Research reportRefining the Ten-metre Walking Test for Use with Neurologically Impaired People
Introduction
‘The communication and interpretation of results is often made difficult due to uncertainty surrounding important definitions and testing protocols. An example of uncertainty in the protocols used for testing is illustrated by the ten-metre walking test. While many authors now advocate this simple test of walking ability, the literature offers little guidance as to the protocol by which to measure a subject’ (Durward et al, 1999).
In physiotherapy for neurologically impaired patients, considerable time may be spent on the remediation of gait problems. One might therefore assume that therapists are devoting some time to its measurement and documentation, including some form of objective gait assessment. However, as Turnbull and Wall stated in their 1985 paper discussing gait assessment: ‘There is … a reluctance on the part of physiotherapists to use objective measurement systems.’ One reason they gave for this reluctance is that locomotor disorders are frequently complex in nature, with much inform-ation thus being needed in order to de-scribe them. The expectation is there-fore that objective measurement systems will be equally complex and thus difficult to use.
Some methods of gait analysis are complex and difficult to use. Gait analysis laboratories are at the complex end of the spectrum in this respect (Bell et al, 1996). They tend to be of limited availability, require much costly and sophisticated equipment, and can be highly comp-licated to operate. Thus they are fairly unlikely to be used in everyday clinical practice.
Relatively simple methods of gait anal-ysis have been developed, some having a long history. Typical examples include:
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Asking subjects to walk across a floor which has been dusted with chalk. Gait parameters can then be measured from their footprints.
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Obtaining a stride record and walking time by asking subjects to walk along a walkway with markers attached to their shoes (eg Holden et al, 1984; Wolfson et al, 1990; Riley et al, 1999).
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Asking subjects to walk along a grid pattern while the assessor records salient details with a stop-watch (Robinson and Smidt, 1981; Wall and Scarbrough, 1997).
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Using a standardised checklist, listing typical gait deviations, each of which is recorded as being absent or present (eg Goodkin and Diller, 1973; Seymour and Dybel, 1998; Lord et al, 1998).
Simple methods like these are not how-ever always straightforward to use. This fact, combined with an apparent general reticence on the part of (some) therapists to use measurement tools, presumably decreases the likelihood of their con-sistent and frequent use.
The simple expedient of timing how long it takes subjects to walk a specified distance, as a measure of gait perform-ance, is not a new idea. Jebsen et al (1970) proposed and investigated timing how long it takes subjects to walk 25 yards, as part of a battery of tests used to assess mobility. Reliability was found to be good, and it was suggested that such testing provided ‘an objective means of following changes in patient function’.
Bohannon (1987) suggested measuring subjects' velocity (and cadence) over a distance of eight metres. Though few details were given of the actual test procedure used, it was later shown that this procedure had good reliability (Bohannon and Andrews, 1990). Clinic-ally significant relationships between performance on this timed test and other measures of gait performance were also shown.
Ada and colleagues (1990) described the use of a self-timed ten-metre walking test for a head-injured patient to report his progress during gait re-education. In this case, measurement was used to facilitate self-directed activity aimed at continued motor recovery.
Robertson and Cashman (1991) used a timed four-metre walking test in their evaluation of auditory feedback in the remediation of gait difficulties caused by unilateral neglect. In this example, the timed test was used as the main assess-ment measure of gait improvement in a single case study.
More recently still, a timed walk over six metres now forms one component of the Elderly Mobility Scale (Smith, 1994). This has become a very popular assessment tool in UK-based elderly rehabilitation.
Many studies, carried out with a variety of patient groups, describe some similar form of timed walking test. Though the distance used seems to vary (see above), emphasis seems to be placed on the use of a distance of ten metres (eg Wade et al, 1987; Ada et al, 1990; Wolfson et al, 1990; Macleod and Grant, 1994). Though spec-ific discussion as to why this distance has been chosen is difficult to find, its practicality and validity is understandable. Ten metres is probably the minimum functionally significant distance in the recovery of independent walking. It is also probably a typical distance in clinical gait remediation, in terms of the free length of treatment areas and/or parallel walking bars. Ten metres is thus both a practical and meaningful distance to use.
In 1987 Wade et al first described and documented the specific use of a ten-metre walking test to monitor recovery of gait following stroke. This involved timing how long it takes subjects to walk ten metres from a standing start, moving at their usual speed with their usual walking aids. Inter-rater and test-retest reliability were found to be good, though a specific operational procedure for the test was not given. In many cases, improvement (increase) in walking speed was accom-panied by an improvement in functional performance (ie degree of help and instruction needed, and the type of walking aid required if needed). The test was proposed as a valid, reliable and objective measure of gait performance following stroke.
Since 1987, Wade and colleagues, as well as others, have contributed sign-ificantly to the literature on the test's use (Wade et al, 1992; Collen et al, 1990, 1991; Collen and Wade, 1991; Van Herk et al, 1998). During this period, the ten-metre test (or variations of it) appears to have gained in popularity in UK clinical and research environments. Anecdotal reports, tog-ether with documented experiences such as those referred to, suggest that the test is being used widely as a physiotherapy assessment tool with neurologically impaired patients.
The aims of this paper are to:
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Describe a specific procedure for the test.
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Report on the reliability of that described procedure.
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Give some relevant normative data for the test.
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Give some examples of the test's use with neurologically impaired subjects.
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Discuss some of the issues relating to use of the test with neurologically impaired patients.
A particular focus of this paper is the test's use with adult subjects whose neurological impairment is a result of severe traumatic brain injury, ie patients whose injury resulted in a coma of six hours or more (MDS, 1988).
Section snippets
Operational Procedure
The procedure for carrying out the ten-metre test is not described in detail in the literature. In deference to the test's originators, as well as to those clinicians who already use some form of the test, it is clearly a simple matter to time how long it takes someone to walk a fixed distance from a standing start. However, for the purposes of establishing more fully the extent of a test's reliability and sensitivity, it is obviously important to have a specified operational procedure. This
Normal Subjects
As an examination of the inter-rater reliability of the described test procedure, two raters tested 28 normal subjects (14 men, 14 women) in the manner already described. This was a convenience sample of healthy volunteer undergraduate students readily available to the testers. This resulted in 84 (3 ×28) potential pairs of timed trials, of which 82 pairs were recorded (two pairs spoiled, one pair by each rater).
As Bland and Altman (1986) have suggested, the calculation of a correl-ation
Head Injured Subjects
As a test of inter-rater reliability with patients, two raters tested ten traumatic brain injury patients who were able to walk independently, although some used walking aids. This was again a sample of convenience, using subjects who were attending the local branch of Headway* as clients, while the author was employed there as a
Discussion
As Wade et al concluded in 1987: ‘The measurement of the time taken to walk ten metres could be a simple objective measure of walking ability.’ With the optional inclusion of a step-count to indicate cadence, the ten-metre test seems to be a simple and reliable method for measuring aspects of walking ability in neurologically impaired patients. This report suggests an operational procedure for the test, offers further evidence as to the reliability of this simple measure, and provides further
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