Discussing Prognosis Through Balance Assessment: An Integrated Guide to the Full Postoperative Rehabilitation Flow
[Positioning of this magazine] This article is positioned as Step 5: Integration into Clinical Judgment. It is a summary article that integrates all the knowledge of the scales learned in this magazine, organizing the entire process from postoperative rehabilitation assessment to discharge decisions. Please use it as the culmination of this magazine.
Magazine: Evidence-Based Functional Assessment and Clinical Judgment
To those who have read through this magazine, there is one last thing I want to convey. Balance assessment is not about measuring numbers, but about having the language to discuss 'what kind of life this patient will be able to lead after discharge.' In this article, after organizing how to use and connect assessments from the acute phase to discharge, I will take up two 'difficult cases' often encountered in clinical practice.
The Three Stages of Postoperative Rehabilitation and the Purpose of Assessment
When assessing postoperative patients, what you want to know changes depending on the timing. It is easy to organize by thinking in roughly three stages.
Stage 1: Post-op to 1 week (Safety Confirmation)
The main purpose during this period is to confirm whether 'today's rehabilitation can be carried out safely.' Since weight-bearing restrictions, pain, and effects on vitals take precedence, the focus is on grasping walking independence (FAC) and rough balance ability rather than precise functional assessment. Even if performing the BBS, it is not necessary to seek all 14 items, and often sufficient information can be obtained just by observing the 3 items of 'standing balance, transfers, and turning.'
Stage 2: 1 to 2 weeks post-op (Progress Tracking)
Once safety is ensured, move on to tracking 'whether recovery is occurring.' The trends in TUG and BBS become the main indicators. What is important here is not a single numerical value, but the amount of change. Changes such as '3 seconds faster than last week' or 'BBS went from 48 to 52 points' become the basis for discussing recovery. It is important to keep the MDC (Minimal Detectable Change) in mind and not be swayed by changes within the margin of error (the MDC for TUG is about 3.5 seconds, and for BBS it is about 5 points).
Stage 3: Before discharge (Basis for discharge eligibility)
In the final stage, you will indicate 'whether the patient can return home' and 'what kind of support is needed' using numerical values. By combining multiple indicators such as 6MWT, TUG, FIM, and Barthel Index, you can concretely depict the patient's life after discharge from both the aspects of ADL and mobility. Cut-off values are most effective here. It is required to interpret values such as '13.5 seconds for the TUG cut-off for community-dwelling elderly' in light of the environment of the discharge destination (living alone? are there steps?).
Difficult Case 1: Cases where the numbers are 'on the edge'
Case: 80-year-old female, 2 weeks post-THA. Last week's TUG was 15.8 seconds, and this week it is 14.2 seconds. The discharge destination is living with her husband (home, with steps).
The well-known cut-off for TUG is 13.5 seconds (community-dwelling elderly). This person's 14.2 seconds is just 0.7 seconds over. Should I report it as is, saying 'there is a fall risk because it exceeds the cut-off'?
I want you to stop here. There are two problems.
Problem 1: This cut-off does not apply directly to post-THA patients. The period of 1-2 weeks post-THA is a state where function is normally lower than that of healthy elderly people. There are reports that '20-25 seconds at 2 weeks post-THA' is a guideline as a reference value for postoperative patients. Viewed by that standard, 14.2 seconds is actually a quite favorable progression.
Problem 2: You cannot call it an 'improvement' without knowing the MDC. If it was 15.8 seconds last week, the difference is 1.6 seconds. It is below the TUG MDC (about 3.5 seconds), and statistically, it is 'within the margin of error.' It is not accurate to say 'it became faster than last week.' Conversely, if it was 19 seconds last week, it is a 4.8-second improvement—this can be confidently conveyed as a real change.
Conclusion of judgment: Rather than the numerical value of 14.2 seconds alone, after considering the two points of 'which reference value to compare with' and 'whether the amount of change is real,' convey it together with the living environment after discharge (presence of steps, presence of caregivers). You can show the basis to other professionals in the form of, 'Although it exceeds the cut-off standard at this point, it is favorable as a postoperative progression. To safely return to a home with steps, I would like 1-2 more weeks of practice opportunity.'
Difficult Case 2: Cases where pain and cognitive decline are intertwined
Case: 75-year-old male, 1 week post-TKA. Resting VAS 4/10, active VAS 7/10. Repeatedly confirmed 'what should I do?' during BBS. MMSE is scheduled to be conducted at a later date, but there is information from the family that 'forgetfulness has increased recently.'
In this case, the scale values may not reflect actual "function."
Problem 1: Functional limitations due to pain and true ability are mixed.
In the acute phase after TKA, there are always movement limitations due to pain. If low scores are obtained on the BBS or TUG, it will lead to incorrect assessment unless you distinguish whether this is a "balance ability issue" or "defensive movement due to pain." It is important to re-evaluate before and after pain management or for the therapist to describe in their observations the "ability when the influence of pain is removed."
Problem 2: Cognitive function affects the reliability of balance assessment.
Items in the BBS such as "single-leg stance" and "standing with eyes closed" assume an understanding of verbal instructions. If cognitive function is impaired, a lack of understanding of the task will lower the score. Furthermore, cognitive impairment is an independent risk factor in assessing fall risk, and it is known that fall risk increases significantly when a score of 26 or lower is confirmed on the MMSE/HDS-R.
Conclusion for judgment:
For this case, it is required to: 1) perform an MMSE early to grasp the score, 2) re-evaluate the TUG after recording the pain control status, and 3) combine it with the FAC rather than just the BBS to describe the "current level of independence" from multiple perspectives. Rather than reporting that "the numbers are low," carefully analyzing "what is lowering the numbers" is the core for new to third-year therapists to level up.
Three points for discussing prognosis with numbers
1. Cut-offs are "materials for dialogue," not "pass/fail criteria"
Rather than the fact that a score exceeded or fell below a cut-off, it is important to have the words to convey "why that number is what it is" and "what needs to be improved to change it." Numbers are an entrance to start a conversation, not a conclusion.
2. Use MDC/MCID for the amount of change
Aim for a state where you can say, "The TUG has improved by 5 seconds, and this is a genuine improvement that exceeds the MDC," rather than just "It is getting better." This increases reliability for patients, families, and all other staff members.
3. Discuss using "consistency across multiple scales" rather than a single number
If the TUG is improving but the FIM is not changing, there is a possibility that generalization to ADLs is not occurring. If the BBS is high but falls continue, it is necessary to review cognitive function and environmental factors. By confirming whether multiple assessments are "pointing in the same direction," the accuracy of prognosis prediction increases significantly.
How to read this magazine guide
I will organize the overall picture and reading order of the magazine "Evidence-Based Balance Assessment and Judgment."
For first-time readers (new to 2nd year):
→ First, grasp the overall picture with the clinical judgment flowchart → Select the appropriate scale according to the situation you want to assess using the scene-specific scale selection articles → Learn the details in each scale article (BBS, TUG, 6MWT, FAC, FIM, BI, 10m walk, MMSE/HDS-R)
For those who want to deepen their use of numbers (2nd to 4th year):
→ Use scales differently by disease with the disease-specific cut-off articles → Understand the meaning of the amount of change with the MDC/MCID articles
For those who want to improve their ability to communicate to the team:
→ Refer to Case 2 in this article and practice how to combine multiple scales in practice
Balance assessment is not for the sake of measuring. It is for creating evidence-based words to discuss "whether that patient can live without falling after discharge" and "how far the family can be at ease." When you have those words, assessment truly becomes the core of rehabilitation.
All articles in this magazine can be read together in "Evidence-Based Balance Assessment and Judgment."
Related articles in this magazine
→ Clinical Judgment Flowchart: Visualizing Fall Risk and Discharge Decision-Making