Living4Health | Tinetti Gait / Balance Scale

Sitting Balance

Leans or slides in chair (0)

Steady / Safe (1)

Arising from Chair

Unable without help (0)

Able, but uses arms to help (1)

Able, without using arms (2)

Attempts to Arise

Unable without help (0)

Able, requires more than 1 attempt (1)

Able to rise with 1 attempt (2)

Immediate Standing Balance (First 5 Seconds)

Unsteady (staggers, moves feet, trunk sway) (0)

Steady, but uses cane/walker/furniture for support (1)

Steady without any support (2)

Standing Balance

Unsteady (0)

Steady, but wide stance (heels >4” apart) or uses support (1)

Narrow stance without any support (2)

Nudge Test (Requires second, qualified person)

Begins to fall (0)

Staggers, grabs, or catches self (1)

Steady (2)

Eyes Closed Balance

Unsteady (0)

Steady (1)

Turning 360 Degrees - Continuity

Discontinuous steps (0)

Continuous steps (1)

Turning 360 Degrees - Stability

Unsteady (grabs/staggers) (0)

Steady (1)

Sitting Down

Unsafe (misjudged distance, falls into chair) (0)

Uses arms or choppy motion (1)

Safe, smooth motion (2)

Initiation of Gait (Walking)

Any hesitancy or multiple attempts to start (0)

No hesitancy (1)

Step Length - (Right / Left Foot)

Does NOT pass left stance foot (0)

Passes left stance foot (1)

Does NOT pass right stance foot (0)

Passes right stance foot (1)

Step Height - (Right / Left Foot)

Right foot does NOT completely clear floor (0)

Right foot completely clears floor (1)

Left foot does NOT completely clear floor (0)

Left foot completely clears floor (1)

Step Symmetry

Right and left step length appear unequal (0)

Right and left step length appear equal (1)

Step Continuity

Stopping or discontinuity between steps (0)

Steps appear continuous (1)

Path Deviation

Marked deviation (0)

Mild/moderate deviation or uses walking aid (1)

Straight path without walking aid (2)

Trunk Stability

Marked sway or uses walking aid (0)

No sway, but flexion (knees/back) or spreads arms for balance (1)

No sway, no flexion, no use of arms/aid (2)

Walking Stance

Heels apart while walking (0)

Heels almost touching while walking (1)

Tinetti Gait / Balance Scale

Tinetti Gait / Balance Scale

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