The
North
Star
Ambulatory
Assessment
The North Star Ambulatory Assessment has been developed by the
Physiotherapy Assessment and Evaluation Group of the North Star Clinical Network for the
assessment of ambulant boys with Duchenne muscular dystrophy (DMD)
The North Star Project is supported by Muscular Dystrophy Campaign
© Copyright 2006-2011 MDC/North Star Clinical Network
May be used free of charge. Selling without prior written consent prohibited. Obtain
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NORTH STAR AMBULATORY ASSESSMENT (NSAA)
The following pages give test details and instructions for the patient and a scoring sheet with details for
grading. They should be used in conjunction with each other. Please familiarise yourself with the test detail
before starting to evaluate patients.
Clear explanations of the methods employed to achieve motor goals are given but it is not possible to be
exhaustive in the descriptions, particularly of modifications to activity. DMD children usually present with
commonly recognisable adaptations to activity but they may modify their activity to achieve functional goals in
slightly differing ways. Generally however activities are graded in the following manner:
2 - ‘Normal’ – no obvious modification of activity
1 - Modified method but achieves goal independent of physical assistance from another
0 - Unable to achieve independently
Equipment
15cm high box step, height appropriate chair/height adjustable plinth, stopwatch, 10m marked ‘runway’
General test instructions
If you think that the child is capable of a better performance, it is acceptable to ask the child to repeat
the item and re-score if appropriate. You should attempt all activities at each assessment
Do not use a mat unless it is required to gain co-operation. If a mat must be used, make sure it is not
heavily padded. Note in comments and do so for all subsequent evaluations
Please note that for many of the items socks and shoes should not be worn
For the timed tests – rise from floor and 10m ‘run’ - please note the time in seconds and only to the
nearest tenth of a second
Rise from floor
Components of Gowers’ manoeuvre:
Turns towards the floor (into a four-point kneeling position or rolls to prone)
Places hands on the floor to assist rising and walks hands back in towards him
Uses one or both arms to push up on legs to achieve upright standing
Large base of support by abducting hips and extending knees
Figure: Gowers’ Manoeuvre (from W.R. Gowers’ Pseudohypertrophic muscular paralysis,
1879)
© Copyright 2006-2011 MDC/North Star Clinical Network Page 3 of 5
North Star Ambulatory Assessment Test Detail and Instructions to Patient
Test Item Instructions to patient Start position/test detail Comments
Can you stand up tall for Feet should be no further than
me for as long as you 10cm apart and heels on the
1. Stand Minimum count of 3 seconds to score 2.
can and as still as you ground if possible. Arms by sides.
can NO shoes should be worn.
If the patient generally toe walks but occasionally gets
Can you walk from A to Walk without shoes/socks on. heels flat, or can on request they should score 1.
2. Walk B (state to and where Observe walk for at least 10 steps Should be enough of a distance to observe ‘normal
from) for me. in both saggital and coronal planes. gait’ for that subject
Use a size-appropriate chair (without armrests) or
Stand up from the chair Starting position 90º hips and height adjustable plinth. Alternatively a box step under
3. Stand up from chair keeping your arms knees, feet on floor/supported on a the feet to achieve the correct starting position could
folded if you can box step. be used. Arms should be kept crossed throughout the
activity to score 2.
4 & 5. Can you stand on your
Minimum count of 3 seconds to
Stand on one leg right/left leg for as long Best done on the floor rather than on a mat.
score 2. NO shoes should be worn.
Right + Left as you can?
6 & 7. Can you step onto the Support may be provided by the use of a height
Stands facing the box step. Step
Climb box step top of the box using your adjustable plinth, or, if not available one ‘neutral’ hand
should be 15cm high
Right + Left right/left leg first? from the therapist.
8 & 9. Can you step down from Stands on top of the box step Support may be provided by the use of a height
Descend box step the box using your facing forwards. Step should be adjustable plinth, or, if not available one ‘neutral’ hand
Right + Left right/left leg first? 15cm high from the therapist.
Starting position supine on a mat. If patient turns into prone or towards the floor to work
Can you get from lying
10. Gets to sitting No pillow should be used under their way into sitting 1 should be scored. Aiming for
to sitting?
head. long sitting.
Score 1 if the child stands independently of furniture
Can you get up from the Starting position supine with arms
but demonstrates any part of the Gowers’ manoeuvre.
11. Rise from floor floor as fast as you can by sides, legs straight. No pillow to
Attempt activity without use of furniture in the first
(from supine)? be used.
instance.
Can you lift your head to Ask patient to keep arms crossed over chest during
look at your toes Supine, arms folded across chest. the activity to avoid self-assist. Also ask to look at toes
12. Lifts head
keeping your arms No pillow should be used. to ensure neck is flexed – should be a chin to chest
folded? manoeuvre.
Must clear both feet at the same time to score 2.
Can you stand on your Standing on the floor. No shoes to Watch for inversion. If substantial inversion but forefeet
13. Stands on heels
heels? be worn. are still lifted – score 1. If only inversion with lateral
border of foot still on the ground score 0.
Standing on the floor, feet fairly Want height, not forward movement. Small amount of
14. Jump How high can you jump?
close together. forward movement acceptable
Starting position standing on floor
15 & 16. Can you hop on your
on right leg. No shoes should be Needs obvious floor clearance to score 2
Hop Right + Left leg right/left leg?
worn.
A straight 10m walkway should be
clearly marked in a quiet space. ‘Duchenne jog’ - not a true run (there probably IS a
Go as fast you can Use a stop watch. Ensure safety of double support phase), but more than a walk. Typically
17. Run (10m)
to……(give point) patient. They should self select characterized by excessive use of arms, trunk rotation,
speed after being asked to go ‘as substantial ’waddle’. No real ‘push-off’
fast as they can’.
© Copyright 2006-2011 MDC/North Star Clinical Network Page 4 of 5
North Star Ambulatory Assessment - score sheet
Name: Date:
Date of Birth: Examiner name and signature:
Test Item 2 1 0 Comments
Stands upright, still and Stands still but with some degree of
symmetrically, without compensation (e.g. on toes or with Cannot stand still or
1. Stand compensation (with heels flat and legs abducted or with bottom stuck independently, needs support
legs in neutral) for minimum count out) for minimum count of 3 (even minimal)
of 3 seconds seconds
Loss of independent
Walks with heel-toe or flat-footed Persistent or habitual toe walker, ambulation. May use KAFOs
2. Walk
gait pattern unable to heel-toe consistently or walk short distances with
assistance
Keeping arms folded. Starting With help from thighs / push on
3. Stand up from chair position 90º hips and knees, feet on chair / prone turn or alters starting Unable
floor/supported on a box step. position by widening base.
Stands but either momentarily or
Able to stand upright in a relaxed
with trunk side-flexion or needs
4. Stand on one leg - right manner (no fixation) for count of 3 Unable
fixation e.g. by thighs adducted or
seconds
other trick
Stands but either momentarily or
Able to stand upright in a relaxed
with trunk side-flexion or needs
5. Stand on one leg - left manner (no fixation) for count of 3 Unable
fixation e.g. by thighs adducted or
seconds
other trick
Goes up sideways / rotates trunk /
6. Climb box step - right Faces step – no support needed Unable
circumducts hip or needs support
Goes up sideways / rotates trunk /
7. Climb box step - left Faces step – no support needed Unable
circumducts hip or needs support
Faces forward, steps down
Sideways, skips down or needs
8. Descend box step -right controlling weight bearing leg. No Unable
support
support needed
Faces forward, steps down
Sideways, skips down or needs
9. Descend box step -left controlling weight bearing leg. No Unable
support
support needed
Starts in supine – may use one Uses two arms / pulls on legs or
10. Gets to sitting Unable
hand / arm to push up turns towards floor.
Exhibits at least one of the
(a) NEEDS external support of
No evidence of Gowers’ components described on page 2 – Time (seconds)
11. Rise from floor object e.g. chair OR (b)
manoeuvre. in particular rolls towards floor, __._
Unable
and/or use hand(s) on legs
Head is lifted but through side
In supine, head must be lifted in
12. Lifts head flexion or with no neck flexion Unable
mid-line. Chin moves towards chest
(protracts)
Both feet at the same time, clearly
standing on heels only (acceptable Only raises forefeet or only
13. Stands on heels Unable
to move a few steps to keep manages to dorsiflex one foot.
balance) for count of 3
One foot after the other (skip) or
Both feet at the same time, clear the
14. Jump does not fully clear both feet at the Unable
ground simultaneously
same time.
Able to bend knee and raise heel,
15. Hop right leg Clears forefoot and heel off floor Unable
no floor clearance
Able to bend knee and raise heel,
16. Hop left leg Clears forefoot and heel off floor Unable
no floor clearance
Both feet off the ground (no double Time (seconds)
17. Run (10m) ‘Duchenne jog’. Walk
stance phase during running) _ _. _
TOTAL= /34
© Copyright 2006-2011 MDC/North Star Clinical Network Page 5 of 5
References
1. Mayhew A, Cano S, Scott E, Eagle M, Bushby K, Muntoni F, The North Star Clinical Network for
Paediatric Neuromuscular Disease. Moving towards meaningful measurement: Rasch Analysis of
North Star Ambulatory Assessment in Duchenne muscular dystrophy. Dev Med Child Neurol.
2011 Mar 17. doi: 10.1111/j.1469-8749.2011.03939.x. [Epub ahead of print]
2. Mazzone E, Martinelli D, Berardinelli A, Messina S, D'Amico A, Vasco G, Main M, Doglio L, Politano
L, Cavallaro F, Frosini S, Bello L, Carlesi A, Bonetti AM, Zucchini E, De Sanctis R, Scutifero M,
Bianco F, Rossi F, Motta MC, Sacco A, Donati MA, Mongini T, Pini A, Battini R, Pegoraro E, Pane M,
Pasquini E, Bruno C, Vita G, de Waure C, Bertini E, Mercuri E. North Star Ambulatory Assessment,
6-minute walk test and timed items in ambulant boys with Duchenne muscular dystrophy.
Neuromuscul Disord. 2010 Nov;20(11):712-716
3. Mazzone ES, Messina S, Vasco G, Main M, Eagle M, D'Amico A, Doglio L, Politano L, Cavallaro F,
Frosini S, Bello L, Magri F, Corlatti A, Zucchini E, Brancalion B, Rossi F, Ferretti M, Motta MG, Cecio
MR, Berardinelli A, Alfieri P, Mongini T, Pini A, Astrea G, Battini R, Comi G, Pegoraro E, Morandi L,
Pane M, Angelini C, Bruno C, Villanova M, Vita G, Donati MA, Bertini E, Mercuri E. Reliability of the
North Star Ambulatory Assessment in a multicentric setting. Neuromuscul Disord.
2009;19(7):458-461.
4. Eagle M, Scott E, Main M, Sheehan J, Michelle M, Guglieri M, Straub V, Bushby K. Steroids in
Duchenne muscular dystrophy (DMD): Natural history and clinical evaluation using the North
Star Ambulatory Assessment (NSAA). Poster presented at the World Muscle Society Conference,
Sicily. Abstract in Neuromuscul Disord. 2007; 17(9-10): 774
5. Scott E, Eagle M, Main M, Sheehan, J. The North Star Ambulatory Assessment. Poster presented
at the Annual Meeting of the British Paediatric Neurology Association, 2006. Abstract in Dev Med
Child Neurol 2006; 48(Supp. 104): 27
