Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests

Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests Acute care handbook for physical therapists (fourth edition) chapter 23 functional tests

Functional Tests 23

Paul E.H Ricard

CHAPTER OBJECTIVE

To provide a description of functional tests applicable to the inpatient acute care setting, including a description of how to perform each test, the applicable population, and how results may be interpreted.

PREFERRED PRACTICE PATTERNS

These functional tests and outcome measures apply to many body systems For this reason, specific practice patterns are not delineated in this chapter Please refer to Appendix A for a complete list of the preferred practice patterns in order to best delineate the most applicable practice pattern for a given patient

Clinicians frequently look for the “best” test for particular functional activities (e.g., balance)

To date, however, few if any “gold standard” functional tests have been identified in the litera-ture Several contributing factors are that functional activities have multisystem components and outcomes can vary based on environment, time of day, or prior patient practice The purpose of this chapter is therefore to describe more common functional tests that can objec-tively measure the functional levels of various patient populations in the acute care setting, and not to compare one test to another

Fortunately, the literature on functional tests and measures is consistently expanding Although attention should be paid to the patient population used to validate each test described in this section, a particular functional test still may be useful in patient examination and evaluation in a population not yet specifically studied A clinician should consider all factors when interpreting the outcomes of any clinical test and continue to read current litera-ture to keep abreast with changes in test validation and interpretation

CHAPTER OUTLINE

Berg Balance Scale

Procedure

Interpretation of Results

Timed “Up and Go” Test

Procedure

Interpretation of Results

Functional Reach Test

Procedure

Interpretation of Results

Tinetti Performance Oriented

Mobility Assessment

Procedure

Interpretation of Results

Sit-to-Stand Tests

Short Physical Performance

Battery

Acute Care Index of Function

Exercise Testing

Six-Minute Walk Test

Incremental or Ramp

Exercise Tests

Conclusion

Appendix 23A Functional Tests

A Performance Oriented

Mobility Assessment I

B Short Physical Performance

Battery

CLINICAL TIP

The American Physical Therapy Association (APTA) has online tools to assist with making evidence-based practice decisions, such as “Hooked on Evidence,” and “Open Door.”1 Individual hospital facilities may also have online resources that are updated and reflect evidence-based practice for particular patient populations.2

The functional tests presented in this chapter were selected because of their ease of use, reliable and valid test results, and the appropriate population in the acute care setting Where applicable, interrater (tested by different therapists) and intrarater (retested over time by a single therapist) reliability3 and content,* construct,† and predictive‡ validity will be noted

in the respective description of each test.3

Berg Balance Scale The Berg Balance Scale (BBS) is a 56-point scale that evaluates 14 tasks Katherine Berg developed this test to assess the level of function and balance in various patient

‡ Predictive validity: Ability of a test to predict future performance.

† Construct validity: Degree to which a theoretical construct is measured against the test.

*Content validity: Degree to which a test actually measures what it was designed for.

populations.4Table 23-1 describes the appropriate population,

required equipment, completion time, reliability, and validity

of the BBS

Interpretation of Results

Higher scores on the BBS indicate greater independence and better ability to balance.7 In contrast, lower scores indicate a greater fall risk Prior evidence suggested that a total score of less than 45 predicted that the patient is at risk for falls.8,9

However, more recent literature by Katherine Berg discourages the use the score as a dichotomous scale (i.e., determining fall risk based on values being greater than or less than 45 points).10

Rather, the score should be used to represent a continuum of balance, through the use of likelihood ratios.10

CLINICAL TIP

For patients with multiple sclerosis, the BBS is reported to be

less efficient in discriminating between patients who tend to fall

as compared to patients less likely to fall.5

TABLE 23-1 Overview of the Berg Balance Scale

Elderly patients who

have sustained acute

cerebrovascular

accident and/or are

in a rehabilitation

setting

Ruler Stopwatch Chair Step stool Flat surface

10-20 minutes required

to complete test Interrater reliability: ICC = 0.98

rs = 0.88 Intrarater reliability:

ICC = 0.98 Internal consistency:

Cronbach’s alpha = 0.96

Concurrent validity:

Tinetti, r = 0.91 Get up and go, r = −0.76

Predictive validity:

<45 score predicts falls (sensitivity 53%)

ICC, Intraclass correlation coefficient; r, correlation coefficient; rs, Spearman’s rank correlation coefficient.

Data from Thorbahn L, Newton R: Use of the Berg Balance Test to predict falls in elderly persons, Phys Ther 76(6):576-583, 1996; Conradsson M, Lundin-Olsson

L, Lindelof N et al: Berg Balance Scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facili-ties, Phys Ther 87:1155-1163, 2007; Thompson M, Medley A: Performance of community dwelling elderly on the timed up and go test, Phys Occup Ther Geriatr 13(3):17-30, 1995; Whitney S, Poole J, Cass S: A review of balance instruments for older adults, Am J Occup Ther 52(8):666-671, 1998; Berg K, Wood-Dauphinee

S, Williams JI, et al: Measuring balance in the elderly: preliminary development of an instrument, Physiother Can 41:304, 1989.

Procedure

The patient is evaluated and graded on a sequence of balance

activities, such as sitting unsupported with arms folded, rising,

standing, transferring between one surface and another,

reach-ing forward in standreach-ing, pickreach-ing up objects off the floor, turnreach-ing

around in a full circle, and standing on one leg.4 Scoring for

each task ranges from 0 to 4 A score of 0 indicates that the

patient is unable to complete a particular task A score of 4

indicates that the patient can completely carry out the task.4

The 14 tasks consist of6:

• Sitting to standing

• Standing unsupported

• Sitting unsupported

• Standing to sitting

• Transfers

• Standing with eyes closed

• Standing with feet together

• Reaching forward with an outstretched arm

• Retrieving object from floor

• Turning to look behind

• Turning 360 degrees

• Placing alternate foot on stool

• Standing with one foot in front of the other foot

• Standing on one foot

A short form of the BBS has been developed and demonstrates

psychometric test properties similar to those of the original BBS

The short form of the BBS includes 7 activities rather than 14,

and the scoring levels are reduced to three (0, 2, 4) This

modi-fied BBS has been shown to have good validity and reliability

in patients who have had a cerebrovascular accident (CVA).6

Box 23-1 outlines the seven items on this modified BBS

BOX 23-1 Short Form of Berg Balance Scale

Items:

• Reaching forward with outstretched arm

• Standing with eyes closed

• Standing with one foot in front

• Turning to look behind

• Retrieving object from floor

• Standing on one foot

• Sitting to standing

Data from Chou CY, Chien CW, Hsueh IP et al: Developing a short form of the Berg Balance Scale for people with stroke, Phys Ther 86:199, 2006.

CLINICAL TIP

The modified BBS was developed with patients who have had

a CVA To date, the validity of this test has not been evaluated

on any other patient populations

CLINICAL TIP

In patients who are over 65 years of age and are dependent in

at least one personal activity of daily living, a change of 8 points

on the BBS is necessary to demonstrate a genuine change in function.11

Timed “Up and Go” Test The “up and go” test was originally developed in 1986 to serve

as a clinical measure of balance in elderly people.12 The original

TUG score of 24 seconds or more are more likely to fall in the next 6 months than are patients with scores of less than

24 seconds.17 When used in an acute care setting, this test can objectively demonstrate improvements in balance and ambula-tion Over the course of therapy, it is expected that the time the patient takes to complete the TUG test will decrease as the patient improves.14

test used a numeric scoring system to determine a patient’s level

of balance but was later modified to a timed version by Posiadlo

and Richardson in 1991.13 The TUG test uses a time score to

assess gait and balance in the elderly population and is

sum-marized in Table 23-2.14

Procedure

The patient is timed during a five-part mobility task from start

to finish The task consists of the following15:

1 Rising from an armchair

2 Walking 3 meters

3 Turning around

4 Walking 3 meters back to the armchair

5 Sitting down

It is important to instruct the patient to walk at a

comfort-able and normal pace to maintain safety throughout the test It

is appropriate to provide assistance for the patient if it is needed

Documenting the level of assistance (i.e., assistive device,

contact guard) is essential in demonstrating progress when

per-forming the test over time

Interpretation of Results

Test completion in fewer than 20 seconds indicates that the

patient is independent with functional mobility.15 The time

needed to complete the test may improve for many reasons,

including: (1) altering the use of an assistive device, (2) actual

change in function, and (3) increased familiarity of the test, or

a combination of these Therefore it is important to periodically

perform this test over the course of a patient’s physical therapy

intervention to allow for comparison to baseline results

As described in Table 23-2, when compared to other

func-tional tests (i.e., BBS), with regard to balance testing, the TUG

test is a consistent test of the balance characteristics in this

population The ability or inability to complete the TUG test

helps to stratify patients according to their fall risk Patients

who are unable to complete the TUG test for nonphysical

reasons (including refusal or inability to follow instructions

[e.g., dementia or delirium]) appear to have higher rates of

falling as compared to patients who are unable to do the TUG

test for physical reasons (inability to sit, stand, or walk

inde-pendently, or with standby assistance).16

Additionally, patients who have undergone hip fracture

surgery and are discharged from the acute care setting with a

Data from Whitney S, Poole J, Cass S: A review of balance instruments for older adults, Am J Occup Ther 52(8):666-671, 1998; Posiadlo D, Richardson S: The timed “up and go”: a test of basic functional mobility for frail elderly persons, J Am Geriatr Soc 39:142-148, 1991; Berg KO, Wood-Dauphinee SL, Williams JI

et al: Measuring balance in the elderly: validation of an instrument, Can J Public Health 83:S7-S11, 1992; Portney LG, Watkins MP, editors: Foundations of clinical research applications to practice, Norwalk, CT, 1993, Appleton & Lange.

TABLE 23-2 Overview of the Timed “Up and Go” Test

Geriatric population

with various

diagnoses

1 to 3 minutes to complete test ArmchairStopwatch

Assistive device *

Interrater reliability:

r = 0.99 Intrarater reliability:

r = 0.99

ICC = 0.99

Content validity: none reported Concurrent validity: Berg balance scale

ICC, Intraclass correlation coefficient; r, correlation coefficient.

*If necessary, an assistive device may be used while performing this test.

CLINICAL TIP

Caution should be exercised in interpreting the scores of the TUG test when administered to a frail elderly patient who has multisystem impairments Patients with these characteristics may have TUG scores as low as 10 seconds but may still be at risk for falling.18

Functional Reach Test The functional reach test was developed to assess the risk for falls in the elderly population and is a dynamic measure of stability during a self-initiated movement.19 The functional reach test evaluates balance by measuring the maximum dis-tance an elderly person can reach forward, backward, and out

to the side while standing on the floor at a fixed position (Table 23-3).7

Procedure

The procedure involves a series of three trials of the distance a patient is willing to reach from a fixed surface.7 After every reach, distance is measured with a yardstick attached to the wall

at shoulder level The difference in inches between a person’s arm length and maximal forward, backward, and sideward reach with the shoulder flexed to 90 degrees while maintaining a fixed base of support in standing is then recorded.12,20 The mean of three trials is the score

Interpretation of Results

The functional reach in inches correlates with the patient’s rela-tive risk for falling (Table 23-4).19

When working with an elderly patient in an acute care setting, this test may be an objective way to quickly gauge balance abilities and determine the need for balance treatment,

portion The balance subscale, the performance oriented assess-ment of balance (POAB), can be used individually as a separate test of balance

Procedure

The balance maneuvers are graded on an ordinal scale as normal (2 points), adaptive (1 point), or abnormal (0 points) The gait maneuvers are graded as normal or abnormal, with the excep-tion of a few items A combinaexcep-tion of the total points for the balance and gait portions are summed together to determine the final score.12,23 A summary of the Tinetti POMA can be found in Appendix 23A

Interpretation of Results

A total combined score on the balance and gait subscales of the Tinetti POMA correlates with the patient’s relative risk of falling (Table 23-6).24 This functional test is an effective and objective measure to predict falls in elderly and adult popula-tion, as well as assist in determining progress over time in therapy

Sit-to-Stand Tests There are several sit-to-stand tests25-35 currently being used in the clinical setting with some supporting evidence These tests have been utilized for the assessment of balance or lower extrem-ity strength and function, with validextrem-ity not fully established for either use Definitive agreement on the specific procedure for the sit-to-stand test has not been established

The procedures for sit-to-stand tests have included timing the patient’s ability to complete 5 or 10 repetitions, counting the number of stands completed by the patient in 30 seconds, and varying the conditions such as the use of arms to stand up

A meta-analysis by Bohannon cautiously reports normative values for the 5-repetition sit-to-stand test in elders In persons who are 60 to 69 years of age, mean times to complete this test

CLINICAL TIP

If the procedure of the functional reach test is followed correctly,

then scores of either the first or second trial or the mean of the

first two trials will have no significant difference from that of

the mean of all three trials.21 This may be useful for clinicians

who do not have time to perform three trials or if the patient

does not have the endurance to perform three trials

TABLE 23-4 Functional Reach Test Results

Data from Duncan PW, Weiner DK, Chandler J, et al: Functional reach: a new

clinical measure of balance, J Gerontol 45:M192-M197, 1990.

an assistive device, or both It is important to remember that

there are limitations to the population that can participate in

this test Elderly patients who are frail, demented, or both, are

excluded, because participation in this test may lead to

unneces-sary injury or falls

Tinetti Performance Oriented

Mobility Assessment

The Tinetti Performance Oriented Mobility Assessment

(POMA) is a performance test of balance and gait maneuvers

used during normal daily activities.22 This test has two subscales

of balance and gait, as described in Table 23-5 There are 13

maneuvers in the balance portion and 9 maneuvers in the gait

TABLE 23-3 Overview of the Functional Reach Test

Elders who are community

ambulators, patients who

have undergone hip

fracture surgery

Population limitation excludes

patients with dementia,

extreme spinal deformities,

severely restricted upper

extremity function, frail

elders, and nursing home

residents

Yardstick Level Assistive device *

<5 minutes to complete test Test-retest reliability:r = 0.89

Interrater reliability:

ICC = 0.99

Concurrent validity:

Walking speed, r = 0.71

Tandem walk, r = 0.71 Center of pressure, r = 0.71

Predictive validity:

>10 inches: not likely to fall 6-10 inches: two times more likely to fall

1-6 inches: four times more likely to fall

0 inches: 28 times more likely to fall

ICC, Intraclass correlation coefficient; r, correlation coefficient.

*An assistive device may be used while performing this test if it is necessary.

Data from Thapa PB, Gideon P, Fought RL et al: Comparison of clinical and biomechanical measures of balance and mobility in elderly nursing home residents,

J Am Geriatr Soc 42:493-500, 1994; Portney LG, Watkins MP, editors: Foundations of clinical research applications to practice, Norwalk, CT, 1993, Appleton & Lange, p 689; Sherrington C, Lord SR: Reliability of simple portable tests of physical performance in older people after hip fracture, Clin Rehabil 19:496-504, 2005.

were 11.4 seconds, whereas persons who were 80 to 89 had

mean times of 12.7 seconds.35

Despite some of the inconsistencies reported in the literature

about this test, performing a suitable version of the sit-to-stand

test during the examination of patients can still yield helpful

information, as there is a relationship between the sit-to-stand

test with instrumental activities of daily living and balance In

addition, a sit-to-stand test can be used to describe the

limita-tions during a functional activity and measure improvement

over time Repeating the same procedure within the same

clini-cal facility will help to improve reliability of these results

CLINICAL TIP

When documenting a sit-to-stand test, make sure to describe

the test characteristics such as seat height, use of arms or no

arms, repetitions (5 or 10), and/or time to complete the test, as

well as when to stop timing, either at the last stand or sit

TABLE 23-5 Overview of the Tinetti Performance Oriented Mobility Assessment

Balance portion: adult or geriatric

population with a wide variety of

diagnoses

Chair Stopwatch 10-15 minutes to complete test Interrater reliability: 85% ± 10%

agreement balance portion

Concurrent validity:

Berg, r = 0.91

Predictive validity: ≤18 total score predicts high fall risk

r, Correlation coefficient.

Data from King MB, Judge JO, Whipple L et al: Reliability and responsiveness of two physical performance measures examined of a functional training intervention, Phys Ther 80(1):8-16, 2000; Tinetti M: Performance oriented assessment of mobility problems in elderly patients, J Am Geriatr Soc 41:479, 1986; Nakamura DM, Holm MB, Wilson A: Measures of balance and fear of falling in the elderly: a review, Phys Occup Ther Geriatr 15(4):17-32, 1998; Wee JYM, Bagg SD, Palepu A: The Berg Balance Scale as a predictor of length of stay and discharge destination in an acute stroke rehabilitation setting, Arch Phys Med Rehabil 80(4):448-452, 1999; Anemaet W, Moffa-Trotter M: Functional tools for assessing balance and gait impairments, Top Geriatr Rehabil 15(1):66-83, 1999.

TABLE 23-6 Tinetti Results

From Tinetti ME, Williams TF, Mayewski R: Fall index for elderly patients

based on number of chronic disabilities, Am J Med 80:429-434, 1986.

Short Physical Performance Battery

The Short Physical Performance Battery (SPPB) was initially

developed in 1994 and involved a cohort of people aged 65 years

or older living in the community.36 It has since been validated

for larger patient demographics.37-40 The test consists of three

subsections: balance, walking speed, and chair stand time (see

Appendix 23A) Each section is scored on a 0- to 4-point scale

The total score is then compared to predictive values to describe

the degree of limitation to mobility (Table 23-7).37,41

The reliability for the SPPB subsections varies, with the

balance subscore having the weakest score.37 The standard error

TABLE 23-7 SPPB Score Classifications

From Puthoff ML: Outcome measures in cardiopulmonary physical therapy: short physical performance battery, Phys Ther 19(1):17-22, 2008.

of measurement for the SPPB has been calculated to 1.42 points, whereas the minimal clinically important difference (MCID) has been reported to be from 0.54 to 1.34 points.37,42 Although the original authors indicated that a 1-point score change was sig-nificant, score improvements closer to 2 would more greatly support actual change.36,37

Acute Care Index of Function The Acute Care Index of Function (ACIF) was developed in

1988 to standardize the assessment of functional status in patients with acute neurologic deficits.43,44 The test is based on patient performance measured in four domains: mental status, bed mobility, transfers, and mobility Higher scores denote better patient performance

For the functional aspects of the exam (bed mobility, trans-fers, and mobility) there are three possible choices for scoring performance: unable, dependent, or independent; point values are 0, 4, and 10, respectively.43 For the mental status portion of the test, only the absence or presence of patient performance is issued point values The sums of all the scores for each of the domains are then averaged.43 Finally, each domain is indepen-dently weighted by a multiplier to help detect change in per-formance and to discriminate between discharge disposition.44

This test possesses good validity (rs = 0.81, p < 0.01) and good interrater reliability (weighted kappa 0.88-0.98), except

in the area of “impaired safety awareness” (weighted kappa 0.60), which was due to the more subjective nature of the ques-tion.43,44 The test has subsequently been used to describe the functional status of patients with lower extremity orthopedic

provide similar measures of exercise tolerance and therefore was adopted by clinicians for its convenience (Table 23-8).49,50

Although this test is considered a time-limited, submaximal exercise test, it may cause patients with advanced heart disease and end-stage lung disease to approach their maximal work effort.48,51 In patients with advanced heart disease, regression equations have been used to predict peak oxygen uptake values (peak VO2).52

health conditions.45 To date the minimal clinically detectable

change score for this test has not yet been calculated.44

CLINICAL TIP

Clinicians may want to consider using the ACIF to help make

appropriate discharge recommendations, thereby reducing

readmissions and helping patients get to the appropriate level

of care

CLINICAL TIP

There is also a 2-minute walk test that has been used for the functional capacity assessment of patients after cardiac surgery, those patients with chronic obstructive pulmonary disease, and for persons after amputation.53-55 Although the 2-minute walk test may lack normative data, it may be considered in places with lack of space such as in the home setting

TABLE 23-8 Overview of the Six-Minute Walk Test

Patients with cardiac and/or

pulmonary disease and

osteoarthritis of the knee

Chair Stopwatch Pulse oximeter Portable blood pressure cuff Rate of perceived exertion scale Visual pain analog scale Measuring wheel

10-15 minutes to complete test Test-retest reliability:ICC = 0.93 Responsiveness index validity: 0.6

ICC, Intraclass correlation coefficient.

Data from King MB, Judge JO, Whipple L et al: Reliability and responsiveness of two physical performance measures examined of a functional training intervention, Phys Ther 80(1):8-16, 2000; Woo MA, Moser DK, Stevenson LW et al: Six-minute walk test and heart rate variability: lack of association in advanced stages of heart failure, Am J Crit Care 6(5):348-354, 1997; Kovar PA, Allegrante JP, MacKenzie CR et al: Supervised fitness walking in patients with osteoarthritis of the knee: a randomized controlled trial, Ann Intern Med 116:529-534, 1992; Guyatt GH, Sullivan MJ, Thompson PJ et al: The 6-minute walk: new measure of exercise capacity

in patients with chronic heart failure, Can Med Assoc J 132:919-923, 1985; McGavin CR, Gupta SP, McHardy GJR: Twelve-minute walking test for assessing dis-ability in chronic bronchitis, BMJ 1:822, 1976; Butland RJ, Pang J, Gross ER et al: Two-, six-, and twelve-minute walking tests in respiratory disease, BMJ 284:1607, 1982.

Exercise Testing

Although maximal exercise testing with evaluation of exhaled

gases is considered the gold standard to evaluate a person’s

cardiopulmonary capacity, maximal testing is not commonly

performed in the acute care setting Submaximal tests, however,

can be used safely to help a clinician with differential diagnosis

of the etiology of a patient’s fatigue or shortness or breath

(SOB), describing a person’s current aerobic capacity, estimating

maximal capacity, or prescribing exercise, or as an outcome

assessment.46 Despite the submaximal design, these exercise

tests may result in a symptom-limited test that, in some patient

populations, approaches a maximal effort, particularly in a very

deconditioned patient

Although not within the scope of this test, exercise

prescrip-tion based on actual effort during an exercise test can be more

accurate than exercise prescribed on heart rate or perceived effort

alone The clinician is referred to the text American College of

Sports Medicine Guideline for Exercise Testing and Prescription47 for

further details on exercise testing and prescription

Six-Minute Walk Test

The 6-minute walk test (6MWT) is a time-limited measure of

functional capacity in which a patient walks as far as possible

on a course for 6 minutes.48 This test evolved from the 12-minute

walk test, originally designed to assess disability levels in

patients with chronic bronchitis.49 The 6MWT was found to

Procedure Premeasure the course in a flat, straight, enclosed corridor, approximately 30 meters (100 feet) in length to minimize turns.56 Patients should use their usual walking aid and foot-wear and have rested in a chair for 10 minutes before the start

of the test For standardization of the test, patients are encour-aged to carry their own oxygen source, are asked not to talk to anyone during the test, and are not followed by the clinician during the test Standardized encouragement, or lack thereof, has been shown to influence the results of the walking test.57

Standard encouragement, if used, should be said with a normal tone and identify only the time left (i.e., “You have 2 minutes left You are doing a good job”).57 The standardized initial instructions to the patient, according to the American Thoracic Society (ATS), can be found in Box 23-2

Although following ATS guidelines is preferred, it is recommended that the performance of the 6MWT in the acute setting be altered to maximize patient safety in recognition of the larger potential for medical or physical variability in this patient population During the test, it is recommended that the

in patients’ functional activity tolerance A minimal change in walking distance of 54 to 70 meters has been shown to be clini-cally significant for improving functional status for patients with chronic obstructive pulmonary disease (COPD).67 For frail, elderly patients with chronic heart failure the 6-minute walk test is a responsive measure of cardiac status.68

Incremental or Ramp Exercise Tests

In the case of persons who are not sufficiently challenged during time-based exercise testing, an incremental or ramp exercise test should be considered Most incremental exercise test protocols described in the literature, such as the Bruce Protocol, may be too challenging even at the initial stage for the inpatient population Modified incremental tests however, such as the Modified Balke-Ware, should be considered for special patient populations

The Modified Balke-Ware consists of nine stages at a con-stant velocity of 5.6 kph (approximately 3.47 mph) while increasing the elevation from 6% to 22% in 2% increments each minute.69 Modified tests, such as the Modified Balke-Ware, have lower initial workloads, thus reducing the floor effect while efficiently increasing the workload in a short period of time to both engage the aerobic pathways and reduce the impact of a ventilation impairment to performance For example, most persons with cystic fibrosis admitted to the hospital for an exacerbation of their illness may not be challenged sufficiently

by the 6MWT but are significantly challenged during the Mod-ified Balke-Ware treadmill test

therapist walk slightly behind the patient to allow close

moni-toring of heart rate (HR) and saturation of peripheral oxygen

(Spo2), but also to guard the patient if necessary Because of the

potential for variations in vital signs from baseline values, HR,

Spo2, respiratory rate (RR), rate of perceived exertion (RPE),

and rate of perceived dyspnea (RPD) should be monitored every

2 minutes and for at least 2 minutes after the test has terminated

to assess patient recovery If the patient is unable to complete

the full 6 minutes, then the distance covered on termination is

measured along with establishing the reason for termination by

the patient

CLINICAL TIP

Although the 6MWT was initially performed in a 30-meter

hallway, studies have attempted to validate the test in other

formats such as on a treadmill for space, safety, and monitoring

issues frequently found in the acute care patient population

The conclusions reached in the literature thus far are currently

mixed regarding a 6MWT performed on a treadmill.58-61 It is

important to consider the validity and patient safety when

choosing how to perform the 6MWT

TABLE 23-9 Prediction Equations for 6-Minute Walk

Test Distance

Enright,

1998 63 Healthy men between 40 and 80 years of age

Expected 6 MWD = (7.57 × height in cm)

− (5.02 × age) − (1.76 × weight in kg) − 309 meters

Healthy women between 40 and 80 years of age Expected 6 MWD = (2.11 × height in cm)

− (2.29 × weight in kg) − (5.78 × age) + 667 meters

Troosters,

1999 64 Age range = 50 to 85 years of age

Expected 6 MWD = 218 + (5.14 × height in cm

− 5.32 × age) − (1.80 × weight in kg + (51.31 × gender*)

*Male = 1, female = 0 Gibbons,

2001 65 Age range = 22 to 79 years of age

Expected 6 MWD = 868.8 − (2.99 × age)

− (74.7 × gender*)

*Male = 0, female = 1 Enright,

2003 66 Age range greater than or equal to 65 years of age

Healthy women:

Expected 6 MWD = 493 + (2.2 × height in cm)

− (0.93 × weight in kg) − (5.3 × age) Healthy men: Add 17 meters to results of above equation

6 MWD, 6-Minute walk distance.

From American Thoracic Society Board of Directors: ATS Statement:

Guide-lines for the six-minute walk test, Am J Resp Crit Care Med 166:111-117,

2002.

BOX 23-2 Standardized Instructions for the

6-Minute Walk Test

“The object of this test is to walk as far as possible for 6 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 Now I’m going to show you Please watch the way I

turn without hesitation.” Demonstrate by walking one lap yourself

Walk and pivot around a cone briskly “Are you ready to do that?

I am going to use this counter to keep track of the number of laps

you complete I will click it each time you turn around at this

starting line Remember that the object is to walk AS FAR AS

POSSIBLE for 6 minutes, but don’t run or jog Start now or

when-ever you are ready.”

Interpretation of Results

Many studies have examined the usefulness of the 6-minute

walk test in specific populations and have found it to be effective

in predicting oxygen consumption and determining the efficacy

of surgical intervention on functional mobility.49,50,52,62 A

number of regression equations have been developed to predict

6-minute walk test distance in healthy adults (Table 23-9).63-66

These prediction equations can be used by physical therapists

as a means of determining the level of deficits in their patients

and ultimately in prescribing exercise and measuring progress

the body of evidence for established functional tests grows and new tests are described With the increasing push to provide efficient and effective care across health care, physical therapists need to continue to objectively document how we positively affect patient performance while reducing the overall cost of care

Conclusion

Functional tests are quick and useful tools by which a clinician

can objectively measure change in a patient’s performance over

time The clinician is encouraged to review recent literature as

References

19 Duncan PW, Weiner DK, Chandler J et al: Functional reach:

a new clinical measure of balance, J Gerontol 45:M192-M197, 1990.

20 Newton R: Reach in four directions as a measure of stability in older adults, Phys Ther 76:S23, 1996.

21 Billek-Sawbney B, Gay J: The functional reach test; are 3 trials necessary? Top Geriatr Rehabil 21(2):144-148, 2005.

22 Umphred DA, editor: Neurological rehabilitation, ed 3,

St Louis, 1995, Mosby, pp 808-809, 812, 816-817, 822-823, 828-829.

23 Tinetti ME: Performance oriented assessment of mobility problems in elderly patients, J Am Geriatr Soc 41:479, 1986.

24 Tinetti ME, Williams TF, Mayewski R: Fall index for elderly patients based on number of chronic disabilities, Am J Med 80:429-434, 1986.

25 Csuka M, McCarty DJ: Simple method for measurement of lower extremity muscle strength, Am J Med 78:77-81, 1985.

26 Lord SR, Murray SM, Chapman K et al: Sit-to-stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people,

J Am Geriatr Soc 57:M539-M543, 2002.

27 Bohannon RW: Alternatives for measuring knee extension strength of the elderly at home, Clin Rehabil 12:434-440, 1998.

28 Bohannon RW, Smith J, Hull D et al: Deficits in lower extremity muscle and gait performance among renal transplant candidates, Arch Phys Med Rehabil 76:547-551, 1995.

29 Cheng PT, Liaw MY, Wong MK et al: The sit-to-stand movement in stroke patients and its correlation with falling, Arch Phys Med Rehabil 79:1043-1046, 1998.

30 Hughes C, Osman C, Woods AK: Relationship among performance on stair ambulation, functional reach, and Timed

Up and Go tests in older adults, Issues Aging 21:18-22, 1998.

31 Newcomer KL, Krug HE, Mahowald ML: Validity and reliability of the timed-stands test for patients with rheumatoid arthritis and other chronic diseases, J Rheumatol 20:21-27, 1993.

32 Bohannon RW, Shove ME, Barreca SR et al: Five-repetition sit-to-stand performance by community-dwelling adults: a preliminary investigation of times, determinants, and relationship with self-reported physical performance, Isokinet Exerc Sci 15(2):77-81, 2007.

33 Judge JO, Schechtman K, Cress E: The relationship between physical performance measures and independence in instrumental activities of daily living, J Am Geriatr Soc 44:1332-1341, 1996.

34 Whitney SL, Wristley DM, Marchietti 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 85(10):1034-1045, 2005.

35 Bohannon RW: Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders, Percept Motor Skills 103:215-222, 2006.

36 Guralnik JM, Simonsick EM, Ferrucci L et al: A short physical performance batter assessing lower extremity function: associated with self-reported disability and prediction of mortality and nursing home admission, J Gerontol 49:M85-M94, 1994.

1 American Physical Therapy Association: Evidence and research

http://www.apta.org/EvidenceResearch Accessed February 16,

2012.

2 Brigham & Women’s Hospital Department of Rehabilitation

Services: Physical therapy standards http://

www.brighamandwomens.org/Patients_Visitors/pcs/

rehabilitationservices/StandardsofCare.aspx?sub=1 Accessed

February 16, 2012.

3 Portney LG, Watkins MP, editors: Foundations of clinical

research applications to practice, Norwalk, CT, 1993, Appleton

& Lange, pp 680, 689.

4 Wee JYM, Bagg SD, Palepu A: The Berg Balance Scale as a

predictor of length of stay and discharge destination in an acute

stroke rehabilitation setting, Arch Phys Med Rehabil

80(4):448-452, 1999.

5 Cattaneo D, Regola A, Meotti M: Validity of six balance

disorders scales in persons with multiple sclerosis, Disabil

Rehabil 28(12):789-795, 2006.

6 Chou CY, Chien CW, Hsueh IP et al: Developing a short form

of the Berg Balance Scale for people with stroke, Phys Ther

86:195-204, 2006.

7 Nakamura DM, Holm MB, Wilson A: Measures of balance and

fear of falling in the elderly: a review, Phys Occup Ther Geriatr

15(4):17-32, 1998.

8 Berg KO, Wood-Dauphinee SL, Williams JI et al: Measuring

balance in the elderly: validation of an instrument, Can J Public

Health 83:S7-S11, 1992.

9 Berg K, Wood-Dauphinee S, Williams JI et al: Measuring

Balance in the elderly: preliminary development of an

instrument, Physiother Can 41:304, 1989.

10 Muir SW, Berg K, Chesworth B et al: Use of the Berg Balance

Score for predicting multiple falls in community-dwelling

elderly people: a prospective study, Phys Ther 88(4);449-459,

2008.

11 Conradsson M, Lundin-Olsson L, Lindelof N et al: Berg Balance

Scale: intrarater test-retest reliability among older people

dependent in activities of daily living and living in residential

care facilities, Phys Ther 87:1155-1163, 2007.

12 Whitney S, Poole J, Cass S: A review of balance instruments for

older adults, Am J Occup Ther 52(8):666-671, 1998.

13 Posiadlo D, Richardson S: The timed “up and go”: a test of

basic functional mobility for frail elderly persons, J Am Geriatr

Soc 39:142-148, 1991.

14 Thompson M, Medley A: performance of community dwelling

elderly on the timed up and go test, Phys Occup Ther Geriatr

13(3):17-30, 1995.

15 White J: Functional assessment tools-use them! Phys Ther Case

Rep 3(4):188-189, 2000.

16 Large J, Gan N, Basic D et al: Using the timed up and go test

to stratify elderly inpatients at risk of falls, Clin Rehabil

20:421-428, 2006.

17 Kristensen MT, Foss NB, Kehlet H: Timed “up & go” test as a

predictor of falls within 6 months after hip fracture surgery,

Phys Ther 87:24-30, 2007.

18 Nordin E, Rosendahl E, Lundin-Olsson L: Timed “up & go”

test: reliability in older people dependent in activities of daily

living-focus on cognitive state, Phys Ther 86(5):646-655, 2006.

53 Leung ASY, Chan KK, Sykes K et al: Reliability, validity, and responsiveness of a 2-minute walk test to assess exercise capacity

of COPD patients, Chest 130(1):119-125, 2006.

54 Brooks D, Parsons J, Tran D et al: The two-minute walk test as

a measure of functional capacity in cardiac surgery patients, Arch Phys Med Rehabil 85(9):1525-1530, 2004.

55 Brooks D, Hunter JP, Parsons J et al: Reliability of the two-minute walk test in individuals with transtibial amputation, Arch Phys Med Rehabil 83(11):1562-1565, 2002.

56 American Thoracic Society Board of Directors: ATS statement: Guidelines for the six-minute walk test, Am J Respir Crit Care Med 166:111-117, 2002.

57 Guyatt GH, Pugsley SO, Sullivan MJ et al: Effect of encouragement on walking test performance, Thorax

39:818-822, 1994.

58 Stevens D, Elpern E, Sharma K et al: Comparison of hallway and treadmill six-minute walk tests, Am J Respir Crit Care Med 160(5 Pt 1):1540-1543, 1999.

59 Camargo VM, do Carmo dos Santos Martins B, Jardim C et al: Validation of a treadmill six-minute walk test protocol for the evaluation of patients with pulmonary arterial hypertension, J Bras Pneumol 35(5):423-430, 2009.

60 de Almeida FG, Victor EG, Rizzo JA: Hallway versus treadmill 6-minute-walk tests in patients with chronic obstructive pulmonary disease, Respir Care 54(12):1712-1716, 2009.

61 Olper L, Cervi P, De Santi F et al: Validation of the treadmill six-minute walk test in people following cardiac surgery, Phys Ther 91(4):566-576, 2011.

62 Laupacis A, Bourne R, Rorabeck C et al: The effect of elective total hip replacement on health-related quality of life, J Bone Joint Surg [Am] 75:1619, 1993.

63 Enright PL, Sherrill DL: Reference equations for the six minute walk in healthy adults, Am J Respir Crit Care Med

158:1384-1387, 1998.

64 Troosters T, Gosselink R, Decramer M: Six minute walking distance in healthy elderly subjects, Eur Respir J 14:270-274, 1999.

65 Gibbons WJ, Fruchter N, Sloan S et al: Reference values for a multiple repetition 6-minute walk test in healthy adults older than 20 years, J Cardiopulm Rehabil 21:87-93, 2001.

66 Enright PL, McBurnie MA, Bittner V et al: The 6 minute walk test: a quick measure of functional status in elderly adults, Chest 123:387-398, 2003.

67 Redelmeier DA, Bayoumi AM, Goldstein RS et al: Interpreting small differences in functional status: the six minute walk test

in chronic lung patients, Am J Respir Crit Care Med

155:1278-1282, 1997.

68 O’Keefe ST, Lye M, Donnellan C et al: Reproducibility and responsiveness of quality of life assessment and six minute walk test in elderly heart failure patients, Heart 80:377-382, 1998.

69 Marinov B, Kostianev S, Turnovska T: Submaximal treadmill test for screening of physical capacity in pediatric age group, Pediatria 15(2):38-41, 2000.

37 Puthoff ML: Research corner outcome measures in

cardiopulmonary physical therapy: short physical performance

battery, Phys Ther 19(1):17-22, 2008.

38 Ostir GV, Volpato S, Fried LP et al: Reliability and sensitivity

to change assessed for a summary measure of lower body

function: results from the Women’s Health and Aging Study,

Clin Epidemiol 55:916-921, 2002.

39 Wolinsky FD, Miller TR, Malmstrom TK et al: Four year lower

extremity disability trajectories among African American men

and women, J Gerontol A Biol Sci Med Sci 62:525-530, 2007.

40 Ostir CV, Markides KS, Black SA et al: Lower body functioning

as a predictor of subsequent disability among older Mexican

Americans, J Gerontol A Biol Sci Med Sci 53:M491-M495,

1998.

41 Guralnik JM, Ferrucci L, Simonsick EM et al: Lower-extremity

function in persons over the age of 70 years as a predictor of

subsequent disability, N Engl J Med 332:556-561, 1995.

42 Perera S, Mody SH, Woodman RC et al: Meaningful change and

responsiveness in common physical performance measures in

older adults, Am Geriatr Soc 54:743-749, 2006.

43 Roach KE, Van Dillen LR: Reliability and validity of the Acute

Care Index of Function for patients with neurologic impairment,

Phys Ther 68(7):1098-1101, 1988.

44 Scherer SA, Hammerick AS: Research corner outcomes in

cardiopulmonary physical therapy: acute care index of function,

Cardiopulm Phys Ther J 19(3):94-97, 2008.

45 Roach KE, Ally D, Finnerty B et al: The relationship between

duration of physical therapy services in the acute care setting

and change in functional status in patients with lower-extremity

orthopedic problems, Phys Ther 78(1):19-24, 1998.

46 Balady GJ, Arena R, Sietsema K et al: Clinician’s guide to

cardiopulmonary exercise testing in adults: a scientific statement

from the American Heart Association, Circulation 122:191-225,

2010.

47 American College of Sports Medicine: ACSM’s guidelines for

exercise testing and prescription, ed 8, Philadelphia, 2010,

Lippincott Williams & Wilkins.

48 Guyatt GH, Sullivan MJ, Thompson PJ et al: The 6-minute

walk: new measure of exercise capacity in patients with chronic

heart failure, Can Med Assoc J 132:919-923, 1985.

49 McGavin CR, Gupta SP, McHardy GJR: Twelve-minute

walking test for assessing disability in chronic bronchitis, BMJ

1:822, 1976.

50 Butland RJ, Pang J, Gross ER et al: Two-, six-, and

twelve-minute walking tests in respiratory disease, BMJ 284:1607,

1982.

51 Olsson LG, Swedberg K, Clark AL et al: Six minute corridor

walk test as an outcome measure for the assessment of treatment

in randomized, blinded intervention trials of chronic heart

failure: a systematic review, Eur Heart J 26(8):778-793, 2005.

52 Cahalin LP, Mathier MA, Semigran MJ et al: The six-minute

walk test predicts peak oxygen uptake and survival in patients

with advanced heart failure, Chest 110:310, 1996.

APPENDIX 23A FUNCTIONAL TESTS

A Performance Oriented Mobility Assessment I

1 = Holds onto chair to keep upright

0 = Leans, slides down in chair

2 Arising from chair 2 = Able to rise in a single movement without use of arms

1 = Uses arms (on chair or walking aid) to pull or push up; and/or moves forward in chair before attempting to arise

0 = Multiple attempts required or unable without human assistance

3 Immediate standing balance

1 = Steady, but uses walking aid or other object for support

0 = Any sign of unsteadiness

4 Standing balance 2 = Steady, able to stand with feet together without holding object for support

1 = Steady, but cannot put feet together

0 = Any sign of unsteadiness regardless of stance or holds onto object

5 Balance with eyes closed (with

feet as close together as

possible)

2 = Steady without holding onto any object with feet together

1 = Steady with feet apart

0 = Any sign of unsteadiness or needs to hold onto an object

6 Turning balance (360 degrees) 2 = No grabbing or staggering; no need to hold onto any objects; steps are continuous (turn is a

flowing movement)

1 = Steps are discontinuous (patient puts one foot completely on floor before raising other foot)

0 = Any sign of unsteadiness or holds onto an object

7 Nudge on sternum (patient

standing with feet as close

together as possible, examiner

pushes with light even pressure

over sternum three times)

2 = Steady, able to withstand pressure

1 = Needs to move feet, but able to maintain balance

0 = Begins to fall, or examiner has to help maintain balance

8 Neck turning (patient asked to

turn to side and look up while

standing with feet as close

together as possible)

2 = Able to turn head at least halfway side to side and able to bend head back to look at ceiling;

no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain

1 = Decreased ability to turn side to side or to extend neck, but no staggering, grabbing, or symptoms of lightheadedness, unsteadiness, or pain

0 = Any sign of unsteadiness or symptoms when turning head or extending neck

9 One leg standing balance 2 = Able to stand on one leg for 5 seconds without holding object for support

1 = Some staggering, swaying, or moves foot slightly

0 = Unable

10 Back extension (ask patient to

lean back as far as possible,

without holding onto object)

2 = Good extension without holding object or staggering

1 = Tries to extend, but decreased range of motion (compared with other patients of same age)

or needs to hold object to attempt extension

0 = Will not attempt or no extension seen or staggers

11 Reaching up (have patient

attempt to remove an object

from a shelf high enough to

require stretching or standing

on toes)

2 = Able to take down object without needing to hold onto other object for support and without becoming unsteady

1 = Able to get object but needs to steady self by holding onto something for support

0 = Unable or unsteady

12 Bending down (patient is asked

to pick up small objects [e.g., a

pen] from the floor)

2 = Able to bend down and pick up the object and able to get up easily in a single attempt without needing to pull self up with arms

1 = Able to get object and get upright in a single attempt but needs to pull self up with arms

or hold onto something for support

0 = Unable to bend down or unable to get upright after bending down, or takes multiple attempts to become upright

1 = Needs to use arms to guide self into chair, or movement is not smooth

0 = Falls into chair, misjudges distances (lands off center)