Remote measures and assessment tools

I am concerned that we are all using assessment techniques which lack known reliability and validity if conducted in a context different to that in which they are supposed to be used (i.e. using them remotely rather than face-to-face).

Physiotherapist, Musculoskeletal/Rheumatology


Some practitioners have concerns about the validity, reliability and safety of the physical assessment tools and outcome measures they are using when these have not been designed for remote use. The evidence for when and how they can be successfully used remotely is limited, but this section includes some of the commonly used assessment tools that can be used remotely. This is not intended to be a comprehensive list, but includes examples of outcomes that practitioners report having used them remotely with some success, with links to studies that have assessed validity and reliability.

For guidance on safely carrying out remote assessments, see our information governance and safety section.

 

Assessment tips

  • Plan what you want to assess in advance and let the patient know what to expect prior to, and at the beginning of the consultation.
  • Ask the patient to wear bright and contrasting clothes (like different coloured trousers, socks and shoes). This helps with seeing movement and distinguishing body regions or sources of pain. Clothing should be loose and comfortable but should not obscure the body region you will be assessing – for example, a t-shirt might be best for upper limb assessments.
  • Start with a comprehensive subjective assessment and make use of this as much as possible: 

Listening to patients and undertaking thorough subjective examinations can give many insights into our expected outcomes. When I have done this, I would say that my outcomes following remote objective screening do not change. This means that where any doubt or difficulties occur during the assessment of physical impairment I’m confident that despite this, the safest outcome for the patient happens.

Physiotherapist, Trauma and Orthopaedics


  • Use copying movements when demonstrating a movement or exercise (make sure your hands/arms/the relevant body part can be seen in the camera).
  • Ask lots of probing questions and encourage the patient to describe clearly where demonstration is not possible. Consider using a prompt sheet with reminders to ask about different symptoms where visual cues are lacking (e.g. fatigue, weakness, continence, speech and swallowing).
  • When asking the patient to describe sources of pain, encourage them to be specific. Ask them to point with one finger to the worst affected location and where the pain radiates.
  • Objective testing is more difficult over the phone or video. Some tests may need to be done face-to-face – e.g. reflexes, sensory/motor testing, specific strength testing and special tests. Keep it simpler than a face-to-face assessment, capturing key elements of general mobility rather than looking at detailed and higher level activities – functional assessments and global movements will be easier. Don’t try to look at too much: 

Try to only assess one or two impairments or functions to make it more likely that the experience for both patient and therapist is successful.

Physiotherapist, Neurology


  • Observe and compare healthy and affected sides or limbs to check for swelling, atrophy or any other deformities: “Non-standardised comparison of the contralateral hand/arm is a good tool.” (Occupational Therapist, Trauma & Orthopaedics)
  • Observe the patient carefully in their home environment – you might not be able to watch them walk into the clinic room, but you can ask them to show you how they move and function in their own surroundings. 

Somebody might be able to get on and off a chair in clinic because we’ve got nice suitable high orthopaedic kind of chairs, but then you actually see what they’re trying to get out of at home and no wonder they’re having difficulty, or no wonder they’re falling when they’re trying to get out of their chair because it’s very low and it’s not supportive.

  Occupational Therapist, Neurology


  • Have different consultations with different purposes: 

The first session is about getting to know the patient and then decide what level of assessment to perform. For example, if the patient is unsteady I complete a more functional assessment with a family member (if possible). If it is safe then I have completed a more formal balance assessment (e.g. Berg Balance Scale) but with the family member close by.

Physiotherapist, Neurology

 

  • Consider using asynchronous assessments as an alternative to, or to complement ‘live’ consultations. You could ask the patient or a family member to take photos or record a video, for example to show how the patient moves or their functional ability. Beforehand, check your organisation’s governance guidance around this. See our information governance and safety section.

Further guidance: Video from Flinders University with ‘Clinical examples of tele-physiotherapy’

Explanatory notes for the studies below

ICC refers to Intraclass Correlation Coefficient. This measures the test-retest and inter-rater reliability of data in groups (i.e. how reliable and consistent are the results when repeated over time or between people). An ICC closer to 1 indicates increasing similarity between groups with >0.9 being excellent reliability.

R refers to Pearson’s r. This measures the degree of correlation between two different variables. The correlation can be positive or negative and the larger the number the greater the correlation (e.g. foot size will be positively correlated with height).

Gait assessment

Analysis of functional mobility

Technology for remote assessment:
Wide angled webcam using high bandwidth transmission frequency

Validity / reliability:
Moderate to good inter-rater reliability for Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) across all configurations (ICC = 0.66 - 0.77). Moderate validity for in-person (R = 0.62) and Normal Speed video (R = 0.74) ratings compared with the Slow Motion review. (Venkataraman 2020)

Key studies / resources:
Venkataraman (2020) Teleassessment of Gait and Gait Aids: Validity and Interrater Reliability 

Tempero-spatial variables

Technology for remote assessment:
Accelerometers
Smartphone
Sensors placed in shoes

Validity / reliability:
Excellent reliability (ICC = 0.74 - 0.97) across smartphone assessed step length and gait velocity measures, and high correlation between smartphone and ‘GAITRite’ assessed step length/speed (R = 0.798 - 0.985) (Silsupadol et al. 2017)

Key studies / resources:

Step count / activity level

Technology for remote assessment:
Commercial grade activity trackers such as Fitbit, Polar monitor etc.

Validity / reliability:
High validity versus Actigraph accelerometer for Fitbit One (ICC = 0.94) and Charge HR (ICC = 0.86). Variable reliability - overestimation of between 167 and 2690 steps in comparison to research grade accelerometers. (Stainton et al. 2018)

Key studies / resources:
Stainton et al. (2018) The validity and reliability of consumer-grade activity trackers in older, community-dwelling adults: A systematic review

TUAG (Timed Up And Go)

Technology for remote assessment:
iTUG (instrumented Timed Up And Go) using a free smartphone application downloaded via iTunes - requires IOS 9.0 or later.

Validity / reliability:
Excellent test/retest reliability: ICC = 0.97 for iTUG time across heterogeneous patient groups (Yamada et al. 2019)

Key studies / resources:


Technology for remote assessment:
ITUG-Triaxial accelerometer measured via a device worn on a belt around the waist (Bts-g walk)

Validity / reliability:
Good reliability (R = 0.9) for temporal measures of gait (Salarian et al. 2010)
Excellent reliability ICC = 0.998 - in comparison to stopwatch-timed TUG/opto-electronic/Gait lab system (gold standard) (Kleiner et al. 2017)

Key studies / resources:

Two-minute walk test (2MWT)

Technology for remote assessment:
Smartphone app / commercial activity monitor

Validity / reliability:
Excellent agreement between Fitbit and visually counted steps (ICC = 0.88) for the 2MWT (Paul et al. 2015)

Key studies / resources:
Paul et al. (2015) Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults 

Six-minute walk test (6MWT)

Technology for remote assessment:
Smartphone apps (e.g. SA-6MWT app). May be linked with Google Fit for Android phones.

iPod Touch 5th generation internal sensor

Validity / reliability:
High correlation (R = 0.9) between smartphone assessed outdoor 6MWT and trundle wheel measurement (Salvi et al. 2020)

High correlation between iPod Touch and body worn sensors (R = 0.9) across all temporo-spatial gait parameters (Proessl et al. 2018)

High correlation (R = 0.99) between staff-administered clinic 6MWT and self-administered 6MWT via app (Brooks et al. 2015)

Key studies / resources:

 

Musculo-skeletal assessment

Range of motion

Technology for remote assessment:
Internet / virtual goniometry
Video-based assessment

Validity / reliability:
Internet-based goniometer valid and accurate (knee joint range) even with low bandwidth. ICC = 0.77 - 0.99 for intra-tester reliability and ICC = 0.93 - 0.99 for inter-tester reliability (Russell et al. 2003)

Knee and wrist joint range assessment with virtual goniometry reliable and feasible but may be less accurate than face-to-face, particularly for inexperienced clinicians. Inter-rater reliability ICC = 0.78 for student vs ICC = 0.9 for experienced clinicians (Mehta et al. 2020)

Good to excellent concurrent validity of internet-based physiotherapy assessments across 7 separate studies (Mani et al. 2016)

Key studies / resources:

Shoulder assessment

Technology for remote assessment:
Video-based assessment

Validity / reliability:
Consistent with the reliability of conventional assessment methods (Steele et al. 2012)

Key studies / resources:

Knee assessment

Technology for remote assessment:
Video-based assessment

Validity / reliability:
High level of intra-rater (89%) and moderate level of inter-rater (67%) reliability for telerehabilitation assessments (Richardson et al. 2016)

Key studies / resources:

Ankle assessent

Technology for remote assessment:
Video-based assessment

Validity / reliability:
High agreement between face-to-face and internet assessed diagnoses with 76% exact agreement (Russell et al. 2010)

Key studies / resources:

Spine examination

Technology for remote assessment:
Video-based assessment

Validity / reliability:
High agreement between face-to-face and telerehabilitation evaluations (alpha reliability > 0.80) for 7 of the 9 outcome measures. Excellent inter- and intra-rater reliability (ICC = 0.92 - 0.96) (Palacin-Marin et al. 2013)

Key studies / resources:

General guidance for musculo-skeletal assessments via video link

Technology for remote assessment:
Video-based assessment

Validity / reliability:
Good concurrent validity and excellent reliability for virtual musculoskeletal assessments across most areas (Mani et al. 2016)
High level of agreement between videoconference assessment and in-person assessment of patients with chronic lumbar spine, knee or shoulder conditions referred to a tertiary advanced-practice physiotherapy screening clinic (Cottrell et al. 2018)

Key studies / resources:

 

Neurological assessment

Neuro-psychological tests

e.g. Symbol Digit Modalities Test, SDMT

Technology for remote assessment:
Video-based assessment.

Validity / reliability:
High correlation between standard SDMT and Smartphone-based Symbol Digit Modalities Test (S-SDMT) (ICC = 0.838), but SDMT score was on average 12% higher than S-SDMT score (van Oirschot et al. 2020)

Key studies / resources:

Neurological assessment

e.g. range of motion post-stroke

Technology for remote assessment:
Video-based assessment

Validity / reliability:
Valid and reliable measurement of upper limb range of motion following stroke (Hoffmann et al. 2007)

Key studies / resources:

Spasticity

Technology for remote assessment:
Video-based assessment

Validity / reliability:
Almost perfect agreement (94%) between two examiners identifying spasticity remotely (Harper et al. 2021)

Key studies / resources:

 

Other assessments

Balance: Berg balance scale

Technology for remote assessment:
Recommendations: High-definition video with slow motion review (bandwidth >768kbps and frame rate >30fps)

Validity / reliability:
High inter-rater reliability comparing face-to-face and high definition video (ICC = 0.96) (Venkataraman et al. 2017)

Key studies / resources:

Function: Sit-Stand (e.g. five times sit-stand, 30 second sit-stand)

Technology for remote assessment:
Sensors within iPhone 6 or Samsung Galaxy phone placed in trouser pocket
Accelerometer
Video assessment

Validity / reliability:
Strong correlation between smartphone measured sit-stand (via internal sensors) and face-to-face stopwatch measurement (R > 0.97). Good to excellent inter-rater reliability (ICC > 0.98) for all three outcomes assessed: Five Times Sit-Stand, TUAG and 30 Second Sit-Stand (Lein et al. 2019)

Key studies / resources:

Hand examination

Range of motion, sensation, strength testing, functional testing, and special tests / provocative manoeuvres

Technology for remote assessment:
Video-based assessment

Validity / reliability:
High agreement between telehealth assessment and traditional clinical assessment for a range of subjective and objective outcomes (Worboys et al. 2018)

Key studies / resource:

Orthopaedic assessment (range of motion and function)

Technology for remote assessment:
Video-based assessment
Virtual goniometer using a Chrome extension such ‘Protractor’
Smartphone goniometer

Validity / reliability:
Excellent reliability (inter- and intra-rater) and validity of smartphone apps such as Clinometer and Goniometer-Pro in comparison to normal goniometer. ICC > 0.75 for more than 50% of joint movements reported in 23 studies (Keogh et al. 2019)

Key studies / resources:

Falls risk assessments

Technology for remote assessment:
Video-based assessment.

Key studies / resources:

Commonly used patient-reported outcomes

In our survey, practitioners reported using a range of patient-reported outcome measures as part of the remote assessment. Most of these could be sent via e-mail or post prior to the consultation. The most frequently assessed aspects of health and wellbeing, with some examples of questionnaires that practitioners had used are:

Activities of daily living

  • Barthel Index for Activities of Daily Living
  • Disabilities of the Arm, Shoulder & Hand (DASH)
  • Nottingham Extended Activities of Daily Living (NEADL) Scale

Caregiver wellbeing

  • Caregiver Strain Index (CSI)
  • Adult Carer Quality of Life (AC-QoL) questionnaire

Cognitive 

  • Montreal Cognitive Assessment (MoCA)
  • Addenbrooke’s Cognitive Examination (ACE-III)

COVID-specific

COVID-19 Yorkshire Rehabilitation Screen (C19-YRS). Telephone assessment tool with 19 self-reported items, each with a severity score of 0-10. Developed by the COVID-19 Multidisciplinary Team (MDT) Rehabilitation Teams of Leeds, Airedale and Hull NHS Trusts. Free to use.


Post-ICU Presentation Screen (PICUPS) tool. There is also a PICUPS Plus tool (and a community version). 16 items, 0-5 score. See framework for assessing early rehabilitation needs following treatment in intensive care.

Note: C19-YRS and PICUPS tools are complementary

Post-COVID-19 Functional Status (PCFS) Scale – recommended by NHSI.

Fatigue Severity Scale (FSS)

  • Modified Fatigue Impact Scale (MFIS)
  • Global Fatigue Index (GFI)

Mobility 

  • Rivermead Mobility Index (RMI)
  • Prosthetic Limb Users Survey of Mobility (PLUS-M™) Version 1.0

Psychosocial 

  • Hospital Anxiety and Depression Scale (HADS)
  • Patient Health Questionnaire 9 (PHQ-9)
  • Generalised Anxiety Disorder Questionnaire (GAD-7)

Quality of life (health-related, generic) 

  • EQ-5D-5L
  • Short Form 36 (SF-36) Health Survey Questionnaire

Speech

  • Overall Assessment of the Speaker's Experience of Stuttering (OASES)
  • Voice Handicap Index (VHI-10)

Other disease-specific 

Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)

Egen Klassifikation (EK Scale) for muscular dystrophy and atrophy

Multiple Sclerosis Impact Scale (MSIS-29)
12-item Multiple Sclerosis Walking Scale (MSWS-12)

Parkinson’s Disease Questionnaire (PDQ-39) and PDQ-Carer have versions designed for remote use

Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39)