Identifying individuals at high risk of hospitalization and rehospitalization is critical for successful patient outcomes and sustainable reimbursement in home healthcare. As agencies employ various strategies to predict hospitalization probability, one tool with strong evidence for its utility in assessing risk of functional decline, hospitalization, nursing home admission, and mortality is the Short Physical Performance Battery (SPPB). The tool has strong validity and reliability metrics with evidence of a linear correlation between SPPB scores and lower extremity weakness (Guralnik et al., 2000). There is also evidence of its value in predicting a loss of ability to ambulate 400 meters (Vasunilashorn et al., 2009). The components of the SPPB are detailed by Guralnik (n.d.) and on the Shirley Ryan Ability Lab website (n.d.). The tool (https://www.cdc.gov/steadi/pdf/4-Stage_Balance_Test-print.pdf) consists of a series of three progressively harder standing balance tests, two timed trials of self-selected gait speed assessment over 3 or 4 meters, and a chair rise test. Each of the three assessments is rated on a 4-point scale with a maximum score of 12 (highest function) and lowest score of 0 (lowest function).
The balance test component uses the first three standing positions of the Four Stage Balance Test: feet side-by-side, semitandem, and tandem (Figure 1). The number of seconds the individual can maintain each of the positions is recorded. One point is awarded for maintaining the side-by-side and semitandem positions for at least 10 seconds or 0 points if the position is held less than 10 seconds. The tandem stance is scored 2 points for maintaining the position for at least 10 seconds, 1 point for 3 to 9.99 seconds, and 0 points for less than 3 seconds or not attempted. The scores awarded to each position are totaled for a maximum of 4 points for the balance testing portion of the SPPB.
The second segment of the SPPB scoring involves two timed trials of either the 3-meter or 4-meter walk test (Verghese et al., 2009). The 3-meter distance may be more amenable in the home environment given potential space restrictions. A tape measure or TheraBand(TM) cut to a premeasured length of 3 or 4 meter and a timer are needed for this test. Scoring for the 3- and 4-meter testing is detailed in Table 1. The fastest of the two trials is used to award a maximum score of 4 points for the gait speed section of the SPPB.
The chair rise is the third and final segment of the assessment (Shirley Ryan Ability Lab, n.d.). A firm chair and timer are needed to carry out this test. First, a single sit-to-stand chair maneuver is requested of the individual to test if it can be performed safely without the use of the upper extremities. The person is then asked to rise from sitting to standing five times as rapidly as they can while the tester times the test. The individual must maintain crossed arm over their chest while moving from seated in a chair to full standing and then returning to seated in the chair. A maximum score of 4 points is awarded corresponding to the amount of time it took to complete the test (Table 2).
After completing all three segments of the SPPB, scores are added for a final score of 0 and 12. There is evidence that patients with poor SPPB scores at hospital discharge (0-4) have a greater risk of rehospitalization or death compared with those with better SPPB scores (8-12) (Volpato et al., 2011). Furthermore, patients with early decline in SPPB score after discharge have more difficulty performing activity of daily living and are at a higher risk of rehospitalization or death over the next year (Volpato et al.).
The SPPB is a useful and effective way to quantify function and assess risk in the home care setting. With practice, all three measures can be conducted in 5 to 10 minutes with minimal and easily accessible equipment. The SPPB tool also provides an objective measure that can be used to demonstrate progress over time in varied physical domains (balance, gait speed, lower extremity strength) that may be useful in supporting the need for skilled rehabilitation services.
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