Short Physical Performance Battery. SPPB Course Objectives: SPPB and Fortune Telling. Development and Origin of SPPB

Transcription

1 Short Physical Performance Battery Brad Abrams PT, DPT, GCS, CEEAA Julie Ashcroft MPT, CEEAA SPPB and Fortune Telling Is there a way to meaningfully predict future functioning of elderly patients? Can we give concrete reasons therapy would be important for their health? Is it beneficial to demonstrate improved predicted function? Decreased risk of developing a disability and of nursing home admission? Can a tool identify when intervention could avert development of disability? Yes! SPPB Course Objectives: 1. Recognize the valuable development/origins of SPPB 2. Be ready to effectively perform and score the SPPB 3. Calculate and interpret SPPB score 4. Apply the score to clinical settings 5. Access additional resources Development and Origin of SPPB National Institute on Aging( NIA): Established Population for the Epidemiologic Studies of the Elderly(EPESE) Objective Performance Measure of Physical Function(Lower Extremity) Disease/Pathology - Impairment - Functional Limitations - Disability (Nagi) SPPB Links Functional Limitation to: Future Disability, Nursing Home Admissions, and Mortality(now more!)

2 SPPB - Functional Limitation as a Predictor International Classification of Functioning, Disability, and Health (ICF) Classifies subjects across a wide range of function Predicts many adverse outcomes Identifies non-disabled persons who have functional limitations and are at a higher risk of adverse outcomes Targets a subset of the population for clinical trials Adapted from the World Health Organization International Classification of Functioning, Disability and Health (ICF) model, WHO Lifestyle, Habits Social Background Educations Products/Technology Support/Relationships Attitudes, Services Movement System--What is it? APTA Vision Statement: Transforming society by optimizing movement to improve the human experience. Goal: The physical therapy profession will define and promote the Movement System (MS) as the foundation for optimizing movement to improve the health of society. MS Definition: The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts. Potential Applications of SPPB Identifying high levels of functioning Identifying non-disabled persons at risk of disability Clinical vital sign Evaluating change Interventional Studies Cross-national and cross-cultural studies

3 SPPB - Who, where and what? Elderly population Persons must have ability to walk(4m), but can use assistive device. Most, even with cognitive impairments, can perform Most environments - Home health, outpatient, assisted living, nursing home, Hospital Current performance indicator AND prognostic indicator Short Physical Performance Battery - Overview Objective Performance Test (performed in this order): Timed standing balance - 3 positions Side-by-side, Semi-tandem, and Tandem Timed 4-meter walk - normal gait speed Chair rise - Single and Timed Multiple Sit to stands (no arm support) Equipment Stopwatch, Chair (18 high), Marked 3-4m walk path (tape, tape measure or rolling tape measure) Short Physical Performance Battery - Scoring Each Component is given a score of 0 to 4 Score of 0 given for inability or refusal to fully perform Scores 1-4 are quartiles of the population Summary score of components added together for total score of 0-12 Summary and Component scores can be interpreted separately SPPB - Familiar and NOT Familiar Balance - Support to obtain foot position is OK, any compensatory motion OK, 10 seconds only. (differences: Single Leg Stance Test, Rhomberg, Fullerton, STEADI) Gait speed - 4 meters (or 3m), start at start line - with mov t (NOT Begin ), foot must fully cross finish line to stop clock, any assistive device is ok, but not encouraged (differences: Fast Gait Speed, TUG) Chair Stands - Single Sit to stand, Start on Begin, stop when strait on 5th stand, arms across chest, 60 second limit (Differences: 5 times Sit to Stand, 30 second Chair Stand)

4 Short Physical Performance Battery - Balance Support the person until ready, then let go and begin timing. Make sure foot position is correct - Semi-Tandem = heel next to big toe. Fully demonstrate the allowed body motions during the script.(emphasize) Time stops when: moves feet, grabs arm of tester, or completes 10 seconds Tandem position 2 points possible - 2pts for 10 sec, 1pts for 3 to 9.99 sec Short Physical Performance Battery - Timed Walk SPPB - Timed Walk - specifics Start walking at start line - only when starting to move (Not at Begin ) Walk at usual speed - NOT fast speed (No pacing, no encouraging) Can use assistive device (but encouraged NOT to use one, if possible) Timing stops when first foot completely crosses the 4 M line Score the faster of the 2 timed walks Course should have ½ Meter on each end unobstructed

5 Short Physical Performance Battery -Chair rise Short Physical Performance Battery - Chair rise Arm position - folded arms across chest, at all times Emphasize to perform quickly and demonstrate as such Timing - START at Begin and STOP when fully strait on 5th stand Single chair stand - if unable, then 0 score and stop No pacing with counting, coaching or counting Stop test if unable to complete in 1 minute, or unsafe Short Physical Performance Battery - Demo SPPB - Summary/Tips/Reminders Summary: Putting it all together! Demonstration I need a Volunteer! Just try it. Get going, learn from practicing Other Tips: Reminders: Follow along with your script/score sheet Questions?

6 SPPB Scores Calculate Scores How scoring was developed Interpret the scores SPPB as performance measure for studies Distribution of Performance Times to Complete 5 Chair Stands According to Age and Sex Percent Percent Age Sex Mean (sec) Males 13.2 Females Age 80+ Sex Mean (sec) Males 15.0 Females 16.1 Unable Unable Time (seconds) Performance Test Categories Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94. Death Rates According to Individual Performance Tests Age and Sex Adjusted Death Rates According to Performance Test Summary Score Age and Sex Adjusted Deaths per 100 Person Years Test Category Walk Chair Stands Standing Balance % Distribution Performance Test Summary Score Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94.

7 Nursing Home Admission Rates According to Performance Test Summary Score Age and Sex Adjusted Guralnik JM, et al. J Gerontol Med Sci. 1994;49:M85-M94. Three-Level Hierarchical Classification of Disability Related to Lower Extremity Function Baseline Prevalence % Non-disabled Disabled in higher mobility Walking 1/2 mile Climbing stairs Disabled in ADLs + higher mobility 14.8 Transfer from bed to chair Using toilet Bathing Walking across a small room + Higher Mobility (walk ½ mile, stairs) ADLs = activities of daily living. Disability Status at Four Years According to Baseline Gait Speed Among Those Non-Disabled at Baseline Iowa EPESE Non- Disabled Mobility Disabled ADL + Mobility Disabled Disability Status at Four Years According to Baseline Performance Score Among Those Non-Disabled at Baseline Percent Iowa EPESE Non- Disabled Mobility Disabled ADL + Mobility Disabled Category Walking Speed (m/sec) Guralnik JM, et al. N Engl J Med. 1995;332: Summary Performance 0 ADL = activity of daily living Guralnik JM, et al. N Engl J Med. 1995;332: Score

8 Disability Rates According to Performance Score: Observed Rates in Hispanic EPESE Compared to Predicted Rates from EPESE Models Using Functional Limitation as an Outcome Percent Mobility disability ADL disability Summary Performance Score 1 Guralnik JM, et al. J Gerontol Med Sci. 2000;55:M221-M yr. projected 2 yr. observed 1 yr. projected 12 To study the effects of disease and impairment on functional outcome a more proximal outcome measure than disability To evaluate functional consequences of a risk factor or an intervention Can observe the effect free of environmental influences Good psychometric properties Disadvantage changes in functional limitations difficult to interpret in relation to problems in daily life Distribution of Change in Performance Score (1992 Score 1988 Score) Iowa EPESE Adjusted Mean Change in Physical Performance Score ( ) According to Level of Depressive Symptoms P trend = N= N=305 * 7-12 N=289 ** N=213 *** 20 N=137 Penninx BWJH, et al. JAMA. 1998;279: Adjusted for baseline performance score, demographics, behavioral risk factors, and disease status. Penninx BWJH, et al. JAMA. *P <.1, **P <.05, ***P <.001 compared to CES-D = ;279:

9 Change in Summary Performance Score Over Interval During Which Participants Were Hospitalized for Specific Events Women s Health and Aging Study Potential Applications of Physical Performance Measures Identifying high levels of functioning Identifying non-disabled persons at risk of disability Ostir GV, et al. J Clin Epidemiol. 2002;55: MI = myocardial infarction CHF = congestive heart failure Clinical vital sign Evaluating change Intervention studies Cross-national and cross-cultural studies Summary of SPPB so Far... Summary of SPPB so Far... A group of measures that combines balance tests, gait speed, and chair stands Interpretation/Meaning The scores can range from 0 (worst performance) to 12 (best performance). Has predictive validity showing a gradient of risk for mortality, nursing home admission, disability, and future disability in currently non-disabled appearing individuals Interpretation/Meaning (con t) A score of "0" in any single domain: places individual at significantly heightened risk for further decline in other domains and in function, increased risk of nursing home admission, self care needs and mortality risk. SPPB can be used as an outcome measure in various studies

10 SPPB and Falls--Study SPPB and Falls--Results Association Between Short Physical Performance Battery and Falls in Older People 2014 Italy, Cross Sectional Study 2,710 Community Dwelling Older Adults Excluded those with severe physical impairments Aims Do SPPB Scores related to recurrent fallers Which test is most strongly associated with higher fall rate? Falls and Aggregate SPPB Scores M F Risk 0-6 ^ ^ 3x 7-9 ^ Individual Tests M Bal GS F ^ <.75 m/s Non-fallers had 0-1 falls, Recurrent fallers had >1 fall Interview and EHR review STS ^ >16.7s SPPB and Hospitalization--Study Predictive Value of SPPB Following Hospitalization in Older Patients Italy, 2011 n= Able to walk MMSE = 18+ Dx: CHF, pneumonia, COPD, minor stroke SPPB on admission, discharge, and 1 month later Phone call f/u: functional decline, hospitalizations, vital status SPPB and Hospitalization--Results Higher SPPB score at discharge inversely correlated with ADL decline SPPB 0-4 higher risk of hospitalization and death compared to SPPB score 8-12 Early decline in SPPB score after discharge had steeper increases in ADL difficulty, rehospitalization, and death A 1-point increase of the SPPB score at discharge was associated with a 14% reduction of the risk of hospitalizations + death combined.

11 SPPB and All-cause Mortality--Study Pavasini, Guralnick, et al, 2016 Meta-analysis including 17 studies, n = 16,534, mean age 76 US, Europe, Korea (7 IT) f/u 1-11 years Included community based, outpatient, and hospitalized patients Scores stratified: 0-3, 4-6, 7-9, SPPB and All-cause Mortality--Results Poor performance and all-cause mortality highly consistent across follow up length, subsets of participants, geographic area, AGE SPPB <10 predictive of increased risk for all-cause mortality All-cause mortality for SPPB scores of 7-9 were higher in younger population, diabetics, and men Can SPPB be used as a surrogate end point of all-cause mortality in trials needing to quantify benefit of rehab programs? SPPB and 400m Walk Use of the SPPB to Predict Loss of Ability to Walk 400 Meters (2009) Longitudinal Epidemiological Study, Italy (InCHIANTI Study) Aim: Examine the association of the SPPB to ability to walk 400m n=542, 65+ Community dwelling older adults 3 year follow up Age and Sex-Adjusted Proportion of Participants Unable to Complete 400 Meter Walk at 3-Year Follow-Up by Baseline SPPB Score Unable to walk 400m after three years (%) p for trend <0.001 < Baseline SPPB 1 Score n Source: InChianti Study, Vasunilashorn et al. J Gerontol Med Sci,.

12 Movement System Definition The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts. Sarcopenia and Cognitive Impairment using SPPB as Physical Performance Measure--Study Aim: ID modifiable factors for loss of muscle mass in older adults with MCI and AD Singapore, 2017 n=108 Strength, muscle quality, blood biomarkers for inflammation and endocrine deficiency 3 categories No sarcopenia (38%) Pre-sarcopenia (13%) Sarcopenia (49%) Sarcopenia and Cognitive Impairment using SPPB as Physical Performance Measure--Findings No sarcopenia (38%)--highest lean muscle mass Pre-sarcopenia (13%)--lowest % Body fat, highest SPPB and activity Sarcopenia (49%)--highest pro-inflammatory or endocrine deficient state Muscle quality beyond muscle mass as determinant of functional performance in CI Older Adults Efficiency of muscle tissue has greater impact on function than isolated decline in muscle mass Severity of CI was not associated with sarcopenia or pre-sarcopenia Supplementation and SPPB as a Performance Measure Effects of daily vitamin D supplementation on respiratory muscle strength and physical performance in Vitamin D-deficient COPD patients; a pilot trial (2017) A 12 week intervention with protein-enriched foods and drinks improved protein intake but not physical performance of older patients during the first 6 months after hospital release: a randomised control trial (2017)

13 Summary of SPPB Research SPPB scores also show gradient of risk for falls, hospitalizations, all-cause mortality, loss of community mobility lower scores, Recurrent fallers: scores 0-4, tasks: men STS, women walking speed 1-point increase of the SPPB score at discharge was associated with a 14% reduction of the risk of rehospitalization and death SPPB <10 predictive of increased risk for all-cause mortality SPPB </= 7 predictive of loss of 400m walk ability at 3 years Summary of SPPB Research SPPB used as outcome measure in different parts of movement system Muscle quality beyond muscle mass is determinant of functional performance in CI Older Adults (pre-sarcopenic outperformed non-sarcopenic and sarcopenic) Vit D and protein supplementation alone (without ex s) did not affect physical performance Case Studies What is the ICF? Describe using ICF Movement System Contributors MS Diagnoses/Descriptors SPPB Results: Risk interpretation and Guiding Treatment (start, stop, continue) SPPB Results: MS Considerations and impact on score Review ICF Describe Movement System The International Classification of Functioning, Disability and Health (ICF) A framework for organizing and documenting information on functioning and disability (WHO 2001) It conceptualises functioning as a dynamic interaction between a person s health condition, environmental factors and personal factors WHO 2013

14 International Classification of Functioning, Disability, and Health (ICF) Movement System--What is it? APTA Vision Statement: Transforming society by optimizing movement to improve the human experience. Goal: The physical therapy profession will define and promote the Movement System (MS) as the foundation for optimizing movement to improve the health of society. Adapted from the World Health Organization International Classification of Functioning, Disability and Health (ICF) model, WHO Lifestyle, Habits Social Background Educations Products/Technology Support/Relationships Attitudes, Services MS Definition: The human movement system comprises the anatomic structures and physiologic functions that interact to move the body or its component parts. Movement System--Purpose Establish PT Expertise and body of knowledge Diagnosis and interventions Develop and implement treatment 1. To have ALL Physical Therapists 2. Consider, review, or examine (look at) ALL systems and 3. Identify which system(s) is/are contributing to the movement problem 4. To prioritize treatments. Movement System Considerations Pathoanatomic diagnosis--traditionally treat the anatomical problem Pathokinesiologic/Kinesiopathologic mechanisms-- The faulty movement pattern induces the pathology (Sahrmann 2017)

15 Movement System Diagnoses Movement System Diagnoses (con t) MVMT. PATTERN COORDINATION DEFICIT (muscle imbalances, mvmt impairments) FORCE PRODUCTION DEFICIT (disuse) FRACTIONATED MOVEMENT DEFICIT (CVA, MS) POSTURAL VERTICAL DEFICIT (backward falls) Inability to coordinate an intersegmental task because of a deficit in timing and sequencing of one segment in relationship to another. Weakness, may be muscle, neuromuscular junction, peripheral nerve, or central nervous system dysfunction Inability to fractionate (isolate) movement associated with moderate or greater hyperexcitability, Always a central neurological deficit. Inaccurate perception of vertical orientation resulting in postural control deficits and the tendency to resist correction of center of mass alignment. SENSORY DETECTION DEFICIT (peripheral neuropathy) HYPOKINESIA (parkinsons s disease, extra-pyramidal syndromes) DYSMETRIA (ataxia) Inability to execute intersegmental movement due to lack of joint position sense or multi-sensory failure affecting joint position sense, vision, and/or the vestibular system. Slowness in initiating and executing movement. Inability to grade forces appropriately for the distance and speed aspects of a task. Rapid movements are generally too large, and slow movements are generally too small for their intended purpose. Performance deteriorates with faster speeds SENSORY SELECTION AND WEIGHTING DEFICIT (vestibular hypofunction, BPPV) Inability to maintain postural orientation or motor performance as a result of decreased ability to screen for and attend to appropriate sensory inputs COGNITIVE DEFICIT (AD, anoxia, brain injury) Impaired motor control related to lack of arousal, attention, or ability to apply meaning to situation that is appropriate for age. Ceiling (10-12) Floor (0-3) Ceiling and Floor Best Tests (Mini, Brief, Full) Fullerton Advanced Balance Scale DGI/FGA 30 Second Sit to Stand Function in Sitting Test Sitting Balance Scale Describe/Time Bed Mob and Transfers Summary SPPB-- 3 items ( stage balance, normal gait speed, sit to stand), minimal equipment, efficient, effective, and accurate. Gradient of risk for re-hospitalizations, loss of ADL independence, loss of community mobility, disability, nursing home admission, hospitalition, falls, and death. A 1 point change is significant and meaningful. Quantifies performance but does not describe movement quality or movement system contributors.

16 Study ID Date Tester Initials SHORT PHYSICAL PERFORMANCE BATTERY PROTOCOL AND SCORE SHEET All of the tests should be performed in the same order as they are presented in this protocol. Instructions to the participants are shown in bold italic and should be given exactly as they are written in this script. 1. BALANCE TESTS The participant must be able to stand unassisted without the use of a cane or walker. You may help the participant to get up. Now let s begin the evaluation. I would now like you to try to move your body in different movements. I will first describe and show each movement to you. Then I d like you to try to do it. If you cannot do a particular movement, or if you feel it would be unsafe to try to do it, tell me and we ll move on to the next one. Let me emphasize that I do not want you to try to do any exercise that you feel might be unsafe. Do you have any questions before we begin? A. Side-by-Side Stand 1. Now I will show you the first movement. 2. (Demonstrate) I want you to try to stand with your feet together, side-by-side, for about 10 seconds. 3. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. 4. Stand next to the participant to help him/her into the side-by-side position. 5. Supply just enough support to the participant s arm to prevent loss of balance. 6. When the participant has his/her feet together, ask Are you ready? 7. Then let go and begin timing as you say, Ready, begin. 8. Stop the stopwatch and say Stop after 10 seconds or when the participant steps out of position or grabs your arm. 9. If participant is unable to hold the position for 10 seconds, record result and go to the gait speed test.

17 Study ID Date Tester Initials B. Semi-Tandem Stand 1. Now I will show you the second movement. 2. (Demonstrate) Now I want you to try to stand with the side of the heel of one foot touching the big toe of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. 3. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. 4. Stand next to the participant to help him/her into the semi-tandem position 5. Supply just enough support to the participant s arm to prevent loss of balance. 6. When the participant has his/her feet together, ask Are you ready? 7. Then let go and begin timing as you say Ready, begin. 8. Stop the stopwatch and say Stop after 10 seconds or when the participant steps out of position or grabs your arm. 9. If participant is unable to hold the position for 10 seconds, record result and go to the gait speed test. C. Tandem Stand 1. Now I will show you the third movement. 2. (Demonstrate) Now I want you to try to stand with the heel of one foot in front of and touching the toes of the other foot for about 10 seconds. You may put either foot in front, whichever is more comfortable for you. 3. You may use your arms, bend your knees, or move your body to maintain your balance, but try not to move your feet. Try to hold this position until I tell you to stop. 4. Stand next to the participant to help him/her into the tandem position. 5. Supply just enough support to the participant s arm to prevent loss of balance. 6. When the participant has his/her feet together, ask Are you ready? 7. Then let go and begin timing as you say, Ready, begin. 8. Stop the stopwatch and say Stop after 10 seconds or when the participant steps out of position or grabs your arm.

18 Study ID Date Tester Initials SCORING: A. Side-by-side-stand Held for 10 sec 1 point If participant did not attempt test or failed, circle why: Not held for 10 sec 0 points Tried but unable 1 Not attempted 0 points Participant could not hold position unassisted 2 If 0 points, end Balance Tests Not attempted, you felt unsafe 3 Not attempted, participant felt unsafe 4 Participant unable to understand Number of seconds held if instructions 5 less than 10 sec:. sec Other (specify) 6 Participant refused 7 B. Semi-Tandem Stand Held for 10 sec 1 point Not held for 10 sec 0 points Not attempted 0 points (circle reason above) If 0 points, end Balance Tests Number of seconds held if less than 10 sec:. sec C. Tandem Stand Held for 10 sec 2 points Held for 3 to 9.99 sec 1 point Held for < than 3 sec 0 points Not attempted 0 points (circle reason above) Number of seconds held if less than 10 sec:. sec D. Total Balance Tests score (sum points) Comments:

19 Study ID Date Tester Initials 2. GAIT SPEED TEST Now I am going to observe how you normally walk. If you use a cane or other walking aid and you feel you need it to walk a short distance, then you may use it. A. First Gait Speed Test 1. This is our walking course. I want you to walk to the other end of the course at your usual speed, just as if you were walking down the street to go to the store. 2. Demonstrate the walk for the participant. 3. Walk all the way past the other end of the tape before you stop. I will walk with you. Do you feel this would be safe? 4. Have the participant stand with both feet touching the starting line. 5. When I want you to start, I will say: Ready, begin. When the participant acknowledges this instruction say: Ready, begin. 6. Press the start/stop button to start the stopwatch as the participant begins walking. 7. Walk behind and to the side of the participant. 8. Stop timing when one of the participant s feet is completely across the end line. B. Second Gait Speed Test 1. Now I want you to repeat the walk. Remember to walk at your usual pace, and go all the way past the other end of the course. 2. Have the participant stand with both feet touching the starting line. 3. When I want you to start, I will say: Ready, begin. When the participant acknowledges this instruction say: Ready, begin. 4. Press the start/stop button to start the stopwatch as the participant begins walking. 5. Walk behind and to the side of the participant. 6. Stop timing when one of the participant s feet is completely across the end line.

20 Study ID Date Tester Initials GAIT SPEED TEST SCORING: Length of walk test course: Four meters Three meters A. Time for First Gait Speed Test (sec) 1. Time for 3 or 4 meters. sec 2. If participant did not attempt test or failed, circle why: Tried but unable 1 Participant could not walk unassisted 2 Not attempted, you felt unsafe 3 Not attempted, participant felt unsafe 4 Participant unable to understand instructions 5 Other (Specify) 6 Participant refused 7 Complete score sheet and go to chair stand test 3. Aids for first walk None Cane Other Comments: B. Time for Second Gait Speed Test (sec) 1. Time for 3 or 4 meters. sec 2. If participant did not attempt test or failed, circle why: Tried but unable 1 Participant could not walk unassisted 2 Not attempted, you felt unsafe 3 Not attempted, participant felt unsafe 4 Participant unable to understand instructions 5 Other (Specify) 6 Participant refused 7 3. Aids for second walk None Cane Other What is the time for the faster of the two walks? Record the shorter of the two times. sec [If only 1 walk done, record that time]. sec If the participant was unable to do the walk: 0 points For 4-Meter Walk: For 3-Meter Walk: If time is more than 8.70 sec: 1 point If time is more than 6.52 sec: 1 point If time is 6.21 to 8.70 sec: 2 points If time is 4.66 to 6.52 sec: 2 points If time is 4.82 to 6.20 sec: 3 points If time is 3.62 to 4.65 sec: 3 points If time is less than 4.82 sec: 4 points If time is less than 3.62 sec: 4 points

21 Study ID Date Tester Initials 3. CHAIR STAND TEST Single Chair Stand 1. Let s do the last movement test. Do you think it would be safe for you to try to stand up from a chair without using your arms? 2. The next test measures the strength in your legs. 3. (Demonstrate and explain the procedure.) First, fold your arms across your chest and sit so that your feet are on the floor; then stand up keeping your arms folded across your chest. 4. Please stand up keeping your arms folded across your chest. (Record result). 5. If participant cannot rise without using arms, say Okay, try to stand up using your arms. This is the end of their test. Record result and go to the scoring page. Repeated Chair Stands 1. Do you think it would be safe for you to try to stand up from a chair five times without using your arms? 2. (Demonstrate and explain the procedure): Please stand up straight as QUICKLY as you can five times, without stopping in between. After standing up each time, sit down and then stand up again. Keep your arms folded across your chest. I ll be timing you with a stopwatch. 3. When the participant is properly seated, say: Ready? Stand and begin timing. 4. Count out loud as the participant arises each time, up to five times. 5. Stop if participant becomes tired or short of breath during repeated chair stands. 6. Stop the stopwatch when he/she has straightened up completely for the fifth time. 7. Also stop: If participant uses his/her arms After 1 minute, if participant has not completed rises At your discretion, if concerned for participant s safety 8. If the participant stops and appears to be fatigued before completing the five stands, confirm this by asking Can you continue? 9. If participant says Yes, continue timing. If participant says No, stop and reset the stopwatch.

22 Study ID Date Tester Initials SCORING Single Chair Stand Test YES NO A. Safe to stand without help B. Results: Participant stood without using arms Go to Repeated Chair Stand Test Participant used arms to stand End test; score as 0 points Test not completed End test; score as 0 points C. If participant did not attempt test or failed, circle why: Tried but unable 1 Participant could not stand unassisted 2 Not attempted, you felt unsafe 3 Not attempted, participant felt unsafe 4 Participant unable to understand instructions 5 Other (Specify) 6 Participant refused 7 Repeated Chair Stand Test YES NO A. Safe to stand five times B. If five stands done successfully, record time in seconds. Time to complete five stands. sec C. If participant did not attempt test or failed, circle why: Tried but unable 1 Participant could not stand unassisted 2 Not attempted, you felt unsafe 3 Not attempted, participant felt unsafe 4 Participant unable to understand instructions 5 Other (Specify) 6 Participant refused 7 Scoring the Repeated Chair Test Participant unable to complete 5 chair stands or completes stands in >60 sec: If chair stand time is sec or more: If chair stand time is to sec: If chair stand time is to sec: If chair stand time is sec or less: 0 points 1 points 2 points 3 points 4 points

23 Study ID Date Tester Initials Scoring for Complete Short Physical Performance Battery Test Scores Total Balance Test score Gait Speed Test score Chair Stand Test score Total Score points points points points (sum of points above)

24 Short Physical Performance Battery 1. Balance Tests Side-by-Side Stand Feet together side-by-side for 10 sec 10 sec (1 pt) Semi-Tandem Stand Heel of one foot against side of big toe of the other for 10 sec < 10 sec (0 pt) < 10 sec (+0 pt) Go to 4-Meter Gait Speed Test Go to 4-Meter Gait Speed Test 10 sec (+1 pt) Tandem Stand Feet aligned heel to toe for 10 sec 2. Gait Speed Test 10 sec (+2 pt) sec (+1 pt) <3 sec (+0 pt) Measures the time required to walk 4 meters at a normal pace (use best of 2 times) <4.82 sec 4 pt sec 3 pt sec 2 pt >8.7 sec 1 pt Unable 0 pt 1m 2m 3m 4m 3. Chair Stand Test Pre-test Participants fold their arms across their chest and try to stand up once from a chair able 5 repeats Measures the time required to perform five rises from a chair to an upright position as fast as possible without the use of the arms unable Stop (0 pt) sec 4 pt sec 3 pt sec 2 pt >16.7 sec 1 pt >60 sec or unable 0 pt 105

25 References Beelen, J., de Roos, N., & de Groot, L. (2017). A 12-week intervention with protein-enriched foods and drinks improved protein intake but not physical performance of older patients during the first 6 months after hospital release: a randomised controlled trial. British Journal Of Nutrition, 117 (11), Ferrucci, L., Penninx, B., Leveille, S., Corti, M., Pahor, M., & Wallace, R. et al. (2000). Characteristics of Nondisabled Older Persons Who Perform Poorly in Objective Tests of Lower Extremity Function. Journal Of The American Geriatrics Society, 48 (9), Guralnik, J., Ferrucci, L., Simonsick, E., Salive, M., & Wallace, R. (1995). Lower-Extremity Function in Persons over the Age of 70 Years as a Predictor of Subsequent Disability. New England Journal Of Medicine, 332 (9), Guralnik, J., Simonsick, E., Ferrucci, L., Glynn, R., Berkman, L., & Blazer, D. et al. (1994). A Short Physical Performance Battery Assessing Lower Extremity Function: Association With Self-Reported Disability and Prediction of Mortality and Nursing Home Admission. Journal Of Gerontology, 49 (2), M85-M94. Ostir, G., Volpato, S., Fried, L., Chaves, P., & Guralnik, J. (2002). Reliability and sensitivity to change assessed for a summary measure of lower body function. Journal Of Clinical Epidemiology, 55 (9), Pavasini, R., Guralnik, J., Brown, J., di Bari, M., Cesari, M., & Landi, F. et al. (2018). Short Physical Performance Battery and all-cause mortality: systematic review and meta-analysis. Retrieved 30 March 2018, from Penninx, B. (1998). Depressive Symptoms and Physical Decline in Community-Dwelling Older Persons. JAMA, 279 (21),

26 Rafiq, R., Prins, H., Boersma, W., Daniels, J., den Heijer, M., Lips, P., & de Jongh, R. (2017). Effects of daily vitamin D supplementation on respiratory muscle strength and physical performance in vitamin D-deficient COPD patients: a pilot trial. International Journal Of Chronic Obstructive Pulmonary Disease, Volume 12, SHORT PHYSICAL PERFORMANCE BATTERY (SPPB) GUIDE. (2018). sppbguide.com. Retrieved 31 March 2018, from Studenski, S., Perera, S., Wallace, D., Chandler, J., Duncan, P., & Rooney, E. et al. (2003). Physical Performance Measures in the Clinical Setting. Journal Of The American Geriatrics Society, 51 (3), Tay, L., Leung, B., Wee, S., Tay, K., Ali, N., Chan, M., & Lim, W. (2018). Association of nutrition and immune-endocrine dysfunction with muscle mass and performance in cognitively impaired older adults. Archives Of Gerontology And Geriatrics, 75, Treacy, D., & Hassett, L. (2018). The Short Physical Performance Battery. Journal Of Physiotherapy, 64 (1), Vasunilashorn, S., Coppin, A., Patel, K., Lauretani, F., Ferrucci, L., Bandinelli, S., & Guralnik, J. (2009). Use of the Short Physical Performance Battery Score to Predict Loss of Ability to Walk 400 Meters: Analysis From the InCHIANTI Study. The Journals Of Gerontology Series A: Biological Sciences And Medical Sciences, 64A (2), Veronese, N., Bolzetta, F., Toffanello, E., Zambon, S., De Rui, M., & Perissinotto, E. et al. (2014). Association Between Short Physical Performance Battery and Falls in Older People: The Progetto Veneto Anziani Study. Rejuvenation Research, 17 (3),

27 Volpato, S., Cavalieri, M., Sioulis, F., Guerra, G., Maraldi, C., & Zuliani, G. et al. (2010). Predictive Value of the Short Physical Performance Battery Following Hospitalization in Older Patients. The Journals Of Gerontology Series A: Biological Sciences And Medical Sciences, 66A (1),