Functional Tests

Chapter 23


Functional Tests





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 literature. 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 objectively 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 literature to keep abreast with changes in test validation and interpretation.



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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 populations.4 Table 23-1 describes the appropriate population, required equipment, completion time, reliability, and validity of the BBS.




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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



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, reaching forward in standing, picking up objects off the floor, turning 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:



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 modified 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:



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.



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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.



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



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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 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 summarized in Table 23-2.14





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 functional 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 independently, or with standby assistance).16


Additionally, patients who have undergone hip fracture surgery and are discharged from the acute care setting with a 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 ambulation. 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



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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 distance 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 relative 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, 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 unnecessary injury or falls.



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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.



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


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Jul 12, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Functional Tests

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