The Activities-Specific Balance Confidence (ABC) Scale

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Assessing balance and fall risk is a key part of the physical therapy evaluation for older adults, especially in the home health and acute care settings. Many internal and external factors play a role in a person’s risk of falling. An important but often overlooked factor is balance confidence.

The Activities-Specific Balance Confidence (ABC) Scale provides a means of objectively measuring balance confidence and has been validated to assess community-dwelling older adults, individuals living with Multiple Sclerosis, Parkinson’s Disease, and more.

Why is it Important to Assess Balance Confidence?

Assessing an individuals balance confidence using the ABC Scale can provide valuable information about your patient’s true risk of falling, especially when combined with a functional assessment such as the Berg Balance Scale (BBS).

Someone who is overly confident but scores poorly on the BBS may be more likely to put themselves in situations beyond their actual capacity. This patient will require additional education to improve their insight into their functional abilities and/or require caregiver supervision to reduce risk of falling.

On the other hand, someone with low balance confidence will likely have a fear-of-falling and limit their activity, leading to further deconditioning and worsening mobility. It is unlikely that these patients will see significant improvements in mobility until their balance confidence is addressed.

The ABC Scale is particularly useful because it allows the clinician to identify up to 16 specific activities that your patient is having difficulty with or is afraid of attempting. If the activities are important to the patient, you can easily turn them into balance interventions.

What is the Activities-Specific Balance Confidence (ABC) Scale?

The Activities-Specific Balance Confidence (ABC) Scale is a patient-reported outcome measure that asks individuals to rate how confident they are that they will not lose their balance while performing 16 different activities.

The ABC Activities range from common tasks like walking around the house to less common and more challenging situations, like stepping off of a moving escalator while carrying packages.

How to Administer the Activities-Specific Balance Confidence Scale

The Activities-Specific Balance Confidence (ABC) Scale [Downloadable PDF]

The ABC Scale can be self-administered or administered via personal or telephone interview. Electronic versions of the ABC Scale are also available.

The patient is asked to rate their confidence in their balance, while performing 16 activities, on a percentage scale of 0 to 100, where 0 is a certainty of falling or becoming unstable and 100 is complete confidence in the patient’s own ability to stay balanced.  

The 16 ABC activities are as follows:

How confident are you that you will NOT lose your balance or become unsteady when you…

  1. …walk around the house?
  2. …walk up or down a set of stairs?
  3. … bend over to pick up a slipper or other items from the floor of a closet floor?
  4.  …reach for a small can off of a shelf at eye level?
  5. …stand on your tiptoes and reach for something that is above your head?
  6. …stand on a chair and reach for something?
  7. …sweep the floor?
  8. …walk outside of the house to a car that is parked in the driveway?
  9. …get into or out of a car?
  10. …walk across the parking lot to the mall or stores?
  11. …walk up or down a ramp?
  12. …walk in a crowded mall where people are rapidly walking past you?
  13. …are bumped into by people as you walk through the mall?
  14. …step onto or off of an escalator while you are holding onto a railing?
  15. …step onto of off of an escalator while holding onto parcels such that you cannot hold onto the railing?
  16. …walk outside on icy sidewalks?

The rating should be the patient’s perceived confidence in their stability. In other words, there is always a chance that someone might trip and fall in their home but should report their confidence with no other outside force acting on them to unbalance them.

If the patient typically uses any kind of walking aid or would normally hold onto support when performing the task, they should rate their confidence as if those supports were in place. If the activity isn’t something that the patient normally does, instruct them to imagine their confidence in their stability if they were doing the activity.

Scoring the ABC Scale

The Activities-Specific Balance Confidence Scale is scored by adding up all of the patient’s responses and dividing by the number of questions (16). In other words, the final score is the average of the 16 individual scores for each activity.

Scores range from 0 to 100%, where 0% is certainty of falling or becoming unstable and 100% is complete confidence in their balance ability.

Fall Risk Cut-Off Scores for the ABC Scale

Community-Dwelling Older Adults

≤58% is the optimal cut-score for distinguishing fallers vs non-fallers in older adults (Moiz et al,2017).

Older adults who score <67% are more likely to have a fear-of-falling (Reelick et al, 2009).

Lower Extremity Amputation

Scores ≤80% is associated with a risk of multiple falls in individuals with a lower extremity amputation (Sawers & Hafner, 2019).

Parkinson’s Disease

Scores ≤46% is associated with recurrent falls in those with Parkinson’s Disease (Almeida et al, 2014).

≥76% is the optimal cut-off score for ruling-out fall risk with a sensitivity 84% (Landers et al, 2008).

Multiple Sclerosis

Scores <40% are predictive of falls in the previous month (Cattaneo et al, 2006).

References

Almeida LRS, Valença GT, Negreiros NN, et al. Recurrent falls in people with parkinson’s disease without cognitive impairment: focusing on modifiable risk factors. Parkinson’s Disease. 2014;2014:432924.

Cattaneo D, Regola A, Meotti M. Validity of six balance disorders scales in persons with multiple sclerosis. Disabil Rehabil. 2006;28(12):789-795.

Landers M, et al. Postural instability in idiopathic Parkinson’s disease: discriminating fallers from nonfallers based on standardized clinical measures. JNPT. 2008;32(2):56-61.

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

Reelick M, et al. The influence of fear of falling on gait and balance in older people. Age Ageing. 2009:1-6.

Sawers A & Hafner B. Using clinical balance tests to assess fall risk among established unilateral lower limb prosthesis users: cutoff scores and associated validity indices. PM&R. 2019. doi: 10.1002/pmrj.12160.

The ABC Scale

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The Short Physical Performance Battery

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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.


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The Value of Measuring Gait Speed & How to Administer the Gait Speed Test

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It’s hard to understate the importance of a gait speed test. This relatively simple-seeming measure provides a wealth of information for patients and older adults in particular. Gait speed can help determine a variety of diverse indicators, from fall risk to cognitive decline, and even death.

Understanding the importance of this test, what it indicates, and how to perform and measure it will help both you and your patients.

What is the Gait Speed Test?

The Gait Speed Test – sometimes also referred to as the Walking Speed test – is useful in assessing the mobility and functional status of a variety of patient populations. In fact, this measure is so important in assessing patients, it’s been referred to as the “6th vital sign” (Fritz et al, 2009).

The Gait Speed Test is precisely what its name implies – a test to measure the speed that a patient is able to walk over a specific distance on a level surface. The test is versatile – it can be performed in any number of environments – and can be offered to and completed by a wide range of individuals and diagnosis.

Why the Gait Speed Test Matters

As alluded to in the previous section, gait speed results are a powerful measure that is as crucial as vitals like blood pressure and can indicate far more than just functional mobility. Gait speed can also be used as a diagnostic tool in detecting “risky” individuals, who may be more vulnerable for adverse events.

There have been several studies published within the last year that propose cut-off values for independently predicting poor outcomes. The outcomes include falls (Stefan et al, 2020), fractures (Alajlouni et al, 2020), hospital length of stay and re-hospitalizations (Villani et al, 2020), quality of life (Lilamond et al, 2020), and post-operative delirium (Rao et al, 2020), to name a few.

Gait speed is considered a valid indicator of independence in various patient populations. Older adults who walk >1.1 m/s likely have the energy capacity to perform household activities (Studenski, 2009), whereas those who walk ≤0.67 m/s are more likely to experience onset of difficulty with self-care such as dressing or bathing (Huang et al, 2010).

Some people may experience these changes in function at different walking speeds. For example, individuals after a myocardial infarction, or heart attack, have 2.3-fold greater odds of developing new inability to perform activities of daily living (ADLs) when their comfortable speed is less than 0.8 m/s (Flint et al, 2018). This is because walking ability is influenced by several physiological subsystems which are affected differently based on varying diagnoses, and even age or gender. The subsystems that influence walking include the central nervous system, perceptual system, muscle, skeletal and joints, energy production, and peripheral nervous system (Ferrucci et al, 2000).

Gait speed results should be a key part of goal-setting and determining effectiveness of interventions. For every 0.2 m/s increase in speed achieved, there is a 38% decrease in the odds of demand for personal care (Studenski, 2003). For the results to be useful, however, administration of the test must be standardized and consistent each time it is completed.

How to Administer the Gait Speed Test

Despite being an indicator of potential issues in a variety of subsystems and a measure of potential independence, the gait speed test is easily conducted with very little equipment. All that is needed is the ability to measure out the appropriate distance for the test path and a means of tracking time.

While the 10-meter walk test is most common, shorter distances of 8- or even 4-meters can be used if necessary. The actual distance you choose, however, is less important than maintaining consistency on retests. A recent study by Krumpoch et el (2020) found small but statistically significant differences when comparing gait speed over 4- and 8-m distances.

Rope lengths, tape, or cones and a tape measure are all ways to quickly set up the walking course. For a 10-meter walk test, measure and mark the overall length of the track. Add 2 additional marks 2-meters before and after the start and end points. These segments allow for acceleration and deceleration so that the actual portion of the test that is being measured is the patient’s true walking speed.

The test should be performed a minimum of two times but ideally three times, and an average calculated. These instructions assume that a 10-meter distance is being measured.

When ready to perform the first trial, have the patient line up at the first mark (2-m before the starting line). Let them know that you’ll be timing them and that, when you say “Go” you want them to walk at their normal pace until you say “stop”.

Begin timing when the patient’s front foot first crosses the starting mark, and cease timing when they cross the 10-meter mark. Remember, don’t tell them to “Stop” until they are at least 2-meters past the end mark in order to minimize deceleration during the full 10-meters. If an assistive walking device is used, be sure to note that along with the times.

Scoring the Gait Speed Test

Assuming that three trials were completed, add up the results from those trials and divide by 3. This will give you the average seconds it takes the patient to walk the timed distance. Once the average is found, divide the distance – 10 meters – by the average number of seconds. This will give you the patient’s average speed in meters/second.

Gait speed 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.

Walking speed or gait speed is a crucial measure that can indicate the need for further intervention and increased care. It can also be an early indicator of issues within a host of subsystems. With minimal equipment needed, there is little reason not to perform this vital test with patients who are able to safely participate.


References

  1. Cesari M, Kritchevsky SB, Penninx BWHJ et al (2005) Prognostic value of usual gait speed in well-functioning older people–results from the Health, Aging and Body Composition Study. J Am Geri- atr Soc 53:1675–1680
  2. Ferrucci L Bandinelli S Benvenuti E et al.  Subsystems contributing to the decline in ability to walk: bridging the gap between epidemiology and geriatric practice in the InCHIANTI study. J Am Geriatr Soc 2000;48(12):1618–1625
  3. Flint K, Kennedy K, Arnold S, et al. Slow Gait Speed and Cardiac Rehabilitation Participation in Older Adults After Acute Myocardial Infarction. J Am Heart Assoc. 2018;7e008296.
  4. Fritz, S., Lusardi, M. White Paper: “Walking Speed: the Sixth Vital Sign”. Journal of Geriatric Physical Therapy. 2009; 32(2):2-5.
  5. 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.
  6. Schoon Y, Bongers K, Van Kempen J et al (2014) Gait speed as a test for monitoring frailty in community-dwelling older people has the highest diagnostic value compared to step length and chair rise time. Eur J Phys Rehabil Med 50:693–701
  7. Stefan L, Kosavic M, Zvonar M.Gait Speed as a Screening Tool for Foot Pain and the Risk of Falls in Community-Dwelling Older Women: A Cross-Sectional Study. Clinical Interventions in Aging. 2020; 15:1569–1574.
  8. Studenski S Bradypedia: is gait speed ready for clinical use? J Nutr Health Aging 2009;13(10):878–880
  9. Studenski S, Perera S, Patel K et al (2011) Gait speed and survival in older adults. JAMA 305:50–58
  10. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51(3):314-322.
  11. Krumpoch S, Lindemann U, Rappi A, et al. The effect of different test protocols and walking distances on gait speed in older persons. Aging Clinical and Experimental Research. 2020. https://doi.org/10.1007/s40520-020-01703-z
  12. Lilamand M, Saintout M, Vigan M, et al. Quality of life, physical performance and nutritional status in older patients hospitalized in a cardiology department. Journal of Geriatric Cardiology (2020) 17: 410-416.
  13. Lindholm B, Brogårdh C, Odin P, Hagell P. Longitudinal prediction of falls and near falls frequencies in Parkinson’s disease: a prospective cohort study. Journal of Neurology. 2020.
  14. Rao Q, Shi S, Afilalo J, et al. Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement. Clinical Interventions in Aging. 2020:15 1471–1479.
  15. Villani ER, Vetrano DL, Franza L, Carfì A, Brandi V, Volpato S, Corsonello A, Lattanzio F, Ruggiero C, Onder G, Palmer K. Physical performance measures and hospital outcomes among Italian older adults: results from the CRIME project. Aging Clin Exp Res. 2020 Sep 14. doi: 10.1007/s40520-020-01691-0. Epub ahead of print. PMID: 32929695.
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Using The 6 Minute Walk Test

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Advancements in the treatment of cardiovascular disease (CVD) has led to improved prognosis in recent years; however, healthcare utilization and costs has also increased (1-3). The World Health Organization reported that annual medical spending on CVD is expected to reach $818 billion by 2030. 

Exacerbation is common in this population and further reduces physical function, leading to increased hospital readmission risk and costs (1-4). Physical therapists play a key role in improving physical function which significantly reduces the risk of readmission and improves quality of life.

It is important that PTs are able to measure functional capacity and identify high risk patients with CVD, heart failure, and other cardiac conditions as well as those with chronic respiratory disease. While a maximal test such as the cardiopulmonary exercise test holds the place as the gold standard in this type of evaluation, performing this test is not always feasible. An alternative that is easy to administer with minimal equipment is the 6-minute walk test (6MWT). 

The value of the 6MWT test goes beyond measures for cardiac and respiratory concerns. Today, this test is administered to monitor aspects of health and functional status as well as determine effectiveness of interventions in a wide array of populations.

Which Patients is the 6 Minute Walk Test Used For?

To be clinically useful for a given patient population, an outcome measure must first be reliable. That is, the test must produce consistent results under different conditions (i.e., over time, by different different clinicians).

The 6MWT has acceptable (ICC>0.8) test-retest reliability for:

  • Alzheimer’s Disease/Dementia (5,6)
  • Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) (7)
  • Chronic Obstructive Pulmonary Disease (COPD) (8)
  • Community-Dwelling Older Adults (9)
  • Coronary Artery Disease (10)
  • Duchenne Muscular Dystrophy (11)
  • Heart Failure (12)
  • Huntington Disease (13)
  • Kidney Disease on Hemodialysis (14)
  • Multiple Sclerosis (15)
  • Myasthenia Gravis 16)
  • Parkinson’s Disease (17)
  • Stroke (18)
  • Total Hip/Knee Replacement (19)
  • Traumatic Brain Injury (20)

What Does the 6 Minute Walk Test Measure?

The 6MWT can be used for a variety of purposes, from response to therapy to indications of disease severity and predictions of mortality.

As a measure of functional status, the 6MWT is useful for:

  • Acute respiratory distress syndrome (ARDS)
  • Cardiac surgery
  • COPD
  • Coronary artery disease
  • Heart failure
  • Hip fracture
  • Older adults (age 60-101)
  • Osteoarthritis
  • Peripheral arterial disease
  • Pulmonary arterial hypertension

6MWT can be used as a predictive measure of hospitalization, poor outcomes, mortality and/or morbidity in:

  • Cancer
  • Cardiac surgery
  • COPD
  • Heart failure 
  • Peripheral arterial disease 
  • Pulmonary hypertension
  • Restrictive lung disease

The test can help indicate progress and performance in response to certain therapies, as well:

  • Acute respiratory distress syndrome (ARDS)
  • Cardiac surgery
  • CIDP
  • COPD
  • Coronary artery disease
  • Heart failure
  • Muscular Dystrophy

How to Administer the 6 Minute Walk Test

Administering the 6MWT requires attention but is relatively straightforward and requires minimal equipment. A physical or occupational therapist can perform the test almost anywhere, from a corridor to a patient’s own home, as long as there is enough clear walkway to set up a track. It is not recommended to perform the 6 MWT outdoors if it can be avoided.

Ideally, the path will be 50 to 100 feet but should be at least 3 meters or 9.8 feet. Measurement of the path will be important when determining results, whether by hand or using a 6-minute walk test calculator.

Equipment Needed for the 6-Minute Walk Test

  • Markers for the path’s endpoints: these could be almost anything that won’t get in the way, from small playground cones to chairs.
  • A means of measuring the distance between endpoints of the path: a tape measure or even squares of tile can help measure the distance.
  • Timing device: A stopwatch or watch.
  • A chair for resting, if needed.

Setting up the 6-Minute Walk Test

  1. Measure and mark the walking path.
  2. Set the patient up to begin at one end of the marked path.
  3. Upon the nurse or therapist saying “Go”, the timer should be started and the patient will walk back and forth between the marked endpoints for 6 minutes.
  4. The patient may stop during the test if they need to rest, but the timer should continue to run.
  5. When the time is complete, the patient should stop where they are. Measure the final distance and allow the patient to rest.

If you will be administering the test more than once on the same day the patient should be given a 30-minute break between tests.

Which Actions Should the Clinician Take During the 6-Minute Walk Test?

As the practitioner administering the test, you should plan to do the following:

  1. Keep an eye on the time.
  2. Monitor the patient closely for distress.
  3. Keep a chair at hand in case the patient needs to rest during the test.
  4. Ensure measurements – distance, time, etc. – are recorded and computed accurately.
  5. At the end of each minute, give the patient encouragement without indicating performance, and inform them of the time remaining. For instance, you could say:
    – “You’ve got 5 minutes remaining. You’re doing well.”
    – “Good job. You have 4 minutes remaining.”
    – and so on.
  6. Make sure that the patient stops in place at the end of the 6 minutes.

Interpreting Test Results 

Six-minute walk test norms are variable by population demographics, physical attributes, track size, and presenting conditions. For instance, patients who walked in one direction on a track tended to walk further distances than those asked to walk back and forth (Scivoletto et al, 2011). Re-tests should be performed in a manner consistent with the initial testing.

Normative Data

The following scores are considered “worse than average” for their respective age groups: (Lusardi et al, 2003)

  • 60-69 yrs: < 420 meters 
  • 70-79 yrs: < 439 meters
  • 80-89 yrs: < 292 meters
  • 90-101 yrs: < 265 meters

Cut-Off Scores

Chronic Obstructive Pulmonary Disorder (COPD)

  • <350 meters is associated w/ increased mortality, airflow limitation, dyspnea, depressive symptoms, & overall poor prognosis (Spruit et al, 2010).

Heart Failure

  • Those who walk <522 meters are more likely to develop functional impairment (Costa et al, 2014)
  • <468 meters is associated with ~3x greater risk of hospitalization or death in one year (Wergrzynowska-Teodorcyk, 2013; Ferreira, 2019)

Left Ventricular Assist Device (LVAD)

  • <300 meters is associated with poor exercise tolerance, worse quality of life; higher frequencies of bleeding, infection, right heart failure, & cardiac arrhythmias post-operatively 
  • Each 10 meters less than <300 meters is associated with 21% greater risk of mortality (Hasin et al, 2012)

Lung Cancer

  • <305 meters is predictive of unsuccessful surgical outcome after pulmonary resection surgery (≤90 day survival) (Holden, 1992)

Pulmonary Hypertension

  • <332 meters is associated with significantly lower 2-yr survival rate (Miyamoto et al, 2000)

Stroke

  • Those walking <205 meters are likely limited to household ambulation; require assistance for community mobility (Fulk et al, 2017)

Accurate measurement is key to identifying high risk patients, developing a plan of care, and determining treatment efficacy. While it’s possible to use pencil and paper, there are readily available 6MWT calculators available for mobile devices that can remove the time and energy required to perform calculations, interpret results, and document findings.

Measuring up the value of physical therapy

A Leading Tool In Quality Care & Outcome Measures





References

  1. Butler J, Kalogeropoulos A: Hospital strategies to re- duce heart failure readmissions: where is the evidence? J Am Coll Cardiol 2012;60:615–617. PMID:22818073, DOI:10.1016/j.jacc.2012.03.066
  2. Gheorghiade M, Vaduganathan M, Fonarow GC, Bonow RO: Rehospitalization for heart failure: prob- lems and perspectives. J Am Coll Cardiol 2013;61:391– 403. PMID:23219302, DOI:10.1016/j.jacc.2012.09.038
  3. SperryBW,RuizG,NajjarSS:Hospitalreadmissionin heart failure, a novel analysis of a longstanding prob- lem. Heart Fail Rev 2015;20:251–258. PMID:25287658, DOI:10.1007/s10741-014-9459-2
  4. Gheorghiade M, Follath F, Ponikowski P, Barsuk JH, Blair JE, Cleland JG, Dickstein K, Drazner MH, Fonarow GC, Jaarsma T, Jondeau G, Sendon JL, Me- bazaa A, Metra M, Nieminen M, Pang PS, Seferovic P, Stevenson LW, van Veldhuisen DJ, Zannad F, Anker SD, Rhodes A, McMurray JJ, Filippatos G, European Society of Cardiology European Society of Intensive Care Medicine: Assessing and grading congestionin acute heart failure: a scientific statement from the Acute Heart Failure Committee of the Heart Failure Association of the European Society of Cardiology and endorsed by the European Society of Intensive Care Medicine. Eur J Heart Fail 2010;12:423–433.
  5. Chan WLS, Pin TW. Reliability, validity and minimal detectable change of 2-minute walk test, 6-minute walk test and 10-meter walk test in frail older adults with dementia. Exp Gerontol. 2018.
  6. Ries, JD, et al. Test-retest reliability and minimal detectable change scores for the timed up & go test, the six-minute walk test, and gait speed in people with alzheimer disease. Physical Therapy. 2009;89(6):569-579.
  7. Spina E, Topa A, Iodice R, et al. Six-minute walk test is reliable and sensitive in detecting response to therapy in CIDP. J Neurol. 2019.
  8. Hernandes, Wouters, Meijer, et al. Reproducibility of 6 minute walking test in patients with COPD. European Respiratory Journal. 2011;38:261-267
  9. Steffen TM, Hacker TA, et al. Age- and gender-related test performance in community-dwelling elderly people: six-minute walk test, berg balance scale, timed up & go test, and gait speeds. Physical Therapy.  2002;82(2):128-137.
  10. Bellet RN, Adams L, Morris NR. The 6-minute walk test in outpatient cardiac rehabilitation: validity, reliability and responsiveness–a systematic review. Physiotherapy. 2012;98:277–286.
  11. McDonald CM, Henricson EK, Abresch RT, et al. The 6-minute walk test and other clinical endpoints in duchenne muscular dystrophy: reliability, concurrent validity, and minimal clinically important differences from a multicenter study. Muscle & Nerve. 2013;48(3):357-368.
  12. Demers C, McKelvie RS, Negassa A, Yusuf S. Reliability, validity, and responsiveness of the six-minute walk test in patients with heart failure. Am Heart J, 142. 2001;698-703.
  13. Quinn L, Khalil H, Dawes H, et al. Reliability and minimal detectable change of physical performance measures in individuals with pre-manifest and manifest Huntington disease. Phys Ther. 2013;93(7):942–56.
  14. Segura-Orti E, Martinez-Olmos FJ. Test-retest reliability and minimal detectable change scores for sit-to-stand-to-sit tests, the six-minute walk test, the one-leg heel-rise test, and handgrip strength in people undergoing hemodialysis. Phys Ther. 2011;91:1244-1252.
  15. Decavel P, Moulin T, Sagawa Y. Gait tests in multiple sclerosis: Reliability and cut-off values. Gait & Posture. 2019;67:37-42.
  16. Resqueti, Oliveira, Dourado, et al. Reliability of the six-minute walk test in patients with generalized myasthenia gravis. Fisioterapia e Pesquisa. 2009;16(3):223–228.
  17. Steffen T & Seney M. Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified parkinson disease rating scale in people with parkinsonism. Physical Therapy. 2008;88(6).
  18. Eng JJ, Dawson AS, et al. Submaximal exercise in persons with stroke: test-retest reliability and concurrent validity with maximal oxygen consumption. Arch Phys Med Rehabil. 2004;85(1):113-118.
  19. Kennedy DM, Stratford PW, Wessel J, et al. Assessing stability and change of four performance measures: a longitudinal study evaluating outcome following total hip and knee arthroplasty. BMC Musculoskeletal Disorders. 2005;6:3.
  20. Mossberg KA. Reliability of a timed walk test in persons with acquired brain injury. Am J Phys Med Rehabil. 2003;82(5):385-390.
  21. Balke B. A simple field test for the assessment of physical fitness. Rep Civ Aeromed Res Inst US. 1963(53):1 – 8.
  22. Troosters T, Gosselink R, Decramer M. Six minute walking distance in healthy elderly subjects. Eur Respir J. 1999 Aug;14(2):270-4
  23. Mudge S, Stott NS. Timed walking tests correlate with daily step activity in persons with stroke. Archives of physical medicine and rehabilitation. 2009; 90(2):296-301.
  24. Focht B, Rejeski WJ, Ambrosius W, Katula J, Messier S. Exercise, self-efficacy, and mobility performance in overweight and obese older adults with knee osteoarthritis. Arthritis and rheumatism. 2005;53(5):659-65.
  25. Lord S, Menz H. Physiologic, psychologic, and health predictors of 6-minute walk performance in older people. Archives of physical medicine and rehabilitation. 2002; 83(7):907-11.
  26. Gulmans VAM, vanVeldhoven NHMJ, deMeer K, Helders PJM. The six-minute walking test in children with cystic fibrosis: reliability and validity. Pediatr Pulmonol 1996;22:85–89.
  27. King S, Wessel J, Bhambhani Y, Maikala R, Sholter D, Maksymowych W. Validity and reliability of the 6 minute walk in persons with fibromyalgia. J Rheumatol 1999;26:2233–2237.
  28. Scivoletto, G., Tamburella, F., et al. (2011). “Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients.” Spinal Cord 49(6):736-740.
  29. Ferreira JP, Metra M, Anker SD, et al. Clinical correlates and outcome associated with changes in 6-minute walking distance in patients with heart failure: findings from the BIOSTAT-CHF study. European Journal of Heart Failure. 2019.
  30. Ruhl AP, Huang M, Colantuoni E, et al. Healthcare Resource Use and Costs in Long-Term Survivors of Acute Respiratory Distress Syndrome/ A 5-Year Longitudinal Cohort Study. Crit Care Med. 2017;45(2)/196–204. doi/10.1097/CCM.0000000000002088.
  31. Castel MA, Méndez F, Tamborero D, et al. Six-minute walking test predicts long-term cardiac death in patients who received cardiac resynchronization therapy/ EP Europace. 2009;11(3):338-342.
  32. Holden, DA, Rice, TW, Stelman, K et al. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest. 1992; 102: 1774–1779
  33. Lusardi M. Functional Performance in Community Living Older Adults.  Journal of Geriatric Physical Therapy. 2003. 26(3):14-22.
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The 5 Time Sit-to-Stand Test

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Understanding the abilities of patients to complete everyday tasks can indicate functional limitations and quality of life. The Five Times Sit to Stand Test (5xSTS) can be a valuable tool for therapists assessing functional independence, is simple to administer, and requires minimal equipment.

What is the Five Times Sit-to-Stand Test?

The sit to stand movement is a fundamental activity of daily life and can provide valuable insight into a patient’s health and functional status. The 5xSTS measures the amount of time it takes for a patient to sit and stand five times in succession with arms folded across their chest. 

The 5xSTS has been studied extensively in persons aged 20 to 90+ with various neurologic and orthopedic diagnoses that may impact their mobility. 

The test can be used to identify patients at risk of falling (Buatois et al, 2010), hospitalization (Cesari et al, 2009), functional decline (Deshpande et al, 2013), caregiver requirement (Shimada et al, 2013), frailty (Abizanda et al, 2012), and more.

Equipment needed

All that is needed to do the 5XSST is a standard height chair (43 cm) with a backrest and the ability to time and record the results of the test.

Instructions

  1. The patient begins seated with their back against a chair and arms folded across their chest.
  2. The therapist should stand beside the patient and appropriately guard to ensure safety.
  3. Instructions for patient: “When I say ‘Go’, stand up and sit down as quickly as you can 5 times in a row. Stand fully upright each time and try not to touch the backrest when you sit between reps.”
  4. Demonstrate the test.
  5. Have the patient perform 1 practice trial, followed by 1-3 timed trials.
  6. When the patient is ready, say “Go” and start the timer.
  7. Stop the timer when the patient’s buttocks touches the seat following the 5th stand.

Scoring the test

  1. Record the time from command “Go” until the patient’s buttocks touches the seat following the 5th stand.
  2. Perform 1-3 timed trials.
  3. Final score is the average of the timed trials.

Interpretation of the Five Times Sit-to-Stand Test

Accurate measurement and recording of the 5xSTS is crucial in determining effectiveness of interventions. Furthermore, it is important that the normative data and cut-off scores used to interpret your patient’s results matches their demographics. This is because what is considered “normal” for one patient may be “abnormal” for another due to physiological differences in age, gender, and diagnoses.

Normative data for the 5xSTS test (Bohannon et al, 2010; Lusardi et al, 2003):
  • 20-29 yrs ⇒ 6.0±1.4 sec 
  • 30-39 yrs ⇒ 6.1±1.4 sec
  • 40-49 yrs ⇒ 7.6±1.8 sec
  • 50-59 yrs ⇒ 7.7±2.6 sec
  • 60-69 yrs ⇒ 8.4±0.0 sec (male), 12.7±1.8 sec (female)
  • 70-79 yrs ⇒ 11.6±3.4 sec (male), 13.0±4.8 sec (female)
  • 80-89 yrs ⇒ 16.7±4.5 sec (male), 17.2±5.5 sec (female)
  • 90+ yrs ⇒ 19.5±2.3 sec (male), 22.9±9.6 sec (female)
Cut-off scores offer a number of insights into patient risk and functional ability:

Patients with a score of greater than or equal to 17 seconds have been found to have a 30% greater risk of hospitalization (Cesari et al, 2009).

Older adults are at risk of recurrent falls with scores greater than 15 seconds (Buatois, et al, 2010). 

Increased fall risk in patients with Parkinson’s Disease was found for scores greater than 16 seconds (Duncan et al, 2011). Similarly, those with vestibular disorders had an increased fall risk with scores over 15 seconds (Buatois, et al, 2008).

A minimal change in the score will offer a noticeable improvement in function (Duncan et al, 2011; Meretta et al, 2006). Patients who are able to decrease their score by as little as 2.5 seconds will see significant improvement.

Long term goals should be to improve the patient’s score to within normal for their age bracket and to reduce the risk of falling, hospitalization, and functional decline. Minimally, the goal should be for a patient’s score to be below 17 seconds.

References

  • Buatois S, Perret-Guillaume C, Gueguen R, et. el. A simple clinical scale to stratify risk of recurrent and older falls in community-dwelling adults aged 65 years. Phys Ther. 2010;90(4):550-560.
  • Cesari M, Kritchevsky SB, Newman AB, et al. Added value of physical performance measures in predicting adverse health-related events: results from the health, aging, and body composition study. Journal of the American Geriatrics Society. 2009;57(2):251-259.
  • Deshpande N, Metter EJ, Guralnik J, et al. Predicting 3-year incident mobility disability in middle-aged and older adults using physical performance tests. Arch Phys Med Rehabil. 2013;94(5):994-997.
  • Shimada H, Suzuki T, Suzukawa M, et al. Performance-based assessments and demand for personal care in older Japanese people: a cross-sectional study. BMJ open. 2013;3(4).
  • 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.  
  • Bohannon RW, Bubela DJ, Magasi SR, et al. Sit to stand test: performance and determinants across the age-span. Isokinet Exerc Sci. 2010;18:235–240.
  • Lusardi M. Functional Performance in Community Living Older Adults.  Journal of Geriatric Physical Therapy. 2003. 26(3):14-22.
  • Duncan RP, Leddy AL, et al. Five times sit-to-stand test performance in parkinson’s disease. Arch Phys Med Rehabil. 2011;92(9):1431-1436.
  • Buatois S, Manckoundia P, Gueguen R, et al. Five times sit to stand test is a predictor of recurrent falls in healthy community-living subjects aged 65 and older. J Am Geriatr Soc. 2008;56(8):1575-1577.
  • Meretta B, Whitney S, Marchetti G, et al. The five times sit to stand test: Responsiveness to change and concurrent validity in adults undergoing vestibular rehabilitation. Journal of Vestibular Research. 2006;16:233‐243.
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