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Validity and Reliability of the Short Physical Performance Battery in

Two Diverse Older Adult Populations in Quebec and Brazil
Aline Nascimento Freire, Ricardo Oliveira Guerra, Beatriz Alvarado, Jack M.
Guralnik and Maria Victoria Zunzunegui
J Aging Health published online 15 March 2012
DOI: 10.1177/0898264312438551
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551Freire et al.Journal of Aging and Health
The Author(s) 2012

JAHXXX10.1177/0898264312438

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Validity and Reliability

of the Short Physical
Performance Battery in
Two Diverse Older Adult
Populations in Quebec and
Brazil

Journal of Aging and Health

XX(X) 116
The Author(s) 2012
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0898264312438551
http://jah.sagepub.com

Aline Nascimento Freire, MSc1,

Ricardo Oliveira Guerra, PhD1,
Beatriz Alvarado, MD, PhD2, Jack M. Guralnik, PhD3,
and Maria Victoria Zunzunegui, PhD4

Abstract
Objectives: To assess the validity and reliability of the Short Physical Performance Battery (SPPB) in adults 65 to 74 years old, capable in all basic activities
of daily living (ADL), in Quebec and Brazil. Methods: Participants were recruited in St. Bruno (Quebec) by local advertisements (n = 60) and in Santa Cruz
(Brazil) by random sampling (n = 64). The SPPB includes tests of gait, balance,
and lower-limb strength. Disability status was categorized as intact mobility, limited mobility, and difficulty in any of ADL. Results: There was a graded decrease
in mean SPPB scores with increasing limitation of lower limbs, disability, and
poor health. Using the testretest reliability the authors evaluated the intraclass
1

Universidade Federal do Rio Grande do Norte, Natal-RN, Brazil

Queens University, Kingston, Ontario, Canada
3
University of Maryland School of Medicine, Baltimore, MD, USA
4
Centre de recherche du Centre Hospitalire de lUniversit de Montral, Montreal, Canada
2

Corresponding Author:
Ricardo Oliveira Guerra, Department of Physiotherapy, Universidade Federal do Rio Grande
do Norte, Av. Sen. Salgado Filho, 3000 - Campus Universitrio, Natal-RN 59078-970, Brazil
Email: roguerra@ufrnet.br

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Journal of Aging and Health XX(X)

correlation coefficient, which was high in both samples: .89 (95% CI: 0.83, 0.93)
in St. Bruno and .83 in Santa Cruz (95% CI: 0.73, 0.89). Discussion: This study
provides evidence for the validity and reliability of SPPB in diverse populations.
Keywords
Short Physical Performance Battery, older adults, validity, reliability, Canada,
Brazil

Introduction
The Short Physical Performance Battery (SPPB) is one of the most common
tools to measure physical performance in population studies on aging
(Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995). The SPPB captures a hierarchy of functioning from high levels of function to severe deterioration of lower-extremity function, with higher scores indicating better
lower-body function. It is related to mobility disability and activities of daily
living (ADL) disability (Guralnik et al., 2000).
The SPPB is composed of three tasks: a hierarchical balance task, a short
walk at the usual speed, and five repetitive chair stands. Low scores in the
SPPB have predictive value for a wide range of health outcomes: mobility
loss, disability, hospitalization, length of hospital stay, nursing home admission, and death (Guralnik et al., 2000, 1994; Penninx et al., 2000; Volpato
et al., 2008). Reliability of the SPPB has been shown to be remarkably high
in the U.S. populations, with intraclass correlation coefficient (ICC) values
ranging between .88 and .92 (Ostir, Volpato, Fried, Chaves, & Guralnik,
2002). Sensitivity to change was formally evaluated by assessing the change
in the SPPB score associated with new onset of myocardial infarction, stroke,
hip fracture, and congestive heart failure. Decrements of SPPB were all significant. A decrease in SPPB was also observed for the group experiencing
any of these events compared with those without any of these four medical
conditions during follow-up (Ostir et al., 2002). Normative values of SPPB
have been published for representative U.S. populations by 5-year age groups
and sex (Guralnik et al., 2000); however, distributions of scores in diverse
populations are unknown.
Although the SPPB is an objective measure of physical performance and
less influenced by culture, educational level, and language than self-reported
measures of function and disability, there is a need to ascertain its validity
and reliability across populations, before it can be introduced into widespread
practice. We have conducted a pilot study in nondisabled men and women,

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Freire et al.

between 65 and 74 years of age, living in Canada and Brazil. One of the
objectives of this pilot study was to assess the validity and reliability of the
SPPB in people living in Quebec (Canada) and Rio Grande do Norte (Brazil),
communities that differ in culture, language, education, and income. As far as
we know, the SPPB has not been used in Canadian (Anglophone or Francophone)
populations or translated into French. In Brazil, the SPPB has been used in a sample of people older than 60 recruited at a geriatric clinic (Gomes et al., 2009;
Sposito et al., 2010). Testretest reliability of the SPPB in a sample of 30 institutionalized older adults from Brazil was high (ICC = .88; Nakano, 2007).
We present the analysis of reliability and validity of the SPPB in two
community samples. We evaluated the reliability by measuring the consistency of the SPPB at two different times. Previous studies have shown high
levels of correlation between the presence of some chronic conditions and
lower levels of SPPB (Ferrucci et al., 2000) and high predictive values of
SPPB for disability (Guralnik et al., 2000). Thus, we also evaluated the
validity of SPPB against presence of chronic conditions, mobility limitations, and disability in ADL.

Methods
Population and samples. Data are from a pilot study that was done in
preparation for a longitudinal research study on mobility in aging at two
Canadian and two Latin American sites. This larger study aims at increasing
knowledge on the sex/gendermobility gap and to guide community preventive strategies.
The pilot study took place in St. Bruno (Qubec, Canada) and in Santa
Cruz (Rio Grande do Norte, Brazil) between October and December 2009.
These communities represent very different socioeconomic conditions. St.
Bruno is a middle-class suburban population of 25,000 in habitants, located
15 km from Montreal. Santa Cruz is a city of 32,000 inhabitants in the center
of a rural area of northeast Brazil, located 150 km from Natal, the capital of
the province of Rio Grande do Norte.
Sample size calculations. This pilot study assessed the reliability and validity of a series of instruments intended for the longitudinal research project.
Sample size calculations were done to estimate the reliability of dementia and
depression assessment instruments: assuming a true Cohens Kappa of 0.80
against a null hypothesis of kappa = 0.45, in dichotomous measures with 20%
presence of the characteristics under study (e.g., dementia or depression) and
a power of 80%, we calculated a sample size of 64 (Cantor, 1996). This sample size of n = 64 is also sufficient to estimate an ICC of .80 for a continuous

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Journal of Aging and Health XX(X)

measurement such as the SPPB score and a minimum acceptable level of

reliability of .60 (Walter, Eliasziw, & Donner, 1998).
Eligibility criteria: (a) between 65 and 74 years of age, and (b) free of severe
ADL disability. Severe ADL disability was defined as the inability to perform
any of the following activities without help from another person: bathing,
getting out of bed, eating, grooming, or using the toilet. Those who reported
difficulties, but could do the above activities, were included in the study.
Sampling strategy: The sample participants at St. Bruno were recruited by
advertisements in the local newspapers and local stores. At Santa Cruz, a
community random sample was drawn from the municipal roll and was stratified by mobility disability (difficulty walking a mile or climbing one flight of
stairs) and sex, in 4 equal cells of 16 people, until recruitment of 64 people
had been achieved. Response at Santa Cruz was close to 100%.
Interviewer training. Interviewers at each site were trained using the same
standard training based on videotapes, protocol instructions, and data entry
forms at each site. SPPB assessments in St. Bruno were done by local nurses
who were trained by the principal researchers according to the researchers
domains of expertise. Assessments in Santa Cruz were done by local physiotherapists who were trained by the principal researchers who also participated in the training at the St. Bruno site. The three components of the test,
the scoring system, and the instructions are clearly explained in a video presentation available at the website given in the reference below.
Language. The questionnaires and all data collection documents were
translated from English into French and Portuguese. The SPPB instruction
manual is available online in English (http://www.grc.nia.nih.gov/branches/
ledb/sppb/). Professional translators translated instructions and coding sheets
into French. In Brazil, we used a Portuguese transcultural adaptation previously developed and tested in a nursing home population (Nakano, 2007).
Data Collection. Data were collected during two home visits, 5 to 7 days
apart in St. Bruno and 4 to 5 days apart in Santa Cruz. Each participant was
visited by a single interviewer, who was responsible for all data collected
from that participant. The duration of the first visit was between one and one
and a half hours; the second visit lasted between 30 and 45 min.
Variables. The SPPB includes three tests of lower-body function: a hierarchical test of standing balance, a 4-meter walk, and five repetitive chair
stands (Guralnik et al., 1995). Each SPPB component test (balance, gait, and
chair stand) is scored from 0 to 4 with a score of 0 representing inability to
perform the test and a score of 4 representing the highest category of performance, with scoring cutpoints derived from a large representative population
of older persons (Guralnik et al., 1994). For the balance tasks, the participants

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Freire et al.

are asked to stand with their feet side by side, followed by the semitandem
(heel of one foot along side the big toe of the other foot) and tandem (heel of
one foot directly in front of and touching the other foot) positions for 10 s
each. For gait speed, a 4-meter walk at the participants usual pace was timed.
For those who did not have 4 meters of space available in their homes, a
3-meter course was used and scoring was modified as indicated in the instructions. The test was repeated twice with the faster of the two walks used. For
the ability to raise from a chair, participants were asked to stand up and sit
down 5 times as quickly as possible with arms folded across their chests. This
was done only after participants first demonstrated the ability to rise once
without using their arms. Further details on the administration of these tests
have been published in the original papers (Guralnik et al., 1995, 1994) and
can be viewed at the SPPB website (Guralnik, 2011). A summary performance score was obtained by adding the scores of each individual SPPB
component test (range 0-12), with higher scores indicating better lower-body
function (Guralnik et al., 1994).
Chronic conditions were assessed by self-report as having been diagnosed
by a medical doctor for hypertension, heart diseases, diabetes, cancer,
chronic respiratory disease, arthritis, and depression. A single question on
self-reported health status (SRH) with five categories of response (excellent,
very good, good, fair, and poor) was also inquired. Single mobility items
from the Nagi scale related to mobility of the lower extremities (degree of
difficulty in pushing a large object such as an armchair, lifting a weight of
5 kg, climbing one flight of stairs, walking a mile, and kneeling or crouching)
were also assessed (Nagi, 1976). Depressive symptoms were assessed by the
Center for Epidemiologic Studies Depression Scale (CES-D), a 20-item selfreport scale. The overall score ranges from 0 to 60. The scale is often dichotomized: a score 16 indicates high probability of depression, whereas a score
< 16 indicates strong probability that depression is not present.
Disability was measured by self-report and classified using a hierarchical
scale: intact mobility, mobility disability and no ADL difficulty, and difficulty
in performing ADLs. This scale has been shown to have predictive validity for
mortality (Corti, Guralnik, Salive, & Sorkin, 1994). Mobility disability was
defined as having difficulty in walking a mile or climbing a flight of stairs
(Guralnik et al., 2000). Since the SPPB measures lower-extremity function, we
have included here only ADLs such as using the toilet, bathing, and dressing to
define ADL difficulty, as in similar research (Guralnik et al., 2000).
Living arrangements were classified into four categories: alone, with a
spouse, with a spouse and children, or only with children. Given the socioeconomic differences between the two populations, site-specific criteria for

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Journal of Aging and Health XX(X)

education and income were used. Education was categorized in St. Bruno as
less than high school, high school, vocational training, and university, and in
Santa Cruz as illiterate, incomplete primary, and primary education or more.
Income was measured in St. Bruno as less than C$1,000/month, between
C$1,000 and C$3,000, and more than C$3,000/month. In Santa Cruz, as in
any Brazil area, income is defined as a multiple of the minimum salary, which
is currently fixed on an amount equivalent to C$345/month (see Table 1).
Income sufficiency was assessed by a single question: Do you think you have
less money, enough money, or more than enough money to cover basic needs?
Occupation was assessed by the longest-held occupation and later reclassified
into four categories: manual, nonmanual, housewife, and professional.
Statistical analysis. ICCs were used to estimate testretest reliability. To
assess the construct validity of the SPPB total score, independent-samples t
tests were used to compare means of SPPB total score by the presence or
absence of selected chronic conditions and to compare means of SPPB total
score and components and the presence or absence of lower-extremity difficulties. ANOVA (analysis of variance) models were used to test for linear
trends of SPPB according to self-rated health categories. The F statistic to
test for linear trend was used to generate p values. Last, the F statistic to test
for linear trend was used to generate p values for the association between the
SPPB total score and components and disability levels. A mixed linear model
was fit to test for a learning effect, defined as a systematic improvement
between the first and the second administration of the SPPB during the two
home visits, separated by a week. Analysis was conducted with SPSS version
18 and STATA 9.0.

Results
Study populations. Table 1 shows the distribution of demographic and
socioeconomic indicators in both samples. Living arrangements, education,
and absolute income differed markedly in the two populations, and different
categories were needed to classify participants at each site. In St. Bruno,
almost half of the sample lived alone, whereas in Santa Cruz, this percentage
did not reach 10%. In St. Bruno, 40% of the participants reported a university
education, whereas in Santa Cruz, the equivalent percentage was illiterate. In
St. Bruno, 10.3% of participants had an income of less than C$1,000/month,
which corresponds to a minimum salary. In Santa Cruz, the minimum salary
was C$345/month, and 9.4% of participants fell into this category; 9.4% of
the older adults in Santa Cruz had more than 5 times the minimum salary.
More participants in Santa Cruz than in St. Bruno reported their income was

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Freire et al.
Table 1. Distribution of Demographic and Socioeconomic Indicators in Both
Samples

Sex (n)
Women
Men
Living arrangements (%)
Alone
With spouse only
With children

St. Bruno
(n = 60)

Santa Cruz
(n = 64)

41.0
19.0

32.0
32.0

40.0
51.7
5.0

With grandchildren

1.7

With parents
Education (%)
Less than high school
High school and some colleague

3.3

University
Income (monthly, %)
Less than C$1,000
Between C$1,000 and C$2,000
Between C$2,000 and C$3,000
More than C$3,000
Sufficiency of income (%)
Very sufficient
Sufficient
Insufficient
Occupation (%)
Manual worker
Nonmanual worker
Housewife
Professional

26.7
33.3
40.0
10.3
43.1
32.8
13.8

Alone
With spouse only
With spouse and
children
With children and
family

9.4
15.6
54.7
20.3

Illiterate
Less than primary
school
Primary and more

40.6
32.8

Less than MS*

From 1 to 5 MS
More than 5 MS

9.4
81.3
9.4

26.6

27.1
61.0
11.9

17.5
49.1
33.3

26.7
35.0
5.0
33.3

74.2
16.1
3.2
6.5

Note: MS = minimum salary.

not sufficient to cover basic needs (33.3% in Santa Cruz, compared with
11.9% in St. Bruno). Concerning the occupation held for the longest period,
the population of St. Bruno was evenly distributed between manual, nonmanual, and professional workers; in Santa Cruz, 74.2% of participants

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Journal of Aging and Health XX(X)

Table 2. Short Physical Performance Battery (SPBB) Reliability in Populations

Between 65 and 74 Years of Age in Santa Cruz (Rio Grande do Norte, Brazil) and
St. Bruno (Qubec, Canada)
Santa Cruz (n = 64)

St. Bruno (n = 60)

ICC

95% CI

ICC

95% CI

SPPB total
SPPB gait
SPPB chair
SPPB balance

.83
.75
.73
.55

(0.73, 0.89)
(0.63, 0.84)
(0.60, 0.83)
(0.38, 0.71)

.89
.90
.78
.75

(0.83, 0.93)
(0.85, 0.94)
(0.67, 0.87)
(0.63, 0.85)

Note: ICC = intraclass correlation coefficients; 95% CI = 95% confidence interval.

reported a manual occupation. The proportion of housewives was similar and

small in both samples (7.3% of women in St. Bruno and 6.7% in Santa Cruz).
SPPB reliability. Table 2 shows the estimates of testretest reliability for the
whole sample and separately for each site. Using the criteria proposed by
Landis and Koch (1977), it was found that the reliability was extremely high
for the total SPPB score in both research sites, .83 in Santa Cruz and .89 in
St. Bruno. In St. Bruno, reliability was also almost perfect for the gait component (.90) and substantial for the chair stand (.78) and balance (.75) scores.
In Santa Cruz, reliability was substantial for the gait (.75) and chair stands
(.73) components and moderate for the balance task (.55).
A systematic improvement of 0.53 points was observed in the SPPB score
when comparing performance during the second and first assessments. This
improvement was higher among people with mobility disability (0.72) than
among those without intact mobility (0.32); the improvement was significant
in both groups (p < .001).
Validity of the SPPB. The average of the two SPPB scores in Santa Cruz was
8.59 (2.5) and in St. Bruno 9.63 (2.44). Tables 3 and 4 show the mean values of SPPB according to chronic conditions and self-rated health at each site.
Reported comorbidity (two or more chronic conditions) was lower in Santa
Cruz (37.5%) than in St. Bruno (66.7%), contrary to expectations of a higher
number of chronic conditions in Santa Cruz. Although all chronic conditions
were significantly associated with lower scores of SPPB in St. Bruno, only
arthritis and depression were associated with the SPPB score in Santa Cruz.
Table 4 demonstrates the associations of self-rated health with the SPPB.
More than half of the St. Bruno participants rated their health as excellent or

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Freire et al.

Table 3. Mean (SD) Values of SPPB According to Self-Reported Chronic Conditions

at Each Site
Santa Cruz
Variables

Comorbidity
0-1 chronic conditions 40
24
2 and more
Hypertension (self-reported)
Yes
30
No
34
Diabetes
Yes
9
No
55
Lung disease
7
Yes
57
No
Cancer
Yes
3
61
No
Heart disease
8
Yes
56
No
Arthritis
Yes
20
44
No
Depression
18
CES-D 16 or more.
CES-D <16
46
Obesity
Yes
10
No
54

M (SD)

St. Bruno
p value

M (SD)

20
40

10.60 (1.39)
9.15 (2.71)

38
22

9.21 (2.80)
10.36 (1.43)

11
49

7.55 (3.05)
10.10 (2.04)

13
47

8.50 (3.12)
10.05 (2.03)

7
52

10.86 (0.69)
9.56 (2.49)

16
44

8.50 (3.12)
10.05 (2.03)

40
20

9.25 (2.67)
10.40 (1.73)

13
47

8.15 (3.21)
10.04 (2.04)

22
38

8.64 (2.77)
10.30 (2.01)

.20
8.90 (2.42)
8.08 (2.60)
.85
8.53 (2.45)
8.64 (2.58)
.60
9.00 (1.41)
8.52 (2.64)
.21
9.71 (1.49)
8.40 (2.50)
.17
6.66 (4.93)
8.68 (2.36)
.47
8.00 (2.97)
8.67 (2.45)
.01
7.45 (2.96)
9.11 (2.10)
.03
7.55 (3.22)
9.00 (2.06)
.13
7.50 (2.75)
8.79 (2.42)

p value
.02

.07

.001

.02

.17

.02

.08

.012

.01

Note: CESD-D = Center for Epidemiologic Studies Depression Scale; SPBB = Short Physical
Performance Battery. Independent-samples t test was used to generate p values. SPPB score
ranges from 0 to 12

very good, and only 3 participants (<5%) rated their health as excellent or
very good in Santa Cruz. Although only 6 people (10%) rated their health as
fair/poor in St. Bruno, this was the case for two thirds of the sample participants in Santa Cruz. In spite of the differences in the distribution of self-rated

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10

Journal of Aging and Health XX(X)

Table 4. Mean (SD) of SPPB According to Self-Rated Health at Each Site

St. Bruno

Santa Cruz

Self-rated health

SPPB

p value

SPPB

p value

Very good/excellent
Good
Fair
Poor

34
20
3
3

10.47 (1.76)
9.05 (2.35)
7.67 (4.93)
6.60 (2.64)

<.001

3
20
34
7

10.66 (1.15)
9.60 (1.87)
8.23 (2.24)
6.57 (3.95)

<.001

Note: SPPB = SPBB = Short Physical Performance Battery. F test for linear trend to generate p
values. SPPB score ranges from 0 to 12.

health between the two populations, the mean values of SPPB by level of
SRH were remarkably similar in both samples. For instance, the mean SPPB
among those rating their health as good was 9.05 in St. Bruno and 9.60 in
Santa Cruz.
Table 5 shows the means of SPPB total score and each component according to the presence or absence of difficulty encountered in performing the
lower-extremity items on the Nagi scale: pulling a large object such as an
armchair, lifting a weight, climbing stairs, walking a mile, and kneeling or
crouching. For each item except for climbing stairs in Santa Cruz, lower
SPPB scores were significantly associated with having difficulty or being
unable to perform the activity. It is likely that self-reported difficulty in
climbing stairs is inaccurate in Santa Cruz, since it is very flat, with few twostory buildings and virtually no stairs.
Table 6 shows the means of the total SPPB score and each of its components according to the three levels of the disability scale: no mobility disability, mobility disability, and any ADL disability. Lower SPPB scores were
observed with increasing disability level. This gradient was also observed in
the scores for gait and the repetitive chair stands. However, differences in the
balance score by disability level did not follow a clear gradient, but higher
performance was observed for those reporting intact mobility.

Discussion
Results of this pilot study demonstrate evidence of validity and substantial
reliability of the SPPB in two very different populations: a French-speaking
middle-class population in Quebec (Canada) and a Portuguese-speaking low

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Freire et al.

Table 5. Mean (SD) of SPPB Total Score According to Difficulty in Lower-Extremity

Items (Nagi Scale)
St. Bruno (n = 60)
Difficulty

Santa Cruz (n = 64)

Able

Armchair
SPPB total
10.36 (1.95)
SPPB gait
3.74 (0.59)
SPPB balance
3.77 (0.62)
SPPB chair stands
2.85 (1.14)
Weightlifting
SPPB total
10.28 (1.88)
SPPB gait
3.73 (0.62)
SPPB balance
3.80 (0.59)
SPPB chair stands
2.75 (1.11)
Climb one flight of stairs
SPPB total
10.51 (1.72)
SPPB gait
3.79 (0.60)
SPPB balance
3.86 (0.51)
SPPB chair stands
2.86 (1.10)
Walk 1 mile
SPPB total
10.89 (1.22)
SPPB gait
3.92 (0.27)
SPPB balance
3.89 (0.45)
SPPB chair stands
3.07 (0.97)
Kneel
SPPB total
11.15 (1.03)
SPPB gait
3.92 (0.26)
SPPB balance
3.92 (0.38)
SPPB chair stands
3.29 (0.87)

Difficulty
Unable

p value

Able

Unable

p value

8.28 (2.72)
3.14 (1.14)
3.43 (0.92)
1.71 (1.01)

.001
.012
.096
<.001

9.74 (1.61)
3.66 (0.55)
3.78 (0.58)
2.80 (1.10)

7.75 (2.72)
3.08 (0.84)
3.08 (1.36)
1.59 (0.98)

.001
.004
.015
.010

7.67 (2.92)
2.93 (1.18)
3.20 (1.01)
1.53 (1.06)

<.001
.002
.007
<.001

9.60 (1.57)
3.68 (0.57)
3.76 (0.54)
2.16 (1.08)

7.11 (2.89)
2.81 (0.85)
2.81 (1.52)
1.50 (0.99)

<.001
<.001
.001
.016

7.41 (2.62)
2.88 (1.17)
3.12 (0.94)
1.41 (0.79)

<.001
<.001
<.001
<.001

9.45 (1.90)
3.45 (0.68)
3.72 (0.70)
2.27 (1.03)

7.88 (2.74)
3.23 (0.91)
3.08 (1.36)
1.57 (1.04)

.012
.288
.260
.009

7.45 (2.50)
2.86 (1.16)
3.23 (0.97)
1.37 (0.73)

<.001
<.001
<.001
<.001

9.37 (1.67)
3.56 (0.60)
3.65 (0.71)
2.16 (1.01)

7.52 (3.04)
3.00 (0.96)
3.00 (1.49)
1.52 (1.09)

.003
.005
.024
.018

8.39 (2.57)
3.21 (1.08)
3.42 (0.90)
1.75 (1.00)

<.001
<.001
.009
<.001

9.84 (1.43)
3.69 (0.47)
3.84 (0.37)
2.31 (1.08)

7.73 (2.73)
3.08 (0.91)
3.05 (1.37)
1.60 (1.00)

.001
.003
.006
.010

Note: SPBB = Short Physical Performance Battery. p values were generated using independent-samples t
tests. SPPB score ranges from 0 to 12. The score for each SPPB component ranges from 0 to 4.

socioeconomic status population from Rio Grande do Norte (Brazil). The

validity of the SPPB was demonstrated by the strong and consistent association with health status measures, in spite of the socioeconomic and cultural
differences between St. Bruno and Santa Cruz.
Our results indicate substantial reliability for the total SPPB score and a
possible learning effect, as measured by the difference between two measures
under the same conditions (home interview, same interviewer). For logistical
reasons and to reduce respondent burden, we asked interviewers to complete
all measures for a given participant within 1 work week. Thus, the two SPPB

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Journal of Aging and Health XX(X)

Table 6. Mean (SD) of SPPB Total Score According to Level of Disability, Mobility
Disability, or Any ADL Disability
Level of disability (St. Bruno, n = 60)

No mobility
disability

SPPB total 10.89 (1.24)

SPPB gait
3.92 (0.28)
SPPB
3.89 (0.46)
balance
SPPB chair 3.08 (0.98)
stand

Mobility
disability

Any ADL
disability

Level of disability (Santa Cruz, n = 64))

p value

No mobility
disability

Mobility
disability

Any ADL
disability

8.40 (2.21) 7.00 (2.16)

3.30 (1.06) 2.62 (1.19)
3.40 (1.07) 3.15 (0.90)

<.001
<.001
.004

9.90 (1.74)
3.70 (0.47)
3.80 (0.52)

8.19 (2.25) 7.83 (2.90)

3.33 (0.86) 3.00 (0.90)
3.09 (1.22) 3.26 (1.29)

.015
.017
.210

1.70 (1.06) 1.23 (0.44)

<.001

2.40 (1.14)

1.76 (0.94) 1.56 (1.04)

.031

p value

Note: SPBB = Short Physical Performance Battery. F test for linear trend to generate p values. SPPB score
ranges from 0 to 12. The score for each SPPB component ranges from 0 to 4.

measures were taken 5 to 6 days apart. We believed this temporal separation

to be reasonable given similar separations in a previous reliability study
(Ostir et al., 2002). The learning effect we observed should be expected in
this relatively young and nonADL-dependent population, especially given
the short interval between SPPB measures, during which it was unlikely that
true changes in physical function occurred.
Perera, Mody, Woodman, and Studenski (2006) stated that annual changes
in the SPPB score between 0.27 and 0.50 could indicate small meaningful
changes and that annual SPPB changes between 0.99 and 1.34 would indicate
substantial change. The community-dwelling population in the study of Perera
et al. had a baseline average SPPB of 8.3 (2.7), somewhat lower but not far
from the average SPPB in our two populations. Our results suggest that clinically interpretable improvements of performance should take into account the
learning effect, particularly in younger older adult communities with little
cognitive impairment. However, the possible learning effect would cancel out
in clinical trials using the SPPB as outcome, since learning would be present
both in the intervention and in the control group (Rejeski et al., 2009).
The validity of the SPPB across populations in several states in the United
States has been previously ascertained by Guralnik et al. (2000), who showed
the high predictive value of the SPPB for different levels of mobility and
ADL disability in the EPESE study and Hispanic EPESE studies. More
recently, performance measures have been shown to predict ADL difficulty
(Wennie Huang, Perera, VanSwearingen, & Studenski, 2010) and loss of ability
to walk 400 meters over 3 years (Vasunilashorn et al., 2009). The reliability
and the sensitivity to change of the SPPB scores has been previously

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Freire et al.

established by Ostir et al. (2002) in a longitudinal study of a large population

of older women with disabilities in the United States. Our study contributes
some evidence for the reliability and validity of the SPPB in diverse non
English-speaking populations outside of the United States. Out of the three
SPPB tests, the gait test had the strongest associations with all disability and
health outcomes in both populations, and its predictive value was established
by Guralnik et al. Our pilot results are consistent with this observation. The
gait score is most strongly associated with the Nagi items and with the three
levels of disability in both populations. Recent research is now attempting to
examine components of gait variability to predict health outcomes (Brach,
Perera, Studenski, & Newman, 2008).
We found a lack of association between the presence of some chronic conditions and the SPPB score in Santa Cruz, such as diabetes, hypertension, and heart
diseases, for which previous associations have been found, and for which we
found significant associations in St. Bruno. It is likely that those chronic conditions were underreported in Santa Cruz, due to illiteracy or being undiagnosed.
Given the lower socioeconomic level of the population in Santa Cruz, we were
expecting higher levels of chronic conditions. Our previous analysis of the SABE
(Spanish acronym for Salud, Bienestar y Envejecimiento or Health, Well-being
and Aging Survey) participants from 7 Latin American populations in the age
group of 65 to 74 showed a higher prevalence of most chronic diseases (diabetes, hypertension, heart disease, arthritis) than what we found in Santa Cruz
(Zunzunegui, Alvarado, Beland, & Vissandjee, 2009). Since there is universal
health care in Brazil, it is likely that high health illiteracy in Santa Cruz has led to
underestimation of these conditions based on self-report.
Our study has some limitations. First, due to its cross-sectional nature,
predictive validity cannot be assessed. Second, we cannot state the representativeness of the sample in St. Bruno. We relied on a volunteer sample in
St. Bruno because it was estimated that it would take 18 months or more to
obtain clearance to use the Quebec Medicare list for random sampling. The
sample from Santa Cruz is a stratified random sample of the population of
Santa Cruz, but caution must be exercised not to interpret the distribution of
health indicators as prevalence without taking into account the sampling
scheme (not the aim of this article). However, the associations between the
SPPB total score and the self-rated health and functional limitations are similar at both sites, which suggests that the possible selection bias of the
St. Bruno sample is not a threat to the validity of the results. In spite of these
limitations, this study contributes to the literature by supporting the validity
and reliability of this physical performance measurement tool in diverse populations at the extremes of socioeconomic distribution.

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14

Journal of Aging and Health XX(X)

Acknowledgments
We thank the participants of St. Bruno and Santa Cruz and the nurses and physiotherapists who worked as interviewers during field work.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The authors disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: This work has been funded by the
Canadian Institutes of Health Research as project 187083 in 2008-30-010 Catalyst
Grant : Pilot projects in Aging.

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