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Focus on Function: Physical Performance Test

Vol. 16 •Issue 6 • Page 6
Geriatric Function

Focus on Function: Physical Performance Test

Quality of life and the ability to function in the roles of choice and the roles ascribed by society are paramount to our sense of well-being, and our personal assessment of what is meaningful in life. Geriatric clients are no more or less dedicated to their roles than are younger clients.

As health care professionals, we should be dedicated to providing ways to assess ability not only for younger individuals, but also for older adults who would benefit from a comprehensive evaluation of function, to help them either improve or return to their baseline level of functional capacity.

Testing Options

This column begins with the presentation of The Physical Function Test1 (PPT) as the first part in a series of columns titled "Focus on Function." The PPT was specifically designed by the developers Reuben and Siu as a performance-based test for the elderly patient population. It has been shown to be a valid and reliable measure (Pearson's r = .99 {9-item}; r = .93 {7-item}) for estimating physical performance or function within the elderly population.1

Construct and concurrent validity were established via comparison of other measures of health, such as cognitive status, self-reported health status and mental health.1,2 The purpose of this instrument is to assess observable tasks performed by the individual that mimic activities of daily living. There are two versions of the PPT, a nine-item and a seven-item test. In the nine-item test, tasks such as writing, eating, lifting, dressing, bending, turning, walking and two elements of stair climbing are performed, timed and scored. Each of the nine items has 0 to 4 levels of performance.

The seven-item test excludes the two elements of stair climbing. Examples of some items include: writing a sentence and picking up a penny from the floor. Individuals are given a maximum of two tries to successfully complete each test item. Timed measurements are rounded to the nearest 0.5 seconds and scored according to criteria listed on the test scoring sheet.

Administration of the PPT takes approximately 10 minutes and proceeds in an eight-step manner.2

Step 1: The subject is cued, by saying the word "go" to write the sentence "whales live in the blue ocean." Timing begins from the time the tester says go until the subject lifts the pen from the paper at the end of the sentence. It is essential that all words be included and legible.

Step 2: The subject is cued, by saying the word "go" to pick up five previously placed kidney beans from a bowl located five inches from the edge of the desk in front of the subject. An empty coffee can is placed on the table on the subject's nondominant side. Using the dominant hand, the subject is instructed to pick up the beans, one at a time, and place them in the coffee can. Timing begins when the command "go" is given until the last bean is heard hitting the bottom of the coffee can.

Step 3: Testing begins with the placement of a heavy book (such as a Physician's Desk Reference) on a table in front of the subject. The subject is then instructed using the command word "go" to place the book on a shelf located above shoulder level. Timing begins from the word "go" to the time the book is resting on the shelf.

Step 4: Using the subject's own sweater or cardigan, or a lab coat supplied by the tester, the subject is asked to put on and then take off the item of clothing. The sweater or lab coat needs to rest squarely on the shoulders of the subject before it is removed. Timing begins from the command word "go" until the garment is completely removed.

Step 5: A penny is placed on the subject's dominant side approximately 1 foot away. The subject is then cued by the word "go" to pick the penny up from the floor and stand up. Timing begins from the command "go" until the subject is standing erect with the penny in hand.

Step 6: Within an open area, the subject is instructed to turn 360 degrees. If the subject takes discontinuous steps, a score of 0 is given; if continuous steps are taken, a score of 2 is given; if the subject is unsteady, grabs onto something or staggers, a score of 0 is given; if the subject is steady, a score of 2 is applied.

Step 7: The subject is brought to a 50-foot long testing area. The subject is then asked to walk forward for a total of 25 feet and back for a total of 25 feet. Timing begins when the examiner says "go" until the subject is back at the starting point.

Step 8: Before initiating this part of the exam, subjects are made aware of the possibility that they may experience cardiac and respiratory symptoms such as chest pain or shortness of breath. The subject is instructed to inform the examiner if they begin to experience any of these symptoms. The test is commenced with the subject being escorted up the stairs. Timing begins from the command of "go" until the subject's first foot reaches the top of the flight of the stairs. Documentation of the number of flights (with a maximum four) climbed (up and down in one flight).

A maximum score of 36 is possible for the nine-item test, and the seven-item test has a maximum total score of 28.

Frailty, Independence

The nine-item test scores can be interpreted in terms of frailty. Individual scores ranging from 32-36 are considered not frail. Scores ranging from 25-32 indicates mild frailty; 17-24 indicates moderate frailty and less than 17 is considered dependent. A score of less than 15 is predictive of recurrent falls on the nine-item test.

Avoidance of activities such as ADLs, in conjunction with a fear of falling, are variables in the transition to physical frailty, as measured by the PPT in the elderly population.3 Administration of the PPT and measures of cognitive and mood status have been found to be predictive of falls during stays in a geriatric rehabilitation unit.4,5 If an older person scores less than a 15 on the long version, this is predictive of falls.5

The seven-item test scores are interpreted in terms of independence, with individuals achieving scores ranging from 21-28 considered independent, and individuals with scores ranging from 3-15 considered dependent.

Functional Expertise

Proper interpretation and designation of scores on the PPT has consequences for both the patient and the physical therapist in terms of the development of prescribed treatment and goals. Of course, the physical therapy evaluation, patient input and other components of the comprehensive functional assessment (CFA) should be taken into account when establishing an appropriate plan of care for individual patients.

Therapists are functional experts, and should be using functional activity as the major focus of treatment. The Functional Activity code (97530) is one of the best paid codes because it truly encompasses therapy skills. With that said, we rarely see therapists using this code and we believe we should be using it in our billing as the core of treatment. In addition, Vreede just published a randomized controlled trial showing that a functional training program is more effective than progressive resistance program.6 With this information, therapists must continue to focus on the functional aspect of treatment.

Treatment Options

Treatment should focus on exercises and functional activities specifically oriented to the items in which the patient is deficient. For example, if the patient demonstrated difficulty donning and doffing a garment, is it not prudent to work on the components of doing such a task? This would include employing techniques to increase upper extremity and trunk range of motion, strength and coordination.

If the patient has difficulty climbing stairs, beginning with balance activities, progressing from static double-limb and single-limb support to dynamic step through activities would be advocated. Progressing to steps one, two and three, both with and without a rail, would also be realistic. In the same essence, strengthening of the lower extremities would be advantageous in order to facilitate other activities.

As this article details, the PPT is beneficial as one component of a comprehensive functional evaluation that would assist physical therapists in incorporating relevant and effective functionally designed plans of care for elderly patients. It has the added benefit of helping to predict recurrent falls in the geriatric patient which, in turn, may reduce hip fractures and other traumatic injuries that often plague this population.

Additionally, reducing frailty is important in the geriatric population, as increased frailty many times corresponds to placement in an extended care facility.


1. Reuben, D., & Siu, A. (1990). An objective measure of physical function of elderly outpatients: The physical performance test. Journal of the American Geriatric Society, 38, 1105-1112.

2. Lewis, C. (2000). The Functional Tool Box.

3. Delbaere, K., Crombez, G., Vanderstraeten, G., Willems, T., & Cambeir, D. (2004). Fear-related avoidance of activities, falls, and physical frailty. A prospective community-bassed cohort study. Age & Aging, 33(4), 368-373.

4. Cornali, C., Franzoni, S., Stofler, P., & Trabucchi, M. (2004). Mental functions and physical performance abilities as predictors of falling in a geriatric evaluation and rehabilitation unit. Journal of the American Geriatric Society, 52(9), 1591-1592.

5. VanSwearingen J., et al. (1998). Assessing recurrent fall risk of community-dwelling, frail older veterans using specific tests of mobility and the physical performance test of function. Journal of Gerontology, 53A(6), M457-M464.

6. Vreede, P., et al. (2005). Functional-task exercise versus resistance strength exercise to improve daily function in older women: A randomized, controlled trial. Journal of the American Geriatric Society, 53(1), 2-11.

Dr. Lewis is a physical therapist in private practice and president of Premier Physical Therapy of Washington, DC. She lectures exclusively for GREAT Seminars and Books, Inc. Dr. Lewis is also the author of numerous textbooks. Her Website address is Dr. Shaw is an assistant professor in the physical therapy program at the University of South Florida and she is dedicated to the area of geriatric rehabilitation. She lectures exclusively for Great Seminars and Books in area of geriatric function.


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