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Walking disorders not only significantly reduce activities of daily living and lower the quality of life, but also increase the burden on caregivers and the use of social resources. Therefore, an appropriate assessment of walking independence is very important in physiotherapy practice. Several indices have been reported to assess walking independence in stroke patients. Most of them are evaluated with a focus on physical function and balance ability, and the cut-off values for each indicator have been reported. This chapter describes the validity, relevance, and cut-off values of the balance and walking indices used to assess walking independence in stroke patients, and outlines their clinical applications.
Neurorehabilitation Laboratory, Graduate School of Health Sciences, Kyoto Tachibana University, Kyoto, Japan
Department of Rehabilitation, Tesseikai Neurosurgical Hospital, Osaka, Japan
Shoya Fujikawa
Neurorehabilitation Laboratory, Graduate School of Health Sciences, Kyoto Tachibana University, Kyoto, Japan
Department of Rehabilitation, Tesseikai Neurosurgical Hospital, Osaka, Japan
Shun Sawai
Neurorehabilitation Laboratory, Graduate School of Health Sciences, Kyoto Tachibana University, Kyoto, Japan
Department of Rehabilitation, Tesseikai Neurosurgical Hospital, Osaka, Japan
Hideki Nakano*
Neurorehabilitation Laboratory, Graduate School of Health Sciences, Kyoto Tachibana University, Kyoto, Japan
*Address all correspondence to: nakano-h@tachibana-u.ac.jp
1. Introduction
Aging is often associated with a decline in physical function, which ultimately leads to a loss of independence while performing activities of daily living (ADL). Walking is a general ADL and is important as a major determinant of the quality of life (QOL) in older people. Walking velocity has been called the ‘sixth vital sign’ because it is a central indicator of health and function in older people [1]. There is also a significant difference in the walking velocity and ADL dependence between those with sarcopenia and healthy older people [2]. Furthermore, walking velocity indicates neuromuscular quality and is an important determinant of aging [2]. Algorithms involving walking velocity measurement that have been developed to determine sarcopenia in older adults are simple and reliable [3]. They have also been used to diagnose functional impairments and dependency disorders in older adults [3, 4, 5]. Similarly, a decrease in walking velocity because of reduced muscle mass is associated with aging [1]. These factors raise the concern that the likelihood of developing a walking disorder increases with age, even in the absence of specific diseases. Walking disorders are accompanied by limitations in mobility and activity and they restrict ADL and lower the QOL. Therefore, maintaining and improving the walking ability during rehabilitation is an important goal for physiotherapists. In this chapter, the evaluation indices that are generally used to determine walking independence and those used to determine walking independence in stroke patients are described in sections.
2. The various assessment indicators in the determination of walking independence
Most measures of walking independence are based on walking ability, physical function [disease and motor function in the region of the impairment], and balance ability. This section describes various assessment indices used to determine walking independence.
2.1 General assessment indicators for determining walking independence
There are a wide range of diseases that require physiotherapy. Therefore, physiotherapists need to consider the characteristics of individual diseases and the stage of the disease to appropriately assess the degree of walking independence. The most commonly used evaluation indices for walking independence are those that assess balance and walking indicators. The Functional Reach Test (FRT), Berg Balance Scale (BBS), and Mini-Balance Evaluation Systems Test [Mini-BESTest] are commonly used as evaluation indices for balance ability, and their reliability and validity have already been reported [6, 7]. The 10-meter walking test [10MWT] [8] and the Timed Up and Go (TUG) test are generally used as walking indicators. This section summarizes the assessment indicators commonly used in walking independence assessment and their details (Table 1).
In patients admitted to recovery wards, the cut-off value for walking independence is 0.8 m/s. In community-dwelling elderly, indoor walking independence is 0.5 m/s; outdoor walking independence is 1 m/s.
The cut-off value for determining a balance disorder is ≥13.5 s.
Table 1.
Generally used assessment indicators for determining walking independence.
TUG is reportedly a reliable assessment, strongly correlating with balance, postural control, walking ability, and fall risk [8, 13]. TUG ≥13.5 s and BBS < 46 points are the cut-off values for a balance disorder [9]. In frail older adults, the cut-off value of the FRT to determine the risk of falling is ≥18.5 cm [6]. Furthermore, the cut-off value of the Mini-BESTest to determine walking independence in patients admitted to rehabilitation wards is 18 points [10]. The BBS score of hip fracture patients admitted to rehabilitation wards helps to predict walking independence at discharge and determine treatment according to the predicted level of independence [14]. The reported cut-off value for the 10MWT, a walking indicator, for walking independence in patients in recovery wards is 0.8 m/s, indoor walking independence in older adults living in the community is 0.5 m/s, and outdoor walking independence is 1 m/s [11, 12]. As described above, several previous studies have reported on the use of general balance and walking indicators to identify cut-off values for determining walking independence and fall risk.
2.2 Indicators for assessing walking independence based on walking ability in stroke patients
Walking disorders are one of the most serious consequences associated with stroke, and approximately 30% of stroke patients have difficulty walking independently even in the chronic phase [15]. In addition, 38% of stroke patients are unable to walk at 6 months after stroke onset [16]. Stroke is a neurological disease and its sequelae are associated with physical disability. Walking disorders are observed in more than 50% of stroke patients. Walking disorders may be due to motor or sensory disorders, spasticity, or balance disorders [17]. It is necessary to assess the factors involved in walking disorders to improve walking independence. Walking ability includes walking independence, velocity, and endurance. The Functional Ambulation Categories (FAC) are used to assess walking independence, the 10MWT to assess walking velocity, and the 6-minute walk test (6MWT) to assess endurance. Stroke patients suffer problems such as motor paralysis and sensory impairment [17, 18]. Moreover, impaired balance is due to reduced motor control of the limbs, pelvis, and trunk, sensory impairment, and impaired spatial perception of the body [19]. Furthermore, impaired balance has been reported to lead to reduced mobility [20]. Therefore, it is essential to assess gait ability from multiple perspectives using the above assessment indices to appropriately assess stroke patients’ gait ability (Figure 1).
Figure 1.
Assessment index for gait ability in stroke patients.
The FAC is a walking indicator that classifies walking ability on a 6-point scale from 0 to 5 based on the amount of care required while walking and has been reported to have excellent reliability in patients with post-stroke hemiplegia [21]. The FAC at 4 weeks after stroke onset has been reported to have predictive validity for walking ability at the regional level 6 months after stroke onset [21]. In addition, walking velocity is one of the most sensitive measures to assess walking independence, using an assessment index related to walking indicators, walking velocity being one of the walking ability indicators [22]. It has also been reported that the comfortable walking velocity for the 10MWT is a valid walking indicator for assessing walking ability in stroke patients [23]. Another study reported that the trunk control test (TCT) and FAC can predict walking independence 45 days after stroke onset [24]. Previous studies have compared the BBS, Mini-BESTest, and Functional Gait Assessment (FGA) in terms of reactivity, floor effect, and ceiling effect at different levels of walking: The BBS showed the highest relative effect in the FAC2-3 group and the Mini-BESTest showed the highest relative effect in the other two groups (FAC 4-5 and 6) [25]. In patients with FAC 2-3, the floor effect occurred with the FGA, and in patients with FAC 6, the floor effect occurred with the BBS [22]. The BBS is suitable for stroke patients with FAC 2 to 5, while the MBT and FGA are suitable for stroke patients with FAC 4 to 6 [25]. The cut-off values for the 10MWT in stroke patients are <0.4 m/s for those with walking independence at home, 0.4–0.8 m/s for those with walking independence in a limited area, and > 0.8 m/s for those with walking independence in the community [26]. Furthermore, walking endurance and velocity are good predictors of whether subacute stroke patients will reach community walking levels at 6-month post-discharge. The cut-off values are 195 m and 0.56 m/s, respectively [27]. The 10MWT and 6MWT have different cut-off values depending on which level of walking independence is targeted, so the meaning of the measured times and distances should be interpreted according to the needs of the individual patient.
2.3 Indicators for determining walking independence based on physical function in stroke patients
Patients present with a wide range of clinical symptoms following stroke. Post-stroke motor function impairment appears as muscle weakness, abnormal muscle tone, and impaired motor coordination, and mobility is also impaired with these symptoms. Voluntary neurological recovery of post-stroke motor function progressively improves over the first 3–6 months after stroke onset, before reaching the ceiling [28]. In physiotherapy, it is necessary to quantitatively assess physical function and plan intervention methods tailored to the patient, with the aim of improving the patient’s physical function.
Various assessment indices, such as the Fugl-Meyer Assessment (FMA), Brunnstrom recovery stage, Motor Assessment Scale (MAS), and Stroke Impairment Assessment Set, have been developed to evaluate motor function in stroke patients.
The reliability and validity of these assessment measures have been reported [29, 30, 31]. Stroke also reduces the ability of the trunk coordination immediately after stroke onset. In particular, reduced trunk muscle activity reduces pelvic movement, affecting trunk asymmetry and causing reduced balance ability [32]. The TCT and Trunk Impairment Scale (TIS) are reliable and valid as assessment indices of trunk function in stroke patients [33, 34, 35]. It has also been reported that in stroke patients, the TIS score on admission is strongly correlated with the National Institutes of Health Stroke Scale, upper limb FMA, and lower limb FMA scores [29]. Furthermore, trunk function has been shown to influence stroke severity and upper and lower limb motor function. The cut-off values for determining walking independence in stroke patients using each index to assess motor function are described below. Patients with a lower limb MAS score of ≥5 within 4 weeks after stroke onset can walk independently [36]. In addition, patients with a TCT score of ≤50 at 14 days after stroke onset have a FAC < 4 [34]. Thus, previous studies have shown that the motor function of the paralyzed lower limb and trunk function affect the physical functional factors involved in the degree of walking independence in stroke patients.
2.4 Indicators for the assessment of walking independence based on balance ability in stroke patients
Stroke causes a variety of complications, including muscle weakness, sensory impairment, and cognitive decline [35]. Sensory impairment, in particular, affects balance and postural control in stroke patients and is important for keeping the body upright and stable under different conditions [37]. Reduced balance ability after stroke is associated with reduced ADL [38] and limited social participation [39]. Decreased balance ability is caused by reduced motor control of the limbs, pelvis, and trunk, sensory impairment, and reduced spatial cognition of the body [19]. It has also been reported that reduced balance ability increases the risk and fear of falling [20] and leads to reduced ADL and a lower QOL [40]. After stroke, patients present with a wide variety of clinical symptoms. It is, therefore, essential to assess motor function as described in the previous section and balance function in detail (Figure 2).
Figure 2.
Assessment indices for physical function and balance in stroke patients.
The commonly used balance assessment indices in stroke patients include the BBS, FRT, TUG, and one-leg standing (OLS). Their role in determining treatment strategy is limited, but their effectiveness in stroke patients has been reported [41]. The cut-off value of the FRT to determine the presence of falls in stroke patients is 15.0 cm [42]. The BBS, one of the typical assessment indices, has also been found to be a very valid and reliable means of assessment of balance ability in stroke patients [43]. This section provides a table summarizing the assessment measures used in gait independence assessment in stroke patients and their details (Table 2).
Suitable assessment measure for stroke patients with FAC 2 to 5. Stroke patients with a score of 29 or more on admission will recover to community ambulation or no walking aids after 4 weeks. A score of 12 or more on admission leads to ambulatory independence for non-ambulatory patients. The cut-off value for predicting falls and the non-fall group for stroke patients on admission is 31 points. The cut-off value for community walking (>0.8 m/s) is 47.5 points.
Mini-Balance Evaluation Systems Test (Mini-BESTest) [46, 47, 48]
Reliable assessment indicator at any stage of the disease. The assessment indicator is suitable for stroke patients with FAC 4–6. Cut-off values for the walking independence assessment are not known. The cut-off value for community walking (>0.8 m/s) is 18.5 points.
In patients admitted to recovery wards, the cut-off value for walking independence is 0.8 m/s. In community-dwelling elderly, indoor walking independence is 0.5 m/s; outdoor walking independence is 1 m/s.
The assessment of FAC at 4 weeks after stroke onset is reported to provide predictive validity for the ability to walk at the community level 6 months after stroke onset.
In subacute stroke patients, the cut-off value for predicting whether the community walking level will be reached at 6 months after discharge from the hospital is 195 m.
Table 2.
Indicators for the assessment of walking independence in stroke patients.
The BBS has been reported to have a cut-off value of 31 points as a discriminatory criterion between the falls and non-fall groups in hospitalized stroke patients [44]. In addition, stroke patients with a BBS score of ≥29 points on admission recover to community ambulation or walking ability without walking aids after 4 weeks. It has been reported that if the BBS score on admission is ≥12 points, non-ambulatory patients can reach walking independence [45]. Furthermore, the cut-off value for the BBS score in chronic stroke patients based on walking at the community level (>0.8 m/s) has been reported to be 47.5 points [46]. However, because the BBS, OLS, and FRT have floor and ceiling effects [49, 50, 51], the Mini-BESTest was newly developed as a balance assessment indicator for patients with neurological disorders. The Mini-BESTest is an evaluation index that calculates scores for six factors related to balance function (biomechanical constraints, stability limits, postural change—predictive postural control, reactive postural control, sensory function, and walking stability). It is also a useful indicator for clarifying therapeutic intervention strategies for patients with balance disorders by identifying problems in individual balance functions by the element [47, 48]. The Mini-BESTest has also been tested for reliability and validity at all stages of stroke patients. Furthermore, the cut-off value of the Mini-BESTest in stroke patients based on walking at the community level (>0.8 m/s) has been reported to be 18.5 points [46]. In summary, walking independence and fall risk can be better determined by assessing the balance ability using the BBS, Mini-BESTest, and FRT (Table 2).
3. Determining walking independence based on brain imaging in stroke patients
Pathophysiological changes in motor recovery after stroke mainly occur within the first 15 weeks after stroke, regardless of the severity of the initial motor impairment [52]. Motor impairments stabilize after 6 months, which is considered as the chronic phase [53]. However, it has been reported that motor function continues to improve during the chronic phase through various mutually complementary brain plasticities [52]. Brain imaging showing the structure and function of the motor cortex has also been reported to help predict both motor recovery and motor outcome after stroke [54]. Specifically, it has been suggested that the measurement of the corticospinal tract (CST) in the acute phase may predict motor function. Early measurement of the number of fibers in the CST predicts motor outcome (FMA score) at 12 months, especially in patients with first stroke [55]. The number of fibers in the ipsilateral and contralateral CST (FA value) in the acute phase suggests a good recovery of motor function after stroke [56]. Moreover, neuroimaging and neurophysiology CST biomarkers can predict the prognosis of motor function and response to treatment after stroke and are recommended for use in clinical trials, including patient stratification [57]. The CST can be elucidated using magnetic resonance imaging, and the FA values of diffusion tensor imaging in particular have been identified as a reliable tool to identify the structural integrity of CST after stroke [58, 59]. In summary, brain imaging is a clinically important indicator when planning individualized rehabilitation of patients. Recently, several studies have reported the use of brain imaging to predict recovery of motor paralysis in stroke patients. It has been suggested that the FA value of the ipsilateral CST on day 14 after stroke onset is significantly correlated with improvement in motor paralysis [60, 61, 62, 63]. However, the association with an index to assess walking independence is not clear and is a subject for subsequent studies.
In this chapter, each section describes an index to determine the degree of walking independence in stroke patients. It is clear that not only the reliability and validity of individual assessment indices but also the degree of brain damage, motor paralysis, trunk function, balance, and walking ability correlate with each other. Therefore, physiotherapists must assess the disability caused by stroke from multiple perspectives. In addition, it is important to match the cut-off values for balance and walking ability to determine the degree of walking independence. In the future, it will be important to clarify the relationship between the results of brain imaging analysis and indices of physical function, balance, and walking ability to improve the accuracy of prognostic prediction and establish evidence for walking independence in stroke patients.
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Written By
Ryosuke Yamamoto, Shoya Fujikawa, Shun Sawai and Hideki Nakano
Submitted: 05 July 2023Reviewed: 15 September 2023Published: 10 November 2023
Open access peer-reviewed chapter
