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NINDS CDE Notice of Copyright
North Star Ambulatory Assessment (NSAA)
Availability
Please visit this website for more information about the instrument: North Star Ambulatory Assessment.
 
The NSAA is copyright © 2017 The Newcastle upon Tyne Hospitals NHS Foundation Trust & Great Ormond Street Hospital NHS Foundation Trust on behalf of the UK North Star Clinical Network and Muscular Dystrophy UK. You may print or use the NSAA for academic or research purposes but any modification, translation or reproduction for redistribution or commercial exploitation of part or all of the contents in any form is strictly prohibited without our express written permission.
 
For further information contact: Muscular Dystrophy, UK
Classification
Supplemental: Duchenne Muscular Dystrophy/Becker Muscular Dystrophy (DMD/BMD) and Spinal Muscular Atrophy (SMA)
Short Description of Instrument
The North Star Ambulatory Assessment was developed by the Physiotherapy Assessment and Evaluation Group of the North Star Clinical Network to measure functional ability in ambulant boys with Duchenne muscular dystrophy (DMD).
 
Test details and instructions for the patient and a scoring sheet with details for grading should be used in conjunction with each other.
 
Specific Construct Measured: Motor abilities - proximal and axial muscle strength
Comments/Special Instructions
The NSAA is administered by a trained clinical evaluator, and test takes approximately 10-15 min to complete
 
A 15cm high box step, height appropriate chair/height adjustable plinth, stopwatch, 10m marked 'runway' is needed to administer the NSAA.
 
General test instructions:
  • If child is capable of a better performance, it is acceptable to ask the child to repeat the item and re-score if appropriate. All activities should be attempted all 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' maneuver:
    • 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. 
Scoring and Psychometric Properties
Scoring: 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). Age at which 85% of controls achieve full score *3 = 3 years of age, *3.5 = 3.5 years of age, *4 = 4 years of age
 
This scale is ordinal with 34 as the maximum score indicating fully-independent function. (Physiopedia, 2023)
 
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.
 
Psychometric Properties: Validated only in DMD boys aged >3y
 
A questionnaire-based study showed that clinicians considered NSAA as clinically relevant. (Mercuri et al., 2008)
 
A psychometric assessment of NSAA by Mayhew et al., (2011) showed that NSAA is valid with a good targeting which equates to a better interpretation of results. This psychometric assessment also showed that the hierarchy of items within NSAA was supported by clinical expert opinion, thereby increasing its clinical interpretability. The NSAA scale items are listed based on their level of difficulty, which is mostly agreed by experts (ρ = 0.80). (Mayhew et al., 2011)
Rationale/Justification
Strengths: The NSAA cab be used to monitor the progression of disease and treatment effects. The NSAA is a quick, specific, reliable, valid, and clinically relevant method to measure the functional motor ability of ambulant children with DMD. (Mayhew et al., 2011; Mazzone et al., 2009; Mercuri et al., 2008; Scott et al., 2012) The NSAA is also suitable to be used in research Mercuri et al., 2008) and in multicentric settings provided that adequate training is given. (Mazzone et al., 2009)
 
Weaknesses: The NSAA is not a useful assessment in non-ambulant boys with DMD or those with severe cognitive or behavioral problems. (Mazzone et al., 2010)
References
Key References:
Scott E, Eagle M, Mayhew A, Freeman J, Main M, Sheehan J, Manzur A, Muntoni F; North Star Clinical Network for Paediatric Neuromuscular Disease. Development of a functional assessment scale for ambulatory boys with Duchenne muscular dystrophy. Physiother Res Int. 2012 Jun;17(2):101-9.
 
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. Dev Med Child Neurol 2006; 48(Supp. 104): 27.
Muscular Dystrophy UK. North Star Ambulatory Assessment. Available at: NSAA_Only_ManualVersion-2.0_May-2017 (musculardystrophyuk.org) (accessed 22 October 2024)
 
North Star Ambulatory Assessment (NSAA) © 2017 Great Ormond Street Hospital NHS Foundation Trust & The Newcastle upon Tyne Hospitals NHS Foundation Trust.
 
Additional References:
 
De Sanctis R, Pane M, Sivo S, Ricotti V, Baranello G, Frosini S, Mazzone E, Bianco F, Fanelli L, Main M, Corlatti A, D'Amico A, Colia G, Scalise R, Palermo C, Alfonsi C, Tritto G, Romeo DM, Graziano A, Battini R, Morandi L, Bertini E, Muntoni F, Mercuri E. Suitability of North Star Ambulatory Assessment in young boys with Duchenne muscular dystrophy. Neuromuscul Disord. 2015 Jan;25(1):14-8.
 
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
 
Ergul Y, Ekici B, Nisli K, Tatli B, Binboga F, Acar G, Ozmen M, Omeroglu RE. Evaluation of the North Star Ambulatory Assessment scale and cardiac abnormalities in ambulant boys with Duchenne muscular dystrophy. J Paediatr Child Health. 2012 Jul;48(7):610-6.
 
Mayhew A, Cano S, Scott E, Eagle M, Bushby K, Muntoni F; North Star Clinical Network for Paediatric Neuromuscular Disease. Moving towards meaningful measurement: Rasch analysis of the North Star Ambulatory Assessment in Duchenne muscular dystrophy. Dev Med Child Neurol. 2011 Jun;53(6):535-42.
 
Mayhew AG, Cano SJ, Scott E, Eagle M, Bushby K, Manzur A, Muntoni F; North Star Clinical Network for Neuromuscular Disease. Detecting meaningful change using the North Star Ambulatory Assessment in Duchenne muscular dystrophy. Dev Med Child Neurol. 2013 Nov;55(11):1046-52.
 
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 Jul;19(7):458-61.
 
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):712-6.
 
Mazzone E, Vasco G, Sormani MP, Torrente Y, Berardinelli A, Messina S, D'Amico A, Doglio L, Politano L, Cavallaro F, Frosini S, Bello L, Bonfiglio S, 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, Gasperini S, Previtali S, Napolitano S, Martinelli D, Bruno C, Vita G, Comi G, Bertini E, Mercuri E. Functional changes in Duchenne muscular dystrophy: a 12-month longitudinal cohort study. Neurology. 2011 Jul 19;77(3):250-6.
 
Mercuri E, Mayhew A, Muntoni F, Messina S, Straub V, Van Ommen GJ, Voit T, Bertini E, Bushby K; TREAT-NMD Neuromuscular Network. Towards harmonisation of outcome measures for DMD and SMA within TREAT-NMD; report of three expert workshops: TREAT-NMD/ENMC workshop on outcome measures, 12th--13th May 2007, Naarden, The Netherlands; TREAT-NMD workshop on outcome measures in experimental trials for DMD, 30th June--1st July 2007, Naarden, The Netherlands; conjoint Institute of Myology TREAT-NMD meeting on physical activity monitoring in neuromuscular disorders, 11th July 2007, Paris, France. Neuromuscul Disord. 2008 Nov;18(11):894-903.
 
Mercuri E, Coratti G, Messina S, Ricotti V, Baranello G, D'Amico A, Pera MC, Albamonte E, Sivo S, Mazzone ES, Arnoldi MT, Fanelli L, De Sanctis R, Romeo DM, Vita GL, Battini R, Bertini E, Muntoni F, Pane M. Revised North Star Ambulatory Assessment for Young Boys with Duchenne Muscular Dystrophy. PLoS One. 2016 Aug 5;11(8):e0160195.
 
Physiopedia. North Star Ambulatory Assessment. Accessed: 24 October 2023 from North Star Ambulatory Assessment - Physiopedia (physio-pedia.com)
 
Document last updated October 2024