Sarah Wilson, SPT & Christine Greve, SPT
I believe the tool best fitted for my population found in the Rehab Measures Database is the 10-meter walk test method 2. This tool was tested on patients with hip fracture and was a valid test for my population. In an outpatient setting there is room to complete the whole 14 meters for the test to be performed so that it is more accurate to show the patients’ walking speed and to evaluate their functional mobility. The 10-meter walk test method 2 is a simple test that can be administered in less than 5 minutes and all the therapist needs is a tape measure, stopwatch, paper, and pen.1 Method 2 allows the patient to have time to accelerate and time to decelerate after the 10-meters.1 This test is good for the outpatient environment because there is plenty of room in the facilities gym and it is also done fast enough that it should not interfere with any other patients’ rehab. This tool can easily be used to see a patients’ improvement with walking speed and mobility. The construct validity for patients’ that have surgically repaired hip fractures has excellent correlation with the 6MWT, LE strength, and LE power.1
The 6 minute walk test (6MWT) is an optimal tool used to measure gait and aerobic capacity among patients that received surgical repair for a hip fracture. The 6MWT is an endurance measure that assesses the distance a person can walk on a measured walkway during 6 minutes. The link to the 6MWT, a further description of the test, and other populations assessed with the 6MWT are listed on rehabmeasures.org.2 The following information was taken from a population of patients 65 years or older (men or women), within 17 days of surgical repair of a unilateral hip fracture, and at least partially weight-bearing.3
Hip fracture inclusion criteria was 65 years or older (men or women), within 17 days of surgical repair of a unilateral hip fracture, at least partially weight-bearing; surgical repair occurred at a minimum of 4 days post hip fracture; prior to fracture the patients were living in the community, able to ambulate independently at home, and without cognitive impairment according to Folstein’s Mini-Mental State Examination score >/= 24.3
In my opinion, the best tool would be the 6MWT. This test is feasible and very easy to do in the outpatient setting. It does not take much time to perform but still gives you very valuable information. While the 10-meter walk test allows you to see the patients’ walk speed the 6MWT can see your walk speed along with the patients’ endurance. When a patient is in the outpatient setting they want to be able to get around their community as soon as possible this will show a patient how well they will be able to ambulate around the community. This test can also show a hip fracture patient how much farther they have to go in therapy whether they need to improve on strength or their aerobic capacity. This can be determined by asking the patient what was slowing the patient down during the test. Although the 10-meter walk test is a good test for hip fracture patients in the outpatient setting, I believe the 6MWT is the best test for this population.
1. Ali D, Raad J. Rehab measures. 10 Meter Walk Test Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=901&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPageView%3DShared. Published 2010. Updated 2013. Accessed 1/29, 2013.
2. Rehab Institute of Chicago. Rehabilitation measures database. Rehabilitation Measures Database Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=895. Published 2010. Updated 2010. Accessed 1-31-13.
3. Latham NK, Mehta V, Nguyen AM, et al. Performance-based or self-report measures of physical function: Which should be used in clinical trials of hip fracture patients? Arch Phys Med Rehabil. 2008;89(11):2146-2155. Accessed 2/3/2013 10:54:48 AM. doi: 10.1016/j.apmr.2008.04.016.
Assisted Living Facility
Kelly McGraw SPT
When assessing the ability to walk and move around after a hip fracture with surgical repair, there are many tools to measure functional outcomes.1 Patient’s living in an assistive living facility are typically higher functioning and living independently, with some exceptions for ADLs. A tool that has been shown to have a minimal detectable change score for hip fractures is the 10 Meter Walk Test (10MWT).2, 3 This tool is one of the best for hip fractures because it is easy to use, taking approximately five minutes or less to perform. It also helps to determine how mobile a patient is and whether they are able to ambulate with or without an assistive device. More information on the 10MWT can be found on the rehab measures website (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=901&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FView%3D%257b0C859D90%252d7478%252d4C9B%252d9575%252d784C4A9A2D85%257d%26PageView%3DShared)
When searching for other tools that help to assess walking and moving around after a hip fracture with surgical repair, one test that is used in many practices is the Timed Up and Go test (TUG). The TUG has been tested and shown to be valid and reliable in a variety of different patient populations, including but not limited to: Stroke, Community-dwelling Older Adults, Parkinson’s Disease, Spinal Cord Injury, Arthritis, and Low Back Pain.4 There have been a variety of studies that have used the TUG when assessing functional recovery after a hip fracture. A study conducted by Ganz et al.5 used the TUG and found a significant difference from admission to discharge to a skilled nursing facility (SNF) after a hip fracture. Patients in the SNF received 30-45 minutes of daily physical therapy consisting of therapeutic exercises, gait training, balance training, and ADL training. Another study performed by Kristensen et al.6 found that the TUG scores for patients after a hip fracture varied depending on what type of assistive device the patient used. Overall, patients using a Rollator walker performed the TUG faster than those patients using a standard walker or Lofstrand crutches. The Rehab Measures website provides some pertinent information with regards to community-dwelling older adults and the TUG, however the website does not provide any information regarding the TUG and hip fractures. (http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPaged%3DTRUE%26p_Title%3DModified%2520Rankin%2520Handicap%2520Scale%26p_ID%3D921%26View%3D%257b0C859D90%252d7478%252d4C9B%252d9575%252d784C4A9A2D85%257d%26PageView%3DShared%26PageFirstRow%3D101)
For patients residing in an assistive living facility, either of these tests would be suitable for assessing walking and moving around after a hip fracture with surgical repair. Both tests require only a small space and can be conducted very quickly. For this patient population, I would most likely choose to use the TUG, because I believe it gives a better indication of ability to move around a home. By having the patients perform sit to stand, stand to sit, ambulation, and turning around, it allows for higher levels of function to be shown. Both tests show a patients ability to ambulate, however the TUG delves further into mobility. Either of these tests could be used to capture functional change in patients with hip fractures, however, a better test could be developed to fully assess change for this specific patient population.
1. Woodka M. Skilled nursing vs. assisted living. http://www.onshift.com/executive-perspectives-on-staffing/skilled-nursing-vs-assisted-living/. Updated 2012. Accessed January 31, 2013.
2. Ali D. Rehab measures: 10 meter walk test. Rehabilitation Measures Database: The Rehabilitation Clinician's Place to Find the Best Instruments to Screen Patients and Monitor Their Progress Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=901&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FView%3D%257b0C859D90%252d7478%252d4C9B%252d9575%252d784C4A9A2D85%257d%26PageView%3DShared. Updated 2013. Accessed January 31, 2013.
3. Latham NK, Mehta V, Nguyen AM, et al. Performance-based or self-report measures of physical function: Which should be used in clinical trials of hip fracture patients? Arch Phys Med Rehabil. 2008;89(11):2146-2155. doi: 10.1016/j.apmr.2008.04.016; 10.1016/j.apmr.2008.04.016.
4. Ali D. Rehab measures: Timed up and go. Rehabilitation Measures Database: The Rehabilitation Clinician's Place to Find the Best Instruments to Screen Patients and Monitor Their Progress Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903&Source=http%3A%2F%2Fwww%2Erehabmeasures%2Eorg%2Frehabweb%2Fallmeasures%2Easpx%3FPaged%3DTRUE%26p_Title%3DMoss%2520Attention%2520Rating%2520Scale%26p_ID%3D1078%26View%3D%257b0C859D90%252d7478%252d4C9B%252d9575%252d784C4A9A2D85%257d%26PageView%3DShared%26PageFirstRow%3D101. Updated 2013. Accessed January 31, 2013.
5. Ganz SB, Peterson MG, Russo PW, Guccione A. Functional recovery after hip fracture in the subacute setting. HSS J. 2007;3(1):50-57. doi: 10.1007/s11420-006-9022-3; 10.1007/s11420-006-9022-3.
6. Kristensen MT, Bandholm T, Holm B, Ekdahl C, Kehlet H. Timed up & go test score in patients with hip fracture is related to the type of walking aid. Arch Phys Med Rehabil. 2009;90(10):1760-1765. doi: 10.1016/j.apmr.2009.05.013; 10.1016/j.apmr.2009.05.013.
Skilled Nursing Facility
Jessica Zink SPT
The purpose of the 10 Meter Walk Test (10MWT) is to assess walking speed in meters per second over a short duration of time. 1 There are two methods of delivery for this test. For method one, the patient walks without assistance for 10 meters and the time is measured for the middle 6 meters (allowing for acceleration and deceleration). For method two, the patient walks a total of 14 meters and the time is measured for the middle 10 meters (allowing for acceleration and deceleration). For method two, assistive devices can be used and should be kept consistent for each trial. There are many tests used to assess gait speed at various distances (2-Min Walk Test, 6-Min Walk Test) however the 10MWT is used most frequently. The 10MWT is easy to administer, requiring less than 5 minutes to complete and requiring little equipment—stopwatch and a clear path of 14 meters. The test does not require training in order to administer the test. The classification for the test is as follows: < 0.4 m/s indicates patients are more likely to be household ambulators, 0.4 – 0.8 m/s indicates patients are limited community ambulators, and > 0.8 m/s indicates patients are community ambulators. For more information on the 10MWT 1, refer to:
One outcome measure that is used in the clinical setting for reporting functional status following hip fractures is the Lower Extremity Functional Scale (LEFS). The LEFS is a self reported questionnaire that assesses the functional status of patients with any musculoskeletal condition of the lower extremity. 2 The LEFS was developed to be efficient in administration, scoring, and recording, to include a wide range of lower extremity orthopedic conditions, to be able to document a wide range of disability levels, and to provide reliable and valid measurements. For more information on the LEFS, refer to this list:
• ICF Domain: Activity
• Time to administer: < 5 minutes
• Number of Items on the tool: 20
• Equipment: Paper and pencil
• Training: None
• Cost: Free
• Population: Adults with lower extremity conditions
• Minimally detectable change (MDC): 9
• Cut-Off Scores: 0 = low function; 80 = high function
Patients living in skilled nursing facilities often require increased assistance with activities of daily living as well as ambulation. It is important to measure functional status following surgical repair of hip fractures. The best way to determine functional ability is to have a patient perform functional tasks. The 10MWT allows a physical therapist to observe a patient’s ability to walk 10 meters and record the time it takes to perform the task. The patient can perform the test with or without an assistive device—this should be held consistent and recorded in all future measurements. However, the 10MWT has been show to have poor correlation in clinic vs. natural environments. 1
The LEFS is a self-reported questionnaire used to determine perceived functional status. Some of the questions included in the LEFS include: usual work, housework, or school activities, walking between rooms, getting into or out of the bath, lifting an object, walking two blocks, and rolling over in bed. The patient ranks their ability from 0 (extreme difficulty or unable to perform the activity) to 4 (no difficulty). It is important to include the patient’s perception of his or her own functional ability.
Both the 10MWT and LEFS allow for measurement of change between outcome measure assessment days. The ease of administration allows the tests to be administered quickly, efficiently, and often. A clinician can see a change in the time it takes the patient to ambulate 10 meters in the 10MWT as well as observe a change in rating of ability to perform functional tasks in the LEFS.
There is not one test that can assess the complete functional ability of a patient nor should one test be the only means of determining the progress of a patient. Both the 10MWT and LEFS take less than 5 minutes to complete. If a clinician does not want to use their time with the patient to have the patient fill out the LEFS, the questionnaire can be given to the patient ahead of time. Clinically, it would be beneficial when measuring a patient’s functional ability to test with functional tasks as well as perceived ability to perform the tasks. Clinicians should consider using performance measures as well as self-reported measures when observing and measuring a change in a patient’s functional status following surgical repair of a hip fracture.
1. Rehab Institute of Chicago. 10 meter walk test. Rehab Measures Web site. http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=901. Published 2010. Updated 2010. Accessed January 31, 2013.
2. Binkley JM, Stratford PW, Lott SA, Riddle DL. The lower extremity functional scale (LEFS): Scale development, measurement properties, and clinical application. north american orthopaedic rehabilitation research network. Phys Ther. 1999;79(4):371-383.
Home Care Setting
Justin Yerkes SPT
10 Meter Walk Test
This functional outcome measure assesses gait speed of an individual without assistance for 10 meters. Time starts when the toes of the leading foot cross the 2-meter mark and time stops when the toes of the leading foot cross the 8 meter mark; this allows for acceleration and deceleration.1 Assistive devices can used and should be documented and kept consistent from test to test.
In regards to functionality, cost, and treatment goals, the 10 meter walk test is the best outcome measure for a hip fracture with surgical repair. It takes less than 5 minutes to administer, is free, and requires a small space of 14 meters in length. This allows the tool to capture the Medicare G Code of Walking and moving around in the clinical setting as well as in the patient’s home. The 10 meter walk test has been researched on the Medicare population (>65 years old) who have had a hip fracture with surgical repair. It is a valid outcome measure for this population with a minimal detectable change (MDC) of 0.17 m/s and a test-retest reliability of .95-.99.1, 2 Normative Data is available so patients as well as clinicians can compare scores with the rest of the population.
Another functional outcome measure in the literature that captures improvement of a hip fracture with surgical repair is the:
Title: Six Minute Walk Test (6MWT)
Instrument Review provided at: http://www.rehabmeasures.org/Lists/RehabMeasures/PrintView.aspx?ID=895
Evidence Based Article provided at:
The purpose of this tool is to test endurance by measuring the maximum distance a person can walk in six minutes. Minimal equipment is required such as a stop watch and measuring wheel, and an assistive device may be used. The six minute walk test takes six to 30 minutes to complete, is free, and no training is required. It does capture the Medicare G Code of walking and moving around but with an endurance component. The six minute walk test is not specified as a functional outcome measure specifically for hip fracture with surgical repair on the rehabmeasure.org website. However, other literature states that this test is valid for the functional impairment. A study by Latham et al.2 took 108 community dwelling patients 65 years or older (men or women), within 17 days of surgical repair of a unilateral hip fracture, who were at least partially weight-bearing. This study compared various outcome measurements specific to patients with this functional impairment. Measurements were taken at baseline and at 12 weeks and found the following clinically important numbers for the 6MWT.
• ICF Domain: Activity
• Time to administer: 6-30 minutes
• Number of Items on the tool: Not Applicable
• Equipment: Stop watch, Measuring wheel to measure distance
• Training: None
• Cost: Free
• Population: 65 years or older s/p surgical repair of a unilateral hip fracture
• Minimally detectable change (MDC): 53.51 meters
• Construct Validity: 0.62 (0.46-0.75) for leg strength
Comparing the two outcome Measures:
In the study by Latham et al.2 both the 10 meter walk test and six minute walk test showed significant change (<0.01) in improvement from baseline to week 12, and a similar construct validity rating of improvement. Both functional outcome tools capture the Medicare G code of walking and moving around for a hip fracture with surgical repair. However, in the home care environment time and especially space is an issue. Therefore, the 10 Meter Walk Test will measure the appropriate function, while allowing for a practical form of functional measurement in the home care setting.
1. The Rehabilitation Clinician's Place to Find the Best Instruments to Screen Patients and Monitor Their Progress. Rehabilitation Measures Database website. http://www.rehabmeasures.org/default.aspx. Accessed January 30, 2013
2. Latham NK, Mehta V, Nguyen AM, et al. Performance-based or self-report measures of physical function: Which should be used in clinical trials of hip fracture patients? Arch Phys Med Rehabil. 2008;89(11):2146-2155. doi: 10.1016/j.apmr.2008.04.016; 10.1016/j.apmr.2008.04.016.
Julianne Wright SPT
Timed “Up & Go”:
The timed “Up & Go” (TUG) test is a well known measure of functional mobility in the geriatric population.1 It is a reliable measure2, sensitive in predicting falls in patients with a previous hip fracture3 and correlated to gait speed and Berg Balance scores in patients with a hip fracture4. The TUG is also a quick test requiring less than 3 minutes and minimal equipment, only a chair and stopwatch.1 The TUG focusses on the patients ability to transition from a seated position to standing and walk a short distance before returning to a seated position; these basic mobility tasks are essential in the home environment.
The TUG is more a measure of basic mobility skills and less focused on endurance than many other outcome measures used in assessment of the hip fracture patient such as a 6 minute walk test. Unlike these tests which may be better suited for an outpatient environment the TUG encompassed the necessities for individuals unable to leave their home setting. These individuals are unlikely to need to walk great distances while being treated in the home-care environment, and it is more important for their functional mobility that they maintain balance in transfers and safely ambulate short distances.
If the TUG is performed in the environment that the patient will spend most of their time in and on the surfaces that they are faced with then it is an excelent predictor of their functional mobility in that setting.
1. Ali, D. Raad, J. (2010). Rehab Measures: Timed Up and Go. Retrieved from: http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=903
2. Podsiadlo, D. Richardson, S. The Timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc, 39 (1991), pp. 142–148.
3. A. Shumway-Cook, S. Brauer, M. Woollacott. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther, 80 (2000), pp. 896–903.
4. M. Thompson, A. Medley. Performance of community dwelling elderly on the Timed Up and Go Test. Phys Occup Ther Geriatr, 13 (1995), pp. 17–30.