** NOTE: this website will be shutting down in 2019. All resources have been moved to the Spinal Cord Injury Research Evidence (SCIRE) Project website: https://scireproject.com/outcome-measures/outcome-measure-tool/standing-walking-toolkit/**
Please email clinical [AT] rickhanseninstitute [DOT] org with any questions.
TOOLKIT FOR SCI STANDING AND WALKING ASSESSMENT
A clinical guide for individuals with spinal cord injury.
- Why is this information important?
- Resource Requirements
- Training resources
- Additional resources
This toolkit is supported by the Rick Hansen Institute and was created by the following collaborators:
Molly Verrier, Dip(P&OT), MHSc
Associate Professor Emeritus and
Adjunct Senior Scientist
Departments of Physical Therapy, Rehabilitation Science, Institute of Medical Science and Physiology, Faculty of Medicine University of Toronto and University Heath Network-Toronto Rehabilitation Institute, Lyndhurst Centre, SCI Mobility Laboratory
Dany Gagnon, BScPT, MSc, PhD
Université de Montréal, Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitain (CRIR), Institut de réadaptation Gingras-Lindsay-de-Montréal
Kristin Musselman, BScPT, MSc, PhD
Scientist, Neural Engineering & Therapeutics Team Toronto Rehabilitation Institute – University Health Network; Assistant Professor Dept. of Physical Therapy, University of Toronto SCI Mobility Lab, Lyndhurst Centre
Heather Askes, BSc, RHSCIR Site Coordinator, Parkwood Hospital
Chris Alappat, MScPT, Toronto Rehabilitation Institute
Jean-François Lemay, MPT, PhD, Institut de réadaptation Gingras-Lindsay-de-Montréal
Shannon Sproule, BA, BScPT, Rick Hansen Institute
Kristen Walden, BScPT, Rick Hansen Institute
Laurent Bouyer, BSc, PhD, Université Laval
Gillian Coates, BScPT, G. F. Strong Rehabilitation Centre
Lindsey Guilbault, MScPT, St. Joseph’s Health Care
Kristina Guy, MSc, Toronto Rehabilitation Institute
Lynsey Hamilton, MSc, Rick Hansen Institute
Andrew Kwok, MPT, Glenrose Rehabilitation Hospital
Michelle Read, PT, Hamilton Health Sciences Centre
Isabelle Robidoux, PT, Institut de réadaptation Gingras-Lindsay-de-Montréal
Audrey Roy, BScPT Institut de réadaptation Gingras-Lindsay-de-Montréal
Deborah Tsui, MScPT, Hamilton Health Sciences Centre
Heather Flett, BScPT, MSc, Toronto Rehabilitation Institute
Tania Lam, BSc, PhD, University of British Columbia
Sylvie Nadeau, PhD, Institut de réadaptation Gingras-Lindsay-de-Montréal
Vanessa Noonan, PT, PhD, Rick Hansen Institute
John Steeves, BSc, PhD, University of British Columbia
Dalton Wolfe, PhD, University of Western Ontario
Jaynie Yang, MScPT, PhD, University of Alberta
Numerous other experts in the field of ambulation involving individuals with SCI were consulted in the development of these assessment tools. This initiative would not have been possible without the diligence and tenacity of those involved.
For questions or comments on this toolkit, please contact clinical [AT] rickhanseninstitute [DOT] org.
The RICK HANSEN SPINAL CORD INJURY REGISTRY (RHSCIR) is a pan-Canadian prospective observational registry located at 31 major Canadian acute care and rehabilitation facilities. Of these 31 facilities, 13 offer rehabilitation services, 16 offer acute services and two offer combined services. Across Canada, RHSCIR is collecting comprehensive SCI data for the purpose of improving SCI care and clinical outcomes. Using standardized research protocols and data collection forms, RHSCIR tracks the experiences and outcomes of people with traumatic SCI during their journey from injury, through acute care , rehabilitation to community reintegration and beyond Details about participants' spinal cord injuries including extent of injury and level of paralysis, recovery, and success of various treatments are among the data recorded.
The data collected in RHSCIR contains powerful information that will help track the effectiveness of specific treatments, practices or programs for improving functional outcomes and quality of life after SCI. RHSCIR promotes, encourages and supports the pursuit of excellence in all areas of SCI health care management.
To learn more about RHSCIR, please visit www.rickhanseninstitute.org.
02 WHY IS THIS INFORMATION IMPORTANT?
The ability to stand and walk is a very important goal for many individuals with spinal cord injury. This toolkit focuses on various levels or thresholds of functional abilities and then links appropriate outcome measures to use when patients reach these thresholds. These outcome measures allow clinicians to test the patient’s readiness for walking, as well as to assist in identifying areas of deficit that need to be addressed clinically.
The information collected in these modules will be added to RHSCIR. Our team of clinical and data experts will provide you and your program with data entry, analysis services and nationally-benchmarked reports available free of charge. This information will assist in providing validated and supported evidence-based practice with the potential to improve efficiencies in the health care system and ultimately improve outcomes for individuals living with spinal cord injury.
Benefits to Patients and Clinicians
Collection and reporting of this data can benefit patients, physical therapists and clinicians by:
Setting realistic, timely goals with the patient.
Monitoring a patient’s progress.
Directing therapeutic interventions and priorities.
Determining whether the patient is ready for progression in standing and walking skills.
Determining whether patients are able to stand or ambulate independently and safely.
Improving patient's knowledge and confidence of what they are currently safe to do in standing or walking.
Evaluating when it might be advisable to use a wheelchair or some other form of mobility aid for safety or energy conservation reasons.
Understanding the meaningfulness of walking ability for the home, workplace and community.
Identifying patients have the most potential for walking recovery. This ensures proper outpatient follow-up to develop the skills which lead to community ambulation.
Resourcing walking rehabilitation programs over the life course for fitness purposes.
Implementing physical therapy interventions customized to specific patient’s goals in the context of their potential capabilities.
Benefits to Program
Collection and reporting of this data can benefit the Program by:
Implementating standardized assessment tools for functional walking to ensure safe and effective mobility and mobility treatments at your facility.
Ensuring the utilization of walking programs for health benefits as part of clinical practice.
Determining required equipment and supplies to optimize clinical practice and safety (e.g. walking aids, transfer aids, body weight support treadmills, orthoses, robot aided gait training devices etc.).
Guiding falls prevention programs and meeting Accreditation Canada’s Required Organizational Practice regarding falls.
Continuity between health care providers with regard to standing and walking mobility.
Offering comparators to national data to ensure your facility is providing a high standard of care.
Reporting metrics to facility administrators which may assist with determining staffing allocation and budget priorities.
Assisting in development of standardized standing and walking therapy protocols.
Benefits to Research
Collection and reporting of this data can benefit research by:
Providing a larger sample size of data from the SCI population across Canada which will allow for more accurate and meaningful interpretation and analysis.
Developing and participating in clinical trials designed to evaluate the efficacy of interventions to optimize walking capacity.
Evaluating the effectiveness of various treatment approaches.
Assisting with the creation of best practice guidelines in walking assessment with the SCI population.
Assisting in identifying research priorities and work with clinicians to develop research questions and proposals.
What Happens Once I Collect the Data?
Providing invaluable data to RHSCIR: Once you collect the data, your facility’s Rick Hansen Spinal Cord Injury Registry (RHSCIR) coordinator will collect this information and input the data into the registry database along with additional relevant clinical information. The national RHSCIR team has developed a number of practices to ensure patient confidentiality is maintained and strict privacy policies and procedures are adhered to.
Providing a baseline for walking management across Canada: The de-identified data from your site will be aggregated and reported back on a quarterly basis and will provide information on your hospital’s RHSCIR patients who stand and walk.
To access your site’s data reports, click here. Please see your local RHSCIR coordinator, or designated representative, to receive this login information. If you are not sure who that is, please contact us at clinical [AT] rickhanseninstitute [DOT] org.
WHY IS THIS INFORMATION IMPORTANT?
03 RESOURCE REQUIREMENTS
In order to implement this Standing and Walking Initiative there are environmental, personnel and knowledge requirements that are outlined below. Along with the material and resources in this toolkit, each RHSCIR site will have an assigned clinical lead that will be a resource to the clinical staff regarding the details of completing and collecting the data in the module. Also available on the login portion of this website is a discussion board for standing and walking questions, both about this toolkit and clinical issues.
Each outcome measure will have detailed instructions as well as equipment requirements and time requirements. The Outcome Measures selected for this module are:
Berg Balance Scale (BBS)
Modified Timed Up and Go (mTUG)
Modified Activities Specific Balance Confidence Scale (mABC - discharge only)
Modified Spinal Cord Injury Functional Ambulation Profile (mSCI - FAP - advanced only)
Modified MiniBEStest (mMiniBEStest - research only)
Modified 6 Minute Walk Test (m6MWT)
10 metre walk test (10MWT)
Any of these forms can be used by your facility to collect data on non-RHSCIR participants and promote ongoing best practice.
How Do I Decide Which Outcome Measures to Use and When to Use It?
A flow sheet has been developed to direct when to administer the various outcome measures with your patients.
Pair this with the Canadian Standing and Walking Stage definitions (içi en français).
Want more information on how to stage your patients? These algorithms can help.
Looking for examples of other facilities' assessment forms and policies? Click here to login.
There are data collection forms for each specific outcome measure as well as a Standing and Walking Tracking Form. This tracking form is used to collect data regarding what stage each patient is at during their rehabilitation stay. This information is to be collected at least at admission and upon discharge. The definitions of the various stages identified on the tracking form are outlined in detail in the following pages.
The Canadian Standing and Walking Measures (SWM) are being collected by seven RHSCIR rehabilitation facilities.
There are three levels of collection:
Five facilities will be collecting the SWM which includes:
- Berg Balance Scale
- Modified Timed Up and Go (TUG) Test
- Activites-Specific Balance Confidence Scale (ABC) (içi en français)
- 10 Meter Walk Test
- Modified 6 Minute Walk Test
Two facilities will be collecting the Advanced SWM and includes:
- all of the SWM above; AND
- Modified Spinal Cord Injury Functional Ambulation Profile (mSCI-FAP)
Two facilities will be collecting the Research SWM and includes:
- all of the SWM AND Advanced SWM; AND
- Modified MiniBESTest
On admission the patient is assessed and it is determined what stage he or she is at. The first Standing and Walking Outcome Measure is not required until the patient reaches Stage 1B (patient has voluntary but non-functional lower extremity movement).
These forms meet the minimum requirements for data collection; please add any additional facility specific information to the forms. If you would like assistance with incorporating your facility information on the form, please contact us at clinical [AT] rickhanseninstitute [DOT] org.
1. At admission, determine what stage your patient is at according to the Canadian SCI Standing and Walking Stage Definitions sheet and/or decision tree.
2. Record the stage your patient is at on the Canadian SCI Standing and Walking Mobility Tracking Form.
3. If your patient is at Stage 1B or greater, perform the outcome measure(s) indicated on the Canadian SCI Standing and Walking Assessment Tool.
4.Regularly reassess your patient's stage during their inpatient stay. If the stage changes, record it on the Canadian SCI Standing and Walking Mobility Tracking Form and perform a baseline ‘threshold’ assessment for any new outcome measure(s) indicated. Note: any outcome measures where a baseline threshold assessment was completed previously do not need to be reassessed at this time.
5. At discharge, determine what stage your patient is at according to the Canadian SCI Standing and Walking Stage Definitions sheet &/or Decision tree.
6. Record the stage your patient is at on the Canadian SCI Standing and Walking Mobility Tracking Form.
7. If your patient is at Stage 1B or greater, perform the outcome measure(s) indicated on the Canadian SCI Standing and Walking Assessment Tool. Note: any outcome measures where a baseline threshold assessment has been completed previously should be reassessed at this time.
More detailed Instructions for each specific outcome measure, including equipment requirements, and drawings of the set-up for each test are available below. The instruction sheets also include interpretation values, as well as references.
- Berg Balance Scale
- Modified Timed Up and Go (TUG) Test -- instructional video
- Activites-Specific Balance Confidence Scale (ABC)
- 10 Meter Walk Test (10mwt)
- Modified 6 Minute Walk Test (m6mwt)
- Modified Spinal Cord Injury Functional Ambulation Profile (mSCI-FAP) -- instructional video
- Modified MiniBESTest
06 TRAINING RESOURCES
Standing & Walking Resources
- Videos for the following outcome measures can be found on the Spinal Cord Injury Rehabilitation Evidence (SCIRE) website: 10MWT, 6MWT (though not with the Borg) and the Berg Balance Scale.
- Instructional YouTube videos for the mSCI-FAP and mTUG are available
- mMiniBESTest, an extended version of the miniBESTest video will be provided to the sites performing this measure. Instructions can be found at: http://bestest.us/learn/portal/.
Assessment Forms and Chart Inserts here you'll find examples of pre-printed orders, policies and guidelines as well as assessment and charting sheets relating to standing and walking assessment and treatment.
1. Musselman K, Brunton K, Lam T, Yang J. Spinal cord injury functional ambulation profile: a new measure of walking ability. Neurorehabil Neural Repair. 2011;25(3):285–93.
2. Wood-Dauphinee S, Berg K, Bravo G, Willliams J. The Balance Scale: Responding to clinically meaningful changes. Can J Rehabil. 1997;10:35–50.
3. Scivoletto G, Tamburella F, Laurenza L, Foti C, Ditunno JF, Molinari M. Validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients. Spinal Cord. Nature Publishing Group; 2011 Jun;49(6):736–40.
4. King L, Horak F. On the Mini-BESTest: Scoring and the Reporting of Total Scores. Phys Ther. 2013;93(4):571–5.
5. Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–8.
6. Powell LE, Myers AM. The Activities-specific Balance Confidence ( ABC ) Scale. J Gerontol A Biol Sci Med Sci. 1995;50A(1):M28–34.
7. Van Hedel HJ, Wirz M, Dietz V. Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch Phys Med Rehabil. 2005 Feb;86(2):190–6.
8. Wirz M, Müller R, Bastiaenen C. Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair. 2010 Jan;24(1):70–7.
9. Berg K, Wood-Dauphinee S, Williams JI. The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med. 1995 Mar;27(1):27–36.
08 ADDITIONAL RESOURCES
Rehabmeasures.org contains more information on each measure, along with more normative values. Search for each test at www.rehabmeasures.org.
SCIRE also has evidence-based guidelines for lower limb rehabilitation.
Verrier MC, Craven C, Flett HM, Nadeau S, & the E-Scan Investigative Team. Walking. In: Craven C, Verrier M, Balioussis C, Wolfe D, Hsieh J, Noonan V, Rasheed A, Cherban E, editors. Rehabilitation Environmental Scan Atlas: Capturing Capacity in Canadian SCI Rehabilitation. Vancouver: Rick Hansen Institute; 2012. p. 52–27.www.rickhanseninstitute.org/images/stories/ESCAN/RHESCANATLAS2012WEB_2014.pdf