The Short Physical Performance Battery (ASSESSMENT)

Abstract

ASSESSMENT TYPEThe Short Physical Performance Battery (SPPB) is an objective measurement instrument of balance, lower extremity strength, and functional capacity in older adults (>65 years of age). It was developed by the National Institute on Aging (NIA). Three domains, which include balance, usual or self-selected gait speed, and lower limb strength, are assessed by a three-stage balance test (feet side-by-side, semitandem, and tandem positions), a 3-m or 4-m gait speed test (time spent to walk the course), and a repetitive chair stand test (five times chair sit-to-stand test), respectively (1,2). A 0- to 12-point scale is used to score the sum of the three assessments with higher point values corresponding with greater levels of physical function and lower disability, whereas lower point values correspond with lower levels of physical function and higher disability, respectively (1,2). BENEFITS OF THE ASSESSMENT The SPPB is a standardized and clinically relevant assessment of functional performance, balance, and lower extremity strength in older adults (3–6). This test requires minimal equipment and can be performed by health-fitness professionals that work with elderly clients in field, community, or clinical settings. The SPPB has demonstrated sensitivity and responsiveness to exercise-based interventions over time (4–7) and can be completed in approximately 10 to 15 minutes. Results from the SPPB can help health-fitness professionals formulate physical activity and exercise program interventions to improve physical function in their older adult clients. Because it has demonstrated good sensitivity to changes in physical condition and performance over time, it can help guide program design and monitor improvements in fitness and lower limb function upon reassessment. Figure 1 depicts the three assessments from the SPPB.Figure 1: The three assessments from the SPPB.INTRODUCTION The SPPB was originally developed to assess lower extremity function in more than 5,000 persons 71 years and older (1). Results from the SPPB can help practitioners validly characterize older persons across a broad spectrum of lower extremity function (1,2). It is a powerful predictor of disability, institutionalization, and mortality (1,2,8). The SPPB has been subsequently used to identify mobility limitations and disability potential in persons with peripheral artery disease (5,9) and chronic obstructive pulmonary disease (10). This assessment also can be used to determine the need for and the responses to physical activity interventions in persons with sarcopenia (7) and as a predictor of the inability of older adults to walk 400 m (approximately two blocks which is considered another valid measure of disability) (11). It has been determined to be responsive and sensitive to changes in physical function over time (4,6). In addition, Ishiyama and colleagues (12) determined that an SPPB score of 9.5 was the cut point for the presence of sarcopenia in a cohort of elderly in-patient cardiac rehabilitation patients. The purpose of this Do It Right column is to describe the administration, scoring, and interpretation of the SPPB. To hear a summary of this column from author Peter Ronai, see Supplemental Digital Content 1, Video 1 (introduction), http://links.lww.com/FIT/A127. The NIA (13) has made educational materials regarding the SPPB available for use without permission or royalty fees. This site will allow you to download a training video that includes comprehensive instructions on the administration of the battery, safety tips, a scoring sheet, and background information on publications that support the methodology. A smart phone app also is available. It can be accessed at https://sppbguide.com/. EQUIPMENT Required equipment includes a standard height armless chair, stopwatch, adhesive tape, a 4-m rope or chain, measuring tape, SPPB scoring forms and directions, and a flat, well-lit floor or corridor long enough to accommodate a 4-m walking course and at least half a meter distance before and after the starting and finish lines, respectively. Alternatively, a 3-m course with a half meter zone before and after the starting and finish lines can be used if the testing area is smaller. PRIMARY PHYSICAL DOMAINS ASSESSED The SPPB assesses balance, gait speed, and lower extremity strength and function to predict mobility disability, morbidity, and mortality in older adults (1,2,8,11). TESTING PROCEDURE The SPPB is divided into three primary assessments, which include standing balance (in three separate foot placement patterns), comfortable gait speed over either a 3-m or a 4-m course and a timed five-repetition chair stand assessment (1,2). Clients should be medically cleared before participating in the SPPB. Standardized procedures and instructions for administering, scoring, and interpreting results of and from each portion of the SPPB from the NIA are available for free by downloading a video from their web site at https://sppbguide.com/ and should be followed in a script-like manner with all clients (1,13). STANDING BALANCE The client should be able to stand unassisted without the use of a cane or walker, but you may help them to get up initially. Clients are asked to hold three increasingly difficult standing positions for 10 seconds each. The positions include side-by-side (standing with feet parallel and touching), semitandem (standing with feet parallel with the heel of 1 foot touching the base of the big toe of the other foot), and tandem (standing with 1 foot directly in front of the other, with the heel of the front foot touching the tips of the toes on the opposite foot) and should be administered in this order. The following section describes verbal client directions and administration and safety procedures for each of the three standing balance subtests. Parallel Stance “I want you to try to stand with your feet together, side-by-side, for about 10 seconds. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop.” Stand next to the client to help them into the side-by-side position. Supply just enough support to the participant’s arm to prevent loss of balance. When the participant has his/her feet together, ask, “Are you ready?” Then let go and begin timing as you say, “Ready, begin.” Stop the stopwatch and say “Stop” after 10 seconds or when the participant steps out of position or grabs your arm. Semitandem Stance “Now I will show you the second movement” (demonstrate this test for the client). “Now I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop.” Stand next to the participant to help them get into the semitandem position and supply just enough support to the participant’s arm to prevent loss of balance. When the client has their feet together, ask, “Are you ready?” If the client indicates that he/she is ready, let go and begin timing as you say, “Ready, begin.” Stop the stopwatch and say “Stop” after 10 seconds or when the participant either steps out of position or grabs your arm. If clients cannot hold the position for 10 seconds, record the time, bypass the tandem stance test position, and administer the gait speed test next. Tandem Stance “Now I will show you the third movement” (demonstrate this test for the client). “Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop.” Stand next to the participant to help him/her into the tandem position and supply just enough support to the client’s arm to prevent loss of balance. When the client has their feet together, ask, “Are you ready?” If the client indicates that he/she is ready, let go and begin timing as you say, “Ready, begin.” Stop the stopwatch and say “Stop” after 10 seconds or when the participant steps out of position or grabs your arm. Participants received a score of “1” if they can hold the side-by-side stand for 10 seconds but cannot hold the semitandem stand for 10 seconds. Participants receive a score of “2” if they can hold the semitandem stand for 10 seconds but cannot hold the tandem stand for more than 2 seconds. Participants receive a score of “3” if they can hold the semitandem stand for 10 seconds and the tandem stand for more than 2 to 9 seconds. Participants receive a score of “4” if they hold the tandem stand for a full 10 seconds (1,2,9). Figure 2 depicts the parallel, semitandem, and tandem positions during the standing balance test component of the SPPB. See Supplemental Digital Content 2, Video 2, http://links.lww.com/FIT/A128, for demonstrations of the three stages of the standing balance assessment.Figure 2: Parallel, semitandem, and tandem stand positions during the standing balance test.GAIT SPEED First Gait Speed Test For the first gait speed test, have the client standing with you at one end of the walking course (typically marked with adhesive tape). State to the client, “Now I am going to observe how you normally walk. If you use a cane or other walking aid and you feel you need it to walk a short distance, then you may use it. This is our walking course. I want you to walk to the other end of the course at your usual speed, just as if you were walking down the street to go to the store” (demonstrate the walking test for the client). “Walk all the way past the other end of the tape before you stop. I will walk with you. Do you feel this would be safe?” Have the participant stand with both feet touching the starting line. “When I want you to start, I will say, ‘Ready, begin.’” After the client acknowledges the instruction and indicates they are ready, say, “Ready, begin.” Press the start/stop button to start the stopwatch as the participant begins walking. Walk behind and to the side of the participant (out of their visual field) and do not set the pace for them. If necessary, safety spotting can be applied from this position. Stop timing when one of the participant’s feet is completely across the end line. Repeat a second time and record the best time of two trials (1). Second Gait Speed Test Have the client reposition themselves at the other end of the walking course, standing with both feet touching the starting line. State to the client, “Now I want you to repeat the walk. Remember to walk at your usual pace, and go all the way past the other end of the course. When I want you to start, I will say, ‘Ready, begin.’” Once the client acknowledges this instruction, the health-fitness professional will say, “Ready, begin.” Once the client’s foot starts to move across the tape mark, press the start/stop button on the stopwatch. At this point, you will repeat the procedures for the first gait speed and stop timing once the client is completely across the end line. Figure 3 depicts the gait speed test at the start, middle, and finish. See Supplemental Digital Content 3, Video 3, http://links.lww.com/FIT/A129, for a demonstration of the Gait Speed Test.Figure 3: The gait speed test.CHAIR STAND TEST Single Chair Stand Say to the client, “Let’s do the last movement test. Do you think it would be safe for you to try to stand up from a chair without using your arms? The next test measures the strength in your legs.” (Demonstrate and explain the test procedure to the client.). “First, fold your arms across your chest and sit so that your feet are on the floor; then please stand up keeping your arms folded across your chest” (record whether the client can perform one repetition with arms crossed). If participant cannot rise without using arms, say, “Okay, try to stand up using your arms.” This is the end of their test. Record result and go to the scoring page. If the client is able to perform the single chair stand safely and properly, proceed to the repeated chair stand test. Repeated Chair Stands Say to the client, “Do you think it would be safe for you to try to stand up from a chair five times without using your arms?” (Demonstrate and explain the test to the client). Say, “Please stand up straight as quickly as you can five times, without stopping in between. After standing up each time, sit down and then stand up again. Keep your arms folded across your chest. I’ll be timing you with a stopwatch.” When the client is properly seated, say, “Ready, stand” and begin timing. Count out loud as the participant rises each time a repetition is completed and their legs are fully straightened up to five times. Stop the stopwatch when the client has straightened up completely for the fifth repetition. In addition, stop the stopwatch if the client becomes tired or short of breath during the test, uses their arms, after 1 minute, if the client has not completed five chair stands, or at your discretion if you are concerned about the client’s safety. *If the client appears fatigued before completing the five chair rises, confirm this by asking them, “Can you continue?” Continue timing the client if they say “Yes” and stop and reset the watch if they say “No.” Practitioners should stand in front of the client (without impeding their movement) in case safety spotting becomes necessary. Figure 4 depicts the repeated chair stand test. See Supplemental Digital Content 4, Video 4, http://links.lww.com/FIT/A130, for a demonstration of the repetitive chair stand test.Figure 4: The repetitive chair stand test.SPOTTING AND SAFETY TIPS To enhance safety, the administration scripts mentioned in the previous section should be read verbatim in a standardized manner to each client, and each client should be asked if they have any questions and whether or not they feel safe attempting a task after reading each direction. Spotting should be provided by being close enough to stabilize each client by their arms without helping them perform any of the tasks. It is especially important to be out of the client’s visual field during the gait speed test to avoid pacing their walking speed. SCORING AND INTERPRETATION Each assessment item within the SPPB should be scored and interpreted with the standardized instructions developed by Jack Guralnick, M.D., Ph.D. for the NIA (1,13). Please refer to https://sppbguide.com/, which provides administration, scoring, and interpretation instructions and directions for each item within the SPPB from the NIA. Typically, scores ≥10 out of 12 points correspond with higher levels of balance, lower body strength, mobility, and physical function (1). Lower scores indicate more severe mobility, strength, and functional limitations as well as higher rates of morbidity and all-cause mortality (14) and indicate a need for more targeted interventions (1). Perera and colleagues (4) have suggested using 0.5- and 1.0-point score differential during reassessment as small and meaningful changes occur respectively in the SPPB over time. A decrease of one point may indicate that an older adult client has had a meaningful decline in mobility and physical function (4). Ishiyama and colleagues (12) have suggested using 0.3 to 0.8 points and 0.4 to 1.5 points as small but meaningful and substantial changes in SPPB performance respectfully. ADDITIONAL INFORMATION The SPPB can be administered before establishing physical activity and exercise program interventions for improving balance, mobility, strength, and physical function and as an instrument to monitor progress and program outcomes. In addition, exercise program development can be guided by both the composite and the individual item scores obtained during the administration of the SPPB. SUMMARY The SPPB is an effective, time-efficient assessment of balance, lower extremity strength, and function that health-fitness professionals can administer in clients classified as older adults (>65 years of age). It is sensitive to changes in physical function over time, can be conducted in a field setting, requires minimal equipment and space, and can be used to help design physical activity interventions for improving physical performance in older adults. According to Perera and colleagues (4), “like vital signs such as body weight or BP, performance measures may offer a powerful mechanism to understand and act on the health care needs of older adults.” NOTE TO READERS In the video, 1) the practitioner walks next to the client but should be slightly behind and out of the peripheral vision of the client to ensure safety while avoiding pacing the client. 2) The participant sets his feet before the exercise physiologist’s demonstration for both the side-by-side and semitandem balance tests. The client should not set their feet until the exercise physiologist positions themselves behind the client and is ready to start the timer. 3) During the repeat sit-to-stand test, the client’s feet come off the floor. The client’s feet should remain on the floor during the test. If the client’s feet do not reach the floor, they can shift forward on the seat so that their feet are on the floor.