5 Overlooked Assessments for Exercise Prescription in Older Adults
We as physical therapists are seeing an increasing number of older adults presenting with issues related to frailty, poor balance, and generalized deconditioning. Our aging adult clients have distinct needs that require unique assessment tools for exercise program design. Here, we’ll review overlooked assessments that will level up your care of the older adult.
Note that this list is not all inclusive. We won’t review well-known tests like the 30 second Sit-to-Stand or measuring single leg balance for time. Rather, this list focuses on valuable tests that many clinicians are missing AND require minimal equipment and space-which is an issue in many outpatient clinics.
These assessments cover a few key areas: muscle power, strength and endurance, aerobic capacity, and balance.
1) 4-Stair climb power test
A common issue in older adults is a decline in muscle power, which is strongly related to a decrease in functional mobility. Some assessments, like the 30 Second sit-to-stand, also measure other qualities such as muscular endurance and cardiorespiratory capacity. This makes it difficult to determine the extent to which muscle power limits a client’s mobility.
The 4-Stair Climb Power Test is a quick assessment of lower extremity power, which requires minimal equipment (1). This test is an abbreviated version of the Stair Climb Power Test and only requires that the client ascend 4 steps as quickly as possible (using a handrail if needed). The 4-Stair Climb Power test is valuable for tracking both muscle power and quantifying progress on functional tasks such as stair negotiation. To learn how to perform and interpret the results of this test, check out Dr. Mariana Wingood’s Masterclass “Exercise Prescription for Aging Adults”.
Muscle strength and endurance
2) Single leg heel rise test
While we routinely measure gross lower extremity strength and endurance with older adults, we often miss a crucial component: plantar flexor strength and endurance. Plantar flexion strength and endurance is strongly associated with gait and balance capabilities in older adults (2). To measure plantar flexor performance we need more than manual muscle testing (MMT). MMT for the plantar flexors has a ceiling effect because these muscles tend to be strong and the short lever arm for MMT limits its ability to gauge functional weakness for many individuals.
Instead, we can use the single leg heel rise test, where the client performs single leg heel rises at a rate of 1 per second until failure. This test has age and sex matched normative data which can aid in goal setting for your client. For full details on administration and interpretation of this assessment, check out Dr. Wingood’s Masterclass on Exercise for older adults.
3) 2-Minute step test
As Dr. Wingood discusses in her masterclass, there are pulmonary and cardiovascular changes that limit older adults’ functional capacity. This not only influences our prescription of aerobic exercise, but how we structure an exercise program for an older adult. For example, if a client has low aerobic capacity, they may require longer rest breaks. Further, they may need to start with a higher frequency of weekly sessions of shorter duration, since they may lack the work capacity for longer exercise sessions.
While the 6-minute walk test provides valuable insights into aerobic capacity, some clinics may not have the equipment or space to perform this test. The 2-minute step test evaluates aerobic capacity by measuring the number of times the client lifts their right knee to a mark taped against a wall. This test is not only time efficient, but eliminates balance as a limiting factor, since the client is able to hold onto an object for support. This assessment also has age and sex matched normative data for comparison (3).
For an expert breakdown of administration and interpretation of this test, read Dr. Wingood’s research review here.
Balance and fall risk are a common concern with older adults and are influenced by many factors. The Brief-BESTest swiftly assesses several of these areas including: lateral hip strength, stability limits, anticipatory postural adjustment, reactive postural adjustment, sensory orientation, and stability in gait (4). Since this assessment examines each area separately, it allows us to target a client’s most critical balance impairments. If time permits there are longer versions of this assessment (the Mini-BESTest and BESTest), however many clinicians find that the Brief-BESTest provides sufficient information.
5) Four square step test
For older adults, most falls occur when walking (as opposed to standing or sitting), thus objective measures of dynamic balance are vital (5). The four square step test examines stepping in multiple directions by having the client step over objects forward, sideways, and backward (6). This test not only assesses their ability to clear the ground when stepping, but also their capacity to perform anticipatory postural adjustments in multiple directions. An important caveat is that this assessment is challenging, so it may not be appropriate for a patient with major mobility and balance impairments.
Effective assessment is crucial for quality exercise prescription and monitoring the efficacy of an exercise program for older adults. The assessments described here provide valuable information and require minimal equipment. In addition to these standardized assessments, we should also evaluate the client’s response to specific exercises over time (e.g. being able to increase the load and/or volume indicates a positive response to the exercise program).
To summarize, the assessments you can implement today to improve your practice are:
- 4-Step Climb Power Test
- Single Leg Heel Rise Test
- 2-Minute Step Test
- Four Square Step Test
For more on how to optimize care of older adults, check out Dr. Wingood’s Masterclass on Exercise prescription for aging adults..
Want to learn how to optimise your exercise prescription for older adults?
Dr Mariana Wingood has done a Masterclass lecture series for us on:
“Exercise prescription for aging adults”
You can try Masterclass for FREE now with our 7-day trial!
- Ni, M., Brown, L. G., Lawler, D., & Bean, J. F. (2017). Reliability, Validity, and Minimal Detectable Change of Four-Step Stair Climb Power Test in Community-Dwelling Older Adults. Physical therapy, 97(7), 767–773. https://doi.org/10.1093/ptj/pzx039
- Hashish, R., Samarawickrame, S. D., Wang, M. Y., Yu, S. S., & Salem, G. J. (2015). The association between unilateral heel-rise performance with static and dynamic balance in community dwelling older adults. Geriatric nursing (New York, N.Y.), 36(1), 30–34. https://doi.org/10.1016/j.gerinurse.2014.09.003
- Bohannon, R. W., & Crouch, R. H. (2019). Two-Minute Step Test of Exercise Capacity: Systematic Review of Procedures, Performance, and Clinimetric Properties. Journal of geriatric physical therapy (2001), 42(2), 105–112. https://doi.org/10.1519/JPT.0000000000000164
- Marques, A., Almeida, S., Carvalho, J., Cruz, J., Oliveira, A., & Jácome, C. (2016). Reliability, Validity, and Ability to Identify Fall Status of the Balance Evaluation Systems Test, Mini-Balance Evaluation Systems Test, and Brief-Balance Evaluation Systems Test in Older People Living in the Community. Archives of physical medicine and rehabilitation, 97(12), 2166–2173.e1. https://doi.org/10.1016/j.apmr.2016.07.011
- Boyé, N. D., Mattace-Raso, F. U., Van der Velde, N., Van Lieshout, E. M., De Vries, O. J., Hartholt, K. A., Kerver, A. J., Bruijninckx, M. M., Van der Cammen, T. J., Patka, P., Van Beeck, E. F., & IMPROveFALL trial collaborators (2014). Circumstances leading to injurious falls in older men and women in the Netherlands. Injury, 45(8), 1224–1230. https://doi.org/10.1016/j.injury.2014.03.021
- de Aquino, M., de Oliveira Cirino, N. T., Lima, C. A., de Miranda Ventura, M., Hill, K., & Perracini, M. R. (2022). The Four Square Step Test is a useful mobility tool for discriminating older persons with frailty syndrome. Experimental gerontology, 161, 111699. https://doi.org/10.1016/j.exger.2022.111699
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