Journal of Gerontology: MEDICAL SCIENCES Copyright 2001 by The Gerontological Society of America

2001, Vol. 56A, No. 4, M248–M252

Validity of the Multi-Directional Reach Test: A

Practical Measure for Limits of Stability in
Older Adults
Roberta A. Newton

Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania.

Background. Falls occur not only in the forward direction, but also to the side and backward. The purpose of this
study was to develop a portable and valid tool to measure limits of stability in the anterior-posterior and medial-lateral
directions.

Methods. Two hundred fifty-four community-dwelling older persons were administered the Berg Balance Test
(BBT), the Timed Up & Go Test (TUG), and the Multi-Directional Reach Test (MDRT). For the MDRT, subjects per-
formed maximal reaches with the outstretched arm forward (FR), to the right (RR), to the left (LR), and leaning back-
ward (BR), with feet flat on the floor. Reach was measured by the subject’s total hand excursion along a yardstick
affixed to a telescoping tripod.

Results. Mean scores on the MDRT were FR ⫽ 8.89 ⫾ 3.4 in., BR ⫽ 4.64 ⫾ 3.07 in., RR ⫽ 6.15 ⫾ 2.99 in., and LR ⫽
6.61 ⫾ 2.88 in. Interclass Correlation (ICC2,1) for the reaches were greater than .92. Reliability analysis (Cronbach’s
Alpha, .842) demonstrated that directional reaches measure similar but unique aspects of the MDRT. The MDRT dem-
onstrated significant correlation with the BBT sum and significant inverse relationship with the scores on the TUG. Re-
gression analysis revealed that activity level contributed to scores in the forward, right, and left direction and that fear of
falling contributed to scores in the backward direction.

Conclusion. The Multi-Directional Reach Test is an inexpensive, reliable, and valid tool for measuring the limits of
stability as derived by reach in four directions. Values obtained on relatively healthy community-dwelling older adults
serve as norms for screening patient populations.

A S the population of older adults increases, there is an

acute awareness of the impact of falls and fall-related
injuries because of morbidity, rising health care costs, and
reduction in the quality of life for the elderly. Although re-
search (1) and public health agendas (2) target the reduction
of falls and related-injuries among older adults, the number
of hip fractures has increased as demonstrated in the mid-
decade report of Healthy People 2000. Unintentional inju-
ries are the sixth leading cause of death in individuals over
age 65 and are the leading cause of death in people over age
85. The majority of these deaths are related to falls.
The fear of falling is common in older adults who have or
have not sustained a fall. Estimates range as high as 73% of
older adults have a fear of falling, which may lead to a de-
crease in activity levels and an increased risk of falls (3–5).
Not only is fear of falling a recognized concern of older
adults, but older adults also fear not being able to get up once
a fall has occurred (6). Approximately half of the older adults
who have fallen once or more than once required help to get
up after one of the fall episodes (6,7). These facts are of
concern particularly in light of the numbers of older adults
who live alone.
The ability to confidently and safely perform routine
daily activities requires the older adult to generate appropriate
motor strategies to navigate in an environment containing
both stationary and moving objects within varying contexts.
Balance is also needed while the individual manipulates the
environment and the feet are stationary. Activities such as
bending or reaching up or to the side require shifting the
center of gravity (COG) within the base of support (BOS).
Once the COG moves outside the BOS, the limits of stabil-
ity (LOS) for the currently executed balance strategy are ex-
ceeded. An automatic movement strategy is executed to
maintain balance by either realigning the COG within the
BOS or by evoking a step strategy and establishing a new
BOS. If the appropriate movement strategy is not executed,
the individual may stumble or fall in an attempt to regain
balance.
The Functional Reach Test (FRT) is an inexpensive and
easy to use tool to assess LOS in the forward direction (8).
The FRT measures LOS only in the forward direction.
Older adults with balance instability tend to overestimate
their forward reach ability (9). An overestimation of forward
reach coupled with reduced postural limits (10,11) may cause
loss of balance in older adults performing activities associ-
ated with moving the COG toward the forward LOS.
Older adults also fall laterally and backward (12). Hip
fractures are more likely to occur with a sideways fall (13–
15), and among women wrist fractures are more likely to
occur from falling on the outstretched hand in the backward
direction (13). Induced sway in lateral direction during
blindfolded conditions has been found to be an excellent
predictor of fall risk (16,17). An assessment tool was devel-
oped to measure medio-lateral reach, but as with the For-

M248
 MULTI-DIRECTIONAL REACH TEST M249

ward Reach Test it is limited in the direction of reach (18).

Knowledge of reach in one direction has not been shown to
predict reach in other directions.
A primary aim of this study was to test the reliability and
validity of the Multi-Directional Reach Test (MDRT) as an
inexpensive screening tool to measure the limits of stability
in four directions. That is, how far an individual can volun-
tarily reach, thereby shifting the COG to the limits of the
BOS with the feet stationary. A secondary aim was to deter-
mine whether reach in one direction predicts reach in other
directions. A preliminary introduction to this test is found
elsewhere (19). Figure 1. Positions of the Multi-Directional Reach Test. A, Posi-
tion for the individual to reach forward or lean backward. B, Position
for the individual to reach to the right. The task was repeated using
METHODS the left arm.
Subjects were 254 community-dwelling older adults (mean
age ⫽ 74.1 ⫾ 7.9 years) from senior centers or residential
housing centers located in North Philadelphia, a federally Two trials were recorded for each direction. The procedure
designated medically underserved area. Older adults were was repeated with the backward (BR), right (RR), and left
excluded if they were wheelchair bound or could not lift (LR) directions.
both outstretched arms to 90⬚ in the forward direction. Appropriate descriptive statistics were used to analyze data
Eighty-six percent of the population represented minority from the questionnaire. Test-retest reliability was obtained for
backgrounds. The majority of the participants were women the MDRT. Pearson correlation statistics were used to com-
who lived alone. pare scores on the MDRT to scores on the BBT and TUG.
After signing an informed consent form, subjects com- Multiple regression analysis was used to determine how fac-
pleted a questionnaire that included demographics, health, tors such as health status, activity status, fall history, and fear
activity status, and fall history. Translators were used for of falling as measured by a Fear of Falling Index contributed
Spanish-speaking subjects. The questionnaire included items to scores on the MDRT. ANOVA with post-hoc Bonferroni
related to health status (excellent, good, fair, poor), the num- analysis was used to examine the mean for each direction of
ber of falls in the past six months, the frequency of perform- the MDRT in relation to the use of assistive devices and health
ing social and physical activities, and a fear of falling index status (i.e., excellent, good, fair, poor).
(6,20). The Berg Balance Test (BBT) (21), the Timed Up &
Go Test (TUG) (22), and the MDRT were administered. RESULTS
The customary assistive device was permitted only during Table 1 gives the socio-demographic and health status
the performance of the TUG. data for the sample. The group, by self-report, considered
The BBT assesses performance on 14 routinely performed their health status as good to excellent (67.1%), did not have
activities. Tasks include standing, turning 360⬚, picking up a fear of falling (58.6%), and had not fallen in the past 6
an object from the floor, and alternate foot placement (19). A months (78.6%). Approximately 19% of the older adults did
zero to four point rating system is used for each task for a not take medications, and 10% took more than four medica-
maximum score of 56. The TUG is a timed measure of an tions. The majority of older adults did not use an ambulatory
individual’s ability to stand, walk 10 ft, and return to the ini- device (69.6%), and those using a mobility aid used a cane.
tial seated position. Subjects completed the TUG at their
typical pace.
The following procedures were used for the MDRT (Fig-
ure 1). A yardstick affixed to a telescoping tripod was Table 1. Sociodemographic and Health Status
placed at the level of the subject’s acromion process. Prior
Mean age 74.1 ⫾ 7.9 y
to the reach, the yardstick was leveled so that it was hori-
Gender Self-report health status
zontal to the floor. The older adult lifted an outstretched arm Men 21.5† Excellent 13.5
to shoulder height, paused for an initial reading, then reached Women 78.5 Good 53.6
as far forward (FR) as possible. Instructions given to older Race Fair 27.8
adults were “without moving your feet or taking a step, reach African American 69.0 Poor 5.2
as far (direction given) as you can, and try to keep your hand Hispanic 17.1 Assistive device
along the yardstick.” For the backward direction the subject Caucasian 11.9 No 69.6
Other 2.0 Yes 30.4
was asked to “lean as far back as you can.” Individuals used Living status Fear of falling
their typical strategy to accomplish the task. Participants Alone 51.6 Not afraid 58.6
used their arm of choice for the forward and backward tasks, With others 48.4 Afraid, same activity level 24.3
and used the respective arm for the right and left reaches. Medications Afraid, decr activity level 17.1
The start and end positions of the index finger of the out- None 19.3 Tripped/Fallen in the past 6 mo
stretched hand were recorded, and the difference represented 1–4 70.5 No 78.6
⬎4 10.2 Yes 21.4
the total reach for that direction. Feet were maintained flat
on the floor; if the feet were moved, the trial was discarded. †Values are percentages.
M250 NEWTON

Table 2. Scores on the Berg Balance Test, Timed Up & Go, and .0947. t-tests for paired samples demonstrated no significant dif-
Multi-Directional Reach Test ference between the two trials for reach in the forward direction.
Test Mean SD Min Max
Significant differences were noted between trials for the back-
ward, right, and left directions, indicating a practice effect
BBT (max. ⫽ 56) 48.6 6.0 23.0 56.0 across the two trials; however, effect sizes were small: FR ⫽
TUG (s) 15.6 7.0 6.0 47.8
MDRT
0.09, BR ⫽ 0.14, RR ⫽ 0.18, and LR ⫽ 0.21. Table 3 presents
FR (in) 8.89 3.4 0.5 16.8 a correlation matrix for the four directions of reach. A strong
BR (in) 4.64 3.1 0.4 14.0 correlation for the reaches is noted (p ⵑ .0004). Cronbach’s al-
RR (in) 6.86 3.0 0.7 18.2 pha, a measure of the internal consistency of the test instrument,
LR (in) 6.61 2.9 0.0 14.4 was 0.842 (Table 3). Deletion of any one of the test items did
Note: BBT ⫽ Berg Balance Test; TUG ⫽ Timed Up & Go Test; MDRT ⫽ not significantly improve the alpha value.
Multi-Directional Reach Test; FR ⫽ arm stretched forward; BR ⫽ leaning back- The Pearson correlation statistic (Bonferroni adjust-
ward; RR ⫽ arm stretched to the right; LR ⫽ arm stretched to the left. ment, p ⵑ .0004) revealed that scores on the MDRT demon-
strated significant correlation with the BBT sum: FR (r ⫽
0.476), BR (r ⫽ 0.356), RR (r ⫽ 0.389), and LR (r ⫽ 0.390). It
Table 2 shows the scores for the BBT, TUG, and MDRT. also revealed that scores on the MDRT demonstrated signif-
Distribution for the average reaches in the four directions is icant inverse relationships with the scores on the TUG: FR
located in Figure 2. Interclass correlation, ICCs (1,2), for the (r ⫽ ⫺0.442), BR (r ⫽ ⫺0.333), RR (r ⫽ ⫺0.260), and LR
MDRT were FR ⫽ 0.942, BR ⫽ .0929, RR ⫽ .0926, and LR ⫽ (r ⫽ ⫺0.310).

Figure 2. Distribution of reach scores for the Multi-Directional Reach Test (average of two trials). A, Histogram of forward reach scores. B,
Histogram of backward reach scores. C, Histogram of right reach scores. D, Histogram of left reach scores.
 MULTI-DIRECTIONAL REACH TEST M251

Table 3. Reliability Analysis (Cronbach’s Alpha) for the
Multi-Directional Reach Test Correlation Matrix
Direction FR BR RR
FR 1.0000
BR 0.4979 1.0000
RR 0.6176 0.4957 1.0000
LR 0.6104 0.4926 0.7493 1.0000
Alpha ⫽ 0.842
Note: Abbreviations as in Table 2.
Table 4 shows the mean scores for each direction of reach
in relation to various health factors. Multiple regression
analysis examining activity level, fear of falling, health sta-
tus, and fall history revealed that the activity level contrib-
uted significantly ( p ⬍ .0004) to the scores in the forward,
right, and left directions. Fear of falling, as measured by the
Fear of Falling Index, contributed significantly to scores in
the backward direction. Subjects were subdivided relative to
health status, use of an assistive device, and history of falls.
Mean scores on the MDRT for each subcategory were ob-
tained (Table 4). No significance associations ( p ⬎ .5) were
noted between mean scores on the MDRT and these catego-
ries of health status.
DISCUSSION
Limitations in the ability to shift the center of gravity to-
ward the limits of stability may result in reductions in the
activity level of older adults. The use of force plates to ex-
amine postural responses to unexpected perturbing condi-
tions or to measure forward reach may not be practical for
screening, particularly in community settings (23–25). In
addition, force-plate studies using destabilizing forces evoke
a compensatory motor response compared with an anticipa-
tory balance strategy evoked during voluntary movement of
the COG when the person performs activities of daily living.
This study examined the reliability, validity, and practi-
cality of the MDRT to measure limits of stability in settings
where computerized force-plate systems are too expensive
or where a more mobile clinical assessment is required. When
voluntarily moving the center of gravity toward the limits of
stability (with feet not moving), a greater excursion is ex-
pected in the forward compared with the backward direction,
and medio-lateral excursions should be symmetrical. This
excursion pattern was observed with the MDRT (Figure 2).
Reaches to the right and left were symmetrical and therefore
were not influenced by either arm or foot dominance. Be-
cause of the biomechanical arrangement of the ankle and
foot, there is a greater capability for forward excursion of
the body over the foot than for backward excursion. In addi-
LR
tion, fear may be contributing to this decreased amount of
BR as noted by a significant affect of fear, as measured by
the Fear of Falling Index, on the BR scores. Although not
tested, muscle strength of the anterior tibialis and hip abduc-
tor muscles may contribute to reach scores in the respective
directions.
In this group of community-dwelling older adults, no as-
sociation was noted between assistive device use, health sta-
tus, or self-report of falls. However, the results indicate a
tendency for lower mean reaches for each of these catego-
ries. To determine if the MDRT predicts falls, a sample of
community-dwelling older adults with medically documented
falls is currently under study. The group of older adults repre-
sents primarily a culturally diverse sample (86.1% African
American and Hispanic) from a relatively low socio-economic
region (North Philadelphia). The predictability of the MDRT
for assistive device usage and falls needs to be examined in
other socio-economic and ethnic groups, in homebound com-
munity-dwelling older adults, and in those residing in long
term care facilities.
In this study, older adults voluntarily performed the MDRT
in a freestanding environment and not close to a wall as noted
in the FRT. Therefore, the MDRT may be more challenging
because there is no wall to provide perceived security. This
factor may account for the lower mean FR observed in the
MDRT (8.89 in) as compared with published mean values of
the FRT (10.9 in.) (26). A lower reach score also occurred
because the subjects were instructed to maintain the feet flat
on the floor and not to take a step. Such instructions provide
a more accurate assessment of the limits of stability. Overbal-
ancing and taking a step indicates that the postural strategy
used to maintain COG over the BOS was exceeded and that a
new movement strategy was evoked to maintain balance.
When administering the MDRT, it is recommended that
two trials be given for each direction. Although there was a
notable difference between the first and second trials in the
backward, right, and left directions, the effect size was small.
That is, the relative magnitude of the differences between the
two trials for a particular reach direction was small. Variation
in the movements used to perform the reach may account for
the differences noted between the two trials per task. A cur-
rent study will examine the method of reach in each direction
through component analysis of movement patterns used in
the upper extremities, trunk, and lower extremities.
Cronbach’s alpha was not improved with the deletion of
any one of the reach directions, indicating that each direc-
tion measures similar but unique aspects. This finding indi-

Table 4. Mean Multi-Directional Reach Test Scores in Relation to Selected Measures of Falls Status
Assistive Device Health Status Falls

No Yes Excellent Good Fair Poor No Yes

Direction Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Forward (in) 9.72 (3.19) 7.10 (3.11) 9.29 (3.37) 9.07 (3.46) 8.81 (3.33) 6.43 (2.94) 9.07 (3.19) 8.38 (4.07)
Backward (in) 5.39 (3.19) 3.25 (2.20) 5.16 (3.18) 5.09 (3.19) 3.86 (2.69) 3.33 (2.90) 4.80 (3.1) 4.06 (2.94)
Right (in) 7.57 (2.96) 5.62 (2.55) 7.54 (4.10) 7.0 (2.89) 6.53 (2.57) 5.25 (2.46) 7.08 (3.04) 6.12 (2.76)
Left (in) 7.33 (2.80) 5.33 (2.45) 6.94 (3.03) 6.56 (2.83) 6.60 (2.99) 5.72 (1.57) 6.86 (2.80) 5.67 (3.06)
M252 NEWTON
cates that measurement in a single direction (e.g., forward
reach) does not necessarily predict reach values in the other
directions. Because falls occur in all directions, reach as a
measure of the limits of stability needs to be assessed in all
directions.
Although the effect of test order was not examined, it is
recommended that a standard order of forward, backward,
right, and left directions be used to compare the scores with
published values. Because the backward direction is associ-
ated with the Fear of Falling Index, this direction should not
be the first direction tested.
Scores on the MDRT demonstrated an appropriate posi-
tive relationship with scores on the BBT; that is, the higher
the scores on the BBT (max ⫽ 56), the greater the distance
reached in all directions on the MDRT. Conversely, scores
on the MDRT demonstrated an appropriate inverse relation-
ship with scores on the TUG; that is, the faster the individ-
ual performed the TUG (lower timed scores), the greater the
distance reached in all directions on the MDRT. The signif-
icant but low correlation between scores in the MDRT and
scores on the BBT and TUG indicate that these screening
tests measure similar but unique aspects of balance abilities.
Therefore, it may be justified to perform these tests in con-
junction with one another to obtain a more comprehensive
assessment of balance abilities. The MDRT measures the
limits of stability with the feet stationary; the TUG mea-
sures balance abilities during various phases of standing,
walking and turning, and the BBT measures balance abili-
ties while the individual performs tasks that mimic tasks
routinely performed in every day life.
In summary, the MDRT is a valid and reliable clinical
measure for limits of stability. The screening tool can be
used with other tools such as the BBT and TUG to obtain a
comprehensive clinical measure of balance abilities in older
adults. On the basis of such assessments, effective preventa-
tive and rehabilitative measures can be developed.
Acknowledgments
This work was partially supported by HSRA/PHS 1 D27 AH 00720.
I thank DeWitt Kay, PhD, for his statistical support.
Address correspondence to Roberta A. Newton, PhD, Department of
Physical Therapy, Temple University, 3307 North Broad St, Philadelphia,
PA 19140. E-mail: rnewton@astro.temple.edu
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Received August 13, 1999
Accepted March 31, 2000
Decision Editor: William B. Ershler, MD