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Potter K. A Clinical Practice Guideline: Core Set of Outcome Measures for Neurologic Physical Therapy. MPTA Spring 2018

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A Clinical Practice Guideline: A Core Set of Outcome Measures

forNeurologic Physical Therapy

Kirsten Potter, PT, DPT, MS

[email protected]

Objectives

• Identify the rationale for the development of a core set of OMs for neurologic physical therapist practice

• Summarize the processes used to develop a core set of OMs

• Identify the core set of OMs for use with individuals with neurologic conditions to measure gait, balance, transfers, and patient stated goals

• Describe the Knowledge Translation (KT) Framework

• Using the KT Framework, identify strategies for implementing the core set in educational, clinical practice, and research settings

This Clinical Practice Guideline was supported by the Academy of Neurologic Physical Therapy and Funded by the APTA – Department

of Practice

Jenni Moore, PT, DPT, NCS – RIC/SRALKirsten Potter, PT, DPT, MS ‐ Rockhurst University

Jane E. Sullivan, PT, DHS, MS ‐ Northwestern University

• Graduate Assistant: Kate Blankshain, PT, DPT – Northwestern University• Medical Librarian: Linda O’Dwyer, MA, MSLIS – Northwestern University• Methodologists:

Sandra L Kaplan, PT, DPT, PhD ‐ Rutgers, The State University NJChih‐Hung Chang, PhD ‐ Northwestern University


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First, a bit about you…

• What is your role?– PT or PTA

– Clinician, academician, researcher, manager

• What outcome measures (OMs) do you most commonly use in practice?

• What are factors (barriers/facilitators) of using OMs in your setting?

• What OMs do you think should be in a core set of OMs for patients with neurologic conditions?

KnowledgeTranslation Framework

4

3

1

2

Identify the Problem(Why is a core set needed?)

1. Describe the rationale and processes for the CPG for a

core set of outcome measures (OMs) recommended for

individuals with neurologic conditions

2. Identify the core set of outcome measures

3. Discuss knowledge translation plan for the Core Set


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Synthesis of Taskforce Work

243 measures were examined:

–MS 63

–PD 57

– SCI 63

– Stroke 54

–TBI 88

–Vestibular 45

68

109

69

Body function/structureActivity

Participation

EDGE Taskforces Accomplishments

• Responded to Academy member requests to identify “best” OMs

• Created a template for evaluating OMs

• Positively influenced clinical practice & entry-level education

What Was Missing?

• Delphi process not as rigorous as processes used for meta-analyses, systematic reviews, CPGs

• Still TOO MANY highly recommended tools

• EDGE recommendations were for a specific neurologic condition; yet, most clinicians are working with multiple populations.


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Identify a core set of OMs for use

• Across neurologic populations

• Across levels of acuity and practice settings

Benefits of Using a Core Set of OMs

• Reduce unwanted variabilityin care

• Ensure systematicdocumentation

• Facilitate comparisonsacross patients, therapists, and practices

• Help determine efficacy of interventions

• Identify need for further OM‐related research

CPG

CPG Scope & Focus

Online surveys targeting 2 stakeholder groups:

1.Consumers ‐ clients with neurologic diagnoses who received PT

• Survey focus reasons for seeking PT, goals for PT, & relevance of OMs to care

2.Physical therapists practicing in adult neurology

• Survey focus important constructs to assess via OMs; key clinical utility factors; importance and usefulness of a core set of OMs

CPG Focus

PTsBalanceGait

Patient‐Stated GoalsTransfers

ConsumersBalanceGait

CPG Core Set FocusBalanceGait

TransfersPatient‐Stated Goals


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Core Set

Strength of

Evidence

Strength of

Evidence

LiteratureLiterature

OMOM

Tools Considered n= 288

Met Generic Filter n=211 Excluded n=78

Met 75% Construct Filter n=106 Excluded n=105

Data in > Neuro Population Filter n=54

Excluded n=52

True Outcome Measure Filter n=53 Excluded n=1

Clinical Utility Filter n=45 Excluded n=8

> 1 Study each in Reliability & Responsiveness Filter n=18 Excluded n=27

Measure SelectionStarted with 243

EDGE tests/measures

Removed those rated 1/4

Left 222 EDGE measures

Balance (n=12)

Clinician Rated Measures (10) Patient‐reported OMs (2)

Berg Balance Scale Dynamic Gait Index Dynamic Gait index, 4 itemFour Square Step TestFunctional Gait AssessmentFunctional Reach Test Mini Balance Evaluation Systems Test Timed Up and Go Test & TUG Dual Task Tinetti POMATrunk Impairment Scale

Activities Specific Balance Confidence Scale Falls Efficacy Scale International

OMs Considered for Core Set


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Gait (n=4)

Clinician Rated Measures (3) Patient‐reported OMs (1)

2 Minute Walk Test6 Minute Walk Test10 Meter Walk Test

Rivermead Mobility Index

Transfers (n=2)

Clinician Rated Measures (2)

5 Times Sit to StandRivermead Mobility Index (Modified)

Patient Stated Goals (n=0)

PROs (0)

None met criteria

OMs Considered for Core Set

Literature Search

Search Terms included condition‐related terms, construct‐related terms, and names of tools

PubMed MEDLINE, Embase, CINAHL,

CENTRAL Register of Controlled Trials

Inclusion criteria:• English language: OM and article

• Article purpose: Study psychometrics of OMs• Adults with neurologic conditions

• Sample size ≥ 30 (or power analysis)

Articles Identified (n = 18,429)

Title/abstract Review(n = 12,491)

Full‐text Review(n = 578)

Articles Critically Appraised(n = 115)

Articles Considered in CPG(n = 64)

Duplicates Removed(n = 5,938)

Excluded(n = 11,913)

Excluded(n = 491)

Excluded(n = 51)

Literature Review


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Critical Appraisal Tool

Used to score articles and strength of psychometric properties of each OM

described in article

– COnsensus‐based Standards for the selection of health Measurement INstruments (COSMIN)

– Developed online version of COSMIN

(Mokkink et al 2010)

Review Process

• Each article was independently scored by 2 trained article reviewers

• GA compared reviews and identified any inconsistencies in scoring and asked reviewers to confirm those scores

• One of CPG core team functioned as “tie breaker” in cases of where consensus was not reached

Steps to Grade the Level of Evidence

Assess strength of dataAssess strength of dataLevel of evidence across populations and categories

Combine information by instrumentCombine information by instrumentLevel of evidence

Psychometric properties Patient pop. Categories

Score strength of psychometric propertyScore strength of psychometric propertyLevel I vs. II

Score level of evidence of the articleScore level of evidence of the articleMethodologic quality


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Scoring of Articles

• Methodologic Quality –

– Level I score: > 50% of COSMIN criteria met

– Level II score: < 50% COSMIN criteria met

• Excluded articles with < 20% of criteria met

Scoring of Articles

Scoring of Psychometrics


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Grades of Recommendation

A Strong evidence A preponderance of level I studies, but least 1

level I study directly on the topic support the

recommendation.

B Moderate evidenceA preponderance of level II studies but at least 1

level II study directly on topic support the

recommendation.

C Weak evidence A preponderance of level III studies, but at least 1

level III study directly on topic support the

recommendation.

P PracticeBest practice based on expert opinion (review

papers, white papers, consensus documents

developed by various methodology (e.g., Delphi,

RAND) and the clinical experience of the

guideline development group.

R ResearchAn absence of research on the topic, or

conclusions from existing studies on the topic are

in disagreement.

Populations

• Stroke

•MS

• PD

• TBI

• SCI

• Vestibular

• Huntington’s

•Other (e.g. ALS, GB)

Categories

• Acute

• Chronic stable

• Chronic progressive

Identify a core set of OMs for use: • Across patients

with any neurologic condition

• Across levels of patient acuity and practice settings

Grading the Evidence for each OM

• Level I evidence in – ≥ 2 populations and 3 categories AND

• Level I strong internal consistency &/or reliability, and standard error (MDC, SEM) evidence in:– ≥ 2 populations and 3 categories STRONG recommendation OR

– ≥ 2 populations and 2 categories MODERATE recommendation

A Strong

evidence

A preponderance of level I

studies, but least 1 level I study

directly on the topic support the

recommendation.

B Moderate

evidence

A preponderance of level II

studies but at least 1 level II study

directly on topic support the

recommendation.

C Weak

evidence

A preponderance of level III

studies, but at least 1 level III

study directly on topic support

the recommendation.

P PracticeBest practice based on expert

opinion (review papers, white

papers, consensus documents

developed by various

methodology (e.g., Delphi, RAND)

and the clinical experience of the

guideline development group.

R ResearchAn absence of research on the

topic, or conclusions from

existing studies on the topic are

in disagreement.


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Berg Balance ScaleEvidence Table

Berg Balance Scale, Acute Samples

# Studies Populations Internal

Consistency

Reliability Standard

Error

Ceiling Floor Other

8 Level I

Studies

1 SCI4

6 Stroke5‐10

1 Mixed

Acute and

Chronic

Stroke11

1 Strong

(+++)

Stroke6

2 Strong

(+++)

Stroke6,10

1 strong (?)

Stroke8

1 Strong (?)

Stroke103 Strong (‐‐‐)

Stroke6,9,11

1 Strong (‐‐‐)

SCI4

3 Strong

(+++) Stroke5‐

7

4 Strong

(+++) Stroke5‐

7,11


Stroke6

MDC in

Stroke10

Berg Balance Scale, Chronic Stable Samples

5 level 1

Studies

1 SCI12

3 Stroke13‐15

1 Mixed

Acute and

Chronic

Stroke11

NT 2 Strong

(+++)

Stroke13,14

1 Strong

(+++) SCI12

2 Strong (?)

Stroke13,142 Strong (‐‐‐)

Stroke11,152 Strong

(+++)

Stroke11,15

SEM14,

MDC13,14 in

Stroke

Berg Balance Scale, Chronic Progressive Samples

4 level 1

Studies

1 HD16

3 PD3,17,18

1 Strong

(+++) in

PD3

1 Strong

(+++) HD16

3 Strong

(+++)

PD3,17,18

1 Strong (?)

HD16

1 Strong (?)

PD3


PD18

1 Strong

(+++) PD18

MDC in

HD16 and

PD3

MIC in MS19

The Core Set

Balance

• Activities‐specific Balance Confidence Scale

• Berg Balance Scale

• Functional Gait Assessment

Gait

• 6 Minute Walk Test

• 10 Meter Walk Test

Transfers

• 5 Times Sit to Stand

Aggregate Acute Chronic Stable Chronic Progressive

ABC Level I; strong3 Level I studies.

Evidence quality I; strong



Berg Level I; strong16 Level I studies.




FGA Level I; moderate. 5 Level I and 1 Level II studies.



Evidence quality I; moderate

6MWT Level I; moderate. 9 Level I studies in chronic stable & chronic progressive

Evidence qualityV; best practice

Evidence quality I; moderate


10mWT Level I; moderate. 9 Level I studies in chronic stable &chronic progressive conditions.




5xSTS Evidence quality V; best practice





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Action Statement:Use of the Core Set

Clinicians should use and document the OMs in the core set toassess change over time. The core set includes the BBS, FGA, ABC,10mWT, 6MWT, and 5TSTS, and the recommended patient goalassessment for adults who are undergoing neurologic physicaltherapy. The core set should be administered with patients whohave goals and the capacity to improve transfers, balance, and/orgait. In cases when a patient cannot complete one or more coreset OMs (e.g., a patient who is unable to walk; thus, cannotcomplete the 10mWT or 6MWT), a score of 0 should bedocumented. The core set should be administered under thesame test conditions at least two times, at admission anddischarge, and when feasible between these periods.

Evidence Quality: II; Rec. Strength: Moderate

Recommendations: Patient Stated Goals

• No measures met final criteria for core set

• Best practice recommendations:– Document patient‐stated goals using an OM (e.g., Goal Attainment Scale) a minimum of two times

• Task, performance conditions, time to complete or level of independence desired

– Discuss OM results with patients & collaborative decision‐making

• Purpose and results of OMs, how OM informed the plan of care,

14 Research Recommendations

1. Studies that assess psychometric properties across patient populations/acuity levels

2. Newly developed or promising measures that didn’t make the core set criteria ( e.g. Mini‐BESTest, Timed Up and Go)

3. Studies that assess gaps in constructs (e.g. Transfers, Patient stated goals)

4. KT administration procedures: study psychometrics

5. Impact of discussing OM results and shared decision‐making with patients


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Knowledge Translation CPG Task Force

• Amelia Siles (Co‐Chair) PT, DPT, NCS• Maggie Bland (Co‐Chair) PT, DPT, NCS, MSCI• Libby Anderl PT, DPT• Megan Eikenberry PT, DPT, NCS• Arlene McCarthy PT, MS, DPT, NCS• Genevieve Olivier PT, PhD candidate, DPT, NCS• Teresa Rice PT, MPH, NCS• Wendy Romney PT, DPT, NCS, PhD candidate• Hallie Zelenik PT, DPT

What’s Next Knowledge Translation

Passive

Strategies

• Tools in National Outcomes Database

• Journal publications

• PT Now ( APTA)

• Guidelines.gov

• Clinician tip sheets, KT products & tools

• Patient education materials advocacy/support groups

Educational Strategies

• Webinars• Online courses• Slides show for PT schools

• Journal club reading list, suggested discussion points

• Core set OM administration protocols

Implementation Strategies

• KT plan & documents to support implementation

• Audit/feedback instructions/tips

• KT network to support use of package

Tips to Implementing Core Set OMs in Clinical Practice

1. Each core set OM is to be used if the patient has:– Goals in the area– The capacity to improve in

the area

2. If the patient is unable to perform a core set OM at current time, but is expected to improve, score as a 0.

– Current debate: Patients needing assistance for gait measures

• When to administer core set OMs:– Admission (within few

days)– Discharge– Interim, if feasible

• Follow KT administration protocols (coming soon!)– Document alterations to

protocol used


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KT Standardized Administration Protocols

• KT group discussion is underway related to scoring the measure when a patient needs physical assistance vs. scoring it a “0”.

– Possibility exists for significant changes in the protocols from the current draft versions

– So, please don’t implement in practice yet.

KnowledgeTranslation Framework

4

3

1

2

Adapt Knowledge to Local Context

• Form groups according to setting (acute care, IP rehab, OP rehab, education/research)

• Answer the questions:

– Which of the core set measures are you already using in your work?

– What are the benefits of using these measures?


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Barriers & Facilitators to Using the Core Set OMs

• In your groups, answer the questions:

– What are barriers to using the core set OMs in your setting?

– For each barrier, identify 1‐2 feasible facilitators that will increase ease of using the core set OMs in your setting.

– What additional assistance do you need? Any recommendations for the CPG KT committee?

Discussion

• The core set of OMs should help to reduce unwanted variability in practice, facilitate improved documentation, enable comparisons across clinicians/patients/facilities, help determine treatment efficacy, and identify needs for future research.

• Knowledge translation & implementation strategies are underway and will be available soon!


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References:• Cohen ET, Potter K, Allen DD, et al. Selecting Rehabilitation Outcome

Measures for Persons with Multiple Sclerosis. International Journal of MS Care. 2015;17:181‐189.

• Kahn JH, Tappan R, Newman CP et al. Outcome measure recommendations from the spinal cord injury EDGE Task Force. PTJ. 2016;11(1):1832‐1842.

• Mokkink LB, Terwee CB, Knol DL, et al. Protocol of the COSMIN study: COnsensus‐based Standards for the selection of health Measurement INstruments. BMC medical research methodology. 2006;6:2.

• 2Mokkink LB, Terwee CB, Gibbons E, et al. Inter‐rater agreement and reliability of the COSMIN (COnsensus‐based Standards for the selection of health status Measurement Instruments) checklist. BMC medical research methodology. 2010;10:82.

• Mokkink LB, Terwee CB, Knol DL, et al. The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC medical research methodology. 2010;10:22.

• Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN study reached international consensus on taxonomy, terminology, and definitions of measurement properties for health‐related patient‐reported outcomes. Journal of clinical epidemiology. 2010;63(7):737‐745.

• Mokkink LB, Terwee CB, Patrick DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2010;19(4):539‐549.

• McCulloch KL, deJoya AL, Hays K, et al. Outcome measures for persons with moderate to severe traumatic brain injury: Recommendations from the American Physical Therapy Association Academy of Neurologic Physical Thearpy TBI EDGE task force. JNPT. 2016:40(4):269‐280.http://dx.doi.org/10.1590/bjpt‐rbf.2014.0143.

• Potter K, Cohen ET, Allan DD, et al. Outcome measures for individuals with multiple sclerosis: Recommendations from the American Physical Therapy Association Neurology Section Task Force. Phys Ther. 2014:94(5):593‐608.

• Straus SE, Tetroe J, Graham I. Defining knowledge translation. CMAJ. 2009;181(3‐4):165‐168.

• Sullivan JE, Crowner BE, Kluding PM, et al. Outcome measures for individuals With stroke: recommendations from the American Physical Therapy Association Neurology Section Task Force. Phys Ther.2013;93:1383‐1396.

SUMMARY OF ACTION STATEMENTS A. ACTION STATEMENT 1: STATIC AND DYNAMIC SITTING AND STANDING BALANCE ASSESSMENT Clinicians should use the Berg Balance Scale (BBS) for adults with neurologic conditions who have goals to improve static and dynamic sitting and standing balance and have the capacity to change in this area. The BBS should be administered under the same test conditions using the protocol recommended by the CPG Knowledge Translation (KT) Committee at admission, discharge, and when feasible, between these periods for patients with:

Acute conditions: Evidence Quality: I; Rec. Strength: Strong

Chronic Stable conditions: Evidence Quality: I; Rec. Strength: Strong

Chronic Progressive conditions: Evidence Quality: I; Rec. Strength: Strong B. ACTION STATEMENT 2: WALKING BALANCE ASSESSMENT Clinicians should use the Functional Gait Assessment (FGA) for adults with neurologic conditions who have goals to improve balance while walking and have the capacity to change in this area. The FGA should be administered under the same test conditions using the protocol recommended by the CPG KT Committee at admission, discharge, and when feasible, between these periods for patients with:



Chronic Progressive conditions: Evidence Quality: I; Rec. Strength: Moderate A. ACTION STATEMENT 3: BALANCE CONFIDENCE ASSESSMENT. Clinicians should use the Activities-Specific Balance Confidence Scale (ABC) to assess self-reported change in balance confidence in adults with neurologic conditions who have goals and the capacity to change in this area. The ABC should be administered under the same test conditions using the protocol recommended by the CPG KT Committee at admission, discharge, and when feasible, between these periods for patients with:



Chronic Progressive conditions: Evidence Quality: I; Rec. Strength: Strong B. ACTION STATEMENT 4. WALKING SPEED ASSESSMENT. Clinicians should use the 10 Meter Walk Test (10mWT) for adults with neurologic conditions who have goals to improve walking speed and have the capacity to change in this area. The 10mWT should be administered (per the protocol by Steffen et al (as adapted by the CPG KT Committee) under the same test conditions at admission, discharge, and when feasible, between these periods for patients with:

Acute conditions: Evidence Quality: V; Rec. Strength: Best Practice


Chronic Progressive conditions: Evidence Quality: I; Rec. Strength: Strong B. ACTION STATEMENT 5: WALKING DISTANCE ASSESSMENT. Clinicians should use the 6 Minute Walk Test (6MWT) for adults with neurologic conditions who have goals to improve walking distance and the capacity to change in this area. The 6MWT should be administered (per the Quinn et al protocol (as adapted by the CPG KT Committee) under the same test conditions at admission, discharge, and when feasible, between these periods for patients with: Acute conditions: Evidence Quality: V; Rec. Strength: Best Practice

Chronic Stable conditions: Evidence Quality: I; Rec. Strength: Moderate

Chronic Progressive conditions: Evidence Quality: I; Rec. Strength: Strong

P. ACTION STATEMENT 6: TRANSFER ASSESSMENT. Clinicians should document the transfer ability of adults with neurologic conditions who have goals to improve transfers and have the capacity to change. Documentation should include the type of transfer, level of required assistance, equipment or context adaptations, and time to complete. In patients who have goals and the capacity to improve sit to stand transfers, the Five Times Sit-to-Stand (5TSTS) may be used. The 5TSTS and documentation of other transfers may be administered under the same test conditions using the protocol recommended by the CPG KT Committee at admission, discharge, and when feasible, between these periods for adult patients with neurologic conditions. (Evidence Quality: V; Rec. Strength: Best Practice). P. ACTION STATEMENT 7: DOCUMENTATION OF PATIENT GOALS. Clinicians should document patient-stated goals and monitor changes in individuals with neurologic conditions, using an outcome measure such as the Goal Attainment Scale (GAS), reporting the task, the performance conditions, and the time to complete or level of independence desired. Patient goals should be documented at least two times, at admission and discharge, and, when feasible, between these testing periods. (Evidence Quality: V; Rec. Strength: Best Practice) B. ACTION STATEMENT 8: USE OF THE CORE SET OF OUTCOME MEASURES. P. ACTION STATEMENT 9: DISCUSSING OUTCOME MEASURE RESULTS AND COLLABORATIVE/SHARED DECISION-MAKING WITH PATIENTS. Clinicians should discuss the purpose of OMs, OM results, and how these results influence treatment options with patients undergoing neurologic physical therapy. Collaboratively, the clinician and patient should decide how these data should inform the plan of care. (Evidence quality: V; Rec. strength: Best Practice)

Summary of Research Recommendations

R. Research recommendation 1: Researchers should further examine the BBS, to determine its

psychometric properties in neurologic conditions other than stroke, SCI, PD, HD, and MS. Properties such

as SEMs, MDCs, and MCID/MICs should be established for individuals with scores throughout the range

of the scale in all adult neurologic conditions. Specific information regarding the functional levels of

individuals who may benefit from the BBS, and when to start with or transition to another OM, is needed.

Determination of optimal administration timing would assist clinicians in administering the BBS within a

reasonable timeframe of when “real change” would be expected. Development and comprehensive

testing of a BBS short-form would decrease administration burden.

R. Research recommendation 2: Studies on OMs that provide a comprehensive assessment of sitting

balance across acute, chronic progressive, and chronic conditions are needed. These should aim to

determine the psychometric properties, including reliability and to identify information to assist in

interpretation, such as MDCs and MIC/MCIDs.

R. Research recommendation 3: Specific information regarding the functional levels of individuals who

may benefit from the FGA and when to start with or transition to another OM is needed. Determination

of optimal administration timing would assist clinicians in administering the FGA within a reasonable

timeframe of when real change can be expected. Development and psychometric testing of a FGA short-

form would decrease administration burden.

R. Research recommendation 4: Studies are needed to examine other OMs, such as the Mini-BESTest

and TUG, in individuals with acute, chronic progressive, and chronic stable neurologic conditions. While

the FGA had enough evidence to support its inclusion of the core set, more comprehensive measures of

standing and walking balance should be tested to ensure a complete comparison against the FGA.

Properties such as reliability, internal consistency, measurement error, floor and ceiling effects, MDCs,

and MIC/MCIDs should be established across neurologic conditions.

R. Research recommendation 5: Studies are needed to determine the psychometric properties (e.g.,

reliability) of the ABC in acute, chronic progressive, and chronic stable neurologic conditions. Further,

information to assist clinicians in interpreting the results of the ABC, such as MDCs and MIC/MCIDs, should

be established across neurologic conditions. Specific information regarding the characteristics of

individuals who may benefit from the ABC is needed.

R. Research recommendation 6: Studies are needed to examine other OMs, such as the Falls Efficacy

Scale International, in individuals with acute, chronic progressive, and chronic stable neurologic

conditions. While evidence supports the inclusion of the ABC in the core set, other patient-reported

measures of balance should be studied to ensure a comprehensive comparison to the ABC. Properties

such as reliability, internal consistency, measurement error, floor and ceiling effects, MDCs, and

MIC/MCIDs should be established across neurologic conditions.

R. Research recommendation 7: Studies are needed to explore the reliability and clinically important

change (e.g., MCID) of the 10mWT in individuals with acute neurologic conditions. Clinically important

change should also be determined in chronic stable conditions. Studies to determine the presence of

floor and ceiling effects should be conducted in persons with chronic progressive and chronic stable

conditions.

R. Research recommendation 8: Studies are needed to examine the Walk-12 in individuals with acute,

chronic progressive, and chronic stable neurologic conditions. Psychometric properties such as reliability,

internal consistency, measurement error, floor and ceiling effects, MDCs, and MIC/MCIDs should be

established across neurologic conditions.

R. Research recommendation 9: Studies are needed to determine the intra-rater and inter-rater

reliability, and clinically important change (e.g., MCID), of the 6MWT in individuals with acute neurological

conditions. Data to assist in measuring change (e.g., MDC, SEM, MCID) are needed in individuals with

acute and chronic stable neurologic conditions.

R. Research recommendation 10: Studies are needed that explore the feasibility and psychometric

properties of the 5TSTS to objectively describe the transfer abilities of adults with neurological conditions,

especially those other than individuals with PD, across the continuum of care and spectrum of acuity.

Further study of the 30SCST is warranted, particularly relative to reliability and data to interpret change

in individuals with neurologic conditions.

R. Research recommendation 11: Studies should explore the feasibility and psychometric properties,

including reliability and data to assist in interpreting change (e.g., MDC, MCID/MIC) of the GAS and other

OMs that capture the individual goals of adults with neurological conditions across the continuum of

care and spectrum of acuity.

R. Research recommendation 12: Studies are needed that explore the impact of using the core set of OMs

on rehabilitation outcomes, including factors related to implementation (e.g. time, cost, etc.). Studies

should explore the impact of using the core set of OMs to support clinical decision-making across

neurologic conditions and categories. Future measurement studies should be designed to meet the

COSMIN requirements for excellent methodology with regards to sample size, design and rigor of

statistical analysis of psychometric properties.8,9,39,41

R. Research recommendation 13: The CPG KT Committee is developing standardized administration

procedures for all six OMs in the core set. Studies are needed to determine the psychometric properties

of these protocols across acute, chronic progressive, and chronic conditions in clinical practice.

R. Research recommendation 14: Research is needed on the impact of discussing OM results and shared

decision-making with patients receiving neurologic physical therapy, including the development and

impact of OM-related information (e.g., OM-related decision aids) on the understanding and involvement

of a patient in his/her care and on the achievement of patient goals. Further, research should develop

and test the use of decision-aids that incorporate the core set.

Core Measure: Berg Balance Scale (BBS)

Overview The BBS is a widely-used, clinician-rated scale used to assess sitting and standing, static and dynamic balance.

Number of Test Items The BBS consists of 14 functional balance items that focus on the ability to maintain a position and perform postural adjustments to complete functional movements. (Berg, 1992).

Scoring Each item is a 5-point ordinal scale ranging from 0 to 4, with 0 indicating an inability to complete the task entirely and 4 indicating an ability to complete the task criterion. (Hiengkaew, 2012)

Items are scored relative to time, level of independence or supervision required. Points are deducted for requiring supervision, assistance and/or taking more than the allotted time to complete the task.

Supervision is required in the event of excessive sway or safety concerns.

Equipment A standard height chair with armrests (Berg, 1992)

A standard height chair without arm rests (Berg, 1992)

A 0.5 inch slipper (Steffen, 2008) or a shoe

A ruler

A stopwatch

A step or stool of average height (8-9 inch step stool) (Steffen, 2008)

Time (new clinician) Time (experienced clinician)

20-30 minutes

15-20 minutes

Equipment See previous

Cost Cost of equipment only.

Logistics-Setup Item 1: Sitting to standing. o Patient is seated in a standard height chair (18-20 inches),

free standing chair with arm rests

Item 2: Standing unsupported o Patient is standing quietly with feet shoulder width

support on a solid surface

o Examiner has stop watch in hand

Item 3: Sitting with back unsupported o Patient is seated, back unsupported but feet supported on

floor or a stool o Examiner has stop watch in hand

Item 4: Standing to sitting o Patient is standing quietly in front of a chair with arm rests

Item 5: Transfers (Berg, 1992 and 1989, PT NOW summary) o Arrange two chairs at approximately 90 degrees for a

pivot transfer. You may use two chairs (one with arm rests and one without) or a bed and a chair with arm rests. *Ensure that the patient will transfer both directions and that they will be transferring from one surface without arm rests and one surface with arm rests.

Item 6: Standing unsupported with eyes closed o Patient is standing quietly o Examiner has stop watch in hand

Item 7: Standing unsupported with feet together o Patient is standing quietly with feet together o Examiner has stop watch in hand

Item 8: Reaching forward with outstretched arm while standing o Patient is standing quietly with both arms lifted to 90

degrees of shoulder flexion with fingers extended. If the patient has a shoulder impairment limiting the ability to lift arms symmetrically, use only the arm that can be lifted to 90 degrees easily and painlessly. Examiner is holding a ruler at the end of the fingertips. If the patient is unable to extend fingers, utilize the metacarpal phalangeal joint instead of the fingertips.

Item 9: Pick up object from the floor from a standing position o Patient is standing quietly o A slipper or shoe is placed in front of the patient, close to

the patient's feet. The patient should be able to bend and easily

reach the slipper. This is not a test for forward reach or limits of stability.

Do not substitute with any object that is shorter or taller than a slipper toe box or shoe as this will make the subject bend lower or not as far as intended for this criteria.

Item 10: Turning to look behind, over left and right shoulders o Patient is standing quietly

o Examiner is standing in front of the patient to accurately assess rotation and weight shift

Item 11: Turn 360 degrees o Patient is standing quietly o Examiner has stop watch in hand

Item 12: Placing alternate foot on step or stool while standing unsupported

o Patient is standing quietly o Examiner places a 9-inch step stool in front of the patient,

or the patient is able to stand in front of a flight of steps (Steffen, 2008)

o Examiner stands close by to provide assistance if needed o Examiner has the stop watch in hand

Item 13: Standing unsupported one foot in front o Patient is standing quietly o Examiner has the stop watch in hand

Item 14: Standing on one leg o Patient is standing quietly o Examiner has the stop watch in hand

Logistics-Administration Item 1: Sitting to Standing (Berg, 1992 and 1989 and PTNOW Summary)

o Instructions: Please stand up, try not to use your hands for support.

Item 2: Standing unsupported o Instructions: Please stand for 2 minutes without holding on

Item 3: Sitting with back unsupported o Instructions: Please sit with arms folded for 2 minutes

Item 4: Standing to sitting o Instructions: Please sit down

Item 5: Transfers o Instructions: Please transfer from this chair, with arm

armrests, to that chair, without arm rests, and back again.

Item 6: Standing with eyes closed o Instructions: Please close your eyes and stand still for 10

seconds

Item 7: Standing with feet together o Instructions: Place your feet together and stand without

holding.

Item 8: Reaching forward with outstretched arm while standing o Instructions: Lift arm to 90 degrees. Stretch out your

fingers and reach forward as far as you can. o Fingers are not touching the ruler at any point during the

test. Both arms are utilized by the patient to avoid trunk

rotation during the forward reach. If one arm is utilized, provide verbal cueing to the patient to limit trunk rotation.

o Examiner measures how far the patient can reach in the most forward lean position, without trunk rotation or losing balance.

Item 9: Pick up object from the floor from a standing position o Instructions: Pick up the shoe/slipper which is placed in

front of your feet o Examiner pays attention to how close the patient is able

to get to the object o Examiner also ensures that the patient is not using the

back of the legs against a bed or chair during the reach

Item 10: Turning to look behind over left and right shoulders o Instructions: Turn to look directly behind you over toward

left shoulder. Repeat to the right. o Examiner may pick an object to look at directly behind the

subject to encourage a better twist turn o Examiner assess the amount of trunk rotation and weight

shift

Item 11: Turn 360 degrees o Instructions: Turn completely around in a full circle. Pause.

Then turn a full circle in the other direction. o Examiner times the time it takes to complete each full

turn.

Item 12: Placing alternate foot on step or stool while standing unsupported

o Instructions: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times.

o Examiner times the time it takes to complete task

Item 13: Standing unsupported one foot in front o Instructions: (Demonstrate to subject) Place one foot

directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough ahead that the heel of your forward foot is ahead of the toes of the other foot.

Item 14: Standing on one leg o Instructions: Stand on one leg as long as you can without

holding on with your hands. Do not let your lifted leg touch your standing leg

Logistics-Scoring All items are summed to calculate a total score

Scoring (Berg, 1992 and 1989 and PTNOW Summary)

Item 1: Sitting to Standing Scoring o 4: able to stand without using hands, stabilizes

independently o 3: able to stand independently using hands o 2: able to stand using hands after several tries o 1: needs minimal aid to stand or to stabilize o 0: needs moderate or maximal assist to stand

Item 2: Standing unsupported (if patient scored 4 points, points fulfilled for item 3, move onto item 4)

o 4: able to stand safely for 2 minutes o 3: able to stand 2 minutes with supervision o 2: able to stand 30 seconds unsupported o 1: needs several tries to stand 30 seconds unsupported o 0: unable to stand 30 seconds unsupported

Item 3: Sitting with back unsupported o 4: able to sit safely and securely for 2 minutes o 3: able to sit 2 minutes under supervision o 2: able to sit for 30 seconds o 1: able to sit 10 seconds o 0: unable to sit without support for 10 seconds

Item 4: Standing to sitting o 4: sits safely with minimal use of hands o 3: controls descent by using hands

Without hands would lead to uncontrolled descent o 2:uses back of legs against chair to control descent o 1: sits independently but has uncontrolled descent o 0: Needs assistance to sit

Item 5: Transfers o 4: able to transfer safely with minor use of hands o 3: able to transfer safely, definite need of hands o 2: able to transfer with verbal cueing and/or supervision o 1: needs one person assist o 0: needs two person assistance or supervision for safety

Item 6: Standing unsupported with eyes closed o 4: able to stand 10 seconds safely o 3: able to stand 10 seconds with supervision o 2: able to stand 3 seconds o 1: unable to keep eyes closed 3 seconds but stays steady o 0: needs help to keep from falling

Item 7: Standing unsupported with feet together

o 4: able to place feet together independently and stand 1 minute safely

o 3: able to place feet together independently and stand for 1 minute with supervision

o 2: able to place feet together independently and to hold for 30 seconds

o 1: needs help to attain position but able to stand 15 seconds feet together

o 0: needs help to attain position and unable to hold for 15 seconds

Item 8: Reaching forward with outstretched arm while standing o 4: can reach forward confidently >25 cm (10 inches) o 3: can reach forward > 12.5 cm safely (5 inches) o 2:can reach forward > 5 cm safely (2 inches) o 1: reaches forward but needs supervision o 0: loses balance while trying/requires external support

Item 9: Pick up object from the floor from a standing position o 4: able to pick up slipper safely and easily o 3: able to pick up slipper but needs supervision o 2: unable to pick up but reaches 2-5 cm (1-2 inches) from

slipper and keeps balance independently o 1: unable to pick up and needs supervision while trying o 0: unable to try/needs assist to keep from losing balance

or falling

Item 10: Turning to look behind over left and right shoulders o 4: looks behind from both sides and weight shifts well o 3: looks behind one side only other side shows less weight

shift o 2: turns sideways only but maintains balance o 1: needs supervision when turning o 0: needs assist to keep from losing balance or falling

Item 11: Turn 360 degrees o 4: able to turn 360 degrees safely in 4 seconds or less o 3: able to turn 360 degrees safely one side only in 4

seconds or less o 2: able to turn 360 degrees safely but slowly o 1: needs close supervision or verbal cueing o 0: needs assistance while turning

Item 12: Placing alternate foot on step stool while standing unsupported

o 4: able to stand independently and safely and complete 8 steps in 20 seconds

o 3: able to stand independently and complete 8 steps> 20 seconds

o 2: able to complete 4 steps without aid with supervision o 1: able to complete >2 steps needs minimal assist o 0: needs assistance to keep from falling/unable to try

Item 13: Standing unsupported one foot in front o 4: able to place foot tandem independently and hold 30

seconds o 3: able to place foot ahead of other independently and

hold 30 seconds Foot must completely pass the other foot (Alzayer,

2009) Step width should be no wider than shoulders

o 2: able to take small step independently and hold 30 seconds

o 1: needs help to step but can hold 15 seconds o 0: loses balance while stepping or standing

Item 14: Standing on one leg o 4: able to lift leg independently and hold >10 seconds o 3: able to lift leg independently and hold 5-10 seconds o 2: able to lift leg independently and hold = or >3 seconds o 1: tries to lift leg unable to hold 3 seconds but remains but

remains standing independently o 0: unable to try or needs assist to prevent fall

Additional Recommendations

To track change, it is recommended that this measure is administered a minimum of two times (admission and discharge), and when feasible, between these periods, under the same test conditions for the patient.

Common Questions and Variations

1. “If my patient cannot stand, should I still complete the BBS?”

a. If you anticipate that the patient is going to be able to stand and complete

transfers, you should complete the BBS at evaluation to document change

over time. If the patient cannot complete any elements of the BBS, they will

have a score of 0 which will be their starting score. The recommendation

would be that all patients have a baseline Berg balance score. (Kinney, 2013)

2. “Can I provide touching assistance, or hold the gait belt, during the balance

components of the BBS?”

a. If a patient requires touching assistance for an item, the lowest associated

score for that item should be utilized or the specified score for that item (i.e.

Item 1 sitting to standing: a score of 1 is if needs minimal aid to stand or

stabilize, or 0 if needs moderate or maximal assist to stand)

3. “Can the patient use an assistive device for any elements of the BBS?”

a. Assistive devices should not be used by a patient when performing the BBS. If the patient normally utilizes an assistive device to perform a respective task, the administrator should encourage the patient to attempt the task without it. (Berg, 1992) If the patient cannot perform the item without an assistive device they will be scored a “0”.

b. If an assistive device is utilized during the test, the score should not be included in aggregate data analysis, if this data is used for program evaluation, for example.

4. “Can a hospital bed or mat table serve as one of the seating surfaces during the

BBS?”

a. Yes, however attempts should be made to preserve the standard height of

18-20 inches. If unable, the variation in height of the surface should be

indicated and standardized within the practice/facility.

5. Item 9: “What if I don't have a shoe/slipper available? Can I use a box of tissues

instead of a slipper or a shoe? Can I use a pen on the floor instead of a slipper?”

a. Do not substitute with any object that is shorter or taller than a slipper toe

box or shoe as this will make the subject bend lower or not as far as the item

intended.

6. Item 8: “What arm should the patient use to reach forward?”

a. Where possible, both arms should be used however in instances where it is

difficult to lift one arm (Ie. hemiparesis, shoulder ROM limitation), the intact

arm can be used provided that the patient is not utilizing trunk rotation to

achieve further reach (PT NOW summary)

7. Item 12: ”How high does the step/stool need to be?”

a. Standard height of a step is 8 inches

b. Steffen (2008) documented the use of a 9-inch step stool

c. A step/stool that is at least 8 inches, no greater than 9 inches in height is

recommended

8. Item 13& 14: Does it matter which leg the patient stands on (SLS) or which is in

front/back (tandem)?”

a. The BBS allows the patient to self-select the limb that they would stand on

for both of these items

b. In instances where a patient has unilateral impairment, it is recommended

that the patient be tested on the involved limb (SLS) and by standing on the

involved limb and taking the forward step with the uninvolved limb (tandem)

(Straube, 2013)

9. Item 13: “What if the patient loses their balance trying to get into or hold full

tandem? Do I automatically score a "0" for that item?”

a. The test instructions indicate that a demonstration should be given to the

patient showing them the option for tandem stance, and also the foot-ahead

stance required to achieve a score of 3. Thus, if a patient attempts tandem

and cannot achieve this, the tester can cue the patient to try the alternate

position with demonstration.

References

1. Berg KO, Maki B, Williams JI, et al. Clinical and laboratory measures of postural

balance in an elderly population. Arch Phys Med Rehabil. 1992;73:1073-1080.

2. Blum L, Komer-Bitensky N. Usefulness of the Berg Balance Scale in stroke

rehabilitation: a systematic review. Phys Ther. 2008;88:559-566.

3. Chinsongkram B, Chaikeeree N, Saengsirisuwan V, Viriyatharakij N, Horak FB,

Boonsinsukh R. Reliability and validity of the Balance Evaluation Systems Test

(BESTest) in people with subacute stroke. Physical therapy 2014;94(11):1632-43.

4. Schlenstedt C, Brombacher S, Hartwigsen G, Weisser B, Moller B, Deuschl G.

Comparing the Fullerton Advanced Balance Scale with the Mini-BESTest and Berg

Balance Scale to assess postural control in patients with Parkinson disease. Archives

of physical medicine and rehabilitation 2015;96(2):218-25.

5. Hiengkaew V, Jitaree K, Chaiyawat P. Minimal detectable changes of the Berg

Balance Scale, Fugl-Meyer Assessment Scale, Timed "Up & Go" Test, gait speeds, and

2-minute walk test in individuals with chronic stroke with different degrees of ankle

plantarflexor tone. Archives of physical medicine and rehabilitation

2012;93(7):1201-8.

6. Blum, Lisa, and Nicol Korner-Bitensky. "Usefulness of the Berg Balance Scale in

stroke rehabilitation: a systematic review." Physical therapy 88.5 (2008): 559-566.

7. Steffen T, Seney M. Test-retest reliability and minimal detectable change on balance

and ambulation tests, the 36-item short-form health survey, and the unified

Parkinson disease rating scale in people with parkinsonism. Physical therapy

2008;88(6):733-46.

8. Alzayer, Lamia, Marianne Beninato, and Leslie G. Portney. "The accuracy of

individual Berg Balance Scale items compared with the total Berg score for

classifying people with chronic stroke according to fall history." Journal of Neurologic

Physical Therapy 33.3 (2009): 136-143.

9. Kinney CL, Eikenberry MC, Noll SF, Tompkins J, Verheijde J. Standardization of

interdisciplinary clinical practice and assessment in stroke rehabilitation. Int J Phys

Med Rehabil. 2013;1:7.

10. Straube D, Moore J, Leech K, Hornby TG. "Item Analysis of the Berg Balance Scale in

Individuals with Subacute and Chronic Stroke." Topics in Stroke Rehabilitation. 2013;

20: 3, 241-249.

11. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly:

Validation of an instrument. Canadian Journal of Public Health. 1992;S2:7-11.

Core Measure: Functional Gait Assessment

Overview The FGA is designed to assess postural stability during gait and assesses an individual's ability to perform multiple motor tasks while walking. The tool is a modification of the 8-item Dynamic Gait Index, developed to improve reliability and reduce ceiling effect.

Number of Test Items 10 items: gait on level surface, change in gait speed, gait with horizontal and vertical head turns, gait with 180° pivot turn, stepping over obstacles, gait with narrow base of support, gait with eyes closed, backwards gait and stairs.

Scoring Each item is scored on an ordinal scale from 0 (severe impairment) to 3

(normal ambulation). All items are summed to calculate a total score

(max. 30).

0 = severe impairment (Cannot perform without assistance, severe gait deviations or imbalance; deviates from walkway, increased time to perform task) 1 = moderate impairment 2 = mild impairment 3 = normal ambulation (no gait or balance impairment, completion of task in a timely manner)

Equipment Stopwatch

Measuring device to mark off area

Marked walking area = 20 feet (6m); width 12 inches (30.48cm)

Obstacle of 9-inch height (22.86 cm) using at least two stacked shoe boxes

Set of steps that are 8 inches high with bilateral rails


20 minutes

5-10 minutes

Cost Free

No training required

Logistics-Setup Would be beneficial to have a dedicated space or designated pre-measured area to complete the test to eliminate distractions and disruptions during administration. Would be beneficial to complete re-testing in the same place/environment.

A marked pathway of 20ft (6m); width 12 inches (30.48cm) in a designated area over solid flooring is required.

Quiet conditions

Starting Position: Patient is standing quietly in a comfortable position at the start of the 20ft marked walking area, except for the following items listed below (Wrisley, 2004):

Item 6: Step over Obstacle

o Patient is standing quietly in a comfortable position at the start of the 20ft marked walking area with a shoebox positioned in the middle of the walkway

Item 7: Gait with Narrow Base of Support o Patient is standing quietly in a comfortable position with arms

folded across chest at the start of a hallway allowing for 12ft (3.6 m)

Item 9: Ambulating Backwards o Patient is standing quietly in a comfortable position at the start

of the 20ft marked walking area facing backwards

Item 10: Steps o Patient is standing quietly in a comfortable position at the base

of the steps

Logistics-Administration Test may be performed with or without an assistive device

Individuals should walk without physical assistance of another person

Retest in the same designated area/environment

When administering walking items, do not walk in front of or directly beside the patient, as this “paces” the patient and can influence the speed they walk. Instead, walk at least a half step behind the patient.

Item 1: Gait Level Surfaces (Wrisley, 2004) o Instructions: Walk at your normal speed from here to the next

mark (6 m [20ft])

Item 2: Change in Gait Speed o Instructions: Begin walking at your normal pace (for 1.5m [5ft]),

when I tell you “go,” walk as fast as you can (for 1.5m [5ft]). When I tell you “slow,” walk as slowly as you can (for 1.5m [5ft]).

Item 3: Gait with Horizontal Head Turns o Instructions: Walk from here to the next mark 6m (20ft) away.

Begin walking at your normal pace. Keep walking straight; after 3 steps, turn your head to the right and keep walking straight while looking to the right. After 3 more steps, turn your head to the left and keep walking straight while looking left. Continuing alternating looking right and left every 3 steps until you have completed 2 repetitions in each direction.

Item 4: Gait with Vertical Head Turns o Instructions: Walk from here to the next mark 6m (20ft) away.

Begin walking at your normal pace. Keep walking straight; after 3 steps, tip your head up and keep walking straight while looking up. After 3 more steps, turn your head down and keep walking straight while looking down. Continuing alternating looking up and down every 3 steps until you have completed 2 repetitions in each direction.

Item 5: Gait and Pivot Turn

o Instructions: Begin with walking at your normal pace. When I tell you, “turn and stop,” turn as quickly as you can to face the opposite direction and stop.

Item 6: Step over Obstacle o Instructions: Begin walking at your normal speed. When you

come to the shoebox, step over it, not around it, and keep walking.

Item 7: Gait with Narrow Base of Support o Instructions: Walk on the floor with arms folded across the

chest, feet aligned heel to toe in tandem for a distance of 3.6m [12ft]. The number of steps taken in a straight line are counted for a maximum of 10 steps.

Item 8: Gait with Eyes Closed o Instructions: Walk at your normal speed from here to the next

mark (6m [20 ft]) with your eyes closed.

Item 9: Ambulating Backwards o Instructions: Walk backwards till I tell you to stop.

Item 10: Steps o Instructions: Walk up these stairs as you would at home (i.e.

using the rail if necessary). At the top turn around and walk down.

Logistics-Scoring All items are summed to calculate a total score.

Item 1: Gait level Surface (Wrisley, 2004) o 3 Normal: Walks 20ft; no assistive devices, good speed, no

evidence for imbalance, normal gait pattern, deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.

o 2 Mild Impairment: Walks 20ft in less than 7 seconds but greater than 5.5 seconds, uses assistive device, slower speed, mild gait deviations or deviates 15.24-25.4cm (6-10in) outside 30.48cm (12in) walkway width.

o 1 Moderate Impairment: Walks 20ft; slow speed, abnormal gait pattern, evidence for imbalance or deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width. Requires more than 7 seconds to ambulate 20ft.

o 0 Severe Impairment: Cannot walk 20ft without assistance, severe gait deviations or imbalance, deviates greater than 15 in outside of the 12 in walkway width or reaches and touches the wall.

Item 2: Change in Gait Speed o 3 Normal: Able to smoothly change walking speed without loss

of balance or gait deviation. Shows a significant difference in walking speeds between normal, fast, and slow speeds. deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.

o 2 Mild Impairment: Is able to change speed but demonstrates mild gait deviations, deviates 15.24-25.4cm (6-10in) outside

30.48cm (12in) walkway width, or no gait deviations, but unable to achieve a significant change in velocity, or uses an assistive device.

o 1 Moderate Impairment: Makes only minor adjustments to walking speed, or accomplishes a change in speed with significant gait deviations, deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width, or changes speed but loses balance but is able to recover and continue walking.

o 0 Severe Impairment: Cannot change speeds, deviates greater than 15 in outside the 12-in walkway width, or loses balance and has to reach for wall or be caught.

Item 3: Gait with Horizontal Head Turns o 3 Normal: Performs head turns smoothly with no change in gait.

deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width

o 2 Mild Impairment: Performs head turns smoothly with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.24-25.4cm (6-10in) outside 30.48cm (12in) walkway width, or uses an assistive device

o 1 Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width, but recovers, can continue to walk.

o 0 Severe Impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12-in walkway width, loses balance, stops or reaches for wall)

Item 4: Gait with Vertical Head Turns o 3 Normal: Performs head turns smoothly with no change in gait.

Deviates no more than 15.24 cm (6 in) outside of the 30.48-cm (12-in) walkway width.

o 2 Mild Impairment: Performs task with slight change in gait velocity (eg, minor disruption to smooth gait path), deviates 15.24-25.4cm (6-10in) outside 30.48cm (12in) walkway width or uses assistive device.

o 1 Moderate Impairment: Performs head turns with moderate change in gait velocity, slows down, deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width but recovers, can continue to walk.

o 0 Severe Impairment: Performs task with severe disruption of gait (eg, staggers 15 in outside 12-in walkway width, loses balance, stops, reaches for wall).

Item 5: Gait with Pivot Turn o 3 Normal: Pivot turns safely within 3 seconds and stops quickly

with no loss of balance. o 2 Mild Impairment: Pivot turns safely in >3 seconds and stops

with no loss of balance, or pivots turns safely within 3 seconds and stops with mild imbalance, requires smalls steps to catch balance

o 1 Moderate Impairment: Turns slowly, requires verbal cueing, requires several small steps to catch balance following turn and stop.

o 0 Severe Impairment: Cannot turn safely, requires assistance to turn and stop.

Item 6: Step over Obstacle o 3 Normal: Is able to step over 2 stacked shoe boxes taped

together (9 inch total height) without changing gait speed; no evidence for imbalance.

o 2 Mild Impairment: Is able to step over one shoe box (4.5 in total height), but must slow down and adjust steps to clear box safely.

o 1 Moderate Impairment: Is able to step over on shoe box (4.5 in total height) but must slow down and adjust steps to clear box safely. May require verbal cueing.

o 0 Severe Impairment: Cannot perform without assistance.

Item 7: Gait with Narrow Base of Support o 3 Normal: Is able to ambulate for 10 steps heel to toe with no

staggering. o 2 Mild Impairment: Ambulates 7-9 steps. o 1 Moderate Impairment: Ambulates 4-7 steps. o 0 Severe Impairment: Ambulates less than 4 steps heel to toe or

cannot perform without assistance.

Item 8: Gait with Eyes Closed o 3 Normal: Walks 6m (20ft), no assistive devices, good speed, no

evidence of imbalance, normal gait pattern, deviates no more than 15.24cm (6in) outside the 30.48cm (12in) walkway width. Ambulates 6m (20ft) in less than 7 seconds.

o 2 Mild Impairment: Walks 6m (20ft), uses assistive device, slower speed, mild gait deviations, deviates 15.24-25.4cm (6-10in) outside 30.48cm (12in) walkway width. Ambulates 6m (20ft) in less than 9 seconds but greater than 7 seconds.

o 1 Moderate Impairment: Walks 6m (20ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width. Requires more than 9 seconds to ambulate 6m (20ft).

o 0 Severe Impairment: Cannot walk 6m (20ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1cm (15in) outside 30.48cm (12in) walkway width or will not attempt task.

Item 9: Ambulating Backwards o 3 Normal: Walks 6m (20ft), no assistive device, good speed, no

evidence for imbalance, normal gait pattern, deviates no more than 15.24cm (6in) outside 30.48cm (12in) walkway width.

o 2 Mild Impairment: Walks 6m (20ft), uses assistive device, slower speed, mild gait deviations, deviates 15.24-25.4cm (6-10in) outside 30.48cm (12in) walkway width.

o 1 Moderate Impairment: Walks 6m (20ft), slow speed, abnormal gait pattern, evidence for imbalance, deviates 25.4-38.1cm (10-15in) outside 30.48cm (12in) walkway width.

o 0 Severe Impairment: Cannot walk 6m (20ft) without assistance, severe gait deviations or imbalance, deviates greater than 38.1cm (15in) outside 30.48cm (12in) walkway width or will not attempt task.

Item 10: Steps o 3 Normal: Alternating feet, no rail. o 2 Mild Impairment: Alternating feet, must use rail. o 1 Moderate Impairment: Two feet to a stair, must use rail. o 0 Severe Impairment: Cannot do safely.




1. “If I only have 4 steps with bilateral railings is that ok or do I need an entire flight?”

a. The test can be accomplished with a set of 4 or more steps. The steps need to have

bilateral rails and should be standard step height (approximately 8”).

2. “What if I don't have a set of stairs at all?”

a. If the patient does not attempt all test items, this is a deviation from the standardized procedure, therefore interpretation of the score with use of normative values or cut of scores would not be appropriate.

b. Any partial score should not be included in any aggregate data analysis, if this data is used for program evaluation, for example.

c. Completion of only some test items may be useful to the individual patient. For example, the patient may benefit from education on the value of gait speed or a safety strategy during performance of multiple motor tasks. The individual score (partial score) may be used to set an individual goal for a future trial or session.

3. “What if my patient requires assistance?”

a. If the patient requires assistance to complete any item, the score is recorded as a 0. 4. “For Item 7: Gait with Narrow Base of Support, is it ok to have them walk on the line that

marks the walkway?” a. Yes. Per discussion with developing authors Sue Whitney and Diane Wrisley tape

was used on the ground for this item when the test was first developed. 5. “What if my patient cannot walk?”

a. The FGA should not be administered for patients that do not have the capacity to

walk; however, a score of 0 may be documented in these instances.

b. If a patient is unable to ambulate, but has the goals and capacity to improve

balance, a baseline score of 0 should be documented for the FGA.

6. “What if my patient demonstrates a high score?”

a. If a patient demonstrates a high score near 30 out of 30, or is likely to do so, the

clinician may need to select a more challenging outcome measure to assess change

over time.

b. If a patient scores near the top of the FGA scale, it may not be necessary to re-

administer the test.

References [1]

1. Wrisley, D.M., et al., Reliability, internal consistency, and validity of data obtained with the functional gait assessment. Phys Ther, 2004. 84(10): p. 906-18.

Core Measure: Activities-Specific Balance Confidence Scale

Overview Subjective (self-report) measure of balance confidence in performing various activities without losing balance or experiencing a sense of unsteadiness.

Number of Test Items 16 items

Scoring Rate from 0% to 100%

0% = no confidence

100% = complete confidence

Equipment None


Approximately 10 minutes (Raad, 2013)

Cost Free

Logistics-Setup Paper Survey

Logistics-Administration Administration by face-to-face interview is recommended. (Powell, 1995)

The ABC can be self-administered via a paper copy. (Powell, 1995)

Instructions (also on the paper copy): For each of the following activities, please indicate your level of self-confidence by choosing a corresponding number from the following rating scale 0% 10 20 30 40 50 60 70 80 90 100 No Confidence Completely Confident

“How confident are you that you will not lose your balance or become unsteady when you…

Item 1: o ... walk around the house? ___%

Item 2: o ... walk up or down stairs? ___%

Item 3: o ... bend over and pick up a slipper from front of a closet floor?

___%

Item 4: o ... reach for a small can off a shelf at eye level? ___%

Item 5: o ... stand on tip toes and reach for something above your head?

___%

Item 6: o ... stand on a chair and reach for something? ___%

Item 7: o ... sweep the floor? ___%

Item 8: o ... walk outside the house to a car parked in the driveway? ___%

Item 9: o ... get into or out of a car? ___%

Item 10: o ... walk across a parking lot to the mall? ___%

Item 11: o ... walk up or down a ramp? ___%

Item 12: o ... walk in a crowded mall where people rapidly walk past you?

___%

Item 13: o ... are bumped into by people as you walk through the mall?

___%

Item 14: o ... step onto or off of an escalator while you are holding onto a

railing? ___%

Item 15: o ... step onto or off an escalator while holding onto parcels such

that you cannot hold onto the railing? ___%

Item 16: o ... walk outside on icy sidewalks? ___%

Logistics-Scoring Ratings for each item should be whole numbers (0-100).

Total the ratings (possible range = 0-1600) and divide by 16 (number of items) to get the individual’s ABC score or overall percentage of balance confidence. (Powell, 1995)

Scoring: Total ÷ 16 = _____ % of self-confidence (ABC score)

100% is indicative of the highest level of confidence.

80% indicative of high level of physical functioning

50-80% indicative of low level physical functioning (Myers, 1998)

< 67% older adults at risk for falling; predictive of future falls (LaJoie, 2004)




1. “What if the patient doesn’t complete one of the tasks on the ABC?”

a. The patient should rate how confident they would be if they had to perform the activity,

even if they do not currently do the activity. (Myers, 1998)

2. “What if the patient typically uses an assistive device when they complete the activity in

question? Should they rate their confidence with or without the assistive device?”

a. The patient should rate their confidence with the device they are using. (Myers, 1998)

b. Recommendations would be to document the assistive device and keep the assistive device consistent between trials and reassessments.

c. It is likely, however that the type of assistive device may change over time. This is ok, just be sure to document which type of device is used.

3. “What if the patient qualifies their responses with different rating for "up" versus "down" or

"onto" versus "off" (i.e. items 2, 9, 11, 14, or 15)?”

a. It is suggested to solicit separate ratings and use the lowest confidence of the two

ratings, as this will limit the entire activity. For example, if on item 2 (…walk up or down

stairs? _____%), the patient says they are 80% confident walking up the stairs and 60%

confident walking down the stairs, their score for this item is 60%. (Myers, 1998)

4. “Can a score still be computed if an individual does not complete all of the items?”

a. Yes. An ABC score can still be determined by summing the ratings and diving by the

number of items answered if an individual answers at least 75% (12/16) of the

questions. Most commonly omitted is the last item (…walk outside on icy sidewalks?

_____%) in warmer climates. (Myers, 1998)

5. “What if my patient is unable to read the instructions/questions (b/c of cognition,

speech/language, vision deficits, etc)? Can I read it to them?”

a. Yes, the measure can be administered by personal or telephone interview, if needed.

6. “What if my patient does not speak English. Is the ABC available in other languages?”

a. Yes. The ABC has been translated into a variety of other languages. However, the

reliability and validity of these translations should be understood when administering a

translated version of the ABC. Languages available: Spanish (Montilla-Ibáñez, 2017),

German (Schoot, 2008), Chinese (Mak, 2007), French-Canadian (Salbach, 2006), Korean

(Jang, 2003), Dutch (Van Heuvelen, 2005), Persian (Hassan, 2015), Brazilian-Portuguese

(Marques, 2013), Arabic (Alghwiri, 2015), Hindi (Moiz, 2016), Turkish (Karapolat, 2010).

7. “What if my patient has a decline in the ABC score, percent of balance confidence, but as a

clinician I believe it is due to improved awareness and insight, not regression?”

a. If this happens it may be helpful for the clinician to look across other objective measures

to provide support and rationale for the clinician’s conclusions.

References

1. Raad J, Moore J, Hamby J, Lainez Rivadelo R, Straube D. A brief review of the Activities-

specific Balance Confidence Scale in older adults. Arch Phys Med Rehabil. 2013;94(7):1426-

1427.

2. Powell LE, Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A

Biol Sci Med Sci. 1995;50A(1):M28-34.

3. Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative properties of the

Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci. 1998;53A:M287-294.

4. Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural

sway, reaction time, the Berg balance scale and ABC scale for comparing fallers and non-

fallers. Arch Gerontol Geriatr. 2004; 38:11-26

5. Montilla-Ibáñez, Alharilla, et al. "The Activities-specific Balance Confidence scale: reliability and validity in Spanish patients with vestibular disorders." Disability and rehabilitation. 2017; 39.7:697-703.

6. Schott, N. "German adaptation of the" Activities-specific Balance Confidence (ABC) scale" for the assessment of falls-related self-efficacy." Zeitschrift fur Gerontologie und Geriatrie. 2008; 41.6:475-485.

7. Mak, Margaret K., et al. "Validation of the Chinese translated activities-specific balance confidence scale." Archives of physical medicine and rehabilitation. 2007; 88.4:496-503.

8. Salbach, Nancy M., et al. "Psychometric evaluation of the original and Canadian French version of the activities-specific balance confidence scale among people with stroke." Archives of physical medicine and rehabilitation. 2006; 87.12:1597-1604.

9. Jang, Soong Nang, et al. "The validity and reliability of Korean fall efficacy scale (FES) and activities-specific balance confidence scale (ABC)." Journal of the Korean Geriatrics Society. 2003; 7.4:255-268.

10. Van Heuvelen, M. J., et al. "Is the Activities-specific Balance Confidence Scale suitable for Dutch older persons living in the community?." Tijdschrift voor gerontologie en geriatrie. 2005; 36.4:146-154.

11. Hassan, Hoory, et al. "Psychometric evaluation of persian version of activities-specific balance confidence scale for elderly persians." Auditory and Vestibular Research. 2015; 24.2:54-63.

12. Marques, Amelia P., et al. "Brazilian-Portuguese translation and cross cultural adaptation of the activities-specific balance confidence (ABC) scale." Brazilian journal of physical therapy. 2013; 17.2:170-178.

13. Alghwiri, Alia A., et al. "The activities-specific balance confidence scale and berg balance scale: Reliability and validity in Arabic-speaking vestibular patients." Journal of Vestibular Research. 2015; 25.5-6:253-259.

14. Moiz, Jamal Ali, et al. "Cross-cultural adaptation and psychometric analysis of the hindi-translated activities-specific balance confidence Scale." Middle East Journal of Rehabilitation and Health. 2016; 3.1

15. Karapolat, H., Eyigor, S., Kirazli, Y., Celebisoy, N., Bilgen, C., & Kirazli, T. Reliability, validity, and sensitivity to change of Turkish Activities-specific Balance Confidence Scale in patients with unilateral peripheral vestibular disease. International Journal of Rehabilitation. Research. 2010; 33(1):12-18.

Core Measure: 10 Meter Walk Test

Overview The 10MWT assesses walking speed in meters/second over a short distance.

Number of Test Items One test item

The test can be completed in two conditions: comfortable walking speed and fast walking speed. 2 trials should be completed in each condition. The average between the two trials should be recorded as walking speed in meters/second. (Steffen, 2008)

Comfortable walking speed has been associated with less measurement error, and should be completed first if doing both conditions. (Tyson, 2009)

Scoring The time taken to ambulate 6 meters is recorded to the nearest 1/100 of a second. 6 meters is then divided by the time taken to ambulate and recorded in meters/second. (Watson, 2002, Steffen, 2008)

Equipment Stopwatch

A clear pathway of at least 10 meters (32.8 feet) in length in a designated area over solid flooring (Stephens, 1999, Watson, 2002)


5 minutes or less

5 minutes or less

Cost Free

Logistics-Setup A clear pathway of at least 10 meters (32.8 feet) in length in a designated area over solid flooring is required.

Measure and mark the start and end point of a 10 meter walkway.

Add a mark at 2 meters and 8 meters (identifying the central 6 meters which will be timed).

Quiet conditions (Steffen, 2008)

Logistics-Administration Comfortable walking speed: o Have the patient start on the 0 meter mark. o Instructions to patient: "Walk at your own comfortable walking

pace and stop when you reach the far mark."

Fast walking speed: o Have the patient start on the 0 meter mark (start line) o Instructions to patient: "Walk as fast as you can safely walk and

stop when you reach the far mark."

Rest breaks are allowed between trials, if needed.

When administering the test, do not walk in front of or directly beside the patient, as this “paces” the patient and can influence the speed and distance they walk. Instead, walk at least a half step behind the patient.

Logistics-Scoring Individuals walk without physical assistance of another person for a distance of 10 meters.

The time is measured for the intermediate 6 meters to allow for patient acceleration and deceleration. (Tyson, 2009, Steffen, 2008).

o The time is started when any part of the leading foot crosses the plane of the 2 meter mark.

o The time is stopped when any part of the leading foot crosses the plane of the 8 meter mark. (Steffen, 2008).




1. “Can the patient use physical assistance to ambulate?”

a. No, the patient must be able to walk unassisted to complete the test. The

requirement of assistance may reduce the validity and reliability of the test by

causing the patient to walk at a different speed than he/she would be able to safely

ambulate on their own. If there is a safety concern regarding the patient’s walking

ability, the recommendation would be to stand near the patient but slightly behind

without any physical contact.

b. If the patient requires physical assistance to perform the test, he/she would receive

a score of 0 meters/second for this test. This would be their baseline score. It is

recommended to collect a baseline score on all patients, even if this means that

they will receive a 0 m/s.

c. If the patient attempts the test and does complete it with assistance, the clinician should document the quality of this performance, even though the score is “0”. The details of assistance level and quality of movement will be valuable to the clinician who re-administers the test at a later date. This will provide more information for this clinician to better interpret the influence of this factor on observed change in performance (Salbach 2017)

2. What if my patient cannot complete 2 trials? a. Two trials is highly recommended to achieve the most accurate information. If a

patient cannot tolerate 2 trials, it is acceptable to document the score for one trial only.

3. What if my patient cannot complete trials under both conditions of “comfortable” and “fast” walking speed?

a. It is recommended to start the test with the “comfortable walking speed” condition.

b. Consider that if a patient has goals to return to the community, the assessment of fast walking speed has more value. If a patient has the ability to walk fast, he/she may be able to more fully participate in the community and adapt to environmental context. If the projected outcome for the patient is community ambulation, a fast gait speed should be collected at the earliest time point possible, and re-testing is recommended to track change.

4. “Where should the therapist stand and guard?”

a. Standing behind the patient will reduce the likelihood of the clinician setting the

pace and will also keep the clinician and stop watch out of sight of the patient to

reduce the likelihood of the patient "racing." (Watson, 2002)

5. “Can the patient use an assistive device during the test?”

a. Yes, the patient can use an assistive device during the test. Recommendations

would be to document the assistive device and keep the assistive device consistent

between trials and reassessments. Inappropriate assistive devices can have a

negative impact on walking speed and therefore reduce the validity of the test.

(Watson, 2002).

b. It is likely, however that the type of assistive device may change over time. This is

ok, just be sure to document which type of device is used. Typically the less

restrictive a device is, the faster the patient will go.

6. “Can the patient use orthotics or bracing during the test?”

a. Yes, the patient should wear the walking devices necessary for ambulation (AFO,

KAFO, Neuroprostheses, etc). The walking device should be documented and kept

consistent between trials and assessments. (Jackson, 2008)

b. If the patient no longer needs the orthosis which was used in the initial test, it

would be appropriate to repeat the test without the orthosis and document this

fact.

c. Expert opinion would recommend using what the patient is most likely to use in

their own environment.

7. “What if I don’t have 10 open meters to do the assessment?”

a. Variations to the 10 meter walk test exist, including the 5 meter walk test. Clinical

recommendations would be to utilize a "rolling start and finish" during the 5 meter

walk test to allow for acceleration and deceleration. It is important to note that the

5 meter walk test has not been validated in as many conditions as the 10 meter walk

test. (Tyson, 2009, Jain, 2016)

8. “Should I count the number of steps taken to complete the 10 Meter walk test?”

a. You can! The steps to complete may provide insight into stride length. Although

documenting this number may add individual value to specific clinical situations,

there has not been extensive research in this area validating the observational step

count in various neurological conditions. (Watson, 2002)

References

1. Jackson, Amie, et al. "Outcome measures for gait and ambulation in the spinal cord injury population." The journal of spinal cord medicine 31.5 (2008): 487-499.

2. Jain, Astha. "Impact of Static v/s Dynamic Start on Results of 10 Metre Walk Test in Patients with Acute Traumatic Brain Injury." Indian Journal of Physiotherapy and Occupational

Therapy-An International Journal 10.1 (2016): 11-14. 3. Scivoletto G, Tamburella F, Laurenza L, Foti C, Ditunno JF, Molinari M. Validity and reliability

of the 10-m walk test and the 6-min walk test in spinal cord injury patients. Spinal cord 2011;49(6):736-40.

4. Steffen, Teresa, and Megan Seney. "Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism." Physical therapy 88.6 (2008): 733-746.

5. Stephens, Joan M., and Patricia A. Goldie. "Walking speed on parquetry and carpet after stroke: effect of surface and retest reliability." Clinical rehabilitation 13.2 (1999): 171-181.

6. Tyson, Sarah, and Louise Connell. "The psychometric properties and clinical utility of 7. Quinn L, Khalil H, Busse M, et al. Reliability and Minimal Detectable Change of Physical

Performance Measures in Individuals With Pre-manifest and Manifest Huntington Disease. Physical Therapy [serial online]. July 2013;93(7):942-956. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed August 18, 2017 measures of walking and mobility in neurological conditions: a systematic review." Clinical rehabilitation 23.11 (2009): 1018-1033.

8. Watson, Martin J. "Refining the ten-metre walking test for use with neurologically impaired people." Physiotherapy 88.7 (2002): 386-397.

9. Salbach N, O’Brien K, Brooks D, et al. Considerations for the Selection of Time-Limited Walk Tests Poststroke: A Systematic Review of Test Protocols and Measurement Properties. J

Neurol Phys Ther. 2017; 41:3-17.

Core Measure: Six Minute Walk Test (6MWT)

Overview This measure examines walking endurance. Participants will walk around the perimeter of a set circuit for a total of six minutes.

Number of Test Items 1

Scoring Distance in meters that a patient covers in 6 minutes

Equipment 12 meter long hallway or open area (e.g., quiet gym)

Markings to indicate turnaround (e.g.: cones)

Stopwatch

Mechanical lap counter or pencil and paper

Measuring instrument (meters)

Chair


< 10 minutes

< 10 minutes

Cost Free

Logistics-Setup In a hallway at least 12 meters long or open area

There should be a clear pathway on the sides and at either end.

A turnaround point approximately 124 cm wide with clear markings should be set up at both ends

A chair should be placed at one end

Logistics-Administration Prior to administering the measure, the patient should be sitting in a chair, rested, near the starting point of the test.

Please review any contraindications and take resting heart rate.

Instructions to the patient in sitting (Quinn, 2013): o “The aim of this test is to walk as far as possible in six minutes.

You will walk back and forth in the hallway. Six minutes is a long time to walk, so you will be exerting yourself. You may get out of breath or become tired. You are allowed to slow down, to stop, and to rest as necessary. You may lean against the wall while resting, but resume walking as soon as you are able. Are you ready to do that?”

o “I am going to use this counter to keep track of the laps you complete. Remember the aim is to walk as far as possible, but do not run or jog.”

o Ask the participant to stand and take resting dyspnea rating using modified Borg Scale.

o “Start now or when you are ready.” o Additional encouragement should be given in a standardized

format every minute:

At 1 minute: "You are doing well, you have 5 minutes to go"

At 2 minutes: "Keep up the good work, you have 4 minutes to go"

At 3 Minutes: "You are doing well, you are halfway done"

At 4 minutes: "Keep up the good work, you have only 2 minutes left"

At 5 minutes: "You are doing well, you only have 1 minute to go"

With 15 seconds to go: “In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you.”

At 6 minutes: “Stop” o Encourangement in any other way should be avoided

The patient may take as many standing rests as they like, but the timer should keep going and record the number of rests that they take and the total rest time.

Patients may use any assistive device or bracing that they are currently using. Clinicians should make a note of what the patient is using.

When administering walking items, do not walk in front of or directly beside the patient, as this “paces” the patient and can influence the speed they walk. Instead, walk at least a half step behind the patient.

Individuals walk without the physical assistance of another person.

Logistics-Scoring Distance (in meters) covered in six minutes calculated by multiplying the number of total laps by 12 meters and adding the distance of the partial lap completed at the time the test ended.

If the patient needs to stop and sit prior to the end of the six minutes, the test ends, and the distance they ambulated is recorded.


The distance (meters) may be recorded at 1 and 3 minutes as well.

Vital signs, including, but not limited to heart rate and dyspnea (assessed using the modified Borg Scale) should be assessed before and after the walk.

Patients should not talk during the test, as this depletes their respiratory reserves. Exceptions to this are if the patient requests to stop the test or needs to report any symptoms (e.g. pain, dizziness).

The person administering the test also should not talk, except to provide updates every minute (as described above). Talking during the test can distract the patient and affect their score on the test.


For patients who are unable to walk, a score of 0 meters should be documented.

.


1. “My current setting does not have a 12 meter hallway or open area available, what should I

do?”

a. Length of the track does matter. According to one study, using shorter hallways or

“tracks” resulted in patients walking shorter overall distances on the 6MWT

compared to when they used longer hallways (Scivoletto, 2011). Therefore, it is

recommended that the test be administered consistent with recommendations

above.

b. If your facility does not have a 12 meter hallway, the test can be administered

outside over level ground free of street crossings. One study investigated an

outdoor test using a GPS compared to a measuring wheel and found similar results

between the two (Wevers, 2011).

c. If your facility does not have a 12 meter hallway, AND you can’t administer the test

outside due to safety, weather, unlevel surfaces, etc., expert opinion is that you

should still administer the test over a shorter track, provided that you are consistent

every time you administer it, and that you document the shorter track distance. Be

aware that the results may not be comparable to published normative values.

2. “My patient requires contact guard assist, can I still administer this measure?”

a. This test should be administered without any physical assistance. It is recommended that you attempt to administer with close supervision assist, instead, but only if safe to do so.

b. However, if it is unsafe to administer with close supervision, the patient should be given a score of 0 meters.

3. “My patient stumbled during the measure and I jumped in to catch them so that they didn’t

fall. How do I score this measure?”

a. Providing assistance during the test is a deviation from the standardized procedure, however may be necessary to preven patient injury. If physical assistance was provided, the patient should be given a score of 0.

4. “My patients are not cognitively intact, and get distracted during the test, frequently

forgetting what their goal is. Can I still administer this measure?”

a. Yes. Examiners can use brief verbal, visual, or tactile cues to keep patients on-task and to remind them of the goal, but be consistent (e.g., “Keep going. Remember your goal is to walk as far as you can in 6 minutes.”). Document the type and frequency of the required cues.

5. “My patient can’t walk for 6 consecutive minutes. Why can’t I just do the 2 Minute Walk,

instead?” a. The good news is that any patient who can walk without physical assistance can

perform the 6MWT. Even if your patient has to end the test well before the 6

minutes are over, they can still receive a score on this test. In some cases the score might be just a few feet distance.

b. In fact, patients who cannot walk without assistance, but who have goals for ambulation, can receive a score of 0 on this test (meaning that they can walk 0 feet in six minutes while following the 6MWT protocol). This is a very useful score, and can allow potentially dramatic improvement to be documented over time.

c. In order to decrease variability in practice and for consistency of measurement across episodes of care and the continuum of care, the 6 Minute Walk Test is the preferred measure of walking endurance. It is recommended that clinicians use this measure instead of (or in addition to) other measures of walking endurance.

6. “My patient requires an assistive device. Can I still administer this measure?”

a. Yes. Whenever possible, use of an assistive device should remain consistent, in order to compare performance over time. Document the device used.

b. It is likely, however that the type of assistive device may change over time. This is okay, just be sure to document which type of device is used. Typically the less restrictive a device is, the faster the patient will go.

7. “My patient has an ankle foot orthosis but rarely wears it at home. Do I test him with or

without it.” a. The decision is ultimately up to the clinician, but the condition chosen needs to be

documented. Expert opinion would recommend using what the patient is most likely to use in their own environment. The same condition should be used for the retest. If the patient no longer needs the orthosis which was used in the initial test, it would be appropriate to repeat the test without the orthosis and document this fact.

References

1. Fulk, G. D. and J. L. Echternach (2008). "Test-retest reliability and minimal detectable change of gait speed in individuals undergoing rehabilitation after stroke." J Neurol Phys Ther 32(1): 8-13. 2. Quinn, L., H. Khalil, H. Dawes, N. E. Fritz, D. Kegelmeyer, A. D. Kloos, J. W. Gillard, M. Busse and N. Outcome Measures Subgroup of the European Huntington's Disease (2013). "Reliability and minimal detectable change of physical performance measures in individuals with pre-manifest and manifest Huntington disease." Phys Ther 93(7): 942-956. 3. Scivoletto, G., F. Tamburella, L. Laurenza, C. Foti, J. F. Ditunno and M. Molinari (2011). "Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients." Spinal Cord 49(6): 736-740. 4. Tappen, R. M., K. E. Roach, D. Buchner, C. Barry and J. Edelstein (1997). "Reliability of physical performance measures in nursing home residents with Alzheimer's disease." J Gerontol A Biol Sci Med Sci 52(1): M52-55. 5. Wevers, L. E., G. Kwakkel and I. G. van de Port (2011). "Is outdoor use of the six-minute walk test with a global positioning system in stroke patients' own neighbourhoods reproducible and valid?" J Rehabil Med 43(11): 1027-1031.

Objectives - cdn.ymaws.com€¦ · (barriers/facilitators) of using OMs in your ... core set of outcome measures (OMs) recommended for individuals with neurologic conditions 2. Identify

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