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  2. Tinetti Performance Oriented Mobility Assessment

Tinetti Performance Oriented Mobility Assessment

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Purpose

To measures an older adult’s gait and balance abilities. Designed to measure balance (including fall risk) and gait function in elderly, but has also been used for patients with various other conditions.

Acronym POMA; TMT (Tinetti Mobility Test) identified as alternative name by Kegelmeyer et al, 2007

Area of Assessment

Balance – Vestibular
Balance – Non-vestibular
Gait

Assessment Type

Performance Measure

Cost

Free

Diagnosis/Conditions

  • Pain Management
  • Parkinson's Disease & Neurologic Rehabilitation
  • Stroke Recovery

Populations

Stroke
Older Adults and Geriatric Care
Non-Specific Patient Population
Amyotrophic Lateral Sclerosis

Key Descriptions

  • Tinetti aimed to develop a measure to screen older adults for balance and gait impairments that was feasible for use (i.e., required no equipment and no training to master), was reliable and sensitive to significant changes, and reflected position changes and gait maneuvers used during daily activities.

    Various versions of the POMA exist, with variations for both the name of the test and means of scoring; this review focuses on the 16 item, 28-point version of the POMA (see Compendium of Instructions for the POMA form).

    Total POMA consists of 16 items: 9 balance (POMA-B) and 7 gait (POMA-G) items.

    3 point ordinal scale, ranging from 0-2, where highest score indicates independence with each test item.

    The majority of the research on the POMA has been done on older adults.

Number of Items

16

Equipment Required

  • Hard, armless chair
  • Stopwatch or wristwatch
  • 15 ft (4.57 meter) walkway

Time to Administer

10-15  minutes

Required Training

No Training

Instrument Reviewers

Initially reviewed by Kirsten Potter, PT, DPT, MS, NCS and the MS EDGE task force of the Neurology Section of the APTA in 5/2011; Updated with references for the PD population by Erin Hussey, DPT, MS, NCS and the PD EDGE task force of the Neurology Section of the APTA in 2013.

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 (VEDGE) 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 for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post) 

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

StrokEDGE

UR

UR

UR

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage: 

 

I

II

III

IV

V

PD EDGE

LS/UR

R

R

R

NR

 

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

UR

UR

UR

UR

StrokEDGE

UR

UR

UR

UR

UR

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

UR

UR

NR

 

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)

MS EDGE

No

No

No

Yes

PD EDGE

No

No

No

Not reported

StrokEDGE

No

No

Yes

Not reported

Considerations

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

Older Adults and Geriatric Care

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Minimal Detectable Change (MDC)

Older adults: (Faber et al, 2006; n = 245 subjects residing in long term self care and nursing are residences; mean age = 84.9(6.0) years)

  • For individual assessments (Rater 1; Rater 2), MDC = 4.2; 4.0
  • For group assessments (Rater 1; Rater 2), MDC = 0.8; 0.7

Cut-Off Scores

Older adults:  

(Harada et al, 2005; n = 53 elderly individuals residing in two residential care facilitators for the elderly, including 25% with neurological conditions)

  • Cutoff score for POMA-B = 14

Older Adults: 

(Sterke et al, 2010; a clinical review of the Tinetti POMA)

  • Cutoff score for POMA-T = 21
  • Cutoff score for POMA-B = 11

Older adults:

(Faber et al, 2006)

  • Cutoff score = 19
  • Cutoff score for POMA-B = 10

Frail elders: (Thomas et al, 2005; n = 30 day hospital patients: 18 fallers, 12 non fallers; mean age for fallers = 79.7(6.7) years; mean age for non-fallers = 81.4(6.7) years)

  • Cutoff score = 11

Normative Data

Older adults:

(Ko et al, 2009; n = 1000 Korean elderly evaluated with ABC, POMA, ADL, and IADL)

  • Mean POMA score for males aged 65-79 years = 26.21(3.40)
  • Mean POMA score for females age 65-79 years = 25.16(4.30)
  • Mean POMA score for males over 80 years = 23.29(6.02)
  • Mean POMA score for females over 80 years = 17.20(8.32)

Older adults:

(Baloh et al, 2003; n = 59 normal older subjects followed up at yearly examinations for 8 to 10 years; mean age = 78.5(3.7) years)

  • Mean Tinetti score at entry into the study = 27.5(0.65)
  • Scores decreased annually and significantly by a mean of 0.50(0.40)

Test/Retest Reliability

Older adults:

(Faber et al, 2006)

  • Excellent test-retest reliability for POMA B and POMA-G (ICC = 0.72-0.86

Older adults:

(van Iersel et al, 2007; n = 39 people with dementia; mean age = 78.3; n = 46 people without dementia; mean age = 73.8; MMSE = 19.1(5.2))

  • Excellent test-retest reliability (ICC = 0.96)

Interrater/Intrarater Reliability

Frail elders:

(Thomas et al, 2005)

  • Excellent intrarater reliability for frail elders, including 38.8% with stroke and 24.9% with PD (ICC = 0.84)

Criterion Validity (Predictive/Concurrent)

Community-dwelling older adults: 

(Lin et al, 2004; n = 1200 people aged 65 and older residing in rural villages in Shin-Sher Township, located in Taichung County in west-central Taiwan)

  • Adequate correlation between POMA-B and Timed Up and Go (r = -0.55)
  • Adequate correlation between POMA-B and Functional Reach (r = 0.48)
  • Adequate correlation between POMA-B and walking speed (r = -0.54)
  • Excellent correlation between POMA-B and Older Adults Resources and Services ADL scale (r = 0.60) 
  • Excellent correlation between POMA-B and Tinnetti gait (r = 0.81) 

Older adults: 

(Ko et al, 2009; n = 1000 Korean elderly evaluated with ABC, POMA, ADL, and IADL)

  • Excellent correlation between POMA, POMA-B, POMA-G and the Activities Specific Balance Confidence Scores (r = 0.689-0.736)

Floor/Ceiling Effects

Older adults:

(Faber et al, 2006)

  • Poor ceiling effect for POMA-G (21.2%)

Older adults:

(Faber et al, 2006)

  • No floor effects

Responsiveness

Older Adults:

(Harada et al, 2005)

  • Sensitivity = 68%
  • Specificity = 78% 

(Sterke et al, 2010)

  • Sensitivity for POMA-Total = 85%
  • Specificity for POMA-Total = 56%
  • Sensitivity for POMA-B = 70%
  • Specificity for POMA-B = 51%

(Faber et al, 2006)

  • Sensitivity = 64%
  • Specificity = 66.1%
  • Sensitivity for POMA-B = 64%
  • Specificity for POMA-B = 66.1%

Frail Elders:

(Thomas et al, 2005)

  • Sensitivity = 83%
  • Specificity = 72%

Stroke

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Minimal Detectable Change (MDC)

Stroke: (Canbek, et al, 2013; n=55 adults admitted to inpatient rehab with first-time stroke; mean age 75(11) years)

  • MDC = 6 points

Cut-Off Scores

Chronic Stroke:

(Soyuer et al, 2007; n = people with chronic stroke, 53 non fallers, 36 one-time fallers, and 11 repeat fallers)

  • Cutoff  score < 20

Test/Retest Reliability

Stroke: 

(Daly et al, 2006; n = 32 subjects (> 1 year after stroke); Group 1, FNS-IM, mean age = 57.7(11.9) years; Group 2, NO-FN2, mean age = 63.6(10.4) years)

  • Excellent test-retest reliability for POMA-G (ICC = 0.91)

Stroke:

(Canbek, et al, 2013; n=55 adults admitted to inpatient rehab with first-time stroke; mean age 75(11) years)

  • Excellent test-retest reliability for POMA (ICC = 0.84)

Criterion Validity (Predictive/Concurrent)

Stroke: 

(Canbek, et al, 2013; n=55 adults admitted to inpatient rehab with first-time stroke; mean age 75(11) years) 

  • Adequate correlation between POMA and the motor domain of the FIM (r = 0.55) 
  • Strong correlation between POMA and gait speed (r = 0.82) 

(Corriveau et al, 2004; n =30 older adults, 15 post stroke and 15 healthy age-matched-adults; mean age for post stroke = 71.8(6.92) years; mean age for healthy = 71.5(6.5) years) 

  • Adequate correlation between POMA and COP-COM for AP direction (-0.58)
  • Adequate correlation between POMA and COP-COM for ML direction (-0.57)

Responsiveness

Chronic Stroke: 

(Soyuer et al, 2007) 

  • Sensitivity = 66% 
  • Specificity = 79.2%

Parkinson's Disease

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Cut-Off Scores

Parkinson’s Disease:

(Kegelmeyer et al, 2007; Parts 1-3, n =30 with PD; mean age 65(10.9) years; HY = 2.41(0.39); Data from parts 1-3 used to establish reliability and concurrent validity; Part 4, n = 156 with PD; mean age = 68.2(11.04) years; HY = 2.5(range 1-4); Part 4 data used to establish concurrent criterion-related validity); all subjects with MMSE > 23/30)

  • Cutoff score < 20 (AUC 72%, Sensitivity 76%, Specificity 66%). 

(Contreras & Grandas, 2012): n = 160 with PD (72 men, 88 women); Mean age 72 (9.5); 62 (38.8%) reported 1 fall since onset of PD and 42 of those (68% of fallers) reported recurrent falls of varying frequency. Mean age at first fall = 70.7 (9.6) years; Mean disease duration at first fall = 7.2 (6) years. Hoehn & Yahr mean = 2.6 (1.0) - stage 1 n = 21, stage 2 n = 63, stage 3 n = 44, stage 4 n = 23, stage 5 n = 9)

  • Cutoff score for Tinetti Total = 17.5
    • Adequate ability to detect fallers: AUC = 0.81, SN = 0.60, SP = 0.86, Accuracy = 52%.
  • Adequate Cutoff score for Tinetti-Balance = 11.5/16 
    • AUC = 0.81 SN = 0.71, SP = 0.79, Accuracy = 76%
  • Adequate cutoff score for Tinetti-Gait = 10.5/12 
    • AUC = 0.77, SN = 0.71, SP = 0.74, Accuracy = 76%

Normative Data

Parkinson Disease:

(Contreras & Grandas, 2012) 

Test

All (n = 160)

Nonfallers (n = 98)

Fallers (n = 62)

P value

Tinetti Balance (16) 

10.9 (5.7) 

13.4 (3.9) 

7.1 (6.0) 

p < 0.001 

Tinetti Gait (12) 

8.6 (4,6) 

10.3 (3.2) 

5.8 (5.2) 

p < 0.001 

Tinetti Total (28) 

19.5 (10.2) 

23.7 (7.0) 

12.9 (11.0) 

p < 0.001 

Interrater/Intrarater Reliability

Parkinson's Disease:

(Kegelmeyer et al, 2007)

  • Excellent interrater reliability 5 raters (ICC = 0.87; 95% CI = 0.8-0.93)
    • Excellent interrater reliability with experienced raters (n = 2; ICC = 0.84; 95% CI = 0.69-0.92)
    • Excellent interrater reliability with student raters (n = 3; ICC = 0.89; 95% CI = 0.8-0.94) 

(Behrman et al, 2002; n = 20 community-dwelling; 10 control without PD (mean age 73.4 (4.24) (community dwelling, 10 w/ idiopathic PD (6 male) (mean age 73.4(4.30); Disease duration 11.2 (6.4) years; Hoehn &Yahr stage 2: n = 3, 3: n = 6 4:n = 1 person, 10 control age and gender-matched (mean age 73.4(4.24) yrs; 6 male, 4 female); min score of 24 on MMSE required)

  • Excellent intrarater reliability for older adults with and without PD using the Tinetti-Gait (r = 0.95)

Criterion Validity (Predictive/Concurrent)

Parkinson’s Disease:

(Kegelmeyer et al, 2007)

  • Adequate Correlation Tinetti and UPDRS 
  • Adequate Correlation Tinetti and Comfortable gait speed 

Tinetti Test component 

UPDRS 

(p < 0.05) 

Comfortable gait speed (p < 0.01) 

Tinetti – Balance & Gait 

r = - 0.45 

r = 0.53 

Tinetti - Balance 

r = -0.40 

r= 0.52 

Tinetti – Gait 

r = -0.43 

r = 0.50 

(Gray et al, 2009; Retrospective correlation design. N = 109 with idiopathic PD (52 men, 57 women); Mean age 74.7 (7.9); Duration since diagnosis 5.42 (5.56) years; HY mean 2.02 (0.73); UPDRS 34.1 (11.2); 46 (42.2%) had died at 7 years. Goal: assessment of potential predictors for mortality using Tinetti, UPDRS, 10 MWT, posture in standing, lying to sitting, sitting to standing, getting up from floor assessments, and time to ascend and descend 4 steps. 

  • Tinetti-POMA Balance 
    • Excellent correlation with total UPDRS (r = 0.646, p < 0.01) 
    • Excellent correlation with 10 meter walk test (r = 0.78, p < 0.01)
    • Excellent correlation with Tinetti-G (r = 0.75, p < 0.01)
  • Tinetti-POMA Gait 
    • Adequate correlation with total UPDRS (r = 0.567, p < 0.01) 
    • Adequate correlation with 10 m walk test (r = 0.439, p < 0.01) 
  • Cox regression analysis: Age, Sex, and Tinetti-B and Tinetti-G scores determined to be independent predictors of mortality. Tinetti Exp(B) = 1.30 (95% CI 1.14-1.49), Sex ExpB = 2.86 (95% CI = 1.52-5.41); Age-at-start Exp(B) = 1.07 (95% CI = 1.52-5.41) 

(Contreras & Grandas, 2012) 

  • With stepwise multivariate regression analysis, only Tinetti Balance was independently associated with falls (OR = 0.847, 95% CI =0.74-0.97, p = 0.017)

Floor/Ceiling Effects

Parkinson’s Disease:

(Kegelmeyer et al, 2007)

  • Floor effect exists for those in later Hoehn & Yahr stages (eg, stages 4 and 5)

(Behrman et al, 2002)

  • Tinetti Gait component showed ceiling effect with the mean of measures for all subjects and all gait cuing conditions within 20% of maximum score

Responsiveness

Parkinson’s Disease: 

(Kegelmeyer et al, 2007) 

  • Sensitivity = 76%
  • Specificity = 66%

(Behrman et al, 2002)

  • Reported that Tinetti Gait lacked responsiveness sensitivity to varied conditions involving targeted gait cues (speed, amplitude, cadence) with mean scores per condition from 10.4 to 11.0 (on 12-point scale). In contrast, motion analysis did detect differences across conditions.

Amyotrophic Lateral Sclerosis

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Interrater/Intrarater Reliability

Amyotrophic Lateral Sclerosis (ALS):

(Kloos et al, 2004; Phase 1, n = 21 subjects with stage III ALS; mean age = 62.81(14.20) years; Phase 2, n =22 subjects with stage III ALS; mean age 57.36(10.71) years)

  • Adequate to excellent intrarater reliability for 6 raters (kappa = 0.40-1.0)

Non-Specific Patient Population

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Criterion Validity (Predictive/Concurrent)

Possible normal pressure hydrocephalus: 

(Shore et al, 2005)

  • Excellent correlation between POMA-G and Functional Ambulatory Performance and gait velocity measured with a GAITRite Portable Walkway System for all subjects at baseline, subjects who would undergo shunt surgery, and post-shunt surgery (r = 0.67-0.82)
  • Adequate to excellent correlation beween POMA-G and gait velocity in subjects who had shunt surgery (r = 0.59)

Floor/Ceiling Effects

Possible normal pressure for hydrocephalus: 

(Shore et al, 2005)

  • Ceiling effect may exist for POMA-G

Bibliography

Baloh, R. W., Ying, S. H., et al. (2003). "A longitudinal study of gait and balance dysfunction in normal older people." Archives of Neurology 60(6): 835.

Behrman, A. L., Light, K. E., et al. (2002). "Sensitivity of the Tinetti Gait Assessment for detecting change in individuals with Parkinson’s disease." Clinical Rehabilitation 16(4): 399-405.

Canbek, J., Fulk, G., et. al. (2013). "Test-retest reliability and construct validity of the tinetti performance-oriented mobility assessment in people with stroke." Journal of Neurologic Physical Therapy, 37(1), 14-19.

Cipriany-Dacko, L. M., Innerst, D., et al. (1997). "Interrater reliability of the Tinetti Balance Scores in novice and experienced physical therapy clinicians." Archives of Physical Medicine and Rehabilitation 78(10): 1160-1164.  

Contreras, A. and Grandas, F. (2012). "Risk of falls in Parkinson's disease: a cross-sectional study of 160 patients." Parkinsons Dis 2012: 362572.

Corriveau, H., Hebert, R., et al. (2004). "Evaluation of postural stability in the elderly with stroke." Arch Phys Med Rehabil 85(7): 1095-1101.

Daly, J. J., Roenigk, K., et al. (2006). "A randomized controlled trial of functional neuromuscular stimulation in chronic stroke subjects." Stroke 37(1): 172-178.

Faber, M. J., Bosscher, R. J., et al. (2006). "Clinimetric properties of the performance-oriented mobility assessment." Phys Ther 86(7): 944-954.

Gray, W. K., Hildreth, A., et al. (2009). "Physical assessment as a predictor of mortality in people with Parkinson's disease: a study over 7 years." Mov Disord 24(13): 1934-1940.

Harada, N., Chiu, V., et al. (1995). "Screening for balance and mobility impairment in elderly individuals living in residential care facilities." Phys Ther 75(6): 462-469.

Kegelmeyer, D. A., Kloos, A. D., et al. (2007). "Reliability and validity of the Tinetti Mobility Test for individuals with Parkinson disease." Physical Therapy 87(10): 1369-1378.

Kloos, A. D., Bello-Haas, V. D., et al. (2004). "Interrater and intrarater reliability of the Tinetti Balance Test for individuals with amyotrophic lateral sclerosis." Journal of Neurologic Physical Therapy 28(1): 12.

Ko, Y. M., Park, W. B., et al. (2009). "Discrepancies between balance confidence and physical performance among community-dwelling Korean elders: a population-based study." International Psychogeriatrics 21(04): 738-747.

Köpke, S. and Meyer, G. (2006). "The Tinetti test." Zeitschrift fur Gerontologie und Geriatrie 39(4): 288-291.

Lin, M. R., Hwang, H. F., et al. (2004). "Psychometric comparisons of the timed up and go, one-leg stand, functional reach, and Tinetti balance measures in community-dwelling older people." Journal of the American Geriatrics Society 52(8): 1343-1348.

Mitchell, K. D. and Newton, R. A. (2006). "Performance-oriented mobility assessment (POMA) balance score indicates need for assistive device." Disabil Rehabil Assist Technol 1(3): 183-189.

Protas, E. J., Harris, C., et al. (2000). "Sensitivity of a clinical scale of balance and gait in frail nursing home residents." Disabil Rehabil 22(8): 372-378.

Shore, W. S., DeLateur, B. J., et al. (2005). "A comparison of gait assessment methods: Tinetti and GAITRite electronic walkway." Journal of the American Geriatrics Society 53(11): 2044-2045.

Soyuer, F. and Ozturk, A. (2007). "The effect of spasticity, sense and walking aids in falls of people after chronic stroke." Disabil Rehabil 29(9): 679-687.

Sterke, C. S., Huisman, S. L., et al. (2010). "Is the Tinetti Performance Oriented Mobility Assessment (POMA) a feasible and valid predictor of short-term fall risk in nursing home residents with dementia?" International Psychogeriatrics 22(2): 254.

Thomas, J. I. and Lane, J. V. (2005). "A pilot study to explore the predictive validity of 4 measures of falls risk in frail elderly patients." Archives of Physical Medicine and Rehabilitation 86(8): 1636-1640.

Tinetti, M. E. (1986). "Performance-oriented assessment of mobility problems in elderly patients." J Am Geriatr Soc 34(2): 119-126.

vaniersel, M., Benraad, C. M., et al. (2007). "Validity and reliability of quantitative gait analysis in geriatric patients with and without dementia." Journal of the American Geriatrics Society 55(4): 632-633.

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