Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review
Abstract
:1. Introduction
2. Materials and Methods
2.1. Search Strategy
2.2. Study Selection
2.3. Data Collection
3. Results
3.1. Synthesis of the Results
3.1.1. The Gait Profile Score
3.1.2. The 10 Meter Walk Test
3.1.3. The Spinal Cord Injury Functional Ambulation Profile
3.1.4. The Timed up and Go Test
3.1.5. The Five Times Sit-to-Stand Test
3.1.6. The Six-Minute Walk Test
3.1.7. The Walking Index for Spinal Cord Injury (WISCI)
3.1.8. The Spinal Cord Injury Functional Ambulation Inventory
3.1.9. The Spinal Cord Independence Measure mobility items
3.1.10. The Locomotor Stages in Spinal Cord Injury
3.1.11. The Berg Balance Scale
3.1.12. The Community Balance and Mobility Scale
3.1.13. The Activity-based Balance Level Evaluation Scale
4. Discussion
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Property | Definition | Standard Value |
---|---|---|
Reliability | Reproducibility: degree to which the score is free from random error (including test re-test reliability, intra- and interrater reliability) [14]. Internal consistency: homogeneity of the items [14]. | Intra- and interrater reliability (Spearman or Pearson coefficients, k coefficient 1, ICC 2): ≥0.75 excellent, 0.40–0.74 moderate, ≤0.39 poor [14]. Test re-test reliability: SRD 3 [16]. Cronbach’s α: ≥0.80 excellent, 0.70–0.79 adequate, ≤0.69 poor [14]. |
Validity | Assessing if the instrument actually measures what it intends to measure [14]. Criterion validity (concurrent, convergent, predictive) is the extent to which scores on a particular questionnaire relate to a gold standard. For most of the functional scales, there was no criterion standard and, hence, construct validity was used [17]. | Jaspen coefficient of multiserial correlation (M) [18], point biserial correlation coefficient (rpb) [19], Spearman (ρ) or Pearson (r) coefficients: ≥0.70 excellent, 0.50–0.69 moderate, ≤0.49 poor [14]. |
Responsiveness | The ability of a questionnaire to detect clinically important changes over time [17]. Floor or ceiling effect: the number of respondents who achieved the lowest (floor) or highest (ceiling) possible score [17]. | SRD 3 [14], ROC analysis 4 [20], p−value 5 [11], SRM 6 (0.20 small, 0.50 medium, >0.80 large responsiveness), linear regression analysis [21]. Problematic when >20% of subjects received either minimum or maximum scores [14]. |
Categories | Outcome Measures |
---|---|
Multivariate walking metrics | GPS 1 |
Spatiotemporal-related walking/balance measures | |
Timed measures | |
Speed-related walking tests | 10MWT 2 |
SCI-FAP 3 | |
Speed-related balance tests | TUGT 4 |
FTSST 5 | |
Distance measures (endurance-related walking tests) | 6MWT 6 |
Categorical measures of ambulation | |
Walking assessment measures | WISCI 7 |
SCI-FAI 8 | |
Multidimensional measures (locomotor-related subscales) | SCIMIOMob 9 |
LOSSCI 10 | |
Balance measures | BBS 11 |
CB&M 12 scale | |
ABLE 13 scale |
Reference | Outcome Measures | Sample Size | Injury Features: Etiology (E) AIS 1 | Population: Age (Mean ± SD) Gender (M/F) 2 | Inclusion/Exclusion Criteria (IC/EC) | Psychometric Properties | Results |
---|---|---|---|---|---|---|---|
Wedege et al. [22] | GPS | 15 | E: Traumatic and non-traumatic. AIS 1: D. | Age range: 25–62 11 M/4 F. | IC: ≥ 1 year post-injury, ability to walk 10 m without personal assistance. EC: other diseases affecting gait; BTIs 3 and orthopedic treatment or neurosurgery in the lower limbs within the last 3–6 months. | Inter-and intra-session reliability. | ICC ≥ 0.93 (intersession, except hip rotation), ≥0.96 (intrasession). |
Van Hedel et al. [23] | 10MWT 6MWT TUGT | 22 75 | E: Traumatic and ischemic. AIS 1: A-D. | Reliability group: 52 ± 20 14 M/8 F. Validity group: 54 ± 20 45 M/30 F. | IC: WISCI II > 0 and no additional gait impairments. | Inter- and intrarater reliability and concurrent validity. | r > 0.97; |r| > 0.88 (10MWT, 6MWT, and TUGT correlated between each other), |ρ| > 0.60 (correlated with WISCI II). |
Poncumhak et al. [19] | 10MWT TUGT FTSST | 66 16 | E: Traumatic and non-traumatic. AIS 1: C, D. | Validity groups: FIML 4 6: 50.9 ± 13.4 22 M/11 F. FIML 4 7: 50.2 ± 9.5 24 M/9 F. Reliability group: 50.8 ± 10.3 11 M/5 F. | IC: ability to stand up independently and to walk at least 50 m with or without AADs 5 (FIML 4 scores 6–7). | Concurrent validity and interrater reliability. | rpb = 0.78, −0.69, −0.60 (10MWT, TUGT, and FTSST correlated with FIML 4, respectively); ICC = 0.997–1.00 |
Van Hedel et al. [11] | WISCI II 6MWT 10MWT | 22 | E: Traumatic and non-traumatic. AIS 1: N/A 6. | 45.5 ± 16.7 18 M/4 F. | IC: functional ambulation within the first month after injury (WISCI II ≥ 1). | Responsiveness. | WISCI II (over the first 3 months): p = 0.005; 6MWT and 10MWT (over the first 6 months): p < 0.001–0.01 |
Scivoletto et al. [10] | 10MWT | 37 | E: Traumatic and non-traumatic. AIS 1: C, D. | Age range: 19–77 28 M/9 F. | IC: functional ambulation at home or community, with or without the use of AADs 5. EC: cognitive deficit, cardiac or lung diseases. | Inter- and intrarater reliability. | ICC = 0.95–0.99; p = 0.09 (in both dynamic and static start conditions). |
Musselman et al. [18] | SCI-FAP | 32 60 able-bodied. | E: N/A 6. AIS 1: C, D. | 47.6 ± 14.2 24 M/8 F. 42.9 ± 16.0 34 M/26 F. | IC: ≥ 6 months after injury, ability to walk ≥ 5 m with or without physical assistance and/or AADs 5, free of any disease and changes in medications affecting walking ability, not receiving walking training. IC: > 18 years, ≤ 1 fall in the previous month, free of any disease affecting walking ability. | Interrater and test-retest reliability, internal consistency, convergent and discriminative validity. | ICC = 1.00 (interrater), 0.98 (test-retest); α = 0.95; r = −0.59 (correlated with 10MWT and 6MWT), M = 0.68 (correlated with WISCI II), higher scores in injured individuals related to able-bodied ones. |
Marino et al. [24] | WISCI II | 26 | E: Traumatic and non-traumatic. AIS 1: A, C, and D. | 46.4 ± 19.3 16 M/10 F. | IC: ≥ 6 months after injury, independent lower limb weight bearing once a week. EC: SS 7 WISCI < 6 or equal to 20, any other medical condition which could limit safety ambulation. | Intra- and interrater reliability. | SS 7 WISCI: ICC = 1.00 (intra- and interrater). Maximum WISCI: ICC = 1.00 (intra-), 0.98 (interrater). |
Morganti et al. [25] | WISCI II | 76 | E: Traumatic and non-traumatic. AIS 1: A-D. | 50.4 ± 19.3 184 M/100 F. | IC: WISCI > 0 and < 20.EC: cognitive impairments that disable to participate in the rehabilitation program. | Concurrent validity. | Correlation with SCIM IMob items (ρ = 0.97) and FIML 4 (ρ =0.70). |
Ditunno et al. [26] | WISCI II | 146 | E: Traumatic. AIS 1: B-D. | Age range: 16–69 78% M/22% F. | IC: subjects within 8 weeks of onset of injury and within 1 week of admission for rehabilitation. EC: FIML 4 > 3. | Concurrent and predictive validity. | Correlations at 6 months with BBS (ρ = 0.90), FIML 4 (ρ = 0.89), and 6MWT (ρ = 0.79). |
Scivoletto et al. [16] | WISCI II | 33 | E: Traumatic. AIS 1: C, D. | Median age: 44. 28 M/5 F. | IC: subjects within 3 months of onset of injury, with a motor level of C4-L1 inclusive. | Intra- and interrater reliability, and test re-test reliability. | Maximum WISCI II scores: ICC = 0.975–0.999; SRD = 1.15, 1.68 (tetra- and paraplegics, respectively). |
Field-Fote et al. [27] | SCI-FAI | 22 19 | E: N/A 6. AIS 1: N/A 6. | Validity/reliability group: 32 ± 13 17 M/5 F. Sensitivity group: 31.7 ± 9.4 13 M/6 F. | IC: ability to maintain stance on the weight-bearing limb independently and to take at least 8 steps using any AADs 5. IC: N/A 6. | Intra- and interrater reliability, convergent validity, and sensitivity. | ICC = 0.70–0.96; r = −0.74, −0.70 (gait score correlated with the 10 feet-walking speed); r = 0.58 (gait score correlated with LEMS 8 to assess sensitivity). |
Van Hedel et al. [21] | SCIM II IOMob items | 886 | E: Traumatic. AIS 1 A: 413 AIS 1 B: 113 AIS 1 C: 137 AIS 1 D: 223 | 39 ± 18; 19% F. 42 ± 18; 27% F. 48 ± 20; 32% F. 47 ± 17; 22% F. | IC: patients classified with AIS at 1 month after injury and assessed at least at 2 successive time points (at 2 weeks and 1, 3, 6, and 12 months after injury) with SCIM II and either the 10MWT or WISCI II. | Concurrent, validity, internal, and external responsiveness. | IMob items correlated with 10MWT and WISCI II in AIS C-D: ρ = 0.75–0.91; SRM = 0.67–1.24 (IOMob items in AIS C-D); linear regression analysis = 0.79 (IMob items correlated with 10MWT in AIS C). |
Maurer-Burkhard et al. [28] | LOSSCI | 65 161 | E: N/A 6. AIS 1: C, D. E: N/A 6. AIS 1: A-D. | Reliability group: 44.9 ± 16.0 77% M/23% F. Validity group: 48.3 ± 20.2 65.8% M/34.2% F. | IC: 18–80 years, ≥ 8 weeks after injury, having been assessed by 2 raters in 2 successive assessments within 1–5 days. IC: SCIM databases from the EM-SCI 9 obtained within the first year after injury. | Interrater reliability and construct validity. | WCk 10: 0.98; ρ = 0.77–0.82 (correlated with SCIM IOMob items). |
Lemay et al. [29] | BBS | 32 | E: Traumatic and non-traumatic. AIS 1: D. | 47.9 ± 12.8 25 M/7 F. | IC: ability to walk 10 m independently with or without AADs 5. EC: other neurological conditions or existence of walking difficulties before the injury. | Concurrent validity and responsiveness. | ρ = 0.71–0.82 (correlated with the SCI-FAI, WISCI II, 10MWT and TUGT); ceiling effect: 44.8% (WISCI II), 68.8% (gait score SCI-FAI), 34.4% (BBS and Walking Mobility and assistive devices section of SCI-FAI). |
Wirz et al. [20] | BBS | 42 | E: Traumatic and non-traumatic. AIS 1: A-D. | 49.3 ± 11.5 33 M/9 F. | IC: ≥ 1 year after injury prior to enrollment, ability to walk unless 15 m. EC: < 18 or > 65 years, vestibular or visual systems impairments, and others affecting standing or walking function. | Construct validity, interrater reliability, and responsiveness. | ρ = −0.82, −0.89, −0.93 (correlated with WISCI II, SCIM II Mob items, and 10MWT, respectively); ICC = 0.95; ROC = 0.48 (95% confidence interval = 0.29–0.67), ρ = −0.17 (number of falls), ceiling effect: ±1/3 of subjects (BBS, WISCI II, SCIM II). |
Chan et al. [4] | CB&M scale | 30 | E: Traumatic and non-traumatic. AIS 1: C, D. | 38.3 ± 15.3 23 M/7 F. | IC: < 65 years, FIM 4 ≥ 115 at discharge, ability to complete the CB&M scale and any other balance or walking outcome measures within one week of each other. EC: significant comorbid condition. | Convergent validity, internal consistency. | r = 0.47–0.72 (correlation with the 6MWT, 10MWT and BBS); α = 0.87 |
Ardolino et al. [30] | ABLE scale | 104 | E: Traumatic. AIS 1: A–D. | 38.6 ± 15.0 79 M/25 F. | IC: ≥ 16 years, traumatic origin of the injury. EC: inability to tolerate upright supported sitting for at least 1 min, need for a spinal stabilization device, limited ability to bend or rotate, inability to follow 2-step commands. | Responsiveness. | Minimal floor and ceiling effects. |
Reliability | Validity | Responsiveness | |||||||
---|---|---|---|---|---|---|---|---|---|
Inter- and Intrasession | Test Re-Test | Intrarater | Interrater | Internal Consistency | Concurrent Convergent | Construct | Predictive | Floor/Ceiling Effects | |
GPS | +++ | ||||||||
10MWT | +++ | +++ | ++/+++ | * | |||||
SCI-FAP | +++ | +++ | +++ | ++ | Ceiling | ||||
TUGT | +++ | +++ | ++/+++ | ||||||
FTSST | +++ | ++ | |||||||
6MWT | +++ | +++ | ++/+++ | * | |||||
WISCI II | ++ | +++ | +++ | +++ | +++ | * Ceiling | |||
SCI-FAI | +++ | ++/+++ | +++ | ++ Ceiling | |||||
SCIM IIIOMob | +++ | ++/+++ | |||||||
LOSSCI | +++ | +++ | |||||||
BBS | +++ | +++ | +++ | + Ceiling | |||||
CB&M scale | +++ | +/++/+++ | |||||||
ABLE scale | Ceiling/Floor |
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Sinovas-Alonso, I.; Gil-Agudo, Á.; Cano-de-la-Cuerda, R.; del-Ama, A.J. Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review. Int. J. Environ. Res. Public Health 2021, 18, 9517. https://doi.org/10.3390/ijerph18189517
Sinovas-Alonso I, Gil-Agudo Á, Cano-de-la-Cuerda R, del-Ama AJ. Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review. International Journal of Environmental Research and Public Health. 2021; 18(18):9517. https://doi.org/10.3390/ijerph18189517
Chicago/Turabian StyleSinovas-Alonso, Isabel, Ángel Gil-Agudo, Roberto Cano-de-la-Cuerda, and Antonio J. del-Ama. 2021. "Walking Ability Outcome Measures in Individuals with Spinal Cord Injury: A Systematic Review" International Journal of Environmental Research and Public Health 18, no. 18: 9517. https://doi.org/10.3390/ijerph18189517