Physical Therapy Student's Falls Risk Assessment Toolbox

A Physical Therapy Students Toolbox For Assessing Falls Risk in Seniors PHYT 724 SUPPLEMENTAL INFORMATION CAPSTONE PROJECT SPRING 2012 LINDSEY ASHLEY

Objectives To review selected outcome measures that relate to assessing fall risk in senior adults. To make the student confident in their ability to use and interpret the discussed measures To provide supplemental information to the ADL, Gait and Functional Mobility Tools for Rehab lecture in PHYT 724.

Presentation Overview Things to consider when choosing an outcome measure Test Characteristics The ICF Model and Patient Characteristics Psychometrics: Minimal Detectable Change and Minimal Clinically Important Difference 2. Overview of selected balance measures 1. 1. 2. 3.

Tests that will be covered Berg Balance Scale Activities-Specific Balance Confidence Scale Dynamic Gait Index 10 Meter Walk Functional Gait Assessment 6 Minute Walk Timed Up and Go Tinetti Performance Oriented Mobility Assessment Tinetti Falls Efficacy Scale Single Leg Stance Time

Things to Consider when Selecting an Outcome Measure TEST CHARACTERISTICS PATIENT CHARACTERISTICS AND THE THE ICF MODEL PSYCHOMETRICS

Selecting an Outcome Measure1,2 What is the purpose? To Discriminate To Predictive To Evaluate Is the measure related to what the goals of therapy are? Is the measure appropriate for the patient s capabilities? What type of measure is it? Generic Disease specific Does the measure have good psychometrics? What is the mode? Performance based Self report Is the measure appropriate for the stage of recovery? Is it practical? Time Equipment/Space

The ICF Model

Minimal Detectable Change (MDC)1 Evaluates if true change occurred Vary depending on the patient characteristics Does not provide information about if the change is clinically important Vary depending on the patient characteristics

Minimal Clinically Important Difference (MCID)1 Measures if the change that occurred was clinically meaningful These values do not apply when a patient s condition deteriorates What is the smallest change that is considered important?

Selected Tests B E R G B A L A N C E S C A L E D Y N A M I C G A I T I N D E X F U N C T I O N A L G A I T A S S E S S M E N T T I M E D U P A N D G O T I N E T T I F A L L S E F F I C A C Y S C A L E A C T I V I T I E S - S P E C I F I C B A L A N C E C O N F I D E N C E S C A L E 1 0 M E T E R W A L K 6 M I N U T E W A L K T I N E T T I P E R F O R M A N C E O R I E N T E D M O B I L I T Y A S S E S S M E N T S I N G L E L E G S T A N C E T I M E

The Berg Balance Scale3 Purpose: Assesses balance and falls risk in seniors 14 items : static and dynamic ICF Domain: Activity Time needed: 15-20 minutes Often used for patients with: Brain injury Stroke Community dwelling seniors Multiple Sclerosis Parkinson s Disease Equipment needed: Stop watch Chair with arm rest Ruler Step stool Object to pick up off of floor

The Berg Balance Scale Scoring4-11 Items are scored from 0-4 MDCs: Acute Stroke: 6.9*** Chronic Stroke: 2.5 Parkinson s Disease=5 Elderly with a history of falls=6.5 ADL dependant seniors=8 OR Based on initial score 0-24: 4.6 25-34: 6.3 35-44: 4.9 45-56: 3.3 Higher scores reflect better balance To score, simply add scores from all of the items Maximum score is 56 <45/56 indicates an increased risk of falling

Dynamic Gait Index12 Purpose: To assess the participants ability to adapt to external demands on balance 8 items Time needed: < 10 minutes ICF Domain: Activity Equipment needed: Shoe box Two obstacles Stairs 20 ft of walking space Often used for patients with: Vestibular disorders Multiple Sclerosis Stroke Parkinson s Disease Seniors Can use assistive device if needed

Dynamic Gait Index Scoring13-17 Scores < 19 indicates falls risk Items are scored from 0-3 Higher scores reflex a more functional gait MDCs: Acute & Chronic Stroke: 4 points or 16.6% Peripheral Vestibular Disorders: 3.2 points Parkinson s Disease: 2.9 points or 13.3% Community dwelling seniors with a history of falls: 2.9 points Mark lowest category that applies To score, simply add scores from all items Maximum Score is 24

Functional Gait Assessment18 Purpose: Assess postural stability during gait 10 items Time needed: 5 minutes ICF domain: Activity Equipment needed: Stopwatch 20 feet of walking space Steps Shoe boxes Often used with patients with: Vestibular problems Stroke Seniors An assistive device can be used

Functional Gait Assessment Score19-20 Items scored from 0-3 Scores 22 indicate an increased risk of falling Higher score reflects a more normal gait MDCs: Acute & Chronic Stroke: 4.2 points or 14.1% Mark the highest that applies MCIDs: Vestibular Disorders: 8 points To score, simply add scores from all items Maximum score is 30

Timed Up and Go21 Purpose: assess mobility, falls risk, and balance in seniors Time needed: < 3 minutes Equipment needed: Standard arm chair Stop watch 3 meters of walking space ICF Domain: Activity Often used with patients with: Stroke Seniors Parkinson s Disease LE amputees SCI Arthritis Low Back Pain Rheumatoid Arthritis Acute Medial Patients Multiple Sclerosis Can use assistive device if needed

Timed Up and Go Scoring22-28 Time how long it takes the patient to rise from the chair, complete the task, and return to sitting. MDCs: Chronic Stroke: 2.9 s SCI: 10.8s Parkinson s Disease: 11s (H&Y I-III) 3.5 s or 29.8% (H&Y I-IV) Alzheimer s Disease: 4.09 s Cut scores: Community dwelling seniors: 13.5s Frail Elderly: 32.6 s Older Stroke Patient: 14s LE Amputees: 19s

Tinetti Falls Efficacy Scale29 Purpose: assess awareness balance and stability during ADL 10 items Time needed: 10-15 minutes ICF Domain: Activity & Participation Equipment needed: Pen Test Form Often used with: Community dwelling seniors Adult inpatients Long-term Care Brain injury Stroke Spinal Cord Injury

Tinetti Falls Efficacy Scoring30-32 Items are scored from 1- 10 <80 indicates increased risk of falling A higher score reflects a higher fear/risk of falling <70 indicates increased fear of falling To score, simple add score of all items **Fear of falling can be effected by cognitive impairments Scores range from 10- 100 MDCs not established

Activities-Specific Balance Confidence Scale33 16 items Purpose: subjective measure of participants balance confidence Time needed: 10-20 minutes ICF Domain: Activity Equipment Needed: Pen Test Form Often used with patients with: Stroke Multiple Sclerosis Vestibular Disorders LE amputees Seniors Parkinson s Disease

Activities-Specific Balance Confidence Scoring33-36 Items scored 0-100 <67% indicates a risk for falling Higher score reflects higher balance confidence MDCs: Parkinson s Disease: 13% To score, simply add score of all the items and divide by number of items Scores range from 0-100% 80%: high levels of physical functioning 50-80%: moderate levels of physical functioning <50%: low levels of physical functioning

Tinetti Performance Oriented Mobility Assessment37 Purpose: Assess mobility in seniors 16 items Time needed: 10-15 min ICF Domain: Activity Equipment Needed: Armless chair Stopwatch 15 ft of walking space Often used for patients with seniors across all care settings. Be aware there are several different versions of the test

Tinetti Performance Oriented Assessment Scoring37-39 Items scored from 0-2 Total scores <19 indicates falls risk in long term care. Higher scores reflect better balance Total scores <14 indicates falls risk in residential care. To score, simply add the scores from the balance section to the score from the gait section. MDCs: Long term care: 5 MCIDs: Community Dwelling Seniors: 1.6 Maximum score is 28

10 Meter Walk40 Purpose: to assess walking speed Time needed: <5 minutes ICF Domain: Activity Equipment needed: Stopwatch 14 meters of walking space Often used for patients with: Stroke Parkinson s Disease General Neurologic Movement Disorders Spinal Cord Injury Hip Fracture Multiple Sclerosis Brain Tumor LE amputees Community Dwelling Seniors Assistive devices can be used

10 Meter Walk Scoring40-45 Begin timing when toes of lead foot pass 2 meter mark. MDCs: Chronic Stroke Comfortable pace: 22% change Fast pace: 16% change Parkinson s Disease Comfortable pace: 0.8 m/s Max Speed: 0.25 m/s Hip Fracture: 0.17 m/s Stop timing when toes of led foot pass 8 meter mark. Only 6 meters are timed The score is the average of 3 trials. MCIDs: Geriatrics & Stroke: 0.1 m/s Acute Stroke: 0.16 m/s Ambulation ability is correlated with gait speed.

Six Minute Walk46 Purpose: assess endurance and distance walked Time needed: 6 minutes Equipment needed: Stop watch Premeasured path or a way to measure distance walked ICF Domain: Activity Often used for patients with: Pulmonary disease Heart Failure Stroke Spinal Cord Injury Seniors Fibromyalgia Multiple Sclerosis Parkinson s Disease Assistive device can be used

Six Minute Walk Scoring46-51 Measure the distance a patient can walk in 6 minutes. MDCs: Chronic Stroke: 36.6 m/120 ft or 13% change COPD: 54 m/177ft Parkinson s Disease: 82 m/269 ft Alzheimer s Disease: 110 ft Norms: Age Male Female 60-69 yr 572 m 538 m 70-79 yr 527 m 471 m MCIDs: Geriatrics & Acute Stroke: 50 m/164 ft 80-89 yr 417 m 392m

Single Leg Stance52-55 Purpose: assess single leg, standing balance Time needed: 30 seconds Equipment: Stopwatch Chair or table top ICF Domain: Activity Often used with patients with: Seniors Vestibular problems LE amputees Orthoses LE surgical procedures

Single Leg Stance Scoring52-55 Time how long the patient can balance on one leg. MDCs: Community Dwelling Seniors found to be: 24.1 s 5.5-16.0 s Can be done with eyes open and closed Norms: Age Eyes Open 29.4 22.5 14.2 Eyes Closed 21.0 10.2 4.3 50-59 60-69 70-79

References P O T T E R , K . , F U L K , G D . , S A L E M , Y . , S U L L I V A N , J A N E . ( 2 0 1 1 ) . O U T C O M E M E A S U R E S I N N E U R O L O G I C A L P H Y S I C A L T H E R A P Y P R A C T I C E : P A R T I . M A K I N G S O U N D D E C I S I O N S . J O U R N A L O F N E U R O L O G I C P H Y S I C A L T H E R A P Y . 3 5 ( 2 ) : 5 7 - 6 4 2 . S U L L I V A N , J . , A N D R E W S , A W . , L A N Z I N O , D . , P E R O N , A . , P O T T E R , K A . ( 2 0 1 1 ) . O U T C O M E M E A S U R E S I N N E U R O L O G I C A L P H Y S I C A L T H E R A P Y P R A C T I C E : P A R T I I . A P A T I E N T - C E N T E R E D P R O C E S S . J O U R N A L O F N E U R O L O G I C P H Y S I C A L T H E R A P Y . 3 5 ( 2 ) : 6 5 - 7 4 . 3 . R E H A B M E A S U R E S : B E R G B A L A N C E S C A L E . A C C E S S E D M A R C H 2 9 , 2 0 1 2 . H T T P : / / W W W . R E H A B M E A S U R E S . O R G / L I S T S / R E H A B M E A S U R E S / P R I N T V I E W . A S P X ? I D = 8 8 8 B E R G , K . O . , W O O D - D A U P H I N E E , S . L . , E T A L . ( 1 9 9 2 ) . " M E A S U R I N G B A L A N C E I N T H E E L D E R L Y : V A L I D A T I O N O F A N I N S T R U M E N T . " C A N J P U B L I C H E A L T H 8 3 S U P P L 2 : S 7 - 1 1 5 C O N R A D S S O N , M . , L U N D I N - O L S S O N , L . , L I N D E L F , N . , L I T T B R A N D , H . , M A L M Q V I S T , L . , G U S T A F S O N , Y . , & R O S E N D A H L , E . ( S E P T E M B E R 2 0 0 7 ) . B E R G B A L A N C E S C A L E : I N T R A R A T E R T E S T - R E T E S T R E L I A B I L I T Y A M O N G O L D E R P E O P L E D E P E N D E N T I N A C T I V I T I E S O F D A I L Y L I V I N G A N D L I V I N G I N R E S I D E N T I A L C A R E F A C I L I T I E S . P H Y S I C A L T H E R A P Y , 8 7 ( 9 ) , 1 1 5 5 - 1 1 6 3 . D O I : 1 0 . 2 5 2 2 / P T J . 2 0 0 6 0 3 4 3 6 . D O N O G H U E , D . A N D S T O K E S , E . K . ( 2 0 0 9 ) . " H O W M U C H C H A N G E I S T R U E C H A N G E ? T H E M I N I M U M D E T E C T A B L E C H A N G E O F T H E B E R G B A L A N C E S C A L E I N E L D E R L Y P E O P L E . " J R E H A B I L M E D 4 1 ( 5 ) : 3 4 3 - 3 4 6 . 7 . L A J O I E Y , G A L L A G H E R S P . ( 2 0 0 4 ) . P R E D I C T I N G F A L L S W I T H I N T H E E L D E R L Y C O M M U N I T Y : C O M P A R I S O N O F P O S T U R A L S W A Y , R E A C T I O N T I M E , T H E B E R G B A L A N C E S C A L E A N D T H E A C T I V I T I E S - S P E C I F I C B A L A N C E C O N F I D E N C E ( A B C ) S C A L E F O R C O M P A R I N G F A L L E R S A N D N O N - F A L L E R S . A R C H G E R O N T O L G E R I A T R . 3 8 ( 1 ) : 1 1 - 2 6 . 8 . L I S T O N , R . A N D B R O U W E R , B . ( 1 9 9 6 ) . " R E L I A B I L I T Y A N D V A L I D I T Y O F M E A S U R E S O B T A I N E D F R O M S T R O K E P A T I E N T S U S I N G T H E B A L A N C E M A S T E R . " A R C H I V E S O F P H Y S I C A L M E D I C I N E A N D R E H A B I L I T A T I O N 7 7 ( 5 ) : 4 2 5 - 4 3 0 . 1 . 4 .

References Continued 9. ROMERO ,S. ET AL. (2011). MINIMUM DETECTABLE CHANGE OF THE BERG BALANCE SCALE AND DYNAMIC GAIT INDEX IN OLD PERSONS AT RISK FOR FALLING. JOURNAL OF GERIATRIC PHYSICAL THERAPY. 34(3): 131-137. 10. STEFFEN T, SENEY M. (2008) 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. 88(6):733-746. 11. STEVENSON, T. J. (2001). "DETECTING CHANGE IN PATIENTS WITH STROKE USING THE BERG BALANCE SCALE." AUST J PHYSIOTHER 47(1): 29-38. 12. REHABMEASURES: DYNAMIC GAIT INDEX. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID =888 13. SHUMWAY-COOK, A., BALDWIN, M., ET AL. (1997). "PREDICTING THE PROBABILITY FOR FALLS IN COMMUNITY-DWELLING OLDER ADULTS." PHYSICAL THERAPY 77(8): 812 14. LIN, J. H., HSU, M. J., ET AL. (2010). "PSYCHOMETRIC COMPARISONS OF 3 FUNCTIONAL AMBULATION MEASURES FOR PATIENTS WITH STROKE." STROKE. 15. HALL, C. D. AND HERDMAN, S. J. (2006). "RELIABILITY OF CLINICAL MEASURES USED TO ASSESS PATIENTS WITH PERIPHERAL VESTIBULAR DISORDERS." J NEUROL PHYS THER 30(2): 74-81. 16. HSIEH C, HUANG S, LIN CH, LU W, TAI C, WU R. MINIMAL DETECTABLE CHANGE OF THE TIMED UP AND GO TEST AND THE DYNAMIC GAIT INDEX IN PEOPLE WITH PARKINSON S DISEASE. PHYSICAL THERAPY. 2011(1):114+. 17. ROMERO ,S. ET AL. (2011). MINIMUM DETECTABLE CHANGE OF THE BERG BALANCE SCALE AND DYNAMIC GAIT INDEX IN OLD PERSONS AT RISK FOR FALLING. JOURNAL OF GERIATRIC PHYSICAL THERAPY. 34(3): 131-137.

References Continued 18. REHABMEASURES: FUNCTIONAL GAIT ASSESSMENT. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 19. WRISLEY, D. AND KUMAR, N. (2010). "FUNCTIONAL GAIT ASSESSMENT: CONCURRENT, DISCRIMINATIVE, AND PREDICTIVE VALIDITY IN COMMUNITY-DWELLING OLDER ADULTS." PHYSICAL THERAPY 90(5): 761 1468. 20. LIN, J. H., HSU, M. J., ET AL. (2010). "PSYCHOMETRIC COMPARISONS OF 3 FUNCTIONAL AMBULATION MEASURES FOR PATIENTS WITH STROKE." STROKE. 21. 2. REHABMEASURES: TIMED UP AND GO. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 22. SHUMWAY-COOK, A., BRAUER, S., ET AL. (2000). "PREDICTING THE PROBABILITY FOR FALLS IN COMMUNITY-DWELLING OLDER ADULTS USING THE TIMED UP & GO TEST." PHYS THER 80: 896-903. 23.ANDERSSON, A. G., KAMWENDO, K., ET AL. (2006). "HOW TO IDENTIFY POTENTIAL FALLERS IN A STROKE UNIT: VALIDITY INDEXES OF 4 TEST METHODS." J REHABIL MED 38(3): 186-191. 24. THOMAS, J. I. AND LANE, J. V. (2005). "A PILOT STUDY TO EXPLORE THE PREDICTIVE VALIDITY OF 4 MEASURES OF FALLS RISK IN FRAIL ELDERLY PATIENTS." ARCH PHYS MED REHABIL 86: 1636-1640. 25. DITE, W., CONNOR, H. J., ET AL. (2007). "CLINICAL IDENTIFICATION OF MULTIPLE FALL RISK EARLY AFTER UNILATERAL TRANSTIBIAL AMPUTATION." ARCH PHYS MED REHABIL 88(1): 109-114. 26. FLANSBJER, U. B., HOLMBACK, A. M., ET AL. (2005). "RELIABILITY OF GAIT PERFORMANCE TESTS IN MEN AND WOMEN WITH HEMIPARESIS AFTER STROKE." J REHABIL MED 37(2): 75- 82. 27. LAM, T., NOONAN, V., ET AL. (2007). "A SYSTEMATIC REVIEW OF FUNCTIONAL AMBULATION OUTCOME MEASURES IN SPINAL CORD INJURY." SPINAL CORD 46(4): 246-254

References Continued 28. RIES, J. D., ECHTERNACH, J. L., NOF, L., & GAGNON BLODGETT, M. (JUNE 2009). 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, 89(6), 569-579. DOI:10.2522/PTJ.20080258. 29. 5. REHABMEASURES: TINETTI FALLS EFFICACY SCALE. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 30. REHAB MEASURES: FALLS EFFICACY SCALE. ACCESSED MARCH 30, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=899 31. TINETTI, M., RICHMAN, D., ET AL. (1990). FALLS EFFICACY AS A MEASURE OF FEAR OF FALLING." JOURNAL OF GERONTOLOGY 45(6): P239 32. HAUER, K., YARDLEY, L., ET AL. (2010). "VALIDATION OF THE FALLS EFFICACY SCALE AND FALLS EFFICACY SCALE INTERNATIONAL IN GERIATRIC PATIENTS WITH AND WITHOUT COGNITIVE IMPAIRMENT: RESULTS OF SELF-REPORT AND INTERVIEW-BASED QUESTIONNAIRES." GERONTOLOGY 56(2): 190-199. 33. REHABMEASURES: ACTIVITIES-SPECIFIC BALANCE CONFIDENCE SCALE . ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 34. LAJOIE, Y. AND GALLAGHER, S. P. (2004). "PREDICTING FALLS WITHIN THE ELDERLY COMMUNITY: COMPARISON OF POSTURAL SWAY, REACTION TIME, THE BERG BALANCE SCALE AND THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALE FOR COMPARING FALLERS AND NON- FALLERS." ARCH GERONTOL GERIATR 38(1): 11-26. 35. MYERS, A. M., FLETCHER, P. C., MYERS, A. H., & SHERK, W. (1998). DISCRIMINATIVE AND EVALUATIVE PROPERTIES OF THE ACTIVITIES-SPECIFIC BALANCE CONFIDENCE (ABC) SCALE. THE JOURNALS OF GERONTOLOGY SERIES A: BIOLOGICAL SCIENCES AND MEDICAL SCIENCES, 53A(4), M287-M294. DOI:10.1093/GERONA/53A.4.M287 36. Steffen, T. and Seney, M. (2008). "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 88(6): 733

References Continued 37. TINETTI: PERFORMANCE ORIENTED MOBILITY ASSESSMENT. GERIATRIC EXAMINATION TOOLKIT. UNIVERSITY OF MISSOURI. SCHOOL OF HEALTH PROFESSIONS. DEPARTMENT OF PHYSICAL THERAPY. LAST UPDATED: JAN. 2012. ACCESSED MARCH 31, 2012. HTTP://WEB.MISSOURI.EDU/~PROSTE/TOOL/ 38. CHIU, V., DAMRON-RODRIGUEZ, J., FOWLER, E., HARADA, N., REUBEN, D. B., & SIU, A. (1995, 06; 2012/3). SCREENING FOR BALANCE AND MOBILITY IMPAIRMENT IN ELDERLY INDIVIDUALS LIVING IN RESIDENTIAL CARE FACILITIES.75(6), 12+. 39. FABER, M. J., BOSSCHER, R. J., & VAN WIERINGEN, P. C. (2006). CLINIMETRIC PROPERTIES OF THE PERFORMANCE-ORIENTED MOBILITY ASSESSMENT. PHYSICAL THERAPY, 86(7), 944- 954. 40. . REHABMEASURES: 10 METER WALK. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 41.PERRY, J., GARRETT, M., ET AL. (1995). "CLASSIFICATION OF WALKING HANDICAP IN THE STROKE POPULATION." STROKE 26(6): 982. 42. FLANSBJER, U. B., HOLMBACK, A. M., ET AL. (2005). "RELIABILITY OF GAIT PERFORMANCE TESTS IN MEN AND WOMEN WITH HEMIPARESIS AFTER STROKE." J REHABIL MED 37(2): 75-82. 43. STEFFEN, T. AND SENEY, M. (2008). "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 88(6): 733. 44. PERERA, S., MODY, S., ET AL. (2006). "MEANINGFUL CHANGE AND RESPONSIVENESS IN COMMON PHYSICAL PERFORMANCE MEASURES IN OLDER ADULTS." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 54(5): 743-749.

References Continued 45. TILSON, J. K., SULLIVAN, K. J., ET AL. (2010). "MEANINGFUL GAIT SPEED IMPROVEMENT DURING THE FIRST 60 DAYS POSTSTROKE: MINIMAL CLINICALLY IMPORTANT DIFFERENCE." PHYS THER 90(2): 196-208. 46. REHABMEASURES: SIX MINUTE WALK. ACCESSED MARCH 29, 2012. HTTP://WWW.REHABMEASURES.ORG/LISTS/REHABMEASURES/PRINTVIEW.ASPX?ID=888 47. FLANSBJER, U. B., HOLMBACK, A. M., ET AL. (2005). "RELIABILITY OF GAIT PERFORMANCE TESTS IN MEN AND WOMEN WITH HEMIPARESIS AFTER STROKE." J REHABIL MED 37(2): 75-82. 48. STEFFEN, T. AND SENEY, M. (2008). "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 88(6): 733. 49. REDELMEIER, D. A., BAYOUMI, A. M., GOLDSTEIN, R. S., & GUYATT, G. H. (1997). INTERPRETING SMALL DIFFERENCES IN FUNCTIONAL STATUS: THE SIX MINUTE WALK TEST IN CHRONIC LUNG DISEASE PATIENTS. AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE, 155(4), 1278-1282. 50. PERERA, S., MODY, S., ET AL. (2006). "MEANINGFUL CHANGE AND RESPONSIVENESS IN COMMON PHYSICAL PERFORMANCE MEASURES IN OLDER ADULTS." JOURNAL OF THE AMERICAN GERIATRICS SOCIETY 54(5): 743-749. 51. STEFFEN, T. AND SENEY, M. (2008). "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 88(6): 733. 52. BOHANNON R, LARKIN P, COOK A, SINGER J. 1984. DECREASE IN TIMED BALANCE TEST SCORES WITH AGING. PHYS THER 64:1067-1070 53. GOLDBERG, A., CASBY, A., & WASIELEWSKI, M. (2011). MINIMUM DETECTABLE CHANGE FOR SINGLE-LEG-STANCE-TIME IN OLDER ADULTS. GAIT & POSTURE, 33(4), 737-739. DOI:10.1016/J.GAITPOST.2011.02.020 54. RICHARD W., B. (2012). RESPONSIVENESS OF THE SINGLE-LIMB STANCE TEST. GAIT & POSTURE, 35(1), 173. DOI:10.1016/J.GAITPOST.2011.07.015