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Correlation of Balance Tests Scores with Modified Physical
Performance Test in Indian Community-Dwelling Older Adults
Sunita Yadav* MPT (Neuro), Deepti Dhar** MPT (Paediatrics)
INTRODUCTION
The number of persons above the
age of 60 years is fast growing, especially
in India. India is the second most populous
country in the world has 76.6 million
people at or over the age of 60,
constituting above 7.7% of total
population. Recurrent falls are an
important cause of morbidity and mortality
Abstract: Background and Objective: There is sufficient evidence which shows significant
relationship between balance tests and other functional tests but there is lack of literature
regarding the relationship between balance tests (BBS, MDRT, BPOMA) and Modified
Physical Performance Test in different age groups of older adults. Design: An Observational
Study Subjects: 58 subjects were divided into three different age groups, having the mean age
of 65.33.0 (Group-A), 73.72.4 (Group-B), 82.61.4 (Group-C), mean height of 161.45.6
(Group-A), 164.910.2 (Group-B), 160.35.9 (Group-C) & mean weight of 68.44.8 (Group-
A), 72.76.9 (Group-B), 63.67.7 (Group-C) were recruited in this study from old age home
and local community. Methods: Subjects in each group performed the tests in the following
sequence: BBS (Berg Balance Scale), MDRT (Multi-Directional Reach Test), Modified-PPT
(Physical Performance Test) & BPOMA (Balance Performance-Oriented Mobility Assessment
of Tinetti) with rest period of 5-10 minutes between each scale. Result: The results suggested
that there was a significant positive correlation between balance tests and Modified Physical
Performance Test in different age groups of older adults. Conclusion: The current studyconcluded that Modified physical performance test is a efficient tool to assess static and
dynamic balance and also physical function and ambulation in different age groups of older
adults. It was also observed that out of these balance tests used in the study, MDRT was the
most difficult to understand and perform by subjects above 70 years and the subjects above 80
years found it really hard to understand the procedure.
Keywords: BBS, MDRT, BPOMA, Modified PPT, Balance, Physical Function.
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in the elderly and are a marker of poor
physical and cognitive status.2
Impaired balance and physical
function are the main causes of fall among
the older adults. Stability and orientation
are to distinct goals of the postural control
system. Postural control for stability and
orientation requires both perception and
action. Thus, postural control requires the
complex interaction of neural and
musculoskeletal systems.4
Several researchers show that as
the age increases, the changes in the neural
and musculoskeletal systems disturb the
balance and physical activities.6
As age
increases the physical activities and
physical function also decreases due to
decreased muscular power and strength.11
Both balance problems and physical
inactivity affect the quality of life of older
adults. Therefore the assessment of both
balance and physical function is necessary
for older adults in order to help establish
appropriate treatment goals, increase
awareness of fall risk and assign
appropriate assistive device and to
decrease the disability. Several such
instrument have shown satisfactory
reliability and validity in identifying olderpeople with balance and physical
functional problems, discriminating older
adults by their needs for different assistive
device to maintain balance or predicting
their likelihood of falls and to enhance
physical function.
The Berg Balance Scale was
developed by Kathy Berg (a Canadian
physical therapist) in1993, as a means of
measuring balance in the elderly.
Multi-directional Reach Test
(MDRT) is developed by Roberta A.
Newton in 2001. It allows for analysis of
the patient voluntary postural control.
The Performance Oriented
Mobility Assessment (POMA) scale was
originally developed by Dr. Mary E.
Tinetti and first published in 1986, is a
widely used tool for assessing mobility
and fall risk in older people. In this study
balance subscale of Tinetti assessment is
used to assess the balance of older adults.15
Brown, M, Sinacore, D.R.
developed the modified physical
performance test in 2005 to provide more
focus on gross motor function by
substituting a chair rise task and a balance
task for the writing and stimulated eating
tasks described in the original PPT. The
tool was more useful in identifying deficits
in physical function than the self- report
comparison measure, the functional status
questionnaire. The authors concluded thatthe performance based measure could
assist in early identification of minor
problems in physical functioning, and
allow for opportunity for early intervention
for the patients.16
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Several researchers found that
balancing exercises improve physical
function and previous studies also found
significant correlation between balance
scales and other functional tests.17,18,13,19
Therefore it is clear that there is a
relationship between balance and physical
function.
Yet there is no study to show
relationship between these scales or tests
in different age groups. Therefore the main
purpose of my study is to find out the
relationship between balance tests and
Modified physical performance test.
Second purpose is, the Modified physical
performance test assesses both balance and
physical function in older adults no other
tool is required because it measure the
both static and dynamic balance and also
physical function. It tells about fall risk,
need of assistance device and functional
limitations; additionally it takes less time
to administer as compared to other scale.
METHODOLOGY
This observational study recruited
58 subjects from old age homes and local
community of Delhi and Dehradun
meeting the inclusion criteria. InclusionCriteria: Age - 60 to 89 year old healthy
subjects; Gender- Both male and female;
Ability to abduct and flex the shoulder up
to 90 degrees; Ability to stand for
minimum 10 min. without any assistance;
Ability to walk at least 50 feet before
sitting to rest; Minimal use of rail or cane
while climbing. Exclusion Criteria: Use
of any assistive prosthetic device; History
of any cardiac problem confirmed by
physician; Any history of fainting spells or
extended dizziness due to unknown
reasons History of neurological; vestibular
or auditory deficit confirmed by physician;
History of any visual disorder which will
not be corrected by optical glasses as
confirmed by physician; MMSE score
below 23; History of postural hypotension;
History of recent fractures and severe
arthritic conditions; History of any major
surgeries during last 6 month; History of
any previous balance training; Moderate to
severe hypertensions
Measurement Tools
Berg Balance Scale (BBS)
The BBS was developed to measure
balance among older people with
impairment in balance function by
assessing the performance of 14 functional
tasks. The results are based on how long it
takes to complete specific tasks and how
well the tasks are performed. Each task is
measured on a five point ordinal scaleranging from 0 to 4 (0 = unable to
perform, 4 = independent) so that the
aggregate score ranges from 0 to 56.
Multidirectional Reach Test (MDRT)
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The MDRT is an inexpensive, reliable and
valid screening tool to measure the limits
of postural stability in four directions
(forward, backward, right & left) during
standing. The distance of each reach is
measured in centimetres or inches.
Balance Performance Oriented Mobility
Assessment (BPOMA)
The Tinetti assessment is a physical task-
oriented scale which measures the gait and
balance activities of older adults. In this
study BPOMA was used to assess the
balance of the community dwelling older
adults; it consists 9 tasks. 6 tasks are
measured on a three point ordinal scale
ranging from 0 to 2 and remaining three
tasks are measured on a two point ordinal
scale ranging from 0 to 1 ( 0 = unable to
perform, 1 & 2 = independent). The
maximum score is 16.
Physical Performance Test (Modified-
PPT)
An objective evaluation of overall physical
function was obtained by using modified
PPT. The severity of physical frailty in
physical functioning was assessed using a
modified PPT. It consists of 9 tasks; each
task is measured on a five point ordinal
scale ranging from 0 to 4 ( 0 = unable toperform, 4 = independent) except 7th task
(turning 360 degrees) which ranges from 0
to 1 (0 = unsteady, 1 = steady). The
maximum score is 36.
Procedure
The subjects were recruited based on
inclusion and exclusion criteria the
subjects of different age groups 60 to 69
years of age (Group- A), 70 to 79 years of
age (Group- B), and 80 to 89 years of age
(Group- C). Subjects in each group
performed the tests in a sequence i.e. BBS,
MDRT, Modified-PPT, POMA. The whole
procedure was explained to each subject
and the subject signed a consent form
before performing the study. Description
data was collected which included age,
gender, height, weight and number of falls
in the past 6 months. MMSE score was
also assessed. All subjects were assessed
by all four scales or tests in the following
order BBS, MDRT, Modified-PPT and
BPOMA. All components of each scale
were demonstrated to all the subjects and
one practice session was done for all the
components of four scales by all the
subjects, after that reading was taken. Each
test or scale was administered by myself.
All subjects were offered rest breaks and
water during the session and completed the
approximately 60 minute testing protocol
without complaint of fatigue or
discomfort. The resting period of 5 to 10minute was given after performing each
scale. As a precautionary measure, blood
pressure was checked prior to beginning of
the test session and it was again taken at
the end of the last test performed. One
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person was always nearby vicinity of the
subject.
Data Analysis
The data analysis was done on SPSS 11.5
software. The arithmetical mean and
standard deviation of age, height and
weight in demographic data were
evaluated. Karl pearsons correlation test
was done to analyse the correlation
between balance tests (BBS, MDRT &
POMA) with physical performance test
(modified) among elderly people.
Statistical significance level was set at
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