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Lower Extremity and Balance Assessment:

Which Measures to Use?

J.J. Mowder-Tinney PT, PhD, NCS, C/NDT, CSRS, CEEAA

jjmowder@gmail.com

Find me on LinkedIn and on Medbridge Education

www.neurocollaborative.com

Facebook Group: JJ Mowder PT

Learning Objectives

Compare and contrast valid and reliable

standardized measures used to establish baseline

function

Compare and contrast valid and reliable balance

measures to assist in prioritizing impairments

and risk for falls

Why Use Standardized Measures

Objective Measurements

Focus Treatment

Improved Reimbursements

Show Patient Improvement

mailto:jjmowder@gmail.comhttp://www.neurocollaborative.com/

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StreamRom measurement

mCTSIBFive Time Sit to stand

Functional Reach

PASS/TIS/FISTTUGBerg

Functional Gait AssessmentGait speed

ê

ABC Scale

Participation Restriction

Outcome Measures based on the Disablement Model

Impairment Activity Limitations

Measure Acute IP Rehab Home SNF OP5 Sit to Stand

3 3 3 3 3

ABC 1 3 3 3 3FR 4 4 4 4 4

Berg 3 4 4 4 4DGI 4 4 4 4 4PASS 4 4 4 4 4TIS 3 3 3 3 3

STREAM 4 4 4 4 4TUG 4 4 4 4 4

4- Highly recommended, 3- Recommended

Stroke Edge Task Force – Setting

http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations/stroke

Measure Acute Sub-acute

Chronic

5 Sit to Stand

3 3 3

ABC 1 3 3FR 4 4 4

Berg 3 4 4DGI 4 4 4

PASS 4 3 1TIS 3 3 3

STREAM 4 4 3TUG 4 4 4

4- Highly recommended, 3- Recommended

Stroke Edge Task Force - Acuity

http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations/stroke

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How Many Measures Should I Use?

nThe literature recommends using at least two different measures for balance when trying to identify if a patient is at a risk for falls.

nTry using the Disablement Model and choose measures that equally represent all aspects of the client's limitations to give a broader picture.

Beninato, M., Portney, L. G., et al. (2009). "Using the International Classification of Functioning, Disability and Health as a framework to examine the association between falls

and clinical assessment tools in people with stroke." Physical Therapy 89(8): 816-825.

Things to Consider

Validity Does the tool measure what it is suppose to measure?

Reliability Does the tool produce similar results when administered repeatedly?

Sensitivity Does the tool reflect patient changes (improvement, plateau, decline)?

Will this tool identify patients who have risk?

Specificity Can the tool accurately identify patients who are NOT at risk?

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Things to Consider

Minimal Detectable Change (MDC)

Minimal amount of change that reflects true change by a patient between two time points.

Minimally Clinically Important Difference (MCID)

Minimal change that is clinically/functionally meaningful for the patient.(Example: Gait Speed MCID=0.1 m/s –geriatric, .175m/s chronic stroke, .13 stroke inpt rehab)

Important for goal setting

STREAMMeasures Stroke Rehabilitation Assessment of Movement

Purpose Quantitative eval of motor functioning and predictive of discharge

Scored 30 items across 3 domains. Scored on a 2 pt (extremity) or 3pt (mobility) scale. Quality observed. 70 total score.

Time 15 min for limb subscales + gross mobility

Equipment Mat, one step, 10m walk area

MCID MCID: LE= 1.9 points, Mobility=4.8pointsSmallest real difference 4.2 points

Predictive Total stream

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Lower Extremity Domain

Flexes hip and knee in supine

Flexes hip in sitting

Flexes knee and extends knee in sitting

DF ankle/PF ankle in sitting

Extends knee AND DF ankle in sitting

Abducts affected hip with knee extended

Flexes affected knee with hip extended

DF affected ankle with knee extended

Postural Assessment Scale for Stroke - PASS

Measures Sitting BalancePurpose Assess a persons ability to maintain balance

in lying, sitting, and standing, and changes in postures. Supine to sit both directions, sitting, sit to stand, etc

Time 10 minutesScored 12-item performance based 4-point ordinal

scale (adapted from fugl-meyer assessment)

Equipment Exam Table, watch with second handResponse to change

≥0.8 at 14-30 days, ≥ .63 30-90 days

Concerns Ceiling Effect after 90 daysNotes Most responsive 14-30 days post-stroke

PASS slightly better than Trunk Impairment Scale for predicting function (if only able to sit use TIS)

Trunk Impairment Scale (TIS)Measures Sitting Balance

Purpose Assess the motor function of the trunk after stroke. It contains 17 items consisting of 3 subscales: static/dynamic sitting and coordination: crossing legs, lifting pelvis up, leaning elbow down, rotation, etc.

Time 2-18 minutes

Scored A score of 20 out of 23 indicates normal trunk function.

Equipment Bed or mat

MCID/MCD Not known

Concerns Higher functioning stroke patients

Notes This measure is a reliable, comprehensive assessment of trunk control. There could be floor effects for lower functioning patients if they remove the three static sitting balance items.

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Function in Sitting Test

Measures Sitting BalancePurpose The FIST is a clinical examination of sitting balance, designed to be conducted at

the patient's bedside. Consists of 14 functional, everyday activities as test items.

Time

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Timed Up and Go

MeasuresPurpose Test of mobility, balance, and

locomotor performance.Time 1-2 minutesEquipment Chair with armrests, 3 meters

marked, stopwatchMDC Chronic stroke 2.9 secondsCut Off Scores

A score of 8.5 seconds has been used as a maximum score for subjects with stroke.Cut off score of 14seconds identifying high risk (Podsiadlo and Richardson 1991) 50% sensitivity, 78% specificity

Norms Normal is less than 10 seconds

http://www.medicine.mcgill.ca/strokengine-assess/module_tug_indepth-en.html

Dual Timed Up and Go

• In the TUG (Cognitive), perform TUG while counting backward by threes randomly

• In the TUG (Manual), perform TUG while holding a cup filled with water

• Mean scores for Elderly without falls history• TUG 8.4 sec, TUG man 9.7 sec, TUGcog 9.7 sec

• Difference between TUG manual and Tug is > 4.5 sec, this indicates an increased risk of falls Healthy adults

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Includes quick reference sheets, quick guide for environmental set up and FAQ sheets.http://neuropt.org/practice-resources/anpt-clinical-practice-guidelines/core-outcome-measures-cpg

Berg Balance ScaleMeasures Balance – Risk for Falls

Purpose Measures 14 items on a 0-4 point ordinal scale to assess static balance and fall risk

Time 15-20 minutesEquipment Stopwatch, chair with arms, tape measure, object to

pick up, step stoolMDCMCID

MDC acute stroke: amb with assist 8 points, amb with standby 6 points. Chronic stroke 4 points.7 points for inpatient rehab

Cut Off 45/56 for stroke, 42 cut-off may be better indicator for multiple injurious falls (Tilson etal. Stroke 2012)

Concerns Ceiling and Floor Effects (recommend using the pass if floor effects)

Functional Gait Assessment

Measures Balance and Gait

Purpose Assess postural stability during walking and assesses an individual’s ability to perform multiple motor tasks while walking. Modified from DGI

Time to Administer

New clinician

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Activity-Specific Balance Scale (ABC)Measures Balance Confidence

Purpose Objective measure of reported self confidence in performing ambulatory activities without falling.

Scored 16-item self report 0-100 scaleTime to administer 10-20 minutes Equipment Needed NoneMDC Parkinsons Disease only: 11-13Cut-Off Score High Functional Level: ≥80%

Moderate Functional Level: 50-80%Low Functional Level:

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10 Meter Walk Test/Gait Speed

Gait Speed Calculation: 10 meters/time in seconds

WALK TIME STOPTIME

0 meters 10 meters

STOPWALK

Middleton, Fritz, Lusardi JAPA, 2015

Revised Gait Chart

• Middleton A, Fritz SL, Lusardi M. Walking speed: the functional vital sign. Journal of aging and physical activity. 2015 Apr;23(2):314-22.

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Aerobic Capacity Assessment

• Six minute walk test (6MWT)

• Make sure to include some type of cardiovascular assessment. Make sure to document the distance you choose to walk to be consistent with the number of turns they end up taking.

Five Times Sit to StandMeasures Strength, Endurance, Transfers

Purpose A measure of functional lower limb muscle strength.

Time 12 seconds between healthy and chronic strokeModerate Falls Risk: >15 seconds elderly

Norms 60-69: 11.4 sec, 70-79: 12.6 sec, 80-89: 14.8 sec

Notes Keep arms folded across chest, don’t secure chair, stop timing on 5th sit

http://web.missouri.edu/~proste/toolWhitney etal. Clinical Measurement of sit to stand performance in people with balance disorders. Phys Ther. 2005;85(10):1034-1045.

Which Test Should I Choose?

http://web.missouri.edu/~proste/tool

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So…

• Review Stroke Edge II Task Force recommendations to compare which measures are optimal for your setting and stage of patient

• Review the measures depending on your goal

• Observe these videos and identify measures that would be appropriate to pick for them

Good JOB!

Any Questions?

jjmowder@gmail.com