Categories | Items | Rating [1–5] |
---|---|---|
A) Vegetative functions | 1) Autonomic stability | 1- Instable even at rest, monitoring required |
2 - Stable at rest but requires monitoring at least temporarily | ||
3 - Stable at rest and during nursing, no monitoring required | ||
4 - Slightly instable only during rehabilitation therapy | ||
5 - No marked changes in blood pressure, heart rate or perspiration during nursing or rehabilitation therapy | ||
2) Wakefulness | 1 - Lack of regular sleep-wake cycle, nocturnal agitation, sleepy during the day | |
2 - Infrequent nocturnal agitation and sleepy during the day | ||
3 - Regular sleep-wake-cycle established | ||
4 - Fatigued after rehabilitation therapy of 10-60 min duration | ||
5 - No fatigue, even after rehabilitation therapy of more than 60 min | ||
3) Tolerance to postural changes | 1 - Only supine position is tolerated well, lying on one side less than 20 min | |
2 - Lying on one side tolerated 20-60 min | ||
3 - Lying on one side tolerated 60-120 min | ||
4 - Lying on one side tolerated more than 120 min | ||
5 - Complete tolerance to postural changes | ||
4) Excretion functions (continence) | 1 - No faecal and urinary continence at all, urinary catheter | |
2 - Use of diaper or urine bottle where possible | ||
3 - Use of toilet-chair where possible, no urinary catheter | ||
4 - Continence during the day, nocturnal incontinence | ||
5 - Faecal and urinary continence | ||
Category score | 4 to 20 points | |
B) Oro-facial-functions | 5) Oro-facial stimulation/oral hygiene | 1- No cooperation, no reaction to oro-facial stimulation |
2 - No cooperation, minor reactions upon stimulation | ||
3 - Partial cooperation (e.g. opening mouth) | ||
4 - Good cooperation during oral hygiene | ||
5 - Oral hygiene carried out independently (e.g. toothbrushing) | ||
6) Swallowing | 1 - No/infrequent swallowing of saliva, high danger of aspiration | |
2 - Swallowing of saliva improved, still danger of aspiration | ||
3 - Swallowing of mush possible, drinking still dangerous (aspiration) | ||
4 - No disturbance of swallowing of food, drinking infrequently disturbed | ||
5 - No disturbance of eating and drinking | ||
7) Tongue movements/chewing | 1 - No tongue movements, no chewing | |
2 - Severely disturbed chewing | ||
3 - Chewing improved, tongue movements severely disturbed | ||
4 - Tongue movements improved | ||
5 - No disturbance of tongue movements or chewing. | ||
8) Facial expression | 1 - No facial expression/reaction | |
2 - Some spontaneous facial expression/reaction | ||
3 - Infrequent spontaneous and voluntary facial expression | ||
4- Slightly disturbed voluntary facial expression | ||
5 - Regular facial expression. | ||
Category score: | 4 to 20 points | |
C) Sensorimotor abilities | 9) Muscle tone | 1 - No modulation of muscle tone (spastic or floppy) |
2 - Some modulation of muscle tone may be observed in unaffected limbs | ||
3 - Improved modulation and holding of muscle tone | ||
4 - Good modulation and holding of muscle tone in unaffected limbs | ||
5 - Normal modulation and holding of muscle tone in supine position | ||
10) Head postural control | 1 - No head postural control at all | |
2 - Severely disturbed head postural control during rehabilitation therapy | ||
3 - Infrequently raising the head | ||
4 - Holding up the head for up to 10 min | ||
5 - Normal head posture, longer thann 10 min | ||
11) Trunk postural control/sitting | 1 - No sitting at all | |
2 - Passive sitting | ||
3 - Active sitting, infrequentl correction of trunk position | ||
4 - Active sitting without any help, less than 10 min, still some problems in keeping balance | ||
5 - Physiological trunk posture; sits without help more than 10 min | ||
12) Changing position | 1 - No voluntary changes of position | |
2 - Changes position with help from 1-2 nurses | ||
3 - Changes position with little help from 1 nurse | ||
4 - Changes position almost without any help | ||
5 - Can stand up from a lying position without any help. | ||
13) Standing | 1 - No standing at all. | |
2 - Stands (passively) only 5-10 min with help from 2 nurses | ||
3 - Stands (passively) more than 10 min with help from 2 nurses | ||
4 - Stands (actively) with help from only 1 nurse | ||
5 - Stands without help | ||
14) Voluntary movements | 1 - No voluntary movements | |
2 - Infrequent voluntary movements (e.g. aversion motions) | ||
3 - Grasps, but does not let go | ||
4 - Slight disturbance of grasping and letting | ||
5 - No disturbance of voluntary movements | ||
15) Locomotion/mobility in wheelchair | 1 - No use of a wheelchair at all | |
2 - Passive transport in wheelchair | ||
3 - Patient has trunk and head postural control in wheelchair | ||
4 - Active use of wheelchair by the patient or walking some steps | ||
5 - Independent mobility in wheelchair or ambulation without help | ||
Category score: | 7 to 35 points | |
D) Cognitive abilities | 16) Tactile stimulation | 1 - No response to tactile stimulation |
2 - Nonspecific response to stimulation (e.g. agitation, heart rate or muscle tone changes) | ||
3 -Voluntary response to stimulation, in particular aversion | ||
4 - Grasping or other targeted actions | ||
5 - Adequate reactions to tactile stimulation | ||
17) Visual stimulation | 1 - No response to visual stimulation | |
2- Nonspecific response or short eye contact | ||
3 -Voluntary response to stimulation, eye contact | ||
4 - Targeted actions, eyes search the environment | ||
5 - Adequate reactions to visual stimulation | ||
18) Auditory stimulation | 1 - No response to auditory stimulation | |
2 - Nonspecific response to stimulation (e.g. agitation, heart rate or muscle tone changes) | ||
3 - Voluntary response to stimulation, orientation of eye or head movement to the stimulus | ||
4 - Different reactions to familiar /unfamiliar voices | ||
5 - Assimilation of acoustic information over longer periods of time. | ||
19) Communication | 1 - None. | |
2 - Low-level communication (e.g. expression of discomfort) | ||
3 - Infrequent adequate responses | ||
4 - Patient is able to answer with yes/no | ||
5 - Talking or communicating without problems | ||
20) Comprehension | 1 - None | |
2 - Nonspecific reactions (e.g. muscle tone changes) | ||
3 - Patient is more cooperative, partial comprehension of the situation, apractic/agnostic | ||
4 - Comprehension improved, no apraxia/agnosia | ||
5 - No disturbance of activities of daily living. | ||
Category score: | 5 to 25 | |
EFA total score: | 20 to 100 points |