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Rehabilitation Measures

Push and Release Test

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Purpose

Assess postural instability early and in concurrence with patient complaints. 

May assist in identifying patients with balance impairments before they experience a fall.

Link to Instrument

Instrument Details

Acronym P&R

Area of Assessment

Balance – Non-vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

  • Parkinson's Disease & Neurologic Rehabilitation

Key Descriptions

  • The Push and Release Test was developed as an alternative to the "Pull Test" now included in the United Parkinson’s Disease Rating Scale (UPDRS, Item #30).

     
  • The patient leans back pressing on the hands of the examiner; the examiner then suddenly removes their hands. Scores are based on the patient's correctional response when trying to regain balance.
  • Scoring criteria are as follows:
    0 = Recovers independently with 1 step of normal length and width
    1 = Two to three small steps backward, but recovers independently
    2 = Four or more steps backward, but recovers independently
    3 = Steps but needs to be assisted to prevent a fall
    4 = Falls without attempting a step or unable to stand without assistance.
  • A full description of the Push and Release Test can be found in Jacobs, et al. (2006). Specific steps of administration:
    1) Subject stands in a comfortable stance with eyes open
    2) Examiner stands behind the subject
    3) Examiner instructs subject to do whatever necessary including taking a step to regain balance
    4) Subject pushes backward against palms of examiner’s hands placed on subject’s scapulae while examiner flexes elbows to allow backward movement of trunk and supports subject’s weight with hands
    5) Force of the subject’s push is not strong enough to cause heels to come off ground and subject cannot passively lean back into examiner’s hands: Passive lean allows subjects to be less hesitant to perform test and adds reliability by eliminating variance to test Consistency of perturbation forces applied to subject unlike Pull Test
    6) When subject’s shoulders and hips move to a stable position just behind heels, examiner suddenly removes hands, requiring subject to take a backward step to regain balance.
    7) Subject has to take a step for test to be properly executed. A step is counted only if it is required for subject to maintain balance not to reorient feet.
    8) Time at which examiner releases hands from subject vary to ensure subject cannot anticipate release.

Time to Administer

Less than 5 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed byJulie Gupta, PT, DPT in 9/2011  

ICF Domain

Activity

Measurement Domain

Motor

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.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

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

NR

Not Recommended

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

LS/UR

R

R

R

LS/UR

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

No

No

Yes

Not reported

Considerations

  • Limited evidence on psychometirc properties of the P&R exists for persons in PD H&Y stages 1 and 5.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Parkinson's Disease

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Normative Data

Parkinson’s Disease:

(Jacobs et al., 2006; n = 69 PD and 69 control participants; PD participants mean age = 67 (12) years; mean disease duration 10 (6) years; mean UPDRS score = 24 (12) points)

Descriptive Statistics for Each Balance Test by Group and Trial

 

 

Balance Test:

First Trial Mean (SD); Median (Range)

Third Trial Mean (SD); Median (Range)

Subjects with PD (n = 69)

 

 

Push & Release Test

2.10 (1.16); 2 (0-4)

1.66 (1.23); 2 (0-4)

Pull Test

1.24 (0.89); 1 (0-4)

0.85 (0.89); 0 (0-4)

Pull Test (P&R Scale)

1.76 (1.27); 1 (0-4)

1.09 (1.19); 1 (0-4)

Control Subjects (n = 69)

 

 

 

Push & Release Test

0.63(0.74); 0 (0-3)

0.50 (0.73); 0 (0-3)

Pull Test

0.42 (0.53); 0 (0-2)

0.17 (0.38); 0 (0-1)

Pull Test (P&R Scale)

0.65 (0.78); 0 (0-3)

0.33 (0.59); 0 (0-2)

 

Interrater/Intrarater Reliability

Parkinson’s Disease:

(Jacobs et al, 2006)

  • Adequate interrater reliability for three trials of the Push & Release Test
    • First trial  (ICC = 0.84)
    • Third trial (ICC = 0.83)

Construct Validity

Parkinson’s Disease:

(Jacobs et al, 2006)

  • Excellent convergent validity with self-reports of falls in the past year; first trial (r = 0.604)
  • Adequate convergent validity with self-reports of falls in the past year; third trial (= 0.55)

Responsiveness

Parkinson's Disease:

(Volkovic et al., 2008; n = 82 subjects with Parkinson’s Disease: 36 fallers and 46 non-fallers; mean age = 65.1(9.3) years for fallers and 62.4(8.8) for non-fallers)

  • Sensitivity: Push and Release Test vs. Pull Test

    • Off State 88.9% vs. 69.4%
    • On State 75.0% vs. 69.4%

  • Specificity: Push and Release Test vs. Pull Test

    • Off State 84.8% vs. 97.8%

    • On State 97.8% vs. 82.6%

Bibliography

Jacobs, J. V., Horak, F. B., et al. (2006). "An alternative clinical postural stability test for patients with Parkinson's disease." J Neurol 253(11): 1404-1413. Find it on PubMed

Valkovic, P., Brozova, H., et al. (2008). "Push-and-release test predicts Parkinson fallers and nonfallers better than the pull test: comparison in OFF and ON medication states." Mov Disord 23(10): 1453-1457. Find it on PubMed

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