Elsevier

Physiotherapy

Volume 88, Issue 7, July 2002, Pages 386-397
Physiotherapy

Research report
Refining the Ten-metre Walking Test for Use with Neurologically Impaired People

https://doi.org/10.1016/S0031-9406(05)61264-3Get rights and content

Summary

The remediation of gait problems is a key feature of neurological physiotherapy. The ten-metre walking test is a frequently used outcome measure in this clinical area. Despite its simplicity and apparent popularity, the ten-metre walking test does not have an established operational procedure. This article proposes a procedure, together with a brief account of its origins and features. Using the procedure, acceptable levels of inter-rater reliability were found, with a 95% CI for agreement of −0.38 to +0.38 seconds for normal young subjects and −0.36 to +0.49 seconds for traumatic brain-injured subjects. The ten-metre test results for two groups of head-injured patients are also reported. A focus of the discussion is how the test might best be used in clinical practice, as well as indications for future research still needed. An overall aim of the paper is to commend the continued considered use of the test by physiotherapists working in neurology.

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:

  • Asking subjects to walk across a floor which has been dusted with chalk. Gait parameters can then be measured from their footprints.

  • 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).

  • 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).

  • 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:

  • Describe a specific procedure for the test.

  • Report on the reliability of that described procedure.

  • Give some relevant normative data for the test.

  • Give some examples of the test's use with neurologically impaired subjects.

  • 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

References (41)

  • DavidsonI et al.

    ‘Physiotherapists working with stroke patients: A national survey’

    Physiotherapy

    (2000)
  • KirtleyC et al.

    ‘Influence of walking speed on gait parameters’

    Journal of Biomedical Engineering

    (1985)
  • SmithR

    ‘Validation and reliability of the Elderly Mobility Scale’

    Physiotherapy

    (1994)
  • AdaL et al.

    ‘The patient as an active learner’

  • BlandJM et al.

    ‘Statistical methods for assessing agreement between two methods of clinical measurement’

    Lancet

    (1986)
  • BartlettD

    ‘Dynamic systems theory and its potential role in guiding clinical practice in paediatric neurology’

    Synapse (Canadian Physiotherapy Association, Neurosciences Division Newsletter)

    (1998)
  • BellF et al.

    ‘Movement analysis technology in clinical practice’

    Physical Therapy Reviews

    (1996)
  • BohannonRW

    ‘Gait performance of hemiparetic stroke patients: Selected variables’

    Archives of Physical Medicine and Rehabilitation

    (1987)
  • BohannonRW

    ‘Correlation of knee extension force and torque with gait speed in patients with stroke’

    Physiotherapy Theory and Practice

    (1991)
  • BohannonR et al.

    ‘Correlation of knee extension muscle torque and spasticity with gait speed in patients with stroke’

    Archives of Physical Medicine and Rehabilitation

    (1990)
  • CollenFM et al.

    ‘Residual mobility problems after stroke’

    International Disability Studies

    (1991)
  • CollenFM et al.

    ‘Mobility after stroke: Reliability of measures of impairment and disability’

    International Disability Studies

    (1990)
  • CollenFM et al.

    ‘The Rivermead Mobility Index: A further development of the Rivermead Motor Assessment’

    International Disability Studies

    (1991)
  • ConnellyDM et al.

    ‘Between- and within-rater reliability of walking tests in a frail elderly population’

    Physiotherapy Canada

    (1996)
  • DurwardBR et al.

    ‘Measurement and analysis of functional human movement: The state of the art’

  • GoodkinR et al.

    ‘Reliability among physical therapists in diagnosis and treatment of gait deviation in hemiplegia’

    Perceptual and Motor Skills

    (1973)
  • GormleyP et al.

    ‘Examination of the duration of gait initiation by use of an electrogoniometer’

    Gait and Posture

    (1993)
  • HesseS et al.

    ‘Gait function in spastic hemiparetic patients walking barefoot, with firm shoes, and with ankle-foot orthoses’

    International Journal of Rehabilitation Research

    (1996)
  • HoldenMK et al.

    ‘Clinical gait assessment in the neurologically impaired: Reliability and meaningfulness’

    Physical Therapy

    (1984)
  • HoldenMK et al.

    ‘Gait assessment for neurologically impaired patients: Standards for outcome assessment’

    Physical Therapy

    (1986)
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