Welcome to Part 5 – the Last of Our “Finding Your Balance” Blog Series
Just in case you missed Part 1, 2, 3 or 4, here are the links:
- Part 1: The Functional Reach Test
- Part 2: The Tinetti
- Part 3: The Berg Balance Test
- Part 4: The 4 Square Step Test
Our goal with this 5-Part Blog Series is to provide the therapist working in long-term care {and geriatrics} with a series of clinically relevant objective tests and measures that can be used in your department. For each of the tests reviewed, we provide:
- The “how to”
- The “pros and cons”
- The statistical measures
- The “norms” for the geriatric population
- A ready-to-use printout of a customized test form that you can use in your setting immediately
This objective data should be included in your clinical documentation and will support the necessity of your services and help support your goals and treatment plan. Not only that, but you will gain valuable insight into the specific limitations of your residents and be able to develop a natural progressive treatment plan to keep them on their feet! If you use an EMR, no worries, you can reference the test score in your electronic documentation and keep the paper copy in your soft chart. Remember, Medicare is looking for objective clinical data– so why not give it to them!!
A Quick Recap: Measuring Balance
When selecting a test to measure balance, there are multiple factors therapists consider, which ultimately help match up a test to our resident.
- How practical is the test?
- Is the test easy to administer?
- Can the test be incorporated into a treatment session?
- Is it cost effective?
- Is equipment required?
- Statistically is it a “good” test — is it reliable, valid, reproducible?
For our geriatric residents, there are also multiple additional considerations including: cognition, medications and interactions, sensory impairments, endurance and the severity of the balance impairment we are attempting to measure… just to name a few.
The Timed Up and Go (TUG)
What Does It Measure: The TUG is used to assess mobility, including walking speed, dynamic balance and fall risk. The TUG is a timed test developed by Podsiadlo and Richardson in 1991 as a modification of the GUG. The TUG uses objective timing measures, where the GUG (Get Up and Go test) assessed mobility and fall risk on a subjective scale based on rater observations and judgment.
How Long Does It Take: < 3 minutes
Equipment Needed: Standard armchair approximately 46 cm in height; Stopwatch; Clear straight 10 foot walking path with mark at 9.8 ft point.
How To: Step-by-step test instructions below. A clinic-ready documentation template can be printed out for clinic use by clicking the download button below.
- Place armchair at one end of 10 foot path. Patient starts out sitting in chair with back against chair back.
- Examiner explains and demonstrates procedure: Stand, walk 3 meters (9.8 feet), turn around at the 9.8 ft line mark, walk back to chair and sit.
- Instruct patient to walk at comfortable, safe speed. Walking aides are allowed.
- Time begins when examiner says “go” and ends when buttocks contact chair seat at end of test.
- One practice test is allowed.
Norms:
Normal values are age-specific with walking speed decreasing with age.
Healthy older adults show mean scores as follows:
60-69 years: 8 seconds
70-79 years: 9 seconds
80-89 years: 11 seconds
=>14 seconds represents increased fall risk / > 30 seconds: functional dependence
Cut-Off Scores Indicating Fall Risk:
Community dwelling adults: >13.5 seconds
Older adult in fall clinic: >15 seconds
Frail elderly: > 32 seconds
Parkinsons: > 11 seconds
Pros: Valid, reliable measure of balance; Recognized predictor of fall risk; Correlates strongly with Berg and Functional Reach; Easy to perform; Quick, little space or equipment needed.
Cons: Footgear may impact performance on test; Use of assistive device and/or impaired cognition increased TUG time;
Modifications of the Test:
TUG-Manual (TUG-man): Test is performed with subject carrying cup of water. 2015 study by Tang et al indicates that TUG-man is a better indicator of pre-frailty in community dwelling adults more than 50 years old than TUG or TUG-COG.
TUG-Cognitive (TUG-COG): Test is performed with subject counting backward by 3s from a random number while performing test. 2015 study by Vance et al indicated that the TUG-COG has a greater predictive value than the TUG or TUC-man for Parkinson’s patients.
Print Out of Test and Documentation Form Our Toolbox
Documentation, Billing and Treatment Ideas
The initial performance of the test can be incorporated into an initial evaluation or performed separately at any time during the course of treatment. If the test is performed on the initial evaluation, the score can be documented and used to establish short and long term goals for balance improvement, or “fall risk reduction.” Subsequent repeat performances of the test can be done during a treatment session and the time can be allocated to CPT 97112, neuro muscular re-education, a time-based code incorporating therapeutic procedures to improve balance, coordination, kinesthetic sense, posture, and proprioception. If you choose to use balance as a measure for your Functional Limitation Reporting, the G-Code Category “Changing and Maintaining Body Position” is appropriate, with G8981 for the Current Status, G8982 for the Goal Status and G8983 for the Discharge Status.
Components of treatment sessions can include “walking the line” for balance, incorporating higher level balance activities such as: walking carrying heavy objects, walking with arms overhead in static position, walking with arms in dynamic movement patterns, walking stretching theraband between hands,etc. If you tape a “line” on your treatment floor there are a million-and-one things you can do with the line to work on balance. Be creative!
In Summary
Our patients/residents like to see evidence that they are progressing, as well as challenges, tests and comparison with their peers. The Timed Up and Go allows them to see that they are performing tasks with less loss of balance, and that provides positive reinforcement to continue to progress toward goals. This is a quick and easy test to perform in therapy sessions. Why not familiarize yourself with it today!
Whether you are screening residents for fall risk or providing treatment to residents with balance deficits, if you have not been using objective tests and measures for balance, the TUG is a great place to start. Try it with your balance patients today!
Have some fun and test yourself first!
Any questions, Just Ask! by visiting our Q&A forum.
In Your Corner,
Dolores
Dolores Montero, PT, DPT, GCS, RAC-CT, RAC-CTA
SNF Therapy & MDS Compliance Team
*A special thank you to physical therapist extraordinaire, Laura Minnick, for contributions to this post.
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