Retropulsive Pull Test

Acronym:

Purpose:

The Retropulsion Test' or Pull Test' (Postural Stability Item #30 of the Unified Parkinson's Disease Rating Scale; UPDRS [5]) is a commonly used clinical test of postural stability for patients with PD. This test evaluates the ability of patients to recover from a backward pull on the shoulders.

Description:

Subject stands in a comfortable stance with eyes open (have feet shoulder width apart if they assume an unusually wide or narrow stance). Examiner stands behind the subject. The subject is instructed to do whatever it takes to not fall and are told that the examiner will catch them if they do fall. The examiner gives a sudden, brief backward pull to the shoulders with sufficient force to cause the subject to have to regain their balance. The subject should not know exactly when the pull is coming. Scoring is from 0 to 4 with 0 = recovers independently may take 1 or 2 steps or an ankle reaction; 1 = three steps or more backward but recovers independently; 2 = retropulsion, needs to be assisted to prevent fall; 3 = very unstable, tends to lose balance spontaneously; 4 = unable to stand without assistance (UPDRS method).

Area of Assessment: Balance Non-Vestibular

Body Part: Not Applicable

ICF Domain: Body Function

Domain: Motor

Assessment Type: Performance Measure

Length of Test: 05 Minutes or Less

Time to Administer:

1 minute

Number of Items: 1 item

Equipment Required:

None

Training Required:

Type of training required: reading an article/manual

Cost: Free

Actual Cost:

$0

Age Range: Adult: 18-64 years, Elderly adult: 65+

Administration Mode: Paper/Pencil

Diagnosis: Parkinson's Disease

Populations Tested:

• Parkinson's Disease

Standard Error of Measurement (SEM):

Not Established

Minimal Detectable Change (MDC):

Not Established

Minimally Clinically Important Difference (MCID):

Not Established

Cut-Off Scores:

< 1 = increased risk of falling

Normative Data:

Parkinson's disease: (Visser et al., 2003; 42 patients with PD and 15 healthy volunteers; 20 of the patients with PD were considered stable in regards to falling and 22 unstable based on a questionnaire; 21 subjects with PD mean age = 62.9 (10.6); Hoehn & Yahr mean = 3.0 (0.8); PD unstable mean = 0.67 (0.56); PD stable mean = 0.17 (0.37); controls mean = 0 (0) (Foreman KB et al. 2011; 22 fallers and 14 non fallers, mean age 70.95 (11.41) years, H&Y stage median = 2.5/3 and range (1.5 – 4); PD fallers median = 1.0 (0.91), nonfallers median = 1.0 (0.51)) (Jacobs JV et al. 2006; 88 subjects with PD (27 females, 61 males), mean age = 67 (12) years) first trial mean = 0.42 (0.53) range = 0 - 2 third trial mean = 0.17 (0.38) range = 0 - 1) (Valkovic et al., 2011; 82 subjects (64 men, 18 women) 63.6 (9.1) years old; had PD for 8.1 (5.3) years.

Test-retest Reliability:

Not Established

Interrater/Intrarater Reliability:

Parkinson's disease: (Visser et al., 2003) 1st trial excellent weighted k = 0.93; 3rd trial weighted k = 0.84.

Internal Consistency:

Not Established

Criterion Validity (Predictive/Concurrent):

Parkinson's Disease: (Visser et al., 2003) Predictive for an unexpected pull, first trial (best statistics) Sensitivity/specificity = 0.66 / 0.82 Positive /negative predictive value = 0.83 / 0.67 Overall predictive = 0.71 (Jacobs et al. 2006) Pull test and ABC r2 = 0.28 (Foreman et al., 2011) The Pull test did not predict fall status in either the on or off medication state. (Valkovic et al., 2011) OFF medication Sensitivity = 69.4 Specificity = 97.8 Overall accuracy = 85.4 Positive predictive value = 96.2 Negative predictive value = 80.4 ON medication Sensitivity = 69.4 Specificity = 82.6 Overall accuracy = 76.8 Positive predictive value = 75.8 Negative predictive value = 77.6.

Construct Validity (Convergent/Discriminant):

Not Established

Content Validity:

Not Established

Face Validity:

Not Established

Floor/Ceiling Effects:

Not Established

Responsiveness:

Not Established

Considerations:

There are many different methods for administering this test and the reader must use care to note the applicable research when choosing the test and note that the data presented here apply only the the test as administered on the UPDRS.

Bibliography:

Foreman, K. B., Addison, O., et al. (2011). "Testing balance and fall risk in persons with Parkinson disease, an argument for ecologically valid testing." Parkinsonism Relat Disord 17(3): 166-171. Find it on PubMed

Jacobs, J. V., Horak, F. B., et al. (2006). "An alternative clinical postural stability test for patients with Parkinson's disease." J Neurol 253(11): 1404-1413. Find it on PubMed

Valkovič, P., Brožová, H., et al. (2008). "Push and release test predicts better Parkinson fallers and nonfallers than the pull test: comparison in OFF and ON medication states." Movement disorders 23(10): 1453-1457. 

Visser, M., Marinus, J., et al. (2003). "Clinical tests for the evaluation of postural instability in patients with parkinson's disease." Arch Phys Med Rehabil 84(11): 1669-1674. Find it on PubMed

Instrument in PDF Format: Yes

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