Understanding PT & OT

Functional Tests: Selecting and

Interpreting the Best Assessment

Tools for Your PT & OT PatientsBy: Ernest Roy PT, DPT

Pemi Baker Community Health

About the Presenter

Ernest Roy PT, DPT

30 years practice as a Physical Therapist

9 years in Home Health

Currently Rehab Home Care Team Leader-Pemi Baker Community Health

Guest lecturer for Franklin Pierce University Physical Therapy program

Objectives: Upon completion of the webinar:

Attendees will be able to properly perform at least 6 key functional tests with their patients.

Attendees will be able to appropriately select tests for specific patient populations based on research demonstrating test validity and reliability.

Attendees will possess knowledge of normative values for tests with specific patient populations.

Attendees will possess knowledge of minimal clinically important difference to allow proper test result interpretation at re -assessment.

Attendees will be able to utilize data on test specificity and sensitivity to correctly interpret test results.

Attendees will be able to appropriately gauge patient progress and efficacy of therapy program thru correct use of functional testing.

Attendees will understand how to use functional testing to plan appropriate and safe discharge.

Advantages of Using Functional Testing

Allows comparison to established normative data, often for specific patient populations.

Results are typically numeric, thus satisfying the growing demands for more objective

assessment data to validate the Plan of Care.

Many tests carry predictive powers. Results permit estimates of the likelihood of

certain outcomes, ie, fall risk, remain safely in the community, require SNF placement,

mortality, etc.

Highly useful for identifying Measureable Goals and Outcomes.

Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act

Definitions

Operational Definitions: Function

Function can be thought of as an individual’s ability and willingness to perform a set of

selected tasks.

“All measures involving effort or performance on motor tasks should be considered in

part as measures of behavior.”

Ref: A. Shumway-Cook and M.H. Woollacott, Motor Control:Translating Research into Clinical Practice, Lippincott Williams &

Wilkins, Philadelphia; Baltimore, MD, 2007

Validity: The extent to which a test accurately measures what it is supposed to measure

Reliability: Refers to consistency of results. If the item you are assessing is not

changing, the result of your test should not change. Also refers to the likelihood that 2

trained assessors applying the same test will obtain similar results.

Minimal Detectable Clinical Difference: “The smallest difference in score in the domain

of interest which patients perceive as beneficial and which would mandate, in the

absence of troublesome side effects and excessive cost, a change in the

patient's management.”

Ref: Jaeschke R, Singer J, Guyatt GH. Ascertaining the minimal clinically important difference. Cont Clin Trials. 1989;10:407–415

Minimal Detectable Change

MDC = the minimal amount of change that is required to distinguish a true performance change from a change due to variability in performance or measurement error.

Obtained by calculating the Standard Error of Measurement, which describes absolute reliability

For example: MDC for the TUG test was 1.14 sec for subjects with grade 1-3 knee OA

Ref: Preeti Mohandas Nair, George Hornby T, Andrea Louis Behrman. Minimal Detectable Change for Spatial and Temporal Measurements of GaitAfter Incomplete Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2012 Summer; 18(3): 273–281. doi: 10.1310/sci1803-273

Algahir A, et al. The reliability and minimal detectable change of Timed Up and Go test in individuals with grade 1 – 3 knee osteoarthritis. BMC Musculoskelet Disord. 2015; 16: 174. Published online 2015 Jul 30. doi: 10.1186/s12891-015-0637-8

SpIn and SnOut

More Definitions: Sensitivity &

Specificity

“The specificity describes the ability of a diagnostic test to be correctly negative in the absence of a condition without mislabeling anyone. Thus, a high specificity test has few false positives and is effective in ruling conditions “in” (SpIn).”

“The sensitivity describes the ability of a diagnostic test to identify true conditions without missing anyone by leaving the condition unidentified. Thus, a high sensitivity test has few false negatives and is effective at ruling conditions “out” (SnOut).”

Useful to help establish cut-off scores for test results.

Ref:http://johnwaits.typepad.com/tfmr_clinic_pearls/2010/06/spin-and-snout.html

Example of use of SpIN/SnOut

The MAHC-10 falls risk assessment tool

Initial recommendations for the use of the MAHC-10 set a cutoff score of 4 to identify

patient sat risk of falling

This cutoff score resulted in sensitivity of 96.9% with specificity of only 13.3%

Authors recommended a score of 6 as a better mix of SpIn and SnOut.

Ref: M Calys, K Gagnon, S Jernigan. A Validation Study of the Missouri Alliance for Home Care Fall Risk Assessment Tool.

Home Health Care Management and Practice. Volume: 25 issue: 2, page(s): 39-44 Article first published online: September 6,

2012; Issue published: April 1, 2013 https://doi.org/10.1177/1084822312457942

Outcome Measures used after TKA/THA:

How do Therapists compare with Surgeons?

A 2018 comparison of measures used by NE therapists and orthopedic surgeons found:

Therapists and surgeons use largely different outcome measures.

Surgeons tend to rely on patient reported outcome measures listed in the AJRR guide

Therapists report preferring other measures such as the LEFS, Numeric Pain Scale,

TUG and Single Leg balance tests

Ref:Imada A, Nelms N, Halsey D, Blankstein M, Physical therapists collect different outcome measures after total joint arthroplasty as

compared to most orthopaedic surgeons: a New England study. Arthroplasty Today Volume 4, Issue 1, March 2018, Pages 113-117

Let’s look at some tests!

The Short Physical Performance Battery (SPPB)-a

clinically useful tool:

SPPB consists of 3 subscales

Balance Subscale

4 Meter Walk Test Subscale

Sit to Stand Subscale

Scoring guidelines available at :http://geriatrictoolkit.missouri.edu/SPPB-Score-

Tool.pdf

Ref:Puthoff M, Outcome Measures in Cardiopulmonary Physical Therapy. Cardiopulmonary Physical Therapy Journal. March

2008, Vol 19(1).pp 17-22

MCD, MCID, Reliability for SPPB

MCD: 1 point change in SPPB score “led to meaningful difference in mortality

and nursing home admission.”

MCID: Change in score of 0.54 to 1.34 was found to correlate with small to

substantial change in patient mobility respectively.

Reliability: ICC of 0.88 to 0.92 for a group of 1002 female subjects

SPPB scoring distributions

Score Classification

0-3 Severe Limitations

4-6 Moderate Limitations

7-9 Mild Limitations

10-12 Minimal Limitations

Ref: 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. N Engl J Med. 1995 Mar 2;332(9):556-61.

Chair stand tests

Five times sit to stand test (FTSTST)

MDC was 2.3 seconds in study of 49 patients in a phase 2 or 3 cardiac rehab

program.

A study of older (mean age 73.6 ) females by Goldberg et al, showed MDC of

2.5 seconds

The Goldberg study also noted differences in mean time for the FTSTST

between normal older subjects at 13.4 seconds and 16.4 seconds with older

subjects having balance dysfunction

Ref: Michael L. Puthoff, PT, PhD, GCS1 and Dan Saskowski, MA2 Reliability and Responsiveness of Gait Speed, Five Times Sit to

Stand, and Hand Grip Strength for Patients in Cardiac Rehabilitation. Cardiopulm Phys Ther J. 2013 Mar; 24(1): 31–37.

Ref: Allon Goldberg, Martina Chavis, Johnny Watkins and Tyler Wilson. The five-times-sit-to-stand test: validity, reliability and

detectable change in older females. Aging Clinical and Experimental Research. 2012.Vol 24,#4. 339-344.

Norms for FTSTST

ref: Bohannon et al, Sit-to-stand test: Performance and determinants across the age-span. Isokinet Exerc Sci. 2010; 18(4): 235–240

Age (n) Mean ± SD (95% CI) Min-Max

14–19 (25) 6.5 ± 1.2 (6.0–7.0) 4.7–9.7

20–29 (36) 6.0 ± 1.4 (5.6–6.5) 3.9–11.2

30–39 (22) 6.1 ± 1.4 (5.5–6.8) 4.1–10.4

40–49 (15) 7.6 ± 1.8 (6.6–8.6) 5.6–13.2

50–59 (20) 7.7 ± 2.6 (6.5–8.9) 4.2–12.1

60–69 (25) 7.8 ± 2.4 (6.8–8.7) 4.7–15.1

70–79 (24) 9.3 ± 2.1 (8.4–10.1) 5.5–13.3

80–85 (14) 10.8 ± 2.6 (9.3–12.3) 5.8–17.6

30 second chair stand test

Study performed on 156 patients elderly patients admitted to an ED

Study used a cutoff of 8 repetitions. Those able to do < 8 reps were classified as low

physical performance, > 8 reps = high performance

Study found decreases in 30 sec chair stand rep count correlated with increased ADL

dependency

ADL’s of bathing, cooking, dressing, cleaning, shopping were more likely to be

dependent if 30 sec chair stand reps were < 8.

Ref: Hansen Bruun I, Mogensen CB, Nørgaard B, Schiøttz-Christensen B, Maribo T, Validity and Responsiveness to Change of the 30-Second Chair-

Stand Test in Older Adults Admitted to an Emergency Department. J Geriatr Phys Ther. 2017 Dec 7. doi: 10.1519/JPT.0000000000000166

Norms for 30 second chair stand

Age-Sex cut off scores via CDC data are:

Men Women

Ages 60-64 <14 reps <12 reps

Ages 65-69 <12 reps <11 reps

Ages 70-74 <12 reps <10 reps

Ages 75-79 <11 reps <10 reps

Ages 80-84 <10 reps < 9 reps

Ref:https://www.cdc.gov/steadi/pdf/30_second_chair_stand_test-a.pdf

Let’s practice.

Mr. Smith, recovering from pneumonia & a fall; initial FTSTST, 22.4 sec., after 2 weeks,

20.6 sec. What does result indicate?

1.He has actually improved his ability for chair transfers.

2.His ability for chair transfers has deteriorated.

3.His ability for chair transfers is largely unchanged.

Walking tests, Average Gait Speed

“The 6th Vital Sign”

“Gait speed has been shown to be an indicator of disability, health care utilization, and

survival in older adults”

“a simple, reliable, and feasible measure to perform in the clinic and has been promoted

as the next vital sign, providing insight into patients’ functional capacity”

“Gait speed is mainly determined by exercise capacity but reflects global well-being as

it captures many of the multisystemic effects of disease severity”

Ref:Karpman C, Benzo R, Gait speed as a measure of functional status in COPD patients. International Journal of COPD 2014:9 1315–

1320

Gait Speed Tests

4 Meter walk test

Requires relatively small amount of space. 4 meters = 13.12 feet

Can be timed using stopwatch function on your smart phone.

Test is typically performed from a standing start, although versions with a walking start

can be performed.

Ref: Karpman K, Benzo R, Gait speed as a measure of functional status in COPD patients. International Journal of COPD 2014:9 1315–

1320

Utility of gait speed tests

Older adults were more likely to be hospitalized and require a caregiver with avg gait

speeds of < 0.7 meters/sec

A 0.2 meter/sec increase in gait speed reduced risk of hospitalization.

Gait speed of < 0.5 meters/sec has been identified as an independent predictor of

falling.

MDC for gait speed by Diagnosis

Community Dwelling Older Adults:

Aged 60 years +-MDC = 0.14 meters/second

Parkinson’s Disease:

0.09 meters/second

Status Post Hip fracture

0.08 meters/second

Ref:Middleton A, Fritz S, Lusardi M. Walking Speed: The Functional Vital Sign. J Aging Phys Act. 2015 Apr; 23(2): 314–322. Published online 2014 May 2. doi: 10.1123/japa.2013-0236

MCID for comfortable gait speed

Systematic review of research on comfortable gait speed resulted in 7 studies meeting

criteria. Findings:

Populations in study samples included MS, s/p CVA, hip fracture, and mixed

populations.

Majority of MCID’s were found to be between 0.10 and 0.20 meters/second

Authors stated that “Changes in gait speed of 0.10 to 0.20 m s(-1) may be important

across multiple patient groups”

Ref: :Bohannon RW, Glenney SS, Minimal clinically important difference for change in comfortable gait speed of adults with pathology:

a systematic review. J Eval Clin Pract. 2014 Aug;20(4):295-300. doi: 10.1111/jep.12158. Epub 2014 May 5

Gait Speed tests and Heart Failure

Gait speed = Prognosis in HF

Study of 331 community dwelling patients 70 y/o or > .

Subject results were grouped in tertiles (<0.65, 0.66 to 0.99, 1.0 meters /sec or >) via 4 meter walk test results

Study looked at mortality among the tertiles based on 4 meter walk test speeds

Ref: Pulignano G, et al, Incremental value of gait speed in predicting prognosis of older adults with heart failure: Insights from the IMAGE-HF Study. JACC-Heart Failure. Vol 4, No 4. April 2016. 289-98

Gait speed and cognition in HF

Subjects in each Tertile were assessed with the Mini Mental State Exam. Results:

53% of HF patient in tertile (slowest gait speed) 1 had MMSE score of < 24

41% of tertile 2 subjects had MMSE score < 24

Only 10% of those in tertile 3 had MMSE score < 24

Functional Gait Assessment

10 item test based on the Dynamic Gait Index.

A total of ten items are assessed, with scores for each item being 0,1,2,or 3. Maximum possible score = 30, with higher scores indicative of better ambulation and balance abilities.

Interrater and intrarater reliability was excellent, based on ICC of 0.99

MDC for stroke patients was found to be 5 points.

MDIC for vestibular disorders = 8 points

Ref:Yaqin Yang, MD, Yongjun Wang, MD,∗ Yanan Zhou, BD, Chen Chen, BD, and Deli Xing, BD. Reliability of functional gait assessment in patients with Parkinson disease, Interrater and intraraterreliability and internal consistency. Medicine (Baltimore). 2016 Aug; 95(34): e4545. Published online 2016 Aug 26. doi: 10.1097/MD.0000000000004545

Ref: Lin, J. H., Hsu, M. J., et al. (2010). "Psychometric comparisons of 3 functional ambulation measures for patients with stroke." Stroke 41(9): 2021-2025

Figure of 8 walking test

“A F8W test time of 8.2 s was found to be the most representative for discriminating between healthy elderly and stroke subjects.”

This time resulted in a sensitivity of 100% and a specificity of 89.7%.

Study by Hess showed mean times for adults 65 y/o or > to be 10.5 sec, with mean # of steps = 17.5

Ref:Wong SS, Yam MS, Ng SS The Figure-of-Eight Walk test: reliability and associations with stroke-specific impairments.Disabil Rehabil. 2013;35(22):1896-902. doi: 10.3109/09638288.2013.766274. Epub 2013 Apr 19.

Ref: Hess R, Brach J, Piva S, Swearingen J. Walking Skill Can Be Assessed in Older Adults: Validity of the Figure-of-8 Walk Test. Phys Ther. 2010 Jan; 90(1): 89–99. doi: 10.2522/ptj.20080121

The Six Minute Walk Test: usefulness and

Normative values

6 Minute Norms for Healthy Seniors

Ref: Steffen, T. M., Hacker, T. A., et al. (2002). "Age- and gender-related test performance in community-dwelling elderly people: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and gait speeds." Physical Therapy 82(2): 128-137.

Mean Distance in Meters by Age &

Gender

Age Male Female

60-69 yrs 572 m 538 m

70-79 yrs 527 m 471 m

80-89 yrs 417 m 392 m

PD and Six Minute walk test-norms

80 PD patients with mild to moderate PD, assessed via Six Minute walk test.

Median age was 66 years, 24 F, 66 M

Median HY stage was 2.3

Median Six Minute Walk distance was 394m with SD of 98.4m. (152-613)

Ref: Falvo MJ, Earhart GM. Reference Equation for the Six Minute walk Test in Individuals with Parkinson's Disease. J Rehabil Res

Dev. 2009, 46(9); 1121-1126

MCID for 6MWT

Research conducted by Prof RW Bohannon –currently Prof of Physical Therapy at Campbell Univ. in NC

Bohannon examined a total of 6 studies using the 6 MWT in a variety of patient populations

Patient types included: CAD, COPD, fear of falling, Lung CA

MCID’s ranged from 14 to 31 meters. (46 to 101 feet)

Ref: Bohannon RW, Crouch R. Minimal clinically important difference for change in 6-minute walk test distance of adults with pathology: a systematic review. J Eval Clin Pract. 2017 Apr;23(2):377-381. doi: 10.1111/jep.12629. Epub 2016 Sep 4

Normative distances for 6 Min Walk-CVA

survivors

A systematic review and meta analysis of 127 studies involving > 6000 patients found:

Stroke survivors attained median distance of 284 meters on 6MWT, with SD of 107

meters.

Stroke survivors attained greater distances using a 30 meter walkway vs a longer

walkway or a continuous oval.

Interestingly, whether subjects pivoted left or right did not impact total distance.

Ref: Dunn A, et al. Review Article. Protocol Variations and Six-Minute Walk Test Performance in Stroke Survivors: A Systematic Review with Meta-

Analysis. Stroke Research and Treatment Volume 2015, Article ID 484813, 28 pages http://dx.doi.org/10.1155/2015/484813

6MWT Norms for MS subjects

64 community dwelling subjects were classified using EDSS as either mild or moderate

impairment. Results showed:

Mean Distance for MS subjects with mild disability:

Male = 459 meters Female = 380 meters

Mean Distance for MS subjects with moderate disability:

Male = 237 meters Female = 175 meters

Ref:Jane L. Wetzel, Donna K. Fry, Lucinda A. Pfalzer. Six-Minute Walk Test for Persons with Mild or Moderate Disability from Multiple Sclerosis:

Performance and Explanatory Factors. Physiotherapy Canada, Volume 63, Number 2. 2010;preprint. doi:10.3138/ptc.2009-62

Prognostic value of 6MWT with heart

failure

142 patients completed two 6MWT’s, within one month. Mean f/u period was 14 months.

6MWT was found to be an independent predictor of outcome.

Primary outcome measure was a combined endpoint consisting of hospitalization for

HF and/or death for cardiac reasons.

43 patients reached this endpoint within the mean f/u time

A 6 MWD of < 330 meters was associated with a worse outcome in this study

Ref: Caroline Zotter-Tufaro, et al.Prognostic Significance and Determinants of the 6-Min Walk Test in Patients With Heart Failure and Preserved

Ejection Fraction JACC: Heart Failure .Volume 3, Issue 6, June 2015 DOI: 10.1016/j.jchf.2015.01.010

Useful tests for Patients with Pulmonary

Disease

Prognostic use of 6 MWT for COPD

6 MWT was studied in 104 COPD patients who were followed up a mean duration of 590 days. Findings:

11 patients became deceased during the f/u period.

Mean distance walked for patients who expired was 250 meters. Mean distance for survivors was 480 meters.

Mean Spo2 was 74% for subjects who died during f/u, vs. 86.6% for survivors

Ref: Golpe R, Pérez-de-Llano LA, Méndez-Marote L, Veres-Racamonde A. Prognostic value of walk distance, work, oxygen saturation, and dyspnea during 6-minute walk test in COPD patients. Respir Care 2013 Aug, 58 (8) 1329-34. doi: 10.4187/respcare.02290.

4 Meter Walk test with COPD patients

4 meter walk test was measured in a sample of 586 COPD patients.

Correlated well with 6 MWT benchmark distances for poor (<350 meters) and very poor (< 200 meters) distances.

Speed of 0.8 meters/sec had positive predictive value of 69%, negative predictive value of 98% in predicting very poor exercise capacity.

MCID for usual gait speed is between 0.08 and 0.11 meters/sec

Ref: Kon S, et al. Reliability and validity of 4-metre gait speed in COPD. European Respiratory Journal 2013 42: 333-340; DOI: 10.1183/09031936.00162712

Other recommended functional tests for

pulmonary patients

Review of 42 published articles describing functional tests for COPD patients found:

Gait speed, sit to stand, and 6 min walk test were found to be reproducible, reliable, and valid tests in patients with COPD.

“Outcomes of these tests are correlated with mortality, physical activity in daily life, exercise capacity, dyspnea and quality of life. “

MDC for the 10 meter walk test in COPD was 0.3 to 0.4 meters/sec

MDC for TUG was 1.84 to 2.68 sec.

Ref: Bisca G, et al, Simple Lower Limb Functional Tests in Patients With Chronic Obstructive Pulmonary Disease: A Systematic Review. Archives of physical medicine and rehabilitation. August 2015. 96(12)

Marques A, Reliability, Agreement and Minimal Detectable Change of the Timed Up & Go and the 10-Meter Walk Tests in OlderPatients with COPD. COPD: Journal of Chronic Obstructive Pulmonary Disease .Volume 13, 2016 - Issue 3: 279-287

Balance-Oriented tests

Timed Get Up & Go and PD patients

Study pulled data on 2097 PD patients from 16 participating National Parkinson's Foundation Centers of Excellence.

Mean HY score was 2.37.

Mean TUG result for the non –fallers was 12.09 (5.41)seconds. Fallers = 16.72 (7.73) seconds

Mean TUG for Overall correct classification (fall vs non-fall) was 74%

MDC of 3.5 seconds

Ref: Nocera JR, Stegemöller EI, Malaty, I MD, Okun M, Marsiske M, Hass C, and National Parkinson Foundation Quality Improvement Initiative Investigators. Using the Timed Up & Go Test in a Clinical Setting to Predict Falling in Parkinson's Disease. Arch Phys Med Rehabil. 2013 Jul; 94(7): 1300–1305

Ref:Huang SL, Hsieh CL, Wu RM, Tai CH, Lin CH, Lu WS. Minimal detectable change of the timed "up & go" test and the dynamic gait index in people with Parkinson disease. Phys Ther. 2011 Jan;91(1):114-21. doi: 10.2522/ptj.20090126. Epub 2010 Oct 14.

.

TUG in patients with mild-moderate OA

of the knee

Study of 65 subjects with grade 1-3 OA of the knee

MDC = 1.10 seconds

Inter rate reliability of 0.96, intra rater reliability was 0.97.

Ref: Alghadir A, et al. The reliability and minimal detectable change of Timed Up and Go test in individuals with grade 1 – 3 knee osteoarthritis. BMC Musculoskelet Disord. 2015; 16: 174

The Berg Balance Scale- MDC

A systematic review of 1363 healthy community dwelling seniors 70 y/o and older

found range of scores from 36 to 55.

MDC’s for BBS in study of elderly subjects ranged from 3.3 to 6.3 depending on

starting score

Study on stroke survivors noted MDC of approx. 4.5

Ref: Downs S, et al, Normative scores on the Berg Balance Scale decline after age 70 years in healthy community-dwelling people: a systematic

review. J Physiother. 2014 Jun;60(2):85-9. doi: 10.1016/j.jphys.2014.01.002. Epub 2014 Jun 13.

Ref: Donoghue, D. and Stokes, E. K. How much change is true change? The minimum detectable change of the Berg Balance Scale in elderly people.

J Rehabil Med 2009 41(5): 343-346

Ref:Hiengkaew et al, Arch Phys Med Rehabil 93(7): 1201-1208 2012

Four Square Step Test (FSST)

A simple, valid field test for assessment of balance & fall risk

Diagram shows the stepping patterns required.

Time to complete 1 full lap is recorded

Obstacles used are typically canes, yardsticks, or similar

Ref: Moore M, Barker K, The validity and reliability of the four square step test in different adult populations: a systematic review. Syst Rev. 2017; 6: 187.Published online 2017 Sep 11. doi: 10.1186/s13643-017-0577-5

FSST with stroke survivors

Study comparing responses to the FSST among 15 stroke survivors vs 15 age matched

(median age = 57 y/o)healthy control subjects found:

Median time for healthy subjects was 7.49 with SD of 2.34 sec.

Median for stroke survivors was 17.74 with SD of 9.12 sec.

A cutoff time of 11 seconds discriminated stroke survivors from healthy controls.

MDC has been calculated at 6.73 sec for stroke survivors with a modified version using

tape markers on floor instead of canes/sticks

Ref: Goh, EY et al. Reliability and Concurrent Validity of Four Square Step Test Scores in Subjects With Chronic Stroke: A Pilot Study. Archives of

Physical Medicine and Rehabilitation 2013;94:1306-11

Ref: Roos MA, et al. Development of the Modified Four Square Step Test and its reliability and validity in people with stroke. JRDD. 2016. 54(3):

403-412

FSST and Parkinson’s patients

Study of 53 PD subjects by Duncan and Earhart found:

Median time of 9.59 seconds with medication, 11.02 seconds off meds.

Cut off score for fall risk in PD was 9.68 seconds.

Sensitivity was 0.73, Specificity was 0.57

Ref:Duncan RP, Earhart GM. Four square step test performance in people with Parkinson disease..J Neurol Phys Ther. 2013 Mar;37(1):2-8. doi:

10.1097/NPT.0b013e31827f0d7a.

The 2 Minute Step test

Subject stands upright next to a wall. They are asked to lift the knee to a marker

placed between the patella and top of iliac crest

Subject may hold onto a chair or wall for balance.

Steps alternate from R to L LE. Resting is allowed. Total # of steps to marker in 2

minutes is recorded.

Ref: Jones C.J., Rikli R.E., Measuring functional fitness of older adults, The Journal on Active Aging, March April 2002, pp. 24–30

2 Minute Step Test Norms-Males

2 Minute Step Test Norms-Females

2 Minute Step Test in Heart Failure

patients

Study in 2012 at Kent State Univ. Dept. of Psychology assessed 145 patients diagnosed

with heart failure (HF). Study found:

Mean age was 68.97 years. NYHA was class II or III.

Mean # of steps on 2MST was 58.9 overall

13.8% of participants exhibited impairments in attention, 11.9% showed impairment in

executive function, and 14.5% had impairment in memory

Ref: Alosco ML, et al. The 2-Minute Step Test is Independently Associated with Cognitive Function in Older Adults with Heart Failure. Aging Clin

Exp Res. 2012 Oct; 24(5): 468–474. Published online 2011 Dec 19. doi: 10.3275/8186

The Mini-Best Test (MBT)

Developed as a shorter alternative to the full BEST test. Consists of various balance domains including:

Anticipatory, Reactive Postural Control, Sensory Orientation, & Dynamic Gait

Normative Scores

Ages 60-69 22.4

Ages 70-79 21.6

Ages 80-89 16.2

Ref: Franchignoni, F., Horak, F., Godi, M., Nardone, A., & Giordano, A. (2010). Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. Journal of Rehabilitation Medicine : Official Journal of the UEMS European Board of Physical and Rehabilitation Medicine, 42, 323–331. doi:10.2340/16501977-0537

Ref:Sara Isabel Lebre de Almeida, Alda Marques, Joana Santos, Normative values of the Balance Evaluation System Test (BESTest),Mini-BESTest, Brief-BESTest, Timed Up and Go Test and Usual Gait Speed in healthy older Portuguese people. Rev Port Med Geral Fam 2017;33:106-16

MDC/MCID for the Mini BEST

Balance Disorders_ MDC = 3.5 points, PD- MDC = 5.52 points

PD – MDIC was 4 points

Leddy noted a cut off score using a percentile of items passed of 72%.

This gave a Sensitivity of 0.96 but a low specificity of 0.47.

The more balanced Spin and SnOut values were with cut off at 63% passed items (Sensitivity of 0.88, Specificity of 0.78

Ref:Godi, M., Franchignoni, F., et al. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther 2013. 93(2): 158-167.

Leddy, A. L., Crowner, B. E., et al. Utility of the Mini- BESTest, BESTest, and BESTest sections for balance assessments in individuals with Parkinson disease. J Neurol Phys Ther 2011.35(2): 90-97

For detailed description of each test

domain, go to:

http://www.bestest.us/files/7413/6380/7277/MiniBEST_revised_final_3_8_13

.pdf

Functional Reach Test (FRT)

Norms: Age Men Women

41–69 38.05 cm 35.08 cm

70–87 33.43 cm 26.59 cm

Among stroke survivors, reach of < 15.24 cm was associated with a 4x greater risk for falls 6 months post CVA

FRT differentiated recurrent fallers at a threshold of 18.15 cm

Ref: Williams B, et al, Real-Time Fall Risk Assessment Using Functional Reach Test. International Journal of Telemedicine and Applications. Int J Telemed Appl. 2017;2017:2042974. doi: 10.1155/2017/2042974. Epub 2017 Jan 10

Ref: Alenazi AM, et al. Functional Reach, Depression Scores and Number of Medications are Associated with Number of Falls in People with Chronic Stroke. PM R. 2017 Dec 26. pii: S1934-1482(17)30536-1. doi: 10.1016/j.pmrj.2017.12.005.

What items appear most related to

falls in PD?Comparison of 3 tests (Mini-BEST, BBS and FABS) in terms of ability to predict falls in PD subjects.

All 3 measures were similar in accuracy, with AUC from 0.65 to 0.69

Study found only some items of each test were useful to predict falls

The 6 items were "tandem stance," "rise to toes," "one-leg stance," "compensatory stepping backward," "turning," and "placing alternate foot on stool.”

Ref:Schlenstedt C, Brombacher S, Hartwigsen G, Weisser B, Möller B, Deuschl G. Comparison of the Fullerton Advanced Balance Scale, Mini-BESTest, and Berg Balance Scale to Predict Falls in Parkinson Disease. Phys Ther. 2016 Apr;96(4):494-501. doi: 10.2522/ptj.20150249. Epub 2015 Sep 17.

.

Hand/UE Function tests

Disabilities of the Arm Shoulder & Hand

Scale (DASH)

Study results based on 255 patients referred to PT for intense rehab related to upper

extremity disorders using DASH and QuickDASH tests

MCID: Data suggested a range of 10.83 to 15 points for DASH, & 15.9 to 20 for

QuickDash

MDC = 10.81 points for DASH & 12.85 points for QuickDASH

Study found the 11 item Quick Dash to have high test-re test reliability, comparable to

the DASH

Ref: Franchiognoni F, et al. Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand Outcome

Measure (DASH) and Its Shortened Version (QuickDASH). Journal of Orthopaedic & Sports Physical Therapy, January 2014, volume

44 (1) 30-39.

Nine Hole Peg Test

Set of norms was established using 703 subjects aged 21 to 71+ years of age.

Interrater Reliability was high, 0.984 right, 0.993 left hand

Norms at: https://pdfs.semanticscholar.org/ed3e/796aa8b589ec7cadf8a03f 19e7f83e8c04d7.pdf

SRC for MS patients = 5.32 seconds. MDC = 12.69 sec for stroke survivors

Ref: : Grice KO, Vogel KA, Le V, Mitchell A, Muniz S, Vollmer MA, Adult norms for a commercially available nine hole peg test for finger dexterity. American Journal of Occupational Therapy. Sept/Oct 2003, Vol 57, #5. 570-3.

Feys P et al, The Nine-Hole Peg Test as a manual dexterity performance measure for multiple sclerosis. Mult Scler. 2017 Apr; 23(5):711-720

Achacheluee A, et al, The Test-Retest Reliability and Minimal Detectable Change of the Fugl-Meyer Assessment of the Upper

Extremity and 9-Hole Pegboard Test in Individuals With Subacute Stroke. PHYSICAL TREA MENTS January 2016. Volume 5. Number 4

Nine Hole Peg test and PD patients

262 PD patients assessed with Nine Hole Peg test, median HY stage 2.3.

Average time to complete test was 31.4 s dominant hand side and 32.2 s for

non-dominant hand side.

Women were significantly faster than men

MDC = 2.6 sec for dominant hand, 1.3 sec for non-dominant

Ref: Earhart GM, Cavanaugh JT, Ellis T, Ford MP, Foreman KB, Dibble L. The 9-hole PEG test of upper extremity function:

average values, test-retest reliability, and factors contributing to performance in people with Parkinson disease. J Neurol Phys

Ther. 2011 Dec;35(4):157-63. doi: 10.1097/NPT.0b013e318235da08.

Grip strength tests

MCID & Means for grip strength

Lang, et al, noted MCID of 5 kg and 6.2 kg (dominant and non dominant hemiparetic hands respectively) in their study of grip strength in 52 stroke survivors.

Means vary slightly by author. Jamar user manual for example places median for 60-69 y/o males @ 90-91 lbs. Study in Australia published in 2011 found median for 60-69 y/o males at 88 lbs.

Ref: Lang, C. E., Edwards, D. F., et al.. Estimating minimal clinically important differences of upper-extremity measures early after stroke. Arch Phys Med Rehabil 2008.89(9): 1693-1700

Ref: Massey-Westropp MN, et al. Hand Grip Strength: age and gender stratified normative data in a population-based study. BMC Res Notes. 2011; 4: 127.

Grip strength and prediction of

outcomes

PURE study involving nearly 139,691 subjects in 17 countries on 5 continents. Data on

grip strength found:

During a 4 year f/u period, 2% of the subjects were deceased.

Grip strength was found to be inversely associated with all-cause death, CVA,

cardiovascular mortality, and MI.

Grip strength was a better predictor of cardiovascular mortality than systolic BP.

Ref: Leong DP et al. Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet. 2015 Jul

18;386(9990):266-73. doi: 10.1016/S0140-6736(14)62000-6. Epub 2015 May 13

Use what you have learned: Mrs. Baker

74 y/o COPD patient, recently D/C home from a SNF after a 2 week stay s/p

pneumonia & exacerbation of her COPD. She walks with a cane due to a TKA

she had 7 months prior. 1 fall about a year ago. Can get out of her dining

room captain’s chair by herself but husband has to help her stand from the

sofa.

She states her biggest concern is “being able to walk enough to do some of

my gardening again this spring, my stamina is really bad now”

What tests might you choose to help you assess the important aspects of Mrs.

Baker’s current function and draft a plan of care to help her reach her goal of

gardening again?

Sources for Functional Test info

APTA maintains a webpage with an extensive listing of functional tests

Web address is :http://www.ptnow.org/tests-measures.

Shirley Ryan Ability Lab (Formerly Rehab Institute of Chicago)-website has large array

of data and references for functional testing

Web Address is : https://www.sralab.org/

Questions? Comments?

Thank you for Attending!

Ernest Roy PT, DPT

Home Care Rehab Team Leader

Pemi Baker Community Health

Email: eroy@pbhha.org

Phone: 603-536-2232