Selection of Tools
Objective physical capability measures are effective tools in the health assessment of older adults and are indicators of health status and the risk for mobility loss and functional decline.52 The Toolkit contains the physical capability measures used in the Healthy Aging Across the Life Course (HALCyon) project, a research collaboration on three aspects of healthy aging: physical and cognitive capability, social and psychological well-being, and the underlying biology of aging.53 In addition, there is evidence linking each tool to an individual’s functional status and/or specific functional activities.
The tools are familiar to physiotherapists, inexpensive and easy to use in all clinical situations, as well as relevant to daily activity requirements. The tools have also been used in a number of populations and cultures, confirming their validity for use broadly. Finally, the tools may be used both as assessment and as outcome measures for individual treatment programs.
Each tool is described, with relevant norms and cut point scores indicating risk of mobility limitation. Scores indicating risk of mobility loss are used with permission of Roberta E. Rikli, PhD (Department of Kinesiology, College of Health and Human Development, California State University, Fullerton) and C. Jessie Jones, PhD (Department of Health Science, California State University, Fullerton).
1. Normal walking speed
Walking speed has been described as “the sixth vital sign.”54 It is considered an inexpensive and reliable indication of functional status.55 A recent systematic review confirmed that normal walking speed in autonomous community dwelling seniors is a predictor for such adverse outcomes as “disability, cognitive decline, hospitalization, falls and/or mortality.”56 One study found that improvement in gait speed over one year resulted in a significant reduction in mortality.57
The “10 metre walk test”58 measures self-selected gait speed over six metres, allowing two metres at each end that allow for acceleration and deceleration. The physiotherapist begins timing once the individual’s foot crosses the first two metre mark and ends when his/her foot crosses the second marker. Assistive devices may be used, but they must be present for any repeated tests. Conduct three repetitions and average the three times. To determine actual walking speed, divide the average by six.
NB. If an individual requires assistance in walking the test is invalid.
(Click to enlarge)
- Usual gait speed for adults has been determined as 1.2 to 1.3 m/sec.59
- Crossing a street safely can require gait speeds ranging from 0.74 to 1.2m/sec.60
The table below presents cut points for gait speed in community dwelling older adults that incorporate the effects of subclinical or undiagnosed conditions on gait speeds.61
For the purposes of the Toolkit:
- Gait speed < .80 m/sec indicates mobility impairment62
- Gait speed <.60 m/sec may be indicative of poor health or limited function63
In addition, an individual whose gait slows to talk may be indicative of a balance disorder, early cognitive decline or the effects of polypharmacy (over five medications).64,65
Detailed instructions and recording form for the 10 metre walk test from Geriatric ToolKit.
2. Standing Balance
The Single Leg Stance Test (SLS) is used for a range of conditions with individuals from ages 18-99. Performance scores are associated with gait speed, the risk for falls and level of functional independence.66,67 For example, the ability to stand on one leg is essential for a normal gait pattern and is essential for activities of daily living such as turning, bathing, stair climbing, and dressing.68 Individuals unable to perform the SLS for more than five seconds are at significant risk for falls.69 A recent study found that for otherwise healthy older adults, the inability to stand on one leg with eyes open for 20 seconds may be associated with cognitive decline, cerebral small vessel disease, and stroke.70
For the SLS, the individual places his/her hands on his/her hips (alternatively: arms across chest, hands on shoulders) and is then asked to stand on one leg, unassisted. The physiotherapist uses a stopwatch to time three trials of standing on one leg, eyes open. The test ends when the individual puts his/her foot down, puts the raised leg against the stance leg, or uses his/her arms for balance.
Normative values for Single Leg Stance Test71
||Eyes Open - Best of three trials (sec)
||Eyes Open - Mean of three trials (sec)
Individuals unable to perform SLS longer than 10 seconds are at risk for balance impairment,72 while a score of less than five seconds is significant risk for a fall.73
3. Grip Strength Test
Grip strength is recognized as a predictor for mobility limitation,74 general body strength75 and for physical performance.76
It is tested using a hand-held dynamometer, and the individual chooses which hand will be tested first. The individual is seated comfortably with both feet on the ground. His/her arm is at his/her side, with elbow flexed to 90 degrees, holding the dynamometer in one hand with wrist in the neutral position. The physiotherapist asks the individual to squeeze the dynamometer to his/her maximum ability for six seconds. They are allowed a sub-maximal trial with each hand before the measurement is recorded.
NIH Toolbox video demonstration of Grip Strength Test
A recent analysis of pooled data from multiple studies identified clinically relevant cut points for grip strength associated with mobility impairment in individuals over 65 years of age.77 Mobility impairment was identified as a gait speed of < .8 m/sec. Three categories were identified – normal, intermediate and weak, with normal strength used as the comparator. Cut points for both the intermediate and weak categories indicate weakness associated with risk of mobility impairment, although the weakness in the “intermediate” category was considered less severe.
In both “intermediate” and “weak” levels, cut points are associated with functional limitations, and individuals scoring in either category may benefit from a general strength training program.78
Strength categories for grip strength associated with mobility limitations79
||>32 ( greater than or equal to)
||>20 ( greater than or equal to)