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When looking for a means of assessing lower extremity functioning in older adults, the Short Physical Performance Battery (SPPB) is a personal favorite. It requires minimal equipment and provides objective data on muscle strength, balance, and mobility. The SPPB is so useful for predicting outcomes that it has become a key indicator for acceptance into our lung transplant program at the Hospital of the University of Pennsylvania.
What is the Short Physical Performance Battery?
The Short Physical Performance Battery, or SPPB, is, as its name implies, a series of tests used together to measure the functional performance of the lower extremities.
The test consists of three major components, each of which are scored independently – a set of 3 static balance tests, gait speed, and the five time sit-to-stand test. Points are assigned based on performance of each test element, with an overall maximum score of 12 points.
What does the SPPB measure?
Specifically, the combined tests measure lower extremity strength, balance, and mobility. As alluded to earlier, however, the SPPB is useful far beyond simply measuring lower body functioning.
In fact, it is currently being used within our lung transplant program at the Hospital of the University of Pennsylvania during the pre-transplant work-up to identify frail individuals who may be more vulnerable for post-operative complications.
The SPPB has also been validated to independently predict the risk of declines in activities of daily living (ADLs) (Huang et al, 2010), falls (Laurenti et al, 2018; Veronese et al, 2014), hospitalization (Ashikaga et al, 2018; Saji et al, 2018), and mortality (Afilalo et al, 2017) in a variety of patient populations.
This test is particularly useful for patients post-cardiac surgery. In this population, patients who score <11 points have a 3.8x greater risk of unplanned 30-day hospital readmission (Ashikaga et al, 2018). If scores drop below 9 points, these patients have ~2x greater odds of being institutionalized or developing new disabilities in ADLs within the next year (Afilalo et al, 2017).
The SPPB can also be used as a sensitive monitoring tool for lower limb physical performance with a change of 1 point considered clinically significant (Perera et al, 2006). Furthermore, each 1 point increase is associated with 14% lower odds of hospital readmission (Volpato et al, 2011).
For a complete list of cut-off scores, normative data, and psychometric properties, download the Mobile Measures App.
How is the SPPB Performed?
As previously noted, the SPPB consists of a set of tests that evaluate balance, gait speed, and lower body strength. This is done using a set of 3 standing balance tests, a walking test, and a sit-stand test.
1) SPPB Balance Test
The balance portion of the test has three parts – a side-by-side stand, a semi-tandem stand, and a full tandem stand.
A. Side-by-Side Stand
In the first test, you will ask the patient to stand with their feet together, side-by-side. It’s helpful to demonstrate the position that you would like the patient to take.
Note: The patient may use their arms to help them keep balance, may bend their knees, or move their body during the test to help keep them in place, as long as they do not move their feet or fall. Before beginning the timer, stand next to the patient and help support them until you are sure they have their balance well enough to attempt the test.
When the patient says they are ready, you can start the test. Use a stopwatch and tell the patient to hold position as long as they can. After 10 seconds have passed, tell the patient to stop.
In the event that the patient is unable to complete the full 10 seconds (0 points), stop the balance tests, and move on to part 2 – gait speed test.
If they maintain balance for 10 seconds or more (+1 point), move on to the semi-tandem stand.
B. Semi-Tandem Stand
The second test is similar in most ways to the first, but requires the patient to stand with the side of the heel of one foot touching the big toe of the other. Again, the patient will stand this way for about 10 seconds to complete the test. And, just like the side-by-side, they can use their arms, move their body, or bend their knees to help them keep balance.
If the patient can’t maintain balance for this test (0 points), record the result and proceed to the gait speed test.
If they maintain balance for 10 seconds or more (+1 point), move on to the full tandem stand.
C. Tandem Stand
This test is performed and timed like the first two. However, instead of side-by-side or with one foot slightly in front of the other, in this test the patient will stand with the heel of one foot touching the toes of the other, thus aligning the feet in tandem. Time the test for ten seconds.
Scoring for this part is slightly different:
<3 seconds = 0 points
3 to <10 sec = 1 point
≥10 sec = 2 points
Regardless of performance, it is now time to proceed to the gait speed test.
2) Gait Speed Test
For the gait speed test, you’ll be measuring the speed at which the patient walks 4 meters. When ready, you’ll instruct the patient to walk at a normal pace the length of the course while you time them.
Note: If the patient uses a device to help them walk – a cane or walker, for instance – they may use it for this test but should try and perform at least part of the test without it if possible.
Using a stopwatch, time the patient as they walk the course. Stay with the patient as they walk in case they stumble, fall, or become weak. When they cross the end of the course, stop timing. Once the first pass is complete, have the patient perform the exact same test a second time. For scoring, use the best (fastest) time of the 2 trials.
Scoring the gait speed test:
Unable = 0 points
>8.7 sec = 1 point
6.21-8.7 sec = 2 points
4.82-6.2 sec = 3 points
<4.82 sec = 4 points
3) Chair Stands Test
The last test in the battery is the chair stands test.
Demonstrate to the patient how to perform the test: cross your arms in front of your chest and sit with your feet flat on the floor. Stand up, keeping your arms in place.
Ask the patient to do a single stand from a sitting position without using their arms. If they cannot, you can end the test now (0 points) and calculate the total score.
If, however, they are able to stand without using their arms, ask if they would feel safe performing the action five times, as quickly as they can, without pausing. If they think they can complete the test, tell them to start and begin timing. Stop timing when the patient has completed five repetitions.
Scoring the chair stands test:
>60 sec or unable = 0 points
>16.70 sec = 1 point
13.70-16.69 sec = 2 points
11.20-13.69 sec = 3 points
<11.19 sec = 4 points
SPPB calculators, such as the one included in Mobile Measures app, will significantly reduce the time and energy required to calculate scores, interpret results, and document findings. Try it out FREE for 2 weeks on both Android and Apple devices.
References
- Huang W, Perera S, VanSwearingen J, Studenski S. Performance measures predict the onset of basic ADL difficulty in community-dwelling older adults. J Am Geriatr Soc. 2010;58(5):844-852.
- Lauretani F, Ticinesi A, Gionti L, et al. Short-physical Performance Battery (SPPB) score is associated with falls in older outpatients. Aging Clinical and Experimental Research OnlineFirst. 2018:1-8.
- Veronese N, Bolzetta F, Toffanello ED, et al. Association between short physical performance battery and falls in older people: the Progetto Veneto Anziani study. Rejuvenation Res. 2014;17:276–284.
- Ashikaga K, Saji M, Takanashi S, et al. Physical performance as a predictor of midterm outcome after mitral valve surgery. Heart and Vessels. 2019. https://doi.org/10.1007/s00380-019-01397-y.
- Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011;66(1):89-96.
- Afilalo J, Lauck S, Kim D, et al. Frailty in Older Adults Undergoing Aortic Valve Replacement: The FRAILTY-AVR Study. J Am Coll Cardiol. 2017;70:689-700.
- Abizanda P, Romero L, Sanchez-Jurado PM, Atienzar-Nunez P, et al. Association between functional assessment instruments and frailty in older adults: the FRADEA study. J Frailty Aging. 2012;1(4):162-8.
- Saji M, Higuchi R, Tobaru T, et al. Impact of Frailty Markers for Unplanned Hospital Readmission Following Transcatheter Aortic Valve Implantation. Circ J. 2018;82:2191-2198.
- Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc. 2006;54(5):743–9.
