Tinetti gait & balance evaluation

An assessment of gait & balance that gives a numerical score. Procedure: The components are: 1) Tinetti balance evaluation (16 points) 2) Tinetti gait evaluation (12 points) A total of 28 points. A score of < 20 generally associated with significant risk of falls. Tinetti balance evaluation The patient is seated in a hard, armless chair. The following maneuvers are tested. 1) sitting balance [0 or 1 point] - 0: leans or slides in chair - 1: steady, safe 2) arise [0-4 points] - 0: unable without help - 1: able, but uses arms to help - 1: able, but requires more than 1 attempt - 2: able without use of arms - 2: able to arise with 1 attempt 3) immediate standing balance (1st 5 seconds) [0-2 points] - 0: unsteady (staggers, moves feet), marked trunk sway - 1: steady, but uses walker or cane or grabs other objects for support - 2: steady without walker or cane or other support 4) standing balance [0-2 points] - 0: unsteady - 1: steady, but wide stance (heels > 4 inches apart) or uses cane or other support - 2: narrow stance without support 5) nudge (subject stands with feet as close together as possible), examiner pushes lightly on patient's sternum with palm of hand 3 times [0-2 points] - 0: begins to fall - 1: staggers, grabs, but catches self - 2: steady 6) eyes closed (same position as in #6) [0 or 1 point] - 0: unsteady - 1: steady 7) turn 360 degrees [0-2 points] - 0: discontinuous steps - 1: continuous - 0: unsteady (grabs, staggers) - 1: steady 1 8) sit down [0-2 points] - 0: unsafe, misjudged distance, falls into chair - 1: uses arms or not a smooth motion - 2: safe, smooth motion Maximum of 16 points. Tinetti gait evaluation The patient stands with the examiner, walks down the hallway or across the room (about 25 feet) at his/her 'usual' pace, then back at a 'rapid but safe' pace. 1) initiation of gait (immediately after told to 'go') - 0: any hesitancy or multiple attempts to start - 1: no hesitancy 2) step length & height a) right swing foot - 0: does not pass left stance foot with step - 1: passes left stance foot with step - 0: right foot does not clear floor completely with step - 1: right foot completely clears floor b) left swing foot - 0: does not pass right stance foot with step - 1: passes right stance foot with step - 0: left foot does not clear floor completely with step - 1: left foot completely clears floor 3) step symmetry - 0: right & left step length unequal - 1: right & left step length appear equal 4) step continuity - 0: stopping or discontinuity between steps - 1: steps appear continuous 5) path (observe excursion of 1 foot over about 10 feet) - 0: marked deviation - 1: mild/moderate deviation or uses walking aid - 2: straight walking without walking aid 6) trunk - 0: marked sway or uses walking aid - 1: no sway but flexion of knees or back or spreads arms out while walking - 2: no sway, flexion, abnormal arm spread or walking aid 7) walk stance: - 0: heels apart - 1: heels almost touching while walking Maximum of 12 points.

Related

falls in the elderly Tinetti, Mary

General

balance evaluation gait evaluation numerical rating scale (NRS)

References

Sepulveda GRECC guidelines