Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests

Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests

CHAPTER 23 Functional Tests Paul E.H Ricard CHAPTER OUTLINE CHAPTER OBJECTIVE Berg Balance Scale Procedure Interpretation of Results Timed “Up and Go” Test Procedure Interpretation of Results Functional Reach Test Procedure Interpretation of Results Tinetti Performance Oriented Mobility Assessment Procedure Interpretation of Results Sit-to-Stand Tests Short Physical Performance Battery Acute Care Index of Function Exercise Testing Six-Minute Walk Test Incremental or Ramp Exercise Tests Conclusion Appendix 23A.  Functional Tests A Performance Oriented Mobility Assessment I B Short Physical Performance Battery To provide a description of functional tests applicable to the inpatient acute care setting, including a description of how to perform each test, the applicable population, and how results may be interpreted PREFERRED PRACTICE PATTERNS These functional tests and outcome measures apply to many body systems For this reason, specific practice patterns are not delineated in this chapter Please refer to Appendix A for a complete list of the preferred practice patterns in order to best delineate the most applicable practice pattern for a given patient Clinicians frequently look for the “best” test for particular functional activities (e.g., balance) To date, however, few if any “gold standard” functional tests have been identified in the literature Several contributing factors are that functional activities have multisystem components and outcomes can vary based on environment, time of day, or prior patient practice The purpose of this chapter is therefore to describe more common functional tests that can objectively measure the functional levels of various patient populations in the acute care setting, and not to compare one test to another Fortunately, the literature on functional tests and measures is consistently expanding Although attention should be paid to the patient population used to validate each test described in this section, a particular functional test still may be useful in patient examination and evaluation in a population not yet specifically studied A clinician should consider all factors when interpreting the outcomes of any clinical test and continue to read current literature to keep abreast with changes in test validation and interpretation   CLINICAL TIP The American Physical Therapy Association (APTA) has online tools to assist with making evidence-based practice decisions, such as “Hooked on Evidence,” and “Open Door.”1 Individual hospital facilities may also have online resources that are updated and reflect evidence-based practice for particular patient populations.2 The functional tests presented in this chapter were selected because of their ease of use, reliable and valid test results, and the appropriate population in the acute care setting Where applicable, interrater (tested by different therapists) and intrarater (retested over time by a single therapist) reliability3 and content,* construct,† and predictive‡ validity will be noted in the respective description of each test.3 Berg Balance Scale The Berg Balance Scale (BBS) is a 56-point scale that evaluates 14 tasks Katherine Berg developed this test to assess the level of function and balance in various patient *Content validity: Degree to which a test actually measures what it was designed for † Construct validity: Degree to which a theoretical construct is measured against the test ‡ Predictive validity: Ability of a test to predict future performance 471 472 CHAPTER 23    Functional Tests TABLE 23-1  Overview of the Berg Balance Scale Population Equipment Time Reliability Validity Elderly patients who have sustained acute cerebrovascular accident and/or are in a rehabilitation setting Ruler Stopwatch Chair Step stool Flat surface 10-20 minutes required to complete test Interrater reliability: ICC = 0.98 rs = 0.88 Intrarater reliability: ICC = 0.98 Internal consistency: Cronbach’s alpha = 0.96 Concurrent validity: Tinetti, r = 0.91 Get up and go, r = −0.76 Predictive validity: 10 inches 6-10 inches 1-6 inches Subject unwilling to reach Not likely times more likely times more likely 28 times more likely Data from Duncan PW, Weiner DK, Chandler J, et al: Functional reach: a new clinical measure of balance, J Gerontol 45:M192-M197, 1990 an assistive device, or both It is important to remember that there are limitations to the population that can participate in this test Elderly patients who are frail, demented, or both, are excluded, because participation in this test may lead to unnecessary injury or falls   CLINICAL TIP If the procedure of the functional reach test is followed correctly, then scores of either the first or second trial or the mean of the first two trials will have no significant difference from that of the mean of all three trials.21 This may be useful for clinicians who not have time to perform three trials or if the patient does not have the endurance to perform three trials Tinetti Performance Oriented Mobility Assessment The Tinetti Performance Oriented Mobility Assessment (POMA) is a performance test of balance and gait maneuvers used during normal daily activities.22 This test has two subscales of balance and gait, as described in Table 23-5 There are 13 maneuvers in the balance portion and maneuvers in the gait portion The balance subscale, the performance oriented assessment of balance (POAB), can be used individually as a separate test of balance Procedure The balance maneuvers are graded on an ordinal scale as normal (2 points), adaptive (1 point), or abnormal (0 points) The gait maneuvers are graded as normal or abnormal, with the exception of a few items A combination of the total points for the balance and gait portions are summed together to determine the final score.12,23 A summary of the Tinetti POMA can be found in Appendix 23A Interpretation of Results A total combined score on the balance and gait subscales of the Tinetti POMA correlates with the patient’s relative risk of falling (Table 23-6).24 This functional test is an effective and objective measure to predict falls in elderly and adult population, as well as assist in determining progress over time in therapy Sit-to-Stand Tests There are several sit-to-stand tests25-35 currently being used in the clinical setting with some supporting evidence These tests have been utilized for the assessment of balance or lower extremity strength and function, with validity not fully established for either use Definitive agreement on the specific procedure for the sit-to-stand test has not been established The procedures for sit-to-stand tests have included timing the patient’s ability to complete or 10 repetitions, counting the number of stands completed by the patient in 30 seconds, and varying the conditions such as the use of arms to stand up A meta-analysis by Bohannon cautiously reports normative values for the 5-repetition sit-to-stand test in elders In persons who are 60 to 69 years of age, mean times to complete this test CHAPTER 23    Functional Tests 475 TABLE 23-5  Overview of the Tinetti Performance Oriented Mobility Assessment Population Equipment Time Reliability Validity Balance portion: adult or geriatric population with a wide variety of diagnoses Chair Stopwatch 10-15 minutes to complete test Interrater reliability: 85% ± 10% agreement balance portion Concurrent validity: Berg, r = 0.91 Predictive validity: ≤18 total score predicts high fall risk Data from King MB, Judge JO, Whipple L et al: Reliability and responsiveness of two physical performance measures examined of a functional training intervention, Phys Ther 80(1):8-16, 2000; Tinetti M: Performance oriented assessment of mobility problems in elderly patients, J Am Geriatr Soc 41:479, 1986; Nakamura DM, Holm MB, Wilson A: Measures of balance and fear of falling in the elderly: a review, Phys Occup Ther Geriatr 15(4):17-32, 1998; Wee JYM, Bagg SD, Palepu A: The Berg Balance Scale as a predictor of length of stay and discharge destination in an acute stroke rehabilitation setting, Arch Phys Med Rehabil 80(4):448-452, 1999; Anemaet W, Moffa-Trotter M: Functional tools for assessing balance and gait impairments, Top Geriatr Rehabil 15(1):66-83, 1999 r, Correlation coefficient TABLE 23-6  Tinetti Results TABLE 23-7  SPPB Score Classifications Score Risk Classification Score 24 High Moderate Low Severe limitations Moderate limitations Mild limitations Minimal limitations 0-3 4-6 7-9 10-12 From Tinetti ME, Williams TF, Mayewski R: Fall index for elderly patients based on number of chronic disabilities, Am J Med 80:429-434, 1986 were 11.4 seconds, whereas persons who were 80 to 89 had mean times of 12.7 seconds.35 Despite some of the inconsistencies reported in the literature about this test, performing a suitable version of the sit-to-stand test during the examination of patients can still yield helpful information, as there is a relationship between the sit-to-stand test with instrumental activities of daily living and balance In addition, a sit-to-stand test can be used to describe the limitations during a functional activity and measure improvement over time Repeating the same procedure within the same clinical facility will help to improve reliability of these results   CLINICAL TIP When documenting a sit-to-stand test, make sure to describe the test characteristics such as seat height, use of arms or no arms, repetitions (5 or 10), and/or time to complete the test, as well as when to stop timing, either at the last stand or sit Short Physical Performance Battery The Short Physical Performance Battery (SPPB) was initially developed in 1994 and involved a cohort of people aged 65 years or older living in the community.36 It has since been validated for larger patient demographics.37-40 The test consists of three subsections: balance, walking speed, and chair stand time (see Appendix 23A) Each section is scored on a 0- to 4-point scale The total score is then compared to predictive values to describe the degree of limitation to mobility (Table 23-7).37,41 The reliability for the SPPB subsections varies, with the balance subscore having the weakest score.37 The standard error From Puthoff ML: Outcome measures in cardiopulmonary physical therapy: short physical performance battery, Phys Ther 19(1):17-22, 2008 of measurement for the SPPB has been calculated to 1.42 points, whereas the minimal clinically important difference (MCID) has been reported to be from 0.54 to 1.34 points.37,42 Although the original authors indicated that a 1-point score change was significant, score improvements closer to would more greatly support actual change.36,37 Acute Care Index of Function The Acute Care Index of Function (ACIF) was developed in 1988 to standardize the assessment of functional status in patients with acute neurologic deficits.43,44 The test is based on patient performance measured in four domains: mental status, bed mobility, transfers, and mobility Higher scores denote better patient performance For the functional aspects of the exam (bed mobility, transfers, and mobility) there are three possible choices for scoring performance: unable, dependent, or independent; point values are 0, 4, and 10, respectively.43 For the mental status portion of the test, only the absence or presence of patient performance is issued point values The sums of all the scores for each of the domains are then averaged.43 Finally, each domain is independently weighted by a multiplier to help detect change in performance and to discriminate between discharge disposition.44 This test possesses good validity (rs = 0.81, p < 0.01) and good interrater reliability (weighted kappa 0.88-0.98), except in the area of “impaired safety awareness” (weighted kappa 0.60), which was due to the more subjective nature of the question.43,44 The test has subsequently been used to describe the functional status of patients with lower extremity orthopedic 476 CHAPTER 23    Functional Tests TABLE 23-8  Overview of the Six-Minute Walk Test Population Equipment Time Reliability Validity Patients with cardiac and/or pulmonary disease and osteoarthritis of the knee Chair Stopwatch Pulse oximeter Portable blood pressure cuff Rate of perceived exertion scale Visual pain analog scale Measuring wheel 10-15 minutes to complete test Test-retest reliability: ICC = 0.93 Responsiveness index validity: 0.6 Data from King MB, Judge JO, Whipple L et al: Reliability and responsiveness of two physical performance measures examined of a functional training intervention, Phys Ther 80(1):8-16, 2000; Woo MA, Moser DK, Stevenson LW et al: Six-minute walk test and heart rate variability: lack of association in advanced stages of heart failure, Am J Crit Care 6(5):348-354, 1997; Kovar PA, Allegrante JP, MacKenzie CR et al: Supervised fitness walking in patients with osteoarthritis of the knee: a randomized controlled trial, Ann Intern Med 116:529-534, 1992; Guyatt GH, Sullivan MJ, Thompson PJ et al: The 6-minute walk: new measure of exercise capacity in patients with chronic heart failure, Can Med Assoc J 132:919-923, 1985; McGavin CR, Gupta SP, McHardy GJR: Twelve-minute walking test for assessing disability in chronic bronchitis, BMJ 1:822, 1976; Butland RJ, Pang J, Gross ER et al: Two-, six-, and twelve-minute walking tests in respiratory disease, BMJ 284:1607, 1982 ICC, Intraclass correlation coefficient health conditions.45 To date the minimal clinically detectable change score for this test has not yet been calculated.44   CLINICAL TIP Clinicians may want to consider using the ACIF to help make appropriate discharge recommendations, thereby reducing readmissions and helping patients get to the appropriate level of care provide similar measures of exercise tolerance and therefore was adopted by clinicians for its convenience (Table 23-8).49,50 Although this test is considered a time-limited, submaximal exercise test, it may cause patients with advanced heart disease and end-stage lung disease to approach their maximal work effort.48,51 In patients with advanced heart disease, regression equations have been used to predict peak oxygen uptake values (peak VO2).52   CLINICAL TIP Exercise Testing Although maximal exercise testing with evaluation of exhaled gases is considered the gold standard to evaluate a person’s cardiopulmonary capacity, maximal testing is not commonly performed in the acute care setting Submaximal tests, however, can be used safely to help a clinician with differential diagnosis of the etiology of a patient’s fatigue or shortness or breath (SOB), describing a person’s current aerobic capacity, estimating maximal capacity, or prescribing exercise, or as an outcome assessment.46 Despite the submaximal design, these exercise tests may result in a symptom-limited test that, in some patient populations, approaches a maximal effort, particularly in a very deconditioned patient Although not within the scope of this test, exercise prescription based on actual effort during an exercise test can be more accurate than exercise prescribed on heart rate or perceived effort alone The clinician is referred to the text American College of Sports Medicine Guideline for Exercise Testing and Prescription47 for further details on exercise testing and prescription Six-Minute Walk Test The 6-minute walk test (6MWT) is a time-limited measure of functional capacity in which a patient walks as far as possible on a course for minutes.48 This test evolved from the 12-minute walk test, originally designed to assess disability levels in patients with chronic bronchitis.49 The 6MWT was found to There is also a 2-minute walk test that has been used for the functional capacity assessment of patients after cardiac surgery, those patients with chronic obstructive pulmonary disease, and for persons after amputation.53-55 Although the 2-minute walk test may lack normative data, it may be considered in places with lack of space such as in the home setting Procedure Premeasure the course in a flat, straight, enclosed corridor, approximately 30 meters (100 feet) in length to minimize turns.56 Patients should use their usual walking aid and footwear and have rested in a chair for 10 minutes before the start of the test For standardization of the test, patients are encouraged to carry their own oxygen source, are asked not to talk to anyone during the test, and are not followed by the clinician during the test Standardized encouragement, or lack thereof, has been shown to influence the results of the walking test.57 Standard encouragement, if used, should be said with a normal tone and identify only the time left (i.e., “You have minutes left You are doing a good job”).57 The standardized initial instructions to the patient, according to the American Thoracic Society (ATS), can be found in Box 23-2 Although following ATS guidelines is preferred, it is recommended that the performance of the 6MWT in the acute setting be altered to maximize patient safety in recognition of the larger potential for medical or physical variability in this patient population During the test, it is recommended that the CHAPTER 23    Functional Tests 477 BOX 23-2  Standardized Instructions for the 6-Minute Walk Test TABLE 23-9  Prediction Equations for 6-Minute Walk Test Distance “The object of this test is to walk as far as possible for minutes You will walk back and forth in this hallway Six minutes is a long time to walk, so you will be exerting yourself You will probably get out of breath or become exhausted You are permitted to slow down, to stop, and to rest as necessary You may lean against the wall while resting, but resume walking as soon as you are able You will be walking back and forth around the cones You should pivot briskly around the cones and continue back the other way without hesitation Now I’m going to show you Please watch the way I turn without hesitation.” Demonstrate by walking one lap yourself Walk and pivot around a cone briskly “Are you ready to that? I am going to use this counter to keep track of the number of laps you complete I will click it each time you turn around at this starting line Remember that the object is to walk AS FAR AS POSSIBLE for minutes, but don’t run or jog Start now or whenever you are ready.” Author Equation Enright, 199863 Healthy men between 40 and 80 years of age Expected MWD = (7.57 × height in cm) − (5.02 × age) − (1.76 × weight in kg) − 309 meters Healthy women between 40 and 80 years of age Expected MWD = (2.11 × height in cm) − (2.29 × weight in kg) − (5.78 × age) + 667 meters Age range = 50 to 85 years of age Expected MWD = 218 + (5.14 × height in cm − 5.32 × age) − (1.80 × weight in kg + (51.31 × gender*) *Male = 1, female = Age range = 22 to 79 years of age Expected MWD = 868.8 − (2.99 × age) − (74.7 × gender*) *Male = 0, female = Age range greater than or equal to 65 years of age Healthy women: Expected MWD = 493 + (2.2 × height in cm) − (0.93 × weight in kg) − (5.3 × age) Healthy men: Add 17 meters to results of above equation From American Thoracic Society Board of Directors: ATS Statement: Guidelines for the six-minute walk test, Am J Resp Crit Care Med 166:111-117, 2002 therapist walk slightly behind the patient to allow close monitoring of heart rate (HR) and saturation of peripheral oxygen (Spo2), but also to guard the patient if necessary Because of the potential for variations in vital signs from baseline values, HR, Spo2, respiratory rate (RR), rate of perceived exertion (RPE), and rate of perceived dyspnea (RPD) should be monitored every minutes and for at least minutes after the test has terminated to assess patient recovery If the patient is unable to complete the full minutes, then the distance covered on termination is measured along with establishing the reason for termination by the patient   CLINICAL TIP Although the 6MWT was initially performed in a 30-meter hallway, studies have attempted to validate the test in other formats such as on a treadmill for space, safety, and monitoring issues frequently found in the acute care patient population The conclusions reached in the literature thus far are currently mixed regarding a 6MWT performed on a treadmill.58-61 It is important to consider the validity and patient safety when choosing how to perform the 6MWT Interpretation of Results Many studies have examined the usefulness of the 6-minute walk test in specific populations and have found it to be effective in predicting oxygen consumption and determining the efficacy of surgical intervention on functional mobility.49,50,52,62 A number of regression equations have been developed to predict 6-minute walk test distance in healthy adults (Table 23-9).63-66 These prediction equations can be used by physical therapists as a means of determining the level of deficits in their patients and ultimately in prescribing exercise and measuring progress Troosters, 199964 Gibbons, 200165 Enright, 200366 MWD, 6-Minute walk distance in patients’ functional activity tolerance A minimal change in walking distance of 54 to 70 meters has been shown to be clinically significant for improving functional status for patients with chronic obstructive pulmonary disease (COPD).67 For frail, elderly patients with chronic heart failure the 6-minute walk test is a responsive measure of cardiac status.68 Incremental or Ramp Exercise Tests In the case of persons who are not sufficiently challenged during time-based exercise testing, an incremental or ramp exercise test should be considered Most incremental exercise test protocols described in the literature, such as the Bruce Protocol, may be too challenging even at the initial stage for the inpatient population Modified incremental tests however, such as the Modified Balke-Ware, should be considered for special patient populations The Modified Balke-Ware consists of nine stages at a constant velocity of 5.6 kph (approximately 3.47 mph) while increasing the elevation from 6% to 22% in 2% increments each minute.69 Modified tests, such as the Modified Balke-Ware, have lower initial workloads, thus reducing the floor effect while efficiently increasing the workload in a short period of time to both engage the aerobic pathways and reduce the impact of a ventilation impairment to performance For example, most persons with cystic fibrosis admitted to the hospital for an exacerbation of their illness may not be challenged sufficiently by the 6MWT but are significantly challenged during the Modified Balke-Ware treadmill test 478 CHAPTER 23    Functional Tests Conclusion Functional tests are quick and useful tools by which a clinician can objectively measure change in a patient’s performance over time The clinician is encouraged to review recent literature as the body of evidence for established functional tests grows and new tests are described With the increasing push to provide efficient and effective care across health care, physical therapists need to continue to objectively document how we positively affect patient performance while reducing the overall cost of care References American Physical Therapy Association: Evidence and research http://www.apta.org/EvidenceResearch Accessed February 16, 2012 Brigham & Women’s Hospital Department of Rehabilitation Services: Physical therapy standards http:// www.brighamandwomens.org/Patients_Visitors/pcs/ rehabilitationservices/StandardsofCare.aspx?sub=1 Accessed February 16, 2012 Portney LG, Watkins MP, editors: Foundations of clinical research applications to practice, Norwalk, CT, 1993, Appleton & Lange, pp 680, 689 Wee JYM, Bagg SD, Palepu A: The Berg Balance Scale as a predictor of length of stay and discharge destination in an acute stroke rehabilitation setting, Arch Phys Med Rehabil 80(4):448452, 1999 Cattaneo D, Regola A, Meotti M: Validity of six balance disorders scales in persons with multiple sclerosis, Disabil Rehabil 28(12):789-795, 2006 Chou CY, Chien CW, Hsueh IP et al: Developing a short form of the Berg Balance Scale for people with stroke, Phys Ther 86:195-204, 2006 Nakamura DM, Holm MB, Wilson A: Measures of balance and fear of falling in the elderly: a review, Phys Occup Ther Geriatr 15(4):17-32, 1998 Berg KO, Wood-Dauphinee SL, Williams JI et al: Measuring balance in the elderly: validation of an instrument, Can J Public Health 83:S7-S11, 1992 Berg K, Wood-Dauphinee S, Williams JI et al: Measuring Balance in the elderly: preliminary development of an instrument, Physiother Can 41:304, 1989 10 Muir SW, Berg K, Chesworth B et al: Use of the Berg Balance Score for predicting multiple falls in community-dwelling elderly people: a prospective study, Phys Ther 88(4);449-459, 2008 11 Conradsson M, Lundin-Olsson L, Lindelof N et al: Berg Balance Scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities, Phys Ther 87:1155-1163, 2007 12 Whitney S, Poole J, Cass S: A review of balance instruments for older adults, Am J Occup Ther 52(8):666-671, 1998 13 Posiadlo D, Richardson S: The timed “up and go”: a test of basic functional mobility for frail elderly persons, J Am Geriatr Soc 39:142-148, 1991 14 Thompson M, Medley A: performance of community dwelling elderly on the timed up and go test, Phys Occup Ther Geriatr 13(3):17-30, 1995 15 White J: Functional assessment tools-use them! Phys Ther Case Rep 3(4):188-189, 2000 16 Large J, Gan N, Basic D et al: Using the timed up and go test to stratify elderly inpatients at risk of falls, Clin Rehabil 20:421-428, 2006 17 Kristensen MT, Foss NB, Kehlet H: Timed “up & go” test as a predictor of falls within months after hip fracture surgery, Phys Ther 87:24-30, 2007 18 Nordin E, Rosendahl E, Lundin-Olsson L: Timed “up & go” test: reliability in older people dependent in activities of daily living-focus on cognitive state, Phys Ther 86(5):646-655, 2006 19 Duncan PW, Weiner DK, Chandler J et al: Functional reach: a new clinical measure of balance, J Gerontol 45:M192-M197, 1990 20 Newton R: Reach in four directions as a measure of stability in older adults, Phys Ther 76:S23, 1996 21 Billek-Sawbney B, Gay J: The functional reach test; are trials necessary? Top Geriatr Rehabil 21(2):144-148, 2005 22 Umphred DA, editor: Neurological rehabilitation, ed 3, St Louis, 1995, Mosby, pp 808-809, 812, 816-817, 822-823, 828-829 23 Tinetti ME: Performance oriented assessment of mobility problems in elderly patients, J Am Geriatr Soc 41:479, 1986 24 Tinetti ME, Williams TF, Mayewski R: Fall index for elderly patients based on number of chronic disabilities, Am J Med 80:429-434, 1986 25 Csuka M, McCarty DJ: Simple method for measurement of lower extremity muscle strength, Am J Med 78:77-81, 1985 26 Lord SR, Murray SM, Chapman K et al: Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people, J Am Geriatr Soc 57:M539-M543, 2002 27 Bohannon RW: Alternatives for measuring knee extension strength of the elderly at home, Clin Rehabil 12:434-440, 1998 28 Bohannon RW, Smith J, Hull D et al: Deficits in lower extremity muscle and gait performance among renal transplant candidates, Arch Phys Med Rehabil 76:547-551, 1995 29 Cheng PT, Liaw MY, Wong MK et al: The sit-to-stand movement in stroke patients and its correlation with falling, Arch Phys Med Rehabil 79:1043-1046, 1998 30 Hughes C, Osman C, Woods AK: Relationship among performance on stair ambulation, functional reach, and Timed Up and Go tests in older adults, Issues Aging 21:18-22, 1998 31 Newcomer KL, Krug HE, Mahowald ML: Validity and reliability of the timed-stands test for patients with rheumatoid arthritis and other chronic diseases, J Rheumatol 20:21-27, 1993 32 Bohannon RW, Shove ME, Barreca SR et al: Five-repetition sit-to-stand performance by community-dwelling adults: a preliminary investigation of times, determinants, and relationship with self-reported physical performance, Isokinet Exerc Sci 15(2):77-81, 2007 33 Judge JO, Schechtman K, Cress E: The relationship between physical performance measures and independence in instrumental activities of daily living, J Am Geriatr Soc 44:1332-1341, 1996 34 Whitney SL, Wristley DM, Marchietti GF et al: Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the five-times-sit-to-stand test, Phys Ther 85(10):1034-1045, 2005 35 Bohannon RW: Reference values for the five-repetition sit-tostand test: a descriptive meta-analysis of data from elders, Percept Motor Skills 103:215-222, 2006 36 Guralnik JM, Simonsick EM, Ferrucci L et al: A short physical performance batter assessing lower extremity function: associated with self-reported disability and prediction of mortality and nursing home admission, J Gerontol 49:M85-M94, 1994 37 Puthoff ML: Research corner outcome measures in cardiopulmonary physical therapy: short physical performance battery, Phys Ther 19(1):17-22, 2008 38 Ostir GV, Volpato S, Fried LP et al: Reliability and sensitivity to change assessed for a summary measure of lower body function: results from the Women’s Health and Aging Study, Clin Epidemiol 55:916-921, 2002 39 Wolinsky FD, Miller TR, Malmstrom TK et al: Four year lower extremity disability trajectories among African American men and women, J Gerontol A Biol Sci Med Sci 62:525-530, 2007 40 Ostir CV, Markides KS, Black SA et al: Lower body functioning as a predictor of subsequent disability among older Mexican Americans, J Gerontol A Biol Sci Med Sci 53:M491-M495, 1998 41 Guralnik JM, Ferrucci L, Simonsick EM et al: Lower-extremity function in persons over the age of 70 years as a predictor of subsequent disability, N Engl J Med 332:556-561, 1995 42 Perera S, Mody SH, Woodman RC et al: Meaningful change and responsiveness in common physical performance measures in older adults, Am Geriatr Soc 54:743-749, 2006 43 Roach KE, Van Dillen LR: Reliability and validity of the Acute Care Index of Function for patients with neurologic impairment, Phys Ther 68(7):1098-1101, 1988 44 Scherer SA, Hammerick AS: Research corner outcomes in cardiopulmonary physical therapy: acute care index of function, Cardiopulm Phys Ther J 19(3):94-97, 2008 45 Roach KE, Ally D, Finnerty B et al: The relationship between duration of physical therapy services in the acute care setting and change in functional status in patients with lower-extremity orthopedic problems, Phys Ther 78(1):19-24, 1998 46 Balady GJ, Arena R, Sietsema K et al: Clinician’s guide to cardiopulmonary exercise testing in adults: a scientific statement from the American Heart Association, Circulation 122:191-225, 2010 47 American College of Sports Medicine: ACSM’s guidelines for exercise testing and prescription, ed 8, Philadelphia, 2010, Lippincott Williams & Wilkins 48 Guyatt GH, Sullivan MJ, Thompson PJ et al: The 6-minute walk: new measure of exercise capacity in patients with chronic heart failure, Can Med Assoc J 132:919-923, 1985 49 McGavin CR, Gupta SP, McHardy GJR: Twelve-minute walking test for assessing disability in chronic bronchitis, BMJ 1:822, 1976 50 Butland RJ, Pang J, Gross ER et al: Two-, six-, and twelveminute walking tests in respiratory disease, BMJ 284:1607, 1982 51 Olsson LG, Swedberg K, Clark AL et al: Six minute corridor walk test as an outcome measure for the assessment of treatment in randomized, blinded intervention trials of chronic heart failure: a systematic review, Eur Heart J 26(8):778-793, 2005 52 Cahalin LP, Mathier MA, Semigran MJ et al: The six-minute walk test predicts peak oxygen uptake and survival in patients with advanced heart failure, Chest 110:310, 1996 CHAPTER 23    Functional Tests 479 53 Leung ASY, Chan KK, Sykes K et al: Reliability, validity, and responsiveness of a 2-minute walk test to assess exercise capacity of COPD patients, Chest 130(1):119-125, 2006 54 Brooks D, Parsons J, Tran D et al: The two-minute walk test as a measure of functional capacity in cardiac surgery patients, Arch Phys Med Rehabil 85(9):1525-1530, 2004 55 Brooks D, Hunter JP, Parsons J et al: Reliability of the two-minute walk test in individuals with transtibial amputation, Arch Phys Med Rehabil 83(11):1562-1565, 2002 56 American Thoracic Society Board of Directors: ATS statement: Guidelines for the six-minute walk test, Am J Respir Crit Care Med 166:111-117, 2002 57 Guyatt GH, Pugsley SO, Sullivan MJ et al: Effect of encouragement on walking test performance, Thorax 39:818822, 1994 58 Stevens D, Elpern E, Sharma K et al: Comparison of hallway and treadmill six-minute walk tests, Am J Respir Crit Care Med 160(5 Pt 1):1540-1543, 1999 59 Camargo VM, Carmo dos Santos Martins B, Jardim C et al: Validation of a treadmill six-minute walk test protocol for the evaluation of patients with pulmonary arterial hypertension, J Bras Pneumol 35(5):423-430, 2009 60 de Almeida FG, Victor EG, Rizzo JA: Hallway versus treadmill 6-minute-walk tests in patients with chronic obstructive pulmonary disease, Respir Care 54(12):1712-1716, 2009 61 Olper L, Cervi P, De Santi F et al: Validation of the treadmill six-minute walk test in people following cardiac surgery, Phys Ther 91(4):566-576, 2011 62 Laupacis A, Bourne R, Rorabeck C et al: The effect of elective total hip replacement on health-related quality of life, J Bone Joint Surg [Am] 75:1619, 1993 63 Enright PL, Sherrill DL: Reference equations for the six minute walk in healthy adults, Am J Respir Crit Care Med 158:13841387, 1998 64 Troosters T, Gosselink R, Decramer M: Six minute walking distance in healthy elderly subjects, Eur Respir J 14:270-274, 1999 65 Gibbons WJ, Fruchter N, Sloan S et al: Reference values for a multiple repetition 6-minute walk test in healthy adults older than 20 years, J Cardiopulm Rehabil 21:87-93, 2001 66 Enright PL, McBurnie MA, Bittner V et al: The minute walk test: a quick measure of functional status in elderly adults, Chest 123:387-398, 2003 67 Redelmeier DA, Bayoumi AM, Goldstein RS et al: Interpreting small differences in functional status: the six minute walk test in chronic lung patients, Am J Respir Crit Care Med 155:12781282, 1997 68 O’Keefe ST, Lye M, Donnellan C et al: Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients, Heart 80:377-382, 1998 69 Marinov B, Kostianev S, Turnovska T: Submaximal treadmill test for screening of physical capacity in pediatric age group, Pediatria 15(2):38-41, 2000 480 CHAPTER 23    Functional Tests APPENDIX 23A.  FUNCTIONAL TESTS A.  Performance Oriented Mobility Assessment I Element Scoring Balance   1.  Sitting balance Instructions: Subject is seated in hard, armless chair The following maneuvers are tested = Steady, stable = Holds onto chair to keep upright = Leans, slides down in chair = Able to rise in a single movement without use of arms = Uses arms (on chair or walking aid) to pull or push up; and/or moves forward in chair before attempting to arise = Multiple attempts required or unable without human assistance = Steady without holding onto walking aid or other object for support = Steady, but uses walking aid or other object for support = Any sign of unsteadiness = Steady, able to stand with feet together without holding object for support = Steady, but cannot put feet together = Any sign of unsteadiness regardless of stance or holds onto object = Steady without holding onto any object with feet together = Steady with feet apart = Any sign of unsteadiness or needs to hold onto an object = No grabbing or staggering; no need to hold onto any objects; steps are continuous (turn is a flowing movement) = Steps are discontinuous (patient puts one foot completely on floor before raising other foot) = Any sign of unsteadiness or holds onto an object = Steady, able to withstand pressure = Needs to move feet, but able to maintain balance = Begins to fall, or examiner has to help maintain balance   2.  Arising from chair   3.  Immediate standing balance (first seconds)   4.  Standing balance   5.  Balance with eyes closed (with feet as close together as possible)   6.  Turning balance (360 degrees)   7.  Nudge on sternum (patient standing with feet as close together as possible, examiner pushes with light even pressure over sternum three times)   8.  Neck turning (patient asked to turn to side and look up while standing with feet as close together as possible)   9.  One leg standing balance 10.  Back extension (ask patient to lean back as far as possible, without holding onto object) 11.  Reaching up (have patient attempt to remove an object from a shelf high enough to require stretching or standing on toes) 12.  Bending down (patient is asked to pick up small objects [e.g., a pen] from the floor) 13.  Sitting down = Able to turn head at least halfway side to side and able to bend head back to look at ceiling; no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain = Decreased ability to turn side to side or to extend neck, but no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain = Any sign of unsteadiness or symptoms when turning head or extending neck = Able to stand on one leg for seconds without holding object for support = Some staggering, swaying, or moves foot slightly = Unable = Good extension without holding object or staggering = Tries to extend, but decreased range of motion (compared with other patients of same age) or needs to hold object to attempt extension = Will not attempt or no extension seen or staggers = Able to take down object without needing to hold onto other object for support and without becoming unsteady = Able to get object but needs to steady self by holding onto something for support = Unable or unsteady = Able to bend down and pick up the object and able to get up easily in a single attempt without needing to pull self up with arms = Able to get object and get upright in a single attempt but needs to pull self up with arms or hold onto something for support = Unable to bend down or unable to get upright after bending down, or takes multiple attempts to become upright = Able to sit down in one smooth movement = Needs to use arms to guide self into chair, or movement is not smooth = Falls into chair, misjudges distances (lands off center) CHAPTER 23    Functional Tests 481 A.  Performance Oriented Mobility Assessment I—cont’d Element Scoring Gait Instructions: Subject stands with examiner, then walks 15 ft down a premeasured hallway, turns, and walks back to starting point Subject should use customary walking aid as necessary = Begins walking immediately without observable hesitation; initiation of gait is single, smooth motion = Hesitates; multiple attempts; initiation of gait is not a smooth motion   1.  Initiation of gait (patient is asked to begin walking down hallway)   2.  Step height (begin observing after first few steps; observe one foot, then the other; observe from side)   3.  Step length (observe distance between toe of stance foot and heel of swing foot; observe from side; not judge first few or last few steps; observe one side at a time)   4.  Step symmetry (observe the middle part of walking, not the first or last steps; observe from side; observe distance between heel of each swing foot and toe of each stance foot)   5.  Step continuity   6.  Path deviation (observe from behind; observe one foot over several strides; observe in relation to line on floor [e.g., tiles] if possible; difficult to assess if patient uses a walker)   7.  Trunk stability (observe from behind; side to side motion of trunk may be a normal gait pattern, need to differentiate this from instability)   8.  Walk stance (observe from behind)   9.  Turning while walking = Swing foot completely clears floor but by no more than to inches = Swing foot is not completely raised off floor (may hear scraping) or is raised too high (>2 inches) = At least the length of individual’s foot between the stance toe and swing heel (step length usually longer, but foot length provides basis for observation) = Step length less than the individual’s foot = Step length same or nearly same on both sides for most step cycles = Step length varies between sides or patient advances with same foot with every step = Begins raising heel of one foot (toe off) as heel of other foot touches the floor (heel strike); no breaks or stops in stride; step lengths equal over most cycles = Places entire foot (heel and toe) on floor before beginning to raise other foot; or stops completely between steps; or step length varies over cycles = Foot follows close to straight line as patient advances = Foot deviates from side to side or toward one direction, or patient uses a walking aid = Marked deviation from straight line = Trunk does not sway; knees or back are not flexed; arms are not abducted in effort to maintain stability = No sway but flexion of knees or back or spreads arms out while walking = Any of the preceding features are present = Feet should almost touch as one passes the other = Feet apart with stepping = No staggering or use of a walking aid; turning is continuous with walking; and steps are continuous while turning = Steps are discontinuous but no staggering, or uses walking aid = Staggers; unsteady; stops before initiating turn Data from Tinetti ME: Performance-oriented assessment of mobility problems in elderly patients, J Am Geriatr Soc 34:119-126, 1986; Tinetti ME, Williams TF, Mayewski R: Fall index for elderly patients based on number of chronic disabilities, Am J Med 80:429-434, 1986 482 CHAPTER 23    Functional Tests B.  Short Physical Performance Battery Directions for the Short Physical Performance Battery Balance Subscale Side by side – Patient will stand with feet together, side by side for up to 10 seconds Patient may use arms, bend knees or move body to maintain balance, but may not move feet First demonstrate the position to the patient Then stand next to the patient to help him or her into the side-by-side position Supply just enough support to the patient’s arm to prevent loss of balance When the patient has his or her feet together and is ready, let go and begin timing as you say, “Ready, begin.” Stop the stopwatch and say “stop” after 10 seconds or when the patient steps out of position or grabs your arm If patient is unable to hold the position for 10 seconds, record results, and go to the next subscale If patient can maintain for 10 seconds, go onto the next posture Semi-tandem – Patient will stand with feet together, the toes of one foot aligned with the midpoint of the other foot Follow the same directions as in the side by side stand If patient is unable to hold the position for 10 seconds, record results, and go to the next subscale If patient can maintain for 10 seconds, go onto the next posture Tandem – Patient will stand with one foot in front of the other with the heel of the front foot in contact with the toes of the back foot Follow the same directions as in the side by side stand Record results, and go to the next subscale Four Meter Walk Subscale Mark off a four meter (13.12 foot) course with two cones or pieces of tape The patient will start at one end of the course Instruct the patient to walk at their normal pace as if they are walking down the street or going to the store The patient will begin walking on the command “begin.” Patient should walk past the other end of the course and not slow down until outside the four meter marker Start on “begin” and stop timing when one of the patient’s feet is all the way across the four meter marker Walk behind and to the side of the patient Patients are allowed to use a cane or any other walking device they normally use Patient should repeat this walk twice, with the best time used for scoring Sit to Stand Subscale Single Chair Stand – The patient should be seated in a standard height chair The patient should fold arms across chest and sit so feet are resting on the floor Ask the patient to stand while keeping arms folded across the chest If patient cannot stand without using arms, the test is over Record results on the score sheet If patient can complete the stand, go onto the five chair stands Five Chair Stands – Instruct patient that you will now time how long it takes to complete five chair stands Patient starts with arms folded across chest and sits so feet are resting on the floor On the command “begin,” patient should stand up straight as quickly as possible, sit back down and repeat for a total of five times Count out loud as the patient completes each stand Start timing on “begin” and stop the stopwatch when the patient has straightened up completely for the fifth time Stop the test if the patient becomes tired, short of breath, uses arms, or one minute has passed without all five stands completed Directions adapted from Guralnik JM, Ferrucci L, Pieper CF, et al: Lower extremity function and subsequent disability: consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery, J Gerontol A Biol Sci Med Sci 55:M221-231, 2000 CHAPTER 23    Functional Tests B.  Short Physical Performance Battery—cont’d Score Sheet for the Short Physical Performance Battery Patient Name: _ Date: Balance Score Unable to hold side by side stance for > seconds Side by side stance for 10 sec, but unable to hold semitandem for 10 sec Semitandem for 10 sec, unable to hold full tandem for > sec Full tandem for 3-9 sec Full tandem for 10 sec points point points points points Walk Score (4 Meter or 13.12 feet) Unable to walk If time is more than 8.70 seconds If time is 6.21 to 8.70 seconds If time is 4.82 to 6.20 seconds If time is less than 4.82 seconds points point points points points Time 1: Time 2: Chair Stand Score If the participant was unable to complete the chair stands If chair stand time is 16.7 seconds or more If chair stand time is 13.7 to 16.6 seconds If chair stand time is 11.2 to 13.6 seconds If chair stand time is 11.1 seconds or less Time: points point points points points Total Score Converted Gait Velocity (13.12/time in seconds)*0.68 = mph Date: Balance Score Unable to hold side by side stance for > seconds Side by side stance for 10 sec, but unable to hold semitandem for 10 sec Semitandem for 10 sec, unable to hold full tandem for > sec Full tandem for 3-9 sec Full tandem for 10 sec points point points points points Walk Score (4 Meter or 13.12 feet) Unable to walk If time is more than 8.70 seconds If time is 6.21 to 8.70 seconds If time is 4.82 to 6.20 seconds If time is less than 4.82 seconds points point points points points Time 1: Time 2: Chair Stand Score If the participant was unable to complete the chair stands If chair stand time is 16.7 seconds or more If chair stand time is 13.7 to 16.6 seconds If chair stand time is 11.2 to 13.6 seconds If chair stand time is 11.1 seconds or less Time: points point points points points Total Score Converted Gait Velocity (13.12/time in seconds)*0.68 = mph From Puthoff ML: Outcome measures in cardiopulmonary physical therapy: short physical performance battery, Cardiopulm Phys Ther J 19(1):17-22, 2008 483 ... short physical performance battery, J Gerontol A Biol Sci Med Sci 55:M221 -231 , 2000 CHAPTER 23? ??   Functional Tests B.  Short Physical Performance Battery—cont’d Score Sheet for the Short Physical. .. treadmill test for screening of physical capacity in pediatric age group, Pediatria 15(2):38-41, 2000 480 CHAPTER 23? ??   Functional Tests APPENDIX 23A.  FUNCTIONAL TESTS A.  Performance Oriented... index for elderly patients based on number of chronic disabilities, Am J Med 80:429-434, 1986 482 CHAPTER 23? ??   Functional Tests B.  Short Physical Performance Battery Directions for the Short Physical