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2/24/2016
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Evidence-based Assessment of Functional Strength & Balance in Geriatric
RehabilitationTherapy Network Seminars, Inc.
Nicole Dawson, PT, PhD, GCS
Learning Objectives
Following completion of this webinar, participants will be able to:
• Identify how disablement models can be used to describe functional status
• Identify the appropriate method of choosing the “best” functional assessment tool
• Identify the test and measures to assess strength and balance in older adults
• Identify best practices regarding documentation and goal setting in geriatric rehabilitation
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Age-related Changes
• Muscle
– Type I (slow-twitch) fibers
– Type II (fast-twitch) fibers
– Sarcopenia
• Type II fibers > than Type I fibers
– Preventable, treatable• Bone
– Sarcopenia related to decreases in bone mass
– Trabecular bone affected first
– Menopause: 20-30% loss in trabecular, 5-
Age-related Changes
• Connective Tissue
– Can lose elastic properties or become inflamed
– Risk of injury or pain, decrease function, cause disability
• Obesity
– Increased caloric intake & decreased physical activity
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International Classification of Functioning, Disability and Health
Functional Assessments
• Use of evidence-based practice
– Validity of manual muscle testing (Bohannon, 2002; Bohannon, 2001; Knepler &
Bohannon, 1998; vanBevereen & Avers, 2012)
• Guides further evaluation
• Provides standardized baseline assessments
– Better justifies skilled need for reimbursement
• Allows objective tracking of progress
• More familiar to patient
• Usually easier to perform
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Which one should I use?
• Match assessment to desired outcome
• Level of patient
• Environmental considerations
• Responsiveness to change
– Minimal detectable change (MDC)
• Psychometric properties of assessment tool
– Validity
– Reliability
– Sensitivity and specificity
STRENGTH
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Strength
• Chair stand test
– 30-second test
– Timed 5-repetition test
– Timed 10-repetition test
• Standing heel-rise
• Grip strength
• 30-second arm curl test
Chair Stand Test
• Correlations with knee extensor force
– Range 0.55 to 0.64 with hands
– Range 0.65 to 0.71 without hands
• 10-time repetition chair stand test (Csuka & McCarty, 1985)
– Correlated with well published lower extremity strength
• 30-second chair stand test
– Some older adults may not be able to complete needed reps
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30-second Chair Stand Test
• Lower-body strength
• Number of full stands from a seated position in 30 seconds with arms folded across chest
• Modified from 5- and 10-time stand tests
• Chair stand test highly correlated with other strength measures (Bohannon, 2002; Csuka &
McCarty, 1985; Jones, Rikli & Beam, 1999)
• Successful in detecting exercise effects in healthy older adults (Cavani et al., 2002; DiBrezzo
et al., 2005)
30-second Chair Stand Test
• Equipment– Stopwatch, straight-back chair (placed against wall)
• Procedure– Sit in middle of chair with feet flat and arms crossed– On “go”, rise to full stand then return to fully seated– Complete 1-2 trial repetitions– Time for 30-second scored trial
• Scoring– Number of total full stands completed
in 30 seconds
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30-second Chair Stand Test Chair Stand Test
Age in yearsNormative Time for 5-repetition Chair Stand
(Bohannon, 2006)
60-69 11.4 seconds
70-79 12.6 seconds
80-89 14.8 seconds
Normative Repetitions for 30-second Chair Stand Test (Rikli & Jones, 2013)
Age in years 60-64 65-69 70-74 75-79 80-84 85-89 90-94
Men 14-19 12-18 12-17 11-17 10-15 8-14 7-12
Women 12-17 11-16 10-15 10-15 9-14 8-13 4-11
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Heel-Rise Test
• Measures ankle plantar flexor strength
– Associated with balance and gait speed• Manual muscle testing not helpful due to short lever
arm
• Score associated with age and gender– Assessing for full calcaneal excursion in available ROM
– Assessing for inversion or eversion
• Can use “two-finger” hold for balance– Ensure patient not using hands to push up
Mean Repetitions for Heel Rise (Jan et al., 2005)
Male Female
21-40 years 22.1 16.1
41-60 years 12.1 9.3
61-80 years 4.1 2.7
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Grip Strength
• Uses grip dynamometer
• Correlates upper-limb strength and is associated with functional decline
• Negatively correlated with age (females, r=-0.60; males, r=-0.67: Luna-Heredia et al., 2005)
Normal dynamometry in kg (dominant side)
Mean (SD) Maximum value
50-59Male 46.6 (10.1) 49.4
Female 24.5 (5.5) 26.4
60-69Male 35.7 (10.3) 37.6
Female 19.5 (4.7) 21.1
70-79Male 29.5 (8.1) 31.0
Female 17.0 (5.1) 18.4
80-84Male 24.2 (6.3) 25.6
Female 16.6 (4.1) 17.4
>85Male 21.8 (6.6) 23.4
Female 11.9 (3.6) 15.0
Luna-Heredia et al., 2005
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30-second Arm Curl Test
• Upper-body strength
• Number of biceps curls completed in 30 seconds holding a hand weight
– 5 pounds for women
– 8 pounds for men
• Validity demonstrated through correlation (r=0.82) with Cybex machine arm curl performance (Osness et al., 1996)
• High correlation (r=0.84 men, r=0.79 women) with combined upper body strength composite score (Rikli & Jones, 1999)
30-second Arm Curl Test
• Equipment– Stopwatch, straight-back chair, hand weight (5-pound for women; 8-pound for men)
• Procedure– Seated position with back straight, feet flat on floor and dominant side of body close to
edge of chair– Weight held down at side with hand in handshake grip position– As elbow is flexed, hand is rotated palm up – Weight is returned to side with rotation back
to handshake grip– Trial 1-2 repetitions, then time for 30-second scoring
• Scoring– Total number of arms curls completed
in 30 seconds
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30-second Arm Curl Test 30-second Arm Curl Test
Normative Repetitions for 30-second Arm Curl Test (Rikli & Jones, 2013)
Age in years 60-64 65-69 70-74 75-79 80-84 85-89 90-94
Men 16-22 15-21 14-21 13-19 13-19 11-17 10-14
Women 13-19 12-18 12-17 11-17 10-16 10-15 8-13
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BALANCE
Tests & Measures: Balance
• Ottawa Sitting Scale
• Sitting Balance Scale
• One-leg Stance Test
• Four-square Step Test
• Functional Reach
• Berg Balance Scale
• Fullerton Advanced Balance Scale
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Ottawa Sitting Scale
• Developed to characterize sitting balance in acute care setting with slow to recover patients
• Excellent reliability
– Inter-rater: 0.96 to 0.98
– Intra-rater: 0.99
• Looks at both movement within and outside of base of support
• Ceiling effect of test corresponded with Berg Balance Scores of ≥ 10
Thornton & Sveistrup, 2010
Ottawa Sitting Scale
• 6-item scale completed in 2 conditions
– Maintaining static sitting position
– Moves short distance
– Moves longer distance
– Trunk rotation ability
– Sitting on one hip
– Walking on hips
• Each item is completed with feet supported and unsupported
• Rated on scale 0-4
Thornton & Sveistrup, 2010
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Ottawa Sitting Scale
Thornton & Sveistrup, 2010
Sitting Balance Scale
• Measures sitting balance in frail older adults that are primarily non-ambulatory
• Good internal consistency (α=0.76)
• Good intra-rater reliability 0.96 to 0.99
• Good validity also established
• Scoring 0-4 on each item
Medley & Thompson, 2011
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Sitting Balance Scale
• 11-item scale
– Sitting eyes open
– Sitting eyes closed
– Arm as lever
– Sitting forward reach
– Object from floor
– Alternating feet on PDR
– Lateral sitting reach
– Look over shoulders
– Lateral bend
– Sit to stand
– Object from floor on foam
Medley & Thompson, 2011
One-Leg Stance Test
• First 5 seconds are crucial when assessing balance during one-leg stance (Jonsson et al., 2004)
– Dynamic phase of force variability
– Might depend on strength, neuromuscular system, endurance
• Possible floor effects (Lin et al., 2004)
– 47% of participants unable to complete test
• Good test-retest reliability (Springer et al., 2007)
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One-Leg Stance Test
Age GroupMean in seconds (SE) – Eyes Open
Mean in seconds (SE) – Eyes Closed
18-39 years 43.3 (5.1) 9.4 (9.4)
40-49 years 40.3 (10.8) 7.3 (7.0)
50-59 years 37.0 (12.6) 4.8 (4.8)
60-69 years 26.9 (16.6) 2.8 (2.2)
70-79 years 15.0 (13.9) 2.0 (1.6)
80-99 years 6.2 (9.3) 1.3 (0.6)
Springer et al., 2007
One-Leg Stance Test
• Cut-off score 1.02 seconds (Thomas & Lane, 2005)
– 67% sensitivity; 89% specificity for falls
– Odds ratio 15.22
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Four Square Step Test
• Clinical measure of rapid stepping, change of direction, and obstacle avoidance
• Excellent reliability
– Inter-rater: 0.99
– Retest: 0.98• Highly correlated with TUG (r=0.88)
• Equipment
– Stopwatch and 4 canes• Set-up
– Cross is formed by using 4 canes
– Subject stands in square number 1
Dite & Temple, 2002
Four Square Step Test
• Aim is to step as fast as possible into each square in sequence
– 2, 3, 4, 1, 4, 3, 2, 1
– “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.”
• Score recorded as time to complete the sequence
– Time starts when first foot contacts the floor in square 2
– Time ends when last foot comes back into square 1
Dite & Temple, 2002
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Four Square Step Test
Dite & Temple, 2002
Four Square Step Test
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Four Square Step Test
• Faller scores
– Multiple faller: 23.59 seconds
– Single faller: 12.01 seconds
– Non-faller: 8.70 seconds
• Cut-off score of 15 seconds
– Sensitivity: 86%
– Specificity: 94%
Dite & Temple, 2002
Functional Reach
• Difference between arm’s length and maximal reach forward
• Correlates (r=0.71) with center of pressure excursion (COPE)
• Stable performance across days (r=0.81)
• May be useful in detecting balance impairment and change in balance over time
Duncan, Weiner, Chandler, & Studenski, 1990
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Functional Reach
• Individual stands erect with feet at shoulder width
• With one arm elevated to 90 degrees shoulder flexion
• Ruler is secured to wall at acromion height
• Individual places closed fist against ruler and slides fist as far forward as possible without moving feet or losing balance
• Score (functional reach) is difference between 2 positions
• Usually performed 3 times with average used
Functional Reach
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Age-Related Normative Values for Functional Reach
Men Women
Age Mean (inches) SD Mean (inches) SD
20-40 years 16.7 1.9 14.6 2.2
41-69 years 14.9 2.2 13.8 2.2
70-87 years 13.2 1.6 10.5 3.5
Duncan et al., 1990
Association between Reach and Falls in Next 6 Months
Reach Score Odds Ratio*
(0) Unable to Reach 8.07
(1) Reach ≤ 6 inches 4.02
(2) Reach ≥ 6 inches but ≤ 10 inches 2.00
(3) Reach > 10 inches 1.00
Duncan et al., 1992*Note: adjusted for Age, MMSE, Depression
Tinetti Gait & Balance Scale
• Had lower rates of refusal and inability to complete than the One-leg Stance Test and Functional Reach (Lin et al., 2004)
• Higher risk for ceiling effects than floor effects (Faber et al., 2006)
• Good reliability and validity noted (Faber et al., 2006; Lin et al., 2004)
– Retest reliability ranged from 0.72 to 0.86
– Inter-rater reliability range from 0.80 to 0.93
– Moderately correlated with TUG test (r=-0.55) and ADL scale (r=0.60)
• Significantly predicted the occurrence of falls and changes in ADL function (Faber et al., 2006; Lin et al., 2004)
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Tinetti Gait & Balance Scale
• Consists of 16 items with 2- or 3-point scale
– 8 balance & 8 gaits
• Score ranges from 0 to 28 with higher score better
– Maximum score of 12 on balance items
– Maximum score of 16 on gait items
– MDC value of 4.0 to 4.2 (Faber et al., 2006)
Tinetti Gait & Balance Scale
Balance Section
• Sitting balance
• Rises from chair
• Attempts to rise
• Immediate standing balance
• Standing balance
• Nudged
• Eyes closed
• Turning 360 degrees
• Sitting down
Gait Section
• Initiation of gait
• Step length and height
• Foot clearance
• Step symmetry
• Step continuity
• Path
• Trunk
• Walking time
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Tinetti Gait & Balance Scale
Total Balance Gait
Mean (SD: non-fallers) 20.8 (5.5) 11.1 (3.8) 9.7 (2.4)
Mean (SD: fallers) 17.4 (5.5) 9.2 (3.6) 8.3 (2.7)
Suggested cut-off 19 10 9
Sensitivity 64% 64% 64%
Specificity 66.1% 66.1% 62.5%
Faber et al., 2006
Berg Balance Scale
• 14-item scale to measure balance impairment in older adults
• Equipment required
– Chair, stopwatch, ruler, step, slipper/shoe
• Score ranges 0-56 with higher scores indicating better
– Cut-off score of 45/56 for independent, safe ambulation (Berg et al., 1992)
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Berg Balance Scale
• Sitting to standing
• Standing unsupported
• Sitting with back unsupported but feet supported Standing to sitting
• Transfers
• Standing unsupported with eyes closed
• Standing unsupported with feet together
• Reaching forward while standing
• Pick up object from floor
• Turning to look behind right & left shoulders while standing
• Turn 360 degrees
• Alternating feet on stool
• Standing unsupported one foot in front
• Standing on one leg
Berg Balance Scale
• High validity (Cronbach’s α=0.96) and inter-rater reliability (r=0.98)
• Possible floor and ceiling effects in various populations
• MDC to be 95% confident of true change (Donoghue et al., 2008)
– 45-56 initial score: 4 points
– 35-44 initial score: 5 points
– 25-34 initial score: 7 points
– 0-24 initial score: 5 points
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Berg Balance Scale
• 1-year fall probabilities (Muir et al., 2008)
– 58% of people with BBS ≤ 45/56 fell– 39% of people with BBS > 45/56 fell
• Cut-off thresholds (Muir et al., 2008)
– Any fall• ≤ 45: 25% sensitivity; 87% specificity• ≤ 54: 61% sensitivity; 53% specificity
– Multiple falls• ≤ 45: 42% sensitivity; 87% specificity• ≤ 53: 69% sensitivity; 57% specificity
– Injurious fall• ≤ 45: 29% sensitivity; 86% specificity• ≤ 54: 62% sensitivity; 51% specificity
Berg Balance Scale
Age & Gender Mean (SD)
60-69Male 55 (1.0)
Female 55 (2.0)
70-79Male 54 (3.0)
Female 53 (4.0)
80-89Male 53 (2.0)
Female 50 (3.0)
Steffen, Hacker & Mollinger, 2002
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Berg Balance Scale
BBS Score Any Fall Multiple Falls Injurious Fall
< 40 2.29 5.19 3.3
40-44 1.56 2.07 1.07
45-49 1.34 0.58 1.53
50-54 1.003 0.91 0.78
≥ 55 0.73 0.53 0.75
Muir et al., 2008
Fullerton Balance Scale
• Multidimensional balance scale appropriate for functionally independent older adults (Rose et al., 2006)
• Good reliability– Retest: 0.96
– Inter-rater: 0.94 to 0.97
– Intra-rater: 0.97 to 1.00
• Good validity established (Klein et al., 2010; Rose et al., 2006)
• Approximately 10-12 minutes to administer
• 10-item scale, score 5-point scale on each item
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Fullerton Balance Scale
• Stand with feet together, eyes closed
• Reaching forward to object
• Turn in full circle
• Step up and over
• Tandem walk
• Stand on one leg
• Stand on foam, eyes closed
• Two-footed jump
• Walk with head turns
• Reactive postural control
Fullerton Balance Scale
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Fullerton Balance Scale
• Score ≤ 25 on FAB (Hernandez & Rose, 2008)
– Sensitivity 75%
– Specificity 53%
Evaluation & Documentation
• Make objective
– Use actual scores with interpretation of scores in evaluation
• Connect objective scores with functional limitations
• Identify need for skilled therapy based on findings
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Goal Writing
• Specific
• Measurable
• Attainable
• Realistic
• Timely
THANK YOU!
QUESTIONS?
email: [email protected]
