Daniel Woodward, SPT

East Tennessee State University

HCR Manor Care: Internship I

Reasons for Outcome Measures:a) Objectively document patient progress to confirm the

efficacy of our treatment methodsb) To get reimbursed

A top reason for therapy claim denials:a) Clinical documentation submitted for review does not

support the medical necessity for the services billed7

Balance!

Geriatric Fall Statistics (CDC)1

1 in every 3 adults age 65 and older falls each year

Among older adults, falls are the leading cause of both fatal and nonfatal injuries

In 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.

In 2010, the direct medical costs of falls, adjusted for inflation, was $30 billion.

APTA Section on Geriatrics practice committee recommends:

1. Walking Speed

2. Six Minute Walk Test

3. Timed Up and Go

4. Berg Balance

5. Five Times Sit to Stand

6. Patient Specific Functional Scale

7. Dash or Quick Dash

8. Elderly Mobility Scale

9. Falls Efficacy Scale

*All of the above recommended based on best evidence, practicality of use, responsiveness, and psychometrics

Most current balance measures focus on standing activities and may not be appropriate for two types of patients:

1. Frail, elder adults whom are currently non-ambulatory but whom may at some point be able to stand up or ambulate6

2. Individuals with chronic/progressive diseases such as Alzheimer's, Multiple Sclerosis, or Parkinson's6

Current sitting balance quality is typically measured using a likert scale format

Dynamic vs. Static

Normal -> Good -> Fair -> Poor

Reliability/Validity of this method has not been established6

64 y.o. obese patient who weighs 300 lbs. suffered a (R) below the knee amputation secondary to Type II Diabetes. Patient has been an amputee for several years and has been in a LTC setting using a hoyer lift since July of 2012. Patient is alert and oriented x 3, is non-ambulatory, and is unable to stand up secondary to insufficient upper-body, abdominal, and LE strength. Patient is aware of condition but is highly motivated to excel with therapy and desires to stand up and be re-evaluated for prosthesis since current prosthesis does not fit.

Which standardized outcome measure would you utilize to document this patient's progress with the goal of standing in mind?

1. Tinetti Balance and Gait Assessment? Patient, at most, may score 1/28 Not appropriate

2. Berg Balance? Patient would score 0/56 Not appropriate

3. Functional Reach Test? Patient can't stand Not appropriate

4. Timed Up and Go? Patient can't stand Not Appropriate

5. No outcome measure, just ROM, Strength, Balance, etc? Will this ensure medical necessity for our services?

Who needs outcome measures anyway?

What reliable, valid, and concise outcome measure can be utilized in the clinic for non-ambulatory patients who

may "bottom out" on measures such as the Tinetti Assessment, the Berg Balance Test, the Timed Up & Go,

and the Functional Reach Test?

1. Sitting Balance Scale (SBS)

2. Function in Sitting Test (FIST)

11 item test Items represent functional abilities

related to sitting balance

Scoring: 0-4 point likert scale (0 = worst

performance) (4 = best performance)

Reliability: Inter-rater = Good Intra-rater = Excellent

Validity: Can differentiate individuals with

pathology vs. apparently healthy individuals

Participants with pathology had lower total SBS score than people without pathology

Patient Population: Frail individuals who are primarily

non-ambulatory and who may exhibit floor effects on other common clinical assessments

Time to administer: Less than 10 minutes

Equipment Needed: 12 in. ruler Stop-watch Object such as a slipper or sock Book 3 – 3.5 in. thick 2 lb. cuff weight 15" x 15" x 5 " piece of foam

14 item test

Uses: Quantify sitting balance through basic

everyday activities while seated Assess patient performance on various

functional sitting tasks Track changes in sitting balance over time

Scoring: 0 – 4 point ordinal scale 4 = Independent, 3 = Verbal Cues or Increased Time 2 = Upper Extremity Support 1 = Needs Assistance 0 = Dependent Minimal Detectable Change = 6 points or

more

Reliability/Validity: Confirmed for adults post stroke3

Intra/inter-tester reliability and evaluative validity studies are under way

Patient population: Known or suspected sitting balance

deficits who are unable to participate in balance tests involving tasks in standing and/or gait

Issues with impulsivity or safety while seated

Working on speed, safety, and motor control while seated

Time to administer: Approximately 5 – 10 minutes

Equipment needed: Step stool or riser (for foot positioning,

dependent on patient height) Stopwatch or watch with second hand Tape measure Small, light weight object (can use small,

retractable tape measure or stopwatch) FIST Scoring sheet

Standard Patient Position

*This Position should be maintained throughout the test

Nudge Items

Intended to examine patient's ability to react to an unknown disruption of their balance

Randomly administer throughout test with light pressure

Do NOT tell the patient before you administer the perturbation

3 nudges:

Score Description Selected Example

4 Independent Normal Performance

3 Verbal Cues/Increased Time

Puts hand down to perserve balance, on second attempt after cueing to not use hand can perform without the use of their hand.

2Upper Extremity

SupportMust put hand down to support self after 1-2

repeated attempts after cueing patient to not use hands

1Needs Assistance Generates insufficient balance reaction and

requires min A to maintain upright balance

0Dependent Cannot generate balance reaction and requires

total A when nudged.

FIST Test Item

½ femur on surface; hips & knees flexed to 90°

□ Used step/stool for positioning & foot support

Date: Date: Date:

Random

ly

Adm

inis

tere

d

On

ce

Anterior Nudge: superior sternum

Posterior Nudge: between scapular

spines

Lateral Nudge: to dominant side at

acromion

Static sitting: 30 seconds

Sitting, shake ‘no’: left and right

Sitting, eyes closed: 30 seconds

Sitting, lift foot: dominant side, lift foot 1 inch twice

Pick up object from behind: object at midline, hands breadth posterior

Forward reach: use dominant arm, must complete full motion

Lateral reach: use dominant arm, clear opposite ischial tuberosity

Pick up object from floor: from between feet

Posterior scooting: move backwards 2 inches

Anterior scooting: move forward 2 inches

Lateral scooting: move to dominant side 2 inches

TOTAL/ 56 / 56 / 56

Administered by:

Notes/comments:

Scoring Key:

4 = Independent (completes task independently & successfully)

3 = Verbal cues/increased time (completes task independently & successfully and only needs more time/cues)

2 = Upper extremity support (must use UE for support or assistance to complete successfully)

1 = Needs assistance (unable to complete w/o physical assist; document level: min, mod, max)

0 = Dependent (requires complete physical assist; unable to complete successfully even w/physical assist)

Limitations: Although research supports these assessments as being reliable and valid, there

are only a few studies with small sample sizes that have been completed to date More larger scale studies are needed to further confirm the efficacy of these two

assessments

Cut-Off Scores have not been established yet

Can these two assessments be used in the clinic? Yes SBS

2 studies completed to date confirming reliability/validity Recommended by the APTA Section on Geriatrics practice committee for assessing

low level patients

FIST 2 studies completed to date – results under embargo Sharon Gorman says:

"I can tell you with confidence that the FIST has good to excellent reliability" "The FIST admission/discharge scores correlated good to high with the Berg Balance Scale and

the FIM" "There are many acute care facilities and SNFs that are using the FIST to track individual

progress and find it useful, especially with lower functioning patients"

1. "Falls Among Older Adults: An Overview." Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 20 Sept. 2013. Web. 06 Nov. 2013. http://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html

2. "Function in Sitting Test (FIST)." Samuel Merritt University. N.p., n.d. Web. 06 Nov. 2013. <http://www.samuelmerritt.edu/fist>.

3. Gormon, SL, S. Radtka, ME Melnick, GM Abrams, and NN Byl. "Development and Validation of the Function In Sitting Test in Adults with Acute Stroke." Journal of Neurologic Physical Therapy 34.3 (2010): 150-60. PubMed. Web. 6 Nov. 2013. <http://www.ncbi.nlm.nih.gov/pubmed/?term=Development+and+validity+of+the+Function+in+Sitting+Test+(FIST)+in+adults+with+acute+stroke>.

4. Hartley, Greg, Ellen Strunk, and Michelle Lusardi. Section on Geriatrics Recommended Outcome Measures for Medicare Functional Limitation/Severity Reporting. Rep. N.p., n.d. Web. 6 Nov. 2013. <http://www.geriatricspt.org/userfiles/files/SoG-Joint-Report-March-2013.pdf>

5. Miller, Kenneth. "Section on Geriatrics and Home Health." Functional Limitation Reporting: Tests and Measures for High-Volume Conditions. N.p., n.d. Web. 06 Nov. 2013. <http://www.ptnow.org/FunctionalLimitationReporting/TestsMeasures/Default.aspx>.

6. Medley A, Thompson M. Development , reliability , and validity of the Sitting Balance Scale. 2011;27(7):471–481.

7. "Skilled Nursing Facilities (SNFs): Top Denial Reason Codes for Medical Review, January - March 2013." Skilled Nursing Facilities (SNFs): Top Denial Reason Codes for Medical Review, January - March 2013. A Celerian Group Company, n.d. Web. 06 Nov. 2013. <https://www.cgsmedicare.com/parta/pubs/news/2013/0613/1175.html>.

8. Thompson M, Medley A, Teran S. Validity of the Sitting Balance Scale in older adults who are non-ambulatory or have limited functional mobility. 2012.