Postural Reactions Test

Evidence Reviewed as of before: 15-12-2022
Author(s)*: Annabel McDermott, OT
Editor(s): Annie Rochette, PhD OT
Expert Reviewer: Hanna Sjöholm, PT

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 stroke
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 stroke.
Is this a screening or assessment tool? Screening
Time to administer 5-10 minutes
ICF Domain Function
Versions There is one version of the Postural Reactions Test
Languages Swedish
English
Measurement Properties
Reliability Internal consistency:
No studies have examined internal consistency of the Postural Reactions Test.
Test-retest:
No studies have examined test-retest reliability of the Postural Reactions Test.
Intra-rater:
One study has shown good intra-rater reliability of the Postural Reactions Test.
Inter-rater:
One study has shown good inter-rater reliability of the Postural Reactions Test.
Validity Content:
Face validity of the Postural Reactions Test was established through review and pilot-testing by clinical physiotherapists.
Criterion:
Concurrent:
No studies have examined concurrent reliability 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 validity of the Postural Reactions Test.
Known Groups:
No studies have examined known group validity of the Postural Reactions Test.
Floor/Ceiling Effects No studies have reported on floor/ceiling effects of the Postural Reactions Test. However, a floor effect is possible when used with individuals with good postural stability.
Does the tool detect change in patients? No studies have reported on the responsiveness 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 stroke 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 stroke. Two studies were identified.

Floor/Ceiling Effects

No studies have reported on floor/ceiling effects.

Reliability

Internal consistency:
Internal consistency of the Postural Reactions Test has not been measured.

Test-retest:
Test-retest reliability of the Postural Reactions Test has not been measured.

Intra-rater:
Sjoholm et al. (2018) examined intra-rater reliability of the Postural Reactions Test in a sample of 20 patients with acute stroke. 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 reliability of the Postural Reactions Test in a sample of 20 patients with acute stroke. 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 validity 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 validity 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 stroke, 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 validity of the Postural Reactions Test has not been measured.

Known Group:
Known group validity of the Postural Reactions Test has not been measured.

Responsiveness:

Sensitivity& Specificity:
Sensitivity/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.

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