1.

North Star Ambulatory Assessment (NSAA) – Version 2.0

Test Description

The NSAA is a 17-item scale that grades performance of various functional skills on a scale from 0
(unable), 1 (completes independently but with modifications), and 2 (completed without
compensation).

NOTE: The order has been modified to enable more efficient conduct of the assessment.

a. Climb and Descend stairs: climb box step is performed step up right, step down right, step up
left, step down left.

b. Lifts head is performed before ‘gets to sitting’ and ‘rise from floor’ to avoid fatigue.

Test Guidelines

• Performance of upright activities must not be completed if a lower limb injury exists. However,
the subject may perform the head lift and gets-to-sitting items if he is able. Provide ‘comments’
on the source worksheet.

• Complete the NSAA in the order provided (Please note this has been modified from previous
trials for a smoother administration).

• Do NOT use a mat.

• Please note the time in seconds rounded to the nearest tenth of a second for all timed tests
(eg, rise from floor and 10 m ‘run’).

• Generally, activities are graded in the following manner:

Score of 2 = ‘Normal’ – no obvious modification of activity

Score of 1 = Modified method but achieves goal with no physical assistance

Score of 0 = Unable to achieve goal independently

• If you think the subject is capable of a better performance, due to non-compliance or improved
understanding of task, it is acceptable to ask the subject to repeat the item and re-score if
appropriate.

• If unsure if the performance on a particular item meets the higher criteria, give the subject the
lower score.

Set-Up

• Mark off a 10-metre course in a long, quiet hallway or room. Provide a ‘finish’ line at
approximately 11 metres to ensure the subject moves ‘through’ the 10-metre line, rather than
slowing down prior to finishing.

• Ensure a clear floor space, measuring approximately 10 feet x 12 feet, is available for remaining
assessments (i.e., rise from floor).
Conducting the Test

Test item 1: Standing

Starting Feet must be no further than 10 cm apart and heels on the ground if
position possible. Arms by sides.

Instruction Can you stand up tall for me for as long as you can and as still as you can
for three seconds with your heels flat on the ground?
Scoring detail When counting to 3 – Use “And 1, and 2, and 3” so that three seconds is
achieved on the word of 3.
Score 2 - Minimum count of 3 seconds.
Activity 2 1 0

Standing Stands upright, still, Stands still but with Cannot stand
symmetrical, compensation (e.g. on toes or still or cannot
without with legs abducted or with stand
compensation (heels bottom stuck out/hip flexion, independently,
flat and hips in etc) for minimum count of 3 needs support
neutral rotation) for seconds (even minimal)
minimum count of 3
seconds

Photographs/

Notes

Score 2 -Symmetrical
heels flat

Score 1 – Asymmetric or
compensation

 Test item 2: Walk
Starting position Standing. Observe walk for at least 10 steps in both sagittal and coronal
planes.

Instruction Can you walk from A to B (state to and where from – approximately 8-
10 feet) for me?

Scoring detail Score 1 - If the patient generally toe walks but occasionally gets heels
flat, or can on request, they must score 1

Activity 2 1 0

Walk Walks consistently Persistent or habitual Loss of independent

with heel-toe or flat- toe walker, unable to ambulation – may use
footed gait pattern heel-toe consistently knee-ankle-foot
orthosis (KAFO) or
walk short distances
with assistance

Score 1 – habitual toe
walker

 Test item 3: Stand up from chair
Starting Sitting in chair, bench or plinth with arms folded across chest with his hand up
position by his shoulders and with feet able to reach floor or supported on secure box.
Adjust the seat height so that the hips and knees are at a 90º angle from the
floor. Feet no more than shoulder width apart.

Instruction Can you stand up from the chair keeping your arms folded?

Scoring A size-appropriate chair (without arm-rests) or height adjustable plinth must

detail be used. Alternatively, a box step under the feet to achieve the correct
starting position may be used.

Score 2 - Arms must be kept crossed with the hands up by the shoulders
throughout the activity to score 2

Activity 2 1 0

Stand up Able to stand up keeping arms With help from Unable

from chair folded thighs / push on
chair / prone turn
or alters starting
position by
widening base

Photograph
s/ notes

Score 1 - Needs
two hands to push Score 0 -Unable to
and/or rise from starting
position
Widened base
Score 0 - Needs to
change body
position; and/or
hips extended to
slide forward from
chair (not 90/90)
Score 2 – keeps arms folded and
stands up without widening base

 Test item 4 & 5: Stand on one leg Right & Left
Starting Standing.
position

Instruction Show me how long you can stand on your right / left leg with your arms at
your side.

Count “And 1, and 2, and 3”

Scoring Score 2 – Minimum count of 3 seconds required

detail

Activity 2 1 0

Stand on Able to stand in a Stands but either momentarily or Unable

with trunk side-flexion or needs
one leg relaxed manner (no fixation e.g. by thighs adducted
fixation) for a count
of 3 seconds

Photographs
/ notes

Score 1 -Hooks leg Score 0 -If needs to hold

behind standing leg onto a table or person
for support

Score 2 – Relaxed and
no fixation

Score 1 -Postural
compensation / leaning
to side

 Test item 6 & 8: Climb box step Right & Left
Starting Standing in front of box step, toes no more than 20 cm (~8 in) away from box
position step.

Instruction Can you step onto the top of the box using your right/ left leg.

Scoring detail Box step must be 15 cm high. Score 1: If they need a hand for balance only –
evaluators hand should be kept relatively high. Score 1: If they use a hand on
their thigh. If in doubt whether this is used for balance or support offer them
your hand and repeat test. Score 0: If they put weight through the evaluators
hand (with one or two hands) or unable to climb step

They should not have their hands in their pocket.

Activity 2 1 0

Climbs box Faces step – no support Goes up sideways / rotates trunk / Unable to
circumducts hip or needs hand for
step needed balance perform
independently

Photographs
/ notes

Score 1 – Needs hand for
balance only

Score 2 – Faces step Score 1 - Rotates trunk or
uses hand on thigh

 Test item 7 & 9: Descend box step Right & Left
Starting Standing on box step
position

Instruction Can you step down from the box using your right (or left) leg?

Scoring detail Box step must be 15 cm high.

Score 1: If they need a hand for balance only – evaluators hand should be
kept relatively high. If they use a hand on their thigh. If in doubt whether
this is used for balance or support offer them your hand and repeat test.
Uses method that avoids flexing supporting knee (one on the box step)
Score 0: If they put weight through the evaluators hand (with one or two
hands) or unable to descend step

They should not have their hands in their pocket.

Activity 2 1 0

Descends box Faces forward, steps Sideways, skips down or needs Unable without
hand for balance
step down controlling more than minimal
weight-bearing leg. No support, or requires
support needed hands for support

Photographs/
notes

Score 2 – faces forward Score 1 – Needs hand for
balance. No weight taken
through hand.

Score 1 – Turning to side
to descend

 Test item 10: Lifts head from supine
Starting Supine on a plinth or floor, arms folded across chest and the hands up by the
position shoulders. No pillow must be used.

Instruction Can you lift your head and touch your chin to your chest keeping your arms
folded?

Scoring Ask patient to keep arms crossed over chest during the activity to avoid self-
detail assistance.

Activity 2 1 0

Lifts head In supine, full neck flexion, Head is lifted through side Unable. No
from supine head must be lifted in mid- flexion, partial neck clearance of head
line. Chin moves towards flexion, or with from surface
chest protraction.

Photographs
/ Notes

Score 2 – Chin on chest Score 1 - Didn’t achieve
full range of flexion

 Test item 11: Gets to sitting
Starting Starting position supine on the floor, or large plinth with arms by side. No
position pillow must be used under head.

Instruction Can you get from lying into sitting?

Scoring detail Aim is to move into long sitting rather than sitting over the edge of a
plinth. Use of one hand or arm is acceptable to achieve a score of 2.

Score 1 if patient turns into prone or towards the floor to work their way
into sitting or if uses two arms. Also score a one if the child uses leg
momentum/rocking to get to sitting.

Activity 2 1 0

Gets to sitting Starts in supine – may Uses two arms / pulls on Unable
use one hand / arm to legs or turns towards
push up floor or uses
momentum/rocking

Photographs

/notes

Score 1 - Pulls with both
hands on legs

Score 2 - Only needs one
arm to sit up

 Test item 12: Rise from floor
Starting Starting position supine with arms by sides, legs straight. No pillow to be
position used.

Instruction • Give the following verbal instructions to the patient:

• “When I say GO can you get up as fast as you can and stand up straight
with your arms by your side like a soldier using as little support as
possible”. Give the command “Ready, Set, GO!” and start the
stopwatch when saying “GO”.
• Stop the timer when the patient assumes an upright position with his
arms by his side.
Scoring detail / Activity must be attempted without use of furniture in the first instance.
Diagram
Score 1: If the patient gets to standing independently of any furniture but
demonstrates any part of the maneuver described below.
Components of Gower’s manoeuvre:
Turns towards the floor (into a four-point kneeling position or rolls to
prone).
Places hands on the floor to assist rising from floor 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.
Activity 2 1 0

Rise from floor No evidence of Gower’s Exhibits at least one (a) NEEDS to use
maneuver. of the components external support object
described above – in e.g. chair, wall –still
particular rolls record time OR (b)
towards floor, and/or Unable (time must be
use hand(s) on legs entered as N/A if the
patient scores 0)
Photographs /
Note

Score 2 - Doesn’t roll. Score 1 – Rolls to
Score 0 – Uses chair
Only 1 hand on floor to prone
move into sitting






Score 1 - Uses hand
on thigh

 Test item 13: Stands on heels
Starting position Standing on the floor. No shoes to be worn.

Instruction Can you stand on your heels? Count ‘And 1, and 2, and 3.”

Scoring detail Score 2: Must clear both feet at the same time using clear dorsiflexion

Score 1: If both forefeet are lifted - all metatarsal heads of floor even if
inversion is evident or clear dorsiflexion of one foot.

Score 0: If uses inversion with lateral border (fifth metatarsal) of foot still
on the ground or if just lifts toes.

Activity 2 1 0

Stand on heels Both feet at the same Raises forefoot on both Unable
time, clearly standing on feet – all metatarsal heads
heels only (acceptable to off ground – or clearly
move a few steps to dorsiflexes one foot only
keep balance) for count
of 3

Photograph /
Notes

Score 1 - Both feet raised Score 0 – Unable
but only forefeet to raise even
forefeet

Score 2 – Both feet
raised

 Test item 14: Jump
Starting Standing on the floor, feet comfortably close together
position

Instruction How high can you jump?

Scoring detail Want height, not forward movement. Small amount of forward movement
acceptable

Activity 2 1 0

Jump Both feet at the same One foot after the Unable
time, clear the ground other (skip) or does not
simultaneously fully clear both feet at
the same time

Photographs
/ Notes

Score 0 - Feet do not

leave floor

Score 1 - One step after

the other (skip)
Score 2 – Clears floor

 Test item 15 & 16: Hop Right & Left leg
Starting Starting position standing on floor on right / left leg.
position

Instruction Can you hop on your right / left leg?

Scoring detail Score 2: Needs obvious floor clearance. Must land on one foot. If leaves
floor but lands with two feet this is not a hop.

Activity 2 1 0

Hop Clears forefoot and heel Able to bend knee AND Unable or only
off floor raise heel, no floor raises heel
clearance

Photographs
/ Notes

Score 2 – Clears foot off
floor

Score 1 - Bends knee but
foot does not leave floor

Test item 17: Run (10 metres)
Starting Standing
position

Instruction Give the following verbal instructions to the patient: “When I say GO, you
go as fast as you safely can all the way to me. If you can run, then run. If
you can’t then walk to me as fast as you can.” (Encourage child to run past
the 10-metre mark) by standing at least one metre behind the line. Give
the command “Ready, Set – GO”. Continuously encourage the patient
until he crosses the finish line.

Start the timer when you say “GO”. Stop the timer when the second foot
clears the finish line.

Scoring A straight 12-m walkway must be clearly marked at 10-m in a quiet

department or corridor. A stopwatch must be used to time the walk. They
detail must self-select speed after being asked to go ‘as fast as they can’. Score 1
- ‘Duchenne jog’ - not a true run (There is a double support phase), but it is
faster than a walk. Characterised by excessive use of arms, trunk rotation,
substantial ’waddle’. No real ‘push-off’.

Activity 2 1 0

Run Both feet off the ground ‘Duchenne jog’ or Walk (No
(no double stance phase fast walk acceleration)
during running)

Photographs
/ Notes

Score 2 - Both feet off Score 1 - Picks up speed
the ground but waddles and has one
foot in contact with floor
Definite ‘run’
at all times
NSAA Brief Test Detail
Activity 2 1 0 Score
1. Stand Stands upright, still and Stands still but with some Cannot stand still or
symmetrically, without degree of compensation independently, needs
compensation (with heels (e.g. on toes or with legs support (even
flat and legs in neutral) for abducted or with bottom minimal)
minimum count of 3 stuck out) for minimum
seconds count of 3 seconds

2. Walk Walks with heel-toe or Persistent or habitual toe Loss of independent

flat-footed gait pattern walker, unable to heel-toe ambulation – may
consistently use KAFOs or walk
short distances with
assistance

3. Stand Keeping arms folded. With help from thighs / Unable

up from Starting position 90º hips push on chair / prone turn
chair and knees, feet on or alters starting position
floor/supported on a box by widening base.
step.

4. Stand Able to stand upright in a Stands but either Unable

on one leg relaxed manner (no momentarily or with trunk
– right fixation) for count of 3 side-flexion or needs
seconds fixation e.g. by thighs
adducted

5. Stand Able to stand upright in a Stands but either Unable

on one leg relaxed manner (no momentarily or with trunk
- left fixation) for count of 3 side-flexion or needs
seconds fixation e.g. by thighs
adducted

6. Climb Faces step – no support Goes up sideways / rotates Unable

box step - needed trunk / circumducts hip or
right needs hand for balance

7. Descend Faces forward, steps down Sideways, skips down or Unable

box step – controlling weight-bearing needs hand for balance
right leg. No support needed

8. Climb Faces step – no support Goes up sideways / rotates Unable

box step - needed trunk / circumducts hip or
left needs hand for balance

9. Descend Faces forward, steps down Sideways, skips down or Unable

box step - controlling weight-bearing needs hand for balance
left leg. No support needed
 Activity 2 1 0 Score
10. Lifts In supine, head must be Head is lifted but through Unable
head lifted in mid-line. Chin side flexion or with no neck
moves towards chest flexion (protracts)

11. Gets to Starts in supine – may use Uses two arms / pulls on Unable
sitting one hand / arm to push up legs or turns towards floor.

12. Rise No evidence of Gower’s Exhibits at least one of the (a) NEEDS external Timed
from floor maneuver. Gower’s components support of object e.g.
described– in particular chair OR (b) Unable
rolls towards floor, and/or
use hand(s) on legs

13. Stands Both feet at the same Raises forefoot on both Unable
on heels time, clearly standing on feet – all metatarsal heads
heels only (acceptable to off ground – or clearly
move a few steps to keep dorsiflexes one foot only
balance) for count of 3

14. Jump Both feet at the same One foot after the other Unable
time, clear the ground (skip) or does not fully clear
simultaneously both feet at the same time.

15. Hop Clears forefoot and heel Able to bend knee and Unable
right leg off floor raise heel, no floor
clearance

16. Hop Clears forefoot and heel Able to bend knee and Unable
left leg off floor raise heel, no floor
clearance

17. Run Both feet off the ground ‘Duchenne jog’ or fast walk Walk Timed
(10 m) (no double stance phase
during running)

TOTAL= /34

2. Timed Graded Functional activities

Rise From Floor

Place the participant in a supine position with his arms by his sides and his legs together.
No shoes or socks should be worn.

Give the following verbal instructions to the participant: “When I say GO you get up as fast as
you can and stand up straight with your arms by your side like a soldier”.

Give the command “Ready steady – GO” and start the stopwatch when saying “GO”.

Stop the timer when the participant assumes an upright position with his arms by his side.

Only provide a chair after the participant has attempted to stand from the floor for 30 seconds
and failed.

Record the fastest time and the method they used to achieve this fastest time. You can repeat
if you think they can do it faster or the grade was not representative of their usual ability.

Assign one of the following grades:

NSAA Functional Description
equivalent Grade
grade
0 1 Unable to stand from supine, even with use of a chair DO NOT RECORD
TIME

0 2 Requires furniture to stand up from supine to full DO NOT RECORD

upright posture TIME*

1 3 Rolls over, stands up with both hands “climbing TIME

up” the legs to achieve full upright posture.

1 4 Rolls over, stands up with 1 hand support on leg TIME

1 5 Rolls to the side and stands up with one or both hands TIME
on the floor to start to rise but does not touch legs

2 6 Stands up without rolling over or using hands on legs TIME

* Using furniture to get up makes it easier / faster and if they have not used furniture before a
faster time with furniture would not reflect progression accurately

10-Metre Run/Walk

10m run is graded during the performance of the test for the NSAA. You can repeat the test to
check the time or the grade.

This test measures how fast the subject can run/walk 10 metres.

• Ask the subject to stand upright with both feet behind the starting line and toes touching the
starting line.
• The evaluator should stand at a 12-metre mark. You stand 2 metres past the “finish line”
• Give the following verbal instructions to the subject: When I say GO, you go as fast as you
safely can all the way to me
• Give the command “ready set – GO” and start the stopwatch when saying “GO”.
• Continuously encourage the subject until he crosses the finish line.
• Stop the timer when the second foot clears the finish line.

Note: Encourage the child to keep running across the finish line and not to slow down before the
10-metre mark.

Score the fastest time and record the method they used to complete it in the fastest time.

Assign one of the following grades:

NSAA equivalent Functional Description

grade Grade
0 1 Unable to walk independently

0 2 Unable to walk independently but can walk with knee-ankle-foot

orthosis (KAFO) or support from a person
0 3 Cannot increase walking speed, highly adapted, wide-based lordotic
gait
1 4 Can pick up speed but cannot run, moderately adapted gait

1 5 Nearly running, but runs with a double stance phase, i.e., cannot
achieve both feet off the ground
2 6 Runs and gets both feet off the ground (achieves flight)