Rodney Peterson, MS; Kyle Menkosky, BS; Robert Scales, PhD – Division of Cardiology – Mayo Clinic Arizona

Abstract

A Practical Measure of Balance, Gait and Muscular Power in Older Adults: The Short Physical Performance Battery

©2016 Mayo Foundation for Medical Education and Research

Optimal balance, gait and muscular power are desirable components of physical function in older adults. The Short Physical Performance Battery (SPPB) is a validated office-based assessment of lower extremity functional status that may enhance measures of self-report. This test battery examines an individual’s ability to stand balanced with the feet positioned together side-by-side, in the semi-tandem or tandem stance. Gait is measured with the time to walk a distance of 8 feet and muscular power is assessed with the time to rise from a chair and return to a seated position over 5 repetitions. Subjects are graded for each category of function on an ordinal 0-4 scale with a maximum possible score of 12. In a study of >5,000 adults (>70 years) SPPB performance was a significant predictor of disability, nursing home admission and mortality. The SPPB is a safe and practical assessment physical function that is appropriate for older and frail adults attending cardiac and pulmonary rehabilitation.

Learning Objectives

• Understand the rationale for the assessment of physical function in older adults.

• Describe the testing instructions and grading system for the SPPB.

• Identify a process to measure physical function in cardiac and pulmonary rehabilitation.

Background

With the increased aging population, cardiac and pulmonary rehabilitation is starting to recognize the importance of improved physical function (the ability to perform physical tasks necessary for activities of daily life) in older adults.1-3 There are a variety of performance evaluations that can be used to assess physical function in different populations.4-7 The quantification of balance, gait and muscular power are important components of physical function in older and frail patients. The SPPB is validated office-based assessment that can be easily administered to measure these characteristics in a clinical setting.

Conclusions

Frailty is prevalent among older adults with cardiovascular and pulmonary disease, but often goes unrecognized. This places these individuals at a higher risk of falling, disability, poor clinical outcomes, hospitalization and mortality with an associated lower health related quality of life.21 Early detection of low physical function may identify an opportunity to incorporate interventions to improve clinical outcomes in these individuals. The SPPB is a safe and practical evaluation of physical function that is appropriate for older adults. Testing may identify frailty and that may result in strategic exercise to improve clinical outcomes in patients attending cardiac and pulmonary rehabilitation.

References

1. Mkacher W, Kekki M, et al. 2015, Effect of 6 months of balance training during pulmonary rehabilitation in patients with COPD. J of Card Rehab and Prev, pp. 35:207-213.

2. Haddad M, John M, et al. 2016, Role of the timed up and go test in patients with chronic obstructive pulmonary disease. J of Cardio Rehab and Prev, pp. 36:49-55.

3. Audelin M, Savage P, Ades P. 2008, Exercise-Based cardiac rehab for very old patients (>75 Years). J of Card Rehab and Prev, pp. 28:163-173.

4. Rikli R, Jones J. 1999, Development and validation of a functional fitness test for community-residing older adults. J of Age and Phys Act, pp. 7:129-161.

5. Sharifi F, Fakhrzadeh H, et al. 2015, Predicting risk of the fall among aged adult residents of a nursing home. Arch Gerontol Geriatr, pp. Sept-Oct: 61 (2): 124-130.

6. Balasubramanian CK, Clark DJ, et al. 2015, Validity of the gait variability index in older adults: effect of aging and mobility impairments. Gait Posture, pp. May: 41 (4): 941-946.

7. Cook G, Burton L, et al. Movement: Functional Movement Systems: Screening, Assessment, and corrective strategies. Aptos, CA : On Target Publications, 2010.

8. Guralnik JM, Simonsick EM, Ferrucci L, et al. 1994, A short perfomance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol Med Sci, pp. 49, 2:M85-M94.

9. Guralnik JM, Ferrucci L, Simonsick EM, et al. 1995, Lower Extremety Function in persons over the age of 70 yearsas a predictor of subsequent disability. New England Journal of Medicine, pp. 332:556-61.

10. Volpato S, Cavallini Mc, Sioulis F, et al. 2011, Predictive value of the short physical performace battery following hospitilization in older patients. J Gerontol A Biol Sci Med Sci, pp. 66:89-96.

11. R, Gary. 2012, Evaluation of frailty in older adults with cardiovascular disease: incorporating physical performace measures. J of Cardiovascular Nursing, pp. 27:121-131.

12. Shamliyan T, Talley KM, Ramakrishanan R, Kane RL. 2013, Association of frailty with survival: a systematic literature review. Age Res Rev, pp. 12:719-36.

13. Karindanta S, Heinonen A, Sievanen H, et al. 2007, A multi component exercise regimen to prevent funcitonal decline and bone fragility in home-dwelling elderly women: randomized, controlled trial. Osteoporos Int., pp. 18(4): 453-62.

14. Liu-Ambrose T, Khan KM, Eng JJ, et al. 2004, Balance imporves with resistance or agility training. Increase is not correlated with objective changes in fall risk and physical abilities. Gerontology, pp. 50(6): 373-82.

15. Liu-Abrose T, Khan KM, Eng JJ, et al. 2004, Resistance and agility training reduce fall risk in women aged 75 to 85 with low bone mass: a 6 month rendomized, controlled trial. J Am Geriatr, pp. 52(5): 657-65.

16. Bottaro M, Machado S, Nogueira W, ScalesR, et al. 2007, Effect of high versus low-velocity resistance training on muscular fitness and functional performance in older men. Eur J Appl Physiol, pp. 99:257-264.

17. Earles DR, Judge JO, Gunnarsson OT. 1997, Power as a predictor of functional ability in community dwelling older persons. Med Sci Sports Exerc, p. 27(5 suppl):S11.

18. Foldvari M, Clark M. Laviolette LC, et al. 2000, Association of muscle power with functional status in community-dwelling elderly women. J Gerontol A Biol Sci Med Sci, pp. 55A:M192-199.

19. ACSM. 2011, Quantity and quality of exercise for developing and maintaining cardiorespiratory musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Med Sci Sport Ex, pp. 1334-1359.

20. Akalan C, Scales R, Cornella KA, et al. 2012, Assessing muscular power with a portable device in a clinical setting. Med Sci in Sport Ex, Abstract 2455, pp. 44, 5: S446-447.

21. NIH. 2012, Evaluation of frailty in older adults with cardiovascular diseases. J of Cardiovasc Nurs, pp. March:27(2): 120-131.

22. Studenski S, Perera S, Wallace D, et al. 2003, Physical performace measures in a clinical setting. J Am Geriatr Soc, pp. 51:314-322.

Methods

(A) Muscular Power: Repeated Chair Stands

Instructions: Do you think it is safe for you to try and stand up from a chair five times without using your arms? Please stand up straight as quickly as you can five times, without stopping in between. After standing up each time, sit down and then stand up again. Keep your arms folded across your chest. Please watch while I demonstrate. I’ll be timing you with a stopwatch. Are you ready? Begin.

Grading: Begin stopwatch when patient begins to stand up. Count aloud each time patient arises. Stop timing when patient has straightened up completely for the fifth time. Also stop if the patient uses arms, has not completed rises after 1-minute, or if there is concern about the patient’s safety. Record the number of seconds and the presence of imbalance. Then complete ordinal scoring.

Time: _____seconds (if 5 stands are completed)

Number of stands completed: 1 2 3 4 5

Chair Stand Ordinal Score: _____

0 = Unable 1 = >16.7 seconds 2 = 16.6-13.7 seconds 3 = 13.6-11.2 seconds 4 = <11.1 seconds

Purpose

To identify a safe and practical physical performance evaluation that can be conducted by cardiac and pulmonary professionals to help determine the functional status of older and frail patients.

Discussion

In a study of >5,000 adults (>70 years) SPPB performance was a significant predictor of disability, nursing home admission and mortality.8-9 Patients with the lowest SPPB scores at hospital discharge had a 5-fold greater risk of rehospitalization or mortality compared to the highest quartile. Those with an early decline in SPPB scores one month after discharge had greater limitations in activities of daily living and significantly greater probability of rehospitalization and death during the first year of follow-up.10

Frailty is a heightened vulnerability to stressors in the presence of low physiological reserve.11 When exposed to stressors, persons who are frail have a much higher probability for disproportionate decompensation, negative events, functional decline, disability and mortality.12 Identifying frailty and developing key strategies to prevent and counteract the causes may decrease risk in the cardiac and pulmonary rehabilitation population.

Agility and Gait: Agility and balance training may reduce the risk of falling as well as fear of falling in older adults.13-15 In COPD patients attending pulmonary rehabilitation, balance training that was incorporated into the standard program significantly improved scores on balance.1 More studies are needed to confirm these findings.

Muscular Power: Muscular power is determined by the force or torque of a muscular contraction multiplied by its velocity. Studies have shown that power-producing capabilities are more strongly associated with functional performance than muscle strength in older adults. Muscle power declines at a greater rate than muscular strength as we age.16-18 Improving muscular power in older individuals can be achieved by safely incorporating weight resistance exercise performed at a high velocity.

Training: Training older adults to improve their balance, gait and muscular power is the most beneficial approach to decreasing the effects of frailty.19 Agility, balance, coordination and gait can be improved by incorporating various combinations of tai chi, qigong and yoga movements.19 Muscular power can be enhanced by involving higher velocity movements into any form of resistance training including weight training, band resistance, exercise balls, body weight or water resistance.16-18 Power training should only be included after the individual has been instructed and can perform the required motion with safe and correct form.19

Customization: Exercise training prescriptions should vary depending on the individual’s current performance level.19 Individuals with a lower tolerance for exercise (i.e. low SPPB score) may be prescribed a conservative, but progressive balance, gait and muscular conditioning exercise routine. Individuals with a higher tolerance for exercise (i.e. high SPPB score) may be able to start at a higher level of training.

Technology: Portable 3-way axial accelerometers are now available to assist with the assessment of muscular power in a clinical setting.20 The information generated from this type of technology may provide useful information that could help monitor progress and assist in the customization of an exercise routine for cardiac and pulmonary rehabilitation patients.

(B) Balance

Begin with a semi-tandem stand (heel of one foot placed by the big toe of the other foot). Individuals unable to hold this position should try the side-by-side position. Those able to stand in the semi-tandem position should be tested in the full tandem position. Complete ordinal scoring once you have completed time measures.

(1) Semi-Tandem Stand

Instructions: Now I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. Please watch while I demonstrate.

Grading: Stand next to the patient to help him/her into semi-tandem position. Allow patient to hold onto your arms for balance. Begin timing when patient has the feet in position and stands without holding on for support. Circle one: 2. Held for 10 seconds 1. Held for less than 10 seconds; number of seconds held _____ 0. Not attempted

(2) Side-by-Side Stand

Instructions: I want you to try to stand with your feet together, side by side, for about 10 seconds. Please watch while I demonstrate. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop.

Grading: Stand next to the patient to help him/her into the side-by-side position. Allow them to hold onto your arms for balance. Begin timing when patient has feet together and stands without holding on for support. Circle one: 2. Held of 10 sseconds 1. Held for less than 10 seconds; number of seconds held_____ 0. Not attempted

(3) Tandem Stand

Instructions: Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for 10 seconds. You may put either foot in front, whichever is more comfortable for you. Please watch while I demonstrate.

Grading: Stand next to the patient to help him or her into the side-by-side position. Allow participant to hold onto your arms for balance. Begin timing when patient has feet together and stands without holding on for support. Circle one: 2. Held of 10 seconds 1. Held for less than 10 seconds; number of seconds held_____ 0. Not attempted

Balance Ordinal Score: _____ 0 = Side-by-side 0-9 seconds or unable 1 = Side-by-side 10, <10 seconds semi-tandem 2 = Semi-tandem 10 seconds, tandem 0-2 seconds 3 = Semi-tandem 10 seconds, tandem 3-9 seconds 4 = Tandem 10 seconds

(C) Gait: 8 Foot Walk (2.44 Meters)

Instructions: This is our walking course. If you use a cane or other walking aid when walking outside your home, please use it for this test. I want you to walk at your usual pace to the other end of this course (a distance of 8 feet). Walk all the way past the other end of the tape before you stop. I will walk with you. Are you ready?

Grading: Press the start button to start the stopwatch as the participant begins walking. Measure the time take to walk 8 feet. Then complete ordinal scoring.

Time: _____ seconds

Gait Ordinal Score: _____ 0 = Could not do 1 = >5.7 seconds (<0.43 m/sec) 2 = 4.1-6.5 seconds (0.44-0.60 m/sec) 3 = 3.2-4.0 seconds (0.61-0.77 m/sec) 4 = <3.1 sseconds (>0.78 m/sec)

• The SPPB is a validated office-based assessment of lower extremity functional status that may enhance measures of self-report.

• This test battery examines an individual’s ability to stand balanced with the feet positioned together side-by-side, in the semi-tandem or tandem stance.

• Gait is measured with the time to walk a distance of 8 feet and muscular power is assessed with the time to rise from a chair and return to a seated position over 5 repetitions.

• Subjects are graded for each category of function on an ordinal 0-4 scale with a maximum possible score of 12.8

Summary Ordinal Score: _____ Summary score can range between 0-12 (0 indicates poor function and 12 indicates excellent function). 10 or lower indicates mobility impairment. In subjects older than 65 years of age, the risk of disability and mortality increases 7-9% for every 1-point reduction in the total score.