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Background and Purpose. This study assessed the reliability and validity of walking time measurements using these components. Twenty-eight subjects who had strokes and 28 subjects without impairment were recruited. Subjects without impairment performed better on all 4 tests than did subjects who had strokes. Conclusion and Discussion. The E-FAP can be administered easily and inexpensively. Because the E-FAP scores differentiated subject groups and correlated with known measures of function, the E-FAP may be a clinically useful measure of ambulation.
A combination of impairments can lead to decreased ability to ambulate and an increased risk of falls. Assessments are often undertaken to predict the ability of individuals to use a variety of skills when performing tasks necessary for daily living, leisure, vocational pursuits, and other required behaviors.
In this regard, changes in quantification of walking time and use of assistive devices may be useful in predicting the impact of specific interventions. Inevitably, cognition, 7 balance, 8 , 9 vision and joint position sense, 10 strength, 11 speed, 12 endurance, 13 and adaptability to environmental demands 4 — 6 contribute to successful ambulation. Changes in these variables often are evident in individuals poststroke, 14 , 15 and these changes may be manifested as slow gait speed and altered stance phases 16 , 17 or as compromised ability to regain balance, control movement, or adjust energy expenditure.
Measures of gait have been used in both laboratory and clinical settings. The Functional Ambulation Profile was first described by Nelson, 26 who marked the plantar surface of the foot or shoe and recorded foot contact aspects of gait, such as stride length, cadence, and so on. The conceptualization of a functional ambulation profile presented here ie, the Emory Functional Ambulation Profile [E-FAP] is quite different and is an inexpensive and easily administered assessment of ambulation.
The E-FAP was designed to provide quantitative information about ambulation by measuring time to walk over a standardized array of surfaces and obstacles and accounts for the use of an assistive device.
For the E-FAP to be useful to clinicians, patients, health care decision makers, and third-party payers, reliability and validity of the E-FAP measurements must be established.
Subjects who have had strokes are likely to demonstrate altered ambulation 14 , 18 and should exhibit different scores on an ambulation test than subjects without impairment. Therefore, construct validity would be supported if scores on the E-FAP separate subjects who have had strokes from subjects without impairment.
Because no gold standard or criterion measure of ambulation exists, the concurrent validity of the E-FAP will be evaluated by comparing the E-FAP with tests of gait speed and balance. The Timed Meter Walk Test is reported to yield reliable and concurrent, valid measurements of gait speed in patients who have had strokes.
Good scores on balance scales are positively correlated with high levels of independent mobility in patients poststroke. Furthermore, unlike the other 2 tests, the E-FAP provides information to health care decision makers about how clients ambulate in a variety of environments. These data can be obtained repeatedly during interventions to detect the effectiveness of treatment and to help design home programs.
This knowledge is also important in making decisions about the need for caregivers or altering a home environment or for assessing employment opportunities.
The reliability and validity of the E-FAP component measures should be assessed before the tool can be applied to assess the benefit of interventions to improve walking.
Therefore, the research questions under consideration were: 1 Does the E-FAP differentiate between subjects who have had strokes and subjects without impairment? The 56 volunteer subjects tested were obtained by convenience sampling.
Subject characteristics are presented in Table 1. Eighteen subjects who had strokes required assistive devices: 6 subjects used canes, 2 subjects used ankle-foot orthoses AFOs , 8 subjects used canes and AFOs, and 2 subjects used quad canes and AFOs. Ten subjects who had strokes did not use an assistive device. Twenty-seven subjects without impairment reported no falls; 1 subject without impairment reported a fall during the year preceding the study. Fifty-five subjects demonstrated intact joint position sense; joint position sense for 1 subject with a stroke secondary to aphasia was not tested.
To meet inclusion criteria, subjects were required to perform the following tasks without another individual's assistance: 1 follow simple spoken commands, 2 ascend and descend 5 stairs, 3 get in and out of a chair, 4 walk 10 m on a hard-surfaced floor, and 5 walk 10 m on a carpeted floor. Subjects with strokes could participate if they used an AFO, a cane, a quad cane, a hemiwalker, or any combination of these devices. No other type of assistive device, however, was allowed. The subjects without impairment had to have: 1 no more than 2 falls during the year preceding the study, 2 an absence of a serious medical diagnosis, including pulmonary, cardiac, neurologic, systemic, or musculoskeletal problems or a history of stroke, 3 the ability to ambulate without an assistive device, and 4 an absence of assistance with activities of daily living.
All subjects participating in the study provided written informed consent. The personal physician of each subject with a stroke approved his or her participation in the study.
The number of seconds taken to complete each subtask was recorded. The time to complete each subtask was multiplied by a factor corresponding to the level of assistive device used Figure. Inclusion of the assistance factor as part of the E-FAP serves several purposes. First, this inclusion allows the score to reflect differences in the amount of assistance required by an individual. The assistance factor increases relative to the amount of support offered by the assistance device.
Second, use of an assistance factor permits differentiation of individuals who are walking at the same speed but with different assistive devices. Moreover, the assistance factor can reflect changes in gait speed as patients progress from one device to another. Third, use of the assistance factor offers a clinically descriptive picture for other health care professionals to interpret the E-FAP.
The 5 subtask scores were summed to yield an E-FAP total score. For each subject with a stroke, an E-FAP total score also was computed without the multiplication factor for assistive device. Thus, calculations were made for all subjects with strokes using both an assistance factor and no assistance factor. Matrix depicting the environmental conditions x-axis and amount of assistance y-axis with assistance factor AF. Each subject was instructed to walk at a comfortable, normal pace for 10 m.
Only the middle 6 m, however, was timed to eliminate the effects of acceleration and deceleration. From these data, the speed was calculated by dividing the middle 6 m by the time in seconds required to walk the 6 m. The Berg Balance Test was administered to each subject according to the standard protocol. Performance of each task was scored on a scale from 0 to 4, with 0 representing minimal completion of the task and 4 representing full completion of the task according to test criteria.
A total score of 56 represents perfect performance. The score on the Functional Reach Test was the distance in centimeters of the subject's reach as determined by the total excursion of the subject's third metacarpal in the nonhemiparetic arm of the subjects with strokes or the dominant arm of the subjects without impairment. One practice trial was performed followed by 3 separate test measurements.
The average of the 3 measurements was the subject's final score. With the exception of an AFO, use of assistive devices for subjects with strokes was not allowed during this test. Leg length was measured bilaterally in centimeters for each subject. Following palpation of the superior aspect of the ASIS, the tip of the tape measure was placed on this landmark.
Next, the most prominent point on the medial malleoli was palpated, and the tape measure was extended to this landmark and leg length was then measured. Each subject self-reported age and gender information, and this information was verified by inspection of legal identification eg, driver's license. Information about time since onset of stroke and side of lesion was obtained by self-report or medical chart review.
The height of each subject was measured by having each subject remove his or her shoes and stand upright against a wall marked in inches. Measurement was recorded in inches and later converted to centimeters. Joint position sense was assessed bilaterally for each subject at the following joints: shoulder, hip, knee, and ankle.
Next, the subject was asked to close his or her eyes while the investigator grasped the limb and moved the joint passively into one of the extreme positions.
Prior to test administration, blood pressure was assessed using a sphygmomanometer and stethoscope on the brachial artery. A physician examined that subject.
All other subjects met the blood pressure and heart rate criteria before or after the testing session. Interrater agreement was determined for leg length, joint position sense, and subject characteristics ie, gender, age, height by repeated observations of 2 investigators. To establish reliability between investigators prior to data collection, agreement between the investigators was obtained over 4 trials.
Two investigators scored each of the 4 tests concurrently throughout the study in order to assess interrater reliability at the conclusion of the study. Two of 4 investigators were randomly assigned to each subject for a data collection session. The investigators initially contacted and interviewed each subject by telephone or in person to assess qualification for the study.
Each subject was asked to wear comfortable walking shoes to the 1-hour data collection session. At the start of the data collection session, each subject answered a questionnaire to ensure qualification. One investigator took preliminary measurements, including blood pressure, pulse rate, height, joint position sense, and leg length.
Each subject was offered a 2-minute rest period between tests, if needed. Otherwise, each subject progressed immediately to the next test. For each test, one investigator demonstrated the test and gave specific instructions to the subject.
A second investigator guarded the subject during each task. Each investigator independently recorded performance data on a separate data collection form. On completion of the data collection session, one investigator remeasured the subject's blood pressure and pulse rate. If blood pressure or pulse rate did not descend, a physician was contacted. The mean, standard deviation, and minimum and maximum values were determined for each test score, age, height, and leg length per group and for time since onset of stroke in the subjects with strokes.
Gender in both groups and side of lesion in the subjects with strokes were summarized as frequency of occurrence. Measurements obtained by the primary researcher were used in all analyses except determination of interrater reliability. All test scores and leg-length measurements were interval data, except scores from the Berg Balance Test, which were ordinal data. Normality of distribution and homogeneity of variance for each test score and leg-length measurement were tested using the Walled test and the Sphericity test, respectively.
Scores on the Functional Reach Test, the Timed Meter Walk Test, and the leg-length measure met these assumptions in the subjects with strokes. If data did not meet an assumption, parametric test results are reported only when the nonparametric tests yielded identical results. Otherwise, nonparametric test results are identified. The difference in scores on each subtask of the E-FAP between groups was tested using a Wilcoxon rank sum test with a Bonferroni adjustment.
The correlation between average leg length and scores on the Timed Meter Walk Test for each group and for both groups combined was determined using the Pearson product-moment correlation coefficient. To obtain a power of.
Emory Ambulation Profile; Modified Functional Ambulation Profile
Background and Purpose. This study assessed the reliability and validity of walking time measurements using these components. Twenty-eight subjects who had strokes and 28 subjects without impairment were recruited. Subjects without impairment performed better on all 4 tests than did subjects who had strokes.
Toll-Free U. From high-quality clinical care and groundbreaking research to community programs that improve quality of life, philanthropic support drives our mission and vision. The EFAP assesses functional ambulation in terms of assistance and time under 5 different environmental variables. Instrument Details.
Background and purpose: The modified Emory Functional Ambulation Profile mEFAP is an easily administered test that measures the time to ambulate through 5 common environmental terrains with or without an assistive device or manual assistance. The mEFAP was evaluated for its interrater reliability, test-retest reliability, concurrent validity, and sensitivity to change during outpatient rehabilitation for poststroke gait dysfunction. Methods: Twenty-six poststroke patients were followed up prospectively in a rehabilitation day-treatment program. Conclusions: The mEFAP is a reliable gait-assessment tool for patients with stroke and is sensitive to change in ambulation speed.