adults may be at or near the ceiling of the test, so it may be best to use the SPPB for those who are suspected to have some mobility disability (Vasunilashorn et al., 2009). The SPPB is responsive to improvements in mobility and can be used to document improvements following an exercise intervention (Investigators et al., 2006). The three tasks used in the SPPB are a simple balance measure (the ability to stand with feet together, in a semi-tandem stance, and in a tandem stance for 10 seconds each); the time it takes to complete five repeated chair stands; and self-selected gait speed (Guralnik et al., 1994, 1995). Each task is scored from 0 to 4 for a possible combined maximal score of 12 (Guralnik et al., 1994, 1995). Details for scoring each of the three subsections can be found in Table 4. For all balance tasks, individuals are allowed assistance to move into the position; for example, they may use the wall or the therapist’s hands for balance assistance to get into a semi-tandem stance. However, once in this position they are asked to hold it without assistance. They are allowed to bend their legs and move their arms and trunk however necessary to hold the position, but time ends when they reach 10 seconds for each position or their feet move. Self-selected gait speed is determined as detailed in the above section. During the five timed chair stands individuals are asked to keep their arms crossed over their chest and to perform a full stand without the assistance of their arms. Timing starts when they begin to stand up and ends when they reach full standing position the fifth time. If they are unable to stand without using their upper extremities for assistance it is scored a 0. Generally, a combined score of less than 10 indicates some level of disability (Puthoff, 2008) and is a strong predictor of future disability, risk for institutionalization, and mortality in older adults (Pavasini et al., 2016; Volpato et al., 2011). The minimal clinically important difference is 1 point on the overall score (Perera et al., 2006).
with feet flat on the floor. The forearm should rest on an armrest with the elbow flexed 90 degrees and the forearm in a neutral position with thumb facing upward. The patient should be instructed to squeeze as hard as possible until told to stop. Once the patient starts squeezing, verbal encouragement can be given until the needle of the dynamometer stops rising, which indicates that his or her maximum force has been reached. Three trials on each arm, alternating sides between tests, should be completed, and the single highest grip score from all 6 trials should be used as the patient’s grip strength score (Roberts et al., 2011). The normal values for grip strength for both the left and right hand for males and females can be found in Table 3. Short physical performance battery The SPPB combines the results of three simple functional tasks into a single functional battery with a maximal combined score of 12. The advantage of the SPPB is that it is a simple test of lower extremity function that mimics everyday activities and can be done in a small space (such as an exam room or a patient’s living room) with minimal equipment (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995; Guralnik et al., 1994). A large diversity of research devoted to the SPPB finds that it is a valid and reliable test that can be used across a large variety of populations and settings, including in older adults with pulmonary, cardiovascular, or neurologic disease in both community and hospital settings. (Fisher, Ottenbacher, Goodwin, Graham, & Ostir, 2009; Guralnik et al., 1994, 2000; Puthoff, 2008) The ability to easily apply this test across a large variety of diagnoses and settings makes the SPPB very useful clinically. It should be noted, however, that high-functioning older adults will generally score at or near the maximum for the SPPB. One study estimated that up to 70% of community-dwelling older
Table 4: Scoring the Subsections of the Short Physical Performance Battery Score Balance Gait Speed
Five Chair Stands Cannot perform task.
0
Stand feet side-by-side: 0 to 9 seconds.
Cannot perform task. <0.43 meters/second.
1 Stand feet side-by-side: 10 seconds. Stand feet semi-tandem: 0 to 9 seconds. 2 Stand feet semi-tandem: 10 seconds. Stand full tandem: 0 to 2 seconds.
>16.7 seconds to completed.
0.44 to 0.60 meters/second.
13.7 to 16.6 seconds to completed.
3 Stand full tandem: 3 to 9 seconds.
0.6 to 0.77 meters/second.
11.2 to 13.6 seconds to completed.
4 Stand full tandem: 10 seconds.
>0.78 meters/second.
<11.1 seconds to completed.
Note . Adapted from (Guralnik, 1995).
SPECIAL CONCERNS
experience certain comorbid conditions, such as diabetes, arthritis, or dementia, that may warrant special considerations before and after exercise prescription. While exercise is not contraindicated in these conditions, PTs and PTAs working with older adults should be aware of the various concerns that may arise when working with these populations. seeking to participate in an exercise program should always be referred to their physician for further follow-up and care (Fletcher et al., 2013; Williams et al., 2007). Relative contraindications suggest that a patient may still benefit from aerobic and resistive exercise but that further testing or screening by a physician prior to starting an exercise program may be necessary to ensure the safety of the patient. Generally, relative contraindications suggest that an individual has comorbid conditions that place him or her at higher risk for potential cardiac complications with exercise and that an exercise stress test may be necessary before starting exercise. To ensure their safety, individuals with relative contraindications may also benefit from close monitoring of their vital signs
The benefits of both aerobic and resistance exercise for older adults are clear. Exercise is generally considered to be a relatively safe activity, but good clinical judgment is still necessary when evaluating and prescribing both aerobic and resistance exercise for older adults. Despite its benefits for a majority of older adults, exercise is contraindicated for a minority of individuals due to health concerns. Many older adults Contraindications and screening prior to exercise For a minority of individuals, exercise may be contraindicated. As PTs increasingly participate in direct access patient care, they must have knowledge of the absolute and relative contraindications to exercise. Generally, absolute contraindications result from severe or uncontrolled cardiac disorders that place an individual at an increased risk for sudden cardiac death or other cardiac complications. Absolute contraindications suggest that it is currently unsafe for individuals with these disorders to exercise, and exercise should be held off until such time as these conditions are brought under better medical control. In some cases the patient may require surgical intervention before starting an appropriate exercise program. Patients with any of these absolute contraindications who are
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