ArticleLiterature Review

Is stair negotiation measured appropriately in functional assessment scales?

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

A decline in mobility may result in problems with the negotiation of stairs, which can potentially be hazardous. In practice, stair negotiation is an important aspect of daily living and therefore needs to be assessed carefully. We conducted a systematic literature review to identify the way functional assessment scales assess stair negotiation. We evaluated whether stair negotiation could be assessed in a valid and reliable way with these scales. Forty-three of the 92 identified scales have an item on stair negotiation. In these scales, the definition of 'negotiation of stairs' varies, as does the definition of independence. Important aspects such as safety on stairs are missing from all scales. In contrast to older scales, newer scales consist of items that have been tested for validity and reliability. In none of the scales was the stair negotiation item tested separately for validity. Only two scales examined test-retest reliability and only one measured inter-observer agreement. In current functional assessment scales stair negotiation is measured with great heterogeneity and insufficient validity. In patients and in studies in which assessment of stair negotiation ability is a key part of functional assessment, an improved, well-validated scale is needed. This scale should include not only the subject's physical ability to negotiate stairs, but also safety and change in ability over time.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... these thresholds were chosen in accordance with previous similar studies. 12,16 due to the potential inter-relationship of these factors, the analyses were performed using a forward logistic binary regression, the statistical technique most commonly used for identifying prognostic factors without a bias related to a potential multicollinearity. the logistic regression was performed using as dependent variable: partial and complete recovery of walking ability (score of the "mobility" item of bi = 10 and 15, respectively), partial and complete recovery of stair climbing ability (score of the "stairs" item of BI =5 and 10, respectively), all assessed at discharge. ...
... Even though BI is not a specific scale for assessing overground walking and stair climbing abilities, it is the most commonly used clinical scale to assess independence of patients with stroke in ADLs, with a specific item for walking and one for stair climbing, 23 and it was already used in previous studies about the mobility recovery in patients with stroke. 12,16 for this reason, we used these items to assess independence in overground walking (item "mobility" of bi) and stair climbing (item "stairs" of bi). Treatment all patients performed 3 h/day. ...
... 36 surprisingly, partial anterior circulation infarcts resulted in a good prognostic factor for walking recovery. it could be due to the fact that paci lesions exclude total anterior circulation infarcts (taci), which are clearly more severe, 16 but also posterior circulation infarcts (poci) and lacunar infarcts (laci). [37][38][39][40][41] it is noteworthy that patients received rehabilitation for improving their independence in all the domains of activities of daily living, including walking and stair climbing. ...
Article
Background: After discharge, most patients who have suffered a stroke remain with some limitations in their stair climbing ability. This is a critical factor in order to be independent in real-life mobility. Although there are several studies on prognostic factors for gait recovery, few of them have focused on to the recovery of stair climbing. Aim: The aim of this study was to identify prognostic risk factors for the recovery of stair climbing ability in a large sample of subjects with subacute stroke. Design: Observational study. Setting: Neurorehabilitation Inpatient Unit. Methods: We evaluated subjects within the first month after stroke that had been admitted to an inpatient rehabilitation unit and discharged after an intensive inpatient rehabilitation. Demographical and clinical data were collected. Barthel Index (BI), Trunk Control Test and Motricity Index (MI) scores were recorded at admission and at discharge. Patients received two daily 40-minute sessions of motor rehabilitation, six days per week, during approximately two months. Forward Binary Logistic regressions were used to identify the role of risk factors, using as dependent variables the recovery of stair climbing ability and walking ability at discharge. As independent variables we used age, gender, onset-to-admission interval, side of hemiparesis, trunk control, motricity index (MI), presence of obesity, presence of neglect, presence of depression, classification of cerebral infarction (total anterior circulation, partial anterior circulation, posterior circulation or lacunar infarcts), degree of independence in activities of daily living, and cognitive state, all assessed at admission. Results: A total of 257 subjects were enrolled. BI-score, MI-score and presence of unilateral spatial neglect at admission were able to explain 83% of variance for the recovery of stair climbing ability. Subjects with a BI > 40 at admission were about 17 times more likely to be able to climb stairs again than other patients, and those with MI ≥ 25 were about 9 times more likely than the rest. The presence of unilateral spatial neglect reduced this possibility of recovering stair climbing ability by about 5.5 times. Of these factors, only MI ≥ 25, together with a score at Trunk Control Test > 12, significantly predicted also walking recovery. Conclusions: This study highlights the different prognostic factors for recovering stair climbing and walking abilities, with a major role of unilateral spatial neglect in the former. Clinical rehabilitation impact: There is a need for specific rehabilitation of stair climbing, also for improving the independence in activities of daily living, especially in patients who the clinical staff already knows should manage stairs in their community after being discharged.
... 3-5 However, the reliability and validity of many individual activities, such as stair climbing, that are used to assess ADLs and function are not well established. [6][7][8][9] Stair negotiation (climbing up and down stairs) was among the top 5 tasks that communityresiding older adults rated as being most difficult due to "old age." 6,7 Self-reported ability to climb stairs is considered a key marker of functional independence in older adults. ...
... Poor characterization of stair negotiation has been identified as a major limitation in functional assessment in previous reviews. 7,8 We examined the clinical and functional correlates of self-reported difficulty in climbing up and climbing down stairs separately in a community-residing sample of nondisabled and nondemented older adults. The aims of this study were 3-fold: (1) to examine commonalities and differences in clinical conditions associated with self-reported difficulties in climbing up and down stairs; (2) to establish the reliability for self-reported difficulties in climbing up and down stairs; and (3) to examine whether there was a risk gradient for activity limitations associated with stair negotiation difficulty. ...
... However, many of these subjects are likely to have difficulty climbing stairs. [8][9][10][11] To improve reliability of responses, we did not include subjects with dementia. Our findings should be verified in other clinical and nursing home samples including subjects with disability and dementia. ...
Article
Full-text available
To examine clinical and functional correlates of self-reported difficulty in climbing up or climbing down stairs in older adults. Cross-sectional survey. Community sample. Older adults (N=310; mean age, 79.7 y; 62% women), without disability or dementia. Not applicable. Clinical and functional status as well as activity limitations (able to perform activities of daily living [ADLs] with some difficulty). Of the 310 subjects, 140 reported difficulties in climbing up and 83 in climbing down stairs (59 both). Self-reported difficulty in climbing up stairs was associated with hypertension, arthritis, and depressive symptoms. Difficulty in climbing up stairs was also associated with poor balance and grip strength as well as neurologic gait abnormalities. Subjects with difficulty climbing down stairs had more falls. Both activities were associated with leg claudication, fear of falling, non-neurologic gait abnormalities, and slow gait. Examined individually, self-reported difficulty climbing down stairs captured a wider spectrum of ADL limitations than climbing up stairs. However, combined difficulty in both phases of stair climbing had a stronger association with activity limitations (vs no difficulty; odds ratio, 6.58; 95% confidence interval, 3.35-12.91) than difficulty in any one phase alone. Self-reported difficulty in climbing up and down stairs revealed commonalities as well as differences in related clinical correlates. Difficulty in both climbing up and down stairs should be separately assessed to better capture clinical and functional status in older adults.
... S TAIR NEGOTIATION IS ONE of the most demanding and hazardous activities, with more than 10% of fatal falls in older adults occurring while going down stairs. 1 Self-reported ability to climb stairs is considered a key marker of functional independence in older adults. [1][2][3] Difficulty in climbing stairs in older adults predicted readmission to the hospital within a month after being discharged from the emergency department. 4 In hospital settings, stair-climbing ability is often used to decide whether a patient may be sent home or to a nursing facility. ...
... The questionnaires for stair negotiation, however, are limited by unclear definitions (ie, number of steps), lack of validation, or assessment of only stair ascent and not descent. 3 Moreover, while self-reported difficulty in stair negotiation may be a reliable and valid indicator, 10 it is not a direct measure of this motoric activity and does not adequately capture the variability in performance seen on this task in older adults. Currently, there exists no standard performance test of stair negotiation ability with age and sex norms, and the potential importance of difficulty with stair descent 1,10,11 as an indicator of functional status has been largely overlooked. ...
Article
Full-text available
To establish reference values for stair ascent and descent times in community-dwelling, ambulatory older adults, and to examine their predictive validity for functional decline. Longitudinal cohort study. Mean follow-up time was 1.8 years (maximum, 3.2y; total, 857.9 person-years). Community sample. Adults 70 years and older (N=513; mean age, 80.8 ± 5.1y) without disability or dementia. Not applicable. Time to ascend and descend 3 steps measured at baseline. A 14-point disability scale assessed functional status at baseline and at follow-up interviews every 2 to 3 months. Functional decline was defined as an increase in the disability score by 1 point during the follow-up period. The mean±SD stair ascent and descent times for 3 steps were 2.78 ± 1.49 and 2.83 ± 1.61 seconds, respectively. The proportion of self-reported and objective difficulty was higher with longer stair ascent and descent times (P<.001 for trend for both stair ascent and descent). Of the 472 participants with at least 1 follow-up interview, 315 developed functional decline, with a 12-month cumulative incidence of 56.6% (95% confidence interval [CI], 52.1%-61.3%). The stair negotiation time was a significant predictor of functional decline after adjusting for covariates including gait velocity (adjusted hazard ratio [aHR] per 1-s increase: aHR=1.12 [95% CI, 1.04-1.21] for stair ascent time; aHR=1.15 [95% CI, 1.07-1.24] for stair descent time). Stair descent time was a significant predictor of functional decline among relatively high functioning older adults reporting no difficulty in stair negotiation (P=.001). The stair ascent and descent times are simple, quick, and valid clinical measures for assessing the risk of functional decline in community-dwelling older adults including high-functioning individuals.
... Step Test Evaluation of Performance on Stairs (STEPS). The STEPS tool was constructed based on our clinical experiences and a review of stair negotiation outcome measures [3,[12][13][14][15][16]. It has undergone several revisions to reach its present form based on our experiences using it and feedback from physical therapists (PTs). ...
... Exploratory univariable linear regression was performed to examine the relationships between the STEPS score (AR) and specific physical and cognitive characteristics that the authors deemed most likely to affect stair performance. These characteristics included UHDRS modified motor (items [4][5][8][9][10][11][12][13][14][15], eye movement (items 1-3), and chorea (item 7) subscale scores of the UHDRS motor section. The modified motor score (mMS) measures the ability to perform voluntary movements (e.g., finger taps, gait, tandem walking). ...
Article
Full-text available
Background Individuals with neurological disorders often have difficulty negotiating stairs that can lead to injurious falls. Clinicians lack a clinical tool to identify impairments in stair negotiation and to assist their decision making regarding treatment plans to improve stair performance and safety. We developed a new tool called the Step Test Evaluation of Performance on Stairs (STEPS) that is designed to assess stair performance and safety in neurological populations. Objectives This study aimed to determine interrater and intrarater reliability of STEPS and its concurrent content validity to various clinical balance and mobility measures using individuals with Huntington’s disease (HD) as the first test population. Methods Forty individuals with HD (mean age 50.35) participated. Three observers rated live performances of the STEPS (interrater reliability) and seven observers rated videotaped performances twice (intrarater reliability). STEPS scores correlated with clinical mobility and balance test scores. Results Excellent inter- and intrarater reliability (ICCs = 0.91 and 0.89 respectively) and good internal consistency (α = 0.83) were found. Better STEPS performance correlated with better performance on co-administered motor and mobility measures and Stair Self-Efficacy scores. Per multivariable regression analysis, the Unified Huntington’s Disease Rating Scale modified motor score and descent time were significant predictors of STEPS performance. Conclusions The STEPS tool is easy to administer, requires no special devices and can be completed in less than five minutes. In the HD test population, it shows high reliability and validity making it a potentially useful tool for assessing maneuverability and safety on stairs in HD. The results suggest that the STEPS tool warrants further study to determine STEPS cut-off values for fall prediction in HD and may prove useful as an assessment tool for other neurological disorders.
... Given the impact of stair negotiation on quality of life, this task is increasingly included in both clinical assessment [9] and rehabilitation [10], [11]. Regarding assessment, van Iersel et al. [9] found 43 clinical tests incorporating an item on stair walking. ...
... Given the impact of stair negotiation on quality of life, this task is increasingly included in both clinical assessment [9] and rehabilitation [10], [11]. Regarding assessment, van Iersel et al. [9] found 43 clinical tests incorporating an item on stair walking. In the following years, other scales evaluating stair negotiation have been validated, such as the modified Dynamic Gait Index (mDGI) [12]. ...
Article
Full-text available
Stair ascent is a challenging daily-life activity highly related to independence. This task is usually assessed with clinical scales suffering from partial subjectivity and limited detail in evaluating different task’s aspects. In this study we instrumented the assessment of stair ascent in people with Multiple Sclerosis (MS), stroke (ST) and Parkinson’s disease (PD) to analyze the validity of the proposed quantitative indexes and characterize subjects’ performances. Participants climbed 10 steps wearing a magneto-inertial sensor (MIMU) at sternum level. Gait pattern features (step frequency, symmetry, regularity, harmonic ratios), and upper trunk sway were computed from MIMU signals. Clinical mDGI (modified Dynamic Gait Index) and mDGI-Item 8 (“Up stairs”) were administered. Significant correlations with clinical scores were found for gait pattern features (rs>=0.536) and trunk pitch sway (rs<=-0.367) demonstrating their validity. Instrumental indexes showed alterations in the three pathological groups compared to healthy subjects, and significant differences, not clinically detected, among MS, ST and PD. MS showed the worst performance, with alterations of all gait pattern aspects and larger trunk pitch sway. ST showed worsening in gait pattern features, but not in trunk motion. PD showed fewer alterations consisting in reduced step frequency and trunk yaw sway. These results suggest that the use of a MIMU provided valid objective indexes revealing between-group differences in stair ascent not detected by clinical scales. Importantly, the indexes includes upper trunk measures, usually not present in clinical tests, and provides relevant hints for tailored rehabilitation.
... The findings from such dual-task studies show that older subjects manifest both physical and cognitive deterioration when compared with younger subjects. Negotiating stairs is a difficult daily activity for many older subjects (Startzell et al. 2000; van Iersel et al. 2003). More specifically, more than 10 % of fatal falls among older adults occur while descending stairs (Startzell et al. 2000). ...
... The positive effects of Tai Chi training on postural control have been demonstrated in terms of improved muscle strength, joint proprioception, and sensory organization ability, all of which contribute to postural control (Chen et al. 2012; Li et al. 2005; Tsang and Hui-Chan 2004). Tai Chi is a mind–body exercise that demands motor planning in performing very precisely a prescribed sequence of movement patterns (Tsao 1995). For example, Tai Chi practice requires the mind to concentrate on the ordering of coordinated eye–limb (hand and leg) and eye–body (neck and trunk) movements in a smooth sequence (Li et al. 2001). ...
Article
To compare the performance of older experienced Tai Chi practitioners and healthy controls in dual-task versus single-task paradigms, namely stepping down with and without performing an auditory response task, a cross-sectional study was conducted in the Center for East-meets-West in Rehabilitation Sciences at The Hong Kong Polytechnic University, Hong Kong. Twenty-eight Tai Chi practitioners (73.6 ± 4.2 years) and 30 healthy control subjects (72.4 ± 6.1 years) were recruited. Participants were asked to step down from a 19-cm-high platform and maintain a single-leg stance for 10 s with and without a concurrent cognitive task. The cognitive task was an auditory Stroop test in which the participants were required to respond to different tones of voices regardless of their word meanings. Postural stability after stepping down under single- and dual-task paradigms, in terms of excursion of the subject's center of pressure (COP) and cognitive performance, was measured for comparison between the two groups. Our findings demonstrated significant between-group differences in more outcome measures during dual-task than single-task performance. Thus, the auditory Stroop test showed that Tai Chi practitioners achieved not only significantly less error rate in single-task, but also significantly faster reaction time in dual-task, when compared with healthy controls similar in age and other relevant demographics. Similarly, the stepping-down task showed that Tai Chi practitioners not only displayed significantly less COP sway area in single-task, but also significantly less COP sway path than healthy controls in dual-task. These results showed that Tai Chi practitioners achieved better postural stability after stepping down as well as better performance in auditory response task than healthy controls. The improved performance that was magnified by dual motor-cognitive task performance may point to the benefits of Tai Chi being a mind-and-body exercise.
... Given the impact of stair negotiation on quality of life, this task is increasingly included in both clinical assessment [9] and rehabilitation [10], [11]. Regarding assessment, van Iersel et al. [9] found 43 clinical tests incorporating an item on stair walking. ...
... Given the impact of stair negotiation on quality of life, this task is increasingly included in both clinical assessment [9] and rehabilitation [10], [11]. Regarding assessment, van Iersel et al. [9] found 43 clinical tests incorporating an item on stair walking. In the following years, other scales evaluating stair negotiation have been validated, such as the modified Dynamic Gait Index (mDGI) [12]. ...
... For example, mobility interventions that capitalise on the builtenvironment of the delivery location (i.e., hospital and/or day centre settings), so that improvements can be translated in to home-based settings (i.e. in the patients' home and community-based environments). Stair negotiation, going up and down a flight of stairs with, or without assistance (Van Iersel et al., 2002), is a primary functional requirement for inpatient hospital discharge. Centre-based interventions also facilitate early rehabilitation and adherence to higher training intensity (Lemmey & Okoro, 2013), both of which may promote faster functional recovery and shorter hospital admissions after hip (Oldmeadow et al., 2006) or knee joint surgery (Khan et al., 2008). ...
... As stair negotiation represents a functional outcome measure (Unver et al., 2015;van Iersel et al., 2002) and ADL high on the hierarchy of task demand (Jette et al., 2003), improvements would be expected to translate to less challenging, mobility and ambulatory tasks encountered in daily-life (such as transfers, standing up and walking) (Carr & Shepherd, 1998;Liao et al., 2015). ...
Article
Background: Total hip replacement (THR) and total knee replacement (TKR) are common orthopaedic procedures. However, an optimal programme for post-operative rehabilitation has yet to be established. Stair negotiation is a challenging, habitual task, regularly used as a post-operative functional outcome measure; yet as a physical rehabilitation intervention it appears to be rarely used. Aim: The review purpose was to investigate the effectiveness of stair climbing as a rehabilitation intervention for THR and TKR patients. Methods: MEDLINE, PsycINFO, Science Citation Index, CINAHL, SPORTDiscus and the Cochrane Database of Systematic Reviews were searched. The systematic review targeted studies using stair negotiation as a rehabilitation intervention. Randomised and non-randomised controlled trials, pilot studies, and case studies were included; systematic reviews and meta-analyses were excluded. Results: Of 650 articles identified, ten studies were eligible for review. A predefined data table to extract information from selected studies was used. Of the ten identified reports, two prehabilitation and eight rehabilitation studies included stair negotiation exercises as part of multi-modal physical interventions. Outcome measures were classified as: functional self-reported, perceptual, psychological and those relating to quality of life. Conclusion: Studies were methodologically heterogeneous and typically lacked adequate control groups. It was not possible to determine the impact of stair negotiation exercise on the positive outcomes of interventions. Stair negotiation warrants further investigation as a rehabilitation activity.
... In this random sample of elderly women living in the community, we found that 1 in 5 were unable to climb steps higher than 20 cm—the most usual step height in Norwegian homes— without support (Figure 1). Van Iersel et al. (2003) found that about a third of older people living at home have some difficulties with stairs. The somewhat higher prevalence estimated by Van Iersel et al. might relate to sample selection and different methods of measurement. ...
... Because there is no uniformity in assessing the ability to negotiate stairs in research (van Iersel et al., 2003), it is difficult to compare the results. In conclusion, our findings provide further evidence that difficulty with climbing steps of different heights is a marker of impaired balance and reduced ability to perform functional tasks integrated in daily living. ...
Article
The aim of this study was to investigate walking and health among woman age 75 yr or older, in the associations between the highest step up performed without support by an individual and balance, walking, and health among women age 75+. Records of the highest step, balance, walking, and health were made for 307 women age 75-93 yr living in the community. Eighty percent managed to climb steps higher than 20 cm. There was a statistically significant negative relationship between age and stair-climbing capacity. The highest steps registered were significantly and independently associated with a short time on the timed up-and-go test, long functional reach, low body weight, lack of perceived difficulty walking outdoors, low number of "missteps" when walking in a figure of 8, longer time in one-leg stance, ability to carry out tandem stance, no walking aids outdoors, and not being afraid of falling. These variables together explained 67% of the variance in the step-height score.
... Stair climbing is an important but neglected aspect of independent living. Clinicians should pay attention to the ability to negotiate stairs in elderly and disabled patients [12,16]. Therefore, the aim of the study is to determine how the activity of climbing up and down the stairs is affected by the age [5,6], gender [4,5], cognitive status [6,10], lower extremity pathology [7,9] and medication use [17] in the elderly population in Turkish society. ...
... Currently available generic measurement instruments and disease-specific instruments provide only a global measurement of activity limitations in climbing stairs. Although climbing stairs is included in many of these instruments, this activity is often addressed by 1 or 2 items only [7,12,16]. Therefore, we used in this study a stair climbing scale with excellent scaling characteristics, and adequate to provide a detailed assessment of activity limitations in climbing stairs in elderly people. ...
Article
Full-text available
Background: Stair climbing is an important but neglected aspect of independent living. Clinicians should pay attention to the ability to negotiate stairs in elderly and disabled patients. Objective: The aim of this study was to determine the effects of age, gender, medication use, cognitive status, lower extremity pathology and pain on the activities of stair negotiation in the elderly population in Turkish society. Methods: Volunteer elderly people (254) were included the study. Participants were assessed in terms of their medication use, cognitive status, lower extremity pathology and pain and the activity of climbing the stairs.RESULTS: Significant differences were found on the activities of stair negotiation between the elderly with and without lower extremity pathology, with and without lower extremity pain, with and without medication use (p< 0.05). A positive and moderate correlation was found between age and the activity of stair climbing (r=0.24, p< 0.01).CONCLUSIONS: Activity of stair climbing is affected by age, medication use, the presence of lower extremity pathology and pain. We consider that this information will be helpful for planning an appropriate and effective rehabilitation programme for elderly people for decreasing their risk of falling and increasing their independence level during their activities of daily living.
... 4 Escalas de avaliação funcional podem ser úteis para identificar e monitorar incapacidades, quantificando o nível de dependência e a necessidade de aparelhos de auxílio na execução de tarefas. 5 Em função de os instrumentos existentes não fornecerem uma avaliação mais detalhada da limitação da atividade de subir e descer escadas, Roorda e colaboradores 6 desenvolveram uma escala que afere essa ação. ...
Article
Full-text available
INTRODUCTION: Stair climbing is an essential daily task. Climbing limitations are especially prevalent in elderly populations and affect functional independence. This paper aims to translate and make the cultural adaption to Brazilian Portuguese of the "Activity Limitations in Climbing Stairs" scale and its validation. METHODS: Translation, back-translation and cultural adaptation. Instruments: Guralnik short physical performance battery; timing to ascend and descend a seven-step staircase with handrail. Use of handrail and alternate steps were observed. The scale was reapplied to the same population, after 15 days. Descriptive statistics, with correlation and comparing group tests α<0.05. RESULTS: The study observed 22 patients (72.2% female); average age 76 years. Only one question was revised due to cultural adaptation. The scale score was significantly correlated to stair ascending and descending time and differentiated the group using alternate feet and handrail. The Guralnik test was significantly correlated with stair climbing. The internal consistency was 0.8477. The scale remained stable. CONCLUSION: The "Activity Limitations in Climbing Stairs" scale translation and cultural adaptation was completed. Its validity was established in a group of elderly subjects by the significant scale correlation to the actual task. High internal consistency and stability were determined.
... Since stair climbing places great demands on various systems that deteriorate with aging (e.g., musculo-skeletal, somato-sensory), a decline in mobility may result in problems with the negotiation of stairs and in a higher fall risk. In practice, stair negotiation is an important aspect of daily living activity and needs to be assessed carefully [29]. Tiedemann et al. [30] observed that many factors were associated with stair climbing abilities including knee strength, vision, balance and fear of falling. ...
... The ability of hemiparetic patients to ascend or to descend a flight of stairs is an important aspect of daily living and should be assessed as much as possible. A clinimetric review of existing measures of stair climbing showed that there is great heterogeneity of stair negotiation scales [5]. Tests based on patient interviews are insufficient and direct assessment of stair-climbing performance is necessary since stair performance has been shown to be the best predictor of independent activity in community-dwelling people and is the only factor correlated with domestic extrinsic activity [6,7]. ...
... Despite the higher risk of fall injury or death associated with stair ambulation among older adults, few activities of daily living instruments specifi cally assess this functional activity. In a systematic review of 92 functional general mobility scales, van Iersal et al 11 reported that only 43 scales included items related to stair-climbing ability, and none of these indicated whether the person could safely negotiate stairs. Although self-reports of stair-climbing ability are most common, these questionnaires are often inaccurate because many older adults either do not want to disclose their limitations or do not perceive that they have stair limitations. ...
Article
Full-text available
Falls on stairs are a common cause of injury and death among older adults. Although stair climbing is a component of some instruments that assess activities of daily living, normal speeds for safe stairway ambulation have not been established. Furthermore, little is known about which components of functional mobility are most highly associated with stair-climbing speed. The purposes of this study were to determine the range of normal stair-climbing speeds for ambulatory, community-dwelling older adults and identify which functional mobility tests could best explain this speed. Twenty men and 34 women older than 65 years completed 6 functional mobility tests, including timed heel rises, timed chair stands, functional reach, one-legged stance time (OLST), a timed step test (alternately touching a step 10 times), and self-selected gait speed. Participants were then timed as they ascended and descended a flight of 8 to 10 steps. Combined ascent-descent times were used to calculate stair-climbing speed in steps per second. Stepwise regression techniques determined the best functional predictors for stair-climbing speed. Participants ascended and descended stairs at an average speed of 1.3 steps per second; men tended to ambulate stairs more quickly than women. The best predictors of stair-climbing speed were usual gait speed and OLST (R = 0.79; P = .01), which explained 63% of the variance in stair-climbing speed. Our results were similar to others who reported stair-climbing speeds ranging from 1.1 to 1.7 steps per second for older adults. However, the 2 predictors identified in this study provide a simpler and more accurate model for estimating stair-climbing speed than has been previously reported. Further research is needed to determine whether this speed is sufficient for negotiating stairs in an emergency. In addition, further study is needed to determine which tests/measures best differentiate individuals who can and cannot independently climb a typical flight of stairs. An older adult's stair-climbing speed can be accurately estimated by using a model that includes his or her usual gait speed and OLST. This information will help health care professionals and directors of residential facilities make appropriate decisions related to living accommodations for their older adult clients.
... Despite the higher risk of fall injury or death associated with stair ambulation among older adults, few activities of daily living instruments specifi cally assess this functional activity. In a systematic review of 92 functional general mobility scales, van Iersal et al 11 reported that only 43 scales included items related to stair-climbing ability, and none of these indicated whether the person could safely negotiate stairs. Although self-reports of stair-climbing ability are most common, these questionnaires are often inaccurate because many older adults either do not want to disclose their limitations or do not perceive that they have stair limitations. ...
Data
Full-text available
Background and Purpose: Falls on stairs are a common cause of injury and death among older adults. Although stair climb-ing is a component of some instruments that assess activities of daily living, normal speeds for safe stairway ambulation have not been established. Furthermore, little is known about which components of functional mobility are most highly asso-ciated with stair-climbing speed. The purposes of this study were to determine the range of normal stair-climbing speeds for ambulatory, community-dwelling older adults and identify which functional mobility tests could best explain this speed. Methods: Twenty men and 34 women older than 65 years completed 6 functional mobility tests, including timed heel rises, timed chair stands, functional reach, one-legged stance time (OLST), a timed step test (alternately touching a step 10 times), and self-selected gait speed. Participants were then timed as they ascended and descended a fl ight of 8 to 10 steps. Combined ascent-descent times were used to calculate stair-climbing speed in steps per second. Step-wise regression techniques determined the best functional predictors for stair-climbing speed. Results: Participants ascended and descended stairs at an average speed of 1.3 steps per second; men tended to ambulate stairs more quickly than women. The best predic-tors of stair-climbing speed were usual gait speed and OLST (R = 0.79; P = .01), which explained 63% of the variance in stair-climbing speed. Discussion: Our results were similar to others who reported stair-climbing speeds ranging from 1.1 to 1.7 steps per second for older adults. However, the 2 predictors identifi ed in this study provide a simpler and more accurate model for estimating stair-climbing speed than has been previously reported. Further research is needed to determine whether this speed is suffi cient for negotiating stairs in an emergency. In addition, further study is needed to determine which tests/ measures best differentiate individuals who can and cannot independently climb a typical fl ight of stairs. Conclusions: An older adult's stair-climbing speed can be accurately estimated by using a model that includes his or her usual gait speed and OLST. This information will help health care professionals and directors of residential facilities make appropriate decisions related to living accommodations for their older adult clients. This study was presented as a poster at the American Physical Therapy Association Combined Sections Meeting (Section for Geriatrics) in Chicago, Illinois, on February 2012. The authors declare no confl icts of interest. Address correspondence to:
... 4 Escalas de avaliação funcional podem ser úteis para identificar e monitorar incapacidades, quantificando o nível de dependência e a necessidade de aparelhos de auxílio na execução de tarefas. 5 Em função de os instrumentos existentes não fornecerem uma avaliação mais detalhada da limitação da atividade de subir e descer escadas, Roorda e colaboradores 6 desenvolveram uma escala que afere essa ação. ...
Data
Full-text available
subir e descer escadas Translation, cultural adaptation and validation of a scale measuring activity limitations in climbing stairs Resumo Introdução: Subir e descer escadas são tarefas importantes do cotidiano. A limitação dessa atividade é especialmente prevalente na população idosa, com implicações em sua independência funcional. O objetivo deste estudo foi realizar a tradução, adaptação cultural para a língua portuguesa e validação da escala Activity Limitations in Climbing Stairs, que afere se há limitação da atividade de subir e descer escadas. Métodos: Tradução, tradução reversa e adaptação cultural. Instrumentos utilizados: teste de performance de membros inferiores de Guralnik; tempo de subida e descida de uma escada de sete degraus com corrimão, observando-se a utilização de corrimão e o uso de passos alternados durante a tarefa. Após 15 dias, a escala foi reaplicada na mesma população. Estatística descritiva e testes de correlação, sendo a diferença entre grupos α<0,05. Resultados: Participaram do estudo 22 pacientes (72,2% mulheres), idade média de 76 anos. Na fase de adaptação cultural, uma questão foi revista. O escore da escala se correlacionou significativamente com o tempo de subir e descer a escada, e diferenciou o grupo que utilizava pés alternados e corrimão. O teste de Guralnik se correlacionou significativamente com o tempo de subir e descer a escada. A consistência interna foi de 0,8477. A escala se manteve estável após a segunda aplicação. Conclusão: Foram realizadas tradução e adaptação cultural da Escala Activity Limitations in Climbing Stairs Abstract Introduction: Stair climbing is an essential daily task. Climbing limitations are especially prevalent in elderly populations and affect functional independence. This paper aims to translate and make the cultural adaption to Brazilian Portuguese of the "Activity Limitations in Climbing Stairs" scale and its validation. Methods: Translation,
... Stair negotiation is a commonly performed activity in daily life and useful as a functional measure in a variety of populations [1][2][3][4][5]. However, many current functional assessment scales often neglect stair negotiation completely [6] and the time to complete stairs has largely been neglected as an objective outcome measure. Stair performance has been recognized as important in the Hospital for Special Surgery Score, whereby the ability to perform stair ascent and descent is heavily weighted [7], and the need for more challenging tests other than level walking has been recognized [8], particularly for more able populations. ...
Article
Full-text available
Functional testing is particularly useful in the clinic and for making research translatable; however, finding measures relevant across ages and different conditions can be difficult. A systematic review was conducted to investigate timed stair tests as an objective measure of functional abilities and musculoskeletal integrity. Data were analyzed for their ability to differentiate between controls and patient groups and between different patient groups. Literature was reviewed using the Medline, CINAHL, and PubMed databases until February 2012. Data were grouped according to methodology, ages, and medical conditions. Time per step was calculated to allow comparison between studies. Eighty-eight studies were included in this review. Methodologies varied considerably with stair ascent, stair descent, or a combination of the two being used across a wide range of ages and medical conditions. Times increased with age for ascent, descent, and combined and for a variety of medical problems. Timed stair tests appear to be sensitive to medical conditions but further data are required to obtain normative values for this test. We suggest that timed stair tests should follow a more standardized methodology using a combination of ascent and descent and asking participants to complete the stairs as quickly and safely as possible.
... Furthermore, psychological factors such as the fear of falling can additionally affect stair ambulation abilities [5]. Reasons for poor stair negotiation abilities can include functional disabilities such as dyspnea, but also neurological disorders which affect the motor system [2,6]. Conway et al. [2] found that PD patients showed a significantly slower gait speed while ascending and descending an instrumented staircase, which is likely to be related to an increased risk of falling during stair negotiation. ...
Article
Full-text available
Climbing stairs is a fundamental part of daily life, adding additional demands on the postural control system compared to level walking. Although real-world gait analysis studies likely contain stair ambulation sequences, algorithms dedicated to the analysis of such activities are still missing. Therefore, we propose a new gait analysis pipeline for foot-worn inertial sensors, which can segment, parametrize, and classify strides from continuous gait sequences that include level walking, stair ascending, and stair descending. For segmentation, an existing approach based on the hidden Markov model and a feature-based gait event detection were extended, reaching an average segmentation F1 score of 98.5% and gait event timing errors below ±10ms for all conditions. Stride types were classified with an accuracy of 98.2% using spatial features derived from a Kalman filter-based trajectory reconstruction. The evaluation was performed on a dataset of 20 healthy participants walking on three different staircases at different speeds. The entire pipeline was additionally validated end-to-end on an independent dataset of 13 Parkinson's disease patients. The presented work aims to extend real-world gait analysis by including stair ambulation parameters in order to gain new insights into mobility impairments that can be linked to clinically relevant conditions such as a patient's fall risk and disease state or progression.
... Since stair climbing places great demands on various systems that deteriorate with aging (e.g., musculo-skeletal, somato-sensory), a decline in mobility may result in problems with the negotiation of stairs and in a higher fall risk. In practice, stair negotiation is an important aspect of daily living activity and needs to be assessed carefully [29]. Tiedemann et al. [30] observed that many factors were associated with stair climbing abilities including knee strength, vision, balance and fear of falling. ...
Article
Full-text available
The Dynamic Gait Index (DGI) was developed as a clinical tool to assess gait, balance and fall risk. Because the DGI evaluates not only usual steady-state walking, but also walking during more challenging tasks, it may be an especially sensitive test. The present investigation evaluated the DGI and its association with falls, fear of falling, depression, anxiety and other measures of balance and mobility in 278 healthy elderly individuals. Measures included the DGI, the Berg Balance Test (BBT), the Timed Up and Go (TUAG), the Mini-Mental State Exam (MMSE), the Unified Parkinson's Disease Rating Scale (UPDRS) motor part, the Activities-specific Balance Confidence (ABC) scale and the number of annual falls. The DGI was moderately correlated with the BBT (r=0.53; p<0.001), the TUAG (r=-0.42; p<0.001) and the ABC (r=0.49; p<0.001). Fallers performed worse on the DGI compared to non-fallers (p=0.029). Scores on the DGI were near perfect in men (23.3+/-1.2), but among women, there was a small, but significant (p<0.001) decrease (22.5+/-1.6). The reduction in the DGI score in women was due to stair climbing performance, with many women (65%) choosing to walk while holding a handrail, compared to only 39% of men. Scores on the BBT, the TUAG, the UPDRS and the MMSE were similar in men and women. Conversely, ABC scores and fall history were different. These findings suggest that the DGI, although susceptible to ceiling effects, appears to be an appropriate tool for assessing function in healthy older adults.
... However we agree with the review by van Iersel et al.(2003) that states: "Important aspects such as safety on stairs are missing from all scales" or are included in just one or two items such as in the Activities-specific Balance Confidence scale (Powel and Myers 1995), or the SF-36 health survey (Ware et al., 2000). There is a need, therefore, to develop assessments that provide clear indications of the level of ability of a person while climbing stairs and, ideally, can identify potential difficulties before the person becomes a "faller". ...
Article
The aim was to develop a quantitative approach to identify three stair-climbing ability levels of older adults: no, somewhat and considerable difficulty. Timed-up-and-go test, six-minute-walk test, and Berg balance scale were used for statistical comparison to a new stair climbing ability classifier based on the geometric mean of stair speeds (GeMSS) in ascent and descent on a flight of eight stairs with a 28° pitch in the housing unit where the participants, 28 (16 women) urban older adults (62–94 years), lived. Ordinal logistic regression revealed the thresholds between the three ability levels for each functional test were more stringent than thresholds found in the literature to classify walking ability levels. Though a small study, the intermediate classifier shows promise of early identification of difficulties with stairs, in order to make timely preventative interventions. Further studies are necessary to obtain scaling factors for stairs with other pitches.
... Many functional assessment indices measure stair ambulation ability; however, they tend to lack validity (van Iersel, Olde Rikkert, & Mulley, 2003). Furthermore, large, expensive, and specialized equipment is required for detailed kinetic and kinematic analysis during stair ambulation using a 3D motion analysis system Novak, Li, Yang, & Brouwer, 2011;Samuel, Rowe, Hood, & Nicol, 2011). ...
Article
Objective: Stepping-up motion is challenging task for elderly people in daily life. The present study investigated the relationship between the load pattern during stepping-up motion at maximum speed and physical function in elderly women. Methods: The subjects comprised 109 community-dwelling elderly women (age 72.5±5.3years). The load pattern (maximum load, rate of load production, and stepping-up time) during ascending a 30cm step at maximum speed was measured, using a step up platform that measures the load at the lower and upper level. Physical function, including hip and knee extensor strength and performance on the vertical jump test, one-legged stance test, timed "Up & Go" (TUG) test, and stepping test were measured. Results: Pearson's correlation analysis showed that stepping-up time was correlated with the maximum load at the lower level (r=-0.51), but not with the maximum load at the upper level. A multiple regression analysis showed that hip extensor strength and performance on the vertical jump, TUG, and stepping tests were significant determinants of the load pattern during stepping-up motion in the elderly women. Conclusions: Our study revealed that rapid stepping-up ability was more closely related to the maximum load during push-off at the lower level rather than that during weight loading on the upper level, and that the load pattern during stepping-up motion in elderly women was associated with various physical functions such as the hip extensor strength, leg muscle power, dynamic balance function, and agility.
... Several other investigators have examined the relationship between stair-climbing speed and specific physical performance measures and have reported significant correlations with lower extremity strength, foot problems, reaction time, pain, balance, visual acuity and gait speed [6][7][8][9][10]. Although some functional assessment scales include stair-climbing as a component, a recent review by Van Iersal et al. [11] found that most of these scales lacked sufficient validity and consistency to evaluate how well older adults can actually negotiate stairs. Thus, the aim of this study was to identify which physical performance tests, if any, could best differentiate between older adults who can and cannot safely and independently negotiate stairs with or without the use of handrails or assistive devices. ...
... Otro ítem que también evidenció déficits en los pacientes con EP fue el ascensodescenso de escaleras (p=0.04).Se ha descrito que las limitaciones en este tipo de tareas es uno de los indicadores de discapacidad y declive funcional, considerado crítico para la pérdida de independencia. La prueba de ascenso-descenso de escaleras es una tarea de locomoción compleja para los adultos mayores pues demanda acción de varios sistemas que pueden estar deteriorados con la edad (e.g., somatosensorial y musculoesquelético [217]. El resultado del grupo pacientes sugiere que aún en estadios tempranos pueden evidenciarse discretas limitaciones en actividades tan básicas como el ascenso-descenso de escaleras. ...
... In addition to quantitatively evaluating movement compensations during a step ascent task, it is important to evaluate the relationship to relevant clinical measures such as stair climbing performance. Stair climbing ability is a crucial component of functional independence and quality of life in people with neurological conditions [13,17]. The Functional Stair Test is a reliable test used for clinical assessment of stair navigation [14], however, knowledge of the relationships between movement compensations during a step ascent task and the Functional Stair Test has not been reported and may be overlooked as targets for rehabilitation intervention. ...
Article
Background The biomechanical mechanisms underlying stair climbing limitations are poorly understood in people with multiple sclerosis (MS). Research Questions Are trunk and pelvis motion and lower extremity joint moments during step ascent different between MS and control groups? Are step ascent biomechanics and stair climbing performance associated in people with MS? Methods 20 people with MS (49 ± 12 years, EDSS range: 1.5-5.5) and ten control participants (48 ± 12 years) underwent three-dimensional motion analysis while ascending a 15.2-cm step and also completed a timed Functional Stair Test. Main effects of group (MS vs Control) and limb (Stronger/Dominant vs Weaker/Non-dominant) and interactions were assessed using two-way analyses of variance. Associations between movement patterns during the step ascent and Functional Stair Test performance were performed using Pearson’s correlations and backward stepwise linear regression. Results Significant group main effects were observed in greater sagittal pelvis excursion (p < 0.001), greater sagittal (p = 0.013) and frontal (p = 0.001) trunk excursion, and lower trail limb peak ankle plantar flexion moment (p < 0.001) of the MS group. Significant limb main effects were observed with greater sagittal trunk excursion (p = 0.037) and peak trail limb ankle plantar flexion moment (p = 0.037) in the stronger/dominant limb. A significant interaction was observed in peak knee extensor moment (p = .002). Stair climbing performance in the MS group correlated with sagittal (r = .607, p=<0.001) and frontal pelvis excursions (r = 0.385, p = 0.014), sagittal trunk excursion (r = .411, p = 0.008), and ankle plantar flexion moments (r=-0.415, p = 0.008). Sagittal and frontal pelvis excursion and bilateral handrail use explained a significant amount of variability in stair climbing performance (Adj R² = 0.775). Significance In conclusion, despite the presence of proximal and distal lower extremity movement pattern compensations during a step ascent task, larger pelvis angular excursions are associated with impaired stair climbing performance in people with MS and may serve as targets for future rehabilitation interventions.
... Elderly adults consider stair climbing and descending to be one of the difficulties that is more associated with aging [6]. Due to its easy application, stair performance is recognized as an important method for evaluating functionality and is therefore included in most functionality scales [7]. Nevertheless, it is still rarely applied as single evaluation in the protocols of geriatric care services at the primary level. ...
Article
To develop a hierarchical scale that measures activity limitations in climbing stairs in patients with lower-extremity disorders living at home. Cross-sectional study with Mokken scale analysis of 15 dichotomous items. Outpatient clinics of secondary and tertiary care centers. Patients (N=759; mean age +/- standard deviation, 59.8+/-15.0y; 48% men) living at home, with different lower-extremity disorders: stroke, poliomyelitis, osteoarthritis, amputation, complex regional pain syndrome type I, and diabetic foot problems. Not applicable. (1) Fit of the monotone homogeneity model, indicating whether items can be used for measuring patients; (2) fit of the double monotonicity model, indicating invariant (hierarchical) item ordering; (3) intratest reliability, indicating repeatability of the sum score; and (4) differential item functioning, addressing the validity of comparisons between subgroups of patients. There was (1) good fit of the monotone homogeneity model (coefficient H=.50) for all items for all patients, and for subgroups defined by age, gender, and diagnosis; (2) good fit of the double monotonicity model (coefficient H(T)=.58); (3) good intratest reliability (coefficient rho=.90); and (4) no differential item functioning with respect to age and gender, but differential item functioning for 4 items in amputees compared with nonamputees. A hierarchical scale, with excellent scaling characteristics, has been developed for measuring activity limitations in climbing stairs in patients with lower-extremity disorders who live at home. However, measurements should be interpreted with caution when comparisons are made between patients with and without amputation.
Article
Background/Aims The ability to climb stairs is an important prerequisite for activities of daily living and social participation in older adults, and is therefore an important part of rehabilitation. However, there is no consensus on how to measure stair-climbing ability. The aim of this study was to investigate the test–retest reliability of the measurement of stair-climbing speed (steps per second) as a parameter for functional ability in older adults. Methods A total of 57 participants who were in hospital and 56 participants who were community-dwelling and did not have any limitations in activities in daily living, all aged 60 years and over, ascended and descended a set of 13 stairs twice. The halfway point of the staircase was marked in order to split the time required for both the ascending and the descending actions. Additional measurements consisted of the Functional Reach Test, the Timed Up and Go Test, walking ability using the GAITRite walkway system and the isometric strength of four muscle groups of the lower extremities using a handheld dynamometer. Results Test–retest reliability of the first and second half of the stair-climbing for both ascending and descending showed excellent results for the group of hospitalised participants (intraclass correlation coefficient, [ICC] 0.87, 95% confidence interval [CI] 0.79–0.93 to 0.94, 95% CI 0.9 – 0.97 for comparison of first vs second half of stair climbing; ICC 0.9, 95% CI 0.83-0.94 to ICC 0.95, 95% CI 0.92–0.97 for comparing first vs second measurement)) and moderate to excellent results for the group of community-dwelling participants with no limitations (ICC 0.58, 95% CI 0.37–0.73 to ICC 0.76, 95% 95% CI 0.63-0.85 for comparison of first vs second half of stair climbing; ICC 0.82, 95% CI 0.71-0.89 to 0.92, 95% CI 0.87–0.95 for comparing first vs second measurement). As expected, hospitalised participants took significantly longer descending than ascending stairs (t(56)=6.98, P<0.001, d=0.93). A general and significant trend of increasing speed while descending could be observed in both groups (performing paired sample t-tests). Conclusions The results indicate that stair-climbing speed is not constant and that different patterns exist in older adults who have no limitations and in those who are hospitalised. The use of stair-climbing speed as an assessment tool should include both stair ascent and descent, because differences in these speeds seem to be indicators of stair-climbing ability.
Article
To investigate the construct validity and test-retest reliability of the Climbing Stairs Questionnaire, a patient-reported measure of activity limitations in climbing stairs, in lower-limb amputees. A cross-sectional study. Outpatient department of a rehabilitation center. Lower-limb amputees (N=172; mean +/- SD age, 65+/-12y; 71% men; 82% vascular cause) participated in the study; 33 participated in the reliability study. Not applicable. Construct validity was investigated by testing 10 hypotheses: limitations in climbing stairs according to the Climbing Stairs Questionnaire will be greater in lower-limb amputees who: (1) are older, (2) have a vascular cause of amputation, (3) have a bilateral amputation, (4) have a higher level of amputation, (5) have more comorbid conditions, (6) had their rehabilitation treatment in a nursing home, and (7) climb fewer flights of stairs. Furthermore, limitations in climbing stairs will be related positively to activity limitations according to: (8) the Locomotor Capabilities Index, (9) the Questionnaire Rising and Sitting down, and (10) the Walking Questionnaire. Construct validity was quantified by using the Mann-Whitney U test, Kruskal-Wallis test, and Spearman correlation coefficient. Test-retest reliability was assessed with a 3-week interval and quantified using the intraclass correlation coefficient (ICC). Construct validity (8 of 10 null hypotheses not rejected) and test-retest reliability were good (ICC=.79; 95% confidence interval, .57-.90). The Climbing Stairs Questionnaire has good construct validity and test-retest reliability in lower-limb amputees.
Article
Objective: To establish concurrent validity, interrater and test–retest reliability of the Modified Elderly Mobility Scale (MEMS). Methods: Ninety elderly patients were scored on the MEMS. To establish concurrent validity, 75 patients MEMS scores were compared to Functional Independence Measure (FIM) scores using Spearman's correlation. Videotaped patient performances were used to establish interrater and test–retest reliability using percentage absolute agreement and intraclass correlation coefficients (ICCs). Results: The total MEMS score demonstrated a significant association with the motor (r = 0.725) and total FIM scores (r = 0.718). Absolute agreement for interrater reliability was greater than 93% for all test items, with 97 and 98% for the two new measures, respectively. Test–retest reliability demonstrated similar high levels of absolute agreement and had ICCs ranging from 0.870 to 1.0. Conclusions: The MEMS is a quick, valid and reliable test of motor function of elderly patients with a spread of functional levels.
Article
Research was done combining functional tests, timed up and go (TUG), Berg balance test (BBS) and six minute walk (SMW), subjective scoring and speed of stair climbing. Three distinct groups were found: having considerable, having some and having no difficulties to climb stairs. Using ordinal logistic regression, the best indicator of belonging to one group or another was speed of descent (DS). People who normally go down faster than they go up were classed as having no difficulty climbing stairs (p = 0.011, paired t test) while the people with some difficulties had about the same speed of going up and down stairs (p=0.968). The group a person is classified in could give an indication for the early prescription of suitable AT to aid stair climbing.
Article
Full-text available
This study compared subjects' performance with a nonmicroprocessor knee mechanism (NMKM) versus a C-Leg on nine clinically repeatable evaluative measures. We recorded data on subjects' performance while they used an accommodated NMKM and, following a 90-day accommodation period, the C-Leg in a convenience sample of 19 transfemoral (TF) amputees (mean age 51 +/- 19) from an outpatient prosthetic clinic. We found that use of the C-Leg improved function in all outcomes: (1) Prosthesis Evaluation Questionnaire scores increased 20% (p = 0.007), (2) stumbles decreased 59% (p = 0.006), (3) falls decreased 64% (p = 0.03), (4) 75 m self-selected walking speed on even terrain improved 15% (p = 0.03), (5) 75 m fastest possible walking speed (FPWS) on even terrain improved 12% (p = 0.005), (6) 38 m FPWS on uneven terrain improved 21% (p < 0.001), (7) 6 m FPWS on even terrain improved 17% (p = 0.001), (8) Montreal Rehabilitation Performance Profile Performance Composite Scores for stair descent increased for 12 subjects, and (9) the C-Leg was preferred over the NMKM by 14 subjects. Four limited community ambulators (Medicare Functional Classification Level [MFCL] K2) increased their ambulatory functional level to unlimited community ambulation (MFCL K3). Objective evaluative clinical measures are vital for justifying the medical necessity of knee mechanisms for TF amputees. Use of the C-Leg improves performance and quality of life and can increase MFCL and community ambulation level.
Article
Full-text available
• Using specific instruments and scales to measure mental status, nutritional state, visual acuity, gait, and activities of daily living, we studied 79 medical inpatients aged 70 years or older. We then interviewed the patients' primary physicians and nurses and asked them to rate their patients. The prevalence of functional impairment was high: 25 (32%) of the 79 patients were mentally impaired, 31 (39%) were malnourished, 18 (23%) were visually impaired, 31 (39%) had impaired gait, and 23 (29%) had problems with continence. Although clinicians recognized severe impairments, the sensitivity of their clinical judgment was poor in detecting moderate impairment in four categories: mental status sensitivity was 28% (5/18); nutrition, 54% (14/26); vision, 27% (4/15); and continence, 42% (5/12). With clinical judgment alone, physicians and nurses correctly identify severe impairment, but the more prevalent moderate impairments in mental status, nutrition, vision, and continence are poorly recognized. Comprehensive functional assessment instruments can detect these moderate impairments, which may be remediable through early intervention. (Arch Intern Med 1987;147:484-488)
Article
Full-text available
A ranked assessment of daily living (ADL) scale has been developed to assess activities which may be important to stroke patients who have been discharged home. A questionnaire incorporating 22 ADL activities in four sections was sent by post to 80 consecutively registered stroke patients. Gutmann scaling was carried out on the returned questionnaires, producing acceptable coefficients of reproducibility and scalability. The revised questionnaire was then sent to 20 stroke patients. The same patients were sent an identical questionnaire two weeks later. The overall level of agreement between the two assessments was satisfactory. The extended ADL scale could therefore be used as a postal questionnaire to assist in the follow-up of patients discharged home after a stroke. Due to the scaling properties of the assessment, patient's progress can be monitored and patients can also be compared on the basis of their scale score.
Article
Full-text available
A 36-item short-form (SF-36) was constructed to survey health status in the Medical Outcomes Study. The SF-36 was designed for use in clinical practice and research, health policy evaluations, and general population surveys. The SF-36 includes one multi-item scale that assesses eight health concepts: 1) limitations in physical activities because of health problems; 2) limitations in social activities because of physical or emotional problems; 3) limitations in usual role activities because of physical health problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions. The survey was constructed for self-administration by persons 14 years of age and older, and for administration by a trained interviewer in person or by telephone. The history of the development of the SF-36, the origin of specific items, and the logic underlying their selection are summarized. The content and features of the SF-36 are compared with the 20-item Medical Outcomes Study short-form.
Article
Full-text available
To test the acceptability, validity, and reliability of the short form 36 health survey questionnaire (SF-36) and to compare it with the Nottingham health profile. Postal survey using a questionnaire booklet together with a letter from the general practitioner. Non-respondents received two reminders at two week intervals. The SF-36 questionnaire was retested on a subsample of respondents two weeks after the first mailing. Two general practices in Sheffield. 1980 patients aged 16-74 years randomly selected from the two practice lists. Scores for each health dimension on the SF-36 questionnaire and the Nottingham health profile. Response to questions on recent use of health services and sociodemographic characteristics. The response rate for the SF-36 questionnaire was high (83%) and the rate of completion for each dimension was over 95%. Considerable evidence was found for the reliability of the SF-36 (Cronbach's alpha greater than 0.85, reliability coefficient greater than 0.75 for all dimensions except social functioning) and for construct validity in terms of distinguishing between groups with expected health differences. The SF-36 was able to detect low levels of ill health in patients who had scored 0 (good health) on the Nottingham health profile. The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity. Its use in other contexts and with different disease groups requires further research.
Article
Full-text available
We designed a 15-item neurologic examination stroke scale for use in acute stroke therapy trials. In a study of 24 stroke patients, interrater reliability for the scale was found to be high (mean kappa = 0.69), and test-retest reliability was also high (mean kappa = 0.66-0.77). Test-retest reliability did not differ significantly among a neurologist, a neurology house officer, a neurology nurse, or an emergency department nurse. The stroke scale validity was assessed by comparing the scale scores obtained prospectively on 65 acute stroke patients to the patients' infarction size as measured by computed tomography scan at 1 week and to the patients' clinical outcome as determined at 3 months. These correlations (scale-lesion size r = 0.68, scale-outcome r = 0.79) suggested acceptable examination and scale validity. Of the 15 test items, the most interrater reliable item (pupillary response) had low validity. Less reliable items such as upper or lower extremity motor function were more valid. We discuss methods for improving the reliability and validity of brief examination scales to be used in stroke therapy trials.
Article
Full-text available
Since the relationships between pulmonary function, exercise capacity, and functional state or quality of life are generally weak, a self report questionnaire has been developed to determine the effect of treatment on quality of life in clinical trials. One hundred patients with chronic airflow limitation were asked how their quality of life was affected by their illness, and how important their symptoms and limitations were. The most frequent and important items were used to construct a questionnaire evaluating four dimensions: dyspnoea, fatigue, emotional function, and the patient's feeling of control over the disease (mastery). Reproducibility, tested by repeated administration to patients in a stable condition, was excellent: the coefficient of variation was less than 12% for all four dimensions. Responsiveness (sensitivity to change) was tested by administering the questionnaire to 13 patients before and after optimisation of their drug treatment and to another 28 before and after participation in a respiratory rehabilitation programme. In both cases large, statistically significant improvements in all four dimensions were noted. Changes in questionnaire score were correlated with changes in spirometric values, exercise capacity, and patients' and physicians' global ratings. Thus it has been shown that the questionnaire is precise, valid, and responsive. It can therefore serve as a useful disease specific measure of quality of life for clinical trials.
Article
Full-text available
The widespread introduction of computers into clinical settings has increased the feasibility of conducting comprehensive functional disability assessment. The Functional Status Questionnaire (FSQ) is a brief, self-administered questionnaire designed to facilitate clinical assessment of functional disability. The FSQ items can be scored by computer using a simple algorithm and summarized into disability index scores. These scales have alpha reliability coefficients of .64 to .82 and substantial convergent validity when used with primary care patients. Disability assessment tools like the FSQ can be adapted easily for clinical use by physical therapists.
Article
Full-text available
To develop and validate the Physical Performance and Mobility Examination (PPME), an observer-administered, performance-based instrument assessing 6 domains of physical functioning and mobility for hospitalized elderly. Development of a pass-fail and 3-level scoring system and training manuals for the PPME instrument for use in both clinical and research settings. Two patient samples were used to assess construct validity and interrater reliability of the PPME. A third sample was selected to assess the test-retest reliability of the instrument. (1) 146 subjects > or = 65 years of age with impaired mobility admitted to Medical Units of Stanford University Hospital. (2) 352 subjects > or = 65 admitted to acute Medical and Surgical Services of the Palo Alto VA Medical Center. Patient samples were obtained during hospitalization and followed until 3 months post-discharge. To study test-retest reliability, 50 additional patients, whose clinical condition was stable, were selected from both settings. An expert panel selected 6 mobility tasks integral to daily life: bed mobility, transfer skills, multiple stands from chair, standing balance, step-up, and ambulation. Tasks were piloted with frail hospitalized subjects for appropriateness and safety. Test-retest and interrater reliability and construct validity were evaluated. Construct validity was tested using the Folstein Mini-Mental State Examination, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Geriatric Depression Scale, and modified Medical Outcomes Study Measure of Physical Functioning (MOS-PFR). Two scoring schema were developed for each task: (1) dichotomous pass-fail and (2) 3-level high pass, low pass, and fail. A summary scale was developed for each method of scoring. High interrater reliability and intrarater reliability were demonstrated for individual tasks. The mean percent agreement (interrater) for each pass/fail task ranged from 96 to 100% and from 90 to 100% for the 3 pairs of raters for each task using the 3-level scoring. Kappas for individual pairs of raters ranged from .80 to 1.0 for pass-fail scoring and from .75 to 1.0 for 3-level scoring (all P < 0.01). Intraclass correlation coefficients for 3-level scoring by pairs of raters ranged from .66 to 1.0. For summary scales, the mean intraclass correlation was .99 for both scoring schema. Test-retest reliability for summary scales using kappa coefficients was .99 for both pass-fail and 3-level scoring, and .99 and .98, respectively, using Pearson Product Moment Correlation. Correlations of PPME with other instruments (construct validity) suggest that the PPME adds a unique dimension of mobility beyond that measured by self-reported ADLS and physical functioning, and it is not greatly influenced by mood or mental status (r = 0.70 (ADL), r = 0.43 (IADL), r = 0.36 (MMSE), r = 0.71 (MOS-PFR), r = 0.23 (GDS)). The 3-level summary scale was sensitive to the variability in the patient population and exhibited neither ceiling nor floor effects. The PPME is a reliable and valid performance-based instrument measuring physical functioning and mobility in hospitalized and frail elderly.
Article
Indexes of functional disability are being used increasingly to rate the status of patients studied in clinical research or treated in clinical practice. To determine why so many indexes have been developed and to evaluate their scientific quality, we reviewed the construction and other attributes of 43 indexes that offer ratings for activities of daily living. The six most prominent problems, and some proposed solutions, are as follows: Ratings for the magnitude of performed tasks will be misleading unless the patient's effort or collaboration is suitably considered. Each patient's preferences should be sought to determine which types of disability are the most important goals of therapy. Special transition indexes should be developed if subtle or overt changes are not discerned from the repeated use of single-state indexes. Hierarchical scale arrangements can avoid the loss of descriptive power that occurs when multiple variables are aggregated merely as summations. Documentary evidence can be required to demonstrate the anticipated achievements of an index. New indexes can be constructed if the high statistical "reliability" and "validity" of established indexes are not accompanied by satisfactory clinical "sensibility."
Article
The Index of ADL was developed to study results of treatment and prognosis in the elderly and chronically ill. Grades of the Index summarize over-all performance in bathing, dressing, going to toilet, transferring, continence, and feeding. More than 2,000 evaluations of 1,001 individuals demonstrated use of the Index as a survey instrument, as an objective guide to the course of chronic illness, as a tool for studying the aging process, and as an aid in rehabilitation teaching. Of theoretical interest is the observation that the order of recovery of Index functions in disabled patients is remarkably similar to the order of development of primary functions in children. This parallelism, and similarity to the behavior of primitive peoples, suggests that the Index is based on primary biological and psychosocial function, reflecting the adequacy of organized neurological and locomotor response.
Article
The need to assess functions such as mobility in elderly patients is increasingly recognized. Lacking other methods, clinicians may rely on the standard neuromuscular examination to evaluate mobility. Therefore, we checked the sensitivity of the neuromuscular examination for identifying mobility problems by comparing relevant neuromuscular findings with performance during four routine mobility maneuvers: (1) getting up from a chair, (2) sitting down, (3) turning while walking, and (4) raising the feet while walking. The subjects investigated were 336 elderly persons living in the community. Many subjects who performed poorly during mobility maneuvers did not have the corresponding neuromuscular abnormalities. For example, although hip and knee flexion are needed to sit down safely, abnormal hip flexion was found in only 15% and abnormal knee flexion in only 30% of the subjects who had difficulty sitting down. The relationship between neuromuscular findings and functional mobility was not predictable enough to rely on neuromuscular findings for identifying mobility problems. Therefore, a simple assessment that reproduces routine daily mobility maneuvers should be developed for use in the clinical care of elderly patients.(JAMA 1988;259:1190-1193)
Article
Objective To develop components of a multidimensional Health Assessment Questionnaire (MDHAQ) through the addition of new items in the “patient-friendly” HAQ format, including advanced activities of daily living (ADL), designed to overcome “floor effects” of the HAQ and modified HAQ (MHAQ) in which patients may report normal scores although they experience meaningful functional limitations, and psychological items, designed to screen efficiently for psychological distress in routine care.Methods The new MDHAQ items, as well as scales for pain, fatigue, helplessness, and global health status on a 2-page questionnaire, were completed by 688 consecutive patients with various rheumatic diseases, including 162 with rheumatoid arthritis (RA), 114 with fibromyalgia, 63 with osteoarthritis, 34 with systemic lupus erythematosus, 20 with vasculitis, 18 with psoriatic arthritis, 16 with scleroderma, and 261 with various other rheumatic diseases, over 2 years at a weekly academic rheumatology clinic.ResultsThe new MDHAQ items have good test–retest reliability and face validity. MHAQ scores were highest in patients with RA, and scores for other scales were highest in patients with fibromyalgia. On the advanced ADL, 58% of patients reported difficulty with errands, 68% with climbing stairs, 79% with walking two miles, 87% with participating in sports and games, and 94% with running or jogging two miles. On the psychological items, 75% of patients reported difficulty with sleep, 63% with stress, 61% with anxiety, and 57% with depression. Normal MHAQ scores were reported by 23% of patients and normal HAQ scores by 16% of patients who completed these questionnaires, while fewer than 5% had normal scores on the MDHAQ.Conclusion The MDHAQ items overcome in large part the “floor effects” seen on the HAQ and MHAQ, and are useful to screen for problems with sleep, stress, anxiety, and depression in the “patient-friendly” HAQ format. These data support the value of completion of a simple 2-page patient questionnaire by each patient at each visit to a rheumatologist.
Article
Remaining strong, lean, and physically active may contribute to successful aging, both by maintaining function and by enabling more independent living. The study objective was to investigate this hypothesis among a long-lived population of older Japanese women. A cross-sectional study. The island of Oahu, Hawaii. A total of 705 community-dwelling women (mean age, 74; range, 55-93). As outcomes, 7 physical performance measures including walking speed, the Get Up and Go test, chair stands, functional reach, and hand and foot reaction times, and 8 questions regarding activities of daily living (ADL). As possible predictors, physical activity, body mass index, and quadriceps, grip, and triceps strength. In multivariable models, one or more of the strength tests was associated positively with six of the seven performance-based measures. Among the significant associations, 1-SD increases in strength were associated with 2 to 4% increases in performance compared with the sample mean. Physical activity was independently, and positively associated with the most complex of the tests, the Get Up and Go test. Body mass index (BMI), in contrast to strength and physical activity, was negatively associated with five of the seven performance tests. Among the significant associations, 1-SD increases in BMI were associated with 3 to 8% reductions in performance. In multivariable models strength was also associated positively with seven of the eight ADLs. In the same models, physical activity was positively associated with five and BMI was negatively associated with six of the ADLs. The results suggest that remaining strong, lean, and physically active provided wide-ranging benefits for this population of older Japanese women.
Article
The purpose of this study was to examine the association between maximal isometric strength and mobility among 75-year-old men and women. All those born in 1914 and resident in the city of Jyväskylä in August 1989 comprised the study group (n &equals; 388); 355 persons were interviewed at their homes (92&percnt;): 101 men (81&percnt; of all male residents) and 186 women (75&percnt;) participated in the laboratory strength tests. As part of the home interview the person′s mobility at home, on stairs and outdoors was assessed using a four-point scale: —1 able, 2—able with difficulty, 3—needs help, 4—unable. Poor mobility was more common among the drop-outs than among the strength-tested subjects in both sexes. Maximal isometric strength of hand grip, arm flexion, knee extension and trunk flexion and extension were measured using specially constructed dynamometers. The strength results were adjusted for body weight. The study also included a stair-mounting test and measurement of maximal walking speed. The body-weight adjusted maximal forces were consistently significantly associated with mobility. Those who claimed no problems in the mobility interview and performed better in the walking and stair-mounting tests exhibited greater maximal isometric strength. The present results indicate that maximal isometric strength tests provide useful information about physical functional capacity among elderly people. These findings also suggest that the maintenance of adequate strength could be favourable to the mobility of older persons.
Article
This paper describes a comparative analysis of questionnaire-based measures of functional status and clinical ratings of disability made by general practitioners and health visitors. Both approaches to functional assessment were used in rating 92 elderly primary care patients in terms of their performance of 13 mobility and self-help activities. Simple dichotomous and more complex trichotomous measures of performance were used to summarize functional ability in both the questionnaire and the provider's evaluation. Agreement between questionnaire-based and rater assessments was greatest for less complex mobility and self-help functions in comparisons using both dichotomous and trichotomous scales.
Article
This paper reviews the issues currently being raised by third party payers, Professional Standards Review Organizations (PSROs), government agencies, accrediting bodies, and consumers regarding accountability and program evaluation, and suggests tools which could be utilized when establishing mechanisms for systematic evaluation of medical rehabilitation programs. Program evaluation encompasses consideration relative to efficiency, quality assessment and effectiveness or outcome measurements. This paper suggests several systems which a rehabilitation facility may find helpful when considering the best combination of evaluative tools for its program. A functional status classification system which encompasses a combination of previously reported classification approaches and other measurement tools is discussed.
Article
Criterion-related validity of a new measure of functional ability was conducted according to a causal model based on conceptual models employed in the area of rehabilitative and geriatric medicine. The criteria variables included concurrent diagnosed diseases, global self-rated health, drug consumption and general practitioner (GP) consultations. The measure of functional ability was developed with the intention of achieving a high degree of discrimination among a group of community dwelling elderly.
Article
To determine the accuracy of self-reports of physical functioning by hospitalized elderly. Comparison of two measures. Two-hundred forty-seven medical inpatients (mean age 78.7 years) hospitalized at St. Marys Hospital Medical Center, Madison, WI. Measures of five activities of daily living by self-report and by performance. The rate of agreement between self-report and performance ADL measures was the lowest in the areas of bathing and dressing where the agreement was 63% and 64%, respectively. When patients reported needing no help in these two tasks, they were measured lower 32% of the time for dressing and 42% for bathing. When patients reported needing help in an activity the agreement rate between patient and occupational therapist varied widely, from only 42% for toileting to 78% for bathing. The two factors which were statistically associated with poor agreement between the two ADL measurements were cognitive impairment (P less than 0.001) and a decline from the pre-hospital level of ADL functioning which had occurred during hospitalization (P less than 0.001). These data suggest that there may be significant differences between patient assessments and performance-based measurements of ADL functioning in hospitalized elderly at time of discharge. These differences may have implications for the collection of functional measurements for discharge planning or for geriatric research in the hospital environment.
Article
We conducted a prospective study of the consequences of falls in 325 elderly community-dwelling persons, all of whom had fallen in the previous year. We contacted subjects every week for one year to ascertain falls and to determine the circumstances and consequences of falls. Only 6% of 539 falls resulted in a major injury (fracture, dislocation, or laceration requiring suture), but over half (55%) resulted in minor soft tissue injury. One in ten falls left the faller unable to get up for at least 5 minutes, and one in four falls caused subjects to limit their activities. The risk of injury per fall was about the same regardless of the number of falls a person had during follow-up. The risk of major injury was increased (age- and sex-adjusted odds ratio: 5.9, 95% confidence interval: 2.3-14.9) in falls associated with loss of consciousness compared to nonsyncopal falls. In multivariate analyses of nonsyncopal falls, the risk of major injury per fall was higher in persons having a previous fall with fracture (6.7; 2.1-21.5), a slower Trail Making B time (1.9; 1.1-3.2), and in Whites (18.4; 7.5-44.6). The risk that a nonsyncopal fall would result in minor injury (versus no injury) was increased in persons with a slower hand reaction time (1.8; 1.0-3.2) decreased grip strength (1.5; 1.0-2.3), in Whites (2.0; 1.0-3.7), in falls while using stairs and steps (2.2; 1.0-5.0), and turning around or reaching (3.5; 1.7-7.3). Our findings suggest that neuromuscular and cognitive impairment, as well as the circumstances of falls, affect the risk of injury when a fall occurs.
Article
Self reported physical function was assessed in telephone interviews approximately 3 weeks apart for a sample of 193 persons aged 69 or older. Three measures of physical function were used: a modified Activities of Daily Living scale, three items proposed by Rosow and Breslau, and five items from among those used by Nagi. Agreement between first and second interviews was very good; most subjects reported no impairment in function at either interview. Among those who reported some impairment, the degree of limitation within the specific activities reported as limited and the total number of activities with any degree of limitation agreed exactly for most and within one level for almost all subjects. There was no evidence to suggest that age or cognitive impairment affected the variability of the responses, and reported declines and improvements in function were about equally common.
Article
Direct observation of physical function has the advantage of providing an objective, quantifiable measure of functional capabilities. We have developed the Physical Performance Test (PPT), which assesses multiple domains of physical function using observed performance of tasks that simulate activities of daily living of various degrees of difficulty. Two versions are presented: a nine-item scale that includes writing a sentence, simulated eating, turning 360 degrees, putting on and removing a jacket, lifting a book and putting it on a shelf, picking up a penny from the floor, a 50-foot walk test, and climbing stairs (scored as two items); and a seven-item scale that does not include stairs. The PPT can be completed in less than 10 minutes and requires only a few simple props. We then tested the validity of PPT using 183 subjects (mean age, 79 years) in six settings including four clinical practices (one of Parkinson's disease patients), a board-and-care home, and a senior citizens' apartment. The PPT was reliable (Cronbach's alpha = 0.87 and 0.79, interrater reliability = 0.99 and 0.93 for the nine-item and seven-item tests, respectively) and demonstrated concurrent validity with self-reported measures of physical function. Scores on the PPT for both scales were highly correlated (.50 to .80) with modified Rosow-Breslau, Instrumental and Basic Activities of Daily Living scales, and Tinetti gait score. Scores on the PPT were more moderately correlated with self-reported health status, cognitive status, and mental health (.24 to .47), and negatively with age (-.24 and -.18). Thus, the PPT also demonstrated construct validity. The PPT is a promising objective measurement of physical function, but its clinical and research value for screening, monitoring, and prediction will have to be determined.
Article
For the patient, the most important aspect of parkinsonism is the degree to which the disease interferes with daily living. The patient's self-report may be the only way in which such information can be obtained. Depression and cognitive impairment, however, may influence that self-report. In the present study, three ratings of disability, from the patient, a relative, and an independent observer, showed high levels of agreement. The patients' cognitive function made a small but significant contribution to the accuracy of their self-report judged against the relative's rating. Depression, however, played no role. Agreement between patients and relatives for individual items on the disability questionnaire was reasonably high. The results suggest that patients with parkinsonism can provide accurate self-report of their level of disability, even in the presence of depression and cognitive impairment.
Article
The Canadian Neurological Scale (CNS) was designed to monitor mentation and motor functions in stroke patients. We assessed its validity and reliability on a group of 157 patients with a diagnosis of acute cerebrovascular accident. We determined validity by (1) correlating scale items and total score with the standard neurologic examination; (2) exploring the scale's predictive power with different end points at 6 months--the initial CNS was a significant predictor of outcome; (3) showing that the CNS had higher correlation coefficients with the initial neurologic examination than the Glasgow Coma Scale; and (4) assessing the responsiveness of the scale to change in the neurologic status of stroke patients. Interobserver reliability, measured by kappa statistics on each scale item, was good. Accordingly, we established the validity and reliability of the CNS for its use in clinical studies and in the care of stroke patients.
Article
Based on 1984 data from the Longitudinal Study on Aging, one-third of White persons aged 80 or older living in the community (N = 1,791) were defined as having no difficulty in walking 1/4 of a mile, in lifting 10 pounds, in climbing 10 steps without resting, or in stooping, crouching or kneeling. Physical ability was associated with lower risk of death over two years mean follow-up; Relative odds (RO) = .4 (95 percent confidence interval = .4, .6) and in survivors, lower utilization of hospitals RO = .4 (CI = .3, .7), physicians RO = .6 (CI = .5, .8) and nursing homes RO = .3 (CI = .2, .5) compared with those having difficulty on any of the four functional measures included in the definition of physical ability. Fifty percent of the women and 42 percent of the men physically able at the time of the baseline survey in 1984 remained physically able at follow-up. Continued physical ability in this group was associated with never having had cardiovascular disease RO = 2.1, (CI = 1.2, 3.7), never having had arthritic complaints RO = 1.9 (CI = 1.2, 2.7), a body mass index less than the 75th percentile RO = 1.8 (CI = 1.2, 2.9), younger age (for each decade of age, RO = 2.0 (CI = 1.1, 3.6), and higher level of education (greater than 13 years versus 0-6 years) RO = 2.4 (CI = 1.2, 4.7). These correlates include factors amenable to preventive measures and highlight the need to consider the heterogeneity of the oldest-old in formulating programs aimed at prevention and postponement of disability.
Article
Falls are a leading cause of fatal and nonfatal injuries among the elderly in the United States. Despite the importance of fall injuries, epidemiological studies of falls among the elderly have identified neither their causes nor the methods to prevent them. Therefore, we established a community-based surveillance system in Miami Beach, Florida, as part of a study to assess falls among the elderly. A total of 1,827 fall injury events occurred in this community between July 1985 and June 1986. More than 85% (1,567) of the persons who fell and received care were seen in an emergency room. The remaining cases were identified from one of the three other sources used: fire rescue reports, inpatient medical records, or medical examiner reports. Most falls (97%) were coded as accidental (E880-E888). More than 100 people sought medical assistance for a fall each month. The time of the injury was known for 68% (1,244) of the people who fell. Seventy-four percent of these falls (921) occurred during daylight hours. Fifty-four percent of the falls (986) occurred in and around the home, and 38% of these had a particular area of the home recorded: 42% occurred in the bedroom, 34% in the bathroom, 9% in the kitchen, 5% on the stairs, 4% in the living room, and the remaining 6% in other areas. This surveillance system will help us use the study to clarify the causes of falls in the elderly and identify and evaluate appropriate prevention efforts. It will also help others in designing and implementing other injury surveillance systems.
Article
Several sources of data were used to identify questions worthy of inclusion in a functional assessment questionnaire for older patients. Community hospital use of the Functional Assessment Inventory was reviewed to identify questions that discriminated between inpatients and outpatients. Repeated administrations of the Older Americans Resources and Services questionnaire with elderly patients were reviewed to identify questions that discriminated between community and nursing home status and predicted nursing home placement. Twenty clinicians providing geriatric care identified clinically important questions in a modified Delphi survey. Questions were retained if they: were considered clinically essential; discriminated between inpatients and outpatients and between independent living and nursing home status; predicted nursing home placement; and showed changes in responses over 6 months that predicted subsequent nursing home placement. These questions were organized into a brief, clinically relevant functional assessment questionnaire, known as the Comprehensive Older Persons' Evaluation (COPE), that may facilitate the efficient provision of geriatric care.
Article
The need to assess functions such as mobility in elderly patients is increasingly recognized. Lacking other methods, clinicians may rely on the standard neuromuscular examination to evaluate mobility. Therefore, we checked the sensitivity of the neuromuscular examination for identifying mobility problems by comparing relevant neuromuscular findings with performance during four routine mobility maneuvers: (1) getting up from a chair, (2) sitting down, (3) turning while walking, and (4) raising the feet while walking. The subjects investigated were 336 elderly persons living in the community. Many subjects who performed poorly during mobility maneuvers did not have the corresponding neuromuscular abnormalities. For example, although hip and knee flexion are needed to sit down safely, abnormal hip flexion was found in only 15% and abnormal knee flexion in only 30% of the subjects who had difficulty sitting down. The relationship between neuromuscular findings and functional mobility was not predictable enough to rely on neuromuscular findings for identifying mobility problems. Therefore, a simple assessment that reproduces routine daily mobility maneuvers should be developed for use in the clinical care of elderly patients.
Article
Many physical therapists use descriptive and functional assessments of motor recovery for patients with stroke. The purpose of this study was to establish the reliability of two such assessments. The Modified Motor Assessment Scale (MMAS) assesses motor recovery; the Barthel Index assesses functional independence. Interrater and intrarater reliability were determined for the total scores and individual item ratings using videotaped MMAS and Barthel Index assessments of seven patients with stroke. Therapists viewed and rated the videotaped assessments on two occasions separated by one month. The intrarater reliability results were higher than the interrater reliability results for total scores, and both results were acceptable statistically. Interrater and intrarater reliability of the individual item ratings were also determined. The MMAS and Barthel Index are reliable assessments of motor recovery and function for patients with stroke. Physical therapists are encouraged to use the two scales to document changes in the motor recovery and functional independence of patients with stroke.
Article
The COOP Project, a primary care research network, has begun development of a Chart method to screen function quickly. The COOP Charts, analogous to Snellen Charts, were pretested in two practices on adult patients (N = 117) to test feasibility, clinical utility, and validity. Patients completed questionnaires containing validated health status scales and sociodemographic variables. Practice staff filled out forms indicating COOP Chart scores and clinical data. We held debriefing interviews with staff who administered the Charts. The results indicate the Charts take 1-2 minutes to administer, are easy to use, and produce important clinical data. The patterns of correlations between the Charts and validity indicator variables provide evidence for both convergent and discriminant validity. We conclude that new measures are needed to assess function in a busy office practice and that the COOP Chart system represents one promising strategy.
Article
The Robinson Bashall Functional Assessment (RBFA) for arthritis patients has four scales: self-care, ambulation, transportation, and activity tolerance. Criticism has been directed at the Assessment because it is relatively time consuming and requires a trained professional to conduct it. Tests of reliability revealed that the internal consistency of the total Assessment was moderate, interrater reliability was high, and test-retest reliability ranged from moderate to high. Analysis of scale validity (content, clinical, concurrent, and discriminant validity) showed content validity to be low to moderate. Therapists found the scales more useful in identifying patient problems than in assessing improvement in function over time. There were low positive correlations between dressing, undressing, and ambulation scores and ROM scores on admission. Correlations between the American Rheumatism Association Functional Classification and scales of the RBFA were significant, while the Assessment as a whole and all four scales discriminated significantly between the functional abilities of patients on admission and discharge.
Article
Modified or newly developed disability scales have to be assessed for their validity in terms of an appropriate standard and for reproducibility--inter- and intraobserver variability and intrasubject variability. For ordinal scales with more than two points or categories, correlation or regression coefficients are appropriate estimates of validity. An assessment of the sensitivity and specificity of such a scale is not feasible. Indices of proportion agreement or correlation analysis are frequently used to assess the reproducibility of disability scales. These procedures do not, however, correct for chance-expected agreement between two or more sets of observations. In a study of a 31-point ADL (activities of daily living) index used to measure the level of disability in patients with chronic diseases, scores independently rated by two observers were strongly correlated (r = 0.962), yet the two sets of observations were significantly different. An estimate of kappa statistic, that corrects for chance agreement, showed that there was in fact a poor (36.3%) overall agreement between the observers. It is concluded that the correlation coefficient often overestimates the degree of true agreement, may conceal significant disagreements, and may give misleading information about reproducibility. The kappa statistic should always be used in the assessments of reproducibility of disability scales. Agreement between more than two sets of observations can also be assessed by estimating kappa.
Article
An index of functional impairment is described for use in the assessment of rheumatoid arthritis. The index consists of 17 questions and is simple to perform and not time-consuming. The index has a high degree of intra- and inter-observer reproducibility, and can be performed satisfactorily by paramedical and nonmedical personnel, and by the patient himself. The index does not show change in short-term clinical trials of antiinflammatory drugs, but does change with significant improvement in the patient's functional ability, following, for example, major reconstructive joint surgery. Dr Peter Lee Centre for Rheumatic Diseases 35 Baird Street GlaSgow G4DEH Scotland
Article
Patient satisfaction in performing activities of daily living (ADL) was assessed by using a self-administered questionnaire modified from the Stanford Health Assessment Questionnaire (HAQ). The HAQ includes questions to determine a patient's degree of difficulty and need for help and assistive devices in ADL. A modification of the HAQ (MHAQ) was developed to include questions concerning perceived patient satisfaction regarding the same ADL, along with perceived change in degree of difficulty. In order to add additional questions while maintaining the length of the questionnaire in a format suitable in routine care, the number of ADL included in the MHAQ was reduced from 20 to 8. Information regarding degree of difficulty derived from 8 questions in the MHAQ is comparable with that derived from 20 questions in the HAQ. The response of a patient that a specific activity is associated with difficulty in functional capacity was not inevitably associated with the absence of patient satisfaction; 43.7% of patients responding "with some difficulty" and 19.1% of patients responding "with much difficulty" expressed satisfaction with their functional capacity. A major determinant of expression of patient satisfaction was perceived change in difficulty: 81.4% of patients noting that their function was "less difficult now," in contrast to 16.9% of patients responding "more difficult now," expressed satisfaction. These studies suggest that data regarding patient satisfaction and perceived change in difficulty can be assessed to more completely characterize patients' functional status in ADL.
Article
The Karnofsky Performance Status Scale (KPS) is widely used to quantify the functional status of cancer patients. However, limited data exist documenting its reliability and validity. The KPS is used in the National Hospice Study (NHS) as both a study eligibility criterion and an outcome measure. As part of intensive training, interviewers were instructed in and tested on guidelines for determining the KPS levels of patients. After 4 months of field experience, interviewers were again tested based on narrative patient descriptions. The interrator reliability of 47 NHS interviewers was found to be 0.97. The construct validity of the KPS was analyzed, and the KPS was found to be strongly related (P less than 0.001) to two other independent measures of patient functioning. Finally, the relationship of the KPS to longevity (r = 0.30) in a population of terminal cancer patients documents its predictive validity. These findings suggest the utility of the KPS as a valuable research tool when employed by trained observers.
Article
Scales of ‘Activities of Daily Living’ measure only a patient's ability for self-care. There is no brief scale to measure lifestyle, although this would be useful in determining rehabilitation goals. This paper describes such a scale, developed for use with stroke patients. The data obtained relate to pre-morbid and post-stroke levels of activities. Factor analysis indicates three major factors (domestic chores, leisure/work, outdoor activities). Two of these factors are sex-linked, as predicted. Some evidence is noted of the sensitivity of the index to severity of stroke.
Article
A review of the literature showed that there was no simple objective method of monitoring physical disabilities following a stroke. However, such a tool was considered necessary in order to plan treatment programmes realistically and intelligently and to monitor recovery patterns for clinical and research purposes. As a result an assessment form suitable for testing the physical deficits of hemiplegic patients was developed jointly by the members of the Motor Club. This form has subsequently been evaluated and standardised.
Article
This article summarizes tests of the appropriateness of aggregating specific categories of physical capacities and limitations into aggregate functional status indexes. Self-administered questionnaires were used to gather data from 4,603 people between 14 and 66 years of age. Cumulative indexes defining ranked levels of functional status were derived for two global constructs of functioning (personal and role functioning). Each index is scored to define chronic limitations and those of shorter duration. Personal functioning includes self-care, mobility and physical activity categories. Role functioning includes role and general activity categories. An index that aggregated personal and role limitations did not satisfy the assumptions of cumulative scaling.
Article
The final development of the Sickness Impact Profile (SIP), a behaviorally based measure of health status, is presented. A large field trial on a random sample of prepaid group practice enrollees and smaller trials on samples of patients with hyperthyroidism, rheumatoid arthritis and hip replacements were undertaken to assess reliability and validity of the SIP and provide data for category and item analyses. Test-retest reliability (r = 0.92) and internal consistency (r - 0.94) were high. Convergent and discriminant validity was evaluated using the multitrait--multimethod technique. Clinical validity was assessed by determining the relationship between clinical measures of disease and the SIP scores. The relationship between the SIP and criterion measures were moderate to high and in the direction hypothesized. A technique for describing and assessing similarities and differences among groups was developed using profile and pattern analysis. The final SIP contains 136 items in 12 categories. Overall, category, and dimension scores may be calculated.
Article
The objectives were to identify situational risk factors associated with suffering a serious fall injury and to determine whether, and to what extent, predisposing and situational risk factors contributed independently to risk of suffering a serious fall injury. Nested cohort study. General community. 568 members of a representative sample of community-living persons 72 years of age or older who fell during a median follow-up of 36 months. Candidate predisposing factors, identified during a baseline face-to-face home assessment, were the demographic, cognitive, medical, and physical performance measures associated with an increased risk of serious injury among fallers in a previous analysis of the cohort. Acute host, behavioral, and environmental factors present at the time of the participants' first reported fall constituted potential situational risk factors. The primary outcome was occurrence of a serious fall injury, defined as a fracture, joint dislocation, or head injury resulting in loss of consciousness and hospitalization, during the first fall recorded during follow-up. Sixty-nine subjects (12%) suffered a serious injury during their first reported fall. No acute host factor was associated with increased risk of injury. The environmental and activity factors associated independently with serious injury in multivariate analysis included falling on stairs (adjusted relative risk 2.0; 95% confidence intervals 1.1-3.5), during displacing activity (1.8; 1.0-3.0), and from at least body height (2.1; 1.0-4.7). The independent predisposing factors included female gender (2.1; 1.0-4.4), low body mass index (1.8; 1.2-2.9), and cognitive impairment (2.8; 1.7-4.7). Although 12% of first falls resulted in a serious injury overall, this percentage ranged from 0% to 36% as the number of predisposing risk factors increased from zero to three and from 5% to 40% as the number of situational risk factors increased from zero to three. Further, for any given number of predisposing risk factors, the percentage of fallers suffering a serious injury increased with the number of situational risk factors. Several environmental and behavioral factors contributed to the risk of serious fall injury; this contribution was independent of the effect of chronic predisposing risk factors. Preventive programs that address both predisposing and situational risk factors may result in the greatest injury reduction. These findings support previously recommended multicomponent intervention programs that combine medical, rehabilitative, and environmental components.
Article
For preventive purposes habitual physical activity was investigated in noninstitutionalized elderly and a profile was composed of the most inactive among them. In a cross-sectional study conducted in 1992 in Arnhem, 503 women and 493 men, aged 65-84 yr, were interviewed. Habitual physical activities and total activity scores were assessed with a questionnaire, previously validated for elderly. Among other things, our findings revealed that light housework (e.g. dusting, washing dishes) was carried out by 90% of the women and 61% of the men. Thirteen percent of the women and 9% of the men had no recreational physical activities (sports or other physically active leisure time activities). Physical activity level seems to be associated with age, socioeconomic status (only for men), marital status (only for women), disability, subjective health, presence of chronic diseases, living in houses with stairs, and living close to shops (only for men). For example, age-adjusted odds ratios for being physically inactive were 28.6 and 7.1, respectively, for women and men with disabilities (95% confidence intervals: 6.4-127.0 and 2.7-18.3, respectively). Our findings suggest physically inactive elderly are mainly characterized by older age and a less favorable health. Physical activity of these elderly deserves special attention, to prevent further deterioration and loss of independence.
Article
The objective of this study was to compare two methods of measuring physical function in subjects with a broad range of abilities and to evaluate the effects of cognitive, social, educational, and age factors on the relationship between the two methods. Multiple regression analysis was used to compare self-perceived (dependent variables) with performance measures (independent variables). Covariates included age, gender, Mini-Mental State Exam score, education, living status, and depression score. Five community-dwelling and two nursing home sites. 417 community-dwelling subjects and 200 nursing home residents aged 62-98 years. Self-perceived physical function was assessed with the physical dimension summary score of the Sickness Impact Profile, which comprises three subscales: ambulation, mobility, and body care and movement. Physical performance was evaluated by self-selected gait speed, chair-stand time, maximal grip strength, and a balance score. Nursing home residents and community-dwellers were significantly different (P < .0001) in all variables except age and gender. Self-perceived and performance-based measures were moderately correlated, with a range from r = -.194 to r = -.625 (P < .05). Gait speed was the strongest independent predictor of self-perceived physical function in both groups. Symptoms of depression were also an independent predictor of self-perceived function in nursing home residents; subjects who had such symptoms report more self-perceived dysfunction than would be predicted based on performance tests. Self-selected gait speed is a global indicator of self-perceived physical function over a broad range of abilities. External determinants (depressive symptoms, cognitive function, marital status, etc.) affect self-perceived function in both groups, but gait speed is the greatest single predictor of self-perceived function. In nursing home residents depressive symptomatology is related to self-perceived.
Article
Measuring functional activity for elderly at very low functional levels remains a challenge because many functional instruments have not been standardized in a frail elderly population. The Frail Elderly Functional Assessment questionnaire (FEFA) is a 19-item, interviewer-administered questionnaire designed to assess function in frail elderly at a very low activity level. The purpose of this study was to determine the reliability and validity of this instrument in a frail elderly population. Two groups of subjects over 65 yr old were selected to test the reliability and validity of this questionnaire. Test-retest reliability was determined by correlating the responses of 29 homebound (including nursing home-bound) subjects who answered the questionnaire on two occasions 2 wk apart. To assess the validity of the FEFA, the questionnaire was administered to 23 frail, homebound (including nursing home-bound) elderly subjects who had a Mini-Mental State Examination score of > or = 18. Validity was determined by correlating patient responses to direct observations by the investigators of tasks addressed in the questionnaire. Correlation was also determined against the Katz's Activity of Daily Living index, Lawton's Instrumental Activity of Daily Living index, and the Barthel index. The reliability coefficient was 0.82. Correlation between the FEFA questionnaire and direct observation of questionnaire task performance was 0.90. Construct validity against the Katz's Activity of Daily Living, Lawton's Instrumental Activity of Daily Living, and the Barthel index showed correlations of 0.86, 0.67 and 0.91, respectively. Initial data indicate that the FEFA is a valid and reliable instrument that may be useful in assessing function in frail elderly people.
Article
Stairs are among the most hazardous features of the everyday environment, yet stairway falls have received little research attention. A stratified random sample of Austrian residents was surveyed in person in 1989. Of over 55,000 respondents, 147 reported a stairway injury in the previous year that limited activity for at least one day. Thirty-seven percent of these injuries resulted in hospitalization. Extrapolating to the entire country of 8 million people, each year some 20,000 Austrians sustain serious stairway injuries resulting in over 7,500 hospitalizations. The incidence of stairway injury increases monotonically with age, and females are more at risk than males. The stereotypical stairway injury victim is an elderly woman, not highly educated, who is unmarried and living alone.