JAGS 38:1105-1112 1990

An Obiectjve Measure of Physical Function of Elderl; OdtDatients The Ph;sical k&formance Test J

David B. Reuben, M 4 and Albert L. Siu, MD, MSPH

i

Direct observation of phy ical function has the advantage of providing an objective, quantifiable measure of functional capabilities. We ha e developed the Physical Performance Test PPV, whi h assesses multiple domains of physical function using o serued performance of tasks that simulate activities o daily living of various degrees of difficulty.Two versions re presented: a nine-item scale that includes writing a se fence, simulated eating, tuming 360 degrees, putting o and removing a jacket, lifting a book and putting it on a helfi picking up a penny from the poor, a 50-foot walk t st, and climbing stairs (scored as two items); and a seven-item scale that does not include stairs. The PPT can be completed in less than 10 minutes and requires only a few simple props. We then tested the validity of PPT using 183 subjects (mean age, 79 years) in six settings including four clinical practices (one of Parkinson's disease patients), a board-and-care home, and a senior citizens' apartment.

The PPT was reliable (Cronbach's alpha = 0.87 and 0.79, interrater reliability = 0.99 and 0.93 for the nineitem and seven-item tests, respectively) and demonstrated concurrent validity with self-reported measures of physical function. Scores on the PPT for both scales were highly correlated (.SO to .80)with modified Rosow-Breslau, Znstrumental and Basic Activities of Daily Living scales, and Tinetti gait score. Scores on the PPT were more moderately correlated with self-reported health status, cognitive status, and mental health C24 to .43, and negatively with age F . 2 4 and -.18). Thus, the PPT also demonstrated construct validity. The PPT is a promising objective measurement of physical function, but its clinical and research value for screening, monitoring, and prediction will have to be determined. J Am Geriatr SOC38:1105-1112, 1990

Daily Living [ADLI2 and Lawton-Brody Instrumental Activities of Daily Living [IADL]3), are commonly used in clinical and research settings. These self-report instruments usually ask patients whether they are capable of performing a task or whether they actually perform the task. Observer report scales are similar but rely on a proxy to respond for the patient. Usually the proxy is a family member who lives with the patient or a staff person at an institution. Direct observation requires a cooperative patient and the presence of an examiner. The patient is then led through various tasks and rated by the examiner according to scale criteria. Although direct observation of physical function requires more staff time and effort, this method may provide more accurate and reliable information than selfFrom the Multicampus Division of Geriatric Medicine, University of report or proxy report. For example, Rubenstein et a14 California Los Angeles School of Medicine, Los Angela, California. have shown that functional status scores vary dependCompleted, in part, while Dr.Reuben was a JohnA. Hartford Faculty Development Scholar. Dr.Siu is the recipient of a National Insti- ing on the source of information: patients rate their own function higher than do family or nursing staff. Meatute on Aging Academic Award. Address correspondence and reprint requests to David B. Reuben, surement of physical capabilities by direct observation MD, Multicampus Division of Geriatric Medicine and Gerontology, has the advantage of providing an objective measure of UCLA School of Medicine 32-144 CHS, 10833 Le Conte Avenue, Los the patient's performance. Angeles, CA 90024-1687.

ssessment of function has become a cardinal principle of clinical geriatrics and research on aging. Functional status can provide important information about the need for assistance in personal care, ability to live independently, and prognosis. Moreover, improvement in functional status is an important goal of therapy that is equally important as, if not more important than, control of the physiologic manifestations of disease. Sources of information about function include selfreport, proxy report (e.g., spouse or caregiver), and direct observation. Numerous self-report measures have been described,' and several (e.g., the Katz Activities of

A

0 1990 by the American Geriatrics Society

0002 - 8614/90/$3.50

1106 REUBEN AND SIU

To date, few methods for direct observation of physical performance have been reported. Some have focused on specific physical dimensions such as mobility5 and manual dexterity.6~7Others have focused on a specific purpose such as identifying fallers.* The Performance Test of Activities of Daily Living (PADL)measures a variety of tasks that are required for ADLs and IADLs,~ but it has not been validated in a community-dwelling elderly population. Moreover, some of its items have been perceived as duplicative,’ and the instrument omits several dimensions of physical performance such as stamina/endurance and upper body strength. One approach to assessing physical function by direct observation is to identify dimensions (e.g., strength, mobility, dexterity) that are essential for meeting ADLs and IADLs. Specific tasks that demonstrate competence in these dimensions could then be assessed directly. This information might help define the “limiting factor” in the person’s inability to complete an activity and, thereby, suggest specific assistance that could be provided. For example, if a person were reported to need assistance in laundering, assessment of the physical components necessary to complete this task might identify the source of the disability more precisely (e.g., decreased upper extremity strength). An intervention such as the use of a hoist or aide to load and unload clothing might preserve relative independence. In this study, we report the development and validation of a directobservation method that measures multiple dimensions of physical function at various levels of difficulty to quantify performance capabilities of elderly persons. METHODS

Instrument Development The Physical Performance test was initially created as a 13-item measure that could be completed within 10 minutes and that would require one examiner and a few easily obtainable props. Of the 13 items, two were derived from Williams (unlocking a padlock and opening a door),6 two were from Jebsen7and Williams6 (writinga sentence and simulated eating), three were from Tinetti (arising, turning 360 degrees, and sitting),5 two were from the Performance Test of Activities of Daily Living (drinking from a cup and putting on and removing a jacket)? one from the Cooperating Clinics Committee of the American Rheumatism Association (50-foot walk test),1° and three were new items (lifting a book and putting it on a shelf, picking up a penny from the floor, and climbing stairs). Items were scored by measuring the time required to perform the task, by using previously described scoring rules, or by counting (e.g., number of flights of stairs). An exploratory factor analysis indicated that the instrument was measuring one or two factors. Using nonorthagonal promax rotation, the pattern of items load-

IAGS-OCTOBER 1990-VOL 38, NO. 10

ing on the second factor did not produce a clearly identifiable factor. Thus, we concluded that the instrument measured one underlying factor. Considering these results and tests of internal reliability, we dropped five items from the final scale (drinking from a cup, arising from a chair, unlocking a padlock, turning a doorknob, and sitting in a chair) to facilitate administration of the test. One item (climbing stairs) was recorded as both the time required to climb one flight of stairs and number of flights of stairs climbed. We also created a shortened (seven-item) version of the PPT, one that does not include the stair items, for three reasons: not all facilities have a staircase available, climbing stairs may be considered dangerous for some patients, and the number of stairs that constitutes a flight may vary. The final nine-item and seven-item Physical Performance Tests and scoring are provided in Appendix A. The entire test takes 5 to 10 minutes. For each item, a fivepoint scale (0-4) was created ranging from 4, “most capable or fastest,” to 0, ”unable to do.” Cut-off points for the scale were determined by examining the distribution of scores and then setting cut-off points that were easy to score. Although the scores for each item were not normally distributed, in general the highest category identified subjects in the top 20% and the lowest category identified subjects in the lowest 20% on each item. Scores on the nine-item scale could range from 0 to 36, and scores on the seven-item scale could range from 0 to 28. The protocol for administering the PPT is provided in Appendix B. Dimensions assessed by the PPT include: upper fine motor function, upper coarse motor function, balance, mobility, coordination, and endurance. Specific ADL activities that are simulated include eating, transferring, and dressing. In addition, the test measures the physical capabilities necessary for other IADL activities that are difficult to measure in the office setting. For example, upper extremity strength is necessary to perform laundering; climbing stairs is often essential in using public transportation. The nine items can be categorized by degree of difficulty, with the realization that some variability is to be expected depending upon patients’ physical or emotional handicaps. Items of perceived minimal difficulty are writing a sentence, simulated eating, and turning 360 degrees. Items of moderate difficulty are lifting a book, putting on and removing a jacket, picking up a penny from the floor, and walking 50 feet. The most difficult item is climbing stairs. By including items that extend across a broad range of difficulty, the test provides measures of physical function for a diverse group of elderly patients, ranging from those who are dependent in ADLs to those who are fully independent in IADLs but may demonstrate impairment on an item such as stair climbing.

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AN OBJECTIVE MEASURE OF PHYSICAL FUNCTION

Instrument Testing The Physical Performance Test was tested from January 1988through June 1989 in five patient populations: (1) patients in the UCLA Department of Medicine Practice Group’s geriatrics practice; (2) patients at Rhode Island Hospital’s Medical Primary Care Unit; (3)residents of a senior housing unit in Providence, Rhode Island, attending a health screening fair in the unit; (4) patients of a community-based geriatrics practice in Los Angeles; (5) patients entering a boardand-care home in Los Angeles; and (6) patients with Parkinson’s disease who were followed in an academic group practice at Brown University. Subjects in the first five settings were all 65 years of age or older. Subjects at sites 4 and 5 were not asked to complete the items relating to stairs because of the lack of an available staircase (site 4), and because of institutional reluctance to have its residents perform this task (site 5). Six persons (ranging from undergraduate student to attending physician) were trained by the authors in the administrationof the Physical Performance Test. Subjects were recruited randomly using a random number table from all follow-up visits at site 1, and all candidateswere asked to participate at sites 2 through 6. Patients were excluded if they did not speak Enghsh, could not complete a 10-minute questionnaire, or were deemed “inappropriate” for the study by their primarycare provider or the nursing staff. Inappropriatenessfor the study included reasons such as acute medical illness, profound dementia, and acute psychiatric illness (e.g., paranoia or grief). After informed consent was obtained, each subject was given a 10-minute questionnaire that asked about demographic information, functional status, and recreational activities. Functional status questions were asked in the format “Are you able to . . . ?” Answer choices were “alone, without help from another

person,” ”with help or assistance from another person,” or “unable to do.” Because the great majority of the population was independent in basic ADL and IADL function, we combined the two categories “with help” and ”unable” as being “dependent.” The Mini-Mental State Examinationll was administered, and the subject was asked about health conditions, diseases, and medications. The PPT was then administered according to the protocol (Appendix B), and the subject was given feedback regarding test results. Each session lasted 40 to 60 minutes.

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Instrument Validation and Reliability Testing To assess interrater reliability, 10% of test administrations at site 1were assessed by two raters. Concurrent validity was assessed by comparing scores on the nine-item and seven-item scales with common measures of physical function, including basic Katz Activities of Daily Living,2 the hierarchical scale of instrumental and basic activities of daily living validated by Spector et al,12and a modified version of the Rosow-Breslau scale.13 In addition, we validated the scale against another direct observation measure, the gait score as developed by Tmetti.5 Finally, construct validity was assessed by comparing PPT scores with commonly used measures of other dimensions of health such as mental health (MHI), perceived health status (GHI),“ and mental status (MMSE).” RESULTS The Physical Performance Test was administered to 183 subjects; no untoward complicationsoccurred. Demographic characteristicsof the subjects at each site are presented in Table 1. The mean age of subjects was 79 years (range, 46-94). Mini-Mental State Exam scores

TABLE 1. DEMOGRAPHIC CHARACTERISTICS OF SUBJECTS, BY SITE Site 1

Number of subjects 58 Age (mean) 79 Age range 64-94 Sex (% male) 29 MMSE score (mean) 26 15-30 MMSE score (range) IADL Functional Status (% independent) Prepare meals 86 91 Take medications Manage money 91 81 Do housework 95 Use telephone 70 Travel beyond walking Go shopping 77

2

3

4

5

6

All Sites

12 79 65-93 33 27 22-30

21 78 68-91 10 27 22-30

34 81 68-92 21 25 13-30

37 85 76-92 19 26 16-30

21 65 46-75 71 28 24-30

183 79 46-94 29 26 13-30

91 100 100 91 100 82 82

100 100 100 90 100 90

64 100 100 64 97 71 70

0 0 11 97 92 54 76

76 95 100 86 100 81 76

65 76 79 83 96 71 77

90

W E , Mini-Mental State Examination; ZADL Inshumenfal (Intermediate)Actiuities of Daily Liuing.

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TABLE 2. PERFORMANCE ON INDIVIDUAL TIMED PPT ITEMS Timed PPT Items Writing a sentence Simulated eating Lifting a book and putting it on a shelf Putting on and removing a jacket Picking up a penny Walking 50 feet Climbing a flight of stairs*

% Able to Complete

Average Time to Complete (seconds)

Range (seconds)

S D (seconds)

94

16.7 15.4 4.0 15.6 3.5 25.0 10.6

7.0 -49.0 7.5-56.5 1.5-40.0 2.0-71.5 1.5 - 20.5 10.5-315.5 4.0 - 76.0

6.5 6.8 4.0 8.4 2.1 31.0 11.4

100

94 97 98 98 91

PPT, Physical Performance Tesf. *Excluding subjects of sites 4 and 5.

averaged above the threshold screening cut-off point of 24 at each site, but 15% of our subjects who completed the PPT scored below 24 on the MMSE. Over 80% of subjects at each site were independent (by self-report) in each of the basic ADLs. Self-reported IADL functional status of subjects at each of the sites is presented in Table 1. In general, there was high agreement (90% or greater) between the subjects’ self-reported ability to complete PPT items and their observed ability to complete these tasks. Although the vast majority of subjects were able to complete each task, there was great variation in the difficulty in completing the tasks as reflected by the wide range of times that it took to complete the task (Table 2). Scale Reliability and Validity One-hundred six subjects completed the nine-item test and 179 subjects completed the seven-item test. Four subjects had missing data, and PPT scores could not be calculated. Summary scores are provided in Table 3. Although mean scores did not differ significantly by site, they vaned in a pattern that would be anticipated (i.e., the subjects in the senior citizens’ center performed best and the board-and-care subjects performed worst). Cronbach’s alpha coefficients for the nine-item scale and sevenitem scale were .87 and .79, respectively. Interrater reliability was tested using Pearson’s product-moment correlation; for the nine-item scale and seven-item scale, correlations were .99 and .93, respectively. To assess construct and concurrent validity of the PPT, nine-item and seven-item scores were compared to self-reported measures of physical function. We would expect that PPT scores would be well-correlated with other measures of the same construct, i.e., physical function. We would also expect that PPT scores would be positively but less strongly correlated with other related measures of health (e.g., general health rating, mental health). In fact, the PPT was well-correlated with basic Katz Activities of Daily Living (.65 and .50 for the nineitem and seven-item scales, respectively), the hierarchical scale of instrumental and basic activities of daily

living (.69 and .56), and a modified four-item RosowBreslau scale (30and .69). Because scores on the Katz and hierarchical scale were not normally distributed, we also conducted nonparametric correlations (Spearman) for the seven- and nine-item PPT with these scales; correlations were slightly lower. In addition, the scale was well-correlated with the Tinetti gait score (.78 and .69). Moderate positive correlations were demonstrated between the PPT and measures of other dimensions of health, i.e., mental health (.24 and .32), perceived health status (.32 and .27), and mental status (.47 and .40). As anticipated, PPT scores were weakly negatively correlated with age (- .24 and - .18). A complete correlation matrix is reported in Table 4. DISCUSSION Measurement of physical capabilities by direct observation is attractive because this method provides an objective, quantifiable measure of performance. Moreover,

TABLE 3. SUMMARY OF PHYSICAL PERFORMANCE TEST (NINE-ITEM AND SEVEN-ITEM) RESULTS PPT Scale

Number of subjects Mean score (range) Standard Deviation 10th percentile score 25th percentile score 75th percentile score 90th percentile score Mean score by site 1 (Geriatrics practice) 2 (Medical clinic) 3 (Senior citizens housing) 4 (Community geriatrics practice) 5 (Board-and-care) 6 (Parkinson’spatients) NA, not applicable.

Nine-Item

Seven-Item

106 23.7 (2-35) 7.8 12 21 29 31

179 18.3 (2-28) 5.1 11 15 22 24

22.0 24.7 26.8 NA

18.1 19.3 20.3 17.8

NA 24.5

17.6 18.4

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AN OBJECTIVE MEASURE OF PHYSICAL FUNCTION

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TABLE 4. CORRELATION MATRIX FOR THE PPT AND OTHER PHYSICAL FUNCTION AND HEALTH MEASURES NineItem Score

Nine-Item Score Seven-Item Score Age MMSE Gait Score General Health Rating Mental Health Index Health Perceptions ROSOWBresleau Scale Spector Scale Katz ADL Scale

SevenItem Score

Age

MMSE

Gait Score

General Health Rating

Mental Health Index

Health Perceptions

Rosow Bresleau Scale

Spector Scale

Katz ADL Scale

1.OOO

.97

1.000

-.24 .47 .78 .41

-.18 .40 .69 .40

1.00 -.22 -.17 -.09

1.00 .25 .19

1.00 .27

1.oo

.24

.32

.03

.20

.33

.26

1.oo

.32

.27

-.09

.23

.22

.44

.32

1.oo

.80

.69

-.16

.32

.60

.52

.41

.27

1.oo

.69 (.52). .65 (.42)

.56 (.46) .50 (.33)

-.16

.26

.49

.40

.13

.20

.73

1.oo

.OO

.17

.43

.24

.10

.23

.47

.68

1.00

PPT, Physical Performance Test; MMSE, Mini-Mental State Examination. ‘Given in parentheses are Spearman correlations. AIl others are Pearson correlations.

direct observation eliminates possible discrepancies between what the patient or proxy reports and what the patient can actually do. Other theoretical advantages of performance measures include face validity for the task being performed, better reproducibility, and, perhaps, better sensitivity to change.15 Accordingly, direct observation may be useful both as a clinical tool and as a means of confirming the validity of self-report and proxy-report assessments. On the other hand, direct observation of physical functionalstatus has several drawbacks. First, it must be conducted in the presence of a trained examiner, in contrast to many self-report scales that can be completed at home at the patient’s convenience. Second, many of these assessments rely on props, some of which need to be constructed and readily available. Some require additional clinical space to administer and may interfere with other patient-care activities. Direct observation may also fail to capture the typical performance of a patient in his or her home environment. Patients may be more motivated to perform in a clinical or research setting when being observed. Finally, some measures of physical function may be dangerous. For example, climbing stairs places patients at risk for falling or for exertional angina. Despite the potential value of a valid, reliable, easily administered and easily scored direct-observation test

of multiple dimensions of function, at present a test that meets these criteria is not available. In devising the Physical Performance Test, we have attempted to create a test that measures several domains of functioning, including upper body strength and dexterity, mobility, and stamina. Moreover, we wanted these tasks to be functionally oriented, i.e., to simulate activities of daily living. We wanted them to vary in difficulty so as to capture a broad range of disability. Finally, we wanted the test to be easy to administer by unskilled examiners within a short period of time with only a few easily obtained and inexpensive props. To create this scale, we used parts of well-validated instruments when possible5-7,9JO and added new items to measure domains for which no validated instruments were available. In scoringthe Physical Performance Test, we relied on timed measurementsbecause this method requires minimal observer interpretation or judgment. Thus, it can be administered and scored by a lay person with minimal training. This scoring method has been demonstrated to be useful when testing manual dexterity.6 It also provides a single score, similar to the Mini-Mental State Examination,ll that is easy to calculate and is standard across sites of administration, and can be followed serially. Nevertheless, the use of timed measurementsraises the question of whether a more sophisticated method of scoring that requires more detailed observation such as

1110 REUBEN AND SIU

that used by Tinettis and Kurianskp might add additional diagnostic information. We imagine, however, that the PPT would be more useful as a screening instrument or to monitor response to therapy or rates of decline. Persons with low PPT scores should have more extensive testing before planning or instituting therapy. The PPT was reliable and demonstrated concurrent and construct validity when compared to other measures of functional status. In designing the test, we intended the scale to capture a broader range of dysfunction than that measured using the basic Activities of Daily Living scale. The stronger correlation of the PPT with the more difficult items in the Rosow-Breslau scale (compared to Instrumental or Basic Activities of Daily Living) suggests that the PPT may, in fact, be measuring relatively higher levels of physical function. Like other measures of physical function,16 PPT scores were also correlated positively but less strongly with other measures of health (health perceptions, cognitive status, and mental health), and negatively, although weakly, with age. Thus, the Physical Performance Test appears to have construct validity. Although the Physical Performance Test may be a useful clinical and research instrument, the limitations of this study must be noted. As with validation studies of other functional assessment instruments, we were unable to test against a "gold standard" for functional capacity. Although subjects may have been able to complete tasks in this research setting, they may be less motivated to perform similar tasks at home. The PPT, like all other performance-based or self-reported measures to date, cannot differentiate unmotivated from incapable patients. In addition, the tasks we have chosen may be incomplete measurements of functional status. For example, although subjects were required to put on and take off a jacket, the limiting step for a subject dressing at home may be tying his or her shoes. The issue of generalizability must also be considered. Our population was community-dwelling or residing in a board-and-care facility. The applicability of the PPT to demented or severely impaired patients is yet untested. Finally, we have yet to demonstrate the sensitivity of the PPT in detecting and monitoring clinically significant functional changes or its ability to predict functional decline. In summary, this study supports the reliability and validity of the Physical Performance Test as an objective measure of physical functional capabilities. We envision that as developed and validated, the Physical Performance Test may be useful for screening for functional impairment, monitoring changes in functional status

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(including response to therapy), and perhaps predicting subsequent functional decline. Although additional study of the PPT needs to be conducted, the PPT provides a simple and reliable way of directly observing and documenting physical function in clinical settings. The present validation study also provides normative data for several populations. Finally, because the PPT measures difficult items such as climbing stairs, it might provide more information, especially at higher levels of function, than that obtained from commonly used selfreport measures of function. ACKNOWLEDGMENTS The authors acknowledge the help of Ron Hays for psychometric assistance; Allison Mayer-Oakes a nd JosephOuslander for facilitating data collection; Robert Brook, John Beck, and Gail Greendale for reviewing a draft of the manuscript; and Keith Cannon, Patti Ellert, Shayla Kaysel, Douglas Kiel, Barbara Pearl, and Joan Ten0 for data collection.

REFERENCES 1. Kane RA, Kane R L Assessing the Elderly. Lexington, MA, DC Heath and Co, 1981 2. Katz S, Downs TD, Cash HR, Gmtz RC: Progress in development of the index of ADL. Gerontologist 10(1):20, 1970 3. Lawton MP, Brody EM: Assessment of older people: self-main-

taining and Instrument Activities of Daily Living.Gerontologist 9:179, 1969 4. Rubenstein L, Schairer C, Wieland GD, et al: Systematicbiasesin

functional status assessment of elderly adults: effectsof different data sources. J Gerontol39:689, 1984 5. Tinetti ME Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 34:119, 1986 6. Williams ME, Hadler N, Earp JA: Manual ability as a mark of dependency in geriatric women. J Chron Dis 40:481,1987 7. Jebsen RH, Taylor N, Trieschmann RB, et al: An objective and standardized test of hand function. Arch Phys Med Rehab 50:311, 1969 8.

9. 10. 11. 12. 13. 14. 15.

Hogue CC, Studenski S, Duncan P: Assessing mobility: the first step in preventing falls. Unpublished manuscript Kuriansky J, Gurland 8: The performance test of Activities of Daily Living. Int J Aging Hum Dev 7(4):343,1976 Cooperating Clinics Commitbee of the American Rheumatism Association: A seven day variability study of 499 patients with peripheral rheumatoid arthritis. Arthritis Rheum 8:302, 1965 Folstein MF, Folstein S, McHugh PR Mini-mental state: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189, 1975 Spector WD,Katz S, Murphy JB, et al: The hierarchical relationship between Activities of Daily Living and Instrumental Activities of Daily Living.J Chron Dis 40:481,1987 Rosow I, Breslau N: A Cuttman Health Scale for the aged. J Gerontol 21:556, 1966 Stewart AL, Hays RD, Ware JE: The MOS short-form general health survey: reliability and validity in a patient population. Med Care 26(7):724, 1988 Guralnik JM, Branch LG, Curnmings SR, Curb ID: Physical performance measures in aging research. J Gerontol Med Sci

44(5):M141, 1989 16. Nelson E, Wasson J, Kirk J, et al: Assessment of function in

routine clinical practice: description of the COOP chart method and preliminary findings.J Chron Dis 4O(Suppl1):55S, 1987

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APPENDIX A PHYSICAL PERFORMANCE TEST SCORING SHEET Physical Performance Test Time

Scoring

1. Write a sentence (whales live in the blue ocean)

-c*

2. Simulated eating

s

3. Lift a book and put it on a shelf

-sec

4. Put on and remove a jacket

-sec

5. Pick up penny from floor

-sec

6. Turn 360 degrees

discontinuous steps 0 continuous steps 2 unsteady (grabs, staggers) 0 steady 2 s e c 5 15 sec = 4 15.5-20 sec = 3 20.5-25 sec = 2 >25 sec = 1 unable = 0 s e c 5 5 sec = 4 5.5-10 sec = 3 10.5- 15 sec = 2 > 15 sec = 1 unable = 0 Number of flights of stairs up and down (maximum 4)

7. 50-foot walk test

8. Climb one flight of stairst

9. Climb stairst

e

c

5 1 0 sec-4 10.5-15 sec = 3 15.5-20 sec = 2 >20 sec = 1 unable = 0 510sec=4 10.5-15 sec = 3 15.5-20 sec = 2 >20 sec = 1 unable = 0 5 2 sec = 4 2.5-4 sec = 3 4.5-6 sec = 2 > 6 sec = 1 unable = 0 5 10 sec = 4 10.5-15 sec = 3 15.5-20 sec = 2 >20 sec = 1 unable = 0 5 2 sec = 4 2.5-4 sec = 3 4.5-6 sec = 2 > 6 sec = 1 unable = 0

TOTAL SCORE (maximum 36 for nine-item, 28 for seven-item)

Score

-

-

-

-nine-item -seven-item

*For timed measurements, round to nearest 0.5 seconds. tomit for seven-item scoring.

APPENDIX B: PHYSICAL PERFORMANCE TEST PROTOCOL Administer the Physical Performance Test as outlined below. Subjects are given up to two chances to complete each item. Assistive devices are permitted for tasks 6 through 8. 1. Ask the subject, when given the command "go" to write the sentence "whales live in the blue ocean." Time from the word "go" until the pen is lifted from the page at the end of the sentence. All words must be included and legible. Period need not be included for task to be considered completed. 2. Five kidney beans are placed in a bowl, 5 inches from the edge of the desk in front of the patient. An empty coffee can is

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placed on the table at the patient’s nondominant side. A teaspoon is placed in the patient’s dominant hand. Ask the subject, on the command “go,” to pick up the beans, one at a time, and place each in the coffee can. Time from the command “go” until the last bean is heard hitting the bottom of the can. 3. Place a Physician’s Desk Reference or other heavy book on a table in front of the patient. Ask the patient, when given the command ”go,” to place the book on a shelf above shoulder level. Time from the command “go” to the time the book is resting on the shelf. 4. If the subject has a jacket or cardigan sweater, ask him or her to remove it. If not, give the subject a lab coat. Ask the subject, on the command “go” to put the coat on completely such that it is straight on his or her shoulders and then remove the garment completely. Time from the command “go” until the garment has been completely removed. 5. Place a penny approximately 1 foot from the patient‘s foot on the dominant side. Ask the patient, on the command “go,” to pick up the penny from the floor and stand up. Time from the command “go” until the subject is standing erect with penny in hand. 6. With subject in a corridor or in an open room, ask the subject to turn 360 degrees. Evaluate using scale on PPT scoring sheet. 7.Bring subject to start on 50-foot walk test course (25 feet out and 25 feet back) and ask the subject, on the command “go,” to walk to 25-foot mark and back. Time from the command ”go until the starting line is crossed on the way back. 8. Bring subject to foot of stairs (nine to 12 steps) and ask subject, on the command “go,” to begin climbing stairs until he or she feels tired and wishes to stop. Before beginning this task, alert the subject to possibility of developing chest pain or shortness of breath and inform the subject to tell you if any of these symptoms occur. Escort the subject up the stair. Time from the command “go” until the subject’s first foot reaches the top of the first flight of stairs. Record the number of flights (maximum is four) climbed (up and down is one flight).