Postural Reactions Test

Purpose

The Postural Reactions Test measures all postural reactions required for establishing and maintaining balance. The Postural Reactions Test measures equilibrium and righting reactions in sitting, and protective reactions in sitting and standing.

In-Depth Review

Purpose of the measure

The Postural Reactions Test measures all postural reactions required for establishing and maintaining balance. The Postural Reactions Test measures equilibrium and righting reactions in sitting, and protective reactions in sitting and standing (Sjoholm et al., 2018).

The Postural Reactions Test was developed from literature, clinical experience and in collaboration with patients and physiotherapists (Sjoholm et al., 2018).

Available versions

There is one version of the Postural Reactions Test.

Features of the measure

Items:

The Postural Reactions Test measures equilibrium and righting reactions in sitting, and protective reactions in sitting and standing. The four reactions can be assessed and scored independently of each other (Sjoholm et al., 2018).

Equilibrium reactions and righting reactions are assessed as the assessor leans the patient to the side, or the patient leans by themselves.

• Equilibrium reactions are observed as a movement of the opposite side arm and/or leg.
• Righting reactions are observed as a movement of the head to the opposite side.

Protective reactions are assessed as the assessor gives the patient a push to the side hard enough to move the centre of gravity outside the patients’ support area.

• Protective reactions while sitting are observed in the arm on the side toward which the patient is pushed.
• Protective reactions while standing are observed in the legs.

Scoring:

Equilibrium and righting reactions

• Score 0 = no reaction or an uncertain reaction is observed
• Score 1 = A definite reaction is observed.

Protective reactions – sitting

• Score 0 = No active reaction of the shoulder or arm to prevent a fall
• Score 1 = A slow movement to prevent a fall by putting out the hand or more than the hand, although balance might not be regained
• Score 2 = A fast movement to prevent a fall by putting out only the hand, and balance is regained by doing so.

Protective reactions – standing

• Score 0 = The patient does not take any steps with either leg before the assessor has to catch the patient to prevent a fall
• Score 1 = The patient takes more than one step to regain balance or takes only one step but does not regain balance, sot that the assessor has to catch the patient to prevent a fall
• Score 2 = The patient takes one step with the right or left leg and successfully regains balance.

If the assessor is uncertain whether there is a postural reaction, the lowest score (equal to ‘no reaction’) is given.

What to consider before beginning:

Sitting assessments can be performed while the patient is sitting on a bed or an examining table, with the hands in the lap and the feet either supported or unsupported. Leg crossing is not allowed.

Protective reactions in standing are more easily triggered if the patient is standing with the feet together.

Time:

The Postural Reactions Test takes 5-10 minutes to administer.

Training requirements:

No training requirements have been specified for the Postural Reactions Test.

The assessor must be prepared to prevent the patient from falling.

Equipment:

The Postural Reactions Test does not require specific equipment.

Client suitability

Can be used with:

Individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.
Individuals with limited verbal comprehension (Sjoholm et al., 2018).

Should not be used with:

None stated

Languages of the measure

Swedish
English

Summary

What does the tool measure?	Postural reactions
What types of clients can the tool be used for?	The Postural Reactions Test can be used with individuals with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms.
Time to administer	5-10 minutes
ICF Domain	Function
Versions	There is one version of the Postural Reactions Test
Languages	Swedish English
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Postural Reactions Test. Test-retest: No studies have examined test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Postural Reactions Test. Intra-rater: One study has shown good intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the Postural Reactions Test. Inter-rater: One study has shown good inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Postural Reactions Test.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: Face validityA form of content validity, face validity is assessed by having ‘experts’ (this could be clinicians, clients, or researchers) review the contents of the test to see if the items seem appropriate. Because this method has inherent subjectivity, it is typically only used during the initial phases of test construction. of the Postural Reactions Test was established through review and pilot-testing by clinical physiotherapists. Criterion: Concurrent: No studies have examined concurrent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . of the Postural Reactions Test. Predictive: One study showed that impaired protective reactions in sitting are decisive risk factors for early falls. Construct: Convergent/Discriminant: No studies have examined convergent/discriminant validityThe degree to which an assessment measures what it is supposed to measure. of the Postural Reactions Test. Known Groups: No studies have examined known group validityThe degree to which an assessment measures what it is supposed to measure. of the Postural Reactions Test.
Floor/Ceiling Effects	No studies have reported on floor/ceiling effects of the Postural Reactions Test. However, a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also “ceiling effect.” is possible when used with individuals with good postural stability.
Does the tool detect change in patients?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. of the Postural Reactions Test.
Acceptability	The Postural Reactions Test is non-invasive and quick to administer.
Feasibility	The Postural Reactions Test is suitable for administration in various settings. The assessment is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool?	The Postural Reactions Test can be accessed here. Swedish version (The Postural Reactions Test (Sv inkl ref)) (1) English version (The Postural Reactions Test (Eng inkl ref) (1))

Psychometric Properties

Overview

The Postural Reactions Test was developed in consultation with a convenience sample of physiotherapists and strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients (Sjoholm et al., 2018).

A literature search was conducted to identify all relevant publications on the psychometric properties of the Postural Reactions Test pertinent to use with participants following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Two studies were identified.

Floor/Ceiling Effects

No studies have reported on floor/ceiling effects.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Postural Reactions Test has not been measured.

Test-retest:
Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Postural Reactions Test has not been measured.

Intra-rater:
Sjoholm et al. (2018) examined intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the Postural Reactions Test in a sample of 20 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Ten physiotherapists viewed a video recording of participants’ performance of the Postural Reactions Test, on two occasions at least 2 weeks apart. The medians and quartiles of the two viewing sessions were calculated and the overall proportions of agreement (%) between the two sessions was calculated. The overall percentage of agreement was 86-93%.

Inter-rater:
Sjoholm et al. (2018) examined inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Postural Reactions Test in a sample of 20 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Participants’ performance of the Postural Reactions Test was videorecorded and viewed by ten physiotherapists. The most common score for each participant – and the number of physiotherapists who gave that score – was noted; then the median and quartiles were calculated for how many physiotherapists had scored the most common value for all participants. Results showed that 9-10 out of 10 physiotherapists scored the same value.

Validity

Content:

Face validityA form of content validity, face validity is assessed by having 'experts' (this could be clinicians, clients, or researchers) review the contents of the test to see if the items seem appropriate. Because this method has inherent subjectivity, it is typically only used during the initial phases of test construction.
of the Postural Reactions Test was established in two phases: (i) systematic feedback regarding test instructions and assessment [procedures was gathered from 9 clinical physiotherapists at three group meetings]; and (ii) physiotherapists subsequently pilot-tested the assessment over a 1-year period. This resulted in modified instructions regarding administration and scoring (Sjoholm et al., 2018).

Criterion

Concurrent:
Concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the Postural Reactions Test has not been measured.

 Predictive:
Sjoholm et al. (2022) examined ability of the Postural Reactions Test to predict number of days to first fall and 6-month fall incidence in a sample of 242 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Cox proportional hazard regression analysis and Negative binomial regression analysis (respectively) and 95% Confidence Interval (CI), with significance at p<0.0005 using Bonferroni correction. Participants with a score of 0 (worst side) had more than triple the risk of early falls (HR=3.59, CI 2.07-6.23, p=0.000) than participants with a protective reaction sitting score of 2 (worst side). Participants with no intact protective reactions in sitting on either side had more than double the risk of early falls (HR=2.63, CI 1.66-4.17, p=0.000) than participants with intact protective reactions in sitting on both sides. Comparison between participants with a protective reaction sitting score of 2 (worst side), vs. 1 (worst side), and participants with intact protection reactions in sitting on both sides vs. one side were not significant. Results were not significant for risk of multiple falls (Nberg analysis). Predictive analysis of impairments in protective reactions in standing were not significant.

Construct:

Convergent/Discriminant:
Convergent/discriminant validityThe degree to which an assessment measures what it is supposed to measure.
of the Postural Reactions Test has not been measured.

Known Group:
Known group validityThe degree to which an assessment measures what it is supposed to measure.
of the Postural Reactions Test has not been measured.

Responsiveness:

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
& SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
/Specificity of the Postural Reactions Test has not been measured.

References

Sjöholm, H., Hägg, S., Nyberg, L., & Kammerlind, A. (2018). Reliability of test procedures for postural reactions in people with acute stroke. International Journal of Therapy & Rehabilitation, 25(11), 576-586.

Sjöholm, H., Hägg, S., Nyberg, L., Lind, J., & Kammerlind, A. (2022). Exploring possible risk factors for time to first fall and 6-month fall incidence in persons with acute stroke. SAGE Open Medicine, 10: 1-11. https://doi.org/10.1177/20503121221088093

See the measure

The Postural Reactions Test can be found here in English and in Swedish.