ARTICLE
Development and Validation of the Function In Sitting
Test in Adults With Acute Stroke
Sharon L. Gorman, PT, MS, DPTSc, GCS, Sandra Radtka, PT, PhD, Marsha E. Melnick, PT, PhD,
Gary M. Abrams, MD, and Nancy N. Byl, PT, MPH, PhD, FAPTA
Background and Purpose: Research studies indicate that sitting
balance ability is a substantial predictor of functional recovery after
stroke. There are no gold standards for sitting balance assessment,
and commonly used balance measures do not isolate sitting balance
abilities. This study was designed to develop, pilot test, and analyze
reliability and validity of a short test of functional sitting balance in
patients following acute stroke.
Methods: The Function In Sitting Test (FIST) was constructed af-
ter reviewing balance measures and interviewing 15 physical thera-
pists. A written survey regarding the FIST items and scoring scales
was designed, pilot tested, and sent to 12 additional physical ther-
apists with expertise in measurement construction, balance assess-
ment, and/or research. Thirty-one adults who were within 3 months
following stroke participated in this study.
Results: The expert panel survey was returned by 83.3% of the par-
ticipants. Survey feedback and weighted rank analysis reduced the
number of FIST items from 26 to 17. After subject testing, Item
Response Theory analysis eliminated 3 additional items. The person
separation index was 0.978 and the coefficient alpha was 0.98, in-
dicating high internal consistency of the FIST. The Item Response
Theory analysis confirmed content and construct validity. Concurrent
validity was supported by high correlations to the modified Rankin
Scale, static balance indices, and dynamic balance grades.
Discussion and Conclusions: The 14-item FIST is reliable and valid
in adults following acute stroke. Studies of intra- or intertester reliabil-
ity and evaluative validity studies including applications to other pa-
tient populations with sitting balance dysfunction are now necessary.
Key words: balance measurement, postural control, sitting balance,
stroke
(JNPT 2010;34: 150160)
Department of Physical Therapy, Samuel Merritt University, Oakland, Califor-
nia (S.L.G.), Department of Physical Therapy, San Francisco State Univer-
sity, San Francisco, California (S.R., M.E.M.), and Department of Physical
Therapy and Rehabilitation Science, University of California, San Fran-
cisco (G.M.A., N.N.B.).
Funded in part by a generous grant from the California Physical Therapy
Associations Physical Therapy Fund (#05-10).
Correspondence: Sharon L. Gorman, PT, MS, DPTSc, GCS, Department of
Physical Therapy, Samuel Merritt University, 3100 Telegraph Ave, Oakland,
CA 94609 (sgorman@samuelmerritt.edu).
Portions of this research were previously presented at the 2009 California
Physical Therapy Association Annual Conference and the 2010 Combined
Sections Meeting of the American Physical Therapy Association.
Copyright C 2010 Neurology Section, APTA
ISSN: 1557-0576/10/3403-0150
DOI: 10.1097/NPT.0b013e3181f0065f
150
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BACKGROUND AND PURPOSE
E ach year in the United States, approximately 795 000 per-
sons experience a stroke, and an estimated 4.7 million
individuals currently live with stroke.1,2 Stroke is the leading
cause of serious long-term disability in the United States,2
and falls due to the associated balance deficits are among the
most common and devastating consequences.2,3 Poststroke in-
terventions to reduce falls, facilitate function, and improve
quality of life rely in part on the identification and accurate
and reliable quantification of balance deficits.
Over the last 10 years, balance assessments have re-
ceived considerable attention in the rehabilitation literature.
These balance tests focus primarily on the standing and
walking components of balance, with a variety of stan-
dardized tests and measures created, validated, and reported
in the literature.3-9 The tests incorporate a limited number
of items (or no items) specifically targeting sitting balance
(Table 1).3-8,24 Thus, there is no gold standard assessment
for therapists to use specifically to measure sitting balance or
seated postural control in aging individuals or individuals with
neurological impairments.24,25
There are a number of components considered essential
when measuring sitting balance. These include the ability to
(1) control sitting balance statically during quiet sitting (steady
state control), (2) move oneself in sitting while maintaining
seated postural control (proactive control), (3) maintain seated
postural control during external environmental perturbations
(reactive control),13 and (4) use the lower extremities to as-
sist balancing the trunk, and to integrate (1) lateral control
reactions,26 (2) use of sensory inputs, and (3) proactive and re-
active balance mechanisms to perform functional tasks while
sitting.26 In addition to including these essential elements, to
be of value standardized, balance tests must also have accept-
able reliability and validity.24,27-29
Beyond the lack of item specificity in currently avail-
able sitting balance assessments, sitting balance items in these
tools have scoring systems that are not sensitive to change; for
example, these items are often rated on a dichotomous scale re-
quiring large changes in function to show improvement in the
score.28,30 Adults postneurological insult, including stroke,
have lowered functional abilities and also do not make rapid
changes in these functional scores in the acute phase. Thus,
a dichotomous scoring system is not valuable as an indicator
of improved function in the short term.8,31 Furthermore, cur-
rently available tests require a significant amount of time to
JNPT r Volume 34, September 2010
JNPT r Volume 34, September 2010 Development and Validation of the FIST

Table 1. Comparison of Current Tests Abilities to Measure Sitting Balance

Measure Total No. of Test Items Sitting Balance Specific Items Mechanism Scale
Berg Balance Test10 14 Sit stand Proactive, motor Ordinal, 5 points
Sitting unsupported Steady, sensory
Trunk Control Test11 4 Sitting edge of bed, feet off floor Steady, motor Ordinal, 3 points
Supine sit Proactive, motor
Duke Mobility Skills Profile12 13 Sitting unsupported Steady, sensory Ordinal, 3-5 points
Sitting reach to take object Proactive, motor
Rising from chair Proactive, motor
Bed chair Proactive, motor
Functional Independence Measure 18 Self-care Proactive, motor Ordinal, 7 points
(FIM)13 3 transfers: bed/chair/; toilet; tub/shower Proactive, motor
Physical Performance & Mobility 6 Bed mobility Proactive, motor Ordinal (assistance) &
Exam14 Sit stand Proactive, motor continuous (time,
Repeated chair stands Proactive, motor steps)
Trunk Impairment Scale15 17 Static sitting Steady, sensory Ordinal, 2-3 points
Lateral lean Proactive, motor
Lateral pelvic tilt Proactive, sensory
Trunk rotation Proactive, motor
Mobility Scale for Acute Stroke 5 Supine sit Proactive, motor Ordinal, 6 points
Patients16 Sitting unsupported Steady, sensory
Sit stand Proactive, motor
Fugl-Meyer AssessmentBalance 7 Sit without support Steady, sensory Ordinal, 3 points
subscale17
Rivermead Mobility Index18 15 Supine sit Proactive, motor Dichotomous (y/n)
Sitting unsupported Steady, sensory Self-report
Sit stand Proactive, motor Self-report
Motor Assessment Scale19 18 UE activities in supported sitting Proactive, motor Ordinal, 7 points
Modified Functional Reach20 1 Distance of forward reach in sitting Proactive, motor Continuous, no. of
inches
Performance Oriented Mobility 11 Sitting balance Steady, sensory Ordinal, 3 points
AssessmentBalance subscale21 Sit stand Proactive, motor
Barthel Index22 10 Bathing Proactive, motor Dichotomous (y/n)
Dressing Proactive, motor Ordinal, 3 points
Toilet transfers Proactive, motor Ordinal, 3 points
Bed chair Proactive, motor Ordinal, 4 points
Outcome and Assessment 14 Dressing Proactive, motor Ordinal, 5 points
Information SetADL/IADL Bathing Proactive, motor Ordinal, 6 points
subset23 Toileting Proactive, motor Ordinal, 5 points
Transferring Proactive, motor Ordinal, 6 points
Abbreviations: ADL = activities of daily living; IADL = instrumental activities of daily living.

administer and are based on complex, advanced mobility tasks.
Such factors preclude the practical clinical use of these tests in
adults with acute stroke, lower functional abilities, and/or lim-
ited endurance.30 The documentation of continued improve-
ment becomes difficult, if not impossible, and this impacts
continued insurance coverage of rehabilitation services that
are based on progress.32 The limitations of the currently avail-
able tools often compel therapists to rely on subjective descrip-
tions of improvement in basic transfers, sitting stability, safety,
and assistance needed. While these descriptions may meet the
needs of the therapist, they are of unknown reliability and va-
lidity, they do not capture quantitative outcomes, and they are
not reproducible in a way that allows comparisons to be made
about effectiveness of different balance interventions.24,28,29,33
These shortcomings highlight the need for a tool that specif-
ically measures the continuum of sitting balance func-
tion/dysfunction in individuals with acute neurological insult
who have minimal independence in upright functional ability.
Notwithstanding the limitations in currently available
measurement tools, documentation of sitting balance early
in the recovery phase appears to be important for determin-
ing prognosis. For example, multiple studies report that sit-
ting balance is a valid predictor of functional recovery after
a stroke.8,34-36 The significant predictors appear to be ba-
sic tasks performed in sitting that require trunk balance and
stability.37-39 Individuals with poor or impaired sitting bal-
ance are less likely to be discharged to home settings or
to live independently after a stroke.20 Thus, reliable, valid
measurements of sitting balance could benefit rehabilitation
providers as well as third party payers by helping to prognose
functional recovery more accurately, and earlier, in the initial
period after stroke. This study was designed to close this gap in
the assessment between efficiency and effectiveness of sitting
balance in individuals after acute stroke.
The purpose of this study was to develop the Function In
Sitting Test (FIST) for the assessment of sitting balance deficits
in adults after acute stroke and to determine the reliability and
validity of the test. The FIST is a performance-based balance
measure aimed at comprehensive, specific, efficient, and func-
tional assessment of sitting balance. The test is designed to be


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Gorman et al JNPT r Volume 34, September 2010

administered by the physical therapist at the patients bedside. Table 2. FIST Item Weighted Ranks From Expert Panel
The specific aims of the study were to validate test items on the Surveya
FIST, determine internal consistency, and document content,
construct, concurrent, and face validity of the FIST. FIST Item Weighted Rank Score
Static sit 8.1
METHODS
Reach forward 7.8
This study was approved by the institutional review Pick item up off floor 4.6
boards of San Francisco State University and Alta Bates Sum-

RETAINED FOR PILOT TESTING

Lift uninvolved foot off floor 4.1
mit Medical Center and the Committee for Human Research Lateral reach with uninvolved upper extremity 3.9
at the University of California, San Francisco. Lateral reach with involved upper extremity 2.1
Item Selection Pick up item from behind with uninvolved 1.4
upper extremity
The first version of the FIST was created by open- Sit with eyes closed 1.3
ended interviews with 15 physical therapists from the San Anterior nudge 1.0
Francisco Bay Area working with persons after stroke, a re- Posterior nudge 1.0
view of other clinical measures of balance (Table 1), and in- Anterior scooting (2 ) 0.8
formation about documentation and quantification of sitting Lateral nudge 0.5
balance ability common in clinical settings.11,12,14-24,27-29,41 Pick up item from behind with involved upper 0.5
This process led to a version of the FIST that consisted of 26 extremity
items, which spanned the constructs theorized to contribute to Lift involved foot off floor 0.2
sitting balance including sensory, motor, proactive, reactive, Posterior scooting (2 ) 0.5
and steady state balance factors. An ordinal scale (0-4) was Lateral scooting (2 ) 0.7
used to score each individual test item and was designed sim- Shake head no 1.0
ilar to existing measures of both functional performance and

ELIMINATED FROM PILOT TESTING

balance.6,7,9,24,25,35,41
Expert Panel Survey
Before testing on participants, the first version of the
FIST was critiqued by an expert panel (selected on the basis
of author consensus) of 12 physical therapists, researchers,
and others with relevant expertise in research, teaching, and
publication in the areas of neuromuscular physical therapy,
balance dysfunction, and measurement psychometrics. The 12
members of this expert panel were different individuals from
the previously mentioned 15 physical therapists interviewed
initially. The expert panel participated, via mail survey, on the
first version of the FIST to determine utility of the test items
and adequacy of the scoring system; panel members were
sent a written qualitative survey to determine content and
face validity of the FIST (Appendix 1). The survey questions
addressed the items and the scoring mechanism. Nonrespon-
dents were contacted once via e-mail and once via postcard
to increase the response rate. Ten surveys were ultimately
returned for a response rate of 83.3%. Weighted rankings for
the 26 items were calculated (Table 2), resulting in the removal
of 9 items with a weighted rank less than 1. No significant
changes to the scoring system were recommended by the
experts, and only minor editorial changes were made to the
scoring system to improve clarity. The remaining 17 items were
ordered by perceived or expected difficulty by the researcher
and then randomly ordered to form 2 distinct parallel forms
of the pilot FIST. The 2 alternate versions of the 17-item FIST
differed only in the item order, with both versions containing
the same 17 items, to enable examination of item difficulty
and the potential effect of item order during analysis. This
17-item FIST was then pilot tested on poststroke participants.
Study Participants
Participants with acute stroke (3 months) who had sig-
nificant functional disability were recruited from 2 hospital
Wheelchair motion 1.3
Narrow base of support and put feet close 1.9
together
Lateral weight shift 2.1
Nod head yes 2.6
Posterior weight shift 3.4
Sit to stand transfer 3.5
Anterior weight shift 3.7
Transfer to wheelchair to uninvolved side 4.9
Transfer to wheelchair to involved side 5.1
a
Items scoring less than 1.0 (shaded area) were dropped prior to pilot testing
systems for pilot testing of the FIST instrument. Wide inclu-
sion and specific exclusion criteria were used (Table 3). To be
eligible for the study, participants were required to have mod-
erate, moderately severe, or severe disability according
to the modified Rankin Scale (mRS), a reliable and valid global
measure of disability after stroke.42 This severity level ensured
that the final version of the FIST would be suitable for adults
having a high likelihood of sitting balance dysfunction.43 To
determine eligibility, participants were screened via a ques-
tionnaire after being referred to the study. Consent forms were
signed by all participants or their surrogates; the consent form
allowed for surrogate consent if participants showed impaired
cognition during the general screening process. Power anal-
ysis to achieve a power () of .80 and to detect statistically
significant correlations at the .50 level, with .05, indicated
a need for 29 participants.10
Data collection procedures for participants with acute
stroke involved (1) obtaining informed consent; (2) conduct-
ing a medical records review to obtain demographic data
including the participants age, gender, race, date of stroke

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JNPT r Volume 34, September 2010
Table 3. Participant Criteria
Adult Poststroke Participants
Inclusion criteria
1. Documented history of first stroke in preceding 3 mo before study entry.
2. Written informed consent given by the subject or a legally authorized
representative.
3. Aged 18 y or older.
4. Modified Rankin Scale of 3, 4, or 5 (moderate, moderately severe, and
severe disability) s/p stroke.
Exclusion criteria
1. Severe cognitive deficits limiting ability to follow simple directions, as
documented on speech-language pathology evaluation.
2. History of 2 or more documented transient ischemic attacks in medical
record.
3. Medical condition(s) preventing testing procedures, such as but not
limited to total hip arthroplasty due to restrictions of involved hip flexion
range of motion, medical status such as subject not cleared for
sitting/standing activities by physician, unstable angina, orthostatic
hypotension.
4. Diagnosis of subarachnoid hemorrhage in preceding 6 mo before study
entry.
5. Prior diagnosis of neurodegenerative disease in medical record.
Expert Panel and Clinician Panel Participants
Inclusion criteria
Knowledge and expertise in balance dysfunction, neurologic physical
therapy, research, and/or motor control.
Exclusion criteria
None
onset, method of stroke diagnosis, location of stroke, prior
level of physical function, and current medications; (3) test-
ing of the participant with 1 of the 2 alternate forms of the
17-item FIST; (4) testing using a concurrent measure (sitting
static and dynamic functional balance grades29 ); and (5) de-
termining the mRS.43 Testing of participants with the FIST,
sitting static and dynamic balance grades (Table 4), and mod-
ified Rankin score took no more than 30 minutes to com-
plete.
The FIST was administered in less than 15 minutes, and
no participants required a break during testing. Each partici-
pant sat at the edge of a standard hospital bed without air mat-
tresses with the proximal thigh (1/2 femur length) supported
by the bed. The bed height was adjusted and a step stool was
used if necessary to bring the hips and knees to approximately
Table 4. Static and Dynamic Sitting Balance Gradinga
Grade Static
Normal (4/4) Patient able to maintain steady balance without support
Good (3/4) Patient able to maintain balance without handhold support,
limited postural sway
Fair (2/4) Patient able to maintain balance with handhold support; may
require occasional minimal assistance
Poor (1/4) Patient requires handhold and moderate to maximal assistance
to maintain posture
No balance (0/4)
a
Adapted from Guccione and Scalzitti28 and Finch et al.29

C 2010 Neurology Section, APTA
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Development and Validation of the FIST
90 flexion with both feet flat on the floor or stool. Participants
were guarded during testing to prevent injury or falls. Sitting
static and dynamic balance grades were determined by using
standardized definitions,29 as was the assignment of a modified
Rankin score.43
Data Analysis
Descriptive statistics and frequency analysis were used
to describe characteristics of the participants. Correlation anal-
yses, factor analyses, and Item Response Theory (IRT) anal-
yses were used to determine whether any items could be re-
moved from the FIST. The reliability and face, content, con-
struct, and concurrent validity of the remaining FIST items
were then examined. All statistical calculations were per-
formed with SPSS 16.0 for Windows (SPSS Inc, Chicago,
Illinois) or ConQuest (Australian Council for Educational Re-
search, Hawthorn, Victoria, Australia). Item Response Theory
analyses can determine the order of difficulty of items, locating
them along a continuum while simultaneously plotting partic-
ipants abilities along the same continuum, thereby providing
a representation of the participants sitting balance abilities.
Item Response Theory analysis can also identify items on a tool
that do not fit the tool, helping to identify extraneous items
for deletion from the tool. Likewise, factor analysis is another
statistical method designed to explore the relationships among
items. Through the identification of a factor, researchers can
demonstrate whether the items related to that factor represent
the same or similar underlying constructs.
RESULTS
FIST Pilot Test
Demographics and Descriptive Analysis
The demographics and characteristics of the 31 partic-
ipants are summarized in Table 5. The mean age of the par-
ticipants was 61.5 10.9 years. Two-thirds (21) of the 31
participants were male. Eight-seven percent of the participants
had an ischemic stroke and 61% had left hemiparesis. Prior to
the stroke, participants were predominantly independent with
activities of daily living, instrumental activities of daily living,
and gait. Of the participants in this study, 74% were ranked
from moderately severe to severely disabled on the mRS;
therefore, participants were generally more severely involved
than the typical stroke population.44
Dynamic
Accepts maximal challenge and can shift weight easily and within full
range in all directions
Accepts moderate challenge; able to balance while picking object off
the floor
Accepts minimal challenge; able to maintain balance while turning
head/ trunk
Unable to accept challenge or move without loss of balance
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Table 5. Pilot Test Participant Demographics Table 6. FIST and Concurrent Measure Correlations
Characteristic Spearman Static Sitting Dynamic Sitting Modified
Rho Balance Grade Balance Grade Rankin Scale
Age 61.5 (SD = 10.9)
Range 42 to 86 FIST total score 0.94a 0.92a 0.78a
Gender Male (21) = 67.7% (17 item raw score)
Female (10) = 32.3% FIST total score 0.93a 0.93a 0.73a
Method of CVA diagnosis MRI (1) = 3.2% (14 item raw score)
Respondent location 0.92a 0.92a 0.76a
CT (24) = 77.4%
estimate (logit value)
Clinical diagnosis (6) = 19.4%
Side of CVA Right (12) = 38.7% a
Correlation is significant at the .01 level (2-tailed).
Left (19) = 61.3%
Type of CVA Ischemic (27) = 87.1% Exploratory Factor Analysis
Embolic (4) = 12.9%
Exploratory factor analysis was used to determine item
Motor deficits s/p CVA Yes (30) = 96.8%
No (1) = 3.2%
reduction and describe domains in the FIST. Using princi-
Sensory deficits s/p CVA Yes (29) = 93.5%
pal component analysis with orthogonal varimax rotation, one
No (2) = 6.5% factor was identified, which explained 83.03% of the total vari-
Perceptual deficits s/p CVA Yes (22) = 71% ance of the FIST. This factor highly loaded all 17 FIST items,
No (9) = 29% indicating that all 17 items can be considered to represent a
Speech-language deficits s/p CVA Yes (16) = 51.6% single underlying construct named functional sitting balance
No (15) = 48.4% ability. Thus, this analysis did not yield useful information
Prior level of function: ADL Independent (30) = 96.8% for item reduction.
Needed assist (1) = 3.2%
Prior level of function: IADL Independent (27) = 87.1% Item Response Theory Analysis
Needed assist (4) = 12.9% On the basis of data and different models, estimated
Prior level of function: Gait Independent (30) = 96.8% respondent-level locations and item response-level locations
Dependent (1) = 3.2%
were specified using ConQuest and weighted likelihood es-
Prior level of function: assistive None (26) = 83.9%
device use Used (5) = 16.1% timates. Initial IRT analyses discovered 3 significant misfit-
Prior level of function: gait distance Community distancesa (22) = 71% ting items, lift involved foot, reach behind with involved
Household distancesb (8) = 25.8% arm, and reach laterally with involved arm. Performance
Unable (1) = 3.2% on these 3 items was likely confounded by the participants
Modified Rankin Scale28 Moderate disability (8) = 25.8% motor problems, rather than being specifically related to their
Moderately severe disability (18) = balance deficits. Thus, they were removed from the FIST total
58.1% score for the remaining analyses, resulting in a 14-item FIST,
Severe disability (5) = 16.1%
which was used for the remaining analyses (Appendix 2).
Abbreviations: ADL = activities of daily living; CT = computed tomography;
CVA = cerebral vascular accident; IADL = instrumental activities of daily living; FIST Psychometric Testing (14-Item FIST)
MRI = magnetic resonance imaging; s/p = status post.
a
Community distances = ambulates at least 1000 ft and manage curbs. On the 14-item FIST, 31 participants had scores ranging
b
Household distances = ambulates at least 300 ft regularly in the home. from 0 to 56, out of 56 possible points. The mean score was
34.29 (SD = 16.51), standard error of the mean of 2.97, and
standard error of measurement of 2.03. Coefficient alpha for
this 14-item FIST was .98, showing high internal consistency
of this shortened version of the FIST.
FIST Item Reduction Analyses
Item-to-total Spearman rank coefficient analyses (2-
Correlational Analyses tailed, = .05) were reexamined using the 14-item raw score.
The item-to-item Spearman Rank correlation coeffi- Item-to-total score correlations remained statistically signifi-
cients ranged between 0.61 and 0.97, and the item-to-total cant and in the excellent range between 0.82 and 0.93 (P <
score correlations ranged from 0.82 to 0.93. All correlations 0.01). Correlations with this 14-item total score and concur-
were moderate to excellent and statistically significant (P < rent measures of static and dynamic sitting balance grades and
0.01).43,45 No items were eliminated on the basis of the McMil- mRS were also recalculated, with results remaining statistically
lan and Schumacher46 cutoff guidelines for using correlation significant (P < 0.01) in the excellent to good range (Table 6).
values to eliminate test items (>0.35 and statistical signifi- Spearman rank coefficient correlations between expected item
cance). Spearman Rank correlation coefficients of the total difficulty and observed item difficulty were excellent (0.92),
FIST score to mRS were statistically significant (P < 0.01, and correlations between estimated respondent location and
Table 5) at 0.76. This negative correlation indicated that as observed item difficulty were also excellent (0.97). Item mean
participants scores on the FIST increased, the level of dis- scores, standard deviations, and item frequency estimates were
ability on the mRS decreased. Static and dynamic sitting bal- also calculated for the 14 individual items reflecting the diffi-
ance grades29 demonstrated significant correlations with the culty from easiest to hardest for the 14 FIST items (Table 7).
FIST, ranging from 0.93 and 0.92, respectively (P < 0.01; The 14 items of this shorter FIST version main-
Table 6). tained similar constructs via confirmatory factor analysis,

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JNPT r Volume 34, September 2010 Development and Validation of the FIST

Table 7. FIST Item Difficulty Figure 1. Estimated Item Category and Respondent
Frequency Histogram. Respondent frequency = frequency of
Item Frequency
logit scores calculated from raw 14-item FIST scores. Item
FIST Item Estimate Mean (SD; SE)
category frequency = frequency of logit scores calculated
Static sitting 2.80 3.03 (1.22; 0.22) from individual item scores (0-4) for each of the 14 FIST
Nod no 2.51 2.97 (1.22; 0.22) items. The vertical line represents the construct of sitting
Sitting, eyes closed 2.16 2.90 (1.25; 0.22) balance function expressed in logits that relate sitting balance
Anterior nudge 0.7 2.58 (1.26; 0.23) ability to the probability of a particular response. The flat
Posterior nudge 0.67 2.55 (1.21; 0.22) distribution for the respondents locations (left side) indicates
that respondents had a wide range of sitting balance abilities.
Lift uninvolved foot 0.56 2.55 (1.43; 0.26)
The item category frequency (right side) gives the location
Reach behind with uninvolved arm 0.46 2.55 (1.39; 0.25)
estimates of the items. Each item location indicates the sitting
Lateral nudge 0.41 2.52 (1.51; 0.21) balance ability a generic person must have if there is a 0.50
Forward reach 0.71 2.23 (1.26; 0.23) probability of that person achieving the specified score on
Lateral reach with uninvolved arm 0.82 2.16 (1.42; 0.25) that item. FIST indicates Function In Sitting Test.
Pick up object from floor 0.83 2.19 (1.35; 0.24)
Posterior scoot 1.44 2.06 (1.26; 0.23)
Anterior scoot 1.54 2.03 (1.28; 0.23)
Lateral scoot 1.76 1.97 (1.33; 0.24)

utilizing the same parameters as the exploratory factor

analysis with 1 factor extracted explaining 83.33% of the
total 14-item FIST variance. All 14 items loaded highly
on the single-factor functional sitting balance ability.
Both rating scale and partial-credit models28,47 were
tested using IRT analysis. The partial-credit model fit the
data significantly better, according to the G2 Likelihood
Ratio Test ( 2 39 = 56, P = 0.04), indicating that the respon-
dent response levels were different across items rather than
the same. Only 3 poorly fitting items (out of 14) fell within
the criterion boundaries with estimated locations associated
with a weighted mean square between 0.75 and 1.34 and a expert panel input appears to have been effective since only
weighted mean t statistic between 1.96 and +1.96.48 These 3 3 additional items were eliminated on the basis of statistical
exceptions met acceptable t statistic ranges but fell outside the item analysis of the participant data. In addition, it is likely that
acceptable weighted-mean-square values. The exceptions in- these 3 items did not fit the IRT partial-credit model because
cluded the nod no item (weighted mean square = 0.65 with t they required the participant to use the involved extremity
= 1.1), the anterior nudge item (weighted mean square = while stabilizing the trunk (lift involved foot, lateral reach
0.67 with t = 0.9), and the lateral reach with uninvolved with involved arm, and reach behind with involved arm),
arm item (weighted mean square = 1.60 with t = 1.6). The activities that would be significantly affected by post-stroke
1-parameter, partial-credit, unidimensional model was used hemiparesis. The elimination of these 3 items led to a final re-
for estimating item and respondent locations and their vision to the directions for the FIST reflecting that the person
standard errors. The frequency of respondent values and
frequency of individual item values at each estimate location
is plotted in Figure 1. The person separation reliability Figure 2. FIST Item Reduction Pathway. FIST indicates
was 0.98, indicating high confidence and small error in the Function In Sitting Test.
estimated locations of the respondents in this study. Balance Test/Measure Review
Interviews with local physical therapists (n=15)

DISCUSSION
This study has resulted in the development of a func- Creaon of 26-item FIST Expert Panel review of 26-item FIST (n=10)

tional test of sitting balance for inpatients after acute stroke

Reducon of FIST to 17 items Pilot tesng in parcipants post stroke (n=31)
(Figure 2). The test is short (consisting of 14 items), is easy to
administer, and can be completed in less than 15 minutes. This Item-to-item correlaon analysis
Item-to-total correlaon analysis
short test meets the criteria for reliability and concurrent and Exploratory factor analysis Reducon of FIST to 14 items
IRT analysis
congruent validity. Further research and analysis are needed to
assess intra- and interrater reliability, responsiveness, ability Item-to-total correlaon analysis
Item diculty correlaons
to predict recovery, and applicability for other populations of Concurrent measure correlaons Validaon of 14-item FIST
Conrmatory factor analysis
individuals with neurological impairments. IRT analysis
The FIST was successfully reduced from 26 items to 14
Revision of FIST direcons and item names
items by using a multimethod approach incorporating expert for nal 14-item version of FIST (Appendix B)
panel input and statistical modeling using IRT analysis. The


C 2010 Neurology Section, APTA 155

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Gorman et al
being tested may use their stronger limb, their least affected
limb, or their dominant limb (Appendix 2). This final version
of the FIST may be utilized in assessment of other clinical pop-
ulations with sitting balance dysfunction without any difficulty
caused by requiring the use of an impaired limb.
Reliability and validity of the FIST were also demon-
strated in this study. The high coefficient alpha and person
separation reliability demonstrated a high degree of reliability
of the FIST, while the confirmatory factor analysis identify-
ing 1 factor, functional sitting balance ability, that explained
83% of the variance of the total FIST score, support the reli-
ability of the FIST. Face and content validity of the FIST are
supported by the consensus of the expert panel on selected
items, as testing only identified 3 additional items for removal,
most likely because of the confounding influence of motor im-
pairment on these items. These results demonstrated that the
pilot-tested data and expert panel opinions had a high degree
of cohesiveness. The factor analysis identification of 1 factor
representing functional sitting balance ability strengthens
the evidence for high face and content validity of the 14-item
FIST, as all 14 items appear to represent the construct of sitting
balance. An argument can be made that because of the high
internal consistency of the 14 FIST items, further item reduc-
tions may be indicated. More studies should be conducted to
see whether an even shorter version of the FIST can maintain
reliability while continuing to describe functional performance
in a variety of tasks.
The range of total FIST scores (0-56 points) obtained by
a small sample of 31 participants showed that the full range
of available points is attainable. Item Response Theory results
demonstrate how the individual item estimates covered the
range of adults tested in this study and show that the content of
the FIST spanned the abilities of the participants (Figure 1).48
The locations of the item estimates cover the same range as the
location of the respondent estimates, showing that FIST spans
the content of sitting balance ability for the participants in this
study and also across the 14 items on the FIST. Thus, the con-
tent of the FIST spans a variety of sitting balance abilities and
supports the content validity of the FIST in this population.48
Construct validity of the FIST is supported by examina-
tion of the difficulty of the items on the FIST (Table 7). The
FIST was constructed with the intent to include a range of
items that varied in difficulty, and the high degree of correla-
tion between the expected item difficulty determined a priori
by the researcher and the observed item difficulty calculated
after pilot testing indicated that this goal was met. The ex-
cellent correlation between respondent location estimates and
observed item difficulty further demonstrates the underlying
validity of the FIST to capture the construct of sitting balance
(or seated functional postural control). While it may be pos-
sible to further reduce the number of items on the FIST due
to its high internal consistency, this must be balanced with
maintaining a spread of difficulty of individual test items and
a variety of items to accurately reflect the construct of sitting
balance abilities.
Given the lack of a gold standard for testing seated pos-
tural control, it is difficult to show concurrent validity of the
FIST. The high degree of correlation of the 14-item FIST to-
tal score and respondent location estimates with static and
156
Copyright 2010 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
JNPT r Volume 34, September 2010
dynamic functional balance grades helps support concurrent
validity of the FIST with one of the most commonly used
methods of measuring sitting balance (Table 6).29 The good
correlations of FIST score and respondent location estimates
with mRS, as a representation of disability after a stroke, do
help support the concurrent validity of the FIST. During the de-
sign of this study, there was concern about participant fatigue
affecting performance, so the number of concurrent measures
against which the FIST was to be compared was limited. Dur-
ing this study, none of the participants required the optional
break, and all were able to complete the FIST in less (and
oftentimes significantly less) than 15 minutes. Future research
comparing the FIST to concurrent measures of trunk impair-
ment such as the Trunk Control Test or the Trunk Impairment
Scale is highly recommended.
Only 3 clinical assessment tools are currently available
to evaluate trunk musculature in providing seated postural
stability.49 These tools do not address the complex interac-
tions between postural control and functional performance.
The FIST uses commonly required functional movements to
assess sitting balance and examines activity level consistent
with the International Classification of Functioning, Disabil-
ity, and Health model,50 related to the ability of a person to
perform functional activities. These other measures primar-
ily identify impairments of trunk musculature at the body
functions/structures level of the International Classification
of Functioning, Disability, and Health model. While the FIST
can identify difficulty with sitting balance at the activity level,
it cannot identify which body function/structure impairments
are responsible for the functional balance deficits. Using the
FIST in conjunction with other trunk control measures may
help therapists more readily identify sitting balance dysfunc-
tion and its underlying causes. The FIST adds a method of
examination at the activity level that will benefit therapists con-
sidering comprehensive outcomes and examination schema for
their patients/clients with sitting balance problems.
The FIST demonstrated a high degree of internal consis-
tency evidenced by the high item-to-item correlations, coeffi-
cient alpha, and person separation reliability. In prior studies,
in the acute/subacute stroke population, comparisons between
2 functional scalesthe Modified Rivermead Mobility Index
and Motor Assessment Scaleshowed high internal (within-
scale) consistency and between-scale consistency except for
the sitting balance items on both scales.28,51 The authors of
the study proposed that perhaps these other measures sitting
balance items may be measuring a different construct of mo-
bility rather than sitting balance.51(p132) In addition, current
measures of balance have a low ratio of sitting balance items to
the total number of test items.29 This low ratio can lead to dif-
ficulty using these tests for adults post stroke who have lower
functional levels. The FIST is a more appropriate measure for
these disabled adults since it consists solely of sitting balance
test items that were validated in a group of persons after stroke
with less function.
Seated postural control requires the ability to generate
a combination of component movements to perform complex
functional skills. An assessment that focuses solely on com-
plex functional skills may be biased against lower functioning
individuals. Without tests that include component movements,

C 2010 Neurology Section, APTA
JNPT r Volume 34, September 2010
therapists may not obtain the type of objective information
needed to accurately identify problems in adults who have
lower levels of functioning. The FIST includes the following
items on the basis of balance strategies13 : (1) 3 steady state
or static sitting balance items, (2) 3 items on reactive motor
control in sitting, (3) 3 proactive, scooting movements in sit-
ting, and (4) 5 proactive items requiring that sitting balance
be maintained during body segment motion. Eleven of the
items examine anterior or posterior control while 3 items are
specific to lateral/rotational control in sitting. Lateral balance
control may be more affected by stroke and is more associated
with clinical balance performance.26 The FIST items test var-
ious movements, strategies, and simple to complex movement
patterns in sitting and should improve the identification of spe-
cific areas of difficulty for patients when used in the clinical
setting. Improved problem identification can aid therapists in
setting functional goals, designing interventions, and assessing
outcomes.
Limitations of This Study
All assessment tools have a floor and/or ceiling effect.
It was not anticipated that the FIST would have floor effects,
as it was developed to test individuals with lower-level func-
tional skills. Ceiling effects were anticipated in participants
postneurological insult who have higher levels of functional
skill. For example, persons with higher standing and ambula-
tion ability would approach the ceiling of the FIST. In such
an individual, using existing balance measures weighted to-
ward standing balance and gait abilities would be more ap-
propriate. The mRS, a broad global measure of disability af-
ter stroke, was included in the data collection to ensure that
this pilot study assessed potential ceiling effects.42 The use
of the mRS indicated the level of disability that limits the
effectiveness of the FIST. Participant scores did cover the en-
tire range of possible scores from 0 to 56, but testing with
more individuals, and specifically those with potentially higher
mRS scores, is needed to fully describe ceiling effects for the
FIST. In addition, this study limited participation to persons
with mRSs indicative of probable or possible sitting balance
dysfunction.
This pilot test of the FIST utilized a small sample of 31
participants. Given this small sample size, no subgroup analy-
ses were conducted. Thus, only limited conclusions about the
scoring scale can be made. Further testing with larger samples
is needed. In addition, only 1 review by the expert panel was
conducted. Follow-up reviews are needed. This study tested
the validity of the FIST in an adult acute stroke population
only. The poststroke participants included more males and had
higher rates of motor, sensory, and speech deficits after stroke
than typical poststroke individuals.44 Therefore, generalizabil-
ity to other age groups, medical diagnoses, or other diagnostic
categories may be limited given the homogeneity of partici-
pants tested in this study.
Future Research
A valid and reliable measurement tool for assessing sit-
ting balance such as the FIST will help researchers design
studies to predict functional recovery in individuals during the

C 2010 Neurology Section, APTA
Copyright 2010 Neurology Section, APTA. Unauthorized reproduction of this article is prohibited.
Development and Validation of the FIST
acute phase after stroke. Inter- or intrarater reliability of the
FIST still needs to be determined. Standardized training mate-
rials, including self-study training materials with video exam-
ples for scoring and score report sheets, should be developed to
standardize administration procedures. Validation of the FIST
in other appropriate clinical populations, such as persons with
multiple sclerosis, encephalopathy, Parkinson disease, spinal
cord injury, severe deconditioning, or other medical complexi-
ties, would allow a broader use of the FIST. The FISTs evalua-
tive validity, the ability to capture changes in function over time
with a measure, and effects pre- or postintervention, should
also be investigated. If the FIST shows evaluative validity, es-
pecially over short periods of time (eg, 1-2 weeks), therapists
working in the early stages of rehabilitation in acute care set-
tings would be able to show functional sitting balance gains
in persons with severe impairments. Responsiveness studies
should also compare the FIST to impairment-based tests of
trunk performance such as the Trunk Impairment Scale or
Trunk Control Test in the same sample population, allow-
ing direct comparison between these measures. The predictive
value of the FIST in determination of discharge destination,
risk for falls, and long-term disability should also be explored.
The FIST may also be useful to aid in the determination of the
need for postural supports, restraints, and/or fall risk in acute,
rehabilitation, and skilled nursing facilities with populations
having sitting balance dysfunction.
CONCLUSION
The FIST provides a tool for physical therapists to eas-
ily document sitting balance at the beside of individuals after
acute stroke. This newly developed measure of functional sit-
ting balance is reliable, valid, and easy to administer. The
availability of a sitting-specific balance test designed to doc-
ument seated postural control in persons with lower levels of
functional ability will allow therapists to objectively describe
the status of individuals after acute stroke.
ACKNOWLEDGMENTS
The authors thank the participants and their therapists
for recruitment assistance and participation in this study. They
also thank Diane Allen, PT, PhD, for her input and guidance
with statistical analyses. This study was completed by Sharon
Gorman in partial fulfillment of requirements for the DPTSc
degree at the University of California, San Francisco, and San
Francisco State University.
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JNPT r Volume 34, September 2010 Development and Validation of the FIST

APPENDIX 1 Unable to complete task successfully and independently

Expert Panel Survey of the Function
In Sitting Test
The Function In Sitting Test (FIST) is a newly developed,
functionally based, bedside test of sitting balance. Currently,
the test is 26-item long and the researchers are interested in
decreasing the number of test items to shorten the test without
losing validity or sensitivity.
Please comment on the scoring system for the FIST.
An effort has been made to keep the scoring system
flexible enough for eventual use of the FIST in multiple
patient populations (ie, stroke, spinal cord injury, multi-
ple sclerosis, and encephalopathy) and a variety of health
care settings (ie, inpatient, rehab, home health, and
skilled nursing facility). With these constraints in mind,
please comment on the scoring levels in the space
provided.
FIST Scoring:
4 = Independent
Completes the task independently and successfully
3 = Verbal cues
Completes the task successfully and independently but
may need verbal cues
2 = Upper extremity support
without using upper extremities for support or assistance not
normally required
1 = Needs assistance
Unable to complete task successfully without physical
assistance
0 = Complete assistance
Requires complete physical assistance to perform task
successfully, is unable to complete task successfully with phys-
ical assistance, or dependent
A. Please rate each test item regarding whether you consider
it a function that examines how well someone balances in
sitting by circling Yes or No.
B. Indicate your top-5 choices of items that you would include
in a functional sitting balance test by placing numbers 1 to
10 in the box labeled Inclusion. Placing a 1 in a box
would mean you think it is the most important item and
should definitely be included in the test.
C. Indicate your top-5 choices of items that you should ex-
clude from a functional sitting balance test by placing
numbers 1 to 10 in the box labeled Exclusion. Plac-
ing a 1 in a box would mean you think it is the least
useful item and should be the first excluded from the
test.

Quantifies Sitting Inclusion Exclusion

FIST Test Item Balance? (circle answer) (top 10 choices) (top 10 choices)

Static sitting YES NO

Sitting, lift involved foot YES NO
Sitting, lift uninvolved foot YES NO
Reach forward with outstretched hand at shoulder height on uninvolved side YES NO
Turn and pick up the object from behind with involved extremity YES NO
Turn and pick up the object from behind with uninvolved extremity YES NO
Pick object up off floor YES NO
Anterior pelvic weight shift YES NO
Posterior pelvic weight shift YES NO
Lateral pelvic weight shift YES NO
Reach laterally with outstretched involved hand at shoulder height YES NO
Reach laterally with outstretched uninvolved hand at shoulder height YES NO
Anterior scooting YES NO
Posterior scooting YES NO
Lateral scooting YES NO
Anterior nudge (once, unexpected) YES NO
Posterior nudge (once, unexpected) YES NO
Lateral nudge (once, unexpected) YES NO
Sitting, move feet to narrow base of support YES NO
Mat to wheelchair transfer on involved side YES NO
Mat to wheelchair transfer on uninvolved side YES NO
Sit to stand transfer YES NO
Sitting, eyes closed YES NO
Sitting, move head up and down (nod "yes") YES NO
Sitting, move head side to side (nod "no") YES NO
Sitting in wheelchair, quick wheelchair motion posteriorly YES NO


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Gorman et al JNPT r Volume 34, September 2010

APPENDIX 2
Function In Sitting TestFinal 14-Item Version

Standard Directions: One trial of each test item is allowed. Verbal directions and demonstration as needed are given by the therapist following the directions
for each item later.
Standard Starting Position: Person seated at edge of standard hospital bed (no overlay or specialized air mattresses) with proximal thigh (half of femur length)
in support, hips and knees flexed to 90 , and feet flat in support. Thighs should be positioned in neutral hip abduction and adduction and neutral rotation.
Hands in lap, unless needed for balance support.
1. Anterior nudge (light pressure 1, at sternum)
Without warning, at any time during testing, push participant with light pressure at superior portion of sternum.
2. Posterior nudge (1 time, between scapular spines)
Without warning, at any time during testing, push participant with light pressure between scapular spines.
3. Lateral nudge (1 time on dominant or stronger side, at acromion)
Without warning, at any time during testing, push participant with light pressure at acromion.
4. Static sitting
Sit with your hands in your lap for 30 seconds.
5. Sitting, move head side to side (nod no")
Remain sitting steady and tall without using your hands unless you need them to help you balance. When I tell you to look right," keep sitting straight, but
turn your head to the right. Keep looking to the right until I tell you look left," and then keep sitting straight and turn your head to the left. Keep your head to
the left until I tell you, look straight," and then keep sitting straight but return your head to the center.
6. Sitting, eyes closed
Close your eyes and remain sitting still with your hands in your lap for 30 seconds.
7. Sitting, lift foot (scored once for least involved side, stronger side, or dominant side)
Sit with your hands in lap, and lift your foot 1 inch off floor twice.
8. Turn and pick up object from behind in preferred direction
Turn around and pick up the object that Ive placed behind you. (Object placed in midline, one hands breadth fingertip to base of palm" posterior to hips,
subject may turn to preferred side and use either arm)
9. Reach forward with outstretched hand at shoulder height
Reach with least involved/stronger/less painful arm, with your other arm remaining in your lap, as far as you can while staying balanced. (Perform passively
to assess ROM; must go full available ROM or until abdomen contacts anterior thighs)
10. Lateral reach with hand at shoulder height
Reach out to the side as far as you can; try to keep your hand at the height of your shoulder. Be sure to get all your weight off the opposite side of your
bottom keeping your feet on the floor. (Completes full, available ROM maintaining upright upper trunk/UE position, with contralateral trunk shortening and
clearance of contralateral ischial tuberosity and returns to midline, may go to preferred side, stronger side)
11. Pick object up off floor
Pick this object up off the floor with your hand. (Object placed between feet, may use either hand)
12. Posterior scooting (2 )
Move backward 2 inches without using your arms.
13. Anterior scooting (2 )
Move forward 2 inches without using your arms.
14. Lateral scooting (2 ) (scored once for preferred direction)
Move sideways 2 inches without using your arms.

FIST Scoring Scale

4 Independent 1 Needs Assistance
Completes the task independently and successfully Unable to complete task successfully without physical
3 Needs cues assistance
Completes the task independently and successfully; may 0 Complete Assistance
need verbal/tactile cues or more time Requires complete physical assistance to perform task
2 Upper extremity support successfully, is unable to complete task successfully with phys-
Unable to complete task without using upper extremities ical assistance, or dependent
for support or assistance

160 
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