11 pages and I got nothing concrete out of this that shows there is ANY OBJECTIVE MEASUREMENT OF GAIT. Without that there will never be a way to map rehab protocols to outcome measures. You're screwed.
Measuring ambulation in adults with central neurologic disorders
Karen J. Nolan, PhD a,b,*,
Mathew Yarossi, MS a,c,
Arvind Ramanujam, MS a
Functional ambulation is the extent to which an individual is capable and willing tomove around in their environment.2
Measuring ambulation is a complex task involving clinical expertise, laboratory technology, and the ability to translate information to a community setting.Measuring ambulation can be challenging, because walking occurs in multiple environments and must be assessed at multiple time points to indicate improvement or decline. There is an added complexity, because, in a traditional clinical environment,a single numerical value or scale score is preferred to summarize a series of complex movements,3
whereas in a laboratory environment, researchers typically prefer quantifiable continuous data, which allow for complex analysis of multiple outcome variables. Measuring ambulation in a community also presents unique challenges and often requires a combination of strategies to obtain valid outcomes.4
This review examines strategies for appropriate measurements of ambulation in individuals with CND within 3 distinct environments: (1) clinical, (2) laboratory, and (3) community.The purpose of this article is not to provide an exhaustive list of the measures that can be used to assess ambulation but rather to describe the most frequently used measures and to discuss common challenges faced by clinicians and researchers in establishing an accurate picture of an individual’s ability to ambulate.
Test selection is often dependent on nonclinical criteria such as cost, time to administer, and available equipment.5
It is also important for the patient to understand the test instructions, because unfamiliarity with the test can alter performance and outcomes.5
Some examples of typical clinical assessments commonly used for measuring ambulation can be found in Table 1(See link)
.The Functional Independence Measure (FIM) was designed to measure burden of care in multiple rehabilitation populations.3
The scores are based on clinical observation of 18 items of activities of daily living (ADLs) (13 motor and 5 cognition items).6
Although there are motor items associated with this measure (including 1 item labeled locomotion and 1 labeled stairs), the overall FIM score is often not sensitive enough to reflect improvements in ambulation (particularly in situations in which walking performance has improved without a change in the level of assistance needed). Previous research also revealed a ceiling effect, and the FIM shows poor sensitivity to change in individuals with better walking abilities.
13
The FIM is typically used to determine independence at admission and discharge from inpatient rehabilitation. Another example of a frequently used clinical measure of motor deficits is the Fugl-Meyer Motor Assessment, which has previously been shown to correlate with length of stay in inpatient rehabilitation, and has been found to be predictive of discharge FIM scores and performance in ADLs. The disadvantage of this measure is that it assesses only gross limb movement and not fine or complex movements or coordination. Both the FIM and Fugl-Meyer Motor Assessment as a whole do provide reliable information about the results of rehabilitation, but it is difficult to specifically determine if, and how much, ambulation has improved using either of these assessment tools.The Ambulation Index (AI) is an ordinal rating scale designed to assess independent mobility by evaluating the time and degree of assistance required to walk7.62m(25ft),as well as the ability to transfer.8
Previous research has found the AI to be useful as a grouping variable when measuring ambulation in individuals with stroke.14
The measure is useful in rehabilitation medicine, but it is not sensitive enough to measure small changes in ambulation.Overall, the FIM, Fugl-Meyer, and AI measure impairment and function but have limited usefulness in describing and evaluating ambulation. When measuring ambulation in a clinical environment, it is important to consider that individuals with CND may have difficulty adapting to the demands of walking in the community, such as rising from a chair, stepping over an obstacle, ascending stairs,and navigating various terrains.9
The challenge is to select tasks and terrains that mimic community ambulation that are easy to administer and provide relevant clinical information. The Emory Functional Ambulation Profile (EFAP) and the modified EFAP(mEFAP) were designed to provide quantitative information about ambulation by measuring the time to walk over a standardized array of community obstacles and surfaces, accounting for the use of assistive devices.9,10
The EFAP and mEFAP are reliable and valid clinical tests of ambulation that are sensitive to changes in ambulation speed.9,10
Research in individuals with stroke found that the mEFAP is sensitive to changes in gait function during inpatient rehabilitation and therefore could be used to supplement traditional subjective measures of clinical ambulation.15
Walking tests measure the distance walked in a given amount of time to indicate walking performance. These tests are generally 2, 6, 10, or 12 minutes in duration and are widely used in clinical and research applications for individuals with CND.3
These measures are more quantitative and provide information directly related to ambulation, including walking endurance. Previous research in this area suggests that individuals must negotiate a distance of between 332 and 360 m to access goods and services in the community.16,17
Walking distance is therefore a key indicator of ambulation.18
For individuals with CND, it is important to have clinical assessments that identify individuals who are at risk for falling and may benefit from interventions designed to improve balance.19
The Dynamic Gait Index (DGI) was developed as a clinical tool to assess an individual’s ability to modify gait in response to changing task demands.11
The limitation of the DGI is that scores are reduced for those individualsusing an assistive device, regardless of performance.20
The DGI has been applied to individuals with CND as a reliable measure of dynamic balance and potential fall risk.20,21
The Timed Up and Go (TUG) is a screening test of balance that is commonly used to evaluate functional mobility.19
The time to complete the test is strongly correlated to the level of functional mobility. Adults who complete the TUG in less than20 seconds are considered to be independent in transfer tasks associated with ADLs and can maintain walking speeds sufficient for community ambulation.12,22
In individuals with CND, alterations in gait mechanics, strength, and balance have a direct effect on gait speed.5
The 10-m walk test and timed 7.62 m (25-ft) walk are measures of ambulation capacity in which gait speed is the primary outcome variable. These tests have been widely used in populations with CND and are easy to administer in a clinical environment.3
When measuring ambulation, it is important for clinicians to select measures capable of detecting changes that reflect real life function.23
Gait speed is an important and reliable measure of ambulation for individuals, because safe navigation of community crosswalks mandates that an individual be able to complete a prescribed distance in a defined time period.16,23
Previous research in stroke found that when an ankle foot orthotic was worn on the paretic limb, individuals gained the ability to modulate gait speed. The orthotic intervention provided individuals with stroke with the functional ability to increase speed in the community, which is essential for negotiating obstacles and safely crossing community streets.14,16
Gait speed is used in clinical and research applications as the hallmark of recovery, it is simple to implement, and it has robust psychometric properties.24
Several studies have provided evidence to support the predictive validity of gait speed, and it has
been shown to be positively correlated with level of disability, function, and quality of life in individuals with stroke.25–27
However, what represents a clinically meaningful change in gait speed has not been defined in all patient populations.
Mathew Yarossi, MS a,c,
Arvind Ramanujam, MS a
INTRODUCTION
Throughout rehabilitation medicine, there is an emphasis on the ability to ambulate as a functional outcome and as an overall indicator of quality of life. When ambulation is affected by central neurologic disorders (CND), it is typically as a result of a combination of impairments and the compensatory strategies used to accommodate these impairments. Pathologic ambulation can result from impairments within a single system or within a combination of systems, such as musculoskeletal, neuromuscular,sensory/perceptual, and cognitive/behavioral.1Functional ambulation is the extent to which an individual is capable and willing tomove around in their environment.2
Measuring ambulation is a complex task involving clinical expertise, laboratory technology, and the ability to translate information to a community setting.Measuring ambulation can be challenging, because walking occurs in multiple environments and must be assessed at multiple time points to indicate improvement or decline. There is an added complexity, because, in a traditional clinical environment,a single numerical value or scale score is preferred to summarize a series of complex movements,3
whereas in a laboratory environment, researchers typically prefer quantifiable continuous data, which allow for complex analysis of multiple outcome variables. Measuring ambulation in a community also presents unique challenges and often requires a combination of strategies to obtain valid outcomes.4
This review examines strategies for appropriate measurements of ambulation in individuals with CND within 3 distinct environments: (1) clinical, (2) laboratory, and (3) community.The purpose of this article is not to provide an exhaustive list of the measures that can be used to assess ambulation but rather to describe the most frequently used measures and to discuss common challenges faced by clinicians and researchers in establishing an accurate picture of an individual’s ability to ambulate.
MEASURING AMBULATION IN THE CLINICAL ENVIRONMENT
In a clinical environment, it is important to select measures that can evaluate changes in impairment, function, and performance.3Test selection is often dependent on nonclinical criteria such as cost, time to administer, and available equipment.5
It is also important for the patient to understand the test instructions, because unfamiliarity with the test can alter performance and outcomes.5
Some examples of typical clinical assessments commonly used for measuring ambulation can be found in Table 1(See link)
.The Functional Independence Measure (FIM) was designed to measure burden of care in multiple rehabilitation populations.3
The scores are based on clinical observation of 18 items of activities of daily living (ADLs) (13 motor and 5 cognition items).6
Although there are motor items associated with this measure (including 1 item labeled locomotion and 1 labeled stairs), the overall FIM score is often not sensitive enough to reflect improvements in ambulation (particularly in situations in which walking performance has improved without a change in the level of assistance needed). Previous research also revealed a ceiling effect, and the FIM shows poor sensitivity to change in individuals with better walking abilities.
13
The FIM is typically used to determine independence at admission and discharge from inpatient rehabilitation. Another example of a frequently used clinical measure of motor deficits is the Fugl-Meyer Motor Assessment, which has previously been shown to correlate with length of stay in inpatient rehabilitation, and has been found to be predictive of discharge FIM scores and performance in ADLs. The disadvantage of this measure is that it assesses only gross limb movement and not fine or complex movements or coordination. Both the FIM and Fugl-Meyer Motor Assessment as a whole do provide reliable information about the results of rehabilitation, but it is difficult to specifically determine if, and how much, ambulation has improved using either of these assessment tools.The Ambulation Index (AI) is an ordinal rating scale designed to assess independent mobility by evaluating the time and degree of assistance required to walk7.62m(25ft),as well as the ability to transfer.8
Previous research has found the AI to be useful as a grouping variable when measuring ambulation in individuals with stroke.14
The measure is useful in rehabilitation medicine, but it is not sensitive enough to measure small changes in ambulation.Overall, the FIM, Fugl-Meyer, and AI measure impairment and function but have limited usefulness in describing and evaluating ambulation. When measuring ambulation in a clinical environment, it is important to consider that individuals with CND may have difficulty adapting to the demands of walking in the community, such as rising from a chair, stepping over an obstacle, ascending stairs,and navigating various terrains.9
The challenge is to select tasks and terrains that mimic community ambulation that are easy to administer and provide relevant clinical information. The Emory Functional Ambulation Profile (EFAP) and the modified EFAP(mEFAP) were designed to provide quantitative information about ambulation by measuring the time to walk over a standardized array of community obstacles and surfaces, accounting for the use of assistive devices.9,10
The EFAP and mEFAP are reliable and valid clinical tests of ambulation that are sensitive to changes in ambulation speed.9,10
Research in individuals with stroke found that the mEFAP is sensitive to changes in gait function during inpatient rehabilitation and therefore could be used to supplement traditional subjective measures of clinical ambulation.15
Walking tests measure the distance walked in a given amount of time to indicate walking performance. These tests are generally 2, 6, 10, or 12 minutes in duration and are widely used in clinical and research applications for individuals with CND.3
These measures are more quantitative and provide information directly related to ambulation, including walking endurance. Previous research in this area suggests that individuals must negotiate a distance of between 332 and 360 m to access goods and services in the community.16,17
Walking distance is therefore a key indicator of ambulation.18
For individuals with CND, it is important to have clinical assessments that identify individuals who are at risk for falling and may benefit from interventions designed to improve balance.19
The Dynamic Gait Index (DGI) was developed as a clinical tool to assess an individual’s ability to modify gait in response to changing task demands.11
The limitation of the DGI is that scores are reduced for those individualsusing an assistive device, regardless of performance.20
The DGI has been applied to individuals with CND as a reliable measure of dynamic balance and potential fall risk.20,21
The Timed Up and Go (TUG) is a screening test of balance that is commonly used to evaluate functional mobility.19
The time to complete the test is strongly correlated to the level of functional mobility. Adults who complete the TUG in less than20 seconds are considered to be independent in transfer tasks associated with ADLs and can maintain walking speeds sufficient for community ambulation.12,22
In individuals with CND, alterations in gait mechanics, strength, and balance have a direct effect on gait speed.5
The 10-m walk test and timed 7.62 m (25-ft) walk are measures of ambulation capacity in which gait speed is the primary outcome variable. These tests have been widely used in populations with CND and are easy to administer in a clinical environment.3
When measuring ambulation, it is important for clinicians to select measures capable of detecting changes that reflect real life function.23
Gait speed is an important and reliable measure of ambulation for individuals, because safe navigation of community crosswalks mandates that an individual be able to complete a prescribed distance in a defined time period.16,23
Previous research in stroke found that when an ankle foot orthotic was worn on the paretic limb, individuals gained the ability to modulate gait speed. The orthotic intervention provided individuals with stroke with the functional ability to increase speed in the community, which is essential for negotiating obstacles and safely crossing community streets.14,16
Gait speed is used in clinical and research applications as the hallmark of recovery, it is simple to implement, and it has robust psychometric properties.24
Several studies have provided evidence to support the predictive validity of gait speed, and it has
been shown to be positively correlated with level of disability, function, and quality of life in individuals with stroke.25–27
However, what represents a clinically meaningful change in gait speed has not been defined in all patient populations.
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