Functional Assessment Tools – Flashcards
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increments of change
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• minimum potentially detectable difference - change may not be very significant • minimal detectable difference (MDD) - minimum change detectable beyond the threshold of error - change that is perceived by the rater/PT • minimal clinically important difference (MCID) - difference in those who experience small but impoartant change - difference that is noticed by a pt through significant (though possible small) improvement in performanct
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functional measures of LE strength
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• 30-Second Sit-to-Stand Test: # of times person able to complete full sit to stand to sit without using UEs • 5x Sit-to-Stand Test: time required to complete 5 reps of sit to stand to sit - 20% of community dwelling elderly can't do this at all • Primarily test of quad strength • Try to minimize use of UEs if possible
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chair rise tests
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• Quad strength explains a minimum of 67% of the ability to complete sit to stand in normal population and in those with OA • Correlates better to walking independence than manual muscle test or hand-held dynamometry - MMT is less reliable than all these test, but we are still doing it - outcome measures appear to be more valid and reliable than these other tests
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scoring 30-Second Sit-to-Stand Test
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8 reps or less in 30 seconds for men and women of any age indicates those at risk for loss of functional mobility.
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scoring 5x Sit-to-Stand Test
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• Score of 14.2 seconds or more identifies those with balance dysfunction (subjects over 60 years) • Score of 10 seconds or more identifies those with balance dysfunction (subjects < 60 years) • Performance below the following should be considered worse than average: - 60-69 years: 11.4 sec - 70-79 years: 12.6 sec - 80-89 years: 14. 8 sec
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strengths and weaknesses of chair rise tests
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• Strengths: - Measures ability to perform functional transitional movements - Requires limited equipment and training - Time to complete • Weaknesses: - Limited data on MDC - Standardized chair height does not account for variability in height and/or BMI of patient - Variability in seat height, instructions to patient, method of timing, use of UEs
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UE arm curl test
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• Purpose: to assess upper body strength required for household and other activities that involve carrying and lifting • Equipment needed - 5# weight (women) - 8# weight (men) - Armless chair • can be used in home care setting because it is easy to do and requires very little equipment
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procedure of UE arm curl test
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- Using 5# weight for women and 8# weight for men, have the patient perform a biceps curl using good form in sitting position (upright with back against backrest of armless chair—do not allow forward flexion of trunk) - Determine # of biceps curls that can be completed in 30 seconds.
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Kansas University Medical Center Balance Scales
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• Test performed: - Ranges of balance from sitting and standing positions • Test population: - Early assessment for patients with possible impaired balance • Administration Time: - Can be completed within typical evaluation • Equipment: - None, so we can do this just about anywhere
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procedure: Kansas University Medical Center Balance Scales
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- scale of 0 - 5 (with 1-4+ in between) - both static and dynamic sitting and standing - can be used for patients that need assist for sitting and standing
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strengths and weaknesses of Kansas University Medical Center Balance Scales
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• Strengths: - Evaluates basic balance abilities for low level patients, sensitive to low level ranges. Relates to performance. • Weaknesses: - Not sensitive for the ambulatory patient or those with dynamic balance impairments. - ceiling effect: these patients will max out on this test but may still have underlying balance deficits
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Timed up and go test (TUG)
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• Used to screen individuals prone to falls • Stand from armchair, walk 3 m (approx. 10 ft), turn, return to full sitting back in chair. Patient can use customary walking aid. No physical assistance should be given. • Requires client to be able to follow directions • PT needs to be quiet and not distract the pt by chatting, making it a dual task instead • if the pt has progressed and is no longer using the same AD, perform once with previous AD for comparison and once with new AD for new baseline
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TUG: pt population and equipment
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• Administration time: - 1-2 minutes - set up requires time, so if you can keep it set up all the time you'll be more efficient • Equipment: - Armchair (approximate seat height 46 cm, arm height65 cm) - Stopwatch • Test population: - Must be able to ambulate with or without device, follow 3+step command or good visual memory
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scoring TUG
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• Originally scored on 5-point subjective scale • Timed test: 1 practice then 2-3 trials (average score) • Score >= 13.5 seconds = fall risk in older adults • Score categories: - <10 sec=freely mobile - 30 sec=assist with mobility; difficulty climbing steps, could not go out alone - 20-29 sec=variable
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TUG psychometrics
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• High inter- and intra-rater reliability • Concurrent validity with: - Berg Balance Score (considered the gold standard. TUG has similar results, and is faster than the Berg) - Barthel Index - Gait speed • Highly sensitive (87%) and specific (87%) for predicting falls in community-dwelling older adults
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snout and spin
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• snout - a sensitive test helps rule out disease (when the result is negative) • spin - a very specific test rules in disease with a high degree of confidence • we want something 80% or greater
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MDC for TUG
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- 4.09 sec for persons with Alzheimer's disease
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strengths of TUG
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- Not diagnosis-dependent-can be used with wide variety of pathologies - Simple to perform - Low cost - Minimal equipment - Can be administered by any clinician; requires little training - Functional - May show small but clinically relevant change when it is difficult to observe functional change (continuous variable) - Good first test to use in all settings to determine level of mobility, fall risk
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weaknesses of TUG
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- Limited use with early non-ambulatory rehab patients - Must be ambulatory without assistance, but can use AD - No impairment level discrimination of cause for balance deficit (unlike Berg, that can help show specific impairment based on category) - Limited conclusions for those in 20-29 second range (ceiling effect) - May not be challenging enough for some community-dwelling older adults (ceiling effect)
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considerations for TUG
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• Time taken to complete task varies with use of assistive device—should not compare times if device is changed • Seat height (range 44-47 cm) • Simultaneous performance of additional task (cognitive or manual) increases time (greatest effect in those with fall hx) although not significantly more sensitive/specific than TUG alone
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Dual task TUG: manual task
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• TUG while carrying glass of water placed on table located beside chair, placing it back on table prior to sitting down. - Difference of 4.5 sec or greater between TUG and TUG manual: more prone to falls in following 6 months
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dual task TUG: cognitive task
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• Complete TUG while counting backward by threes from a randomly selected number between 20-100. - 22-25% increase in time to complete with dual task - Dual task TUG no more sensitive indicator for falls than TUG alone.
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strengths and weaknesses of dual task TUG
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• Strengths: - Measurement of divided attention - Provides dynamic environment for persons reentering community - Means to measure those with cognitive impairments (decreased attention, memory) • Weaknesses: - TUG Manual: unable to use assistive device
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unilateral leg stance
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• Test performed: - Shoes on, 30 second maximum, no UE support (may start with UE support but do not start time until hands are off surface); commonly used 5 seconds as cut-off score - knee flexed ~90 degrees, thighs should not touch - Test is ended when patient places UE on support surface, NWB foot is placed on floor, WBing foot moves, trunk movement > 45 degrees • Test population: - Males and females without vertigo, neurological, or orthopedic dysfunction of trunk or LE's • Administration Time: - 1-2 minutes • Equipment: - Stopwatch/timer
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scoring the unilateral leg stance
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• > 20 seconds: no risk for falls • < 12 seconds: fall risk • < 5 seconds high risk for injurious falls • May use cut-off score of 5 seconds to predict falls • Unable to stand for 5 seconds had more gait abnormalities, were older, had lower cognitive scores • Significant predictor of injurious falls (but not all falls) • Subjects unable to balance for 5 seconds have 2.1x risk of incurring injurious fall in next 3 yrs
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strengths and weaknesses of unilateral leg stance
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• Strengths: - Requires little training - Evaluates basic balance abilities of low level patients • Weaknesses: - Not sensitive to ambulatory patients with dynamic balance impairments
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functional reach
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• Measures maximal distance one can reach forward beyond arm's length while standing upright and bending forward with shoulder flexed to 90 degrees. • Keep fist closed and measure position of third metacarpal • Test ends when feet move or patient loses balance • Should not provide UE support for opposite hand • Any reaching strategy is allowed; use dominant arm if possible • Allow at least one practice trial
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functional reach: pt population and equipment
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• Test population: - Any patient who is able to stand for at least one minute without support (usually takes more than 1 minute for setup and trials) • Administration Time - 1-2 minutes • Equipment: - yardstick or measuring tape
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scoring the functional reach
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• 6" and = 10": 1.0x more likely to fall
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strengths and weaknesses of functional reach
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• Strengths: - Simple to administer - Functional - Good measure of margin of stability • Weaknesses: - Measures forward balance only; does not assess lateral stability (lateral falls more likely to be injurious, so there is a multidirectional reach test as well) - Patient must be able to flex shoulder to 90 degrees
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functional reach: importance of context
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- ADLs often require individual to exhibit dynamic standing balance while reaching that involves interaction with a target or object - Smoother, more efficient reaching movements and improved postural control when tasks incorporate reaching to an object or reaching when holding an object - Both object-present contexts resulted in greater reach ability than traditional functional reach condition
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gait changes in aging adult
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• Fewer automatic movements (decreased arm swing, decreased trunk movement) • Decreased speed and amplitude of automatic movements • Increased muscle activity in the gait cycle (increased energy expenditure) • Less accuracy and slower movement, especially in the hip • Decreased swing-to-stance ratio • Decreased vertical displacement • Broader stride width (wider BOS) • Increased variability in toe-floor clearance (pt is more likely to trip, difficulty adjusting to obstacles) • Decreased heel-floor angle (decreased foot-to-floor angle during initial contact, decreased DF) • Slower cadence • Decreased rotation at hips and shoulders • More abnormalities in posture • Mild rigidity, particularly in proximal regions • Decreased ROM that affects gait (hip, knee, ankle) Note: gait speed is correlated to mortality - the slower you walk, the more likely you are to be hospitalized and die
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Gait characteristics associated with increased falls:
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- Increased dual stance time - Decreased stride length - Increased stride frequency - Reduced lateral sway - Excessive medial-lateral trunk displacement - Less PF during push off (huge culprit in decreased gait speed and efficiency) - Less hip extension in terminal stance - Increased knee flexion - Decreased trunk rotation - Increased base of support - Sustained UE abduction - Decreased arm swing
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gait speed
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• Typically measured over a short distance to exclude endurance as a factor • It is also important to consider the distance over which gait speed was measured as shorter or longer test distances may produce different results. • 6-meter pathway with a 2-meter acceleration/deceleration zone at each end has been reported most frequently in the literature
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gait speed procedure
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• Equipment required: - Level surface, 10+ meters - Tape measure - Stopwatch (able to record hundredths of seconds) • Measure comfortable gait speed and fast gait speed • Record 2-3 trials • Report results in meters/second • Patients can use an assistive device and can be physically assisted (reflect in documentation) • A subject's ability to increase or decrease walking speed above or below a "comfortable" pace suggests a potential to adapt to varying environments and task demands (e.g., crossing streets; avoiding obstacles).
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distance for gait speed test
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• Speeds measured over both the 8 and 20 foot distances were correlated strongly (r=.933, p<.001) • Measurement of gait speed is feasible in the home care setting for distances of less than 20 feet as long as one step is possible before measurement is begun • The strong correlation that exists for CGS (comfortable gait speed) measures from 8 and 20 feet gives the home care clinician confidence to use the CGS for comparison to normative data and for its predictive value
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psychometrics: gait speed
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- Reliable - Valid - Sensitive - Specific
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predictive validity of gait speed
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able to predict: - Future health status - Functional decline - Hospitalization - Discharge location - Mortality - Quality of life - Falls - Fear of falling - Rehab potential This helps us as clinicians to determine prognosis and needed length of stay
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scoring gait speed
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• Those who walked 1.0 m/s) • For every 0.1 m/s decrease in baseline walking speed: - Poor health status as per SF-36 (short form 36 is a measure of QOL) - Poorer physical functioning - More disabilities - More rehabilitation visits - Increased medical-surgical visits - Longer hospital stays - Higher costs
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reference values for gait speed
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• "Limited household walkers" (assistance required for stair climbing): 0.23 m/s • "Least-limited community walkers" (independent with stair climbing and 2 moderate community activities such as crossing the street): 0.58 m/s • "Community walkers" (independent in all home and community function): 0.80 m/s • Usual adult walking speed: 1.2-1.4 m/s • Speed required to cross street at slow walk signal: 0.71 m/s • Speed required to cross street at fast walk signal: 1.38 m/s • Speed associated with 95% probability of d/c to IP rehab: 0.3 m/s • Speed associated with 100% probability of d/c to home: 1.13 m/s
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gait speed and fall risk
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• Gait speed demonstrate good sensitivity and specificity (80% and 89% respectively) - Using cut off value was 34 m/min (0.57 m/sec) for increased risk for falling
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FGS vs. CGS
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• Difference between comfortable (CGS) and fast gait speeds (FGS): - Healthy older adults should be able to increase speed from 21-56% above a comfortable speed. Reference data: 29-38% difference between CGS and FGS
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MDC and MCID
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• Minimal Detectable Change: - 0.25 -0.29 m/sec for community dwelling elderly (CGS and FGS) • Minimum Clinically Important Difference (MCID) - +/- 0.1 m/s change: meaningful in persons with below normal gait speed - 0.08 m/s for usual speed; 0.10 m/s for fast gait speed for patients s/p hip fracture - 0.18 m/s comfortable gait speed, 0.25 m/s fast gait speed in patients with Parkinson's disease
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meaningful change in gait speed
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• Best initial estimates of small meaningful change are near 0.05 m/sec for gait speed • Substantial meaningful change is closer to 0.10 m/sec
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strengths of gait speed testing
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- Potential to be of more value in demonstrating change as compared to many other functional measures that utilize ordinal data in that it is a continuous variable without floor/ceiling effects - Can be easily measured in the clinic with a stopwatch - Can be utilized for any patient for whom improvement in ambulation is a functional goal - Can be used for any patient population/dx - Highly correlated to all other measures of walking performance, therefore could be considered a good indicator of overall walking performance
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weaknesses of gait speed testing
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• Space required to assess (at least 4 meters) • Does not capture dynamic function of gait or reflect quality of gait • Many different community standards • Use caution when comparing normative data from different authors because the units of measure for gait speed can be easily misinterpreted or confusing. • Gait speed has been reported in multiple units of time and multiple units for distance in both the English and metric systems: ft/sec, m/sec, cm/sec, ft/min, m/min and mph
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how important is gait speed?
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• The "6th Vital Sign" • The "Functional" Vital Sign • Reflects both functional and physiological changes • Slow gait speed has been shown in several different populations to be the single best predictor of functional decline and disability
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Tinetti Performance Oriented Mobility Assessment (POMA)
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• Task-oriented test that measures gait and balance abilities • Test performed: - 9 items (total of 16 points) identified as components of balance - 7 items (total of 12 points) identified as components of gait - Patient may use customary assistive device (however results in decreased score) • Scoring: - Total score of 28 points for both sections - Scored on 3 point ordinal scale of 0-2 (0 = most impairment; 2 = independent) • Administration Time: 10 minutes • Test population: Elderly adults • Equipment: armless chair
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scoring the Tinetti
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• Scoring Interpretation: - 24: low risk for falls • Changes within participants must be at least 5 points before considered a reliable change
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validity of the Tinetti
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• Lower scores are predictive of falls in community-dwelling and institutionalized elderly • Correlates with laboratory measures of postural sway • Scores correlate with Berg Balance Scale (r = 0.91), with stride length (r= 0.62-0.68) and with single limb stance (r= 0.59-0.64) • Four items related to balance (unsteady sitting down, unable to stand in single stance, unsteady turning, unsteady when nudged) and three items related to gait (increased trunk sway, increased path deviation, speed), in combination, predicted falls
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strengths and weaknesses of Tinetti balance
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• Strengths: - Requires little equipment or training - Covers range of item difficulty - Predictive of falls in elderly community dwelling - Can be used with all adults • Weaknesses: - Category description somewhat vague - Lacks validation with neuro populations - Does not detect minute gait deviations
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Berg Balance Scale
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• Created in 1989 • 14-item scale designed to measure balance • Predicts multiple falls in community-dwelling and institutionalized older adults • Graded on 5 point ordinal scale (0-4); max score of 56 • Performance-based measure • Tasks are rated on either ability to perform or time needed to complete • Tasks simulate actions that may be performed during routine daily activities
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Berg: population and equipment
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• Test population: Typically elderly, with/without pathology; limited assessment in younger populations; can be used for patients with sitting or standing balance impairments. • Administration time: 15-20 minutes • Costs: Limited to minimal cost of necessary equipment. • Equipment needed: Stop watch, ruler, chair, and standard-sized step. • Training for tester: It is recommended that the tester read the test instructions. It is suggested that ability to perform the test improves with use. • Format: Task performance
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scoring the Berg
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• Scores > 45: not at risk for falls; 47.9 - Cane outdoors: 46.6-47.6 - Cane indoors: 44-46.5 - Walker full-time: 26.7-39.6
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Berg: score categories for fall risk
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• >= 48: patient is at low risk for falls and is a safe ambulator without assistive device • 46-47: patient is at low risk for falls but may require assistive device • 37-45: patient is at risk for falls but may be a safe ambulator with assistive device • <37: patient is at high risk for falls • Score of 56/56: 10% risk of fall • In 54-56 pt range: 1 point drop = 3-4% increase in falls • In 46-54 pt range: 1 point drop = 6-8% increase in falls - 46 is recommended cut-off point (82.5% sensitivity and 93% specificity) - Score of 50= 10% risk for fall - Score of 38 = 90% risk for fall - One-leg stance was most significant predictor for falls
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reliability of the Berg
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- high reliability - Internal consistency - Inter-rater reliability - Intra-rater reliability - Test-retest reliability
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validity of Berg
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strong correlation with: - Gait speed - Barthel Index - Admission and discharge FIM scores - Postural sway - Tinetti POMA balance subscale - Timed Up and Go (TUG) - Length of stay in inpatient rehab - Discharge disposition after inpatient rehab - Motor Assessment Scale walking subscale
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Berg: Minimum detectable clinical (MDC) change
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- A minimum change of 6 BBS points is necessary to be confident that performance has changed when assessed by 2 different raters. - A change of 7 BBS points was required for minimum detectable clinical (MDC) change in those who required assistance for walking. - 5 points was the MDC for those needing stand by assistance at a 90% confident level change when assessed in a between-rater situation
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Berg: minimum detectable change
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• 5 points for persons with Parkinson's disease • 5 for elderly persons with/without CVA • 3 for persons with hemiparesis • 5 for persons with TBI • Community -dwellers with h/o falls or near falls - 6.5 points
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Berg: responsiveness
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• Those with highest scores at 12-weeks post-stroke had returned to their homes • Berg is more sensitive to detecting change than the Tinetti subscale or gait speed
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specificity and sensitivity of Berg
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• Scores <45/56 predicted falls in elderly with 53% sensitivity and 93% specificity. • Cutoff score ≤49 predicted 77% of people with history of falls and 86% of people who did not have history of falls. - The Berg, used alone, missed at least 23% of subjects who fell, even when using a higher cutoff of 49/56 • Sensitivity is particularly important when using the Berg to predict falls or to determine the need for further physical therapy assessment • Using scores on the Berg, in combination with the patient's history of falls in the past six months predicted future falls with a much better sensitivity of 91% and a specificity of 82% (n=44)
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prediction of falls: Berg
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- The most frequently used cut-off score of 45 was shown to be predictive of risk for recurrent falls in the elderly by a meta-analysis - With a high specificity, one can confidently use the Berg Balance Score to conclude that patients scoring above 45 are less likely to fall than those with lower scores, however based on the poor sensitivity, those scoring below 45 may not necessarily have an increased incidence of falls - Majority of fallers score closer to the cut-off score of 45 rather than at the lower end of the scale (pt is more mobile but still at risk of fall, more confident) • Subject scoring 45 • Score of 40 or lower associated with fall risk of nearly 100%
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strengths of Berg balance
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- Developed for use with a variety of diagnoses - Extensive research in a variety of settings - Identifies impairments that can be used to direct treatment - Better at discriminating those with multiple falls (vs. single fall or injurious fall) - Low cost - Minimal equipment needed - Can be used in many settings
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weakness of Berg
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- Does not assess gait or sensory organization - Time consuming to administer - Floor and ceiling effects - Only one item assessed in sitting - Decreased ability to predict falls in those with ortho or neuro diagnoses - May be difficult to administer to those with cognitive impairment - Cannot use assistive device
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dynamic gait index (DGI)
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• documents a patient's ability to modify gait in response to changing task demands; developed as part of a profile of tests for prediction of falls in older adults • 8 items measured on 4 point ordinal scale (0-3) • test population - adults, typically those with vestibular involvement (not very sensitive for high level patients) - reliable for pts with vestibular dysfunction, MS, Parkinson's, and stroke • equipment - steps with rails, obstacles to step over and around
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DGI items measured
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• level surface gait • change in gait speed • gait with horizontal head turns • gait with vertical head turns • gait and pivot turn • step over obstacle • step around obstacles • steps
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DGI correlates with
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• Berg • use of assistive device • history of imbalance • balance self-perceptions test
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scoring DGI
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• 19/24 or less indicates fall risk in subjects with and without hx of falling • greater than 22/24 indicates safe ambulators • minimum detectable change = 4 points
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strengths of DGI
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• assesses higher level balance skills that may be required for community function • used to document impairment in patients that score well on Berg, Tinetti • implements dual-tasking aspect of balance as well as sensory processing • used frequently in the vestibular population • limited tools and training required to administer • patients can use assistive device • examines mobility on stairs
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weakness of DGI
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• time to administer • need for certain types of equipment • if subject uses assistive device, score automatically falls below cut-off score of 19 • difficult to effectively guard and monitor quality of gait - use DGI for higher level pt or use an aide to help with guarding and administration of test
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Modified DGI
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• four item test - gait on level surface - gait with speed changes - horizontal head turns - vertical head turns • requires no equipment • max score is 12/12 • clinical psychometric properties of 4-item DGI were equivalent or superior to those of 8-item test • higher specificity of 4-item DGI suggests that a closer evaluation of fall risk factors is indicated if an individual has a score of less than 10/12
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functional gait assessment
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• modification of the DGI, more popular than modified DGI • developed to improve reliability of DGI and reduce ceiling effects • 10 item test • scored on 4-level ordinal scale (0-3) • lower scores indicate greater impairment • more specific scoring criteria than DGI • equipment needed: 2 shoeboxes, stopwatch, stairs
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10 items tested: FGA
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• level surface gait • cahnge in gait speed • gait with horizontal head turns • gait with vertical head turns • gait and pivot turn • step over obstacle • gait with narrow base of support (tandem) • gait with eyes closed • ambulating backwards • steps
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FGA scores correlate with
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• Berg • activities-specific balance confidence scale (ABC) • dizziness handicap inventory • perceived symptoms of dizziness • number of falls in previous 6 months • TUG • DGI • gait speed
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scoring FGA
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Normal score based on age • 80 yo: score greater than 19/30 • cut off score of 22/30 or less is effective in classifying fall risk in older adults and predicting unexplained falls in community-dwelling older adults
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predictive validity of FGA
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• correctively identified all of the participants who fell in 6 months following testing as compared to TUG (83%) and DGI (67%) • MDC = .61 for PD • MDC = 4.2 for stroke • MDC = 8 with vestibular disease
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strengths of FGA
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• assesses wider range of clinical gait activities • useful tool to guide intervention (section that pt loses points on = possible intervention) • eliminated ceiling effect of DGI • more sensitive to change • assesses reliance of vestibular and somatosensory input • clearer operational definitions
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weaknesses of FGA
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• requires 20 foot walking path
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Four-square step test (FSST)
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• equipment: stopwatch, 4 canes (laid in cross pattern), gait belt • can use assistive device • evaluates dynamic balance in multiple directions
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FSST procedure
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• instructions: "try to complete the sequence as fast as possible without touching the sticks. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence" • demonstrate • sequence: (square 1 = upper left) CW => 2-3-4-1 then immediately move CCW => 4-3-2-1 • allow a practice trial • two trials; the best time in seconds is taken as the score • repeat a trial if the subject: fails to complete the sequence successfully loses balance, or makes contact with the cane
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scoring FSST
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• subjects who were unable to face forward during the entire sequence and needed to turn before stepping into the next square were still given a score • scoring = time in seconds • stopwatch starts when the first foot contacts the floor in square 1 • > 12 seconds on the FSST - sensitivity of 80%, specificity = 92% for the identification of subjects with 1 or more risk factors for falls • > 15 seconds - sensitivity = 89% - specificity = 85% or non-multiple fallers - positive predictive value = 86% for detecting hx of falls among community-dwelling adults
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six minute walk test
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• measures distance walked in 6 minutes • objective measure of functional exercise capacity • evaluates global and integrated responses of all systems involved during exercise: pulmonary, cardiovascular, systemic and peripheral circulation, neuromuscular units, muscle metabolism
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six minute walk test procedure
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• self-paced • sub-maximal effort, reflective of daily activities • may be more appropriate for frail individuals • assistive devices may be used • may use oxygen • can use different device in subsequent test • use as long a lap as possible to minimize need to complete frequent full turns (30 meters); score is more accurate with longer lap • monitor vitals and RPE before and after test • may stop to rest but cannot sit (or test terminates) • time continues during standing rests
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when to use six minute walk test
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• indicated in assessment of response to medical interventions in those with moderate to severe heart or lung disease • shown to be sensitive to change as a result of rehab interventions targeting walking performance • walking distance is an important indicator of ability to function in community and complete instrumental IADLs • correlates with formal measures of quality of life
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contraindications to six minute walk test
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do not start the test with these findings: • unstable angina in previous month • myocardial infarction in previous month • resting HR >120 • systolic BP > 180 mmHg • diastolic BP > 100 mmHg
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responsiveness of six minute walk test
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• COPD: 70 meter improvement after intervention is necessary to be 95% confident that improvement was significant • CHF: smallest difference that was associated with noticeable difference was 43 meters - more responsive to deterioration than improvement in heart failure sxs • MDC - 29 meters for CVA, 53 m for severe COPD • MDC: improvement > 70 meters after intervention to be 95% confident that improvement was significant
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reference equations for six minute walk test
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• used to calculate norms, determine the predicted 6 MWT distance for adults 40-80 yo performing the test for the first time • men (7.57 * height in cm) - (5.02 * age) - (1.76 * weight in kg) - 309 meters • women (2.11 * height in cm) - (5.78 * age) - (2.29 * weight in kg) + 667 meters
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strengths of 6 MWT
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• ease of administration • can use assistive device • simple, familiar functional task • minimal equipment needed • no floor/ceiling effects • most widely researched test fo aerobic capacity • can be used with multiple populations • results correlate with completion of IADLs
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weaknesses of 6 MWT
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• space requirements • relies on patient motivation
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two minute walk test
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• same procedures as 6 MWT • used for htose with moderate-to-severe cardiopulmonary disease, frail patients • may not adequately stress cardiopulmonary function in those with mild CP disease • can assess exercise capacity as accurately as longer duration walking tests
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400-meter walk test
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• subjects walk 400 m (1312 feet) as quickly as possible • timed test • monitor vital signs • use 20 meter course • found to elicit greater effort (focus on finishing distances and not walking for a set time) • comparison with 6MWT: 70-79 yo achieved 20% greater walking speed
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scoring 400-m walk test
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• adults 60 yo or greater who cannot complete in 5.5 minutes may be at risk for impending functional mobility • for each additional minute required: risk of death increases by 35%
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two-minute step test
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• patient raises each knee to point midway between patella and iliac crest in 2 minutes • take vitals before and after test • count number of times the right knee reaches the required height (one full cycle is right and left) • if patient tires, he/she may slow down or stop and rest but keep timer running • holding on to wall or stable chair is allowed • target population: older adults who cannot perform traditional fitness tests, looks more at endurance than balance
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strengths and weaknesses of two minute step test
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• strengths - simple test - minimal equipment - can use UE support if needed • weaknesses - not suitable with those with moderate or higher degree of fitness
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two minutes step test correlates with
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• moderate positive correlation between the 6MWT and 2MST • moderate negative correlations between the 2MST and TUG - supports close relationship between cardiovascular endurance and functional mobility
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physical performance test
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• 7 or 9 item version • direct observational test that assesses multiple dimensions of physical function (basic and complex activities of daily living) with different levels of difficulty • simple and inexpensive • can be used in various settings • developed and tested in frail and well community-dwelling and institutionalized older adults
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scoring PPT
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• timed assessment: time is related to score of 0-4 - 4 is fastest 20% - 1 is slowest 20% - 0 is those who can't complete tasks • scores range from 0-36 on 9-item test - 0-28 on 7-item test
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PPT items tested
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• writing a sentence • simulated eating • lifting a book and placing it on a shelf • donning/doffing a jacket • picking up a penny from the floor • turning 360 degrees while standing • walking 50 feet 9-item adds: • time to ascend one flight of stairs • number of flights climbed up and down
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benefits of PPT
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• may detect functional limitation before it becomes measurable by traditional self-reported BADL and IADL scales • lower scores on PPT (increased time to complete task) are predictive of institutionalization and death in older people • use for frail and well community-dwelling or institutionalized older adults - to describe and monitor physical performance - to screen for falls, at risk for recurrent falls (cutoff score of 15) - to predict the need for institutionalization and the likelihood of death
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modified PPT
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• similar to PPT, easier and more commonly used • replaces two items testing hand function with tests of balance and leg strength • more emphasis on mobility tasks • assistive device used for walking and stair climbing tasks only
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items tested on modified PPT
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• lifting a book and placing it on a shelf • donning/doffing a jacket • picking up a nickel from the floor • walking 50 feet • time to ascend one flight of stairs • number of flights climbed up and down • chair rise (5x timed) • turning 360 degrees while standing • balance tasks: side by side, semi-tandem, and full tandem (heel to toe)
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Romberg
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stance with feet side by side, narrow base of support
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scoring modified PPT
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• 32-36: not frail • 25-31: mild frailty • 17-24: moderate frailty • <17: dependent
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mini-BESTest
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• shortened version of the balance evaluation systems test (BESTest) • clinical balance assessment tool that aims to target and identify 6 different balance control systems • specific rehabilitation approaches can be designed for different balance deficits
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scoring mini BESTest
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• 14 item test scored on a 3 level ordinal scale • total score = 28 points per test directions • 2 items have right and left assessment in which the lower score is used within the total score • some studies will use both left and right data, for a total score of 32 points
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Elderly mobility scale (EMS)
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• 20 point validated assessment tool for the frail elderly subjects • appropriate for elderly patients in hospital - EMS > 14 = home - EMS 10-14 = borderline in terms of safe mobility and independence with ADLs (home with help) - EMS <10 = high level of help with mobility and ADL • functional, clinically significant, minimal training needed, assessment tool and outcome measure
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weaknesses of elderly mobility scale
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• difficult to use in community environment • ceiling effect for more able patients • not sensitive for patients with issues of poor confidence
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falls efficacy scale-international (FES-I)
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• short, easy to administer tool that measures level of concern about falling during social and physical activities inside and outside the home - whether or not pt does activity - level of concern on 4 point scale (4 = very concerned, 1 = not at all concerned) • good initial screening tool • can't use with those who are unable to communicate effectively • developed to expand on initial FES - includes social activities that may be considered more challenging by active people (looks at participation in ICF model)
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Fullerton advanced balance scale (FAB)
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• test of both static and dynamic balance under varying sensory conditions • measures balance in higher-functioning active older adults - 10 performance based activities - score of 0-40/40 points possible - items score from 0-4 (higher is better) • cutoff score of 25/40 predicts fallers
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sitting balance scale (SBS)
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• new measure to assess sitting balance in frail older adults • items represent functional abilities related to sitting balance (unsupported with eyes closed, turning to look behind while sitting, pick up objects from floor while sitting)
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scoring SBS
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• 0-4 point Likert scale (0 is worst performance, 4 is best)
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patient specific functional scale (PSFS)
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• patients rate their ability to complete and activity on 11-point scale at a level experienced prior to injury or change in functional status - 0 = unable to perform - 10 = able to perform at prior level • patients select a value that best describes their current level of ability to each activity assessed
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MDC for PSFS
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• ranges from 1.4-2.4 for orthopedic conditions • MCID for spinal stenosis = 1.34 points • MCID for UE MSK conditions = 1.2 points • not recommended for MS
