Assessment Protocols for Standardized Balance Tests Modified

5/20/2018 Assessment Protocols for Standardized Balance Tests Modified

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Assessment Protocols for Standardized Balance Tests

These are selected tests that are simple and quick yet are good indicators of falls risk andare good outcome measures. The first three tests are for static and dynamic balance, andleg strength that are good to use for brief performance screens. These take less than 5minutes. All the balance measures can be used for measuring change in balance andhave good psychometric properties. We include the test protocols, normative values, orrisk cut points and a list of references.

GOOD BRIEF FALL SCREENING TESTS

1. TIMED UP AND GO TEST

2. SINGLE LEG STAND

3. SINGLE CHAIR RISE

OTHER BALANCE MEASURES USEFUL FOR ASSESSMENTS AND/OR OUTCOMES

4. TIMED CHAIR RISE x 5

5. CHAIR RISE # in 30 SEC

6. TANDEM STAND

7. 360oTURN PROTOCOL

8. FOUR SQUARE STEP TEST

9. ALTERNATE STEP TEST

10.TANDEM WALK TEST



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PHYSICAL PERFORMANCE ASSESSMENTS FOR BALANCE AND FUNCTION

You will need a stop watch and masking tape. It is best to tell the client what the test measures,give instructions, and demonstrate each test. You may need to repeat if it is obviously they do notunderstand or were not giving it their best effort. These are all good tests for fall risk butperformance is also influenced by pain, cognitive ability, and other medical conditions. You willneed to interpret the results accordingly.

BRIEF FALL SCREENING TESTS

1. TIMED UP AND GO TESTDescription: The timed "Up & Go" test was developed as a brief screen for mobility and falls risk. Ithas good test-retest reliability and sensitivity and specificity for falls. The timed "Up & Go" testmeasures, in seconds, the time it takes for an individual to stand up from a standard arm chair(approximate seat height of 46 cm, arm height 65 cm), walk a distance of 3 meters (9.84 feet), turn,walk back to the chair, and sit down again. The participant wears his/her regular footwear anduses his customary walking aid (none, cane, or walker). No physical assistance is given.

Instruction:Participants start with their back against the chair, their arms resting on the armrests, and theirwalking aid at hand if needed.

Instruction: When I say "go" Id like you to stand up and walk as quickly as safely aspossible to that line on the floor, turn, return to the chair, and sit down again.

Have the participant practice one trial to be sure they understand the procedure.

Start timing when you say go and stop when the participant sits down.

Use a stop-watch to time the performance and observe balance closely, especially at the turn.

If the participant does not perform the test correctly the first time (e.g., stops at the turn, does notsit down right away, or does not walk all of the way to the 3 meter mark) repeat the test.

Record time in seconds to tenths of a second and which assistive device was used, if any.

Cut Points for this test vary depending on population studied, but generally accepted as 14 sec

2. SINGLE LEG STANCEDescription: Balance ability during a single leg stance. Measures static standing ability (balancewith feet fixed)

Instruction:This test helps us to assess your standing balance. I want you to stand on one leg for aslong as you can, or until I say stop. Watch while I demonstrate. (Demonstrate usingchair/table/counter for initial support.)

You may choose either foot to stand on. You may hold you foot anywhere, but you may notbrace your free leg on the standing leg. Place your arm by your sides and try not to moveyour feet or grab a support unless you need to gain your balance. Hold this position until Isay stop. When you are ready, pick up one of your feet from the floor and hold it as long asyou can.

Start timing when hand leaves the chair/table (if you are not using a support, start when the foot islifted). Stop timing when their free foot touches the ground, their hand contacts the chair/table,their foot moved, or 30 seconds has passed.

Make sure you are close enough to guard the participant and they understand that they should puttheir foot down before they fall.

Record the time to a tenth of a second.



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Cut point Less than 10 sec indicated balance impairment and less than 5 sec fall risk.

3. SINGLE CHAIR RISEDescription: Measures the ability of person to rise from a chair. Chair rise is a complex testrequiring lower limb strength, range of motion, balance and is included in several risk assessmentscales.

Equipment: Stop watch and standard height chair.Tester Notes: Have the participant sit erect in a standard height chair with the chair back againstthe wall. You can use a chair with or without arms but the participants should not use their arms.

Instructions: Id like you to fold your arms across your chest and stand up one time.

Record Yes or No, is able or not. If the participant was NOT ableto get up without using arms do

not perform the Repeated Chair Rise.

Cut Point = unable

OTHER BALANCE MEASURES USEFUL FOR ASSESSMENTS AND/OR OUTCOMES

4. TIMED REPEATED CHAIR RISE x 5 (SIT-to-STAND)Description: Measures the ability of person to rise from a chair repeatedly. Repeated chair risetest requires lower limb strength, range of motion, balance, and endurance. For the sit-to-standtest with five repetitions subjects are asked to rise from a standard height (43 cm) chair withoutarmrests, five times, as quickly as possible with their arms folded across their chest.

Equipment: Stopwatch and standard height chair.

Tester Notes: Check that the client can successful perform a single chair rise before you testrepeated chair rise.

Instructions: Id like you to fold your arms across your chest and when I say go, I want

you to stand up and sit down as quickly as you can five times in row.Record the time from the command gountil the participant is in the final seated position,and the number of completed chair rises (0-5)

Cut point Greater than 15 sec indicator for fall risk

5. 30 SECOND CHAIR RISE - ALTERNATIVE TESTDescription: This chair rise test is a functional measure of lower body strength. This is an itemfrom The Senior Fitness Test (Rikli and Jones 1999). The scores are compared to norms valuesfor gender and age. This is a good test to performance as a group. Each person counts theirstands while you time.

Instruction:

When I say go, I want you to stand up and sit down as quickly as you can until I tell you tostop.You dont have to sit back in the chair completely, but you do have to makesure your buttocks contacts the chair. I am going to count how many times you can up in30 seconds.

Record the number of stands completed in 30 seconds from go command

Cut Point Generally less than 10 is an indication of poor leg strength. As yet there is no fall risk forthis test.



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6. TANDEM STANCEDescription: Assesses static balance narrow base of support. For clients who cannot perform thesingle leg stance, use the TS test for an outcome measure. It is a very responsive measure.

Tester Information: Participants s should wear tennis shoes or shoes with low or no heels.Describe the stance to the resident as you demonstrate it. Stress that if the resident feels itwould be unsafe to try, to tell you. If the activity is not being done properly, demonstrate it againor repeat instructions. Guard the participant for balance loss.

Stand next to the client to help him/her into the position. Make sure you have a table or chair

that the client can use for support. Supply just enough support to the clients arm to prevent lossof balance. Start timing when support is released. Stop after 30 seconds or when the participantsteps out of position.

Instructions: This test will help us assess your balance during standing.

First I will show you the movement then I want you to try it. 'I would like you to stand with t

heel of one foot in front of and touching the toes of the other foot for 30 seconds. Keep you

by your sides and try not to shift your feet. Hold this position until I say stop.'

Record the time held to the nearest tenth of a second. If clients refuse, mark 0 time and indicatethey refused.

Cut point unable to TS for 10 sec is fall risk indicator

7. 360oTURN PROTOCOLDescription: A measure of dynamic balance. The participant turns in a complete circle 360degrees. You can test to either direction but each trial is only one complete turn. The 360and walking speed are highly correlated so you can which to use for dynamic balance.

Tester Notes:Place a piece of masking tape on the floor for a starting position.

The participant stands with arms at his/her side and feet comfortably apart and pointingstraight ahead at the tape.

Start timing from the word GO and stop when the participants shoulders are square facingyou again. Have the participant do two trials. The participant may turn in either direction.

Instructions:When I say go, I want you to turn around at your normal pace making sure to go in acomplete circle and take steps as you turn. Make sure you end up facing me.

Ill show you (demonstrate the turn). You choose which direction you want to turn.When I say 'go' start turning. Ready, go.

Record the time for both trials to the nearest tenth of a second

Cut Point >3.8 sec is indicator of fall risk



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8. FOUR SQUARE STEP TEST

Description: A higher order complex task assessing dynamic balance. This is a good test formore advance balance skills and has a strong cognitive component.

Tester Notes:1. Place four canes (1/2 inch pvc pipe, 35 inch length with a 4-way connector works

well) on the ground to form four squares.

2. Participants start in square one facing square two. Participants step forward intosquare two, sideways to square three, backwards to square four, sideways into one,and then reverse the sequence - sideways into four, forward, sideways, andbackwards to one. The sequence is 1,2,3,4,1,4,3,2,1.

3. Instructions are to complete the sequence as fast as possible without touching thecanes, both feet must make contact with the floor in each square, and to try to stayfacing forward during the entire sequence.

4. The sequence is demonstrated and participants are allowed one practice trial thentime two trials. The best time is recorded. Participants wear their usual shoes andare allowed to turn their body to negotiate the canes if necessary, but should try toface forward at all times. Mistrials occur if the participant cannot complete thesequence, loses balance or steps on a cane. One mistrial is allowed.

Special Instructions: Participants may lose balance, make sure you are guarding. You cancue the participants through the practice, but they should do the subsequent trials withoutcueing. The most common error is not reversing the sequence at box one.

Participant Instructions: We are going to do a stepping test to check your balance. Thisis what I want you to do: Demonstrate sequence and verbalize sequence while you are

demonstrating.Try to complete the sequence as fast as possible without touching thesticks. Both your feet should make contact with the floor in each square. If possible,face forward during the entire sequence. First I would like you practice one time. Onepractice trial is completed to ensure the subject knows the sequence.

Record time from when the first foot contacts the floor in square 2to when the last footcomes back to touch the floor in square1. Two FSST are completed with the best time takenas the score.

Cut point for falls risk >15sec

9. ALTERNATE STEP TEST

Description: The alternate-step test (AST) is a modified version of the Berg Balance Test stool-

stepping task. It involves weight shifting and provides a measure of lateral stability. This testinvolves alternatively placing the entire left and right feet (shoes removed) as fast as possible ontoa step 18 cm high and 40 cm deep.

Instruction: I want you to place you feet on this step alternating R and L feet. Ill show you(demonstrate).

Record: The time taken to complete eight steps, alternating between the left and right feet.

Cut point 10s RR =2.3 (CI 1.4, 3.5) LR =1.57, Sensitivity/specificity, 69/56.

Alternative is to count the number of steps in 10 sec

2 3

1 4



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10. TANDEM WALK TEST

Description:Tandem gait is a high demand activity requiring careful control of both center of mass

movement (head, trunk, pelvis) and the successive re-establishment of a stable, narrow base of

support. Compared to normal gait, the tandem walk test tends to be more specific to impairmentsaffecting balance.

Instruction: There are two ways of conducting this test and evidence for clear cut points for fallsrisk are not well established. Clients are required to walk heel to toe along a 10-foot line as quicklyas possible without errors. Errors included not walking heel to toe, stepping off the gait line, andlosing balance. I want you to walk along this line heel to toe without stepping off the line asquickly as possible, its like a sobriety test.

Record: You can measure performance time and number of errors for three trials and averageacross trials. Counting errors is tricky and not very reliable. An alternative is to ask clients to take 4steps and score it as able or unable.

REFERENCES

Timed Up and Go Test

Podsiadlo D, Richardson S. The Timed Up & Go: A test of basic functional mobility for frail elderlypersons. J Am Geriatr Soc. 1991;39:142-148.

Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896-903.

Bohannon RW. Reference values for the timed up and go test: a descriptive meta-analysis. JGeriatr Phys Ther. 2006;29(2):64-68.

Isles RC, Low Choy NL, Steer M, Nitz JC. Normal Values of Balance Tests in Women Aged2080 J Am Geriatr Soc 52:13671372, 2004

Gunter KB, White KN, Hayes WC, et al. Functional mobility discriminates nonfallers from one-timeand frequent fallers. J Gerontol A BiolSci Med Sci 2000;55:M6726.

Timed Chair Stands

Guralnik JM, Simonsick EM, Ferucci L, et al. A short physical performance batteryassessing lower extremity function: association with self-reported disability and prediction ofmortality and nursing home admission. J Gerontol. 1994;49:M85-M94.

Guralnik JM, Ferucci L, Simonsick EM, et al. Lower extremity function in persons over theage of 70 as a predictor of subsequent disability. N Engl J Med. 1995;332:556-561.

Whitney SL, Wrisley DM, Marchetti 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. 2005;85:10341045

30 sec Chair StandRikli R, Jones J. Development and validation of a functional fitness test for community-residing older adults. Journal of Aging and Physical Activity 1999a;7:129-161

Rikli R, Jones J. Functional fitness normative scores for community-residing older adults,ages 60-94. Journal of Aging and Physical Activity 1999b;7:162-181

Single Limb Stand



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Bohannon R, Larkin P, Cook A, Singer J. 1984. Decrease in timed balance test scores withaging. Phys Ther 64:1067-1070

Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-legstance is an important predictor of injurious falls in older persons. J Am Geriatr Soc.1997;45(6): 735-8.

Tandem and Semi-Tandem Stance

Guralnik JM. Ferrucci L. Simonsick EM. Salive ME. Wallace RB. Lower-extremity function in

persons over the age of 70 years as a predictor of subsequent disability. New EnglandJournal of Medicine. 1995;332(9):556-61.

Guralnik JM. Simonsick EM. Ferrucci L. Glynn RJ. Berkman LF. Blazer DG. Scherr PA.Wallace RB. A short physical performance battery assessing lower extremity function:association with self-reported disability and prediction of mortality and nursing homeadmission. Journal of Gerontology. 1994;49(2):M85-94.

Walking Speed

Ferucci L, Guralnik JM, Salive ME, Fried LP, Bandeen-Roche K, Brock DB, Simonsick EM,Corti MC, Zeger SL. Effect of age and severity of disability on short-term variation in walkingspeed: the Womens Health and Aging Study. J Clinical Epidemiology. 1996;49(10):1089-1096.

Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV, Studenski S,Berkman LF, Wallace RB.Lower extremity function and subsequent disability: consistencyacross studies, predictive models, and value of gait speed alone compared with the shortphysical performance battery. Gerontol A Biol Sci Med Sci. 2000;55(4):M221-31.

Harada N, Chiu V, Damron-Rodrigues J, et al. Screening for balance and mobilityimpairment in elderly individuals living in residential care facilties. Phys Ther. 1995:75:462-469.

Studenski S, Perera S, Wallace D, Chandler JM, Duncan PW, Rooney E, Fox M, GuralnikJM. Physical performance measures in the clinical setting. J Am Geriatr Soc.

2003;51(3):314-22.Van Swearingen JM, Paschal KA, Bonino P, Chen T. Assessing recurrent fall risk ofcommunity dwelling, frail older veterans using specific tests of mobility and the PhysicalPerformance Test of function. J Gerontol A Biol Sci Med Sci. 1998;53:M457-M464.

360 Degree Turn

Gill TM, Williams CS, Mendes de Leon CF, Tinetti ME. The role of change in physicalperformance in determining risk for dependence in activities of daily living amongnondisabled community-living elderly persons. Journal of Clinical Epidemiology.1997;50(7):765-772.

Berg KO, Wood-Dauphinee SL, Williams JI, Maki BE. Measuring balance in the elderly:

validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7-S11.

Van Swearingen JM, Paschal KA, Bonino P, Chen T. Assessing recurrent fall risk ofcommunity dwelling, frail older veterans using specific tests of mobility and the PhysicalPerformance Test of function. J Gerontol A Biol Sci Med Sci. 1998;53:M457-M464.

Reuben DB, Siu AL. An objective measure of physical function of elderly outpatients: ThePhysical Performance Test. J Am Geriatr Soc. 1990;38:1105-1112.

Four Square Step Test

Dite W, Temple VA. A clinical test of stepping and change of direction to identify multiplefalling older adults.Arch Phys Med Rehabil. 2002;83:1566-1571.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12588574&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12588574&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12588574&dopt=Abstracthttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12588574&dopt=Abstract



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Alternate Step Test

Tiedemann A, Shimada H, Sherrington C, Murray C, Lord S. The comparative ability of eightfunctional mobility tests for predicting falls in community-dwelling older people.Age and Ageing2008; 37: 430435

Berg KO, Wood-Dauphinee SL, Williams JI, Maki BE. Measuring balance in the elderly:validation of an instrument. Can J Public Health. 1992;83(suppl 2):S7-S11.

Hill K, Bernhardt J, McGann D et al. A new test of dynamic standing balance for stroke patients:Reliability, validity and comparison with healthy elderly. Physiother Can 1996;48:257262.

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Assessment Protocols for Standardized Balance Tests Modified