Chapter 10: Assessments (part 2)
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Fall Risk Assessments (Mini-BESTest, Berg Balance Scale, TUG Test, Six Minute Walk Test)
Since the PD population is at twice (or more) the risk of falling as their peers, you will surely want to take advantage of some standardized assessments. All assessments in this section are within the scope of practice for personal trainers to rate the client’s risk of falling. This will help the trainer to develop optimal programming for their client based on assessment data.
Another advantage of using these assessments is that they are recognized globally by the medical world. Each assessment comes with specific instructions on how to administer along with a scoring system to rate performance. This makes each of these tests reproducible (although human error is always a factor and therefore no two testers will test exactly the same).
Sharing assessment scores allows others in the field (i.e., physical therapists, neurologists, etc.) to have an idea of the patients’ risk of falling before they meet with them.
A brief description of these assessments is included in this chapter.
To properly implement these assessments, visit the book support website where you will find downloadable forms with instructions and scoring sheets, in addition to video demonstrations for all assessments.
Special note: Always follow HIPAA compliance/privacy laws. Be sure your client or patient signs a release before sharing assessment data with others in the fitness or medical field.
This is a shorten version of the BESTest (Balance Evaluation Systems Test). It is a 14-item test with a maximum score of 28. This test includes the following:
SIT TO STAND
Goal: Patient can stand up from a chair without the use of hands and is able to stabilize independently.
RISE TO TOES
Goal: Patient can stand on toes and stabilize for 3 seconds at maximum height.
STAND ON ONE LEG
Goal: Patient stands on one leg for as long as they can while looking straight ahead.
REACTIVE POSTURAL CONTROL:
COMPENSATORY STEPPING CORRECTION – FORWARD
While standing with feet shoulder width apart, arms at sides, the patient leans forward against the tester’s hands beyond their forward limits. When tester lets go, the patient does whatever is needed, including taking a step, to avoid a fall
Goal: The patient takes a single, large step and recovers independently (a second realignment step is allowed)
COMPENSATORY STEPPING CORRECTION – BACKWARD
Patient stands with feet shoulder width apart and arms at sides, then leans backward against tester’s hands beyond backward limits. When tester lets go, patient does whatever is necessary, including taking a step, to avoid a fall
Goal: Patient recovers independently with one single, large step
COMPENSATORY STEPPING CORRECTION – LATERAL
Patient stands with feet together and arms at sides. Patient will lean into testers hands beyond their sideways limit. When tester lets go, patient does whatever is necessary, including taking a step, to avoid a fall. Repeat test on opposite side
Goal: Patient Recovers independently (in both directions) with 1 step (a crossover or lateral step is OK)
STANCE (FEET TOGETHER); EYES OPEN, FIRM SURFACE
Patient places hands on hips and places feet together until almost touching.
Goal: Looking straight ahead, patient remains as stable and still as possible until tester says stop
STANCE (FEET TOGETHER); EYES CLOSED, FOAM SURFACE
Patient steps onto the foam surface, places hands on hips, and places feet together until almost touching. Tester starts timing when patient closes their eyes.
Goal: Patient remains as stable and still as possible until tester says stop.
INCLINE – EYES CLOSED
Patient steps onto an incline ramp and stands on the incline ramp with toes pointing towards the top. Patient places feet shoulder width apart and puts arms down to their sides. Tester starts timing when patient closes their eyes.
Goal: Patient stands independently for 30 seconds and aligns with gravity
CHANGE IN GAIT SPEED
Patient begins walking at their normal speed. When tester cues to walk fast, the patient walks as fast as they can. When tester cues to walk slow, the patient walks very slowly.
Goal: The patient is able to significantly change walking speeds without imbalance
WALK WITH HEAD TURNS – HORIZONTAL
Patient begins walking at their normal speed. When tester says right, the patient turns their head and looks to the right. When tester says left, the patient turns their head and looks to the left. The patient will try to walk in a straight line during this exercise
Goal: Patient is able to perform head turns with no change in gait speed while demonstrating good balance
WALK WITH PIVOT TURNS
Patient begins walking at their normal speed. When tester cues to turn and stop, the patient turns as quickly as possible, faces the opposite direction, and stops. After the turn, the patient’s feet should be close together
Goal: Patient turns with feet close and FAST (less than 3 steps) and with good balance
STEP OVER OBSTACLES
Patient begins walking at their normal speed. When they get to the box, they step over it, not around it, and keep walking
Goal: Patient is able to step over box with minimal change of gait speed and with good balance
TIMED UP & GO (TUG TEST) WITH DUAL TASK [3 METER WALK]
A piece of tape is placed 3 meters in front of a chair. When tester says GO, the patient will stand up from the chair and walk at their normal speed just beyond the tape on the floor. They then turn around and come back to sit in the chair. When performing TUG with Dual Task, tester will cue patient to count backwards by threes starting at ___. When tester says GO, the patient stands up from the chair, walks at their normal speed just beyond the tape on the floor, turns around, and walks back to sit in the chair. The patient is to continue counting backwards the entire time
Goal: Patient is able to demonstrate no noticeable change in sitting, standing or walking while counting backwards when compared to TUG test without Dual Task.
Berg Balance Scale
This test is comprised of 14 predetermined tasks and is designed to test a person’s ability to balance safely. (Physio-Pedia, n.d.)
- 15-foot walkway
- Stopwatch, wristwatch, or device with a stopwatch
- Two standard chairs (one with arm rests and one without arm rests)
- Step or foot stool
SITTING TO STANDING
Patient is cued to stand up from a sitting position while trying not to use hands for support.
Goal: Patient is able to stand without using hands and stabilize independently
Patient is asked to stand for two minutes without holding onto anything
Goal: Patient is able to stand safely for 2 minutes
SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL
Patient is instructed to sit on a stool or chair with arms folded for 2 minutes.
Goal: Patient is able to sit safely and securely for 2 minutes
STANDING TO SITTING
Patient is instructed to sit down on a chair from standing position
Goal: Patient sits safely with minimal use of hands
Chairs should be arranged for a pivot transfer. The patient is asked to transfer one way toward a seat with armrests and one way toward a seat without armrests. Two chairs may be used (one with and one without armrests) or a bed and a chair can be used
Goal: Patient is able to transfer safely with minor use of hands
STANDING UNSUPPORTED WITH EYES CLOSED
Patient is asked to close their eyes and stand still for 10 seconds
Goal: Patient is able to stand safely for 10 seconds
STANDING UNSUPPORTED WITH FEET TOGETHER
Patient places feet together and stands without holding onto anything
Goal: Patient is able to place feet together independently and stand safely for one minute
REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING
Patient is instructed to lift arm to 90 degrees, stretch out their fingers and reach forward as far as you can
Goal: Patient can confidently reach forward 25 cm (10 inches)
PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
Patient is instructed to pick up a shoe/slipper/light object, which is placed in front of their feet.
Goal: Patient is able to pick up slipper/shoe/object safely and easily
TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING
Patient is asked to turn and look directly behind them, looking over their left shoulder. Repeat on the right side
Goal: Patient is able to look behind on both sides and their weight shifts well
TURN 360 DEGREES
Patient is asked to turn in a full 360 degree circle, pause, and then turn a full circle in the opposite direction.
Goal: Patient is able to turn 360 degrees safely in each direction in 4 seconds or less
PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
Patient is instructed to place each foot alternately on the step or stool and continue until each foot has touched the step/stool four times.
Goal: Patient is able to stand independently and safely complete 8 steps in 20 seconds or less
STANDING UNSUPPORTED ONE FOOT IN FRONT
Patient is instructed to place one foot directly in front of the other. If the patient has difficulty and cannot place one foot directly in front, have the patient step far enough ahead so the heel of the forward foot is ahead of the toes of the other foot
Goal: Patient is able to place feet in a tandem position independently and hold 30 seconds
STANDING ON ONE LEG
Patient is instructed to stand on one leg as long as they can without holding onto anything
Goal: Patient able to lift leg independently and hold for 10 seconds or longer
SCORING: This test uses a five-point ordinal scale, ranging from 0-4. “0” indicates the lowest level of function and “4” the highest level of function. Total Maximum Possible Score = 56 (Berg K, 1992)
Interpretation of Berg Balance Scale:
41-56 = Patient can walk independently
21-40 = Patient walks with assistance
0 –20 = Patient is wheelchair bound
The Timed Up and Go (TUG) Test is part of the Mini-BESTest but can be performed as a separate test. It is a quick, easy and reliable tool to assess your patients’ balance and risk for falls. The only equipment required to perform the test are a chair with arms and a stopwatch. Patients wear their normal footwear and use their regular walking aids if they have any.
With a clearly marked line 3 meters in front of a standard armchair, the patient is instructed to stand up and walk at a comfortable and safe pace to the line on the floor, turn, and return to the chair and sit down again
Goal: Patient is able to perform the task in 12 seconds or less
6 Minute Walk Test
The 6–min walk test is a submaximal exercise assessment that entails the measurement of distance walked over a span of 6 minutes. This test provides a measure for integrated global response of multiple cardiopulmonary and musculoskeletal systems involved in exercise. (Vera Bittner, n.d.)
Standardization of the six-minute walk test is particularly important and full instructions are available on the book support website.