Assessing Walking Ability in Subjects With Spinal CordInjury: Validity and Reliability of 3 Walking Tests

Hubertus J. van Hedel, PT, MS, Markus Wirz, PT, Volker Dietz, MD, FRCP

Question: Are the TUG test, 6-minute walk test (6MWT), and 10-meter walk test (10MWT) reliable and valid walking test measures for patients with a spinal cord injury (SCI)?

• Study Design: cross-sectional study with repeated assessments• Sample: To assess validity, 75 patients (45 males, 30 females) with SCI. Reliability was

determined with 22 patients (14 males, 8 females) with SCI. All patients had chronic SCI, and were selected because they could perform most of the walking tests on the WSCI II and had no additional gait impairments.

• Procedure: To establish reliability, patients were tested during 3 sessions over 7 days. All tests were in the morning prior to other therapies. Intrarater reliability was found by comparing 2 tests performed by the same therapist. Interrater reliability was found by comparing two tests performed by two different therapists. Validity was determined by grouping the patients based on WISCI II criteria and comparing the WISCI II scores with the scores of the other tests. Correlations between the other three tests were also found.

• Outcome Measures: Spearman rank correlation and Pearson correlation coefficient were used to compare the WISCI II to the three tests and to compare the three tests to each other, respectively. Bland-Altman plots were also used to determine reliability.

• Results: Significant correlation between WISCI II and TUG (p=-.76) and a moderate to good correlation between WISCI II and 10MWT (p=-.68). The correlation between the WISCI II and the 6MWT was also significant (p=.60). For patients with WISCI II scores 0-10, the correlation between WISCI Ii and the other three tests was poor. For the groups with a WISCI score of 11-20, the relationship was fair and significant with 10MWT and moderate to good for TUG and 6MWT. For independent walkers, the WISCI II had moderate-good correlations with the TUG (p=-.66), 10MWT (p=-.48), and 6MWT (p=.65). The correlations between the 3 timed walking tests were all significant and between good and excellent. Intrarater and the interrater reliability was excellent for all three tests.

• Strengths:• 1. Patient population include those with lumbar SCI• 2. Reliability and validity were both measured• 3. Three walking tests not designed for assessing patients with a SCI were assessed

for that purpose• 4. Patients had chronic SCI• Weaknesses:• 1. The study didn’t group the subjects based on level of injury but instead on ability• 2. The study didn’t consider what type of assistive device (if any) the patients were

using• Other Elements: In contrast to patients with independent walking, patients with

severe walking disabilities, there was little correlation between the WISCI II and the three timed walking tests. The moderate to good correlations of the 3 tests with the WISCI II indicate that these tests can be used in both clinical practice and research to assess walking function in patients with SCI.

• Citation: Van Hedel, Hubertus J., Wirz, Markus, & Dietz, Volker. Assessing Walking Ability in Subjects With Spinal Cord Injury: Validity and Reliability of 3 Walking Tests. Archives of Physical Medicine and 2005, 86: 190-196.

• 1. The TUG, 6MWT, and 10MWT are all valid measures for assessing functional gait in patients with SCI.

• 2. In patients with poor walking ability, however, the results of the TUG and 10MWT must be interpreted with caution.

Question:

When would you use the TUG, 10MWT, and 6MWT with SCI since they’re all appropriate to use with this population?

Evaluation

SUBJECTIVE• Name: Scott                    Gender: Male              Age: 25                   Evaluation Date: 04/01/2013• Medical Diagnosis: T12-L2 Burst Fracture Complete Spinal Cord Injury (ICD9 806.2), Traumatic Brain Injury

(ICD9 850.0)                                   Date of Onset: 10/17/2010• PATIENT Diagnosis: gait abnormality (ICD9 781.2), poor balance (ICD9 719.7), muscle weakness (ICD9

728.89), loss of sensory bilateral (ICD9 389.11)• Past Medical History: Patient reports history of right shoulder nerve palsy with bruised rotator cuff, triceps, and

biceps musculature in 2006. Patient denies current issues and has full recovery of his right shoulder after rehab.• Current Medical Condition: On 10/17/2010 patient reports he was operating a motor vehicle at speeds

exceeding 100mph when he fell asleep at the wheel and flipped his car five times, being partially expelled from the vehicle. Patient was transported to Grant Hospital where he received a T12-L2 spinal fusion two days following the accident with no reported complications. Patient stayed there an additional nine days before being discharged to Dodd Hall, where he spent the next 18 days. Since then, patient has received outpatient therapy 3x/ week.

• Current Medical Treatment: Patient reports receiving outpatient PT 2x/ week through Genesis Healthcare Systems for strengthening and functional mobility. Patient reports continued gains.

• Medications: Vesicare for bladder sensitivity• Home Setup: Patient lives alone in a 1 story house with a ramp for entry and grab bars throughout home. Patient

reports use of shower chair and detachable shower head. Patient uses manual controls for operating pedals while driving.

• Prior Functional Status:-          ADLs/IADLs: Independent-          Job Title/Description: full time student; tasks include: traveling ½ mile across campus with 10 minutes allotted between classes. Classes last approximately 2 hours at a time.

Current Functional Status:• -          Assistive Devices: Patient uses manual WC for community mobility. Patient reports using

loftstrands with right plantar flexion stop and left toe-off braces for ambulation at home. He will occasionally ambulate with two canes at home for additional workout. Patient wears TED hose at all times except for sleeping.

• -          Patient reports no cognitive or memory deficits associated with TBI.• -          Bowel and Bladder: Patient reports discontinuation of catheterization 6 months ago.• -          Spasticity: Patient reports spasticity activated by cold and prolonged sitting occurring

bilaterally with left more severe than right. Patient reports clonus is broken by applying pressure.• -          Falls: Patient reports five falls since ambulatory, usually occurring with lofstrands on

unstable surfaces with no injuries. Patient fell a few weeks ago but no falls since then.• -          Patient reports no difficulty completing activities such as cooking and cleaning, and that

campus is wheel chair accessible.• -          Hobbies: shooting, hand cycling, fishing, and XboxPatient Goals: To improve proprioception and strengthen back muscle to be able to walk outside for

20 miles with one cane.Pain (type/location/intensity):• -          Overall: 3-4/10 in back after shooting and occasionally with prolonged standing

• OBJECTIVE • VITALS: • Resting: BP=130/90 HR= 68; After 6MWT: BP=160/98    HR= 120            • Pain [0-10 Scale]:• Beginning of eval: L5-S1 “can’t get comfortable” pain 2/10. Generally feels good; only

pain currently is in the lower back and c/o not getting comfortable• End of eval:1/10; patient states it feels better as he moves more• POSTURE ANALYSIS: • Sitting in w/c: slight forward head rounded shoulders• Sitting on mat: feet unsupported, rounded shoulders• GAIT ANALYSIS:• TUG- B canes: 29.1 sec to R of cone, 29.6 sec to L of cone• TUG- lofstrand crutches: 20.62 sec to R of cone, 17.28 sec to L of cone• ENDURANCE:• 6MWT: 693 feet • A/PROM-Upper Extremity SCREEN: all WFL, UE shoulder and elbow flex and ext

tested unilaterally d/t pain and instability in back.

A/PROM- Lower Extremity: all WFL except:

Decreased DF, especially on L, and decreased hip extension B

-greater decreased in DF in long sit

Decreased hip extension and abd B, knee flexion, and all ankle and foot/toe movements (L slightly better than R)

• Trunk ROM:• Unsupported sitting: decreased ROM in lumbar and lower thoracic spine,

with increased upper thoracic compensation. No c-curve in side bending, limited by 50% with motion occurring in thoracic region. Flexion was limited by 75%, extension was limited by 90%.

• -no LOB with R and L side bending, extension, or flexion• Prone:• -extension: Unable to support head and upper thoracic off table without UE

support.• -when propped on elbows, ASIS off of mat • Bed Mobility: The patient was independent with supine to prone through

side lying. Transfer to mat, from w/c: no difficulty. Actually simulated getting into and out of bed from his wc which is significantly higher than his chair without difficulty; he used quick motions with his UE strength and head/hips relationship to lift his body up onto the mat.to bridge, patient can’t get bum off mat. Patient states “can’t push through toes”.