Retropulsive Pull Test

Last Updated

April 01, 2013

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.

Link to Instrument

Instrument Details

Acronym RPT

Area of Assessment

Balance – Non-vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Parkinson's Disease & Movement Disorders

Parkinson's Disease

Testing Procedures:
1) Subject stands in a comfortable stance with eyes open (have feet shoulder width apart if they assume an unusually wide or narrow stance).
2) Examiner stands behind the subject.
3) 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.
4) The examiner gives a sudden, brief backward pull to the shoulders with sufficient force to cause the subject to have to regain their balance.
5) The subject should not know exactly when the pull is coming.
Scoring is from 0 to 4:
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)

Number of Items

1 minutes

Required Training

Reading an Article/Manual

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Deb Kegelmeyer PT, DPT, MS, GCS,& the PD EDGE Task Force of the Neurology Section of the APTA

ICF Domain

Body Function

Measurement Domain

Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:
HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

	I	II	III	IV	V
PD EDGE	NR	NR	NR	NR	NR

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
PD EDGE	No	No	No	Not reported

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.

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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.

Interrater/Intrarater Reliability

Parkinson’s disease:

(Visser et al., 2003)

1^st trial excellent weighted k = 0.93; 3^rd trial weighted k = 0.84.

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.

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