Wang et al, 2004; n = 77; mean age = 59.8 (11.9); 14, 30 and 90 days post stroke)

  • Excellent relationship between all measures (PASS, PASS-3P, BBS and BBS-3P) (rho>/= 0.91, p < 0.0001)

  • Excellent relationship with BBS (p = 0.94, p < 0.0001) and with PASS-3P (p = 0.94, p < 0.0001; ICC = 0.97, 95% CI, 0.96-0.98)

Acute Stroke: (Chien et al, 2007b)

  • Excellent relationship with the SFPASS (ICC = 0.98;96% variance) in 287 individuals at 14 days post stroke

  • Excellent relationship with the SFPASS (ICC = 0.98) in 179 individuals with stroke

Acute Stroke: (Di Monaco et al, 2010; n = 60; mean age = 68.0 (12.2); mean time post stroke = 21.4 (13.3) days)

  • Excellent relationship with the Trunk Impairment Scale (TIS) (p = 0.849, p < 0.001)

Predictive validity:

Acute/Subacute Stroke: (Benaim et al, 1999)

  • Adequate predictive validity of PASS total score (r = 0.75, p < 0.001), transfer items (r = 0.74, p < 0.006) and locomotion items (r = 0.71, p < 0.001) at 30 days post stroke when compared with Functional Independence measure (FIM) scores at 90 days post stroke

Acute Stroke: (Mao et al, 2002)

  • Excellent predictive validity of PASS (p = 0.86-0.90) at 14, 30 and 90 days post stroke when compared with the walking subscale of the Motor Assessment Scale at 180 days post stroke

Acute Stroke: (Hsieh et al, 2002)

  • Excellent predictive validity of the trunk control items of PASS (PASS-TC: items 1,6,7,8,9) (r = 0.68, p < 0.001) at 14 days post stroke when compared with Barthel Index (BI) and Frenchay Activities Index (FAI) at 6 months post stroke

Stroke: (Wang et al, 2004; n = 226 and n = 202; 14 and 30 days post stroke)

  • Excellent predictive validity of PASS and modified PASS that used 3-level scale (12-item PASS-3P) at 14 days (p = 0.78) and 30 days (p = 0.82) post-stroke when compared with BI scores at 90 days post-stroke

Acute Stroke: (Chien et al, 2007b)

  • Adequate predictive validity of PASS (r = 0.49) and SFPASS (r = 0.48) at 14 days post-stroke when compared with BI scores at 90 days post-stroke

  • Excellent predictive validity of PASS (r = 0.83) and SFPASS (0.82) on replication of the process in 179 individuals following stroke on admission to rehabilitation with BI scores on discharge from hospital

Acute Stroke: (Di Monaco et al, 2010)

  • Excellent predictive validity of PASS (p = 0.687, p < 0.001) on admission to inpatient rehabilitation when compared with FIM discharge scores

Acute Stroke: (Yu et al, 2012; n = 85; mean age = 65 (11.6) years, mean time since stroke onset = 19 (5-79) days)

  • Adequate predictive validity of PASS, when compared with BI (r2 = 0.39, p < 0.001) and Stroke Rehabilitation Assessment of Movement mobility subscale (MO-STREAM) (r2 = 0.63, p < 0.001) discharge scores

Acute Stroke: (Yu et al, 2013; n = 66; mean age: 63.1 yrs (12.2); 18 days (6-64) post stroke)

  • Adequate predictive validity of PASS at rehab admission compared to Barthel Index at Discharge (mean = 31 days (6-76); r = 0.69 (p < 0.001)

  • Adequate predictive validity of PASS at rehab admission compared to MO-STREAM at Discharge (mean = 31 days (6-76); r = 0.80 (p < 0.001)

Construct Validity

Acute/Subacute Stroke: (Benaim et al, 1999)

  • Excellent correlations between PASS and FIM total score (r = 0.73), transfer tasks (r = 0.82) and locomotor tasks (r = 0.73); and motricity scores of lower limb (r = 0.78) and upper limb (r = 0.63)

  • Adequate negative correlations with the star cancellation test of spatial inattention (r = 0.53) and lower limb pressure sensitivity (r = 0.45) as well as upper limb pressure sensitivity (r = 0.42)

  • Adequate negative correlations with measurement of postural stabilization (r = 0.48) and postural orientation with respect to gravity (r = 0.36) (Benaim et al, 1999; n = 31; 90 days post stroke)

Acute Stroke: (Mao et al, 2002)

  • Excellent convergent validity between PASS and BI (p= 0.88-0.92)

Acute Stroke: (Hsieh et al, 2002)

  • Excellent convergent validity of PASS-TC with BI (r = 0.89) and with the Fugl-Meyer balance test (FM-B) (r = 0.73)

Stroke: (Wang et al, 2004)

  • Excellent convergent validity of the PASS and PASS 3P with BI (p = 0.84, p = 0.82 respectively)

Acute Stroke: (Chien et al, 2007b)

  • Excellent correlations between the PASS, SF PASS and BI, (PASS, r = 0.87; SFPASS, r = 0.86) and between the PASS, SFPASS and FIM (PASS, r = 0.75; SFPASS, r = 0.75)

Acute Stroke: (Chinsongkram et al, 2014; n = 70, mean age = 57 (12.24) years; mean time since stroke = 1.11 (2.00) month; Thai study)

  • Excellent convergent validity with BESTest (r = 0.96)

Chronic Stroke: (Lin et al, 2010; n = 45, mean age = 60 ± 12.6 years; mean time since stroke = 9 (3-22) months; tested after 1 week, 2 months and 5 months of outpatient therapy; Taiwanese study)

  • Moderate to high convergent validity (ρ) with DGI, DGI-4, and FGA

Time point of assesement

PASS vs DGI

PASS vs DGI-4

PASS vs FGA

1st wk of therapy

0.85

0.75

0.83

2 mos after therapy

0.76

0.74

0.75

5 mos after therapy

0.83

0.78

0.83

 

Subacute Stroke: (Huang et al, 2016; n = 341; mean days post stroke = 34.40; retrospective study completed in Taiwan)

PASS cut-off scores predictive of patient ambulation at discharge:

Scale

Cut-off
points

Non-Ambu-latory
n, %

Ambu
-latory

n, %

Sensitivity/Specificity

ROC curve
AUC

PPV

Static PASS

< 3.5
> 3.5

202; 59.2%
44; 12.9%

21; 6.2%
74; 21.7%

77.9%/
82.1%

0.860

0.627

Dynamic PASS

< 8.5
> 8.5

203; 59.5%
43; 12.6%

21; 6.2%
74; 21.7%

77.9%/
82.5%

0.876

0.632

Total PASS

< 12.5
> 12.5

206; 60.4%
40; 11.7%

20; 5.9%
75; 22%

78.9%/
83.7%

0.884

0.652

p-value for all < 0.001;
AUC = Area Under Curve;
PPV = positive predictive value

Floor/Ceiling Effects

Acute/Subacute Stroke: (Benaim et al, 1999; n = 58; 30 and 90 days post stroke)

  • Large ceiling effects at 90 days post stroke (38%)

Acute Stroke: (Mao et al, 2002;14, 30, 90 and 180 days post stroke)

  • Moderate floor and ceiling effects at all time points (floor effect range = 2.2-3.8%; ceiling effect range = 3.3-17.5%)

Acute Stroke: (Chinsongkram et al, 2014)

  • Large ceiling effect (37.1% of patients received a score within the top 10% of the PASS)

Acute Stroke: (Hsueh et al, 2013; n = 251; mean age = 68.4 (10.4) years; assessed at 14 and 30 days after stroke onset on PASS and SFPASS; Taiwanese study)

  • Moderate floor/ceiling effects for PASS (0-7.2%)

  • Large floor effect (21.9%) for SFPASS at 14 days after stroke onset

  • Moderate floor effect (12.7%) for SFPASS at 30 days after stroke onset

  • Moderate ceiling effect (0-14.3%) for SFPASS

Acute Stroke: (Yu et al, 2013); n = 66; mean age: 63.1 yrs (12.2); 18 days (6-64) post stroke

  • Moderate ceiling effects at rehabilitation admission (1.5%) and at rehabilitation discharge (6.1%)

  • Excellent floor effects at rehabilitation admission (0%) or discharge (0%)

Acute Stroke: (Yu et al, 2012)

  • Moderate floor or ceiling effect at admission (< 15%)

Responsiveness

Acute Stroke: (Mao et al, 2002)

  • Large responsiveness of PASS from 14-30 days (Effect Size (ES) = 0.89)

  • Moderate responsiveness from 30-90 days (ES = 0.64)

  • Low responsiveness from 90-180 days (ES = 0.31)

  • Large overall responsiveness from 14-180 days (ES = 1.12)

  • Large responsiveness from 14-180 days (ES = 1.54) in severe stroke

Acute Stroke: (Yu et al, 2013; n = 66; mean age: 63.1 yrs (12.2); 18 days (6-64) post stroke)

  • Large responsiveness between rehab admission and discharge (mean = 31 days (6-76); ES = 0.86; SRM = 1.23

Stroke: (Wang et al, 2004; n = 202 and n = 167; 14, 30 and 90 days post stroke)

  • Large responsiveness of the PASS and PASS-3P from 14-30 days post stroke (Standard Response Mean (SRM) = 0.84 and 0.86 respectively) and from 14-90 days post stroke (SRM = 1.02 and 1.04 respectively)

  • Moderate responsiveness from 30-90 days post stroke (SRM = 0.65 and 0.67 respectively)

  • Moderate responsiveness of PASS and PASS-3P (PASS SRM range, 0.43-0.78; PASS-3P SRM range, 0.46-0.78) in individuals with mild stroke (Fugl Meyer motor assessment (FM) score of 80 or greater)

  • Moderate to large responsiveness (PASS SRM range, 0.52-1.12; PASS -3P SRM range, 0.56-1.19) in individuals with moderate stroke (FM score 36 to 79)

  • Large responsiveness (PASS SRM range, 0.92-1.35; PASS-3P SRM range, 0.92-1.34) in individuals with severe stroke (FM score 0 to 35)

  • Large responsiveness of both measures in the period of 14-30 days and 14-90 days post stroke as compared to 30-90 days post stroke.

Subacute Stroke: (Chien et al, 2007a)

  • Small responsiveness of the PASS (d = 0.41) over an interval of 2 weeks

Acute Stroke: (Chien et al, 2007b)

  • Small responsiveness of the PASS (ES = 0.42)

  • Small responsiveness of the PASS (ES = 0.43) (Chien et al, 2007b; n = 179; admission to rehabilitation to discharge from hospital)

Acute Stroke: (Yu et al, 2012)

  • Adequate internal responsiveness of PASS (d = 0.87)

  • Sufficient external responsiveness (ic = 0.44, r2 = 0.20, p < 0.001), (ic = 0.77, r2 = 0.59, p < 0.001) to changes in function (BI changes scores) and changes in mobility (MO-STREAM change scores)

Acute Stroke: (Hsueh et al, 2013)

  • Group level responsiveness: moderate to large responsiveness (0.46-0.91) for both PASS and SFPASS

  • Individual patient-level responsiveness: PASS more responsive than SFPASS in that PASS detected significantly greater proportion of participants showing significant improvement than SFPASS (53% versus 43% respectively)

Bibliography

Benaim C, Pérennou DA, Villy J, Rousseaux M, Pelissier JY. Validation of a standardized assessment of postural control in stroke patients: the Postural Assessment Scale for Stroke Patients (PASS). Stroke. 1999;30(9):1862-8. Find it on PubMed

Chien CW, Hu MH, Tang PF, Sheu CF, Hsieh CL. A comparison of psychometric properties of the smart balance master system and the postural assessment scale for stroke in people who have had mild stroke. Arch Phys Med Rehabil. 2007a;88(3):374-80. Find it on PubMed

Chien CW, Lin JH, Wang CH, Hsueh IP, Sheu CF, Hsieh CL. Developing a Short Form of the Postural Assessment Scale for people with Stroke. Neurorehabil Neural Repair. 2007b;21(1):81-90. Find it on PubMed

Chinsongkram B, Chaikeeree N, Saengsirisuwan V, Viriyatharakij N, Horak FB, Boonsinsukh R. Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Physical therapy. 2014;94(11):1632-43. Find it on PubMed

Di Monaco M, Trucco M, Di Monaco R, Tappero R, Cavanna A. The relationship between initial trunk control or postural balance and inpatient rehabilitation outcome after stroke: a prospective comparative study. Clin Rehabil. 2010;24(6):543-54. Find it on PubMed

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(11):2626-30. Find it on PubMed

Hsueh IP, Chen KL, Chou YT, Wang YH, Hsieh CL. Individual-level responsiveness of the original and short-form postural assessment scale for stroke patients. Physical therapy. 2013;93(10):1377-82. Find it on PubMed

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. Journal of rehabilitation medicine. 2016;48(3):259-64. Find it on PubMed

Liaw LJ, Hsieh CL, Hsu MJ, Chen HM, Lin JH, Lo SK. Test-retest reproducibility of two short-form balance measures used in individuals with stroke. Int J Rehabil Res. 2012;35(3):256-62. Find it on PubMed

Liaw LJ, Hsieh CL, Lo SK, Chen HM, Lee S, Lin JH. The relative and absolute reliability of two balance performance measures in chronic stroke patients. Disabil Rehabil. 2008;30(9):656-61. Find it on PubMed

Lin JH, Hsu MJ, Hsu HW, Wu HC, Hsieh CL. Psychometric comparisons of 3 functional ambulation measures for patients with stroke. Stroke; a journal of cerebral circulation. 2010;41(9):2021-5. Find it on PubMed

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):1022-7. Find it on PubMed

Persson CU, Hansson PO, Danielsson A, Sunnerhagen KS. A validation study using a modified version of Postural Assessment Scale for Stroke Patients: Postural Stroke Study in Gothenburg (POSTGOT). J Neuroeng Rehabil. 2011;8:57. Find it on PubMed

Wang CH, Hsueh IP, Sheu CF, Yao G, Hsieh CL. Psychometric properties of 2 simplified 3-level balance scales used for patients with stroke. Phys Ther. 2004;84(5):430-8. Find it on PubMed

Yu WH, Hsueh IP, Hou WH, Wang YH, Hsieh CL. A comparison of responsiveness and predictive validity of two balance measures in patients with stroke. J Rehabil Med. 2012;44(2):176-80. Find it on PubMed

Yu WH, Chen KL, Chou YT, Hsueh IP, Hsieh CL. Responsiveness and predictive validity of the hierarchical balance short forms in people with stroke. Physical therapy. 2013;93(6):798-808. Find it on PubMed

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Available at: http://www.physio-pedia.com/Postural_Assessment_Scale_for_Stroke. Accessed September 20, 2014.

Available at: http://strokengine.ca/assess/module_pass_indepth-en.html. Accessed September 27, 2014.

Available at: http://strokengine.ca/assess/module_pass_psycho-en.html. Accessed September 27, 2014.