extranet.paxxon.com · Web view2018. 5. 7. · Turning 360 degrees _____ 12. Placing alternate foot on stool ... Hips, knees and ankles positioned are at 90 degree of flexion,

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Berg Balance Scale

Set-up and EquipmentYardstickStandard Chair with arm restStandard Chair without arm restStepStopwatch 15 ft walkwayCones as neededTest Form

General Information: This is a 14-item scale designed to measure balance of the older adult in a clinical setting. There is a potential ceiling effect with higher level patients. This scale does not include gait items.

Scoring A five-point ordinal scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Score the LOWEST performance. Total Score = 56.

A change of 4 points is needed to be 95% confident that true change has occurred if a patient scores within 45-56 initially, 5 points if they score within 35-44, 7 points if they score within 25-34 and, finally, 5 points if their initial score is within 0-24 on the Berg Balance Scale.

Cut Off Scores A score of < 45 indicates individuals may be at greater risk of falling. A score of < 40 is associated with almost 100% fall risk.

Interpretation41-56 = independent21-40 = walking with assistance0 –20 = wheelchair bound

ReferencesBerg K, Wood-Dauphinee S, Williams JI, Maki, B (1992). Measuring balance in the elderly: validation of an instrument. Can. J. Pub. Health July/August supplement 2:S7-11 Donoghue D; Physiotherapy Research and Older People (PROP) group, Stokes EK. (2009). How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people. J Rehabil Med. 41(5):343-6. Lusardi, M.M. (2004). Functional Performance in Community Living Older Adults. Journal of Geriatric Physical Therapy, 26(3), 14-22. July 31, 2017 Page 2 of 4

©The Weston Group All Rights Reserved

Transitions

Berg Balance Scale Test FormName: __________________________________ Date: ___________________ Location: ________________________________ Rater: ___________________

GENERAL INSTRUCTIONS Please document each task and/or give instructions as written. When scoring, please record the lowest response category that applies for each item. In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are deducted if:

- the time or distance requirements are not met - the subject’s performance warrants supervision - the subject touches an external support or receives assistance from the examiner

Subject should understand that they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will adversely influence the performance and the scoring.

ITEM DESCRIPTION SCORE (0-4) 1. Sitting to standing ________ 2. Standing unsupported ________ 3. Sitting unsupported ________ 4. Standing to sitting ________ 5. Transfers ________ 6. Standing with eyes closed ________ 7. Standing with feet together ________ 8. Reaching forward with outstretched arm ________ 9. Retrieving object from floor ________ 10. Turning to look behind ________ 11. Turning 360 degrees ________ 12. Placing alternate foot on stool ________ 13. Standing with one foot in front ________ 14. Standing on one foot ________

Total ________


Transitions

Berg Balance Scale 1. SITTING TO STANDING INSTRUCTIONS: Please stand up. Try not to use your hand for support. ( ) 4 able to stand without using hands and stabilize independently ( ) 3 able to stand independently using hands ( ) 2 able to stand using hands after several tries ( ) 1 needs minimal aid to stand or stabilize ( ) 0 needs moderate or maximal assist to stand

2. STANDING UNSUPPORTED INSTRUCTIONS: Please stand for two minutes without holding on. ( ) 4 able to stand safely for 2 minutes ( ) 3 able to stand 2 minutes with supervision ( ) 2 able to stand 30 seconds unsupported ( ) 1 needs several tries to stand 30 seconds unsupported ( ) 0 unable to stand 30 seconds unsupported If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4.

3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL INSTRUCTIONS: Please sit with arms folded for 2 minutes. ( ) 4 able to sit safely and securely for 2 minutes ( ) 3 able to sit 2 minutes under supervision ( ) 2 able to able to sit 30 seconds ( ) 1 able to sit 10 seconds ( ) 0 unable to sit without support 10 seconds

4. STANDING TO SITTING INSTRUCTIONS: Please sit down. ( ) 4 sits safely with minimal use of hands ( ) 3 controls descent by using hands ( ) 2 uses back of legs against chair to control descent ( ) 1 sits independently but has uncontrolled descent ( ) 0 needs assist to sit

5. TRANSFERS INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way toward a seat without armrests. You may use two chairs (one with and one without armrests) or a bed and a chair. ( ) 4 able to transfer safely with minor use of hands ( ) 3 able to transfer safely definite need of hands ( ) 2 able to transfer with verbal cuing and/or supervision ( ) 1 needs one person to assist ( ) 0 needs two people to assist or supervise to be safe

6. STANDING UNSUPPORTED WITH EYES CLOSED INSTRUCTIONS: Please close your eyes and stand still for 10 seconds. ( ) 4 able to stand 10 seconds safely ( ) 3 able to stand 10 seconds with supervision ( ) 2 able to stand 3 seconds ( ) 1 unable to keep eyes closed 3 seconds but stays safely ( ) 0 needs help to keep from falling


Transitions7. STANDING UNSUPPORTED WITH FEET TOGETHER INSTRUCTIONS: Place your feet together and stand without holding on. ( ) 4 able to place feet together independently and stand 1 minute safely ( ) 3 able to place feet together independently and stand 1 minute with supervision ( ) 2 able to place feet together independently but unable to hold for 30 seconds ( ) 1 needs help to attain position but able to stand 15 seconds feet together ( ) 0 needs help to attain position and unable to hold for 15 seconds

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.) ( ) 4 can reach forward confidently 25 cm (10 inches) ( ) 3 can reach forward 12 cm (5 inches) ( ) 2 can reach forward 5 cm (2 inches) ( ) 1 reaches forward but needs supervision ( ) 0 loses balance while trying/requires external support

9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION INSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet. ( ) 4 able to pick up slipper safely and easily ( ) 3 able to pick up slipper but needs supervision ( ) 2 unable to pick up but reaches 2-5 cm(1-2 inches) from slipper and keeps balance independently ( ) 1 unable to pick up and needs supervision while trying ( ) 0 unable to try/needs assist to keep from losing balance or falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING INSTRUCTIONS: Turn to look directly behind you over toward the left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn. ( ) 4 looks behind from both sides and weight shifts well ( ) 3 looks behind one side only other side shows less weight shift ( ) 2 turns sideways only but maintains balance ( ) 1 needs supervision when turning ( ) 0 needs assist to keep from losing balance or falling

11. TURN 360 DEGREES INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction. ( ) 4 able to turn 360 degrees safely in 4 seconds or less ( ) 3 able to turn 360 degrees safely one side only 4 seconds or less ( ) 2 able to turn 360 degrees safely but slowly ( ) 1 needs close supervision or verbal cuing ( ) 0 needs assistance while turning

12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times. ( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds ( ) 3 able to stand independently and complete 8 steps in > 20 seconds ( ) 2 able to complete 4 steps without aid with supervision ( ) 1 able to complete > 2 steps needs minimal assist ( ) 0 needs assistance to keep from falling/unable to try


Transitions

13. STANDING UNSUPPORTED ONE FOOT IN FRONT INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width.) ( ) 4 able to place foot tandem independently and hold 30 seconds ( ) 3 able to place foot ahead independently and hold 30 seconds ( ) 2 able to take small step independently and hold 30 seconds ( ) 1 needs help to step but can hold 15 seconds ( ) 0 loses balance while stepping or standing

14. STANDING ON ONE LEG INSTRUCTIONS: Stand on one leg as long as you can without holding on. ( ) 4 able to lift leg independently and hold > 10 seconds ( ) 3 able to lift leg independently and hold 5-10 seconds ( ) 2 able to lift leg independently and hold ≥ 3 seconds ( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently. ( ) 0 unable to try of needs assist to prevent fall

( ) TOTAL SCORE (Maximum = 56)

Norms (Lusardi, MM).

AGE RANGE SEX MEAN AVERAGE STANDARD DEVIATION60-69 Male 51.0 .25

Female 54.6 0.5

70-79 Male 53.9 1.5Female 51.6 2.6

80-89 Male 41.8 12.2Female 42.1 8.0Male/Female with Device 31.7 10.0

90-101 Male 40.0 1.4Female 36.9 9.7Male/Female with Device 31.8 7.6


Transitions

Functional Reach Test and Modified Functional Reach

Set-up and EquipmentYard Stick and Duct Tape (yardstick to be affixed to the wall at the level of the patient’s

acromion.ChairTape MeasureTest Form

InstructionsThe Functional Reach test can be administered while the patient is standing (Functional Reach) or sitting (Modified Functional Reach).

Functional Reach (standing instructions)

- The patient is instructed to next to, but not touching, a wall and position the arm that is closer to the wall at 90 degrees of shoulder flexion with a closed fist.

- The assessor records the starting position at the 3rd metacarpal head on the yardstick. - Instruct the patient to “Reach as far as you can forward without taking a step.” - The location of the 3rd metacarpal is recorded.

Scores are determined by assessing the difference between the start and end position is the reach distance, usually measured in inches. Three trials are done and the average of the last two is noted.

Modified Functional Reach Test (Adapted for individuals who are unable to stand)

Performed with a leveled yardstick that has been mounted on the wall at the height of the patient’s acromion level in the non-affected arm while sitting in a chair. Hips, knees and ankles positioned are at 90 degree of flexion, with feet positioned flat on the floor.

- The initial reach is measured with the patient sitting against the back of the chair with the upper-extremity flexed to 90 degrees, measure was taken from the distal end of the third metacarpal along the yardstick.

Test consists of three conditions over three trials - Sitting with the unaffected side near the wall and leaning forward - Sitting with the back to the wall and leaning right - Sitting with the back to the wall leaning left.


Transitions

- Instructions should include leaning as far as possible in each direction without rotation and without touching the wall.

- Record the distance in centimeters covered in each direction. - If the patient is unable to raise the affected arm, the distance covered by the acromion

during leaning is recorded.

First trial in each direction is a practice trial and should not be included in the final result.

A 15 second rest break should be allowed between trials.

AveragesFunctional Reach Test

Population Reach Distance RamificationsCommunity Dwelling Elderly 12.8 inches If less than 7 inches

-Unable to leave neighborhood without help-Limited in mobility skills-Most restricted in ADLs

Frail Elderly 9.4 inches If less than 7.28 inches-Significant fall risk

ReferencesDuncan, P. W., D. K. Weiner, et al. (1990). "Functional reach: a new clinical measure of balance." J Gerontol 45(6): M192-197. Katz-Leurer, M., I. Fisher, et al. (2009). "Reliability and validity of the modified functional reach test at the sub-acute stage post-stroke." Disabil Rehabil 31(3): 243-248. Weiner, D. K., D. R. Bongiorni, et al. (1993). "Does functional reach improve with rehabilitation?" Arch Phys Med Rehabil 74(8): 796-800. Weiner, D. K., P. W. Duncan, et al. (1992). "Functional reach: a marker of physical frailty." J Am Geriatr Soc 40(3): 203-207.


Transitions

Functional Reach Test and Modified Functional Reach Test Form

Name:___________________________________________________________

Instructions: Instruct the patient to “Reach as far as you can forward without taking a step”

Date Trial One (Practice) Trial Two Trial Three Total (Average of Trial 2 and 3 only)


Transitions

Modified Clinical Test of Sensory Interaction in Balance (MCTSIB)Set-up and Equipment

Foam PadStopwatchTest Form

Purpose of TestThis test is designed to assess how well an older adult is using sensory inputs when one or more sensory systems are compromised.

This test provides some insight into whether each of the sensory system available for balance are being used effectively. Failure to maintain balance in condition two indicates that the older adults is visually dependent. They are not using somatosensory inputs to maintain balance when eyes are closed. Failure to maintain balance in conditions 3 and 4 indicate that the visual and/or vestibular system is not being used to maintain balance. Poor performance on this test would suggest the need for multisensory training if the medial history does not indicate thatan actual problem(s) exists (e.g., peripheral neuropathy will affect our ability to use somatosensory inputs, etc.).

Check medical history to determine whether the participants has a history of inner ear infections or an inner ear disorder (e.g., meniere’s disease, acoustic neuroma, etc.)

InstructionsStarting Position: Patient stands with feet shoulder width apart and arms crossed over chest.Protocol: A 30-second trial is timed using a stopwatch. Time is stopped during a trial andrecorded if: a) patient deviates from initial crossed arm position, b) patient opens eyes during an “eyes closed” trial condition, or c) patient moves feet (takes a step) or requires manual assistance to prevent loss of balance. A trial is successful if the patient is capable of maintaining the starting position independently for a period of 30 seconds.

A maximum of three (3) trials are performed for all conditions. Trials are performed until thepatient either: a) successfully maintains the starting position for an entire 30-seconds, orb) completes three, 30-second trials to the best of their ability.


TransitionsNormative Data:

Elderly Adults

(Ricci et al, 2009; n = 96 independent elderly; mean age = 74.81 (7.25), 75.19 (7.32) and 74.47 (6.39) years for groups 1 (no falls),2 (one fall), and 3 (recurrent falls), respectively, Elderly Adults)

CTSIB Domain Groups Time (s)

Firm; eyes open Group 1 (no falls) 30 (0)

Group 2 (one fall) 29.9 (0.56)Group 3 (recurrent falls) 29.7 (1.68)

Firm; eyes closed Group 1 (no falls) 29.74 (1.05)Group 2 (one fall) 29.57 (2.38)Group 3 (recurrent falls) 27.93 (5.44)

Foam; eyes open Group 1 (no falls) 30 (0)Group 2 (one fall) 29.27 (4.08)Group 3 (recurrent falls) 26.85 (4.95)

Foam; eyes closed Group 1 (no falls) 26.22 (8.38)Group 2 (one fall) 25.96 (7.45)Group 3 (recurrent falls) 20.97 (11.38)

References

Boulgarides, L. K., McGinty, S. M., et al. (2003). "Use of clinical and impairment-based tests to predict falls by community-dwelling older adults." Phys Ther 83(4): 328-339.

Geldhof, E., Cardon, G., et al. (2006). "Static and dynamic standing balance: test-retest reliability and reference values in 9 to 10 year old children." Eur J Pediatr 165(11): 779-786. Giray, M., Kirazli, Y., et al. (2009). "Short-term effects of vestibular rehabilitation in patients with chronic unilateral vestibular dysfunction: a randomized controlled study." Archives of Physical Medicine and Rehabilitation 90(8): 1325-1331.


Transitions

Liston, R. A. and Brouwer, B. J. (1996). "Reliability and validity of measures obtained from stroke patients using the Balance Master." Archives of physical medicine and rehabilitation 77(5): 425-430.

Loughran, S., Gatehouse, S., et al. (2006). "Does patient-perceived handicap correspond to the modified clinical test for the sensory interaction on balance?" Otology & Neurotology 27(1): 86-91.

Loughran, S., Tennant, N., et al. (2005). "Interobserver reliability in evaluating postural stability between clinicians and posturography." Clinical Otolaryngology 30(3): 255-257.

Nitz, J., Stock, L., et al. (2013). "Health-related predictors of falls and fractures in women over 40." Osteoporosis International 24(2): 613-621.

Suttanon, P., Hill, K. D., et al. (2011). "Retest reliability of balance and mobility measurements in people with mild to moderate Alzheimer's disease." International Psychogeriatrics 23(7): 1152-1159. Whitney, S. L. and Wrisley, D. M. (2004). "The influence of footwear on timed balance scores of the modified clinical test of sensory interaction and balance." Arch Phys Med Rehabil 85(3): 439-443.

Wrisley, D. and Whitney, S. (2004). "The effect of foot position on the modified clinical test of sensory interaction and balance." Archives of physical medicine and rehabilitation 85(2): 335-338.


Transitions

Modified Clinical Test of Sensory Interaction in Balance (MCTSIB) Test FormPatient Name_______________________________

Date of Test________________________________

Proceed to next condition when one 30-second trial is completed or all 3 trials are performed.Administer only one trial per condition if participant able to complete first trial without loss of balance.

Condition 1: Eyes open, firm surface• Total time: ___/30 sec• Total time: ___/30 sec• Total time: ___/30 sec Mean score _____

Condition 2: Eyes closed, firm surface• Total time: ___/30 sec• Total time: ___/30 sec• Total time: ___/30 sec Mean score _____

Condition 3: Eyes open, foam surface• Total time: ___/30 sec• Total time: ___/30 sec• Total time: ___/30 sec Mean score _____

Condition 4: Eyes closed, foam surface• Total time: ___/30 sec• Total time: ___/30 sec• Total time: ___/30 sec Mean Score _____

TOTAL SCORE: ___/120 sec (mean score used for each condition if > 1 trial is performed)

Single Leg Stance Test


Transitions

Set-up and EquipmentChairStopwatchTest Form

Description: This test evaluates balance ability during a single leg stance. Measures static standing ability (balance with feet fixed).

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

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

Record the time to a tenth of a second.

Cut Off Scores (eyes open)

Less than 10 seconds indicates balance impairment.Less than 5 seconds indicates fall risk.- Take resting vital signs.- Have patient/client stand next to a wall. Measure the height of the iliac crest and patella and mark it on the wall. Then place a piece of tape on the wall half the distance between the two.

NormsAge Sex Eyes Open Eyes Closed60-69 Male 28.7 3.1

Female 25.1 2.570-79 Male 18.3 1.9

Female 11.3 2.280-99 Male 5.6 1.3

Female 7.4 1.4

ReferencesBohannon R, Larkin P, Cook A, Singer J. 1984. Decrease in timed balance test scores with aging. Phys Ther 64:1067-1070 Vellas BJ, Wayne SJ, Romero L, Baumgartner RN, Rubenstein LZ, Garry PJ. One-leg stance is an important predictor of injurious falls in older persons. J Am Geriatr Soc. 1997;45(6): 735-8.

Single Leg Stance Test Form


TransitionsName____________________________________________________

INSTRUCTIONS“This test helps us to assess your standing balance. I want you to stand on one leg for as long as you can, or until I say stop. Watch while I demonstrate. (Demonstrate using chair/table/counter for initial

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

Date:_____________ Number of Seconds Eyes Open: ________________________ Number of Seconds Eyes Closed: _______________________





Six Minute Walk Test


Transitions

Set-up and EquipmentHallway free of obstacles Stopwatch Tape Measure or Wheel to calculate distanceCones as neededTest Form

General Information: individual walks without physical assistance for six minutes and the distance is measured.

- Start timing when the individual is instructed to “Go”. - Stop timing at six minutes. - Assistive devices can be used but should be kept consistent and documented from test

to test.- if physical assistance is required to walk, this should not be performed. - This test should be performed at the fastest speed possible.

Patient Instructions (derived from references below): “The object of this test is to walk as far as possible for six 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.”

Averages for Six Minute Walk Test

Population(non assistive devices)

Average

Normal Male Elderly (65+) 1484 ftNormal Female Elderly (65+) 1226 ft

Norms for Six Minute Walk Test


TransitionsAge Gender Mean

60-69 Male

Female

498 m 1634 ft.

405 m 1329 ft.

70-79 Male

Female

475 m 1558 ft.

406 m 1332 ft.

80-89 Male

Female No Assist Device

Assist Device

320 m 1050 ft.

282 m 922 ft.

328 m 1076 ft.

197 m 646 ft.

90-101 Male

Female No Assist Device

Assist Device

296 m 971 ft.

261 m 856 ft.

324 m 1063 ft.

224 m 735 ft.

ReferencesButland RJ, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed). 1982 May 29;284(6329):1607-8. McGavin CR, Gupta SP, McHardy GJ. Twelve-minute walking test for assessing disability in chronic bronchitis. Br Med J. 1976; 3;1(6013):822-3. Rossier P, Wade DT. Validity and reliability comparison of 4 mobility measures in patients presenting with neurologic impairment. Arch Phys Med Rehabil. 2001;82(1):9-13.

Six Minute Walk Test Form


TransitionsPatient Name_________________________________________________________________

Assistive Device and/or Bracing Used:______________________________________________

Date:________ Distance ambulated in 6 minutes: _______________




Timed Up and Go Test (TUG) Set-up and Equipment


Transitions

ChairStopwatchTest Form

General Information: Patients are timed (in seconds) when performing the TUG—3 conditions TUG alone-from sitting in a chair, stand up, walk ten feet, turn around, walk back, and sit down.TUG Cognitive-complete the task while counting backwards from a randomly selected number between 20 and 100. TUG Manual-complete the task while carrying a full cup of water.

The time taken to complete the task is strongly correlated to level of functional mobility, (i.e. the more time taken, the more dependent in activities of daily living). Older adults who take longer than 13.5 seconds to complete the TUG have a high risk for falls.

Cut Off Scores

-TUG alone is13.5 seconds or longer-TUG Manual (while carrying a glass of water) is 14.5 seconds of longer-TUG Cognitive (while counting backwards) is 15.0 seconds or longer Norms

AGE SEX MEAN AVERAGE STANDARD DEVIATION60-69 Male 7.3 sec .025

Female 8.1 sec .970-79 Male 6.8 sec 1.1

Female 8.5 sec 2.880-89 Male 13.5 sec 6.3

Female 13.6 sec 5.5Male/Female with Device 11.0 sec 2.2

90-101 Male 23.4 sec 9.2Female 17.0 sec 5.3Male/Female with Device 19.9 sec 2.5

References: Lundlin-Olsson, L., Nyberg, L., & Gustafson, Y. (1998). Attention, frailty, and falls: the effect of a manual task on basic mobilty. Journal of the American Geriatrics Society, 46, 758-761. Podsiadlo, D., & Richardson, S. (1991). The timed “up & go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142-148.

Timed Up and Go Test (TUG) Test Form


TransitionsPatient Name___________________________________________________

DIRECTIONSThe timed “Up and Go” test measures, in seconds, the time taken by an individual to stand up from a standard arm chair (approximate seat height of 46 cm [18in], arm height 65 cm [25.6 in]), walk a distance of approximately 10 feet), turn, walk back to the chair, and sit down. The subject wears their regular footwear and uses their customary walking aid (none, cane, walker). No physical assistance is given. They start with their back against the chair, their arms resting on the armrests, and their walking aid at hand. They are instructed that, on the word “go” they are to get up and walk at your normal pace to a line on the floor 10 feet away, turn, return to the chair and sit down again. The subject walks through the test once before being timed in order to become familiar with the test. Either a stopwatch or a wristwatch with a second hand can be used to time the trial.

INSTRUCTIONS TO THE PATIENT“When I say ‘go’ I want you to stand up and walk to the line, turn and then walk back to the chair and sit down again. Walk at your normal pace.”

Date Time Score Assistive Device Used? Type

Tinetti Gait and Balance TestSet-up and Equipment

Chair


Transitions

StopwatchTest Form

General Information: The Tinetti Gait and Balance Instrument is designed to determine an elders risk for falls within the next year. It takes about 8-10 minutes to complete. The evaluator should review the questions prior to evaluation of the patient and ask any questions regarding the Instrument prior to beginning. The patient is asked to complete the gait portion first with the evaluator walking close behind the elder and evaluating gait steppage and drift. The patient is then asked to complete the balance portion with the evaluator again standing close by the patient (towards the right and in front). The patient is then asked to sit and the score is then totaled.

ScoringThe higher the score, the better the performance. Scoring is done on a three point scale with a range on each item of 0-2 with 0 representing the most impairment. Individual scores are then combined to form three scales: a Gait Scale, a Balance Scale and then and overall Gait and Balance score. The maximum score for gait is 12 points while the maximum for Balance is 16 points with a total maximum for the overall Tinetti Instrument of 28 points.

Score Interpretation<19 indicates a High Risk for Falls19-24 indicates a Moderate Risk for Falls

References

Baloh, R. W., Ying, S. H., et al. (2003). "A longitudinal study of gait and balance dysfunction in normal older people." Archives of Neurology 60(6): 835.

Behrman, A. L., Light, K. E., et al. (2002). "Sensitivity of the Tinetti Gait Assessment for detecting change in individuals with Parkinson’s disease." Clinical Rehabilitation 16(4): 399-405.

Canbek, J., Fulk, G., et. al. (2013). "Test-retest reliability and construct validity of the tinetti performance-oriented mobility assessment in people with stroke." Journal of Neurologic Physical Therapy, 37(1), 14-19.


Transitions

Cipriany-Dacko, L. M., Innerst, D., et al. (1997). "Interrater reliability of the Tinetti Balance Scores in novice and experienced physical therapy clinicians." Archives of Physical Medicine and Rehabilitation 78(10): 1160-1164. Find

Contreras, A. and Grandas, F. (2012). "Risk of falls in Parkinson's disease: a cross-sectional study of 160 patients." Parkinsons Dis 2012: 362572.

Corriveau, H., Hebert, R., et al. (2004). "Evaluation of postural stability in the elderly with stroke." Arch Phys Med Rehabil 85(7): 1095-1101.

Daly, J. J., Roenigk, K., et al. (2006). "A randomized controlled trial of functional neuromuscular stimulation in chronic stroke subjects." Stroke 37(1): 172-178.

Faber, M. J., Bosscher, R. J., et al. (2006). "Clinimetric properties of the performance-oriented mobility assessment." Phys Ther 86(7): 944-954.

Gray, W. K., Hildreth, A., et al. (2009). "Physical assessment as a predictor of mortality in people with Parkinson's disease: a study over 7 years." Mov Disord 24(13): 1934-1940.

Harada, N., Chiu, V., et al. (1995). "Screening for balance and mobility impairment in elderly individuals living in residential care facilities." Phys Ther 75(6): 462-469.

Kegelmeyer, D. A., Kloos, A. D., et al. (2007). "Reliability and validity of the Tinetti Mobility Test for individuals with Parkinson disease." Physical Therapy 87(10): 1369-1378.

Thomas, J. I. and Lane, J. V. (2005). "A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients." Archives of Physical Medicine and Rehabilitation 86(8): 1636-1640.

Tinetti, M. E. (1986). "Performance-oriented assessment of mobility problems in elderly patients." J Am Geriatr Soc 34(2): 119-126.


Transitions

Tinetti Balance Test Form

Name______________________________________________________________

Evaluated Function Description of Behavior Date DateSitting Balance Leans or slides in chair

Steady, safe01

01

Rises From Chair Unable to rise without helpAble to rise using arms to helpAble to rise without arms to help

012

012

Attempts to Rise Unable to rise without helpAble to rise , requires more than one attemptAble to rise, requires one attempt

012

012

Standing Balance(1st 5 seconds)

Unsteady (staggers, moves feet, trunk sways)Steady, but uses walker or other supportSteady without walker or other support

012

012

Standing Balance UnsteadySteady, but with wide stance and uses supportNarrow stance without support

012

012

Nudged Begins to fallStaggers, grabs, catches selfSteady

012

012

Eyes Closed UnsteadySteady

01

01

Turning 360 Degrees Discontinuous StepsContinuous StepsUnsteady (grabs, staggers)Steady

0101

0101

Sitting Down(getting seated)

Unsafe (misjudged distance, falls into chair)Uses arms or not a smooth motionSafe, smooth motion

012

012

TOTAL BALANCE SCORE (Potential Points:16) /16 /16


Transitions

Tinetti Gait Test Form

Name______________________________________________________________

Evaluated Function Description of Behavior Date DateIndication of Gait Any hesitancy of multiple attempts

No hesitancy01

01

Step Length and Height

Step toStep through rightStep through left

011

011

Foot Clearance Foot dropLeft foot clears the floorRight foot clears the floor

011

011

Step Symmetry Right and left step length are not equalRight and left step length appear equal

01

01

Step Continuity Stopping of discontinuity between stepsSteps appear continuous

01

01

Path Marked deviationMild/moderate deviation or uses a walking aidStraight without a walking aid

012

012

Trunk Marked sway or uses a walking aidNo sway, flexes knnes/back/uses arms to balanceNo sway, no flexion of knees or back use of arms, or walking aid

012

012

Walking Time Heels apartHeels almost touching while walking

01

01

TOTAL GAIT SCORE (Potential Points: 12) /12 /12

TOTAL COMBINED SCORE (Potential Points: 28) /28 /28

Two Minute Step Test


Transitions

Set-up and EquipmentBlood Pressure Kit, Pulse OxTapeTape MeasureStopwatchChairTest Form

- Take resting vital signs.- Have patient/client stand next to a wall. Measure the height of the iliac crest and patella and mark it on the wall. Then place a piece of tape on the wall half the distance between the two.- On the signal “go” the patient/client begins stepping (not running) in place, raising each knee to the mark on the wall, for as many times as possible in the 2 minute period. - Only count the number of times the right knee reaches the required height. That is the score.- If the proper knee height cannot be maintained, ask the participant to slow down, or to stop until they can regain the proper form, but keep the stopwatch running.- At the end of the test, provide a cool down by asking the patient/client to walk slowly for a minute.- A person with impaired balance may use the back of a chair as a touch-hold for stability. (Note this modification in your documentation)- One trial only.- Take post exercise vital signs.

ReferencesRikli RE, Jones CJ (1999). Functional fitness normative scores for community residing older adults ages 60-94. Journal of Aging and Physical Activity, 7, 160-179.

Two Minute Step Test


Transitions

Range of scores between the 25% and 75% percentiles

Age Number of steps – Women

Number of steps – Men

60 - 64 75-107 87-115

65 - 79 73-107 86-116

70 - 74 68-101 80-110

75 - 79 68-100 73-109

80 - 84 60-90 71-103

85 - 90 55-85 59-91

90 - 95 44-72 52-86

Scores less than 65 were associated with lower levels of functional ability

Population: community residing older adults ages 60-94 n = 7,183 5,048 women, 2,135 men years education: 14.5 chronic conditions: 1.7 medications: 1.6 performed moderate exercise >3 times/week: 65%

Exclusion criteria: advised not to exercise by physician CHF, joint pain, chest pain, dizziness, angina during exercise BP > 160/100

Two Minute Step Test Form

Patient Name_________________________________________________________________


Transitions

Date:________ Number of Steps in 2 minutes: _______________




Two Minute Walk Test

Set-up and Equipment


Transitions

Hallway free of obstacles Stopwatch Tape Measure or WheelTest Form

General Information: individual walks without assistance for 2 minutes and the distance is measured.

- Start timing when the individual is instructed to “Go”.- Stop timing at 2 minutes. - Assistive devices can be used but should be kept consistent and documented from test

to test. - If physical assistance is required to walk, this should not be performed. - A measuring wheel or tape is helpful to determine distance walked. - This test should be performed at the fastest speed possible.

Patient Instructions (derived from references below): “Cover as much ground as possible over 2 minutes. Walk continuously if possible, but do not be concerned if you need to slow down or stop to rest. The goal is to feel at the end of the test that more ground could not have been covered in the 2 minutes.”

Norms for 2 Minute Walk Test

Population(non assistive devices)

Low Average

Mid Average

High Average

Normal Elderly (65+) 478.5 feet 580.9 feet 921.4 feetLTC Elderly (65+) 137.8 feet 211.6 feet 242.8 feetRetirement Living Elderly (65+) 371.6 feet 413.4 feet 619.5 feet

ReferencesButland RJ, Pang J, Gross ER, Woodcock AA, Geddes DM. Two-, six-, and 12-minute walking tests in respiratory disease. Br Med J (Clin Res Ed). 1982 May 29;284(6329):1607-8. McGavin CR, Gupta SP, McHardy GJ. Twelve-minute walking test for assessing disability in chronic bronchitis. Br Med J. 1976; 3;1(6013):822-3.

Two Minute Walk Test Form

Patient Name_________________________________________________________________


Transitions

Assistive Device and/or Bracing Used:______________________________________________






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