䢇

Research Report

Clinimetric Properties of the

Performance-Oriented Mobility
Assessment

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Background and Purpose. The Performance-Oriented Mobility Assessment (POMA) is

a widely used instrument that provides an evaluation of balance and gait. It is used
clinically to determine the mobility status of older adults or to evaluate changes over
time. To support the use of the POMA for these purposes, the clinimetric properties
(in particular, responsiveness) were determined. Subjects. Participants (78% female;
mean age⫽84.9 years) were living in either self-care or nursing-care residences.
Concurrent and discriminant validity were assessed with the total group (N⫽245),
whereas reliability and responsiveness were determined with a subsample (n⫽30).
Fall-related predictive validity was assessed with a subsample of 72 participants.
Methods. In addition to the POMA, several reference performance tests were
administered. The POMA was assessed on 2 consecutive days by 2 raters (observers).
The analyses included the calculation of Spearman rank correlation coefficients (R),
limits of agreement (LOA) with Bland-Altman plots, minimal detectable changes at
the 95% confidence level (MDC95), and sensitivity and specificity with regard to
predicting falls. When possible, findings for the total scale (POMA-T) were comple-
mented by findings for its balance subscale (POMA-B) and its gait subscale (POMA-
G). Results. The interrater and test-retest reliability for the POMA-T and the POMA-B
were good (R⫽.74 –.93), whereas for the POMA-G, the reliability values, although
high as well, were systematically slightly lower (R⫽.72–.89). The Spearman correla-
tions with the reference performance tests (R⫽ⱍ.64ⱍ–ⱍ.68ⱍ) indicated satisfactory
concurrent validity for the POMA-T and the POMA-B, but the corresponding findings
for the POMA-G (R⫽ⱍ.52ⱍ–ⱍ.56ⱍ) were less convincing. The discriminant validity values
of the 3 scales were about the same. The LOA for the POMA-T were on the order of
– 4.0 to 4.0 for test-retest agreement and –3.0 to 3.0 for interrater agreement. On the
basis of the MDC95 values, it was concluded that changes in POMA-T scores at the
individual level should be at least 5 points and that those at the group level (n⫽30)
should be at least 0.8 point to be considered reliable. Even when optimal cutoff points
were used, sensitivity and specificity values (varying between 62.5% and 66.1%) for the
POMA-T as well as for its 2 subscales indicated poor accuracy in predicting falls.
Discussion and Conclusion. The POMA-T and its subscale POMA-B have adequate
reliability and validity for assessing mobility in older adults. The POMA-T is useful for
demonstrating intervention effects at the group level. Changes within subjects,
however, should be at least 5 points before being interpreted as reliable changes. The
accuracy of the POMA-T in predicting falls is poor. [Faber MJ, Bosscher RJ, van
Wieringen PCW. Clinimetric properties of the Performance-Oriented Mobility Assess-
ment. Phys Ther. 2006;86:944 –954.]

Key Words: Minimal detectable change, Older people, Performance-Oriented Mobility Assessment,
Reliability, Validity.

Marjan J Faber, Ruud J Bosscher, Piet CW van Wieringen

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944 Physical Therapy . Volume 86 . Number 7 . July 2006

T
he Performance-Oriented Mobility Assessment
(POMA) scale, developed by Tinetti and first
published in 1986,1 is a widely used tool for
assessing mobility and fall risk in older people.
It is easily applied in clinical settings; other than a
standard chair and a stopwatch, no further equipment is
required, and only little experience is needed to master
its use.1 After a few practice sessions, the observer can
complete the assessment in less than 15 minutes.2
Several adapted versions of the POMA have been pub-
lished, but in this article, only the original 28-point
version is considered, as it is the most commonly used
changes being expressed in the units of measurement of
the instrument. Relative reliability is the degree to which
subjects maintain their position in a sample with
repeated measurements, usually assessed with some type
of correlation coefficient.14 Responsiveness is defined as
the ability of an instrument to accurately detect change
when it has occurred.15,16
Only limited clinimetric data on the original POMA have
been published. With regard to test-retest reliability of
POMA-T scores, intraclass correlation coefficients
(ICCs) of .88 (for 40 residents of skilled nursing
homes)17 and .97 (for 8 community-dwelling older peo-

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version.3 The total POMA scale (POMA-T) consists of a
balance scale (POMA-B) and a gait scale (POMA-G).
The POMA-B carries the subject through positions and
changes in position, reflecting stability tasks that are
related to daily activities. In the POMA-G, several quali-
tative aspects of the locomotion pattern are examined.
Each item is scored on a 2- or 3-point scale, resulting in
a maximum score of 28 on the POMA-T and maximum
scores of 16 and 12 on the POMA-B and the POMA-G,
respectively. Originally, the POMA-T was developed to
predict falls in an institutionalized population.3 Later,
the scale also was used in various clinical contexts as a
measure of mobility impairment4 – 6 and to study the
effects of interventions.7–13
A prerequisite for using a clinical measurement tool is
that its clinimetric properties, including validity, reliabil-
ity, and responsiveness, are satisfactory. Validity indicates
whether the instrument does indeed measure what it is
intended to measure. Concurrent validity refers to the
relationship between scores on the scale in question and
scores on other scales intended to measure the same
construct. Predictive validity refers to the degree to which
the scores predict an external criterion. Reliability refers
to the extent to which the measurements are objective
(interrater reliability) and stable over time (test-retest
reliability). Absolute reliability is the degree to which
repeated measurements vary for subjects, with the
ple)4 have been reported. The concurrent validity of
POMA-T scores was investigated in a cross-sectional
study6 of 167 older people with mild balance impair-
ments. Spearman correlations (R) of POMA-T scores
with the results of several balance-related tests were
calculated; these measures included maximum step
length (R⫽.75), tandem stance time (R⫽.69), stance
time on one foot (R⫽.74), tandem walk time (R⫽–.62),
Timed “Up & Go” Test (TUG) (R⫽–.65), and 6-Minute
Walk Test (R⫽.62). For a group of 59 community-
dwelling older people, a Spearman correlation of .79
between POMA-T scores and gait impairment scores
based on a neurologic examination was found.5
With regard to the POMA-B, a test-retest reliability value
(ICC) of .93 was reported for a group of 14 residential
care facility residents.7 Interrater reliability values in that
study, expressed as Pearson correlation coefficients (r),
varied from .76 to .90. For a group of 40 residents of
skilled nursing homes, the ICC indicating interrater
reliability was .75.17 In one study focusing on the inter-
rater reliability of scores on the 8 individual items of the
POMA-B, kappa coefficients ranging from .40 to 1.00
were reported across many raters with various levels of
experience for 29 hospital inpatients and nursing home
residents.18 The predictive validity of scores on the
POMA-B for falls was investigated by Verghese et al19
with a group of 60 community-dwelling older people;

MJ Faber, PhD, is Senior Researcher, Faculty of Human Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands. Address
all correspondence to Dr Faber at Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre, PO Box 9101, 117
KWAZO, 6500 HB Nijmegen, the Netherlands (m.faber@kwazo.umcn.nl).

RJ Bosscher, PhD, is Associate Professor, Faculty of Human Movement Sciences, Vrije Universiteit Amsterdam.

PCW van Wieringen, PhD, is Associate Professor, Faculty of Human Movement Sciences, Vrije Universiteit Amsterdam

Dr Faber, Dr Bosscher and Dr van Wieringen provided concept/idea/research design. Dr Faber and Dr van Wieringen provided writing. Dr Faber
provided data collection, project management, subjects, and data analysis. Dr van Wieringen provided fund procurement. Dr Bosscher provided
consultation (including review of manuscript before submission).

The medical ethical committee of the Vrije Universiteit Medical Centre approved the study protocol.

This article was received May 23, 2005, and was accepted January 31, 2006.

Physical Therapy . Volume 86 . Number 7 . July 2006 Faber et al . 945


with a cutoff value set at a score of 10 points, the
sensitivity was 61.5% and the specificity was 69.5%.
With regard to the POMA-G, an interrater reliability
value (ICC) of .83 was reported for a group of 40
residents of skilled nursing homes.17 The concurrent
validity of scores on the POMA-G was investigated for 34
community-dwelling older people by correlating
POMA-G scores with their ankle ranges of motion,
resulting in a Spearman correlation of .63.4
Although the data presented above are encouraging, the
number of clinimetric studies is still relatively small, in
particular, with regard to validity. Moreover, all reliabil-
ity values reported so far refer to relative reliability; no
findings have been published with regard to absolute
reliability or to the related characteristic of responsive-
ness of the POMA scale. This dearth of published data
raises questions about the use of the POMA for moni-
toring patients’ clinical recovery process or responses to
interventions,20 even though the POMA has been used
extensively for these goals.7–13
Given these considerations, we conducted a large-scale
clinimetric study with older adults living in long-term
care facilities in order to extend the small database with
respect to the relative interrater and test-retest reliability
and validity (concurrent, discriminant, and predictive)
of scores on the original POMA and to add important
information about its absolute reliability and the mini-
mal detectable change, which was the type of change
chosen for a study on responsiveness.15
Method
Participants
Data for the present study were collected from partici-
pants in a randomized controlled trial (RCT) investigat-
ing the effects of 2 exercise programs. These participants
were recruited from 15 long-term self-care and nursing
care residences, with the number of residents ranging
from 120 to 500. In self-care residences, people live
independently but have access to on-site nursing care
and dining and recreational facilities. In nursing care
residences, people live less independently, with provi-
sions for full nursing care if necessary. Preceding the
RCT, all residents were invited to meetings in which
information about the setup of the RCT and exercise
programs was given. People who were interested in
participation were screened on the basis of the following
inclusion criteria: ability to walk independently across a
distance of at least 6 m, with or without the use of a
walking aid; capacity to understand instructions to be
provided during the programs; and absence of medical
contraindications to participation, as judged by the
946 . Faber et al
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volunteers’ general practitioners. The second criterion
was operationalized by a score of at least 18 on the
Mini-Mental State Examination.21 In addition, the nurs-
ing staff judged all volunteers meeting this criterion to
be fit to participate.
Of the 278 interested and eligible participants, 33 were
excluded because they had Mini-Mental State Examina-
tion scores of less than 18. The concurrent and discrimi-
nant validity data for the present study were obtained
from the remaining 245 participants in the RCT. The
reliability and responsiveness data were collected from a
sample of 30 participants living in the last 3 included
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residences. Participants in the RCT who were living in
the latter residences could volunteer to participate in the
reliability and responsiveness study. Predictive validity
was determined for the participants who were randomly
assigned to the control group in the RCT; these partic-
ipants did not receive any intervention, and their fall
history was recorded over a period of 10 months after
randomization for the RCT (n⫽72). The characteristics
of the participants belonging to the 3 study groups are
summarized in Table 1. All participants gave written
informed consent.
Procedure and Data Collection
To assess concurrent validity, 2 research physical thera-
pists, both with 4 years of experience in physical testing
of older adults, made individual assessments of all par-
ticipants. In addition to the POMA, the TUG,22 the
balance test from the Frailty and Injuries: Cooperative
Studies of Intervention Techniques (FICSIT-4),23 and a
gait speed test24 were administered. Information about
the type of walking aid commonly used by the partici-
pants was collected to determine discriminant validity.
For the reliability and responsiveness part of the study, 2
graduate students who were studying human movement
sciences and who received 8 hours of training in scoring
the POMA scored the POMA for the 30 participants on
2 consecutive days while the physical therapists gave the
test instructions to the participants. On both days, the
students scored the POMA simultaneously but indepen-
dently from each other. Given the short interval of about
24 hours between the 2 assessments, changes in perfor-
mance attributable to changing health conditions or
interventions seemed highly improbable. As indicated
earlier, fall-related predictive validity was determined
with the group of 72 control participants in the RCT,
that is, participants who were not involved in an inter-
vention program. Fall data were collected by means of
fall diaries that were kept by the participants over a
period of 10 months. A fall was defined as “an event that
results in a person coming unintentionally to rest on the
ground or other lower level.”25
Physical Therapy . Volume 86 . Number 7 . July 2006
Table 1.
Characteristics of Participants in the Concurrent and Discriminant Validity Study, the Fall-Related Validity Study, and the Reliability and
Responsiveness Study

Value in the Following Study:

Concurrent and
Discriminant Fall-Related Reliability and
Validity Validity Responsiveness
Characteristica (nⴝ245) (nⴝ72) (nⴝ30)

Age, y, X (SD) 84.9 (6.0) 84.7 (6.1) 83.1 (7.3)

No. (%) of women 191 (78) 58 (81) 24 (80)
MMSE score, X (SD) (range⫽0–30) 25.7 (2.9) 25.7 (2.9) 26.5 (2.4)
Self-reported health status, no. (%) of subjects

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Poor 4 (1.6) 0 (0) 1 (3.3)
Fair 87 (35.7) 21 (29.2) 8 (26.7)
Good 104 (42.6) 34 (47.2) 17 (56.7)
Excellent 49 (20.1) 17 (23.7) 4 (13.3)
Walking aid, no. (%) of subjects
None 86 (35) 25 (35) 12 (40)
Cane or stick 26 (11) 9 (13) 5 (17)
Walker 121 (49) 30 (42) 13 (43)
Wheelchair 12 (5) 8 (11) 0 (0)
Physical activity, min/d, X (SD) 65 (49) 70 (46) 75 (50)
Maximum walking speed, m/s, X (SD) 0.76 (0.31) 0.79 (0.34) 0.95 (0.25)
FICSIT-4 score, X (SD) (range⫽0–5) 2.4 (1.3) 2.5 (1.3) 2.6 (1.4)
TUG score, s, X (SD) 24.6 (14.8) 23.0 (14.6) 16.6 (6.0)
GARS score, X (SD) (range⫽18–90) 42.4 (13.1) 39.4 (13.6) 36.8 (11.6)
POMA score, X (SD)
Total (range⫽0–28) 19.3 (5.3) 19.7 (5.7) 18.9 (5.4)
Gait (range⫽0–12) 9.0 (2.5) 9.2 (2.6) 8.4 (2.6)
Balance (range⫽0–16) 10.3 (3.5) 10.5 (3.8) 10.5 (3.1)
a
MMSE⫽Mini-Mental State Examination, FICSIT-4⫽balance test from the Frailty and Injuries: Cooperative Studies of Intervention Techniques, TUG⫽Timed “Up
& Go” Test, GARS⫽Groningen Activity Restriction Scale, POMA⫽Performance-Oriented Mobility Assessment.

Measurement Instruments mined for a larger group of 60 patients by correlating

The original POMA version used in this clinimetric
evaluation (Appendix)1 consists of 8 balance items and 8
gait items to be scored on a 2- or 3-point scale. The
balance items include sitting balance, rising from a chair
and sitting down again, standing balance (eyes open and
eyes closed), and turning balance, adding up to a
maximum score of 12 points (POMA-B). The gait items
include gait initiation, step length, step height, step
length symmetry and continuity, path direction, and
trunk sway, adding up to a maximum score of 16 points
(POMA-G). The total score (POMA-T) ranges from 0 to
28 points. Lower scores indicate poorer performance.
The TUG is a test of basic functional mobility and is
scored as the minimum time needed to stand up from a
standard armchair, walk across a distance of 3 m, turn
around, walk back to the chair, and sit down again.
Interrater reliability (ICC⫽.99) and test-retest reliability
(ICC⫽.99) of TUG scores have been determined for 22
patients attending a geriatric hospital.22 In that same
study, the concurrent validity of TUG scores was deter-
the time to complete the TUG with the Berg Balance
Scale (Pearson r ⫽⫺.81), a gait speed test (Pearson
r ⫽⫺.61), and the Barthel Index (Pearson r ⫽⫺.51).22
The FICSIT-4 is used to test a person’s ability to maintain
balance in parallel stance, semitandem stance, tandem
stance, and one-leg stance. Each position was tested for
a maximum of 10 seconds, and participants proceeded
to the next stance only when the previous stance could
be maintained for at least 3 seconds. A summary score
for the 4 positions was computed as suggested by
Rossiter-Fornoff et al,23 resulting in a scale ranging from
0 to 5 points, with higher scores indicating better
balance performance. The test-retest reliability of scores
on the FICSIT-3 (similar to the FICSIT-4, but without the
one-leg stance) has been determined over intervals
between 2 measurements ranging from 3 to 12 months.
The Pearson r ranged from .25 to .74, with longer
intervals resulting in lower test-retest correlations.23

Physical Therapy . Volume 86 . Number 7 . July 2006 Faber et al . 947


Fast gait speed was determined across a distance of 6 m,
which was marked on the floor with tape. The partici-
pants, who were allowed to use their usual walking aid,
were asked to walk as fast as possible without running.
They were instructed to wait with both feet 1 m behind
the starting line and to start walking after a verbal
command. Timing began after the leading foot crossed
the starting line and stopped after the leading foot
crossed the finish line. The participants were instructed
to continue walking for a short distance after the finish
line was crossed to prevent them from decelerating
before this line was reached. Speed was computed by
dividing distance (in meters) by time (in seconds).24 The
highest speed attained during 1 of 2 attempts was used
for analysis. The test-retest reliability (ICC) for gait
speed over an interval of about 2 weeks for a group of
105 frail older people (mean age⫽78.0 years) was .79.26
The test-retest reliability values (ICCs) determined on
the same day for comfortable and maximum gait speeds
for a group of 96 subjects between 60 and 89 years of age
were .97 and .96, respectively.24
Self-reported limitations in basic activities of daily living
(BADL) and independent activities of daily living
(IADL) were assessed by means of the Groningen Activ-
ity Restriction Scale (GARS).27 The GARS consists of 18
items, covering 11 BADL and 7 IADL tasks, all scored on
a 5-point scale (possible scoring range of 18 –90 points,
with higher scores indicating more limitations). The
GARS has been used to determine changes in disable-
ment over time, to differentiate between degrees of
disability, and to assess the need for professional care.27
The test-retest correlation, determined within a group of
77 subjects over a 4-month interval, was .7428; the inter-
rater reliability has not been determined. An indication
for concurrent validity was found in a population-based
study of 4,777 subjects in which the GARS scores corre-
lated highly with the scores on the physical functioning
subscale of the 20-Item Short-Form Health Survey (SF-
20) (Pearson r⫽⫺.72).29 The latter subscale measures
the extent to which health problems interfere with a
variety of activities (eg, playing sports, carrying groceries,
climbing stairs, and walking).30
Finally, the average number of minutes per day spent on
habitual daily physical activities during the preceding 2
weeks was determined by administering the Longitudi-
nal Aging Study Amsterdam Physical Activity Question-
naire (LAPAQ).31 The LAPAQ covers the frequency and
duration of walking outside, bicycling, gardening, light
and heavy household activities, and sport activities dur-
ing the preceding 2 weeks. The total amounts of activity
measured by the LAPAQ and by means of a 7-day diary
were highly correlated (Spearman R⫽.68; n⫽356; men
and women 65 years of age and older). The test-retest
reliability was established with the same group, and the
948 . Faber et al
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weighted kappa coefficient of the total number of activ-
ities measured by the LAPAQ over 1 year was .65.31
Data Analysis
Assumptions of normality were not met for the POMA-T,
POMA-B, POMA-G, and TUG. Therefore, all calcula-
tions of relative reliability and of concurrent and dis-
criminant validity were based on nonparametric statis-
tics. The computation of absolute reliability and
responsiveness is based on differences in paired obser-
vations, assuming that these differences are normally
distributed. This assumption held true for POMA-T but
not for POMA-B and POMA-G. Consequently, absolute
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reliability findings are provided only for the former
scale.
The relative interrater and test-retest reliability of the
POMA scores were expressed in terms of Spearman rank
correlations (R). These calculations were complemented
by testing the differences between the paired scores
given by the 2 raters and between the paired scores on
the 2 test days by means of a Wilcoxon signed rank test.
Absolute interrater and test-retest reliability for the
POMA-T were visualized by means of Bland-Altman plots
with 95% limits of agreement (LOA).32 In those plots,
the differences (d) between each pair of observations are
presented as a function of the average value for each pair
of observations. Assuming a normal distribution of the
differences, 95% of those differences may be expected to
fall within the interval d ⫾ (1.96 ⫻ SDdiff), with d being
the mean difference and SDdiff being the standard
deviation of the difference. The mean difference d
captures the systematic difference between the paired
observations, whereas the SDdiff captures the agreement
at the level of individual observations.
The responsiveness of the POMA-T was considered at
both the individual level and the group level and is
presented in the units of measurements of this scale. The
responsiveness at the individual level is captured as the
minimal detectable change with a confidence level of
95% (MDC95) at the individual level (MDC95,ind), as
follows:
MDC95,ind ⫽ 1.96⫻ 冑2 ⫻ SEM,
where SEM is the standard error of measurement (ie, the
square root of the within-subject variance).15 Changes
smaller than MDC95,ind cannot be reliably (with a confi-
dence level of 95%) interpreted as “real” changes in the
score for a subject compared with chance fluctuations.
The responsiveness to changes at the group level, known
as the MDC95 at the group level (MDC95,group), depends
on the size of the group (n), as follows33:
Physical Therapy . Volume 86 . Number 7 . July 2006
 MDC95,ind
MDC95,group⫽ .
冑n
Changes smaller than MDC95,group cannot be reliably
(with a confidence level of 95%) interpreted as “real”
changes in the mean score for a group compared with
chance fluctuations.
The concurrent validity of the POMA scores was assessed
by calculating their Spearman rank correlations (R) with
the scores on a number of reference tests described
above. The discriminant validity was calculated by relat-
ing the POMA scores to the type of walking aid com-
monly used by the participants (none, cane or stick,
walker, or wheelchair) by means of a Kruskal-Wallis test
with type of walking aid as the experimental factor,
followed by post hoc comparisons by means of Mann-
Whitney U tests with Bonferroni adjustments.
Fall-related predictive validity was determined by pre-
dicting future falls on the basis of the POMA scores. A
“nonfaller” was defined as a subject who did not fall or
fell only once during the follow-up period, whereas a
“faller” was defined as a subject who fell at least twice
during the follow-up period (as in the study by Tinetti
et al3). Predictive validity was expressed in terms of
sensitivity and specificity. Sensitivity, in this context, is
defined as the probability that a future faller is indeed
predicted to be a faller, whereas specificity is defined as
the probability that a future nonfaller is indeed pre-
dicted to be a nonfaller. Receiver operating characteris-
tic curves were used for selecting the optimal cutoff
scores, and 95% confidence intervals were calculated. All
analyses were performed with SPSS version 11.5* for
Windows.
Results
Floor and Ceiling Effects
The scores on the 3 POMA scales were inspected for
possible floor and ceiling effects by determining the
number of participants with the lowest and highest
possible scores on the 3 scales. The lowest possible
scores, that is, 0 points, on the POMA-T, POMA-B, and
POMA-G were not obtained, whereas 11 (4.5%), 13
(5.3%), and 52 (21.2%) of the participants obtained the
highest possible scores on these tests. The distribution of
the POMA-T scores for the 245 participants is shown in
Figure 1.
Reliability
The Spearman correlations indicating the interrater and
test-retest relative reliability for the POMA scales are
* SPSS Inc, 233 S Wacker Dr, Chicago, IL 60606.
Physical Therapy . Volume 86 . Number 7 . July 2006
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Figure 1.
Histogram of Performance-Oriented Mobility Assessment (POMA)
scores for a group of 245 older adults with mobility impairments and
living in long-term-care facilities.
shown in Table 2. All test-retest reliability values for the
POMA-T, POMA-B, and POMA-G varied between .72
and .86, whereas the interrater reliability values ranged
from .80 to .93. No significant differences between the
pairs of scores were found, except with regard to the
test-retest reliability of the POMA-G scores; on the latter
scale, rater 1 had a significantly lower mean score on day
2 than on day 1 (Wilcoxon signed rank test, P⫽.03).
The Bland-Altman plots illustrating the absolute reliabil-
ity of the POMA-T are shown in Figure 2. From these
plots, it is clear that the mean differences between the
paired observations showed only small and nonsignifi-
cant deviations from 0, indicating that no systematic
differences in scores emerged between the 2 raters or
between day 1 and day 2 of assessment. The 95% LOA
for POMA-T, which also are shown in Table 2, ranged
from – 4.0 to 4.6 for test-retest reliability and from –3.6 to
2.9 for interrater reliability.
Responsiveness
The MDC95 values for both individual and group
changes in POMA-T scores are shown in Table 2. For
individual assessments, the MDC95,ind values were 4.0 to
4.2. When the test-retest assessments were evaluated at
the group level, the MDC95,group values were 0.7 to 0.8.
These values indicate that changes in scores at the
individual level should be at least 5 points and that
changes in mean group scores should exceed 0.8 to be
deemed reliable with a confidence level of 95%.
Validity
The Spearman correlations between the scores on the
POMA scales and the scores on the reference tests
(walking speed, TUG, FICSIT-4, GARS, and LAPAQ),
Faber et al . 949
 ўўўўўўўўўўўўўўўўўўўўўў
Table 2.
Reliability and Responsiveness of the Performance-Oriented Mobility Assessment (POMA) Total Scale (POMA-T), Balance Subscale (POMA-B),
and Gait Subscale (POMA-G) for Test-Retest and Interrater Situations (n⫽30)

Test-Retest Interrater
a
Parameter Rater 1 Rater 2 Day 1 Day 2

POMA-T (range⫽0–28)
Reliability
Spearman R .86 .82 .93 .91
Mean difference 0.5 0.0 0.1 ⫺0.4
95% LOA ⫺3.6 to 4.6 ⫺4.0 to 4.0 ⫺2.8 to 2.9 ⫺3.6 to 2.8
Responsiveness
MDC95,ind 4.2 4.0
MDC95,group 0.8 0.7

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POMA-B (range⫽0–16)
Reliability
Spearman R .78 .74 .90 .88
POMA-G (range⫽0–12)
Reliability
Spearman R .72 .77 .80 .89
a
LOA⫽limits of agreement, MDC95,ind⫽minimal detectable change for individual subjects at a 95% confidence level, MDC95,group⫽minimal detectable change for
a group at a 95% confidence level.

indicating the concurrent validity of

scores for the scales, are shown in
Table 3. All correlations were signifi-
cant at the .01 level. Except for the
correlations with LAPAQ, which were
low, all correlations between the
POMA-T and the POMA-B on the one
hand and the reference tests on the
other hand ranged from ⱍ.64ⱍ to ⱍ.70ⱍ.
The corresponding correlations
between the POMA-G and the refer-
ence tests were lower, ranging from
ⱍ.51ⱍ to ⱍ.56ⱍ.

The mean scores (and standard devi-

ations) on the POMA scales for the
subjects who used no walking aid
(n⫽86), a cane or a stick (n⫽26), a
walker (n⫽121), or a wheelchair
(n⫽12) are shown in Table 4. Signif-
icant group differences between
mean POMA-T scores emerged
between the independent ambulators
and the cane and walker users on the
one hand and the wheelchair users on
the other hand and between the inde-
pendent ambulators and the walker
Figure 2. users. The POMA-B scores differenti-
Bland-Altman plot representing the absolute test-retest reliability on days 1 and 2 for rater 1 (a) ated between the independent ambu-
and rater 2 (b) and the absolute interrater reliability on day 1 (c) and day 2 (d). The within-subject
mean total Performance-Oriented Mobility Assessment score is plotted against the within-subject
lators and the cane users and between
difference. The solid horizontal line indicates the mean difference, and the dashed horizontal the walker and wheelchair users.
lines indicate the upper and lower 95% limits of agreement. Finally, the POMA-G scores led to the
same differentiations as the POMA-T
scores. The wheelchair users were dif-

950 . Faber et al Physical Therapy . Volume 86 . Number 7 . July 2006

Table 3. for the POMA-G, the test scores tended
Concurrent Validity of the Performance-Oriented Mobility Assessment (POMA) Total Scale to be lower on the retest than on the
(POMA-T), Balance Subscale (POMA-B), and Gait Subscale (POMA-G), Expressed as
Spearman Rank Correlations
first test. Combined with the high ICCs
found in previous studies,4,7,17 these
Spearman Rank Correlationb for:
data indicate that the relative reliability
a
characteristics of the POMA scales
Test POMA-T POMA-B POMA-G
seem to be adequate.
Maximum walking speed .65 .64 .52
TUG ⫺.68 ⫺.66 ⫺.56 From a clinical point of view, relative
FICSIT-4 .67 .67 .51 reliability must be considered less rele-
GARS ⫺.70 ⫺.68 ⫺.55
vant than absolute reliability. The LOA
LAPAQ .38 .35 .33
showed that for the POMA-T, no sys-
a
TUG⫽Timed “Up & Go” Test, FICSIT-4⫽balance test from the Frailty and Injuries: Cooperative tematic bias was present for test-retest
Studies of Intervention Techniques, GARS⫽Groningen Activity Restriction Scale, LAPAQ⫽Longitudinal

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Aging Study Amsterdam Physical Activity Questionnaire. and interrater situations. The test-retest
b
All correlations were significant at P⬍.01. reliability data have direct implications
for responsiveness. The responsiveness
findings with regard to the POMA-T
Table 4. indicated that, given a confidence
Discriminant Validity of the Performance-Oriented Mobility Assessment (POMA) Total Scale
(POMA-T), Balance Subscale (POMA-B), and Gait Subscale (POMA-G) for Categories Based interval of 95%, intervention effects
on the Commonly Used Walking Aid for Daily Mobility should be at least 5 points at the indi-
vidual level and at least 0.8 point at the
X (SD) Score ona: group level (with a group size of n⫽30)
Walking
Aid POMA-T POMA-B POMA-G before a real improvement rather than
a chance fluctuation can be reliably
None 21.9 (5.5)A,B 11.9 (3.6)A,B 10.0 (2.3)A,B concluded. It should be emphasized,
Cane 20.0 (4.5)B 11.1 (2.5)A,B 8.8 (2.4)
however, that this real change should
Walker 17.9 (4.4)B,C 9.3 (3.0)C,D 8.6 (2.2)B,C
Wheelchair 12.9 (5.0)A,C,D 6.8 (3.1)C,D 6.2 (2.9)A,C be attributed to the intervention only
when other systematic influences, such
a
Post hoc testing revealed significant subgroup differences after Bonferroni corrections for the following
as spontaneous recovery, are controlled
comparisons: A⫽comparison with walker, B⫽comparison with wheelchair, C⫽comparison with none,
and D⫽comparison with cane. for by means of an adequate control
group.

ferentiated from the other 3 groups, and the independent
ambulators were differentiated from the walker users.
Among the subsample of 72 participants whose data
were entered into the analysis involving falls, 24 (33%)
were classified as “fallers” (at least 2 falls) and 48 (67%)
were classified as “nonfallers” (either no falls or one
fall). Sensitivity and specificity values indicating the
predictive validity of scores for the POMA scales in terms
of discriminating future fallers from nonfallers, are
shown in Table 5. It is evident that the predictive powers
of the POMA-T, POMA-B, and POMA-G are about the
same: Given optimal cutoff values of 19, 10, and 9, the
sensitivity (95% confidence interval) of all of the scales
was 64.0% (44.5%–79.8%), and their specificity values
were 66.1% (53.0%–77.1%), 66.1% (53.0%–77.1%), and
62.5% (49.4%–74.0%), respectively.
Discussion
The relative interrater and test-retest reliability values for
the POMA-T, POMA-B, and POMA-G, as quantified by
Spearman correlation coefficients, were rather high, but
In earlier clinical trials in which the POMA was used as
an outcome measure, statistically significant intervention
effects of 3.5 to 5.3 points (relative to the results for a
control group) were reported.8,11,34,35 Given these aver-
age group effects and the order of magnitude of the
critical MDC95,ind determined in the present study, one
may safely conclude that for a number of subjects,
reliable intervention effects indeed have occurred. Even
in those cases, however, the clinical relevance of the
improvement is not beyond doubt. Clinical relevance
can be demonstrated by showing that the change scores
also exceed the minimal clinically important difference,
defined as the smallest change that ensures clinically
relevant improvement. Several methods have been pro-
posed to determine the minimal clinically important
difference.36 An anchor-based method is preferred, in
which the change in an external criterion that may
be determined from either a clinician’s or a patient’s
perspective is used to “anchor” improvement. How-
ever, finding a valid external criterion, which often
will be very difficult,37 was beyond the scope of the
present study.

Physical Therapy . Volume 86 . Number 7 . July 2006 Faber et al . 951


Table 5.
Predictive Validity of the Performance-Oriented Mobility Assessment (POMA) Total Scale
(POMA-T), Balance Subscale (POMA-B), and Gait Subscale (POMA-G) in Predicting Fallers
and Nonfallers
Value for:
Parameter POMA-T POMA-B
X (SD) score
Nonfallers (n⫽56) 20.8 (5.5) 11.1 (3.8)
Fallers (n⫽25) 17.4 (5.5) 9.2 (3.6)
Optimal cutoff point 19 10
Sensitivity, % (95% 64.0 (44.5–79.8) 64.0 (44.5–79.8)
confidence
interval)
Specificity, % (95% 66.1 (53.0–77.1) 66.1 (53.0–77.1)
confidence
interval)
The concurrent validity values for the POMA-T and the
POMA-B were quite acceptable, as demonstrated by the
association with other physical performance tests
(R⫽ⱍ.64ⱍ–ⱍ.68ⱍ) and self-reported limitations (R⫽ⱍ.68ⱍ–
ⱍ.70ⱍ). The validity of the POMA-G scores was weaker.
The Spearman correlations in question ranged from
ⱍ.51ⱍ to ⱍ.56ⱍ. The correlations between the scores on the
POMA scales and the self-reported amounts of physical
activity (LAPAQ) were low, ranging from .33 to .38. It
may be argued, however, that self-reported physical
activity is less adequate as a reference test, because it is a
measure not of performance but of perception.38 Gen-
erally speaking, the concurrent validity values for the
POMA-T and the POMA-B concur with the (sparse) data
from previous studies.4 – 6 For the POMA-G, no such data
were reported earlier.
Discriminant validity was demonstrated by finding signif-
icant differences between subgroups of subjects defined
according to the type of walking aid that they used.
Although the POMA-T and the POMA-G differentiated
among the same (combined) subgroups and the
POMA-B differentiated between other subgroups, there
is no evidence for clear differences among the discrim-
inatory powers of the 3 scales.
The predictive validity with regard to falling was not
satisfactory for any of the POMA scales. Given optimal
cutoff criteria, both the sensitivity and the specificity of
the POMA-T and its subscales ranged from 62.5% to
66.1%. However, in studies in which other versions of
the POMA scale were used, similar values for sensitivity
and specificity were reported. In a prospective study of
60 community-dwelling older adults and using a 16-point
version of the POMA-B, the sensitivity was 61.5% and the
specificity was 69.5%.19 In another prospective study of
225 community-dwelling adults 75 years of age and older
952 . Faber et al
ўўўўўўўўўўўўўўўўўўўўўў
and using a 40-point version of the
POMA-T, the sensitivity was 70% and
the specificity was 52%.39 In a case-
control study of 80 participants and
using a modified 57-point version of
the POMA, the sensitivity was 70% and
POMA-G
the specificity was 65%.40 Only one
study, a case-control study involving
9.7 (2.4) community-dwelling older people and
8.3 (2.7) using a 24-point version of the
9 POMA-B, demonstrated much higher
64.0 (44.5–79.8) sensitivity and specificity: 95.5% for fre-
quent fallers versus nonfallers.41
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62.5 (49.4–74.0) Conclusion
The POMA-T and its subscales POMA-B
and POMA-G showed good relative reli-
ability, as well as concurrent and dis-
criminant validity. Nevertheless, the
POMA-G performed less well with regard to these clini-
metric properties. Given that the latter scale also showed
a ceiling effect, the POMA-T and the POMA-B should be
preferred. Responsiveness could be assessed only for
POMA-T; at the individual level, a change in score of at
least 5 points proved to be reliable, whereas a change in
the mean score of 0.8 point indicated a reliable change
in the mean score for a group of 30 subjects. Further-
more, it was demonstrated that the usefulness of the
POMA scales for predicting future falls was severely
limited.
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Appendix.
Performance-Oriented Mobility Assessment3

Balance
Instructions: The subject is seated on a hard, armless chair. The following maneuvers are tested.

Maneuver Description of Scoring

1. Sitting balance 0⫽Leans or slides on the chair, unable to maintain an upright position
1⫽Holds onto the chair to be able to sit upright
2⫽Sits stably, upright, and safely on the chair
2. Arising 0⫽Unable to arise without help
1⫽Able to arise but uses arms
2⫽Able to arise in one smooth motion without using arms
3. Immediate standing balance (first 5 s) 0⫽Unsteady, marked staggering, moves feet, marked trunk sway, or grabs object
for support
1⫽Steady but uses walker or cane or mild staggering but catches self without

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grabbing object for support
2⫽Steady without walker or cane or other support
4. Standing balance (after 5 s) 0⫽Unsteady
1⫽Steady but wide stance or uses cane or other support
2⫽Steady with narrow stance and without support
5. Standing balance with eyes closed 0⫽Unsteady
and feet together 1⫽Steady but wide stance or support is needed
2⫽Steady with narrow stance and without support
6. Nudged (light push on sternum, 0⫽Begins to fall, needs support to prevent falling
subject with feet close together) 1⫽Takes more than 2 steps backward to prevent falling
2⫽Steady, takes fewer than 2 steps backward
7. Turning 360° 0⫽Unstable, needs support
1⫽Stable with discontinuous steps (places one foot first before lifting the other)
2⫽Stable without support and with continuous steps
8. Sitting down 0⫽Unsafe (misjudged distance, falls onto chair)
1⫽Uses arms or not a smooth motion
2⫽Safe, smooth motion
Total balance score 0–16 points

Gait
Instructions: The subject stands with the examiner, walks down the hallway or room at the usual pace. The subject is asked to walk down the walkway,
turn, and walk back after being instructed to “go.” The subject should use the usual walking aid. The following characteristics are scored.

Characteristic Description of Scoring

1. Initiation of gait (immediately 0⫽Any hesitancy or multiple attempts to start

after “go”) 1⫽No hesitancy
2a. Step height 0⫽Left foot does not clear floor completely with step or is lifted too high (above right medial malleolus)
1⫽Left foot completely clears floor
0⫽Right foot does not clear floor completely with step or is lifted too high (above left medial malleolus)
1⫽Right foot completely clears floor
2b. Step length 0⫽Left swing foot does not pass right stance foot with step
1⫽Left foot passes right stance foot with step
0⫽Right swing foot does not pass left stance foot with step
1⫽Right foot passes left stance foot with step
3. Step symmetry 0⫽Right and left step lengths are not equal
1⫽Right and left step lengths appear equal
4. Step continuity 0⫽Stopping or discontinuity between steps
1⫽Steps appear continuous
5. Path deviation 0⫽Marked deviation to both sides or in one direction
1⫽Mild or moderate deviation or straight with a walking aid
2⫽Straight without a walking aid
6. Trunk sway 0⫽Marked sway or flexed knees or trunk or uses arms to maintain balance
1⫽Stable trunk balance without sway, no flexion, no use of arms, and no use of walking aid
7. Walking stance 0⫽Heels apart while walking
1⫽Heels almost touching while walking
8. Turning while walking (180°) 0⫽Staggering, taking breaks, discontinuous motion
1⫽Smooth, continuous motion
Total walking score 0–12 points

954 . Faber et al Physical Therapy . Volume 86 . Number 7 . July 2006