Disability Schemes

! International Classification of Functioning,

Functional Assessments Disability, and Health
for Geriatric Clients ! Nagi Scheme (adopted by APTA and
included in the Guide to PT Practice)
Ann Medley, PT, PhD
Texas Woman’
Woman’s University
School of Physical Therapy

Interaction of Concepts ICF Contextual Factors

Person Environment
Health Condition
" gender "Products
(disorder/disease)
" age "Close milieu
" other health "Institutions
conditions "Social Norms
Body Activities Participation "Culture
" coping style
function&structure (Limitation) (Restriction) "Built-
Built-environment
" social
(Impairment)
(Impairment) "Political factors
background
" education "Nature
" profession
Environmental Personal " past experience
Factors Factors " character style

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 Components of
Nagi
Functional Assessment
Active Pathology ! Basic Activities of Daily Living (ADL, BADL)
! Instrumental Activities of Daily Living
(IADL)
Impairment
! Work
! Recreation ??? measures
Functional Limitations
! Mobility
! Balance
Disability ! Ambulation

Assessments of ADL Instrumental ADL

! Functional Independence Measure (FIM) ! Lawton IADL Lawton and Brody, 1969; Lawton, 1988
! 18 items, 7 point scale ! 9 items, 3 points for a total score of 27
! Includes cognitive and communication ! Financial management, shopping, transportation use,
telephoning, medication use, housekeeping, cooking,
components laundry
! Barthel Index
! 10 items, 100 points total Community Public In-
In-Home Waiting for
Housing LTC
24.51 25.15 19.86 18.15

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 Work Measures of Functional Mobility
Walk up 10 steps
!
! 95% of people ! Psychological measures
! Walk quarter of a mile
classified as having
! Sit for 2 hours ! Sitting measures
! Stand for 2 hours no disability had
! Stoop, crouch, kneel minimal physical ! Standing measures
! Reach up overhead limitations ! Static
! Reach out to shake hands 67.9% of people
! ! Dynamic
! Grasp with fingers
considered disabled
! Lift or carry 10 pounds ! Measures of functional mobility
! Lift or carry 25 pounds had severe physical
limitations
! Nagi,
Nagi, 1976

Assessing Psychological Activity-Specific Balance

Aspects of Balance Confidence (ABC) Scale Powell & Myers, 1995

! 16-
16-item self-
self-report questionnaire asking patients
! Activity-Specific Balance Confidence Scale to rate their confidence level while completing
(ABC)
ABC) various functional activities
! Falls Efficacy Scale (FES) ! Scoring: 11-
11-point scale ranging from 0% = no
confidence to 100% = complete confidence
! Interpretation:
! less than 50 = low level of physical functioning (home
care)
! 51-
51-80 = moderate level of functioning (retirement
homes/chronic conditions)
! 81-
81-100 = highly functioning active older adults

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 Falls Efficacy Scale (FES) FES (continued)
ME Tinetti, D Richman, L Powell 1990

! rFES (revised; 11 point scale with low score

! FES (10 point scale with high score
associated with low confidence)
! Rate confidence for completing 10 activities
without falling
! Reduced FES associated with decline in ADL,
IADL, and social function
! Discriminates between those who avoid
activity due to fear of falling and those who
do not
associated with low confidence)
! Same as FES but scoring reversed
! Good test-
test-retest reliabilty ICC= .88
! mFES (modified) low score associated with low
confidence
! Original 10 items plus 4 more
! Good test-
test-retest reliability ICC=.95
! Compared healthy elders with patients at a falls and
balance clinic Hill et al., 1996
! Mean scores on each item for healthy elders: 9.76 (136.6)
! Mean scores for patients: 7.69 (107.7)

Sitting Tests
SITTING
! Sitting forward reach FUNCTIONAL
A B
! Sitting lateral reach REACH
! SBS
Young Middle Old
C
21-
21-39 40-
40-59 65-
65-93
D
Forward 44.9 cm 42.3 cm 32.9 cm
Reach

Lateral 29.5 cm 26.7 cm 20.3 cm

Reach
Thompson & Medley, 2007

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 SBS
Medley & Thompson, 2006, 2007 Item Description STATIC BALANCE TESTS
1 Sitting unsupported with eyes open

! 12 item tool with 4 point 2 Sitting unsupported with eyes closed

scale 3 Sitting unsupported with arms as levers ! Romberg

4 Reaching forward with outstretched arm while
Strong relationship
Sharpened Romberg
!
sitting
(r=.76, p=.001) between !
5 Pick up object from the floor while sitting
total score of self-
self-
assessed steadiness & 6
unsupported
Placing alternate foot on a step stool while
! One Leg Stance
total SBS score sitting unsupported
• Clinicians agreed that 7 Reaching laterally with outstretched arm while
reaching forward with an unsupported

outstretched arm was 8 Turning to look behind over left and right
shoulders while sitting
most important while side
bending on foam was 9 Lateral bend to elbow in sitting

least important in 10 Sit to stand transfers

assessing sitting balance 11 Pick up an object from the floor while sitting
unsupported on foam

12 Lateral bend to elbow in sitting on foam

ROMBERG TEST SHARPENED ROMBERG

! Stand with feet parallel and ! Stand in heel-
heel-to-
to-toe position
together (Some say with arms folded across chest) ! Arms folded across chest with eyes closed
! Close eyes for 20- 20-30 for 60 seconds
seconds ! Time 4 trials for a maximum score of 240
! Judge the amount of sway seconds; or just time one trial up to 60 s
or time position held
! Abnormal test
! Abnormal test ! Excessive sway
Eyes open
!
! Loss of balance
! Loss of balance
! Stepping during test
! Stepping during test

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 SHARPENED ROMBERG
ONE LEG STANCE TEST
PERFORMANCE NORMS Briggs et al., 1989

! Stand with arms crossed, then pick up one

Age Score (seconds) leg and hold with hip in neutral and knee
60-
60-64 56 flexed to 90 degrees
65-
65-69 56 ! Five 30-
30-second trials; max score 150 sec.
or hold for 60 seconds one trial
70-
70-74 48 ! Test both sides noting any differences
75-
75-79 39 ! Criteria to stop: legs touch each other,
foot touches down, arms move from start
80-
80-86 45 position

ONE LEG STANCE TEST Briggs et al., 1989 ACTIVE STANDING TESTS
Age Dominant Non-
Non-dominant ! Functional Reach (forward and lateral)
60-
60-64 38 34 ! Multi Directional Reach Test
65-
65-69 24 24 ! Berg Balance Scale
70-
70-74 18 20 ! Step Test
75-
75-79 11 12
80-
80-86 11 10
All groups 20 20

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 FUNCTIONAL REACH FR Test: Reach Forward
! Designed for elderly population
! Consists of patient reaching as far forward
as possible while maintaining a fixed BOS
in standing
! Score is norm-
norm-based on extent of forward
reach along a yardstick
! Score of 6-
6-7 inches indicates a frail person
with limited ability to perform ADLs &
increased risk of falls Duncan et al. (1990)

FUNCTIONAL REACH NORMS FUNCTIONAL REACH STUDIES

Age Men Women ! Reliability Duncan et al., 1990

! Test-
Test-retest reliability r = .89
20-
20-40 yrs 16.7”
16.7” + 1.9”
1.9” 14.6”
14.6” + ! Interrater agreement on reach measurement =
2.2” .98
2.2”
! Validity
41-
41-69 yrs 14.9”
14.9”+ 2.2”
2.2” 13.8”
13.8”+ 2.2”
2.2”
! Discriminates levels of physical frailty
! FR< 7 in were unable to stand on one leg for 1 sec*
70-
70-87yrs 13.2”
13.2”+ 1.6”
1.6” 13.2”
13.2”+ 1.6”
1.6” ! FR < 7 could not perform tandem walking*
! FR < 7 had slower walking speed*
! FR < 6-
6-7 in more likely to fall**
•Weiner, et al., 1992 *
•Duncan, et al., 1992 **

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 Lateral Reach FR Test: Lateral Reach
! Measures lateral postural stability
! Maximum distance an individual can reach
laterally in a standing position
! Start position: 90 degrees abduction with
elbow extended
! Feet in contact with floor, no knee flexion, no
trunk flexion or rotation
! Good test-
test-retest reliability: ICC .94

Normative Values for

Lateral Reach Performance Data
Lateral Reach (Isles et al, 2004)

Age Group (n) Lateral Reach (cm)

20-
20-29 (40) 22.95 + 0.7
Author Right Left
30-
30-39 (47) 23.09 + 0.66
Brauer et al., 20.06 cm + 4.9 21.04 cm + 2.5
1999 (7.9 + 1.9) (8.3 + 1) 40-
40-49 (95) 18.96 + 0.47

DeWaard et al., 14.9 cm + 5.9 14.3 cm + 5.6 50-

50-59 (93) 18.37 + 0.48
2002 (5.9 + 1.8) (5.4 + 1.8) 60-
60-69 (90) 17.11 + 0.48
70-
70-79 (91) 15.7 + 0.49

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 Validity of Multi-Directional
Multi-Directional Reach Test
Reach Test
! Reach forward, to
the right, the left NO AD* Excellent Good Fair Poor Faller Non-
Non-
and lean backward. AD Health Health Health Health Faller
Forward 9.72 7.10 9.29 9.07 8.81 6.43 8.38 9.07
! Means (in)

Backward 5.39 3.25 5.16 5.09 3.86 3.33 4.06 4.80

! Forward 8.9 in
! Backward 4.6 in Right 7.57 5.62 7.54 7.0 6.53 5.25. 6.12 7.08

! Right 6.8 in Left 7.33 5.33 6.94 6.56 6.60 5.72 5.67 6.86
! Left 6.6 in * Assistive Device
Newton, 2001

Newton, 1997

BERG BALANCE SCALE Berg, et al., 1992

Step Test Hill et al., 1996

! Stepping one foot on, then off, a block as quickly as

possible in a set time period (15 seconds)
! Designed to test sitting & standing balance of
! Incorporates dynamic single limb stance
elderly patients
! Consists of 14 items including sitting balance, sit
!stand, transfers
! Scoring on a five point ordinal scale
(0=unable,4=independent)
! Score of < 45 = risk for multiple falls
! Score of < 36: 100% risk of falling Shumway-
Shumway-Cook et al.
(1997)

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 Step Test DYNAMIC BALANCE TESTS
20-
20-29 30-
30-39 40-
40-49 50-
50-59 60-
60-69 70-
70-79

Hill et al., 17.67 +3.22 17.67 +3.22 ! Dynamic Gait Index

1996
17.35 +3.03 17.35 +3.03 ! Functional Gait Assessment
Nitz et 18.88 16.91 15.59 14.00 ! Tinetti Performance Oriented Assessment
al., 2003
18.69 16.98 15.85 14.28 of Balance and Gait
Isles et 20.72 20.17 18.77 17.13 15.59 13.73
al., 2004
(8.5 cm
block)
Sherrington
and Lord, 4.4 + 6.2
2005 (5 cm affected
block) post
hip fx 6.2 + 6.3
unaffected

DYNAMIC GAIT INDEX Functional Gait Assessment

Wrisley,
Wrisley, et al., 2004

! Evaluates and documents the ability to ! 10 item tool based on DGI

modify gait in response to changing task ! Developed for use with younger patients
demands
with vestibular problems
! Excellent intrarater,
intrarater, interrater and test- test-
retest reliability (Wolf et al., 2001; Shumway-
Shumway-Cook, Gruber, et al.
! Reliability
1997)
! Intra rater: ICC = .83
! Predicts falls among the elderly ! Inter rater: ICC = .84
! Score associated with fall risk ! Moderate correlations with other balance
! <19, 2.58 times more likely to fall Whitney et al. measures
(2000)

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 PERFORMANCE ORIENTED
ASSESSMENT OF BALANCE & Tests of Functional Mobility
GAIT SCALE Tinetti & Ginter,
Ginter, 1988
! Five times sit to stand
! Designed for elderly patients ! TUG
! Consists of 9 balance items & 7 gait items ! TUGC
! Scoring on ordinal scale of 0-
0-2 ! TUGM
! 0 = most impairment
! 2 = independent ! L-test
! Maximum combined score = 28
(Balance=16, Gait=12)
! Interpretation:
! score below 19 = high risk for falls
! score between 19-
19-24 = moderate risk for falls

Five Times Sit to Stand Test Five Times Sit to Stand

Whitney, et al., 2005

! Sit in chair with arms across chest Young

control
Young with
balance
Older
control
Older with
balance
! Stand and sit down 5 times as quickly as 23-
23-57 14-
14-59 63-
63-84 61-
61-90 years
years years years
possible
Whitney, et al. 8.2 15.3 13.4 16.4
! Time on word “go”go” and end when 2005
buttocks touch chair on 5th trial.
60-
60-69 70-
70-79 80-
80-89
! Chair 43 cm height, 47.5 cm depth
Bohannon, 11.4 12.6 12.7
2006
Meta analysis

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 Four Square Step Test Four Square Step Test
! Reliability Multiple Fall Non-
Non-multiple Falls Control

Dite,
Dite, et al., 23.59 12.01 8.7
! Test retest ICC = .98 2002
! Inter rater ICC = .99 >64 years >65 years

! Cut off score of 15 seconds Dite,

Dite, 2002
Whitney, et al.,
2007; vestibular
12.4 + 4.2 14.8 + 4.3
! >15 seconds: multiple faller
Multiple Falls Non-
Non-multiple Falls
! <15 seconds non multiple faller
Dite,
Dite, et al. 32.6 + 10.1 16.2 + 5.3
2007; pts with
amputation

Timed Up & Go (TUG) Test TUG Test-continued

! Adaptation of Get Up & Go Test
! Studies by Thompson & Medley (1995)
! Designed for elderly population ! 175 subjects (65-
(65-79yr) without device scored
! Scoring based on time it takes to go from 10.34 seconds
sit # stand # walk 3 meters & back to # ! 50 subjects (mean age 24) without device
sit scored 7.5 seconds
! Score of 20 or less = independent with ! 175 volunteers with a cane scored 13.67

transfers & gait seconds

! Score of 20-
20-30 = “a gray zone”
zone”
! Score of 30 or more = assistance with
balance & functional activities Podsiadlo & Richardson,
1991

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 TUG Test & Effect of TUG Test &
Assistive Devices Parkinson Disease
! 187 subjects Device Without With ! Thompson & Medley (1998) reported:
randomly assigned to device device ! TUG Test did not discriminate between
one of three groups:
cane, RW, SW Cane 10.04s 13.14s subjects with unilateral involvement vs.
! Age accounted for bilateral involvement
15% of variance RW 11.36s 18.37s
! TUG Test did differentiate between subjects
! Device accounted for SW 12.32s 42.27s with functional limitations vs. subjects without
75% of variance (Medley
& Thompson, 1997) limitations

TUG Variations L-Test

Deathe & Miller, 2005

! Instructions
! Normal safe pace ! Modified version of the TUG; total distance
! Fast safe pace 20 m
! Cognitive ! 2 transfers and 2 turns
Perform cognitive task (math)
!
! Comfortable and safe pace
! Difference score of 5.56 s or greater likely to fall
Shumway-
Shumway-Cook et al., 2000
! Reliability with frail older adults Nguyen, et al., 2007
! Manual ! Interrater:
Interrater: ICC = 1.00
! Carry a cup of water while walking
! Intrarater:
Intrarater: ICC = .97
! Difference score of >4.5 (Lundin- Lundin-Olsson et al., 1998) or >4.98
>4.98
Shumway-Cook et al., 2000) likely to fall
(Shumway-

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 L-Test LAB
Deathe &
Miller, 2005;
Trans
tibial
Trans
femoral ! Go through lab packet and perform
patients with
amputations
29.5
sec
41.7
sec
measures that you are not familiar with
Nguyen, et al. 62 +
2007; frail 47 sec
elders
20-
20-29 30-
30-39 40-
40-49 50-
50-59 60-
60-69 70-
70-79 >80

Medley & 19.38 18.49 19.33 20.32 20.03 23.34 29.02

Thompson,
2008
unpublished
data 160
participants

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