Systematic Review

The short physical performance battery as a

predictor for long term disability or
institutionalization in the community dwelling
population aged 65 years old or older
Justina Gawel, Danika Vengrow, Jenna Collins, Sarah Brown, Alice Buchanan,
Chad Cook
Walsh University, OH, USA

Background: The short physical performance battery (SPPB) is a physical performance measure that has
been used to predict long term disability and/or future institutionalization in adults aged 65 years old or
older. The test involves three dedicated physical performance activities, scored from 0 to 4, with a
summated score of 12. Higher scores reflect higher levels of function.
Objectives: The purpose of this systematic literature review was to investigate the ability of the SPPB to
predict long term disability or future institutionalization in community dwellers aged 65 years old or older
living in the United States.
Methods: This review used the search engines PubMed, CINAHL, and the Cochrane Library, and
investigated all articles that studied the SPPB as a predictor of either long term disability or future
institutionalization. Studies were included if each incorporated the SPPB, involved a community dwelling
population, was written in English, was a longitudinal trial, and reported on functional decline or disability,
or institutionalization. Qualitative scoring was assessed using the Newcastle–Ottawa Scale (NOS); each
study was scored in three categories: selection, comparability, and outcome.
Results: Five articles met the inclusion criteria for this study, of the five, three evaluated the capability of the
SPPB to predict long term disability and two used the SPPB to predict institutionalization. Studies found that
a baseline score of 4–6 on the SPPB indicated that the individual had a 2.9–4.9 increase in risk of
developing a future disability, and a score of 7–9 on the SPPB found a 1.6–2.1 relative risk of developing a
future disability. A baseline score of 10–12 on the SPPB was predictive of no future disability. Lower SPPB
scores were related to increased odds of institutionalization and increased functional decline/disability. The
NOS scores of the included trials ranged from two to three stars for each category demonstrating moderate
to good quality.
Conclusion: Of the investigated studies on the subject, it can be concluded that the SPPB is a predictor of
long term disability or institutionalization in US community dwellers aged 65 years old or older.
Keywords: Disability, Institutionalization, Newcastle–Ottawa quality assessment score, Short physical performance battery, Systematic reviews

Introduction adults who are at risk for developing disability and

As the ‘Baby Boomers’ in the United States continue who may require healthcare intervention.1 As a
to tread toward older age, they become increasingly result, it is necessary to predict the risk for hospital
at risk for diminishing health and declining function, admission by utilizing measures that identify clinical
which can ultimately affect their independence and risk indicators.1,5–9 In addition, objective physical
survival.1,2 Because healthcare costs are continuing to performance measures that involve performing a
rise and the general population is living longer there movement or task according to a standardized
is a growing need to predict and prevent future protocol have been developed to identify at-risk
functional decline.1–4 Useful tools, such as functional older adults in the mild to moderate range of physical
status screenings, were developed to identify older disability.2
The International Classification of Functioning,
Disability, and Health (ICF) has developed a
Correspondence to: Ms J Gawel, Walsh University, OH, USA. Email:
[email protected] standard language and structure for the depiction of

ß W. S. Maney & Son Ltd 2012

DOI 10.1179/1743288X11Y.0000000050 Physical Therapy Reviews 2012 VOL . 17 NO . 1 37
Gawel et al. Short physical performance battery for long term disability or institutionalization

health and health-related conditions.10 Accordingly, Objective and/or subjective self-report measures
the ICF strives to classify health and health-related can be useful in assessing physical abilities, pain,
conditions to define body function and structure functional ability, psychosocial well-being, general
changes, and define what a person with a health health status, and quality of life.11 Both self-
condition can do in a typical environment.10 In the reported and performance-based functional status
ICF, the terms functioning and disability are defined measures predict outcomes such as functional status
separately; the term functioning refers to all body decline, nursing home placement, and mortality.3,11
functions, activities, and participation, whereas dis- Self-reported functional assessment tools are useful
ability is the general term for impairments, which since these are quick to administer and cost effec-
includes activity limitations affecting restrictions in tive; however, these tools may suffer from inaccura-
community participation and personal limitations.10 cies because a person may over- or underestimate
In addition, disability is defined through decline in their capabilities, fail to report a change, or report a
basic activities of daily living (ADLs).2,3,10,11 Activities perceived level of function based on expectations
of daily living include self-care (e.g. bathing, dressing, rather than actual capacity.3 Physical performance
transfers, grooming, toileting, etc.), instrumental (e.g. measures are less inclined to suffer these inaccura-
using the telephone, preparing meals, managing cies, which has led to increased validation of these
household finances, etc.), and mobility (e.g. walking forms of measures.3 Validation of the tools includes
from room to room, climbing stairs, etc.).3,10 Institu- standardization of scoring and assessment of
tionalization is defined as admission into a structured response to an intervention.3,13,14 Physical perfor-
inpatient professional health care facility (e.g. skilled mance tests also facilitate compliance with the
nursing facility, long term acute care, etc.).3,10 Finally, protocols within professional organizations, govern-
long term disability can be defined as difficulty with a ment agencies, and insurer groups.15 Through the
task or needing help with a task where a person did not use of physical performance based measures, the
need help before.10 clinician can be trained to efficiently identify
Standardized tests that assess physical function, community-dwelling older adults in the US who
disabilities, or need for institutionalization are impor- may be at risk for developing long term disabilities
tant for clinicians for predicting future disability and ultimately determine if institutionalization is
in older individuals.1–4,11,12 Additional benefits to necessary.11
utilizing performance measures include ideas for Objective physical performance measures that
active treatments that are targeted toward the involve performing a movement or task according
identified impairments.1 Performance measures also to a standardized protocol have been developed to
aid in making judgments on the patient’s perfor- identify at-risk older adults in the mild to moderate
mance potential4 and can be used as convenient range of physical disability.2 The short physical
universal indicators for health-related risk in older performance battery (SPPB) (Table 1) is a valid
adults.1 physical performance based test that has gained
Table 1 Description and scoring of the short physical performance battery

Test Instructions Scoring

Repeated chair stands The patient is instructed to stand up from The process is a timed event. They are scored
a chair five times without using their arms as as follows:
quickly as they can. The arms are folded 05unable
across the chest and the clinician may provide 1>16.7 seconds
a visual example. 2516.6–13.7 seconds
3513.6–11.2 seconds
4(11.1 seconds
Balance testing There are two test positions. During the first, the For both positions the scoring is as follows:
patient is instructed to begin in a semitandem 25Held for 10 seconds
stance (heel placed by the big toe of the 15Held for less than 10 seconds
opposite foot). If patients are able to hold 05not attempted
this position they are instructed to assume The two scores are summed together.
the full tandem position. During the second the
patients are instructed to stand with their feet
together. Patients are allowed at first to hold on
to the clinician to gather their balance.
Eight foot walk (2.44 m) Patients are allowed to use a cane or other walking This is a timed event. They are scored
device. They are instructed to walk at their usual pace as follows:
through a marked course of greater than 2.44 m. 05could not do
The 2.44 m should be identified for the clinician. 1>5.7 seconds
254.1 to 5.6 seconds
353.2 to 4.0 seconds
4(3.1 seconds

38 Physical Therapy Reviews 2012 VOL . 17 NO . 1

 Gawel et al. Short physical performance battery for long term disability or institutionalization

popularity for assessing lower extremity function in Community dwellers, (4) English, (5) Humans, (6)
older adults.16,17 The SPPB has gained further 65 years old or older, (7) longitudinal studies, (8)
support in the clinical setting because of its high disability, (9) functional decline, or (10) institutiona-
inter-observer (intraclass correlation coefficient [ICC] lization. Two investigators (JG and DV) indepen-
.0.9) and test–retest reliability (ICC50.72).1,18 The dently reviewed titles and abstracts to determine
SPPB addresses the aforementioned skills to include a eligibility for inclusion. Full articles were obtained for
hierarchical test of standing balance, gait speed, and the identified titles and those which met the selection
repetitive chair stands to categorize older individuals criteria were included. Differences of opinion of the
at risk for falls, deconditioning, or other serious health two investigators about study eligibility were resolved
issues.2 Four-point scales are used for each test and a by discussion with a third author (SB). Reviewers
summary score ranges from 0 to 12.1 Higher score were not blind to author(s), institution(s), or journal.
reflect higher levels of function. Types of participants
The purpose of this systematic review was to For eligibility, subjects were required to be commu-
investigate the utility of the SPPB for predicting long nity-dwelling men and women in the US with an
term disability or future institutionalization in US average age of 65 years old or older at the baseline
community dwellers, aged 65 years old or older. This of the longitudinal assessment. In addition, various
review is beneficial to physicians, physical therapists, demographic elements such as medical history, pre-
policy makers, and insurance companies because the scription and non-prescription drug use, health
SPPB is safely and quickly administered and is cost behaviors, and functional statuses were required for
effective.1,3,11 baseline measures.
Methods Types of interventions and outcomes
Types of studies There were no specific interventions required for each
Prospective longitudinal cohort studies were included study. Studies were included in the review if each used
and there were no date restrictions to ensure com- the SPPB during baseline assessment. Outcome
pleteness of the information available. Studies were measures included data collected for the following:
included if graded as ‘fair’ or higher the hierarchy of prediction of disability, functional decline, and
evidence.19 According to Evans, the purpose of the institutionalization. Functional status has been char-
hierarchy is to rank evidence on three dimensions: acterized through use of measures of physical
effectiveness, appropriateness, and feasibility.19 performance. In addition, low scores on outcome
measures from baseline findings indicated disability
Search strategy and selection criteria or a progression to functional decline. Finally,
This study used the search engines PubMed, institutionalization was documented if the subject
CINAHL, and the Cochrane Library. The Preferred was admitted during the study.
Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) guidelines were implemented to Data extraction
outline and write this systematic review. The Information about the method (i.e. design, partici-
PRISMA statement consists of a 27 item checklist, pants, intervention, and outcome measures) and
providing a framework for the development of results (i.e. sample size, incidence rates and number
systematic reviews and meta-analyses.20 The aims of of events) were extracted.
PRISMA are to minimize the risk of faulty reporting Quality and quality assessment
of systematic reviews and improve the clarity and Quality was assessed for each study by two reviewers
transparency in how reviews are composed.20 independently (JG and JC), using the Newcastle–
Searches were performed without any date restric- Ottawa Scale (NOS) for cohort studies. Discrepancies
tions using the following MeSH keywords: geriatric were resolved using open discussion and consensus.
assessment, nursing homes, outcome and process The NOS was developed to assess the quality of
assessment (health care), female, male, task perfor- nonrandomized studies.21 The face/content validity
mance and analysis, lower extremity, disability and inter-rater reliability of the NOS was evaluated
evaluation and independent living. A hand search by experts in the field and was established,21 and
was conducted using the following key words: geria- criterion validity, construct validity, and intra-rater
tric assessment, SPPB, nursing home admission, reliability are yet to be determined.21 At present, the
lower extremity, hospitalization and institution. use of quality scoring scales in observational studies
Experts within the field were contacted in person is controversial and the NOS is the only available tool
or by email to query for additional articles. Only to evaluate these forms of design.22,23 This scale
articles that were written in English were included. consists of three categories: selection, comparability,
Studies were included when they contained any of and outcome; each is comprised of sub-categories
the following: (1) SPPB, (2) United States, (3) defined as numbered items.21 For each numbered

Physical Therapy Reviews 2012 VOL . 17 NO . 1 39

40
Gawel et al.

Physical Therapy Reviews

Table 2 Short physical performance battery as a predictor of disability

2012
Author Participants Intervention(s) Comparison Outcome Design Quality score
24
Huang et al. Community dwellers Short physical performance Baseline to 6 months, Berg Balance Scale was the most Prospective longitudinal Selectionww

VOL .
in the United States battery (SPPB) 12 months, and consistent and strongest predictor cohort study

17
aged 65 years old Berg balance scale 18 months of ADL difficulty over 18 months. Comparabilityww
or older Timed up and go SPPB was the best predictor of Outcomeww
Gait speed onset of ADL difficulty at 12 months

NO .
1
Grip strength 0.739 on 95% CI (0.53–1.03). SPPB
predicted self-reported disability,
nursing home admission and mortality.
Guralnik et al.16 Community dwellers Short physical performance Baseline SPPB A baseline score of 4–6 on the SPPB Prospective longitudinal Selectionwww
in the United States battery (SPPB) score to SPPB is 4.2–4.9 RR more likely to predict cohort study
aged 65 years old score 4 years later disability 4 years later.
or older A baseline score of 7–9 on the SPPB Comparabilityww
is 1.6–1.8 RR more likely to predict Outcomeww
disability 4 years later.
Guralnik et al.25 Community dwellers Short physical performance The relative predictive The SPPB has a decline in risk of Prospective longitudinal Selectionww
in the United States aged battery (SPPB) ability of gait speed to disability with increasing performance. cohort study
Short physical performance battery for long term disability or institutionalization

65 years old or older the SPPB for disability A baseline SPPB score of 4–6 had
Gait speed Baseline to 4 year a 2.9–4.9 RR of disability. A baseline Comparabilityww
follow-up SPPB score of 7–9 had a 1.9–2.1 Outcomeww
RR of disability.
Findings indicate that gait speed
alone is nearly as good a predictor of
disability outcomes as the SPPB.

Note: A maximum of four stars can be allocated to selection, two stars for comparability and three stars for outcome categories. RR5relative risk; CI5confidence interval.
 Gawel et al. Short physical performance battery for long term disability or institutionalization

item under the selection and outcome categories, only

Comparabilityww

Comparabilityww
one star can be awarded. In the comparability

Prospective longitudinal Selectionwww

Prospective longitudinal Selectionwww

Quality Score

Outcomeww

Outcomeww
category, two stars can be awarded for the numbered
item. Finally, the NOS scores on the included trials
ranged from two to three stars for each category (See
Tables 2 and 3).21

Results
The MeSH term searches produced 844 articles on
December 7, 2010. Ten extra studies were identified
cohort study

cohort study
through contacting experts in the field or through a
Design

hand search. A total of 854 articles were found after

duplicates were removed. Of the abstracts identified,
a total of five studies were appropriate for inclusion
score has a 12% relative decrease in the risk of
and hospitalization. A score of 5 or less on the

Each one point increase in the baseline SPPB

disability and future nursing home admission

death, a 21% decrease in the risk of nursing

SPPB led to a 3.4 RR in males and a 2.8 RR

(see Fig. 1). All articles included were published in

home placement, and a 5% decrease in the
The SPPB is a strong indicator in predicting

peer reviewed journals with publication dates ranging

from 1994 to 2010. Characteristics of the included
trials are further described in Table 2 and 3.
All of the articles selected for inclusion included
the SPPB as an assessment tool; three articles looked
in females on a 95% CI.

at the SPPB and its ability to predict disablility.16,24,25

Note: A maximum of four stars can be allocated to selection, two stars for comparability and three stars for outcome categories.
risk of hospitalization

In all three instances, the SPPB was found to be a

strong predictor of disability in the 65 years old or
older population.16,24,25 Two of the studies had a
Outcome

4 year follow-up while the third had follow-ups at 6,

12, and 18 months.16,24,25 Studies by Guralnik et al.
showed that a baseline score of 4–6 on the SPPB
in function and predicting mortality
SBBP to the self-reported physical

indicated that the individual had a 2.9–4.9 increase in

Community dwellers Short physical performance Baseline SPPB score to the SPPB
score of the 36 month follow-up

risk of developing a future disability.16,25 When the

predicting adverse outcomes

and nursing home admission

functioning survey looking at

baseline score was 7–9 on the SPPB, one study by

Guralnik et al. found a 1.9–2.1 relative risk of future
disability25 whereas another study16 reported a 1.6–
Table 3 Short physical performance battery as a predictor of institutionalization

1.8 relative risk of developing a future disability.16 A

Comparison

baseline score of 10–12 on the SPPB was predictive of

no future disability.16 The study by Huang et al.
compared the SPPB (0.74 odds ratio on a 95%
confidence interval of 0.53–1.03) to gait speed (0.57
Guralnik et al.27 Community dwellers Short physical performance

odds ratio on a 95% confidence interval of 0.02–16.0)

at the 12 month follow-up.24 In both tools, the
confidence interval crossed one, therefore, a larger
sample size to fully explain the precision of the
in the United States battery (SPPB)

in the United States battery (SPPB)

instrument is needed.
Intervention

Gait speed

The remaining two studies investigated the SPPB

and its predictability of institutionalization.26,27 Both
studies indicated that the SPPB was a strong predictor
RR5relative risk; CI5confidence interval

of nursing home admission and hospitalization.26,27

aged 65 years old

aged 65 years old

Additionally, results concluded that the SPPB is a

good predictor of institutionalization or disability in
Participants

US community dwelling patients aged 65 years old

or older

or older

or older.26,27 A study by Guralnik et al. showed that

a score of 5 or less on the SPPB led to a 3.4 relative
risk in males and a 2.8 relative risk in females with
a 95% confidence interval.27 Moreover, the study by
Miller et al.26

Miller et al. determined that each one point increase

Author

in the baseline SPPB score has a 12% relative

decrease in the risk of death, 21% decrease in the

Physical Therapy Reviews 2012 VOL . 17 NO . 1 41

Gawel et al. Short physical performance battery for long term disability or institutionalization

Figure 1 PRISMA flow diagram.

risk of nursing home placement, and a 5% decrease Physical performance measures are less influenced
in the risk of hospitalization.26 by pain and depression than self-report measures of
function and more inclined to truly reflect capacity.28
Discussion In addition, because the SPPB is a battery of physical
The purpose of this review was to explore the performance measures, it is more inclined to capture
literature on the ability of the SPPB to predict long the wide contextual elements associated with dis-
term disability or institutionalization in community ability or function.29 In addition to walking speed30
dwelling adults aged 65 years old or older in the US. which is not considered a test battery, two other
It is important for practicing clinicians to reliably physical performance batteries, the Tinetti test and
predict the chances of progression of a dedicated the seven item physical performance test, have also
condition.3,11,25,27 Physical performance measures been shown to predict nursing home placement or
such as the SPPB are economical measures (low hospitalization.31,32
burden) that can likely be implemented in a number The SPPB is a battery that consists of standing
of clinical or community settings. Assessing only balance, gait speed, and repetitive chair stands, all
three different physical performance tests: (1) which require advanced sequential movements or
repeated chair stands, (2) balance testing, and (3) an activities that require strength, balance, dexterity,
eight foot walk appear to predict an individual’s risk and cognitive control.16,17 Individually, the indepen-
for institutionalization or functional disability.2 dent components may be able to identify specific

42 Physical Therapy Reviews 2012 VOL . 17 NO . 1

 Gawel et al. Short physical performance battery for long term disability or institutionalization

2 Ostir GV, Yong-Fang K, Berges IM, Markides KS,

impairments, may be able to measure the effect of an Ottenbacher KJ. Measures of lower body function and risk of
intervention, can be used to assist in goal setting, and mortality over seven years of follow-up. Am J Epidemiol
can be incorporated to motivate patients.11,13,14 In a 2007;166:599–605.
3 Reuben DB, Seeman TE, Keeler E, Hayes RP, Bowman L,
clinical setting, the SPPB has been used to select Sewall A, et al. Refining the categorization of physical
individuals at risk for disability.33 Evidence exists functional status: the added value of combining self-reported
and performance-based measures. J Gerontol 2004;59:1056–61.
that supports the use of interventions such as 4 Moradi B, Benedetti J, Zahlten-Hinguranage A, Schitenwolf
strengthening and aerobic exercise from a discipline M, Neubauer E. The value of physical performance tests for
predicting therapy outcome in patients with subacute low back
such as physical therapy as a mechanism to reduce pain: a prospective cohort study. Eur Spine J 2009;18:1041–49.
disability or retard the progressive effects associated 5 Hall WJ. Update in geriatrics. Ann Intern Med 1996;125:390–7.
6 Reuben DB, Siu A, Kimpau S. The predictive validity of self-
with aging.33–36 report and performance based measures of function and health.
One last potential benefit of the use of the SPPB is J Gerontol 1993;47:M106–10.
as an established baseline measure of yearly function. 7 Williams ME. Identifying the older person likely to require long
term care services. J Am Geriatr Soc 1987;35:761–6.
A SPPB could be incorporated into a yearly physical 8 Gill TM, Williams CS, Tinetti ME. Assessing risk for the onset
examination for individuals over the age of 65 or used of functional dependence among older adults: The role of
physical performance. J Am Geriatr Soc 1995;43:603–9.
by physical therapists as an assessment of current and 9 Guralnik JM, Branch LG, Cummings SR, Curb JD. Physical
future disability.2,3,11,12 The information yielded by performance measures in aging research. J Gerontol
1989;44:M141–6.
the SPPB can aid the clinician in making evidence- 10 Towards a common language for functioning, disability and
based clinical decisions which may ultimately result in health: ICF.World Health Organization: Geneva; 2002.
11 Misailidou V, Maiiious P, Beneka A, Karagiannidis A,
enhanced patient care.1,11,28 Godolias G. Assessment of patients with neck pain: a review
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There are several important limitations in this 12 Kay TM, Myers AM, Huijbregts MPJ. How far have we come
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letal medicine. Man Ther 1997;2:67–74.
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16 Guralnik JM, Ferrucci L, Simonsick EM, Salive ME, Wallace
ability to conclude that an older individual will be RB. Lower-extremity function in persons over the age of
disabled or require instutionalization.16,24–27 In each 70 years as a predictor of subsequent disability. N Engl J Med
1995;332:556–62.
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24 Huang WW, Perera S, VanSwearingen J, Studenski S.
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