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English version of the Modified New Mobility Score (NMS)_language edited and updated with new references_Dec. 2019..pdf

Authors:
Kathleen Mangione at Arcadia University
Kathleen Mangione
Morten Tange Kristensen at Bispebjerg and Frederiksberg Hospital - University of Copenhagen
Morten Tange Kristensen
  • Bispebjerg and Frederiksberg Hospital - University of Copenhagen
Derek John Curtis at Child and Youth Administration
Derek John Curtis
  • Child and Youth Administration
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English version by Derek Curtis, PT, MSc and Morten Tange Kristensen, PT, PhD, 2014, after Danish translation by
Morten Tange Kristensen, Hvidovre Hospital, November 2005, revised March 2008 and January 2010 (approved by
Dr. Martyn Parker). After Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J
Bone Joint Surg Br 1993;75: 797-9. Corrections of text and bullet points in collaboration with Kathleen Kline
Mangione, PT, PhD, FAPTA, December 2019. Further information: mortentange@hotmail.com
The NMS was originally developed for patients with hip fractures1 but can also be used for other diagnostic
groups with walking mobility problems.3,4 NMS assess gait; inside the home, outside the home and while
shopping. A score of 0-3 points is given for each function, resulting in a total score of 0-9 points. Although not
tested formally, an improvement of 1 point on the NMS suggests a clinically meaningful change. Excellent
interrater reliability of the NMS has been established for patients with hip fracture5 and the NMS is a strong
predictor of mortality and other outcomes following hip fracture.1,2,6–9 The NMS can be used for the
evaluation of change and recovery of mobility following fracture.10–12
Manual for recording of the Modified New Mobility Score (NMS):
If the patient occasionally uses a device or a wheelchair for the listed activities, score at the lowest level of
function.
• When evaluating, for example, the pre-
fracture function, ask the patient to recall
their function in the last week before the
occurrence of the fracture. Since many
patients describe their level of function from
months or year ago, confirm their response to,
for example, outdoor walking, by asking for
the last time they've been outside or down
the stairs.
• A person who uses the car as a mean of
transport for shopping and who uses a cane
while shopping is given 2 points for shopping.
• For persons with impaired cognition/insight
and to ensure accuracy, mobility information
should be obtained from relatives, caregivers,
home care or nursing homes.
• A person who, for example, uses a wheelchair
outside the home and while shopping is given
0 points for both walking outside the home
and while shopping.
• A person who does not use a walking aid
inside the home, but instead reaches out onto
furniture, door frames or walls for support, is
given 2 points for inside the home walking.
Walking aid use:
Indoor ____________________ Outdoor ______________________ While shopping ____________________
Result NMS:
Indoor (0-3) ______ Outdoor (0-3) _______ While shopping (0-3) _______ Total (0-9) _______
The New Mobility Score (NMS, 0-9 point) – Modified English version
Mobility
No difficulty
and no aid
With a
walking aid
With help from
another person
Not at
all
Able to get about the house
(indoor walking)
3
2
1
0
Able to get out of the house
(outdoor walking)
3
2
1
0
Able to go shopping
(walking during shopping)
3
2
1
0
Kristensen MT: Modified January 2010 from Parker and Palmer. J Bone Joint Surg 1993; 75: 797-9,1 approved by Dr.
Parker, and published in Kristensen and Kehlet. Danish Medical Journal 2012; 59 (6)2
English version by Derek Curtis, PT, MSc and Morten Tange Kristensen, PT, PhD, 2014, after Danish translation by
Morten Tange Kristensen, Hvidovre Hospital, November 2005, revised March 2008 and January 2010 (approved by
Dr. Martyn Parker). After Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J
Bone Joint Surg Br 1993;75: 797-9. Corrections of text and bullet points in collaboration with Kathleen Kline
Mangione, PT, PhD, FAPTA, December 2019. Further information: mortentange@hotmail.com
The NMS also is referred to as the “Parker Mobility Score” although it was developed together with
Dr. Palmer.1 The present version of the NMS should correctly be cited as: The modified2 and reliable5
New Mobility Score.1
References (selected):
1. Parker MJ, Palmer CR. A new mobility score for predicting mortality after hip fracture. J Bone Joint Surg
Br. 1993;75(5):797-798.
2. Kristensen MT, Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a
fast-track programme. Dan Med J. 2012;59(6).
3. Kristensen MT, Jakobsen TL, Nielsen JW, Jorgensen LM, Nienhuis RJ, Jonsson LR. Cumulated
Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture.
Dan Med J. 2012;59(7).
4. Bodilsen AC, Pedersen MM, Petersen J, et al. Acute hospitalization of the older patient: Changes in
muscle strength and functional performance during hospitalization and 30 days after discharge. Am J
Phys Med Rehabil. 2013;92(9):789-796.
5. Kristensen MT, Bandholm T, Foss NB, Ekdahl C, Kehlet H. High inter-tester reliability of the New
Mobility Score in patients with hip fracture. J Rehabil Med. 2008;40(7):589-591.
6. Kristensen MT, Foss NB, Ekdahl C, Kehlet H. Prefracture functional level evaluated by the New Mobility
Score predicts in-hospital outcome after hip fracture surgery. Acta Orthop. 2010;81(3):296-302.
7. Hulsbæk S, Larsen RF, Troelsen A. Predictors of not regaining basic mobility after hip fracture surgery.
Disabil Rehabil. 2015;37(19):1739-1744.
8. Fitzgerald M, Blake C, Askin D, Quinlan J, Coughlan T, Cunningham C. Mobility one week after a hip
fracture – can it be predicted? Int J Orthop Trauma Nurs. 2018.
9. Kristensen MTMT, Kehlet H. The basic mobility status upon acute hospital discharge is an independent
risk factor for mortality up to 5 years after hip fracture surgery: Survival rates of 444 pre-fracture
ambulatory patients evaluated with the Cumulated Ambulation Score. Acta Orthop. 2018;89(1):47-52.
10. Overgaard J, Kristensen MT. Feasibility of progressive strength training shortly after hip fracture
surgery. World J Orthop. 2013;4(4):248-258.
11. Steihaug OM, Gjesdal CG, Bogen B, et al. Does sarcopenia predict change in mobility after hip fracture?
a multicenter observational study with one-year follow-up. BMC Geriatr. 2018;18(1):1-10.
12. González-Zabaleta J, Pita-Fernandez S, Seoane-Pillado T, López-Calviño B, Gonzalez-Zabaleta JL.
Comorbidity as a predictor of mortality and mobility after hip fracture. Geriatr Gerontol Int.
2016;16(5):561-569.

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Does sarcopenia predict change in mobility after hip fracture? a multicenter observational study with one-year follow-up
Article
Full-text available
  • Mar 2018
  • BMC Geriatr
Background: Patients with hip fracture frequently have sarcopenia and are at great risk of loss of mobility. We have investigated if sarcopenia predicts change in mobility after hip fracture. Methods: This is a prospective, multicenter observational study with one-year follow-up. Patients with hip fracture who were community-living and capable of walking before the fracture were included at three hospitals in Norway (2011-2013). The primary outcome of the study was change in mobility, measured by the New Mobility Score (NMS). Sarcopenia was determined postoperatively by anthropometry, grip strength, and NMS. Results: We included 282 participants and sarcopenia status was determined in 201, of whom 38% (77/201) had sarcopenia, 66% (128/194) had low muscle mass, 52% (116/222) had low grip strength and 8% (20/244) had low pre-fracture mobility (NMS < 5). Sarcopenia did not predict change in mobility (effect 0.2 points; 95% CI -0.5 to 0.9, P = 0.6), but it was associated with having lower mobility at one-year (NMS 5.8 (SD 2.3) vs. 6.8 (SD 2.2), P = 0.003), becoming a resident of a nursing home (odds ratio 3.2, 95% CI 0.9 to 12.4, P = 0.048), and the combined endpoint of becoming a resident of a skilled nursing home or death (odds ratio 3.6, 95% CI 1.2 to 12.2, P = 0.02). Conclusions: Sarcopenia did not predict change in mobility in the year after hip fracture.
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The basic mobility status upon acute hospital discharge is an independent risk factor for mortality up to 5 years after hip fracture surgery: Survival rates of 444 pre-fracture ambulatory patients evaluated with the Cumulated Ambulation Score
Article
Full-text available
  • Sep 2017
Background and purpose — Mortality rates following hip fracture (HF) surgery are high. We evaluated the influence of the basic mobility status on acute hospital discharge to 1- and 5-year mortality rates after HF. Patients and methods — 444 patients with HF ≥60 years (mean age 81 years, 77% women) being pre-fracture ambulatory and admitted from their own homes, were consecutively included in an in-hospital enhanced recovery program and followed for 5 years. The Cumulated Ambulation Score (CAS, 0–6 points, 6 points equals independence) was used to evaluate the basic mobility status on hospital discharge. Results — 102 patients with a CAS <6 stayed in the acute ward a median of 22 (15–32) days post-surgery as compared with a median of 12 (8–16) days for those 342 patients who achieved a CAS =6. Overall 1-year mortality was 16%; in those with CAS <6 it was 30% and in those with CAS =6 it was 12%. Corresponding data for 5-year deaths were 78% and 50%. Multivariable Cox regression analysis demonstrated that the likelihood of not surviving the first 5 years after hip fracture was 1.5 times higher for those with a CAS <6 and for men; 2 times higher for those 80 years or older; increased by 50% per point higher ASA grade; and was reduced by 11% per point higher New Mobility Score, when adjusted for the cognitive and fracture type status. Interpretation — Further studies focused on interventions that improve the basic mobility status of patients with HF should be instigated within the early time period following surgery.
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Feasibility of progressive strength training shortly after hip fracture surgery
Article
Full-text available
  • Oct 2013
To investigate the feasibility of a 6-wk progressive strength-training programme commenced shortly after hip fracture surgery in community-dwelling patients. This prospective, single-blinded cohort study evaluated 31 community-dwelling patients from four outpatient geriatric health centres aged 60 years or older, who started a 6-wk programme at a mean of 17.5 ± 5.7 d after hip fracture surgery. The intervention consisted primarily of progressive fractured knee-extension and bilateral leg press strength training (twice weekly), with relative loads commencing at 15 and increasing to 10 repetitions maximum (RM), with three sets in each session. The main measurements included progression in weight loads, hip fracture-related pain during training, maximal isometric knee-extension strength, new mobility score, the timed up and go test, the 6-min walk test and the 10-meter fast speed walk test, assessed before and after the programme. Weight loads in kilograms in the fractured limb knee-extension strength training increased from 3.3 ± 1.5 to 5.7 ± 1.7 and from 6.8 ± 2.4 to 7.7 ± 2.6, respectively, in the first and last 2 wk (P < 0.001). Correspondingly, the weight loads increased from 50.3 ± 1.9 to 90.8 ± 40 kg and from 108.9 ± 47.7 to 121.9 ± 54 kg in the bilateral leg press exercise (P < 0.001). Hip fracture-related pain was reduced, and large improvements were observed in the functional outcome measurements, e.g., the 6-min walk test improved from 200.6 ± 79.5 to 322.8 ± 68.5 m (P < 0.001). The fractured limb knee-extension strength deficit was reduced from 40% to 17%, compared with the non-fractured limb. Ten patients reported knee pain as a minor restricting factor during the last 10 RM knee-extension strength-training sessions, but with no significant influences on performance. Progressive strength training, initiated shortly after hip fracture surgery, seems feasible and does not increase hip fracture-related pain. Progressive strength training resulted in improvement, although a strength deficit of 17% persisted in the fractured limb compared with the non-fractured limb.
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Cumulated Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture
Article
Full-text available
  • Jul 2012
Regaining basic mobility independence is considered important for elderly hospitalised patients. The Cumulated Ambulation Score (CAS) is a valid tool for evaluating these patients' basic mobility (getting in and out of bed, sit-to-stand from a chair and walking) in orthopaedic wards, and its use is recommended in Denmark for patients with hip fracture. The aims of the present study were to evaluate the feasibility of the CAS in a geriatric ward and to describe its use after hip fracture in Denmark. A total of 101 consecutive patients (with a mean age of 84.9 (standard deviation 7.2) years) were evaluated with the CAS upon admission and at discharge from a geriatric ward, while data concerning the use of the CAS after hip fracture were collected from national Danish reports. All geriatric patients could be evaluated with the CAS. A total of 41% were independent in terms of basic mobility at admission and 83% of patients at discharge from the ward (p < 0.001). Patients who were not independent in basic mobility upon admission died more often during admission or were more often not discharged to their own home than patients who were independent in basic mobility. National data from the year 2010 showed that the CAS was reported by 21 (78%) of the 27 hospitals and used in 92% of the hospitals that will be treating patients with hip fracture in the future. In geriatric wards, the CAS is a feasible tool for evaluating all patients' basic mobility, and we recommend that it be used in other settings and at all hospitals treating patients with hip fracture.
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Most patients regain prefracture basic mobility after hip fracture surgery in a fast-track programme
Article
Full-text available
  • Jun 2012
Treatment of patients with hip fracture has improved over the past decade. Still, some patients do not regain independent mobility within their primary hospital stay even if they follow a multimodal fast-track surgical programme. The aim of the present article was to examine the validity of the preliminary prefracture New Mobility Score (NMS), age and fracture type as independent predictors of in-hospital outcome after hip fracture surgery. The study comprised a total of 213 consecutive patients with a median age of 82 years who were admitted from their own home to a special hip fracture unit. Outcome variables were the regain of independency in basic mobility as evaluated by the Cumulated Ambulation Score, and discharge destination in the community. Multiple logistic regression analysis revealed that patients with a low prefracture NMS and/or an intertrochanteric fracture were 6.5 and four times more likely to not regain independency in basic mobility during admittance than patients with a high prefracture NMS level and a cervical fracture, respectively. In addition, the odds of not regaining independent mobility increased with age by 5% per year. The same three variables significantly increased the odds of patients not being discharged to their own home. Prefracture NMS, age and fracture type were confirmed as independent predictors of in-hospital outcome in patients with hip fracture who followed a multimodal rehabilitation concept.
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Prefracture functional level evaluated by the New Mobility Score predicts in-hospital outcome after hip fracture surgery
Article
Full-text available
  • Jun 2010
  • ACTA ORTHOP
Clinicians need valid and easily applicable predictors of outcome in patients with hip fracture. Adjusting for previously established predictors, we determined the predictive value of the New Mobility score (NMS) for in-hospital outcome in patients with hip fracture. We studied 280 patients with a median age of 81 (interquartile range 72-86) years who were admitted from their own homes to a special hip fracture unit. Main outcome was the regain of independence in basic mobility, defined as. independence in getting in and out of bed, sitting down and standing up from a chair, and walking with an appropriate walking aid. The Cumulated Ambulation score was used to evaluate basic mobility. Predictor variables were NMS functional level before fracture, age, sex, fracture type, and mental and health status. Except for sex, all predictor variables were statistically significant in univariate testing. In multiple logistic regression analysis, only age, NMS functional level before fracture, and fracture type were significant. Thus, patients with a low prefracture NMS and/or an intertrochanteric fracture would be 18 and 4 times more likely not to regain independence in basic mobility during the hospital stay, respectively, than patients with a high prefracture level and a cervical fracture, respectively. The model was statistically stable and correctly classified 84% of cases. The NMS functional level before fracture, age, and fracture type facilitate prediction of the in-hospital rehabilitation potential after hip fracture surgery.
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High inter-tester reliability of the New Mobility Score in patients with hip fracture
Article
Full-text available
  • Aug 2008
To assess the inter-tester reliability of the New Mobility Score in patients with acute hip fracture. An inter-tester reliability study. Forty-eight consecutive patients with acute hip fracture at a median age of 84 (interquartile range, 76-89) years; 40 admitted from their own home and 8 from nursing homes to an acute orthopaedic hip fracture unit at a university hospital. The New Mobility Score, which evaluates the prefracture functional level with a score from 0 (not able to walk at all) to 9 (fully independent), was assessed by 2 independent physiotherapists at the orthopaedic ward. Inter-tester reliability was evaluated using the intraclass correlation coefficient (ICC1.1) and the standard error of measurement (SEM). The ICC between the 2 physiotherapists was 0.98, 95% confidence interval (CI) 0.96-0.99 and the SEM was 0.42, 95% CI -0.40-1.24 New Mobility Score points. No systematic between-rater bias was observed (p>0.05). Patients who were scored differently by the 2 physiotherapists had significantly lower mental scores (p=0.02). The inter-tester reliability of the New Mobility Score is very high and can be recommended to evaluate the prefracture functional level in patients with acute hip fracture.
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Mobility one week after a hip fracture – Can it be predicted?
Article
  • Dec 2017
Objective: Better patient outcomes and more efficient healthcare could be achieved by predicting post hip fracture function at an early stage. This study aimed to identify independent predictors of mobility outcome one week post hip fracture surgery. Methods: All hip fracture inpatients (n=77) were included in this 6 month prospective observational cohort study. Predictor variables were obtained on the first postoperative day and included premorbid function using the New Mobility Score (NMS). Mobility outcome measures one week postoperatively included the Cumulated Ambulatory Score (CAS). Data were analysed with SPSS using binary multiple logistic regression analysis RESULTS: Patients who fell outdoors (OR 3.848; 95% CI, 1.053-14.061), had no delay to surgery (OR 5.472; 95% CI, 1.073-27.907) and had high pre-fracture function (OR3.366; 95% CI, 1.042-10.879) were predicted to achieve independent mobility (CAS = 6) one week postoperatively. Conclusion: Fall location, time to surgery and baseline function predict independent mobility one week after hip fracture, and can be used for early rehabilitation stratification. The NMS and CAS are recommended as standardised hip fracture clinical measures. Orthogeriatric and physiotherapy service initiatives may improve early functional outcome.
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Predictors of not regaining basic mobility after hip fracture surgery
Article
  • Oct 2014
Purpose: Regaining basic mobility after hip fracture surgery is a milestone in the in-hospital rehabilitation. The aims were to investigate predictors for not regaining basic mobility at the fifth post-operative day and at discharge after undergoing hip fracture surgery. Method: In a prospective cohort study 274 hip fracture patients were included. Patients with compromised ability to exercise were excluded leaving 167 patients for analysis. Patient demographics, functional level, method of operation, post-operative hemoglobin and the completion of physiotherapy was registered. Basic mobility was assessed by the Cumulated Ambulation Score. Multivariate logistic regression was performed. Results: Age >80 years (OR = 7.5), low prefracture functional level (OR = 3.0), not completed the physiotherapy on first post-operative day (OR = 4.6) and hemoglobin <6 mmol/L measured on first post-operative day (OR = 5.8) were significant predictors of not regaining basic mobility within the fifth post-operative day (p values: 0.04-<0.0001). Predictors of not regaining basic mobility at discharge were: Age >80 years (OR = 4.3), prefracture functional level (OR = 7.0) and not completed the physiotherapy on first post-operative day (OR = 3.3) (p values: 0.009-<0.0001). Conclusions: This study shows that patients undergoing hip fracture surgery, who are not able to complete physiotherapy on first post-operative day, are at a greater risk of not regaining basic mobility during hospitalization. This highlights the importance of physiotherapy as part of the interdisciplinary treatment. Implications for Rehabilitation Regaining abilities in basic mobility after hip fracture surgery is a primary goal of rehabilitation during hospitalization in the acute ward. The following factors are indentified to predict patients not regaining their previous level of basic mobility: Age >80 years, low prefracture functional level, patients not being able to complete the physiotherapy on the first post-operative day and hemoglobin value <6 mmol/l on the first post-operative day. In future strategies, the findings regarding both modifiable and unmodifiable factors, can be used to conduct early planning of discharge and to take actions in relation to patients who are at a risk of not regaining basic mobility.
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Acute Hospitalization of the Older Patient Changes in Muscle Strength and Functional Performance During Hospitalization and 30 Days After Discharge
Article
  • Apr 2013
  • AM J PHYS MED REHAB
Objective: Acute hospitalization of older patients may be associated with loss of muscle strength and functional performance. The aim of this study was to investigate the effect of acute hospitalization as a result of medical disease on muscle strength and functional performance in older medical patients. Design: Isometric knee-extension strength; handgrip strength; and functional performance, that is, the Timed Up and Go test, were assessed at admission, at discharge, and 30 days after discharge. Twenty-four-hour mobility was measured during hospitalization. Results: The mean (SD) age was 82.7 (8.2) years, and the median length of stay was 7.5 days (interquartile range, 4.25-11). Knee-extension strength did not change over time (1.0 [N·m]/kg, 1.1 [N·m]/kg, and 1.1 [N·m]/kg, P = 0.138), as did handgrip strength (24.2 kg, 23.3 kg, and 23.5 kg, P = 0.265). The Timed Up and Go test improved during hospitalization, from 17.3 secs at admission to 13.3 secs at discharge (P = 0.003), but with no improvement at the 30-day follow-up (12.4 secs, P = 0.064). The median times spent in lying, sitting, and standing/walking were 17.4 hrs per day, 4.8 hrs per day, and 0.8 hrs per day, respectively. Conclusions: Muscle strength did not change during hospitalization and 30 days after discharge in the acutely admitted older medical patients. Despite a low level of mobility during hospitalization, functional performance improved significantly during hospitalization, without further improvement.
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Linked Research

Most patients regain prefracture basic mobility after hip fracture surgery in a fast-track programme
Article
June 2012
Morten Tange Kristensen · Henrik Kehlet