Structured Observations

of Sensory Integration – Motor

Erna Imperatore Blanche, PhD, OTR/L • Gustavo Reinoso, PhD, OTR/L • Dominique Blanche Kiefer, OTD, OTR/L

Name:
Year Month Day

Date of Testing
Gender: Grade:
Date of Birth

School/Facility: Chronological Age

Examiner:
Do not round month up if day exceeds 15.

Referral Information / Reason for Testing:

Score Summary

Overall Total Score: Standard Score: Percentile Rank:

Standard Score Confidence Interval (circle one): 90% 95% to

Comments:

Areas of Concern No Concern Mild Moderate

Postural Control
Motor Planning
Vestibular
Proprioceptive
Fluidity
Assumes Position / Copying Body Position

© 2021 Academic Therapy Publications. All rights reserved.

Users are not allowed to reproduce this form without permission from the publisher.
 Item Set
Item Set SOSI-M Item Item Total ≤15th 16th-24th ≥25th
Data Score percentile percentile percentile

1. Romberg – firm, open

2. Romberg – firm, closed
Romberg
3. Romberg – soft, open
4. Romberg – soft, closed
Romberg Total
5. Heel to Toe – firm, open
6. Heel to Toe – firm, closed
Heel to Toe
7. Heel to Toe – soft, open
8. Heel to Toe – soft, closed
Heel to Toe Total
9. One Foot – right, open
Standing on 10. One Foot – left, open
One Foot
11. One Foot – right, closed
12. One Foot – left, closed
Standing on One Foot Total
Modified Postural 13. Schilder’s – right (converted score)
Schilder’s Arm
Extension Test 14. Schilder’s – left (converted score)
Schilder’s Total
Skipping 15. Skipping
Skipping Total
16. Jumping Jacks
Series of
17. Symmetrical Stride Jumps (ages 7.0+)
Jumps
18. Reciprocal Stride Jumps (ages 7.0+)
Series of Jumps Total
High Kneeling 19. High Kneeling (ages 7.0+)
High Kneeling Total
Overall Score (Subtotal)

2
 a a b b
Postural Control Motor Planning Vestibular Proprioceptive

X
X X X
X
X X

X
X X X
X
X X

X
X
X X X
X X X

X
X

X BMC
c

X BMC
c
c
X BMC
c
X BMC

a Categories based on exploratory factor analysis.

b
Categories based on theory. In order to determine specific proprioceptive difficulties, the COP-R
should be administered and interpreted along with SOSI-M scores.
c Bilateral Motor Coordination – If the examinee demonstrates motor planning difficulties with those
tasks, poor vestibular processing may underlie difficulties with bilateral motor coordination.

3
 Item Set
Item Set SOSI-M Item Item Total ≤15th 16th-24th ≥25th
Data Score percentile percentile percentile

Antigravity Extension 20. Extension

Antigravity Extension Total

Antigravity Flexion 21. Flexion
Antigravity Flexion Total
22. Ocular – Vertical
Ocular
Movements 23. Ocular – Horizontal
24. Ocular – Tracking
Ocular Movements Total
Slow Ramp Movements 25. Slow Ramp (converted score)

Slow Ramp Movements Total

Sequential 26. Sequential Finger Touching – Right
Finger Touching 27. Sequential Finger Touching – Left
Sequential Finger Touching Total
28. Diadochokinesis – Right
Diadochokinesis 29. Diadochokinesis – Left
30. Diadochokinesis – Bilateral
Diadochokinesis Total
Projected Actions 31. Ball in Air
in Time and Space 32. Ball Against Wall (ages 7.0+)
Projected Actions Total
Overall Score (Subtotal)
Overall Total Score
(pages 2 and 4)

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 a a b b
Postural Control Motor Planning Vestibular Proprioceptive

c
X Maintains

d
X
Xd
Xd

X X

X X
X X

X X
X X
X X

X X
X X

/ / / /

a Categories based on exploratory factor analysis.

b
Categories based on theory. In order to determine specific proprioceptive difficulties, the COP-R
should be administered and interpreted along with SOSI-M scores.
c
Vestibular processing contributes to the ability to maintain Antigravity Extension but not to assume the position.
d Vestibular processing contributes to the ability to maintain a stable visual field.

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 Qualitative Observations

Score 1 if “Y” ≤15th 16th-24th ≥25th

Fluidity Y/N
Score 0 if “N” percentile percentile percentile

15a. Fluid and continuous movements

16–18b. Fluid and continuous movements +
16–18c. Fluid movement between sequences +
25c. Movements are fluid +
26–27a. Fluid movements +
28–30a. Fluid movements +
28–30c. Rhythmic movements +
Total =

Score 1 if “Y” ≤15th 16th-24th ≥25th

Assumes Position / Copying Body Position Y/N
Score 0 if “N” percentile percentile percentile

16–18a. Assumes the position independently

20a. Simultaneous lifting of upper and lower extremities +
20d. Assumes first or second position independently +
21a. Simultaneous lifting of upper and lower extremities +
21d. Assumes first or second position independently +
Total =

Scaled
COP-R
Score

Tone and Joint Alignment Domain

Behavioral Manifestation Domain
Postural Motor Domain
Motor Planning Domain
Standard
Score

Overall Standard Score

PRN Score Other Scores

Left
Right

6
 General Directions

Item Administration Guidelines

• All individuals start with Item 5: Heel to Toe, eyes open, firm surface. If the examinee achieves the maximum time on
Item 5, the Romberg Item Set (Items 1 through 4) is NOT administered and it automatically receives a score of 8.

• The items in the following item sets allow for two attempts. If the maximum time is achieved on the first attempt,
do NOT administer the second trial for the item:
• Romberg
• Heel to Toe
• Standing on One Foot
• Antigravity Extension
• Antigravity Flexion

• If the examinee requires assistance to assume the correct positions for the Romberg, Heel to Toe, Antigravity
Extension, and Antigravity Flexion tasks:
• Conduct the first trial.
• Record 0 seconds for this attempt.
• Administer and record the time for the second trial.

• The following items on the SOSI-M are administered only to examinees aged 7-0 years and above.
Do NOT administer these items to examinees under age 7-0.
• Items 17-18 Symmetrical and Reciprocal Stride Jumps
• Item 19 High Kneeling
• Item 32 Medium Ball Against Wall

• Practice trials are provided for Items 16-18 (Series of Jumps) and 31-32 (Projected Actions in Time and Space).
Use only those practice trials as described to teach the tasks for those item sets.

Scoring Guidelines

• For timed items, record time to the whole number only. The provided timer records to 1/100th of a second.
For the purposes of scoring, always round DOWN to the whole number.

• Scoring conversion tables are all found in the Examiner’s Manual, Appendix A.
• Item data to 0 / 1 / 2 scores - Tables A.1 or A.2
• Total raw score to standard score – Table A.3
• Individual Item and Item Set Interpretation – Tables A.6 and A.7
• Qualitative observations – Table A.8

• To use the Individual Item Interpretation table (Table A.6), record the item data (number of seconds,
number of jumps, etc.) on pages 2 and 4 of the Record Form:
• For Items 13, 14, and 25, you will use the converted 0 / 1 / 2 score as your raw data.
• For Items 19, 22, 23, 24, and 32, you will use the number of points (0 – 2) as your raw data.
• For Item 31, use the number of claps as your raw data.
• To use the Item Set Interpretation table (Table A.7) record the item set Total Score on pages 2 and 4
of the Record Form.

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 Administer Items 1-4 only if examinee achieves less than 20 seconds on Item 5 (Heel to Toe - Firm Surface, Eyes Open).

Items 1 – 4: Romberg: Standing with Feet Together

Ages: 5+ Maximum Time (seconds): 25 Administer Trial 2 Only if Trial 1 < 25

Score: Write the time for each attempt. Compare attempts and record the best time.
Add scores from Items 1 to 4 to calculate Romberg Total Score.

1st Attempt 2nd Attempt

Time (in seconds) Time (in seconds) Best Time Score

Item 1: Firm Surface, Eyes Open

Item 2: Firm Surface, Eyes Closed

Item 3: Soft Surface, Eyes Open

Item 4: Soft Surface, Eyes Closed

Romberg Total Score =

Add Items 1 – 4 Scores (0 – 8 points)
All Examinees Start Here

If the examinee achieves maximum time on Item 5 (Heel to Toe - Firm Surface, Eyes Open), write down score of 2
on Items 1 to 4 and score of 8 on Romberg Total Score.

Items 5 – 8: Heel to Toe

Ages: 5+ Maximum Time (seconds): 20 Administer Trial 2 Only if Trial 1 < 20

Score: Write the time for each attempt. Compare attempts and record the best time.
Add scores from Items 5 to 8 to calculate Heel to Toe Total Score.

1st Attempt 2nd Attempt

Time (in seconds) Time (in seconds) Best Time Score

Item 5: Firm Surface, Eyes Open

Item 6: Firm Surface, Eyes Closed

Item 7: Soft Surface, Eyes Open

Item 8: Soft Surface, Eyes Closed

Heel to Toe Total Score =

Add Items 5 – 8 Scores (0–8 points)

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 Items 9 – 12: Standing on One Foot
Ages: 5+ Maximum Time (seconds): 20 Administer Trial 2 Only if Trial 1 < 20

Score: Write the time for each attempt. Compare attempts and record the best time.
Add scores from Items 9 to 12 to calculate Standing on One Foot Total Score.

1st Attempt 2nd Attempt

Time (in seconds) Time (in seconds) Best Time Score

Item 9: Right Foot, Eyes Open

Item 10: Left Foot, Eyes Open

Item 11: Right Foot, Eyes Closed

Item 12: Left Foot, Eyes Closed

Standing on One Foot Total Score =

Add Items 9 – 12 Scores (0 – 8 points)

Items 13 – 14: Modified Postural Schilder’s Arm Extension Test

Ages: 5+ Maximum Time (untimed) Administer Both Trials for Each Side

Score: Circle the degrees of rotation for each attempt. Compare attempts for each side and record the best attempt.
Add scores from Items 13 and 14 to calculate Schilder's Total Score.

1st Attempt 2nd Attempt

Head Rotation 90º Head Rotation 90º Best Attempt Score

Circle Degrees of Trunk/UE Rotation Circle Degrees of Trunk/UE Rotation

Item 13:
To the Right
0 1–45 46+ 0 1–45 46+

Item 14:
0 1–45 46+ 0 1–45 46+
To the Left

Modified Postural Schilder’s Arm Extension Test Total Score =

Add Items 13 – 14 Scores (0 – 4 points)

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 Item 15: Skipping
Ages: 5+ Countdown Time (seconds): 5 Administer Both Trials

Score: Write the number of skips for each attempt. Compare attempts and record the best attempt.

1st Attempt 2nd Attempt

(number of skips) (number of skips) Best Attempt Score

Item 15: Skipping

Skipping Total Score =

Qualitative Observations:
Item 15 Score (0 – 2 points)

Y / N 15a: Fluid and continuous movements

Items 16 – 18: Series of Jumps

Ages: 5+ Jumping Jacks
Countdown Time (seconds): 5 Administer Both Trials
Ages: 7+ Stride Jumps

Score: Write the number of jumps for each attempt. Compare attempts and record the best attempt.
For ages 5 through 6, write Item 16 score to calculate the Series of Jumps Total Score.
For ages 7 and above, add scores from Items 16 to 18 to calculate Series of Jumps Total Score.

1st Attempt 2nd Attempt

(number of jumps) (number of jumps) Best Attempt Score

Item 16: Jumping Jacks

Item 17: Symmetrical Stride Jumps

Item 18: Reciprocal Stride Jumps

Series of Jumps Total Score =

Ages 5 through 6: Item 16 score only (0 – 2 points)
Ages 7 and above: Add items 16–18 Scores (0 – 6 points)

Qualitative Observations:
Y / N 16-18a: Assumes the position independently
Y / N 16-18b: Fluid and continuous movements
Y / N 16-18c: Fluid movement between sequences (does not stop between each sequence)

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 Item 19: High Kneeling
Ages: 7+ Maximum Time (untimed) Administer Both Trials
Score: Circle the score for each side.
Add scores from each attempt to calculate High Kneeling Total Score.

1st Attempt (R) 2nd Attempt (L) Score

(score) + (score) 1st Attempt + 2nd Attempt

Yes No Yes No
Item 19: High Kneeling
1 0 1 0

High Kneeling Total Score =

Item 19 Score (0 – 2 points)

Item 20: Antigravity Extension

Ages: 5+ Maximum Time (seconds): 30 Administer Trial 2 Only if Trial 1 < 30

Score: Write the time for each attempt. Compare attempts and record the best time.

1st Attempt 2nd Attempt

Time (in Seconds) Time (in Seconds) Best Time Score

Item 20: Antigravity Extension

Antigravity Extension Total Score =

Item 20 Score (0 – 2 points)

Qualitative Observations:
Y / N 20a: Simultaneous lifting of upper and lower extremities
Y / N 20b: Maintains head in midline
Y / N 20c: Maintains position effortlessly (some degree of effort is expected)
Y / N 20d: Assumes first or second testing position independently

Item 21: Antigravity Flexion

Ages: 5+ Maximum Time (seconds): 60 Administer Trial 2 Only if Trial 1 < 60
Score: Write the time for each attempt. Compare attempts and record the best time.

1st Attempt 2nd Attempt

Time (in Seconds) Time (in Seconds) Best Time Score

Item 21: Antigravity Flexion

Antigravity Flexion Total Score =

Item 21 Score (0 – 2 points)

Qualitative Observations:
Y / N 21a: Simultaneous lifting of upper and lower extremities
Y / N 21b: Head in midline and chin tuck
Y / N 21c: Maintains position effortlessly (some degree of effort is expected)
Y / N 21d: Assumes first or second testing position independently
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 Items 22 – 24: Ocular Movements
Ages: 5+ Maximum Time (untimed) Administer Both Trials

Score: Circle the score for each attempt. Add scores from each attempt to calculate the item score.
Add scores from Items 22 to 24 to calculate Ocular Movements Total Score.

1st Attempt 2nd Attempt Score

(score) (score) 1st Attempt + 2nd Attempt

Yes No Yes No
Item 22: Stability-Vertical
1 0 1 0

Yes No Yes No
Item 23: Stability-Horizontal
1 0 1 0

Yes No Yes No
Item 24: Tracking
1 0 1 0

Ocular Movements Total Score =

Add Items 22–24 Scores (0 – 6 points)

Qualitative Observations:
Y / N 22-24a: Crossing the midline (no jerky movements across midline)
Y / N 22-24b: Comfort with test (does not rub eyes, no excessive blinking, etc.)
Y / N 22-24c: Maintains head in neutral midline

Item 25: Slow Ramp Movements

Ages: 5+ Maximum Time (untimed) Administer Both Trials
Score: Check the time difference of each attempt. Compare attempts and check the appropriate "Best Attempt" box.

Item 25: 1st Attempt 2nd Attempt Best Attempt

(check box) (check box) (check one box) Score

Same Time (< 1 second)

Before / After (1–3 seconds)

Before / After (3+ seconds)

Slow Ramp Movements Total Score =

Item 25 Score (0 – 2 points)

Qualitative Observations:
Y / N 25a: Symmetrical movements (R and L)
Y / N 25b: Head in midline
Y / N 25c: Movements are fluid, sustains imitation throughout the whole range

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 Items 26 – 27: Sequential Finger Touching
Ages: 5+ Countdown Time (seconds): 5 Administer Both Trials

Score: Write the number of touches for each attempt. Compare attempts and record the best attempt.
Add scores from Items 26 to 27 to calculate Sequential Finger Touching Total Score.

1st Attempt 2nd Attempt

(number of touches) (number of touches) Best Attempt Score

Item 26: Right Hand

Item 27: Left Hand

Sequential Finger Touching Total Score =

Add Items 26–27 Scores (0 – 4 points)

Qualitative Observations:
Y / N 26-27a: Fluid movements (does not stop between movements)
Y / N 26-27b: Most of the time, opposite hand rests (low occurence of associated movements)

Items 28 – 30: Diadochokinesis

Ages: 5+ Countdown Time (seconds): 5 Administer Both Trials
Score: Write the number of sequences for each attempt. Compare attempts and record the best attempt.
Add scores from Items 28 to 30 to calculate Diadochokinesis Total Score.

1st Attempt 2nd Attempt

(number of sequences) (number of sequences) Best Attempt Score

Item 28: Right Hand

Item 29: Left Hand

Item 30: Bilateral

Diadochokinesis Total Score =

Add Items 28–30 Scores (0 – 6 points)

Qualitative Observations:
Y / N 28-30a: Fluid movements
Y / N 28-30b: Most of the time, opposite hand rests (low occurence of associated movements)
Y / N 28-30c: Rhythmic movements

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 Items 31 – 32: Projected Actions in Time and Space
Ages: 5+ Ball in Air
Maximum Time (untimed) Administer Both Trials
Ages: 7+ Ball Against Wall
Score: For item 31, check the number of claps for each attempt. Compare attempts and check the appropriate “Best Attempt” box.
For item 32, circle the score for each attempt. Add scores from each attempt to calculate Item 32 Score .
For ages 5 through 6, copy Item 31 score to calculate the Projected Actions in Time and Space Total Score.
For ages 7 and above, add scores from Items 31 and 32 to calculate the Projected Actions in Time and Space Total Score.

Item 31: Ages 5.0 – 7.11: medium ball 1st Attempt 2nd Attempt
Ages 8.0+: tennis ball (check box) (check box) Best Attempt Score

Ball in Air (0 Claps)

Ball in Air (1 Clap)

Ball in Air (2 Claps)

Ball in Air (3 Claps)

Item 32:
Score
1st Attempt 2nd Attempt 1st Attempt + 2nd Attempt

Yes No Yes No
Medium Ball Against Wall
1 0 1 0

Projected Actions in Time and Space Total Score =

Ages 5 through 6: Item 31 Score only (0 – 2 points)
Ages 7 and above: Add Items 31–32 Scores (0 – 4 points)

SOSI-M Total Score =

For Total Score Ages 5 through 6: do not include Items 17, 18, 19, 32 (0 – 56 points)
For Total Score Ages 7 and above: add all Total Scores for all Tasks (0 – 64 points)

Other or Overall Qualitative Parameters/Observations:

Y / N GOa: Uses ankle strategies to maintain balance
Y / N GOb: Demonstrates adequate LE alignment
Y / N GOc: Choreoathetoid movements observed (fingers)

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© 2021 Academic Therapy Publications. All rights reserved.
Users are not allowed to reproduce this form without permission from the publisher.