Outcome Measures - Questions

what equipment is needed for the 10mWT?

- stopwatch - clear path of at least 10m

how do you perform the 10mWT?

- 2 trials at comfortable walking speed - 2 trials at fast walking speed - avg. each speed and document

what are the items of the FGA?

1. level surface 2. change in speed 3. horizontal head turn 4. vertical head turn 5. pivot turn 6. obstacle 7. narrow BoS 8. eyes closed 9. backwards 10. steps

how long does it take to administer 6MWT?

<10 min

how much time does it take to complete FGA?

<20 min 5-10min

6MWT - what if a patient can't ambulate? should the 6MWT be performed?

For patients who are unable to walk, but have a goal and the capacity to achieve walking, a baseline a score of 0 meters should be documented.

FGA - "What if my patient demonstrates a high score?"

If a patient demonstrates a high score near 30 out of 30, or is likely to do so, the clinician may need to select a more challenging outcome measure to assess change over time. If a patient scores near the top of the FGA scale, it may not be necessary to re-administer the test.

FGA - "What if my patient cannot walk?"

If a patient is unable to ambulate, but has the goals and capacity to improve balance, a baseline score of 0 should be documented for the FGA.

"If my patient cannot stand, should I still complete the BBS?"

If the patient cannot complete any elements of the BBS, they will have a score of 0 which will be their starting score. The recommendation would be that all patients have a baseline Berg Balance score

BBS - "What arm should the patient use to reach forward?"

Where possible, both arms should be used; however, in instances where it is difficult to lift one arm (i.e. hemiparesis, shoulder ROM limitation), the intact arm can be used provided that the patient is not utilizing trunk rotation to achieve further reach.

5TSTS - "Should I include a practice session or multiple trials?"

Yes, a practice session can ensure familiarization with the test. So, if a clinician feels a practice session is warranted then one may be performed. If a patient has limited endurance, consider an abbreviated practice trial of 2 sit to stands to ensure that the patient understands all components of the test.

FGA - "For Item 7: Gait with Narrow Base of Support, is it appropriate to have them walk on the line that marks the walkway?"

Yes. Per 2017 discussion with developing authors Sue Whitney and Diane Wrisley (original authors), tape was used on the ground for this item when the test was first developed.

how long does the BBS take to administer?

less than 20 minutes

"Can I provide touching assistance, or hold the gait belt, during the balance components of the BBS?"

touching assistance If a patient requires touching assistance for an item, the lowest associated score for that item should be utilized or the specified score for that item gait belt If you are unsure of the capabilities of the patient, you may elect to hold a gait belt, but consider completing a second trial without touching assistance by the therapist for a true measure of patient performance.

BBS - "Does it matter which leg the patient stands on (SLS) or which is in front/back (tandem)?"

- The BBS allows the patient to self-select the limb that they would stand on for both of these items - In instances where a patient has unilateral impairment, it is recommended that the patient be tested on the involved limb (SLS) by standing on the involved limb and taking the forward step with the uninvolved limb (tandem).9

BBS - "How high does the step/stool need to be?"

- The International Residential Code4 states that the recommended maximum height of a riser is 7¾ inches. - Steffen et al.3 documented the use of a 9-inch step stool. - A step/stool that is at least 7¾ inches, no greater than 9 inches in height is recommended.

what 3 factors need to be documented from the 6MWT?

- distance, meters - level of assistance - type of AD and/or bracing

how do you set up 10mWT?

- measure & mark 10m - add mark at 2m and 8m (6m in middle that will actually be timed)

what equipment is needed for BBS?

- stopwatch - 2 standard chairs, 1 with armrests and 1 without (18-20 in) - step or stool avg height (7 3/4in - 9in) - slipper or shoe - ruler

What equipment is needed for 6MWT?

- stopwatch - chair - measuring tool (meters) - hallways or open area at least 12m long, with a smooth consistent surface - to objects (cones) to indicate turn around - pencil and paper

what equipment is needed for FGA?

- stopwatch - measuring device - marked walking area = 20 ft (6 m); width 12 in (30.48 cm) - obstacle of 9in, least 2 stacked shoeboxes - set of steps c bilateral rails, 7 ¾ -9 in high

what are the items of the BBS?

1. STS 2. Stand unsupported 3. Sit unsupported 4. Stand to Sit 5. Transfers 6. Standing eyes closed 7. Standing feet together 8. Reaching forward 9. pick up object from floor 10. look behind over shoulder 11. turn 360 12. toe touches on stool 13. tandem 14. SLS

BBS uses a __(#) -point ordinal scale __(#) to __(#)

5-point ordinal scale 0 to 4 0 = inability to complete task 4 - ability to complete task criterion

how long does it take to administer 10mWT?

< or = 5 min

"Can the patient use an assistive device for any elements of the BBS?"

Assistive devices should not be used by a patient when performing the BBS. If the patient normally utilizes an assistive device to perform a respective task, the administrator should encourage the patient to attempt the task without it. If the patient cannot perform the item without an assistive device they will be scored a 0.

ABC Scale - "These questions are not appropriate for patients who are non-ambulatory. Should I utilize this measure?"

Clinicians should use the ABC to assess adults with neurologic conditions who have goals and the capacity to change in this area. If you predict that your patient may ambulate further along in his or her recovery, it may be worthwhile to perform this measure.

BBS - "What if I don't have a shoe/slipper available? Can I use a box of tissues instead of a slipper or a shoe? Can I use a pen on the floor instead of a slipper?"

Do not substitute with any object that is shorter or taller than a slipper toe box or shoe as this will make the subject bend lower or not as far as the item intended.

6MWT - "In my setting the longest area available transitions from laminate flooring to carpet. Is this a problem?"

Ideally the floor surface would be hard and flat2 throughout, as well as being the same, however this may not be possible in all settings, particularly in the home. The test should still be administered in the area that you have, and a consistent administration procedure and environment be utilized each time the test is performed. The variation in surface or environment should be documented and clearly identified as a variation from the standardized procedure above. Be aware that the results may not be comparable to published normative values or appropriate to include in an aggregate analysis.

Can physical assistance be provided in the 10mWT?

If a patient requires assistance, only the minimum amount of assistance required for a patient to complete the task should be provided. The level of assistance documented, however, should reflect the greatest amount of assistance provided during the test.

what if patient is unable to ambulate, should perform 10mWT?

If a patient requires total assistance or is unable to ambulate at all or requires assistance which affects the speed of forward propulsion, a score of 0 meters should be documented For patients who are unable to walk, but have a goal and the capacity to achieve walking, a baseline score of 0 meters/second should be documented.

10mWT - "What if it is not clinically feasible to complete two trials of each condition, comfortable and fast walking speed?"

If four test trials are not clinically feasible, it is recommended that two trials, one trial at a comfortable and one at a fast walking speed, be performed to provide an assessment of the patient's ability to alter gait speed. If two trials are not clinically feasible, it is recommended that a trial of comfortable walking speed be prioritized. Consider that if a patient has goals to return to the community, the assessment of fast walking speed has more value. If a patient has the ability to walk fast, he/she may be able to more fully participate in the community and adapt to environmental context. If the projected outcome for the patient is community ambulation, a fast gait speed should be collected at the earliest time point possible, and re-testing is recommended to track change.

FGA - "What if I don't have a set of stairs at all?"

If the patient does not attempt all test items, this is a deviation from the standardized procedure, therefore interpretation of the score with use of normative values or cut of scores would not be appropriate. Completion of only some test items may be useful to the individual patient. For example, the patient may benefit from education on the value of gait speed or a safety strategy during performance of multiple motor tasks. The individual score (partial score) may be used to set an individual goal for a future trial or session.

5TSTS - "What if my patient cannot complete five repetitions?"

If the patient does not complete five repetitions, a score of 0 seconds should be recorded. When possible, within the medical record it is also recommended to note the reason, such as "unable to perform five repetitions". The clinician can, however, use his or her clinical judgement to record a time for fewer repetitions or provide physical assistance to help the patient complete the assessment, as this information may be valuable to explore change over time for the individual patient.

5TSTS - What if my patient does not stand up fully during the test?

If the patient does not stand up fully, the test should be discontinued and the patient reoriented to the instructions to make a complete stand with each repetition during the test.

6MWT - "My patient stumbled during the measure and I jumped in to catch them and prevent a fall. How do I score this measure?"

If the patient is able to resume walking, the trial can continue. The number of times and the distance at which the patient stumbled should be documented. The level of physical assistance required should be documented using an ordinal 7-point scale as described.

BBS - "How do I assess trunk rotation and weight shift in a patient with post-operative spinal precautions?" (#10 - turn look over shoulder)

If the patient is unable to rotate the trunk due to post-surgical considerations, the patient would score a 0 for this item.

FGA - "What if my patient requires assistance?"

If the patient requires assistance to complete any item, the score is recorded as a 0. Per 2018 discussion with developing author Sue Whitney, an orthosis is not considered an assistive device and does not impact the scoring of the item.

"What if my patient has a decline in the ABC score, the percent of balance confidence, but as a clinician I believe it is due to improved awareness and insight, not regression?"

If this happens, it may be helpful for the clinician to look across other objective measures to provide support and rationale for the clinician's conclusions. Administration of both clinician-rated and patient- reported measures may provide a more comprehensive assessment of balance confidence than administering only a clinician-rated measure. These data points may need to be excluded in aggregate analysis of change scores if the impression is that these do not reflect a true measure of balance confidence.

FGA - "What if my patient uses an assistive device?"

If use of an assistive device is not specified for scoring a particular item, and the patient requires use of that assistive device to complete the item, then the item is scored as a zero.

5TSTS - "What if the individual's feet don't touch the floor when they have their back against the backrest?"

In this scenario, it is permissible to allow the individual to move forward in the chair until their feet are flat on the floor. It is recommended that the deviation from standardized protocol be documented as well

6MWT - "What about monitoring vital signs after the test. Should I check them?"

It is always good practice to monitor vital signs, particularly in patients with cardiovascular or pulmonary involvement. Per the American Thoracic Society Guidelines, it is up to the clinician's judgement on which and if vitals should be obtained.

ABC Scale - "What if the patient qualifies their responses with different rating for 'up' versus 'down' or 'onto' versus 'off' (stairs, car, ramp, escalator, etc.)?"

It is suggested to solicit separate ratings and use the lowest confidence of the two ratings, as this will limit the entire activity. For example, if on item 2 (...walk up or down stairs? _____%), the patient says they are 80% confident walking up the stairs and 60% confident walking down the stairs, their score for this item is 60%.

5TSTS - "What if the individual is very tall?"

It would be appropriate to use a taller chair or apply a seat cushion to bring the hip flexion angle to 90 degrees when in the seated position.3 This condition should be documented as a variation of the standardized procedure.

6MWT - "My current setting does not have a 12-meter hallway or open area available. What should I do?"

Length of the track does matter. According to one study, using shorter hallways or "tracks" resulted in patients walking shorter overall distances on the 6MWT compared to when they used longer hallways4 Therefore, it is recommended that the test be administered consistent with recommendations above. If your facility does not have a 12 meter hallway, the test can be administered outside over level ground, free of street crossings. If your facility does not have a 12 meter hallway, AND you can't administer the test outside due to safety, weather, unlevel surfaces, etc., the test can still be administered over a shorter track, and a consistent administration procedure should be utilized each time the test is performed. The shorter track distance and any other modifications should be documented and clearly identified as a variation from the standardized procedure detailed above. Be aware that the results may not be comparable to published normative values or appropriate to include in an aggregate analysis. Additionally, the 6MWT may have limited feasibility in certain settings with limited walkway space (hospital room, home environment). Thus, clinicians will need to determine the feasibility and appropriateness of the 6MWT in specific situations. If unable to administer due to limited feasibility, the clinician should document "unable to administer" and provide an explanation in the patient's medical record.

5TSTS - "Should my patient touch their back against the back rest between each repetition of sit to stand?"

No, the patient should be encouraged to avoid touching his/her trunk to the backrest between each repetition to minimize utilization of momentum to complete the sit to stand.

Can patients talk during the 6MWT?

Patients should not talk during the test, as this depletes their respiratory reserves. Exceptions to this are if the patient requests to stop the test or needs to report any symptoms The person administering the test also should not talk, except to provide updates every minute. Talking during the test can distract the patient and affect their score on the test.

5TSTS - "What if my patient has a loss of balance and requires physical assistance to prevent a fall?"

Providing assistance during the test is a deviation from the standardized procedure, however, it may be necessary to prevent patient injury. If physical assistance is provided, the patient should be given a score of 0. When possible, within the medical record it is also recommended to note the reason, such "unable to complete test without assistance".

10mWT - "Where should the therapist stand and guard?"

Standing behind the patient will reduce the likelihood of the clinician setting the pace and will also keep the clinician and stopwatch out of sight of the patient to reduce the likelihood of the patient "racing."

FGA - We currently use the Dynamic Gait Index (DGI) in our facility. Can I use this test as a substitution since it is so similar?

The FGA includes three items which are not on the DGI: Gait with Narrow Base of Support, Gait with Eyes Closed, and Ambulating Backwards. The Dynamic Gait Index has one item which is not on the FGA: Step Around Obstacles. Thus, although these tests are similar, they are not interchangeable. The FGA was selected instead of the DGI for inclusion in the core set for the following reasons: better reliability across acute, chronic stable and chronic progressive populations; inclusion of clinically relevant balance items of gait with narrow base of support, gait with eyes closed, and ambulating backwards; and improved response categories to facilitate consistency in outcome measure administration.

"What if the patient doesn't complete one of the tasks on the ABC? How do I score the measure when this occurs?"

The clinician should always try to have the patient complete all items. If appropriate and the patient does not currently do the activity in question, instruct the patient to try and imagine how confident they would be if they had to do the activity. 4 If it is not appropriate or the patient does not complete an item, an ABC score can still be determined by summing the ratings and dividing by the number of items answered if an individual answers at least 12 of the 16 questions. Most commonly omitted is the last item (... walk outside on icy sidewalks? _____%) in warmer climates.4

6MWT - "My patient can't walk for 6 consecutive minutes. Why can't I just do the 2 Minute Walk, instead?"

The good news is that any patient with goals to improve walking distance and capacity can perform the 6MWT. Even if your patient has to end the test well before the 6 minutes are over, he/she can still receive a score (distance walked) on this test. In some cases the score might be just a few meters distance. In order to decrease variability in practice and for consistency of measurement across episodes and the continuum of care, the 6MWT is the preferred measure of walking endurance. It is recommended that clinicians use this measure instead of (or in addition to) other measures of walking endurance.

BBS - "What if the patient can't attain the start position?" (#7 stand unsupported feet together)

The patient should be instructed: "Place your feet together and stand without holding on." In some individuals, other bony or soft tissue restrictions may limit their ability to stand with the feet together. Instruct the patient to place the heels and toes as close together as possible.

ABC Scale - "What if the patient typically uses an assistive device when they complete the activity in question? Should they rate their confidence with or without using the assistive device?"

The patient should rate their confidence in completing the task while using their current device. The assistive device considered by the patient should be documented and kept consistent between trials and reassessments. It is likely, however that the type of assistive device may change over time. If the type of device "used" during rating of confidence has changed, the new type or condition of "no device" should be documented.

FGA - "If I only have four steps with bilateral railings is that ok or do I need an entire flight?"

The test can be accomplished with a set of four or more steps. The steps need to have bilateral rails and should be standard step height (approximately 7 ¾ in [20.32 cm])

BBS - "What if the patient loses their balance trying to get into or hold full tandem? Do I automatically score a 0 for that item?"

The test instructions indicate that a demonstration should be given to the patient showing them the option for tandem stance, and also the foot-ahead stance required to achieve a score of 3. Thus, if a patient attempts tandem and cannot achieve this, the tester can cue the patient to try the alternate position with demonstration.

"My patient needs to stop and sit during the 6MWT. Is it acceptable to keep the clock running while they sit, and then have them stand and continue walking?"

The test stops when a person needs to sit and rest, and this is the distance recorded. A patient can take as many standing rest breaks as needed, even leaning against a wall, but standard procedure is to stop the test when a person needs to sit because this indicates the true distance the patient can walk.

5TSTS - "What if I don't have a chair that is 43-45 cm (17-18 inches) high?"

This is the recommended height for completing the test. If the chair used is a different height, the height should be measured, documented and reported as a deviation from this standardized procedure. Using the same chair height is recommended for ongoing assessments to capture change in the patient. Note that this recommended chair height is different from the recommended chair height in the Berg Balance Scale (18-20 inches).

10mWT - "What if I don't have 10 open meters to do the assessment?"

Variations to the 10mWT exist, including the 5MWT. Clinical recommendations include a "rolling start and finish" during the 5MWT to allow for acceleration and deceleration. It is important to note that the 5MWT has not been validated in as many health conditions as the 10mWT. Individuals or organizations should use the 10mWT standardized protocol to assess aggregate data for their patients. In cases when the protocol cannot be used, the modifications to the administration process should be documented.

5TSTS - "What if my patient cannot stand without using his/her hands?"

When following the standardized procedure, it would be appropriate to document 0 for the score. While 0 seconds would be the fastest possible time to complete the test, it is also impossible and therefore would be clear in any medical record that the patient was unable to perform the test. When possible within the medical record it is also recommended to note the reason, such as "unable; requires use of hands". At the point in time when the patient is able to complete 5 sit-to-stands without the use of upper extremities, a baseline 5TSTS score can be recorded. Arm and hand position influence the momentum and strategy for the sit to stand transition and influence 5TSTS Test scores. If the patient cannot complete the assessment with arms folded, it is permissible to allow the individual to utilize his or her hands to assist. This deviation from standardized protocol should be documented. The standardized protocol score would still be "unable".

10mWT - "My patient requires contact guard assistance, can I still administer this measure?"

Yes, If physical assistance is needed for a patient to complete the 10mWT please document the time (m/s), the level of assistance provided, and the assistive device or bracing used. The level of physical assistance required should be documented using an ordinal 7-point scale described below. It is important to note that the assisted test may not be directly comparable to the distance that patient walks without assistance, and it may not be compared to published normative values.

6MWT - "My patient requires contact guard assist, can I still administer this measure?"

Yes, If physical assistance is needed for a patient to complete the 6MWT, please document the distance in meters, the level of assistance provided, and the assistive device or bracing used. The level of physical assistance documented using an ordinal 7-point scale as described It is important to note that the assisted test may not be directly comparable to the distance that patient walks without assistance, and it may not be compared to published normative values.

can patients use AD in 10mWT?

Yes, any currently using. must be documented.

can patients use bracing in 10mWT?

Yes, any currently using. must be documented.

5TSTS - "Does foot position matter?"

Yes, foot position can impact sit to stand time and has been found to be a limitation in some studies exploring the 5TSTS in neurologic populations. A posterior foot position has been shown to have faster sit to stand times in patients with chronic stroke. Foot position should be self-selected by the patient.

"Can a hospital bed or mat table serve as one of the seating surfaces during the BBS?"

Yes, however attempts should be made to preserve the standard height of 18-20 inches. If unable, the variation in height of the surface should be indicated and standardized within the practice/facility.

10mWT - "Can the patient use an assistive device during the test?"

Yes, the patient can use an assistive device during the test. Recommendations include documenting the assistive device and keeping the assistive device consistent between trials and reassessments. Inappropriate assistive devices can have a negative impact on walking speed and therefore reduce the validity of the test.2 It is likely that the type of assistive device a patient needs may change over time. If/when a different assistive device is indicated, the reason behind a different device choice should be noted. If the patient no longer needs the assistive device, or has progressed to a less restrictive device, it would be appropriate to repeat the test with this change in conditions and document this fact. It is appropriate to have the patient utilize the assistive device which he/she is most likely to use in his/her own environment.

6MWT - "Can the patient use an assistive device during the test?"

Yes, the patient can use an assistive device during the test. Recommendations include documenting the assistive device and keeping the assistive device consistent between trials and reassessments. Inappropriate assistive devices can have a negative impact on walking speed and therefore reduce the validity of the test. It is likely that the type of assistive device a patient needs may change over time. If/when a different assistive device is indicated, the reason behind a different device choice should be noted. If the patient no longer needs the assistive device, or has progressed to a less restrictive device, it would be appropriate to repeat the test with this change in conditions and document this fact.

6MWT - "Can the patient use orthoses or bracing during the test?"

Yes, the patient should wear the walking devices necessary for ambulation (AFO, KAFO, Neuroprostheses, etc). The walking device should be documented and kept consistent between trials and assessments. If the patient no longer needs the orthosis which was used in the initial test, it is appropriate to repeat the test without the orthosis and document this fact. It is appropriate to have the patient utilize the orthosis or brace which he/she is most likely to use in his/her own environment.

10mWT - "Can the patient use orthoses or bracing during the test?"

Yes, the patient should wear the walking devices necessary for ambulation (AFO, KAFO, Neuroprostheses, etc). The walking device should be documented and kept consistent between trials and assessments.6 If the patient no longer needs the orthosis which was used in the initial test, it is appropriate to repeat the test without the orthosis and document this fact. It is appropriate to have the patient utilize the orthosis or brace which he/she is most likely to use in his/her own environment.

FGA - "Can I provide verbal cues or demonstration during the trial, to remind patients when to turn or tilt their head, for example?"

Yes, verbal cues or demonstration are appropriate to the extent that these are needed for the patient to complete the necessary movements. Cues should be kept to a minimum and documented as a condition of the trial(s).

10mWT - "My patient has impaired cognition and gets distracted during the test, frequently forgetting what their goal is. Can I still administer this measure?"

Yes. Examiners can use brief verbal, visual, or tactile cues to keep a patient on-task and to remind him/her of the goal, but be consistent (e.g., "Keep going. Walk to the mark."). Document the type and frequency of the required cues.

6MWT - "My patient has impaired cognition and gets distracted during the test, frequently forgetting the intended goal. Can I still administer this measure?"

Yes. Examiners can use brief verbal, visual, or tactile cues to keep a patient on-task and to remind him/her of the goal, but be consistent (e.g., "Keep going. Walk to the mark."). Document the type and frequency of the required cues.

"What if my patient does not speak English? Is the ABC available in other languages?"

Yes. The ABC has been translated into a variety of other languages. However, the reliability and validity of these translations should be understood when administering a translated version of the ABC. Languages available include: Spanish, German, Chinese, French-Canadian, Korean, Dutch, Persian, Brazilian-Portuguese, Arabic, Hindi, and Turkish. If the measure is administered in a different language, there is a risk of misinterpretation of items for those testers who are not fluent in the given language.

ABC Scale - "What if my patient is unable to read the instructions/questions (due to impaired cognition, impaired speech/language, vision deficits, etc.)? Can I read it to them?"

Yes. The measure can be administered by personal or telephone interview, if needed. Patients with lack of insight into impairments may have difficulty accurately answering the ABC questions. In these cases, clinicians should use their judgement to determine appropriateness of administering this test.

ABC Scale - "What if my patient is unable to correctly interpret the stem question (How confident are you that you can maintain your balance and remain unsteady when you...)? Can you vary it?"

Yes. While adhering to the scripted stem question is preferred for standardization, you can vary/explain the stem if this is a barrier to administering the assessment.

FGA - is a pt. able to use an orthosis? how does this affect scoring?

Yes. an orthosis is not considered an assistive device and score as normally would.

"Should I count the number of steps taken to complete the 10mWT?"

You can! The number steps to complete the test may provide insight into stride length. Although documenting this number may add individual value to specific clinical situations, there has not been extensive research validating the observational step count in various neurological conditions.

what do all outcome measures have in common?

how/when administered - administered at least 2 times, admission and discharge, and when feasible, btw periods under same test conditions review of standard review procedure on annual basis and establish consistency within and among raters using the tool

the FGA is a modification of the DGI, and was developed to..

improve reliability and reduce ceiling effect

FGA - if pt uses AD, they can score no higher than a ___ (#) on any given item

no greater than 2

when should you not administer BBS?

patients who do not have goals to improve static and dynamic balance

when should you take vital signs for a 6MWT?

pre and post testing

what factors are you documenting following the 10mWT?

time to walk 6m, level of assistance, type of AD and/or bracing used

when administering walking items, where should you walk in comparison to pt? why?

walk at least 1/2 step behind pt do not walk in front of or beside as could "pace" pt and influence speed they walk