Remote measures and assessment tools
Top tips and assessment tools that can be used remotely, including research evidence
I am concerned that we are all using assessment techniques which lack known reliability and validity if conducted in a context different to that in which they are supposed to be used (i.e. using them remotely rather than face-to-face).
Physiotherapist, Musculoskeletal/Rheumatology
Some practitioners have concerns about the validity, reliability and safety of the physical assessment tools and outcome measures they are using when these have not been designed for remote use. The evidence for when and how they can be successfully used remotely is limited, but this section includes some of the commonly used assessment tools that can be used remotely. This is not intended to be a comprehensive list, but includes examples of outcomes that practitioners report having used them remotely with some success, with links to studies that have assessed validity and reliability.
For guidance on safely carrying out remote assessments, see our information governance and safety section.
Assessment tips
- Plan what you want to assess in advance and let the patient know what to expect prior to, and at the beginning of the consultation.
- Ask the patient to wear bright and contrasting clothes (like different coloured trousers, socks and shoes). This helps with seeing movement and distinguishing body regions or sources of pain. Clothing should be loose and comfortable but should not obscure the body region you will be assessing – for example, a t-shirt might be best for upper limb assessments.
- Start with a comprehensive subjective assessment and make use of this as much as possible:
Listening to patients and undertaking thorough subjective examinations can give many insights into our expected outcomes. When I have done this, I would say that my outcomes following remote objective screening do not change. This means that where any doubt or difficulties occur during the assessment of physical impairment I’m confident that despite this, the safest outcome for the patient happens.
Physiotherapist, Trauma and Orthopaedics
- Use copying movements when demonstrating a movement or exercise (make sure your hands/arms/the relevant body part can be seen in the camera).
- Ask lots of probing questions and encourage the patient to describe clearly where demonstration is not possible. Consider using a prompt sheet with reminders to ask about different symptoms where visual cues are lacking (e.g. fatigue, weakness, continence, speech and swallowing).
- When asking the patient to describe sources of pain, encourage them to be specific. Ask them to point with one finger to the worst affected location and where the pain radiates.
- Objective testing is more difficult over the phone or video. Some tests may need to be done face-to-face – e.g. reflexes, sensory/motor testing, specific strength testing and special tests. Keep it simpler than a face-to-face assessment, capturing key elements of general mobility rather than looking at detailed and higher level activities – functional assessments and global movements will be easier. Don’t try to look at too much:
Try to only assess one or two impairments or functions to make it more likely that the experience for both patient and therapist is successful.
Physiotherapist, Neurology
- Observe and compare healthy and affected sides or limbs to check for swelling, atrophy or any other deformities: “Non-standardised comparison of the contralateral hand/arm is a good tool.” (Occupational Therapist, Trauma & Orthopaedics)
- Observe the patient carefully in their home environment – you might not be able to watch them walk into the clinic room, but you can ask them to show you how they move and function in their own surroundings.
Somebody might be able to get on and off a chair in clinic because we’ve got nice suitable high orthopaedic kind of chairs, but then you actually see what they’re trying to get out of at home and no wonder they’re having difficulty, or no wonder they’re falling when they’re trying to get out of their chair because it’s very low and it’s not supportive.
Occupational Therapist, Neurology
- Have different consultations with different purposes:
The first session is about getting to know the patient and then decide what level of assessment to perform. For example, if the patient is unsteady I complete a more functional assessment with a family member (if possible). If it is safe then I have completed a more formal balance assessment (e.g. Berg Balance Scale) but with the family member close by.
Physiotherapist, Neurology
- Consider using technologies such as wide-angle webcams (and robotic movement tracking devices where available) – these can improve field of view and aid remote movement assessments (see our paper on technologies to support assessment of movement in video consultations). Where this is not possible, a family member or carer may be able to help to move the camera.
- Consider using asynchronous assessments as an alternative to, or to complement ‘live’ consultations. You could ask the patient or a family member to take photos or record a video, for example to show how the patient moves or their functional ability. Beforehand, check your organisation’s governance guidance around this. See our information governance and safety section.
Further guidance: Video from Flinders University with ‘Clinical examples of tele-physiotherapy’
See the NIHR guidelines for virtual home assessment tools (nihr.ac.uk).
Case study: Post-op video assessment
Explanatory notes for the studies below
ICC refers to Intraclass Correlation Coefficient. This measures the test-retest and inter-rater reliability of data in groups (i.e. how reliable and consistent are the results when repeated over time or between people). An ICC closer to 1 indicates increasing similarity between groups with >0.9 being excellent reliability.
R refers to Pearson’s r. This measures the degree of correlation between two different variables. The correlation can be positive or negative and the larger the number the greater the correlation (e.g. foot size will be positively correlated with height).
Gait assessment
Analysis of functional mobility
Technology for remote assessment:
Wide angled webcam using high bandwidth transmission frequency
Validity / reliability:
Moderate to good inter-rater reliability for Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) across all configurations (ICC = 0.66 - 0.77). Moderate validity for in-person (R = 0.62) and Normal Speed video (R = 0.74) ratings compared with the Slow Motion review. (Venkataraman 2020)
Key studies / resources:
Venkataraman (2020) Teleassessment of Gait and Gait Aids: Validity and Interrater Reliability
Tempero-spatial variables
Technology for remote assessment:
Accelerometers
Smartphone
Sensors placed in shoes
Validity / reliability:
Excellent reliability (ICC = 0.74 - 0.97) across smartphone assessed step length and gait velocity measures, and high correlation between smartphone and ‘GAITRite’ assessed step length/speed (R = 0.798 - 0.985) (Silsupadol et al. 2017)
Key studies / resources:
Step count / activity level
Technology for remote assessment:
Commercial grade activity trackers such as Fitbit, Polar monitor etc.
Validity / reliability:
High validity versus Actigraph accelerometer for Fitbit One (ICC = 0.94) and Charge HR (ICC = 0.86). Variable reliability - overestimation of between 167 and 2690 steps in comparison to research grade accelerometers. (Stainton et al. 2018)
Key studies / resources:
Stainton et al. (2018) The validity and reliability of consumer-grade activity trackers in older, community-dwelling adults: A systematic review
TUAG (Timed Up And Go)
Technology for remote assessment:
iTUG (instrumented Timed Up And Go) using a free smartphone application downloaded via iTunes - requires IOS 9.0 or later.
Validity / reliability:
Excellent test/retest reliability: ICC = 0.97 for iTUG time across heterogeneous patient groups (Yamada et al. 2019)
Key studies / resources:
- Yamada et al. (2019) Quantitative Evaluation of Gait Disturbance on an Instrumented Timed Up-and-go
- Link to video demonstration: https://youtu.be/0TCgxw1FTo0
Technology for remote assessment:
ITUG-Triaxial accelerometer measured via a device worn on a belt around the waist (Bts-g walk)
Validity / reliability:
Good reliability (R = 0.9) for temporal measures of gait (Salarian et al. 2010)
Excellent reliability ICC = 0.998 - in comparison to stopwatch-timed TUG/opto-electronic/Gait lab system (gold standard) (Kleiner et al. 2017)
Key studies / resources:
- Salarian et al. (2010) iTUG, a Sensitive and Reliable Measure of Mobility
- Kleiner et al. (2017) Timed Up and Go evaluation with wearable devices: Validation in Parkinson's disease
Two-minute walk test (2MWT)
Technology for remote assessment:
Smartphone app / commercial activity monitor
Validity / reliability:
Excellent agreement between Fitbit and visually counted steps (ICC = 0.88) for the 2MWT (Paul et al. 2015)
Key studies / resources:
Paul et al. (2015) Validity of the Fitbit activity tracker for measuring steps in community-dwelling older adults
Six-minute walk test (6MWT)
Technology for remote assessment:
Smartphone apps (e.g. SA-6MWT app). May be linked with Google Fit for Android phones.
iPod Touch 5th generation internal sensor
Validity / reliability:
High correlation (R = 0.9) between smartphone assessed outdoor 6MWT and trundle wheel measurement (Salvi et al. 2020)
High correlation between iPod Touch and body worn sensors (R = 0.9) across all temporo-spatial gait parameters (Proessl et al. 2018)
High correlation (R = 0.99) between staff-administered clinic 6MWT and self-administered 6MWT via app (Brooks et al. 2015)
Key studies / resources:
- Salvi et al. (2020) The Mobile-Based 6-Minute Walk Test: Usability Study and Algorithm Development and Validation
- Proessl et al. (2018) Good agreement between smart device and inertial sensor-based gait parameters during a 6-min walk
- Brooks et al. (2015) Accuracy and Usability of a Self-Administered 6-Minute Walk Test Smartphone Application
Musculo-skeletal assessment
Range of motion
Technology for remote assessment:
Internet / virtual goniometry
Video-based assessment
Validity / reliability:
Internet-based goniometer valid and accurate (knee joint range) even with low bandwidth. ICC = 0.77 - 0.99 for intra-tester reliability and ICC = 0.93 - 0.99 for inter-tester reliability (Russell et al. 2003)
Knee and wrist joint range assessment with virtual goniometry reliable and feasible but may be less accurate than face-to-face, particularly for inexperienced clinicians. Inter-rater reliability ICC = 0.78 for student vs ICC = 0.9 for experienced clinicians (Mehta et al. 2020)
Good to excellent concurrent validity of internet-based physiotherapy assessments across 7 separate studies (Mani et al. 2016)
Key studies / resources:
- Russell et al. (2003) Can the Internet be used as a medium to evaluate knee angle?
- Mehta et al. (2020) Virtual assessments of knee and wrist joint range motion have comparable reliability with face‐to‐face assessments
- Mani et al. (2016) Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review
Shoulder assessment
Technology for remote assessment:
Video-based assessment
Validity / reliability:
Consistent with the reliability of conventional assessment methods (Steele et al. 2012)
Key studies / resources:
- Steele et al. (2012) Assessment and Diagnosis of Musculoskeletal Shoulder Disorders over the Internet
Knee assessment
Technology for remote assessment:
Video-based assessment
Validity / reliability:
High level of intra-rater (89%) and moderate level of inter-rater (67%) reliability for telerehabilitation assessments (Richardson et al. 2016)
Key studies / resources:
Ankle assessment
Technology for remote assessment:
Video-based assessment
Validity / reliability:
High agreement between face-to-face and internet assessed diagnoses with 76% exact agreement (Russell et al. 2010)
Key studies / resources:
- Russell et al. (2017) Telerehabilitation Mediated Physiotherapy Assessment of Ankle Disorders
- Eble et al. (2020) The virtual foot and ankle physical examination
Spine examination
Technology for remote assessment:
Video-based assessment
Validity / reliability:
High agreement between face-to-face and telerehabilitation evaluations (alpha reliability > 0.80) for 7 of the 9 outcome measures. Excellent inter- and intra-rater reliability (ICC = 0.92 - 0.96) (Palacin-Marin et al. 2013)
Key studies / resources:
- Palacin-Marin et al. (2013) Agreement Between Telerehabilitation and Face-to-Face Clinical Outcome Assessments for Low Back Pain in Primary Care
- Satin et al. (2020) The Virtual Spine Examination: Telemedicine in the Era of COVID-19 and Beyond
General guidance for musculo-skeletal assessments via video link
Technology for remote assessment:
Video-based assessment
Validity / reliability:
Good concurrent validity and excellent reliability for virtual musculoskeletal assessments across most areas (Mani et al. 2016)
High level of agreement between videoconference assessment and in-person assessment of patients with chronic lumbar spine, knee or shoulder conditions referred to a tertiary advanced-practice physiotherapy screening clinic (Cottrell et al. 2018)
Key studies / resources:
- Mani et al. (2016) Validity and reliability of Internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review
- Cottrell et al. (2018) Agreement between telehealth and in-person assessment of patients with chronic musculoskeletal conditions presenting to an advanced-practice physiotherapy screening clinic
- Murray et al. (2021) Remote musculoskeletal assessment framework: A guide for primary care
- Laskowski et al. (2020) The Telemedicine Musculoskeletal Examination
- Mayo clinic guides to virtual musculoskeletal physical examination, including video guides to various physical assessments
Neurological assessment
Neuro-psychological tests
e.g. Symbol Digit Modalities Test, SDMT
Technology for remote assessment:
Video-based assessment.
Validity / reliability:
High correlation between standard SDMT and Smartphone-based Symbol Digit Modalities Test (S-SDMT) (ICC = 0.838), but SDMT score was on average 12% higher than S-SDMT score (van Oirschot et al. 2020)
Key studies / resources:
Neurological assessment
e.g. range of motion post-stroke
Technology for remote assessment:
Video-based assessment
Validity / reliability:
Valid and reliable measurement of upper limb range of motion following stroke (Hoffmann et al. 2007)
Key studies / resources:
- Hoffmann et al. (2007) Remote measurement via the Internet of upper limb range of motion in people who have had a stroke
- Hussona et al. (2020) The Virtual Neurologic Exam: Instructional Videos and Guidance for the COVID-19 Era
- Smets et al. (2021) Barts Health NHS Trust video guidance on carrying out a virtual neurological examination (VirtuEx).
Spasticity
Technology for remote assessment:
Video-based assessment
Validity / reliability:
Almost perfect agreement (94%) between two examiners identifying spasticity remotely (Harper et al. 2021)
Key studies / resources:
- Harper et al. (2021) A comparative evaluation of telehealth and direct assessment when screening for spasticity in residents of two long-term care facilities
- Verduzco-Gutierrez et al. (2020) Spasticity outpatient evaluation via telemedicine: A practical framework
Other assessments
Balance: Berg balance scale
Technology for remote assessment:
Recommendations: High-definition video with slow motion review (bandwidth >768kbps and frame rate >30fps)
Validity / reliability:
High inter-rater reliability comparing face-to-face and high definition video (ICC = 0.96) (Venkataraman et al. 2017)
Key studies / resources:
- Venkataraman et al. (2017) Tele-Assessment of the Berg Balance Scale: Effects of Transmission Characteristics
Function: Sit-Stand (e.g. five times sit-stand, 30 second sit-stand)
Technology for remote assessment:
Sensors within iPhone 6 or Samsung Galaxy phone placed in trouser pocket
Accelerometer
Video assessment
Validity / reliability:
Strong correlation between smartphone measured sit-stand (via internal sensors) and face-to-face stopwatch measurement (R > 0.97). Good to excellent inter-rater reliability (ICC > 0.98) for all three outcomes assessed: Five Times Sit-Stand, TUAG and 30 Second Sit-Stand (Lein et al. 2019)
Key studies / resources:
- Lein et al. (2019) Assessing a novel way to measure three common rehabilitation outcome measures using a custom mobile phone application
- Lai et al. (2020) COVID-19 Modifications for Remote Teleassessment and Teletraining of a Complementary Alternative Medicine Intervention for People With Multiple Sclerosis: Protocol for a Randomized Controlled Trial (Shows illustrated examples of remotely measured Sit-stand/TUG and balance) Link to therapists’ protocol
Hand examination
Range of motion, sensation, strength testing, functional testing, and special tests / provocative manoeuvres
Technology for remote assessment:
Video-based assessment
Validity / reliability:
High agreement between telehealth assessment and traditional clinical assessment for a range of subjective and objective outcomes (Worboys et al. 2018)
Key studies / resource:
- Worboys et al. (2018) Delivering occupational therapy hand assessment and treatment sessions via telehealth
- Wainberg et al. (2020) The Telemedicine Hand Examination (Video designed for use by patients but may also be useful for practitioners)
Orthopaedic assessment (range of motion and function)
Technology for remote assessment:
Video-based assessment
Virtual goniometer using a Chrome extension such ‘Protractor’
Smartphone goniometer
Validity / reliability:
Excellent reliability (inter- and intra-rater) and validity of smartphone apps such as Clinometer and Goniometer-Pro in comparison to normal goniometer. ICC > 0.75 for more than 50% of joint movements reported in 23 studies (Keogh et al. 2019)
Key studies / resources:
- Tanaka et al. (2020) Telemedicine in the Era of COVID-19: The Virtual Orthopaedic Examination (Includes illustrations of assessment of joint ROM using virtual goniometers, plus function – sit-stand)
- Keogh et al. (2019) Reliability and validity of clinically accessible smartphone applications to measure joint range of motion: A systematic review.
Falls risk assessments
Technology for remote assessment:
Video-based assessment.
Key studies / resources:
- British Geriatrics Society (BGS) blog on conducting virtual falls risk assessments
Commonly used patient-reported outcomes
Practitioners have reported using a range of patient-reported outcome measures as part of the remote assessment.
Most of these could be sent via e-mail or post prior to the consultation.
The most frequently assessed aspects of health and wellbeing, with some examples of questionnaires used by practitioners are:
Activities of daily living
- Barthel Index for Activities of Daily Living
- Disabilities of the Arm, Shoulder & Hand (DASH)
- Nottingham Extended Activities of Daily Living (NEADL) Scale
Caregiver wellbeing
- Caregiver Strain Index (CSI)
- Adult Carer Quality of Life (AC-QoL) questionnaire
Cognitive
- Montreal Cognitive Assessment (MoCA)
- Addenbrooke’s Cognitive Examination (ACE-III)
COVID-specific
COVID-19 Yorkshire Rehabilitation Screen (C19-YRS). Telephone assessment tool with 19 self-reported items, each with a severity score of 0-10. Developed by the COVID-19 Multidisciplinary Team (MDT) Rehabilitation Teams of Leeds, Airedale and Hull NHS Trusts. Free to use.
Post-ICU Presentation Screen (PICUPS) tool. There is also a PICUPS Plus tool (and a community version). 16 items, 0-5 score. See framework for assessing early rehabilitation needs following treatment in intensive care.
Note: C19-YRS and PICUPS tools are complementary
Post-COVID-19 Functional Status (PCFS) Scale– recommended by NHSI.
Fatigue Severity Scale (FSS)
- Modified Fatigue Impact Scale (MFIS)
- Global Fatigue Index (GFI)
Mobility
- Rivermead Mobility Index (RMI)
- Prosthetic Limb Users Survey of Mobility (PLUS-M™) Version 1.0
Psychosocial
- Hospital Anxiety and Depression Scale (HADS)
- Patient Health Questionnaire 9 (PHQ-9)
- Generalised Anxiety Disorder Questionnaire (GAD-7)
Quality of life (health-related, generic)
- EQ-5D-5L
- Short Form 36 (SF-36) Health Survey Questionnaire
Speech
- Overall Assessment of the Speaker's Experience of Stuttering (OASES)
- Voice Handicap Index (VHI-10)
Other disease-specific
Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)
Egen Klassifikation (EK Scale) for muscular dystrophy and atrophy
Multiple Sclerosis Impact Scale (MSIS-29)
12-item Multiple Sclerosis Walking Scale (MSWS-12)
Parkinson’s Disease Questionnaire (PDQ-39) and PDQ-Carer have versions designed for remote use
Stroke and Aphasia Quality of Life Scale-39 (SAQOL-39)