Physical Performance Test

The PPT assesses multiple domains of physical function using observed performance of tasks that stimulate activities of daily living of various degrees of difficulty in populations including older adults, Parkinson’s Disease, non-specific populations and mixed populations.

Link to Instrument

Area of Assessment

Activities of Daily Living
Aerobic Capacity
Balance – Vestibular
Cognition
Communication
Dexterity
Eating
Functional Mobility
Occupational Performance
Processing Speed
Upper Extremity Function

Administration Mode

Cost

Diagnosis/Conditions

• Cardiac Dysfunction
• Parkinson's Disease & Movement Disorders
• Stroke Recovery

Populations

Key Descriptions

• Two Versions:
  A) 9-item scale
  B) 7-item scale
• Scoring:
  A) A 5-point scale of (0-4) on each item
  B) Minimum score of 0 for both scales
  C) Maximum of 36 for 9-item scale; 28 for 7-item scale
  D) A higher totaled score is indicative of better physical performance
• Procedure:
  A) Subject is given a command “go” to perform a task.
  B) Timed to completion in seconds.
  C) A corresponding score is given from 0-4 determined by seconds taken to complete the task.
  D) Scores from each task are totaled.

Number of Items

Equipment Required

• Stopwatch
• Pen
• Paper
• 5 kidney beans
• A teaspoon
• An empty coffee can
• A heavy book
• Shelf
• Jacket, cardigan sweater, or lab coat
• A penny

Time to Administer

Required Training

Instrument Reviewers

Initially reviewed by Sabina N. Wafula in 10/2012.

Updated by Bridget Hahn, OTD, OTR/L Kimberly Lieberman, OTS, Obioma Morton, OTS, and Samantha Lee, OTS in 2019

Body Part

ICF Domain

Measurement Domain

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

Abbreviations:

LS / UR

Reasonable to use, but limited study in target group / Unable to Recommend

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

I

II

III

IV

V

PD EDGE

Recommendations for entry-level physical therapy education and use in research:

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

PD EDGE

Considerations

(Lusardi et al,2003)

• Performance on the PPT for relatively healthy, community living older adults is not well documented.

(Paschal et al, 2006)

• A learning curve can be expected with use of the PPT given the 2 trials of each task

(Reuben & Siu, 1990)

• Unable to test against a gold standard for functional capacity
• Although subjects may have been able to perform tasks in research setting, they may be less motivated to perform similar tasks at home
• PPT cannot differentiate unmotivated from incapable patients
• Tasks chosen may be incomplete measurements of functional status

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Mixed Populations

Standard Error of Measurement (SEM)

Lower Extremity Weakness (Tuttle, Sinacore & Mueller, 2015; n = 45)

• SEM for individuals with healthy obesity (n=10) = 0.47*
• SEM for individuals with diabetes melitus (n=11) = 0.72*
• SEM for individuals with peripheral neuropathy (n=24) = 0.82*

Minimal Detectable Change (MDC)

Lower Extremity Weakness (Tuttle, Sinacore & Mueller, 2015)

• MDC for individuals with healthy obesity (n=10): 1.30*
• MDC for individuals with diabetes melitus (n=11): 2.0*
• MDC for individuals with peripheral neuropathy (n=24): 2.27*

Interrater/Intrarater Reliability

Elderly and Parkinson's Disease: (Reuben & Siu (1990); n = 183; mean age = 79(46-94); elderly outpatients)

• Excellent interrater reliability(r=0.99)

• Excellent interrater reliability (r=0.93)

Internal Consistency

Elderly and Parkinson's Disease: (Reuben& Siu, 1990)

• Excellent internal consistency Cronbach’s alpha (0.87 on 9-item scale and 0.79 on 7-point scale)

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Parkinson and Elderly: (Reuben & Siu, 1990)

• Excellent correlation of the 9-item scale with basic Katz Activities of daily living( r = 0.65)
• Adequate correlation of the 7-item scale with basic Katz Activities of daily living (r = 0.50)
• Excellent correlation of the 9-item scale with the hierarchical scale of instrumental and basic activities of daily living ( r = 0.69)
• Adequate correlation of the 7-item scale with the hierarchical scale of instrumental and basic activities of daily living (r = 0.56 )
• Excellent correlations with a modified four-item Roscow Breslau (r = 0.80 and r = 0.69) for the 9 and 7-item scales
• Excellent correlations for both scales with the Tinnetti gait score (r = .78 and r = 0.69)
• Slightly lower correlations for nonparametric (Spearman) and the 9 and 7-item scales

Predictive Validity:Elderly and Cancer: (Ghosn, et al., 2017; n = 100; mean age = 76 (4) years)

• Patients defined as fit by mean PPT score (> 20) had worse median OS (560 vs 721 days); however, this difference was not significant (p = 0.488 on log rank).

Elderly and Cancer: (Augschoell, et al. 2014: n=77; median age 74 years)

• At the cut-off of ≤ 19, the PPT revealed a positive predictive validity of 89% (95% CI: 76%–96%) and a negative predictive value of 63% (95% CI: 41%–81%) as a screening tool for frailty

Construct Validity

Construct Validity

Parkinson and Elderly: (Reuben & Siu, 1990)

• Poor to adequate correlation of PPT and mental health(MHI) (.24 and .32)
• Adequate to poor correlation of PPT and perceived health status ; (.32 and .27)
• Adequate correlation of PPT and mental status (MMSE); .47 and .40
• Poor correlation with age(-.24 and -.18)

Content Validity

Lower Extremity Weakness (Tuttle, Sinacore & Mueller, 2015)

IMAT vol

6 MW

PPT

Stair POW

Muscle Vol

IMAT/Mus Vol

*Indicates significance (P < 0.05).

IMAT: intermuscular adipose tissue volume; 6 MW: six-minute walk distance; PPT: physical performance test (9 items); Stair Pow: stair power; Muscle Vol: calf muscle volume; IMAT/MusVol: ratio of IMAT/muscle volume in the calf.

Floor/Ceiling Effects

Elderly and Cancer: (Augschoell, et al. 2014: n=77; median age 74 years)

• PPT of ≤ 20 resulted in a pronounced floor effect (55 impaired/15 normal)

Responsiveness

Elderly and Cancer: (Augschoell, et al. 2014: n=77; median age 74 years)

• At the cut-off of ≤ 19, the PPT revealed a sensitivity of 82% (95% CI: 69%–91%), a specificity of 75% (95% CI: 51%–91%).

Non-Specific Patient Population

Cut-Off Scores

9-point scale: (Lusardi et al, 2003; n = 76; mean age (mean age = 82.7 ± 7.9 years; All study participants were community dwelling and independently ambulatory at a FIM locomotor score of 6 or 7)

7-point scale: (Lusardi et al, 2003)

9-point scale: (Brown et al, 2000)

• 25-31 = mild frailty
• 32-36 = not frail

Older Adults and Geriatric Care

Minimally Clinically Important Difference (MCID)

Elderly: (King, 2000; n = 45; mean age = 77.9 (5.9); mobility impaired)

• MDIC for intervention group n = 18 was (2.4)

Test/Retest Reliability

Elderly: (Morala & Shiomi, 2004; n = 39; mean age = 82.5 (5.9) years)

• Good/excellent test-retest reliability in 11 subjects; ICC=0.853 to 0.971 (p <0.05)

Interrater/Intrarater Reliability

Elderly: (King, 2000)

• Excellent interrater reliability for the 8-item PPT ( ICC =.96)

Elderly: (Morala & Shiomi, 2004)

• Excellent interrater reliability in 15 subjects; ICC=0.95 to 0.99 (p <0.05)

Internal Consistency

Elderly: (King, 2000)

• Excellent internal consistency (Cronbach’s alpha= .785)

Criterion Validity (Predictive/Concurrent)

Predictive:

Elderly: (Delbaere et al, 2006; n = 263; mean age 72; community dwelling elderly)

• A low PPT score was the best physical predictor ( OR 4.16; P <0.001)
• Combination of PPT and maximal hand grip strength were the best predictors of future falls

Elderly : (Rozzini et al, 1997; n =549; mean age = 76.9 (5.4) years; 4.6 (2.0) years of education; MMSE and GDS scores 25.5 (4.5, 3.8 (3.2); and were affected by chronic conditions 3.5 (2.3) )

• PPT predicts ADL functional limitations before such limitations were detected using self-report scales in patients with chronic conditions

Construct Validity

Elderly: (Morala & Shiomi, 2004)

Barthel Index: r=0.581 p Mini-Mental State Examination: r=0.316 p Tokyo Metropolitan Institute of Gerontology of Index of Competence: r=0.677 p

Responsiveness

Elderly: (King MB et al, 2000)

• Small responsiveness .8 for the PPT-8

Parkinson's Disease

Standard Error of Measurement (SEM)

Parkinson Disease: (Paschal, 2006; n =14; mean age = 62.4(6.3); mean time of diagnosis 6.4(6.3) years; modified Hoehn and Yahr Stages 2 and 2.5)

• SEM for entire group (n = 14); 1.2 (7-point scale)
• SEM for entire group (n = 14); 1.1 (9-point scale)

Parkinson’s Disease: (King, et al., 2015; n = 58; mean age = 64.2 years (7.3); disease duration = 6.2 (6.1) years)

• SEM for home exercise group (n = 17): 0.87*
• SEM for individual exercise group (n = 21): 0.87*
• SEM for class exercise group (n = 20): 0.65*
• *Calculated using standard deviation and sample size provided in article

Minimal Detectable Change (MDC)

Parkinson's Disease: (Paschal et al, 2006)

• MDC (n = 14); 2.5 (calculated from Paschal, 2006)

Parkinson’s Disease: (King, et al., 2015; over 6 week period)

• MDC for home exercise group (n = 17): 2.41*
• MDC for individual exercise group (n = 21): 2.41*
• MDC for class exercise group (n = 20): 1.80*

*Calculated using standard deviation and sample size provided in article

Test/Retest Reliability

Parkinson’s Disease: (Paschal et al, 2006)

• Excellent test-retest reliability (ICC = 0.818) 7-point scale
• Excellent test-retest reliability ( ICC = 0.895) 9-point scale

Floor/Ceiling Effects

Parkinson's Disease: (Paschal et al, 2006)

• Excellent - Resistant to floor and ceiling effects on scores from the 7 and the 9-item scales.

Responsiveness

Parkinson's Disease: (Paschal et al, 2006)

• Relatively insensitive to short term symptom fluctuations typical in Parkinson's Disease (7-item 6%, 9-item 4%)

Alzheimer's Disease and Progressive Dementia

Test/Retest Reliability

Dementia: (Farrell et al, 2010; n = 33; mean score 10-24; 7-item PPT on 2 days with performance on day 2 videotaped)

• Excellent test-retest reliability determined using ICC (3,1) = 0.90 Elderly: (King, 2000)
• Excellent test-retest reliability on 8-item PPT (ICC = .88)

Interrater/Intrarater Reliability

Dementia: (Farrell et al, 2010)

• Excellent intrarater reliability determined using ICC (3,1) = 0.99
• Excellent interrater reliability determined using ICC (3,1) = 0.96

Criterion Validity (Predictive/Concurrent)

Predictive:

Dementia : (Farrell et al, 2011; n = 34; MMSE score 18.4+3.3; tested with PPT then followed for four month for fall occurrences)

• History of a fall in last 6 months was the only significant predictor of a subsequent fall (p = 0.044)
• Score of 28 or less on 9-item PPT is predictive of diminished aerobic capacity in older adults with AD (Vidoni et al, 2012; n = 130; older adults with and without dementia)
• Moderate sensitivity and specificity (58% and 77%) for a history of a fall
• Negative likelihood ratios were 2.52 and .58
• Moderate sensitivity (67%); moderate specificity (67%) specificity that functionally limiting aerobic capacity would limit function (Vidoni et al, 2012)
• High sensitivity (85%) and moderate specificity (62%) for the 4-point mini-PPT (Vidoni et al, 2012)

Construct Validity

Construct Validity

Dementia : (Shah et al, 2004; n = 99; 85 years and older; n =45 had DAT (CDR = 0.5-2) and n=54 were nondemented controls)

• Moderate correlation (taub > 0.30, p < 0.05) between impaired PPT performance, higher CDR rating and poor general health including difficulty ambulating
• Poor correlation (taub = -0.36) between dementia severity and PPT performance; decreased to (taub = -0.19) after controlling cognitive ability

Chronic Pain

Interrater/Intrarater Reliability

Chronic Pain (Sato, Kaneko & Okamura, 2006; n = 82; mean age = 82.3(8.2) years)

• Excellent interrater rater reliability: ICC=0.997-1.000 (p< 0.01) Excellent intrarater rater reliability: ICC=0.919-0.993

Construct Validity

Chronic Pain: (Sato, Kaneko & Okamura, 2006; n = 82)

• Average correlation with FIM r=.467-.651 p

Movement and Gait Disorders

Standard Error of Measurement (SEM)

Huntington’s Disease (HD) (Quinn, et.al, 2013; n = 75; mean age = 52.12 (11.82) years)

• SEM for individuals with pre-manifest (n=11):0.60
• SEM for individuals with manifest (n=63): 0.88
• SEM for individuals with early stage (n= 20): 1.12
• SEM for individuals with middle stage (n=19): 1.61
• SEM for individuals with late stage (n=24): 1.43

Minimal Detectable Change (MDC)

Huntington’s Disease (HD) (Quinn, et.al, 2013)

• MDC for individuals with pre-manifest (n=11):3
• MDC for individuals with manifest (n=63): 5
• MDC for individuals with early stage (n= 20): 4
• MDC for individuals with middle stage (n=19): 5
• MDC for individuals with late stage (n=24): 5

Test/Retest Reliability

Huntington’s Disease (HD) (Quinn, et.al, 2013)

• Excellent test-retest reliability for participants with manifest HD fMDC; (p <0.05)
  • ICC for individuals with pre-manifest (n=11): 0.76
  • ICC for individuals with manifest (n=63): 0.95
  • ICC for individuals with early stage (n= 20): 0.92
  • ICC for individuals with middle stage (n=19): 0.93
  • ICC for individuals with late stage (n=24): 0.94

  Bibliography

  J. Augschoell, G. Kemmler, M.E. Hamaker, R. Stauder. PPT and VES-13 in elderly patients with cancer: evaluation in multidimensional geriatric assessment and prediction of survival. J Geriatr Oncol, 5 (4) (2014), pp. 415-421 Find it on PubMed.

  Brown, M., Sinacore, D. R., et al. (2000). "Physical and performance measures for the identification of mild to moderate frailty." J Gerontol A Biol Sci Med Sci 55(6): M350-355. Find it on PubMed

  Delbaere, K., Van den Noortgate, N., et al. (2006). "The Physical Performance Test as a predictor of frequent fallers: a prospective community-based cohort study." Clin Rehabil 20(1): 83-90. Find it on PubMed

  Farrell, M. K., Rutt, R. A., et al. (2010). "Reliability of the physical performance test in people with dementia." Physical & Occupational Therapy in Geriatrics 28(2): 144-153.

  Farrell, M. K., Rutt, R. A., et al. (2011). "Are scores on the physical performance test useful in determination of risk of future falls in individuals with dementia?" J Geriatr Phys Ther 34(2): 57-63. Find it on PubMed

  Ghosn, M., Ibrahim, T., Rassy, E., Nassani, N., Ghanem, S., Assi, T. (2017). Abridged geriatric assessment is a better predictor of overall survival than the Karnofsky Performance Scale and Physical. Find it on PubMed.

  King, M. B., Judge, J. O., et al. (2000). "Reliability and responsiveness of two physical performance measures examined in the context of a functional training intervention." Phys Ther 80(1): 8-16. Find it on PubMed

  King, L.A., Wilhelm, J., Chen, Y., Blehm, R., Nutt, J., Chen, Z., Serdar, A., Horak, F.B. (2015). Effects of group, individual, and home exercise in persons with Parkinson disease: A randomized clinical trial. Journal of Neurologic Physical Therapy, 39(4), 204-212. Find it on PubMed.

  Lusardi, M. M., Pellecchia, G. L., et al. (2003). "Functional performance in community living older adults." Journal of Geriatric Physical Therapy 26: 14-22.

  Morala, D. & Shiomi, T. (2004). Assessing Reliability and Validity of Physical Performance Test for the Japanese Elderly. J. Phys. Ther. Sci., 16(1), 15-20. DOI

  Paschal, K., Oswald, A., et al. (2006). "Test-retest reliability of the physical performance test for persons with Parkinson disease." J Geriatr Phys Ther 29(3): 82-86. Find it on PubMed

  Quinn, L., Khalil, H., Dawes, H. Fritz, N., Kegelmeyer, D., Kloos, A., Gillard, J., Busse, M., for the Outcome Measures Subgroup of the European Huntington’s Disease Network. (2013). Reliability and minimal detectable change of physical performance measures in individuals With pre-manifest and manifest Huntington Disease. Physical Therapy, 93 (7), 942–956. Find it on PubMed.

  Reuben, D. B. and Siu, A. L. (1990). "An objective measure of physical function of elderly outpatients. The Physical Performance Test." J Am Geriatr Soc 38(10): 1105-1112. Find it on PubMed

  ROZZINI, R., FRISONI, G. B., et al. (1997). "The effect of chronic diseases on physical function. Comparison between activities of daily living scales and the Physical Performance Test." Age and Ageing 26(4): 281-287.

  Rozzini, R., Frisoni, G. B., et al. (2002). "Geriatric Index of Comorbidity: validation and comparison with other measures of comorbidity." Age Ageing 31(4): 277-285. Find it on PubMed

  Shah, K. R., Carr, D., et al. (2004). "Impaired physical performance and the assessment of dementia of the Alzheimer type." Alzheimer Dis Assoc Disord 18(3): 112-119. Find it on PubMed

  Tuttle, L., Sinacore, D., Mueller, J. (2012) Intermuscular adipose tissue is muscle specific and associated with poor functional performance. Journal of Aging Research, 2012, 1-7. Find it on PubMed

  Sato, D. Kaneko, F., Okamura, H. (2006). Reliability and validity of the Japanese-language version of the physical performance test (PPT) battery in chronic pain patients. Disability and Rehabilitation, 28(6), 397-405. Find it on PubMed

  Vidoni, E. D., Billinger, S. A., et al. (2012). "The physical performance test predicts aerobic capacity sufficient for independence in early-stage Alzheimer disease." J Geriatr Phys Ther 35(2): 72-78. Find it on PubMed

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