therapeutic special tests in the geriatric population

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Therapeutic Special Tests in the Geriatric PopulationSelection, Utilization, and Application

Presented by Andrew Morgan, PT, DPT, MBA, COS-C

Learning Objectives1. Select appropriate performance-based special tests to identify objective patient deficits.

2. Apply objective special tests into routine treatments.

Disclosures• Guidelines exist whereby all speakers must disclose any relevant relationships. All relevant relationships are published

on the course page at www.summit-education.com.

• Summit Professional Education accepts In-kind support for certain live events. Please go to www.summit-education.com and click on a specific workshop date to view disclosures for specific live events.

• Approvals of any activity refer only to continuing education activities and do not imply that there is real or implied endorsement of any product, service, or company referred to in this activity nor of any company subsidizing costs related to the activity.

• You will be notified if a presentation relates to any product used for a purpose other than that for which it was approved by the U.S. Food and Drug Administration.

Andrew Morgan, PT, DPT, MBA, COS‐C

Relevant Financial RelationshipsAndrew Morgan is compensated by Summit as an instructor and by South Texas Therapy Associates as the Director of Therapy Service and Alternate Administrator.

Relevant Nonfinancial RelationshipsAndrew Morgan is a member of the American Physical Therapy Association (APTA), Texas Physical Therapy Association, as well as the home health section.

Therapeutic Special Tests in the Geriatric

Population: Selection, Utilization, and Application

2

Andrew Morgan, PT, DPT, MBA, COS‐C

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Introduction

•Bachelor of Science in Education, May 1999

•Master of Business Administration, May, 2005

•Doctor of Physical Therapy, May 2013

•Texas PT license since 2002•Background primarily in home health

•Director of Therapy Services•Alternate Administrator

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Objectives

• Learner will select appropriate performance‐based special test to identify objective patient deficits.

• Learner will demonstrate ability to integrate objective special tests into routine treatments.

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Definitions

•Evidence‐Based Medicine•Mosby’s Medical Dictionary, 9th edition•The practice of medicine in which the physician finds, assesses, and implements methods of diagnosis and treatment on the basis of the best available current research, the physician's clinical expertise, and the needs and preferences of the patient.

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Definitions

•3 Pillars of Evidence‐Based Medicine•Clinician’s expertise•The more we have, the more we rely on it•Often used in selecting which special test to use

•Patient preferences and needs•Based off of subjective examination • Listen to your patients, they’ll tell you what’s wrong• Listen long enough, they’ll tell you how to fix it

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Definitions

• 3 Pillars of Evidence‐Based Medicine• Best available current research• Level V opinions, case studies• Level IV non‐experimental studies• Level III non‐randomized studies• Level II randomized study• Level I systematic review

•Which of the 3 pillars ismost important?

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Statistical Terminology

• Sensitivity (SnOut)• Known as the true positive rate• A highly sensitive identifies those with the disease• Used to rule out if the test is negative• If it says you don’t have it, you don’t have it

•Specificity (SpIn)• Know as the true negative rate• A highly specific test identifies those without the disease• Used to rule in if the test is positive• If is says you have it, you have it

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Statistical Terminology

•Validity• A test’s ability to measure a specific variable• Does the test measure what it is supposed to measure?

• Reliability• Repeatability/consistency

•Minimal Detectable Change (MDC)• Amount of change in a test to seen by the clinician•Measures true change vs. variation in measurement• Determined by the observer

•Minimal Clinically Important Difference (MCID)• Smallest change to be observed by a patient

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Assessments of Activities of Daily Living

• Barthel Index for ADLs (created by Dorothea Barthel, PT)• 10 item assessment of independence with ADLs with max of 100

• Item values vary• Feeding (10=independent, 5=needs help, 0=unable)• Bathing (5=independent, 0=unable)• Grooming (5=independent, 0=unable)

• Dressing (10=independent, 5=needs help, 0=unable)• Bowel (10=independent, 5=occasional accident, 0=incontinent)• Bladder (10=independent, 5=occasional accident, 0=incontinent)• Toileting (10=independent, 5=needs help, 0=unable)• Bed to chair to bed transfer (15=Ind, 10=<50%, 5=>50%, 0=unable)• Mobility on level surfaces (15=Ind, 10=<50%, 5=>50%, 0=unable)

• Stairs (10=independent, 5=needs help, 0=unable)

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• Barthel Index interpretation• 80‐100• Patient should be able to live independently

• 50‐79• Minimally dependent

• 40‐59• “Partially” dependent

• 20‐39• Very dependent

• <20• Totally dependent

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• Barthel Index• Psychometric properties for detecting dependency• 0.67 sensitivity• 0.78 specificity• MCID=35 points (general)

• MDC=3.0‐27.86 (based on population)

• Excellent interrater reliability • Limitations• Patients with dementia

• Due to prevalence of differential item functioning

•When people from different groups have unequal probability of giving a response

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• Katz Index of Independence of ADLs• 6 items with a max score of 6• Each item is worth 0 (ANY level of assistance) or 1 (NO assistance)• Bathing• Dressing• Toileting• Transferring (in/out of bed to chair)• Continence• Feeding

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• Katz Index of Independence of ADLs interpretation • 6=independent• 4=moderate impairment• 2 or less=severe functional impairment

• Psychometric data• Reliability ranges 0.87‐0.94• High validity• Currently no studies available on sensitivity or specificity (that I could find)• MCID=0.47

• Limitations • Ability to measure small changes• Does not assess higher level ADLs

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• Selecting the right test• Questions to consider…•Who is your patient?• What is the patient able to do?

• What was the prior level of function?

• Was the prior level of function good enough?

•What is your goal?• What data are you attempting to gain?

•What does your clinical judgment say?

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Self‐Reported Outcome Measures

• Fall Efficacy Scale (FES)• First published in 1990 • Researchers included Mary Tinetti, MD • FES is designed to measure fear of falling• Specifically, FES assesses a patient’s confidence in performing various activities without falling

• The test consists of 10 items• Each item scored 1 (very confident) to 10 (no confidence)

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• Fall Efficacy Scale (FES) Items• Take a bath or shower• Reach into cabinets•Walk around the house• Prepare meals (not carrying heavy or hot objects)• Get in and out of bed• Answer the door or phone• Get in and out of a chair• Get dressed and undressed• Grooming• Getting on and off of the toilet

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• Fall Efficacy Scale (FES) interpretation• A score >70 indicates a fear of falling• Reliability is 0.71• But does a fear of falling predict falling?

• Sensitivity (ruling out non‐fallers)• 0.698

• Specificity (ruling in those who fall)• 0.639

• Limitations• Does not measure actual ability to perform tasks

• Relies exclusively on accurate reporting from patient

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• Fall Efficacy Scale (FES)‐variations and updates• The Modified Falls Efficacy Scale (MFES)• 14 Item questionnaire with same scoring (1‐10) as FES

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• Getting dressed/undressed*• Simple meal prep*• Taking a bath or shower*• Getting in and out of a chair*• Getting in/out of bed*• Answering the phone or door*• Walking around the house*• Reaching into cabinets*

• Simple shopping• Ascending/descending stairs at the front or rear of home

• Light housekeeping• Crossing roads• Light gardening or hanging out the wash (whichever is more common)

• Using public transportation


• Fall Efficacy Scale (FES)‐variations and updates• Falls Efficacy Scale International (FES‐I)• 16‐item test• Each item scored 1 (not concerned at all) to 4 (very concerned)

• Differs from the FES

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• Cleaning the house• Getting dressed/undressed*• Simple meal prep*• Taking a bath or shower*• Going to the shop• Getting in and out of a chair*• Ascending/descending stairs• Walking around the neighborhood

• Reaching for something overhead*• Answering the phone on time• Walking on a slippery surface• Visiting a friend• Walking in a crowd• Walking on uneven surface• Walking on a slope• Going to a social event

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• Fall Efficacy Scale (FES)‐variations and updates• Falls Efficacy Scale International Short (short FES‐I)• 7 item questionnaire with same scoring as FES‐I

• Recommended for community‐dwelling older adults

• Items include:• Getting dressed or undressed• Getting in/out of a chair• Ascending/descending stairs• Taking a bath or shower• Reaching for something overhead

• Walking on a slope

• Going to a social event

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• Activities‐specific Balance Confidence Scale (ABC)• Similar to FES• Measure confidence in performing activities without losing balance

• 16 items• Each scored as a percentage (multiples of 10)• Rates confidence in performing a task without losing balance

• Items are added then divided by 16 to give a score

• Interpretation • >80%=high physical functioning• <67%=high fall risk, predictive of future fall (84% of the time)

• Sensitivity=0.93 (Parkinson’s)• Specificity=0.69 (Parkinson’s)

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•Activities‐specific Balance Confidence Scale (ABC)• The 16 items:

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• Walk around the house• Walk up or down stairs• Bend over and pick up a

slipper from the front of the closet

• Reach for an item at eye level• Stand on tiptoes and reach for

something overhead• Stand on a chair and reach for

something• Sweep the floor• Walk outside to a car parked in

the driveway

• Get into/out of the car• Walk across a mall parking lot• Walk up/down a ramp• Walk in a crowded mall with

others walking past you• Bumped into people as you

walk through the mall• Step onto/off escalator while

holding the rail• Step onto/off escalator

without holding the rail• Walk on icy sidewalks


•Activities‐specific Balance Confidence Scale (ABC)• Variations• 6‐item ABC short scale (ABC‐6)• Stand on tiptoes and reach for something overhead

• Stand on a chair and reach for something

• Bumped into people as you walk through the mall

• Step onto/off escalator while holding the rail• Step onto/off escalator without holding the rail• Walk on icy sidewalks

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• Selecting the right test• Questions to consider…•Who is your patient?• What is the patient able to do?

• What is the patient’s cognitive status?

• What was the prior level of function?

• Was the prior level of function good enough?

•What is your goal?• What data are you attempting to gain?

•What does your clinical judgment say?

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Break5 minute

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Performance Based Outcome Measures

• Timed‐up‐and‐go• Say “go” • Start watch (reaction time)• Stand up (muscle strength)•Walk 10 feet/3 meters (gait velocity)• Turn around (vestibular‐semicircular canals)•Walk back (ambulation and balance)• Sit back down (gait velocity)

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• Timed‐up‐and‐go (TUG)• Interpretation (level 1a research)• >13.5 seconds indicates a high fall risk• Specificity=0.74 (“ruling in” those classified as high fall risk)• Sensitivity=0.31 (“ruling out” those classified as high fall risk)

•What is the clinical implication of this?• In terms of falling, what matters more specificity or sensitivity?

• Sensitivity matters more

• Why: we do not want “rule out” someone as a high fall risk who actually is a high fall risk

• In other words, some false positives are acceptable

• Should the TUG be our sole test?• NO

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• Timed‐up‐and‐go (TUG)• Variations (dual‐task TUG)• TUG Cognitive• TUG while counting backwards by 3 from a random number 20‐100

• TUG Manual• TUG while holding a cup filled with water

• Interpretation• Varies based on population• Slightly better than TUG• Neither variation should be used as a sole test

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• 30‐second chair to stand• Patient sits in a straight chair • No arms

• Seat is 17” above the floor• Say “go”• Start the watch

• Count repetitions (number of times patient comes to full standing)• If patient is halfway to standing at 30 seconds, count it

• Age and gender adjusted normative values• Every 5 years from 60 (14/12 reps) to 94 (7/4 reps)

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• 30‐second chair to stand• Interpretation• Sensitivity=0.75 for ruling out future falls• For those performing above age/gender‐adjusted normative value

• Specificity=0.323 for ruling in future falls• For those performing below age/gender‐adjusted normative value

• Clinical utility• MCID = 2

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• 30‐second chair to stand• Variations• 5 x sit to stand/10 x sit to stand• Time to complete sit number of repetitions

• Pros/cons?• 10 second sit to stand• Repetitions is 10 seconds

• Modified 30 second chair to stand (m30STS)• Allows for use of arms

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• Tinetti Performance‐Oriented Mobility Assessment (POMA)• Published by Mary Tinetti, MD• First published in 1986

• Divided into balance assessment (9 items) and gait assessment (8 items)

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• Balance items (0‐16)• Sitting balance• Rises from chair• Attempts to rise• Initial standing balance • General standing balance• Nudged• Standing with eyes closed• Turning 360 degrees• Sitting down

• Gait items (0‐12)• Initiation of gait• Step length and height• Foot clearance• Step symmetry• Step continuity• Path deviation• Trunk sway/control• Base of support


• Tinetti Performance‐Oriented Mobility Assessment (POMA)• Interpretation • High fall risk=18 or less• Moderate fall risk=19‐23• Low fall risk=24 or higher

• Psychometric properties• Sensitivity=0.70 (depending on study)• 70% of people with a high fall risk will have a score lower than 24

• Specificity=0.52 (depending on study)• 52% of people with a score lower than 24 will have a fall within a year

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• Tinetti Performance‐Oriented Mobility Assessment (POMA)• Other important data• Minimal detectable change (MDC)• 4.0• What does this mean for goal setting?

• Minimal clinically important difference (MCID)• Not established

• Highest score obtainable with a walker• 24• What does this mean for goals?

• What does this mean for the test’s validity?

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•Dynamic Gait Index (DGI)• Developed by Shumway‐Cook in 1995• 8 items to assess likelihood of falling• Gait on level surfaces• Change in gait speed• Gait with horizontal head turns• Gait with vertical head turns• Gait and pivot turn• Step over obstacle• Step around obstacles• Up and down stairs

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•Dynamic Gait Index (DGI)• Interpretation• Less than 19/24• Predictive of falls

• Greater than 22/24• Safe ambulators

• Minimal detectable change (MDC)• 3 points (community‐dwelling older adults)

• Minimally clinically important difference (MCID)• 2 points (community‐dwelling older adults)

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• Dynamic Gait Index (DGI)• Overall utility• Sensitivity/Specificity• 0.59, 0.64 (identifying fallers/non‐fallers)• 0.82/0.88 (identifying people with balance impairments)• 0.85/0.74 (identifying people with vestibular disorders)

• Take home message, who is your patient? What are you trying to find?

• Variations• 4‐item DGI or Reduced‐Item DGI• Gait on level surfaces• Change in gait speed• Gait with horizontal head turns• Gait with vertical head turns

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• Berg Balance Scale (BBS)• Test items

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• Sitting to standing

• Standing unsupported

• Sitting with back unsupported but feet on the floor

• Standing to sitting

• Transfer from chair to a chair

• Standing unsupported with eyes closed

• Standing unsupported with feet together

• Reaching forward with outstretched arm while standing

• Pick up object from the floor while standing

• Turning to look behind over left and right shoulders while standing

• Turning 360 degrees each direction

• Place alternate foot on step stool while standing

• Standing unsupported one foot in front

• Standing on one leg


• Berg Balance Scale (BBS)• First published in 1989 by Katherine Berg, PT• Still considered the gold standard for balance assessment

• 14 data points• Each data point is scored 0‐4•Maximum score possible is 56

• Interpretation• 41‐56=Independent• 21‐40=Walking with assistance• 0‐20=wheelchair bound

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• Berg Balance Scale (BBS• Important scores• Generally, <45 correlates to a higher fall risk• Score of <51 AND a history of falls • High fall risk (91% sensitivity, 82% specificity)

• Score of <42 AND no history of falls• High fall risk (91% sensitivity, 82% specificity)

• Score of <40• Nearly 100% fall risk

• Limitation• Potential ceiling effect on higher level patients• Does not include gait items

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• Berg Balance Scale (BBS)• Determining progress• Minimally detectable change• Baseline score 45‐56, 4 points• Baseline score 35‐44, 5 points• Baseline score 25‐34, 7 points• Baseline score 0‐24, 5 points**95% confidence interval

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• 2‐minute step test• Patient stands• Say go (start clock)• Have patient step in place for 2 minutes without holding anything• Knees need to reach height of iliac crest

• Count right knee repetitions for the score•Modifications• Holding to maintain balance

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• 2‐minute step test• Psychometric properties• Age/gender‐adjusted normative values • Every 5 years 60‐94

• Sensitivity=0.811 for law cardiovascular endurance• Specificity=0.636 for low cardiovascular endurance• MDC and MCID • Not established

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• 6‐minute walk test• Test of cardiovascular endurance/aerobic capacity• Patient stands• Say go (start clock)•Walk as far as patient can in 6 minutes• Rest breaks are allowed• Just keep the clock running• Evaluator should walk behind the patient

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• 6‐minute walk test• Psychometrics • Age/gender‐adjusted normative values 60‐90

• Sensitivity/specificity• Vary based off of population• Lung transplant patients waiting for surgery

• Less than 400 meters=0.80/0.27

• Predicting mortality while awaiting surgery

• MCID• 34 meters‐54 meters depending on population

• MDC• 32 meters‐82 meters depending on population

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Clinical Integration of Specialized Tests

•Activities of Daily Living• Consider the Barthel index•When properly performed (and documented)• Identifies functional limitations

• Grooming, dressing, bathing, toileting, transferring

• Identifies deficits in mobility• Gait on stairs• Mobility on level surfaces

• Essentially writes your care plan• Problem>goal>intervention>outcome measure

• Including need for continence training

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•Activities of Daily Living•What about the Katz index?• Like Barthel, it can write your care plan• Identifies deficits in ADLs

• Bathing, dressing, toileting, transferring• Identifies need for continence training

• Remember the 3 pillars of evidence‐based practice• Integrating specialized tests=applying research

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• Self‐reported outcome measures• Needs and preferences of the patient• “If you listen to your patients, they’ll tell you what’s wrong”

• FES (and its variations) and ABC (and variations)• Allows patient to identify the problem• If we know the problem, we can develop a care plan

• Balance training• Quiet room vs. loud and noisy

• “Going to a social event” (FES‐I)• What is real life?

• What is the patient’s confidence level?

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• Self‐reported outcome measures• Needs and preferences of the patient• “If you listen long enough, your patient will tell you how to fix the problem”.

• Self‐reported outcome measures and interventions• Sometimes we need to ask the next question

• The question beyond the test• Patient scores 10 for getting on/off of toilet (FES)• “Tell me about this”

• “I feel weak in my legs and have fallen 3 times”

• “Maybe if I was stronger in my legs”

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• Performance‐Based Outcome Measures• Importance of gait velocity• Several performance‐based tests assess gait velocity• Examples: TUG, 6 minute walk, DGI, Tintetti

• What would you do if your patient’s BP was 220/110?• And the patient had no medications

• Gait velocity may be a valuable vital sign• Gait speed<0.83 m/s=1 year mortality rate triples

• 1.0 m/s predicts independence in ADLs/IADLs

• 1.0 m/s correlates with a decrease risk of hospitalization

• 1.0 m/s indicates a decrease likelihood for an adverse event

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• Performance‐Based Outcome Measures• Importance of gait velocity•What does 1.0 m/s mean in my clinical life?• Consider the TUG

• Total distance covered=6 meters

• Add a turn, transfer, and reaction time

• 13.5 seconds may mean low fall risk, is that good enough

• Consider the 6 minute (360 seconds) walk test• 77 year‐old patient covers 500 meters in 360 seconds=1.38 m/s

• 82 year‐old patient covers 600 feet in 360 seconds=0.56 m/s

• Does a change in 0.1 m/s really matter• Equates with a 12% increase in 1 year mortality

• For every 0.1 m/s decrease in gait velocity

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• Performance‐Based Outcome Measures• Provide specific opportunities for interventions• Tinneti• Identifies poor foot clearance or step length

• DGI• Path deviation with head turns• Unable to reciprocate on stairs

• Berg• Near fall when standing with eyes closed

• 30‐second chair to stand• Requires the use of arms to complete 1 repetition

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Documenting Skilled Services

•Documenting skilled intervention• Therapist skill and patient progress (restorative therapy) • Justifies continued care

• Objective documentation of patient progress is essential• It should reflect the care plan

• How is a specialized, objective test part of a care plan?• Problem (identified during evaluation)

• Goal (what improvement in the problem is reasonable)

• Intervention (what we will do to ensure the goal is met)

• Special test (objectively measures progress towards the goal)

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Documentation

• Special tests and SMART goals• Awareness of MDC and/or MCID of selected test(s)•Writing a goal to improve Tinetti by 2 points is within MDC• Not a measureable goal

•Writing a goal to improve DGI by 1 point is within MDC and MCID• Not a reasonable or measurable goal

• Also important to know what the test measures and thresholds• Baseline Tinetti is 10/28• Goal is to increase to 14/28

• Measureable? Yes• Meets MDC

• Still a high fall risk, so what is the point?

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Documentation

• Special tests and daily treatments• Special tests should not be saved for eval and re‐eval only• Justifying progress• Provide objective measurement of progress

• But be aware of MDC and MCID

• Justifying skill• Interpreting a test is an assessment

• Assessment is a skill

• Response to exercise• Consider the Karovnen formula

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The End

•Questions•Comments•Concerns

•Amusing Anecdotes

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References

Applebaum EV, et al. Modified 30-second Sit to Stand test predicts falls in a cohort of institutionalized older veterans. PLoS One. 2017;12(5):e0176946. Published 2017 May 2. doi:10.1371/journal.pone.0176946

Barry E, et. al. Is the Timed Up and Go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14. Published 2014 Feb 1. doi:10.1186/1471-2318-14-14

Bohannon, RW, et. al. Two-Minute Step Test of Exercise Capacity: Systematic Review of Procedures, Performance, and Clinimetric Properties, Journal of Geriatric Physical Therapy: April/June 2019 - Volume 42 - Issue 2 - p 105-112 doi: 10.1519/JPT.0000000000000164

Gertrudis I. J. M. Kempen, et. al., The Short FES-I: a shortened version of the falls efficacy scale- international to assess fear of falling, Age and Ageing, Volume 37, Issue 1, January 2008, Pages 45–50, https://doi.org/10.1093/ageing/afm157

Jahantabi-Nejad S, Azad A. Predictive accuracy of performance oriented mobility assessment for falls in older adults: A systematic review. Med J Islam Repub Iran. 2019;33:38. Published 2019 May 1. doi:10.34171/mjiri.33.38

Jonasson, SB, et. al. Psychometric properties of the original and short versions of the Falls Efficacy Scale- International (FES-I) in people with Parkinson’s disease. Health Qual Life Outcomes 15, 116 (2017). https://doi.org/10.1186/s12955-017-0689-6

Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and ABC scale for comparing fallers and non-fallers. Arch Gerontol Geriatr. 2004;38:11-26.

Lee, R. The CDC’s STEADI Initiative: Promoting Older Adult Health and Independence Through Fall Prevention. American Family Physician. 2017 August 15; 96(4): 220–221.

Liebzeit D, et. al. Measurement of function in older adults transitioning from hospital to home: an integrative review. Geriatr Nurs. 2018;39(3):336-343. doi:10.1016/j.gerinurse.2017.11.003

Mielenz TJ, et. al. Evaluating a Two-Level vs. Three-Level Fall Risk Screening Algorithm for Predicting Falls Among Older Adults. Frontiers in Public Health. 2020 Aug 13; 8(373): 1-28. doi: 10.3389/fpubh.2020.00373.

Muir-Hunter SW, et. al. Reliability of the Berg Balance Scale as a Clinical Measure of Balance in Community-Dwelling Older Adults with Mild to Moderate Alzheimer Disease: A Pilot Study. Physiotherapy Canada. 2015;67(3):255-262. doi:10.3138/ptc.2014-32

Park EY, et. al. The sensitivity and specificity of the Falls Efficacy Scale and the Activities-specific Balance Confidence Scale for hemiplegic stroke patients. J Phys Ther Sci. 2018;30(6):741-743. doi:10.1589/jpts.28.741

Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34

Park SH, Lee YS. The Diagnostic Accuracy of the Berg Balance Scale in Predicting Falls. Western Journal of Nursing Research. 2017 Nov;39(11):1502-1525. doi: 10.1177/0193945916670894. Epub 2016 Oct 26. PMID: 27784833.

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https://doi.org/10.1093/ageing/afm157

https://doi.org/10.1186/s12955-017-0689-6

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therapeutic special tests in the geriatric population

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