Measurement of Community Ambulation After Stroke
Current Status and Future Developments
Susan E. Lord, MSc; Lynn Rochester, PhD
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Background and Purpose—This report considers the measurement of community ambulation for people with stroke. The
conceptual issues underlying measurement of community ambulation are reviewed, and tests that measure either the task itself
or at least some of its components are identified and discussed.
Conclusions—The findings from this review suggest that although some progress has been made toward identifying community
ambulation as a stand-alone entity, reliable and valid measures have not yet been developed. Gait speed, which is used often
as a proxy measure for community ambulation, does not consistently reflect the level of community ambulation attained, and
continued reliance on its use, particularly the 10-m timed walk, is misplaced. The limitations of the measures reviewed here
point toward self-report as being the most useful outcome for current clinical use. However, this report highlights the need
for research to first inform a theoretical framework for the measurement of community ambulation, from which a
measurement tool or a battery of measurements can be developed and tested. (Stroke. 2005;36:1457-1461.)
Key Words: ambulation 䡲 community 䡲 gait 䡲 mobility 䡲 stroke, acute
M
uch of the impetus for stroke rehabilitation rests in the
desire to regain normal walking, a goal still identified as
relevant months or years after the acute event. For many people,
the reintegration into community life marks the end point of their
rehabilitation. The definition and meaning of community ambulation varies in the literature, and little is known about the
dimensions of the task and the specific attributes required for its
safe and independent execution. Lord et al1 asked 130 homedwelling, post–acute stroke survivors to identify relevant community destinations, and from that a definition of community
ambulation was developed: independent mobility outside the
home, which includes the ability to confidently negotiate uneven
terrain, private venues, shopping centers and other public venues. Patla and Shumway-Cook2 developed an operational definition of community mobility that considered 8 environmental
dimensions: ambient conditions, terrain characteristics, external
physical load, attentional demands, postural transition, traffic
level, time constraints, and walking distance. A subsequent
study,3 whereby people with disability (including stroke) were
observed walking in the community and then compared with
people without disability, identified 4 of these dimensions as
being important: temporal factors, postural transitions, physical
load, and terrain. Interestingly, endurance did not feature as an
important dimension of community ambulation, although earlier
research has identified it as so.4 Although these studies provide
a starting point for the development of a theoretical framework
to describe the focus and components of community ambulation,
further clarification is required. For example, attention is an
attribute of all actions associated with community ambulation,5
and reduced gait performance has been observed with additional
attentional demands.6,7 The relationship between the attentional
cost to maintain motor performance and the actual performance
is complex and may be influenced by a variety of factors, and
assessments need to take account of this.8 It may, therefore, be
prudent to consider measuring attentional cost, implied through
reduced gait performance, as one attribute of community
ambulation.
Mobility outcomes for people with stroke have been evaluated with measures that cover impairment,9 activity,10 participation,11 and health-related quality of life.12 The endorsement of
the International Classification of Functioning (ICF) by the
World Health Assembly in May 200113 turned the spotlight
toward understanding functioning and disability as multidimensional concepts that relate not only to physical and psychological
features but also to each person’s life situation and social role,
which is influenced by external factors, most importantly the
physical environment, physical aids and appliances, societal
attitudes and beliefs, and social policies. Of particular importance to community ambulation is the acknowledgement in the
ICF of the role of environmental factors to functioning, and the
relationship between environment and participation. Although
the ICF is first and foremost a framework and a classification
system rather than a tool for measurement, clinicians and
researchers are encouraged to consider their relationship to each
other and to link or map items from rehabilitation measures to
ICF domains.14 Any new measure of community ambulation
Received October 19, 2004; final revision received March 16, 2005; accepted April 14, 2005.
From the Department of Medicine (Rehabilitation; S.E.L.), Wellington School of Medicine and Health Sciences, University of Otago, Wellington South, New
Zealand; and the School of Health (L.R.), Community and Education Studies, Northumbria University, Coach Lane, Benton, Newcastle upon Tyne, UK.
Correspondence to Susan E. Lord, Dept of Medicine (Rehabilitation), Wellington School of Medicine and Health Sciences, University of Otago, PO
Box 7343, Wellington South. E-mail: [email protected]
© 2005 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
DOI: 10.1161/01.STR.0000170698.20376.2e
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July 2005
The activity and participation domain of
the ICF framework applied to a person
with limited community mobility.
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should, therefore, be considered within the ICF framework,
instead of being separate from it.
Although the ICF does not present a single code for community
ambulation, it is possible to use the framework to classify aspects of
the task. The codes (eg, 4602, 4501, 4502, 4503) are only complete
with the presence of at least 1 “qualifier” that personalizes the
assessment to the individual. In the case of community ambulation,
which is viewed as a task from the activity and participation
domain, the relevant qualifier is the performance qualifier, which
describes what an individual does in his or her own environment.
Further environmental factor qualifiers can be used to denote either
the extent of positive effects of the environment (facilitators) or the
extent of negative effects (barriers). The Figure gives an example of
the measurement of a person’s ability to carry out tasks related to
community ambulation using these components of the ICF
framework.
Current Measures of Community Ambulation
Current measures are composed of items that researchers consider
best represent the task, such as gait velocity or endurance, functional
mobility scales, the locomotion domain of global functional measures; or self-reported levels of activity. The Table lists the measures
that have been used in research that focuses on the attainment of
community ambulation. Gait velocity, measured using the 10-meter
timed walk, is used in both research and clinical situations because
of its simple clinical application, its robust psychometric properties,
and the ratio data it yields. It has been shown to be more responsive
than functional scales to changes in mobility following stroke,15 and
it has been described as the “almost-perfect” measure.16 However,
there is no guarantee that an increase in gait velocity, which must
first exceed the bounds of measurement error,17,18 will denote a
meaningful improvement in performance. Because it is measured
inside, in a predictable, uncluttered, controlled environment, the
skills required for it cannot be assumed to transfer to outside
mobility. Although gait velocity has been used as a key parameter
to measure levels of community ambulation with thresholds that
vary from 48 m/min19 to 79 m/min,4 it is not sufficiently discrete to
be able to classify different levels of community ambulation without
error. In our study,1 which investigated mobility outcomes on
discharge from physical therapy services for people following
stroke, although the relationship between gait speed and attained
levels of community ambulation was moderate (r⫽0.60; P⬍0.01),
the confidence intervals for gait velocity, which presented as the
most robust of the variables measured, still overlapped for 3 of 4
self-reported levels of community ambulation. Perry et al19 likewise
defined three groups of community walkers based on self-report and
gait velocity.
Endurance (another proxy measure for community ambulation) was measured using the 6-minute walk test,20 a test
originally developed to measure the stamina of people with
respiratory and cardiac conditions. Pohl et al21 reported that
although motor impairments impact greatly on the 6-minute
walk test scores, the test does provide insight into endurance for
people with stroke, the pulse rate and systolic blood pressure of
which increased significantly with the test.
Lernier-Frankiel et al4 identified the mobility requirements for
safe community ambulation in the Los Angeles area, and recommended a normal gait speed of 79 m/min, a walking distance greater
Lord and Rochester
Measurement of Community Ambulation After Stroke
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Measures Used to Evaluate Community Ambulation
Items Measured
Gait speed, self-reported
attainment of community
ambulation
Reference(s)
Items Detailed
Lord et al1
m/min derived from 10-meter timed walk
categorized into 3 levels of self-reported
community ambulation
Domain(s) of CA
Represented (ICF)
Dimensions of CA Framework
(Patla and Shumway Cook)
Represented
Activity and participation
Time constraints
Activity and Participation
Time constraints
Activity
Time constraints
Walking as far as the mailbox: 39.6 m/min
Walking in immediate outside environment:
49.2 m/min
Walking to shopping venues and/or other
places of interest: 68.6 m/min
Perry et al19
m/min derived from footswitch stride
analyzer categorized into 3 levels of
self-reported community ambulation
Most-limited community walker: 24 m/min
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Least-limited community walker 35 m/min
Community walker: 48 m/min
Speed, distance, FIM and
FAC
Hill et al24
48 m/min
500 meters
Minimum walking distance
FIM 5
Terrain characteristics
FAC 6
Speed, distance
Robinett and Vondran23
Curb height
Activity
Time constraints
Distance of street and pedestrian crossing,
banks, supermarkets, malls, stores, etc
from closest car park
Activity
Minimum walking distance
Velocity (ranged from 30 m/min to 82.5
m/min for safe street crossing)
Terrain characteristics
Assessed for 3 communities of different
populations: ⬍10 000; 10 000–40 000;
⬎95 000
Speed, distance, stepping
Speed, distance, stepping
Lernier-Frankiel4
Cohen et al22
73 m/min
Activity
Time constraints
332 meters
Minimum walking distance
Stairs and curbs
Terrain characteristics
73 m/min
Time constraints
360 meters
Minimum walking distance
Stairs and curbs
Terrain characteristics
FIM indicates Functional Independence Measure; FAC, Functional Ambulation Category.
than 332 meters, and the ability to step up and down a curb up to 22
centimeters in height. Cohen et al22 who examined community
ambulation in older adults with and without physical disabilities,
suggested parameters that were very similar. Robinett and Vondran23 documented a wide range of distances and gait speeds required
for safe ambulation in communities of different sizes. Hill et al24
suggested 4 criteria for community ambulation that included minimum thresholds for gait velocity (48 m/min), endurance (500
meters), the locomotion domain of the Functional Independence
Measure25 (FIM; score of 5) and the Functional Ambulation
Classification26 (score of 6). The Dynamic Gait Index27 assesses the
effects of speed and direction change, head turns and obstacle
negotiation on gait, although again it is tested in a clinical environment. The Activities-specific Balance Scale,28 which has just been
shown to be valid and reliable for people with stroke,29 is a
self-efficacy scale that evaluates confidence in 16 mobility tasks, 9
of them outside. The Community Balance and Mobility Scale30 is
an example of a test that measures multiple components. It consists
of 13 physical tasks, such as tandem pivot and lateral foot scooting,
and it includes some dual and multiple task items such as walking,
looking, and carrying. Although the scale was developed for people
with traumatic brain injury and may not be suitable for people with
stroke, it may provide a starting point for a tool that captures the
complexity of the task.
Global Scores of Function
Global measures of functional activity usually include several
items that might be considered prerequisite actions required for
community mobility. For example, the Rivermead Mobility
Index10 tests the ability of a person to mobilize independently in
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July 2005
a nonclinical environment, including negotiating uneven terrain
and walking up and down 4 steps without help if necessary and
their ability to run or walk quickly 10 meters without limping in
4 seconds. The highest scoring item on the FIM measures the
ability of an individual to walk 50 meters safely without assistive
devices in a reasonable time frame, but the environment is not
specified. The Barthel Index31 asks about independent mobility
and stairs. However, none of these measures by themselves
gives a complete picture of a person’s ability to walk in the
community.
Self-Reported Measures
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The 2 self-reported measures that accompanied the studies
outlined above provide for different levels of community mobility. Perry et al19 identified 6 functional categories that included the ability to get to appointments, visit friends, go
shopping, go to church, and undertake recreational activities,
with 4 levels of attainment from “unable” to “independent.” In
the study of Lord,1 people were asked whether they walked
independently either as far as the mailbox, around their immediate environment, or to places of interest and/or shopping malls.
Measures of Participation and Quality of Life
Measures of participation, quality of life, life satisfaction, and social
integration often contain several items specific to either community
ambulation or community mobility; the distinction between these
two is not always clear. The Subjective Index of Physical and Social
Outcome, a 14 item scale11 that includes 4 items that cover
movement within the local neighborhood, shopping, leisure activities, and visiting friends. Likewise, the Reintegration to Normal
Living Index32 includes 3 items of similar content. Several items on
The Sickness Impact Profile33 inquire about the ability of a person
to walk distances, to negotiate hills, stairs, and public transportation,
and to gain access to the wider community. The Frenchay Activities
Index34 records the frequency of activities undertaken over a
6-month period and includes items such as local shopping, walking
outside ⬎15 minutes, driving a car or getting on a bus, travel
outings, and car rides. The Nottingham Extended Activities of Daily
Living Index35 contains items that measure, on a 4-point Likert
scale, tasks that denote advanced mobility status, including the
ability to shop. The Stroke Impact Scale36 was developed from the
perspective of the patient and caregiver to provide a multidimensional, broad-stroke outcome measure. The 64-item scale covers 8
domains with items that measure impairment, activity, and participation on a 5-point Likert scale. Eight of these items reflect aspects
of community ambulation or mobility, such as shopping, climbing
flights of stairs, getting in and out of a car, and carrying a heavy
object.
What Might a Relevant Measure for
Community Ambulation Look Like?
In a systematic review of outcome measures used in drug trials
for acute strokes, Duncan et al37 reported a wide variation and
inconsistent use of outcome measures, with little agreement
about what constitutes a favorable or unfavorable outcome. Part
of the problem is that functional outcome measures in rehabilitation have suffered for the lack of a theoretical or conceptual
framework to guide their development.38 A widely accepted
conceptual foundation for the definition and measurement of
community ambulation, and its relationship to community mobility, must be agreed on between both users and researchers
before considering options for measurement.
However, 2 approaches to its measurement have emerged.
The first is to measure the level of task attainment and the
second is to break the task itself down into the impairments
and activities that predict community ambulation. The first is
measured through self-report and aligns itself to measuring
what counts, that is, at what ICF level of activity does this
person attain community ambulation and with what assistance? Although there is empirical evidence to support the
advantages of self-reported measures mostly because of their
superior content validity (eg, the Patient Generated Index39
the Patient-Specific Measure40), this approach may be limited
because of the difficulties in determining criteria for clinically important change in a heterogenous group of patients,
the judgments of whom regarding change are neither necessarily congruent nor consistent over time41 Comparisons of
outcomes across studies, therefore, can become problematic.42 Perhaps more importantly, outcome comparisons do not
help the tester identify which aspects of the task the person
finds difficult to master and identify those people who may
attain community ambulation; the comparisons, therefore, are
less able to inform the rehabilitation process.
The second option requires an operational definition of
community ambulation and the reliable and valid measurement of impairments that constitute the activity as well as
measurement, in a separate domain or test, of the activity
itself, both of which are best tested through observation of
performance. These predictors may include gait speed, postural transitions, dual and/or multiple attention tasks (such as
motor plus walking, cognitive plus walking), attentional cost,
fatigue, motivation, and endurance. Given the likelihood that
performance will vary under different environmental conditions, testing will also need to be carried out in a range of
ecologically valid environments rather than in the clinic.
Development of a measure using this approach will be time
consuming and protracted; because of the complexity of the
task, a substantial body of basic research will first need to be
undertaken before a definitive list of predictors for community ambulation can be identified. An example of a method of
evaluation that examines these issues has been conducted in
people with Parkinson disease both to identify difficulties
compared with a control population and to measure changes
in response to intervention.43,44 We are also currently investigating the effect of a secondary task on gait performance in
people with stroke in ecologically valid environments, which
may also contribute to our understanding of the complexity of
the task. With either approach, it is important to consider the
effect of task limitations on broader domains such as participation and quality of life.45 Ultimately, it may be necessary
to produce a battery of tests that encompasses all domains.
In the interim, it may be expedient for clinicians and
researchers to use an instrument of self-report depicting
different levels of task attainment that extend from accessing
the external home environment to accessing more challenging
environments that include shopping centers and suburban
streets, rural roads, and public transport and that also includes
the ability to do 2 things at once, eg, walking and talking.
Lord and Rochester
Measurement of Community Ambulation After Stroke
Summary
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Community ambulation is the ability to integrate walking with other
tasks in a complex environment. The presence of impaired physical
performance and possible cognitive and behavioral factors will
further interact with the performance of gait and the resultant effect
will be impaired community ambulation. The development of
clinical tests that incorporate dual-task paradigms as part of assessment methods and take into account the context in which assessment takes place (eg, clinic, home, community) may prove helpful
in identifying those who may have difficulty generalizing the
performance of gait in a simple environment to a complex environment. In addition, they may identify those for whom safety in terms
of risk of falls under these more complex situations is an issue. Patla
and Shumway-Cook2 have noted that mobility in a complex
environment is the norm, not the exception, and we require tools
that reflect this. Community ambulation is an ecologically valid
outcome to measure, and although the 10-meter timed walk remains
central to mobility measurement, it needs to be considered alongside
measures that reflect the broader dimensions of this complex task.
Acknowledgments
We thank Dr William Taylor for his comments on an earlier draft of
this manuscript.
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Measurement of Community Ambulation After Stroke: Current Status and Future
Developments
Susan E. Lord and Lynn Rochester
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Stroke. 2005;36:1457-1461; originally published online June 9, 2005;
doi: 10.1161/01.STR.0000170698.20376.2e
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