Purpose

The Activities-specific Balance Confidence Scale (ABC Scale) is a structured questionnaire that measures an individual’s confidence in performing activities without losing balance.

In-Depth Review

Purpose of the measure

The Activities-specific Balance Confidence Scale (ABC Scale) is a structured questionnaire that measures an individual’s confidence in performing activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
without losing balance.

Available versions

The ABC Scale was developed in 1995 using a convenience sample of 15 clinicians (physical and occupational therapists) and 12 physical therapy patients aged over 65 years. Clinicians were asked to ‘name the 10 most important activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
essential to independent living, that while requiring some position change or walking, would be safe and nonhazardous to most elderly persons’. Seniors were asked the same question, in addition to the question: ‘Are you afraid of falling during any normal daily activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, and if so, which ones?’ (Powell & Myers, 1995). Items were chosen to include a number of difficult activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
that potentially posed some hazard. A 0-100% response continuum was chosen to assess self-efficacy.

A modified version of the ABC Scale (ABC-Simplified [ABC-S]) was developed to (a) improve user friendliness by simplifying the cue question and response format; and (b) improve the scale’s congruence with public health falls prevention strategies by removing the final question regarding walking in icy conditions (Filiatrault et al., 2007). The psychometric properties of the ABC-S Scale were tested among a sample of 197 community-dwelling seniors. The ABC-S Scale has demonstrated high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
index 0.86) and good convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
(statistically significant associations with perceived balance; performances on the one-leg stance, tandem stance, tandem walking, functional reach, and lateral reach [on the right side] tests; fear of falling; and occurrence of falls in the previous 12 months). Analyses also showed differing degrees of difficulty across items, allowing for a determination of the scale’s item hierarchy. However, no testing of the ABC-S Scale has been conducted with a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.

A 6-item version of the ABC Scale (ABC-6) was also developed for clinical and research use. It includes 6 activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
from the original ABC Scale on which participants demonstrated least confidence (Peretz et al., 2006). In a study conducted among a sample of 35 community-dwelling seniors, it has been shown to be a valid and reliable measure of balance confidence among community-dwelling adults. The scale could also differentiate confidence levels between fallers and non-fallers (Schepens et al., Goldberg, & Wallace, 2010). To date, no psychometric testing of the 6-item version of the ABC Scale has been conducted with a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.

Features of the measure

Original items:
The ABC Scale consists of 16 questions that require the patient to rate his/her confidence that he/she will not lose balance or become unsteady while performing the following activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
:

1. Walking around the house
2. Walking up or down stairs
3. Bending over to pick up a slipper from the front of a closet floor
4. Reaching for a small can off a shelf at eye level
5. Standing on tiptoes and reaching for something above his/her head
6. Standing on a chair to reach for something
7. Sweeping the floor
8. Walking outside the house to a car parked in the driveway
9. Getting into or out of a car
10. Walking across a parking lot to the mall
11. Walking up or down a ramp
12. Walking in a crowded mall where people rapidly walk past
13. Being bumped into people as they walk through the mall
14. Stepping on to or off an escalator while holding onto a railing
15. Stepping onto or off an escalator while holding onto parcels (so that they are not able to hold the railing)
16. Walking outside on icy sidewalks

If the patient does not currently perform the activity, he/she is instructed to imagine how confident he/she might be if he/she had to do the activity. If the patient normally uses a mobility aid to do the activity, he/she is instructed to rate his/her confidence level as if he/she was using this aid during the activity.

Scoring:
The patient is asked to rate his/her confidence performing activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
without losing his/her balance or becoming unsteady. The original scale is a 0% to 100% continuous response scale. However, in a more recent publication, Myers (1999), replaced the 0%-to-100% continuous response scale with an 11-point response scale that includes 10% anchor increments (0%, 10%, . . ., 100%).

0%	10%	20%	30%	40%	50%	60%	70%	80%	90%	100%
No confidence										Completely confident

The overall score is calculated by adding the item scores and dividing the total by 16 (i.e. the number of items). This total score ranges from 0% to 100%.

Myers et al. (1998) use the following cut-off scores to define level of functioning among active older adults:

• Lower than 50 %: low level of physical functioning
• 50-80 %: moderate level of physical functioning
• Above 80 %: high level of physical functioning

What to consider before beginning:
The ABC Scale provides a subjective measure of balance confidence. Scores are not based on clinician observation of performance. Clinicians should also consider factors such as self-esteem and insight when using the ABC Scale.

Time:
The original ABC Scale takes approximately 10-20 minutes to administer.

Training requirements:
No training requirements have been specified for the ABC Scale.

Equipment:
The ABC Scale is a structured questionnaire that does not require specific equipment.

Alternative forms of the Activities-specific Balance Confidence Scale

None.

Client suitability

Can be used with:

• Individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and other neurological conditions (Moore et al., 2014)
• Individuals with vestibular disorders (Jarlsater & Mattsson, 2003)
• Individuals with lower-limb amputation (Miller, Deathe & Speechley, 2003)
• Individuals with Parkinson’s Disease (Franchignoni et al., 2014)
• Community-dwelling seniors (Myers et al., 1996 ; Myers et al., 1998; Filiatrault et al., 2007)

Should not be used with:

• The ABC Scale is not suitable for individuals with limited insight into their balance impairments. It is not recommended for patients who do not have a rehabilitation goal of improving balance confidence (Moore et al., 2018).

In what languages is the measure available?

Canadian French (Salbach et al., 2006; Filiatrault et al., 2007)
Chinese (Hsu & Miller, 2006; Mak et al., 2007)
Dutch (van Heuvelen et al., 2005)
English (Powell & Myers, 2005)
German (Schott, 2008)
Hindi (Moiz et al., 2017)
Korean (Jang et al., 2003)
Portuguese (Marques et al., 2013)
Swedish (Nilsagard & Forsberg, 2012)
Turkish (Karapolat et al., 2010)

Summary

What does the tool measure?	Self-perceived confidence with mobility.
What types of clients can the tool be used for?	The ABC Scale can be used with, but is not limited to, patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. tool.
Time to administer	10-20 minutes.
ICF Domain	Activity
Versions	ABC-CF (Salbach et al., 2006) ABC-Simplified (Filiatrault et al., 2007) ABC-6 (Peretz et al,2006)
Other Languages	French Canadian, Chinese, Dutch, German, Hindi, Korean, Portuguese, Swedish, Turkish.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: – Two studies have reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ABC Scale in a stroke population (Botner et al, 2005; Salbach et al, 2006). – One study reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ABC-CF Scale in a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population (Salbach et al, 2006). – One study reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of a Swedish translation of the ABC Scale in a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population (Nilsagard & Forsberg, 2012). Test-retest: One study examined test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the ABC Scale within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the overall score and adequate to excellent item level test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). (Botner et al, 2005). Intra-rater: Intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. of the ABC Scale has not been examined. Inter-rater: Inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the ABC Scale has not been examined.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: One study conducted factor analysis of the ABC Scale within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population and results revealed two factors: perceived low-risk activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. and perceived high-risk activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. (Botner et al, 2005). Criterion: Concurrent: Concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the ABC Scale has not been examined within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population. Predictive: Predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the ABC Scale has not been examined within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population. Construct: Convergent/Discriminant: – Three studies (Botner et al., 2005; Salbach et al., 2006; Nilsagard & Forsberg, 2012) have examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the ABC Scale within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population and reported : an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Berg Balance Scale (BBS), gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety. speed, 6 Minute Walk Test (6MWT), Barthel Index (BI), Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second. Categories (FAC) and modified Rivermead Mobility Index (RMI); and adequate negative correlations with the Timed Up and Go test (TUG) and 10-m timed walk test. Correlations with the Medical Outcomes Study 36-Item Short-Form Health Survey – Physical function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). (SF-36 PF) ranged from excellent to poor among studies. – Two studies (Salbach et al., 2006; Nilsagard & Forsberg, 2012) have examined divergent validityThe degree to which an assessment measures what it is supposed to measure. of the ABC Scale within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population and reported: an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the EQ-5D visual analog scale (EQ VAS); an adequate negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Geriatric DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. Scale (GDS); and a low correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the SF-36 Mental component score. – One study (Salbach et al., 2006) examined convergent / divergent validityThe degree to which an assessment measures what it is supposed to measure. of the ABC-CF Scale and reported: an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the EQ VAS; an excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the GDS; adequate correlations with the SF-36 PF, BBS, walking speed, 6MWT and BI; and an adequate negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the TUG. Known Groups: Known-group validityThe degree to which an assessment measures what it is supposed to measure. of the ABC Scale has not been examined within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.
Floor/Ceiling Effects	One study (Salbach et al., 2006) reported no floor/ceiling effects for the total score of the ABC Scale or the ABC-CF Scale in a sample of patients with subacute/chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., but noted a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect." for 3 items and a ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." for 8 items of both scales.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	Not reported.
Does the tool detect change in patients?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. of the ABC Scale within a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. population.
Acceptability	The ABC Scale is non-invasive and quick to administer. The items are considered reflective of real-life activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. .
Feasibility	The ABC Scale is free and is suitable for administration in various settings. The assessment requires minimal specialist equipment or training.
How to obtain the tool?	The print version of the scale may be freely reproduced for student training, research and clinical practices in which therapists and assistants use the scale to assess fewer than 1000 patients per year. Contact primary developer and copyright holder, Dr.Anita Myers at amyers@uwaterloo.ca.

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Activities-specific Balance Confidence (ABC Scale). While numerous studies have been conducted on the use of the ABC Scale with other client populations, this review specifically addresses the psychometric properties of the ABC Scale with individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Three studies were identified (Salbach, Mayo, Hanley, Richards, & Wood-Dauphinee, 2006; Botner, Miller, & Eng, 2005; Nilsagard & Forsberg, 2012). The original paper by Powell & Myers (1995) has also been included below, although please note that this study uses a mixed population of community-dwelling adults and patients receiving physical therapy services; the number of participants who had a strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. was not specified.

Floor/Ceiling Effects

Salbach et al. (2006) examined floor/ceiling effects of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51 and 35, respectively) with subacute/chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and residual walking deficits. The authors reported a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
(whereby more than 20% of participants reported ‘no confidence’ or 0%) for 3 items of both scales; and a ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." (whereby more than 20% of participants reported ‘complete confidence’ or 100%) for 8 items of both scales. There were no floor/ceiling effects for the total score of either scale.

Botner et al. (2005) reported that more than 80% of their study sample (n=77 participants with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.) scored between 40% and 80%, suggesting minimal floor or ceiling effects in their sample.

Reliability

The ABC Scale was developed using a convenience sample of 15 clinicians (physical and occupational therapists) and 12 physical therapy patients aged over 65 years (Powell & Myers, 1995).

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Powell & Myers (1995) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ABC Scale in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients, using Cronbach’s alpha. The authors reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (a = 0.96). Stepwise deletion of each item did not alter internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency..

Botner et al. (2005) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ABC Scale in a sample of 77 participants with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Cronbach’s alpha. Results revealed high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (a=0.94). Stepwise deletion did not alter internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (a=0.93 – 0.94).

Salbach et al. (2006) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and residual walking deficit. The authors reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. for both scales (a= 0.94, 0.93 respectively), measured using Cronbach’s alpha. Stepwise deletion of each item did not improve internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of either scale.

Nilsagard & Forsberg (2012) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of a Swedish translation of the ABC Scale in a sample of 37 patients with acute/subacute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Cronbach’s alpha. Participants were retested 3 months later (n=31). The authors reported high internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. at both time points (a= 0.97, 0.94 respectively).

Absolute reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
:
Salbach et al. (2006) examined absolute reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and residual walking deficit. Standard error of measurement of the ABC Scale was 5.05, and standard error of measurement of the ABC-CF Scale was 5.13.

Scalability:
Powell & Myers (1995) examined scalability of the ABC Scale in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. Scalability encompassed (a) absence of idiosyncratic items, (b) ability of items to discriminate between respondents, and (c) presence of a fixed relation between items. Hierarchicality was measured using Mokken’s Stochastic Cumulative Scaling program (MSP), which revealed a strong cumulative scale (H coefficient = 0.59), and excellent reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
(Rho coefficient = 0.95).

Test-retest:
Powell & Myers (1995) examined 2-week test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the ABC Scale with a sample of 21 community-dwelling seniors. Results revealed excellent overall test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r=0.92, p<0.001). Correlations between the test-retest scores was not significant for two items (car transfers, r=0.19; walking in the home, r=0.36).

Botner, Miller and Eng (2005) examined 4-week test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the ABC Scale with a sample of 24 participants with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using intra-class correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Results indicated excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the overall score (ICC = 0.85; 95% CI 0.68-0.93), and adequate to excellent item level test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(ICC ranged from 0.53 – 0.93).

Intra-rater:
No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the ABC Scale. Administration of the ABC Scale does not rely on clinician-observation of patient performance.

Inter-rater:
No studies have reported on the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the ABC Scale. Administration of the ABC Scale does not rely on clinician-observation of patient performance.

Validity

Content:
Botner, Miller & Eng (2005) conducted factor analysis of the ABC Scale in a sample of 77 participants with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using principal component analysis with Varimax rotation. Results revealed two components:
Factor 1: perceived low-risk activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
(9 items; 55.7% of the variance); and
Factor 2: perceived high-risk activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
(6 items; 12.9% of the variance).
One item (sweeping the floor) loaded almost equally on both components.

Criterion:
Concurrent:
Powell & Myers (1995) examined concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the ABC Scale by comparison with the Falls Efficacy Scale (FES) in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. There was an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between scales (r=0.84, p<0.001).

Predictive:
No studies have reported on the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the ABC Scale.

Construct:
Convergent/Discriminant:
Powell & Myers (1995) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. Convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
was measured by comparison with the Physical Self-Efficacy Scale (PSES). There was an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r=0.49, p<0.001) between the ABC Scale and the PSES score, and an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the ABC scale and the PSES physical abilities subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r=0.63, p<0.001). There was no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the ABC Scale and the PSES general self-presentation subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(r=0.03).

Powell & Myers (1995) examined discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess.
in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. Discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess.
was measured using the Positive and Negative Affectivity Scale (PANAS). Results were non-significant between the ABC Scale and the PANAS overall score, positive affect score and negative affect score.

Botner, Miller and Eng (2005) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the ABC Scale with a sample of 77 participants with chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. Convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
was measured by comparison with the Berg Balance Scale (BBS) and gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed. Results showed an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with both measures (BBS: r=0.36, p<0.001; gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed: r=0.48, p<0.001).

Salbach et al. (2006) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and residual walking deficit, using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients and associated 95% confidence intervals. Convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
was measured by comparison with the BBS, 5-m walking test (comfortable/maximal gaitThe pattern of walking, which is often characterized by elements of progression, efficiency, stability and safety.
speed), Timed Up and Go test (TUG), 6-Minute Walk Test (6MWT), Barthel Index (BI), Medical Outcomes Study 36-Item Short-Form Health Survey – Physical function subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
(SF-36 PF), Geriatric DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
Scale (GDS), and the EQ-5D visual analog scale (EQ VAS). The ABC Scale showed an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with physical function (SF-36 PF: r=0.60), adequate correlations with perceived health status (EQ VAS: r=0.52), balance function (BBS: r=0.42), walking speed (maximum: r=0.43, comfortable: r=0.42), functional walking capacity (6MWT: r=0.40) and functional independence (BI: r=0.37), and adequate negative correlations with functional mobility (TUG: r=-0.34) and depressive symptoms (GDS: r=-0.30). The ABC-CF Scale showed an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with perceived health status (EQ VAS: r=0.68), an excellent negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with depressive symptoms (GDS: r=-0.61), adequate correlations with physical function (SF-36 PF: r=0.56), balance function (BBS: r=0.49), walking speed (maximal: r=0.53; comfortable: r=0.48), functional walking capacity (6MWT: r=0.48), functional independence (BI: r=0.45), and an adequate negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with functional mobility (TUG: r=-0.52).

Nilsagard & Forsberg (2012) examined convergent and divergent validityThe degree to which an assessment measures what it is supposed to measure.
of the ABC Scale in a sample of 37 participants with acute/subacute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Kendall’s coefficient. Participants were retested 3 months later (n=31). Convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
was measured by comparison with the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Categories (FAC), modified Rivermead Mobility Index (m-RMI), TUG, 10-m timed walk test, SF-36 Physical component (SF-36 PS), and the 12-item walking scale. The ABC Scale showed significant adequate correlations at both time points with the FAC (r=0.40, 0.49) and the modified RMI (r=0.38, 0.46), and an adequate to low correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the SF-36 PF (r=-0.33, 0.28). The ABC Scale showed adequate negative correlations at both time points with the TUG (r=-0.46, -0.43), 10-m timed walk test (r=-0.41 at both time points) and 12-item walking scale (r=-0.55, -0.52). Divergent validityThe degree to which an assessment measures what it is supposed to measure.
was measured using the SF-36 Mental component score (SF-36 MF), with which the ABC Scale showed a low correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
at both time points (r=0.22, 0.12).

Known Group:
Powell & Myers (1995) examined known group validityThe degree to which an assessment measures what it is supposed to measure.
in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. Participants were self-categorized according to the following categories: fallers (57%), injured fallers (38%), fear of falling (57%) and activity avoidance due to fear of falling (30%). There was no significant difference in mean ABC scores between participants who had fallen in the past year and those who had not experienced a fall. There was no significant difference in mean ABC scores between participants who had been injured during a fall and those who had not been injured during a fall. Activity avoidance due to fear of falling was significantly more common in low mobility participants compared to high mobility participants (p<0.001). There was a significant difference (p<0.001) in mean ABC scores between high mobility and low mobility participants (t=9.34, ES=1.5). All ABC Scale items excluding item 4 (reaching at eye level) showed a significant difference between high mobility and low mobility participants, indicating an ability to discriminate between the two groups. Score ranges within high and low mobility groups indicated an adequate range of responses (score range 5% – 84% confidence for low mobility participants, 36% – 95% confidence for high mobility participants).

Responsiveness

Powell & Myers (1995) examined responsivenessThe ability of an instrument to detect clinically important change over time.
of the ABC Scale in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. Mean scores ranged from 21% confidence (item 16: walking on an icy sidewalk) to 90% (item 4: reaching at eye level).

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
& SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
Powell & Myers (1995) examined item specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the ABC Scale by comparison with the Falls Efficacy Scale (FES) in a sample of 102 community-dwelling adults aged over 65 and a convenience sample of 18 high-mobility and 7 low-mobility physiotherapy outpatients. ABC Scale items 3-6 correlated significantly with the FES item ‘reach into cabinets or closets’ (r = 0.53-0.67, p<0.001), and ABC Scale items 9-15 correlated with the FES item ‘simple shopping’ (r=0.42-0.75).

References

Activities-specific Balance Confidence Scale. (2013, March 22). Retrieved from URL https://www.sralab.org/rehabilitation-measures/activities-specific-balance-confidence-scale

Botner, E.M., Miller, W.C., & Eng, J. J. (2005). Measurement properties of the Activities-specific Balance Confidence scale among individuals with stroke. Disability and Rehabilitation, 27(4), 156-63.

Filiatrault, J., Gauvin, L., Fournier, M., Parisien, M., Robitaille, Y., Laforest, S., Corriveau, H., & Richard, L. (2007). Evidence of the psychometric qualities of a simplified version of the Activities-specific Balance Confidence scale for community-dwelling seniors. Archives of Physical Medicine and Rehabilitation, 88, 664-72.

Franchignoni, F., Giordano, A., Ronconi, G., Rabini, A., & Ferriero, G. (2014). Rasch validation of the Activities-specific Balance Confidence Scale and its short versions in patients with Parkinson’s Disease. Journal of Rehabilitation Medicine, 46, 532-9.

Hsu, P.C., & Miller, W.C. (2006). Reliability of the Chinese version of the Activities-specific Balance Confidence scale. Disability and Rehabilitation, 28(20), 1287-92.

Jang, S.N., Cho, S.I., Ou, S.W., Lee, E.S., & Baik, H.W. (2003). The validity and reliability of Korean Fall Efficacy Scale (FES) and Activities-specific Balance Confidence scale (ABC). Journal of the Korean Geriatrics Society, 7(4), 255-68.

Jarlsater, S. & Mattsson, E. (2003). Test of reliability of the Dizziness Handicap Inventory and the Activities-specific Balance Confidence scale for use in Sweden. Advances in Physiotherapy, 5, 137-44.

Karapolat, H., Eyigor, S., Kirazli, Y., Celebisoy, N., Bilgen, C., & Kirazli, T. (2010). Reliability, validity, and sensitivity to change of Turkish Activities Specific Balance Confidence Scale in patients with unilateral peripheral vestibular disease. International Journal of Rehabilitation Research, 33, 12-18.

Mak, M.K., Lau, A.L., Law, F.S., Cheung, C.C., & Wong, I.S. (2007). Validation of the Chinese translated Activities-specific Balance Confidence scale. Archives of Physical Medicine and Rehabilitation, 88, 496-503.

Marques, A.P., Mendes, Y.C., Taddei, U., Pereira, C.A.B., & Assumpcao, A. (2013). Brazilian-Portuguese translation and cross cultural adaptation of the activities-specific balance confidence (ABC) scale. Braz J Phys Ther. Mar-Apr; 17(2), 170-178.

Miller, W.C., Deathe, A.B., & Speechley, M. (2003). Psychometric properties of the Activities-specific Balance Confidence scale among individuals with a lower-limb amputation. Archives of Physical Medicine and Rehabilitation, 84, 656-61.

Moiz, J.A., Bansal, V., Noohu, M.M., Gaur, S.N., Hussain, M.E., Anwer, S., & Alghadir, A. (2017). Activities-specific balance confidence scale for predicting future falls in Indian older adults. Clinical Interventions in Aging, 12, 645-651.

Moore, J.L., Potter, K., Blankshain, K., Kaplan, S.L., O’Dwyer, L.C., & Sullivan, J.E. (2018). A core set of outcome measures for adults with neurological conditions undergoing rehabilitation: a clinical practice guideline. Journal of Neurological Physical Therapy, 42, 174-216.

Myers, A.M., Fletcher, P.C., Myers, A.H., & Sherk, W. (1998). Discriminative and evaluative properties of the Activities-specific Balance Confidence (ABC) scale. Journal of Gerontology: Medical Sciences, 53A(4), M287-94.

Myers, A.M., Powell, L.E., Maki, B.E., Holliday, P.J., Brawley, L.R., & Sherk, W. (1996). Psychological indicators of balance confidence: relationship to actual and perceived abilities. Journal of Gerontology: Medical Sciences, 51A(1), M37-43.

Myers, A.M. (1999). Program evaluation for exercise leaders. Waterloo: Human Kinetics.

Nilsagard, Y., & Forsberg, A. (2012). Psychometric properties of the Activities-Specific Balance Confidence Scale in persons 0-14 days and 3 months post stroke. Disability & Rehabilitation, 34(14), 1186-1191.

Peretz, C., Herman, T., Hausdorff, J.M., & Giladi, N. (2006). Assessing fear of falling: can a short version of the Activities-specific Balance Confidence scale be useful? Movement Disorders, 21(2), 2101-5.

Powell, L.E. & Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC) scale. Journal of Gerontology: Medical Sciences, 50A (1), M28-34.

Salbach, N.M., Mayo, N.E., Hanley, J.A., Richards, C.L., & Wood-Dauphinee, S. (2006). Psychometric evaluation of the original and Canadian French version of the Activities-Specific Balance Confidence scale among people with stroke. Archives of Physical Medicine and Rehabilitation, 87, 1597-1604.

Schepens, S., Goldberg, A., & Wallace, M. (2010). The short version of the Activities-specific Balance Confidence (ABC) scale: Its validity, reliability, and relationship to balance impairment and falls in older adults. Archives of Gerontology and Geriatrics, 51, 9-12.

Schott, N. (2008). [German adaptation of the “Activities-Specific Balance Confidence (ABC) scale” for the assessment of falls-related self-efficacy]. Zeitschrift für Gerontologie und Geriatrie, 41, 475-85.

van Heuvelen, M.J., Hochstenbach, J., de Greef, M.H., Brouwer, W.H., Mulder, T., & Scherder, E. (2005). [Is the Activities-specific Balance Confidence Scale suitable for Dutch older persons living in the community?]. Tijdschrift Voor Gerontologie En Geriatrie, 36, 146-54.

See the measure

How to obtain the Activities-specific Balance Confidence Scale

The print version of the scale may be freely reproduced for student training, research and clinical practices in which therapists and assistants use the scale to assess fewer than 1000 patients per year. In all other cases, including: translation into other languages than English, other modifications to the scale itself and/or instructions, use in clinical trials, for commercial or marketing purposes, or in larger scale practices (1,000+ patients per year) and electronic record keeping, permission must be obtained by the researcher or institution. There may be an associated cost.

Dr. Anita Myers is the primary developer and copyright holder of the ABC scale. email: amyers@uwaterloo.ca.

Purpose

The Chedoke-McMaster Stroke Assessment measures physical impairment and disability in clients with stroke and other neurological impairment. The measure consists of an Impairment Inventory and an Activity Inventory (Moreland, Gowland, Van Hullenaar, & Huijbregts, 1993). The first inventory aims to determine the presence and severity of common physical impairments, to classify or stratify patients when planning, selecting interventions and evaluating their effectiveness and to predict outcomes. The second inventory measures changes in physical function (Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, Sanford, Barreca, Vanspall, & Plews, 1993). The Chedoke-McMaster Stroke Assessment is a discriminative, predictive and evaluative tool.

In-Depth Review

Purpose of the measure

The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment measures physical impairment and disability in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and other neurological impairment. The measure consists of an Impairment Inventory and an Activity Inventory (Moreland, Gowland, Van Hullenaar, & Huijbregts, 1993). The first inventory aims to determine the presence and severity of common physical impairments, to classify or stratify patients when planningPlanning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint" (Anderson, 2008, p. 17)
, selecting interventions and evaluating their effectiveness and to predict outcomes. The second inventory measures changes in physical function (Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, Sanford, Barreca, Vanspall, & Plews, 1993). The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment is a discriminative, predictive and evaluative tool. It is recommended that measures of motor impairmentLoss of strength and coordination, decrease in arm or leg movement
, such as the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment, be accompanied by a measure of functional disability such as the Barthel Index (BI) or Functional Independence Measure (FIM) (Poole & Whitney, 2001).

Available versions

There is only one version of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment, which was developed by Gowland, Van Hullenar, Moreland, Vanspall, Barreca, Ward, Huijbregts, Stratford and Barclay-Goddard from the original work by Brunnstrom.

A complimentary measure for the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment, the Chedoke Arm and Hand Inventory (CAHAI), was developed by Barreca, Gowland, Stratford, Huijbregts, Griffiths, Torresin, Dunkley, Miller and Masters, in 2004, to assess, exclusively, the recovery of the paretic upper limb. To date, there are three different versions of the CAHAI. The original version comprehends 13 items, which was then shortened to a version with 9 and 7 items. This CAHAI is summarized in its own module.

Features of the measure

Items:
The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment is a performance-based measure that consists of two inventories: the Impairment Inventory and the Activity Inventory.
The Impairment Inventory is used to determine the presence and severity of common physical impairments. It has six dimensions (recovery stage of the arm, hand, leg, foot, postural control, and shoulder pain). Each dimension is measured on a 7-point scale (Gowland et al., 1993). The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity. The Impairment Inventory is considered to be a discriminative and predictive tool (Huijbregts, Gowland, & Gruber, 2000; Moreland et al., 1993).

The Activity Inventory was originally called the Disability Inventory. Its name changed in 1999, in accordance with the World Health Organization (WHO) terminology (Huijbregts et al., 2000). The aim of this inventory is to measure clinically important changes in the client’s functional ability. This Activity Inventory is made up of the gross motor function and walking indexes.

The gross motor function index consists of the 10 following items: 1 – supine to side lying on strong side; 2 – supine to side lying on weak side; 3 – side lying to long sitting through strong side; 4 – side lying to sitting on side of the bed through strong side; 5 – side lying to sitting on side of the bed through weak side; 6 – standing; 7 – transfer to and from bed toward strong side; 8 – transfer to and from bed toward weak side; 9 – transfer up and down from floor to chair; 10 – transfer up and down from floor and standing. The walking index consists of the 5 following items: 11 – walking indoors; 12 – walking outdoors, over rough ground, ramps, and curbs; 13 – walking outdoors several blocks; 14 – stairs; 15 – age and sex appropriate walking distance in meters for 2 minutes. (Finch et al., 2002; Gowland et al., 1993; Huijbregts at al., 2000). The Activity Inventory is considered an evaluative tool (Huijbregts at al., 2000; Moreland et al., 1993).

Scoring:
The Impairment Inventory is scored on a 7-point scale, where 1 – is flaccid paralysis; 2 – spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
is present and felt as a resistance to passive movement; 3 – marked spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
but voluntary movement present within synergistic patterns; 4 – spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
decreases; 5 – spasticityInvoluntary muscle tightness and stiffness that can occur after a stroke. It is characterized by exaggerated deep tendon reflexes that interfere with muscular activity, gait, movement, or speech. Spasticity can increase initially but wane down later on, after stroke.
wanes but is evident with rapid movement at the extremes of range; 6 – coordination and patterns of movement are near normal; and 7 – normal movement. The 7-point scale corresponds to seven stages of motor recovery. The 7-point scale for shoulder pain is based on pain severity. The minimum score for the Impairment Inventory is 6 and the maximum score is 42 (Gowland et al., 1993).

The Activity Inventory is also scored on a 7-point scale, based on the amount of assistance the individual with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. requires. It is categorized by the need for assistance from another person, the need for equipment, or the need for extra time to accomplish a task (Huijbregts at al., 2000). For the Activity Inventory, the scoring key from the Functional Independence Measure (Keith, Granger, Hamilton & Sherwin, 1987) is used, where 1 – the client needs total assistance; 2 – maximal assistance; 3 – moderate assistance, 4 – minimal assistance, 5 – clients needs supervision; 6 – client is modified independent (needs assistance from devices); 7 – client is timely and safely independent (Gowland et al., 1993).

The maximum score is 100, where higher scores reflect normal function (Finch et al., 2002; Gowland et al., 1993). More specifically, the maximum score for the gross motor function index is 70 and for the walking index is 30 (Gowland et al., 1993). Additionally, a 2-point bonus should be assigned for those who walk, appropriate distances, in meters, accordingly to the norms for their age and sex, on item 15 (the 2-Minute Walk Test) (Huijbregts at al., 2000).

Detailed administration guidelines and scoring are in the development manual that can be obtained by emailing to the following address: djohnstn@mcmaster.ca at a cost of $50.00 CAD.

Time:
The time to administer the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment typically varies from 45 to 60 minutes depending on the client’s ability to complete the required task (Finch et al., 2002; Gowland et al., 1993; Poole & Whitney, 2001). Clients with severe strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. will typically take longer to accomplish all tasks when compared to clients with mild strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Subscales:
The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment is divided into two inventories: Impairment and Activity. The Activity Inventory, initially called the Disability Inventory, subdivides into gross motor and walking indexes (Finch et al., 2002; Gowland et al., 1993; Huijbregts at al., 2000).

Equipment:

• An adjustable table (Finch et al., 2002)
• A chair with armrests (Finch et al., 2002)
• A floor mat (Finch et al., 2002)
• Pillows (Finch et al., 2002)
• Pitcher with water (Finch et al., 2002)
• Measuring cup (Finch et al., 2002)
• A ball 2.5 inches in diameter (Finch et al., 2002)
• A footstool (Finch et al., 2002)
• 2m line marked on the floor (Finch et al., 2002)
• A stopwatch (Finch et al., 2002)

Training:
Training is provided by the authors at McMaster University in Hamilton, Ontario. Further information about training can be obtained by emailing: pmiller@mcmaster.ca

Alternative forms of the Chedoke-McMaster Stroke Assessment

None.

Client suitability

Can be used with:

• Clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
• Clients with other neurological impairment

Should not be used with:

• Clients younger than 19 years old (Finch et al., 2002), as the measure was developed with adults and its psychometrics properties were tested only for this population.
• It is not suited to proxy use.

In what languages is the measure available?

English, French and German

Summary

What does the tool measure?	The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment measures specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegiaComplete paralysis of the arm, leg, and trunk on one side of the body that results from damage to the parts of the brain that control muscle movements. Hemiplegia is not a progressive condition, nor is it a disease..
What types of clients can the tool be used for?	The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment can be used with, but is not limited to clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. and assessment.
Time to administer	An average of 45 to 60 minutes.
Versions	There are no alternative versions.
Other Languages	French.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Chedoke-McMaster Stroke Assessment. Test-retest: One study has examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). using ICC. Intra-rater: One study has examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and reported excellent intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. using ICC. Inter-rater: Three studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Chedoke-McMaster Stroke Assessment and reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. using ICC.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: Two studies have examined the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the Chedoke-McMaster Stroke Assessment. Criterion: Concurrent: One study has examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the Chedoke-McMaster Stroke Assessment and reported excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment total score and the Fugl-Meyer Assessment total score and the Functional Independence Measure (FIM) total score, using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. . Predictive: One study has examined the predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and reported it is a predictor of functional ability and sensorimotor recovery after strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Construct: Convergent: Two studies examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment, 1 reported excellent correlations between similar impairments from the Impairment Inventory and the Fugl-Meyer Assessment and between similar activity limitations from the Activity Inventory and the Functional Independence Measure, using Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. . The other reported excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between totals scores on the Activity Inventory (AI) of the Chedoke-McMaster Stroke Assessment and the Clinical Outcomes Variable Scale at admission, discharge and change from admission to discharge. Known Groups: One study examined known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured. of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and reported that it is able to distinguish between subjects who changed little (<20 on FIM), and those who change more (>20 on FIM), using student t-test.
Floor/Ceiling Effects	No studies have examined floor/ceiling effects of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	No studies have examined the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." /specificity of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment.
Does the tool detect change in patients?	Two studies have examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and reported that it has a large variance ratio and a minimal clinically-important change is expressed by a change of 8 units in the Activity Inventory.
Acceptability	Administration of the entire Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment is lengthy. The test is scored by direct observation.
Feasibility	The Chedoke-McMaster Stroke Assessment must be administered by a trained physical or occupational therapistIn charge of the "assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education."(Suggested by Philips et al, 2002) . It does not require any specialized equipment.
How to obtain the tool?	The Chedoke-McMaster can be ordered by email: djohnstn@mcmaster.ca

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment in individuals with stroke. We identified six studies. The Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment appears to be responsive in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Floor/Ceiling Effects

No studies have examined the floor/ceiling effects of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment.

Reliability

Test-retest:
Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, et al. (1993) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., at a mean age of 64 years. Participants were re-assessed with a 5-day interval. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for the Activity Inventory, as calculated using Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance., was excellent (ICC = 0.98), as were the gross motor function (ICC = 0.96) and walking (ICC = 0.98) indexes.

Intra-rater:
Gowland et al. (1993) estimated the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the Impairment Inventory section of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment in 32 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., at a mean age of 64 years. Participants were assessed at admission to the rehabilitation center, and their performances were videotaped. Scoring on the second evaluation was based on the videotape recorded previously. The intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
, as calculated using ICC was excellent for both Impairment Inventory evaluations (ICC = 0.98), as well as for the dimension’s shoulder pain (ICC = 0.96), postural control (ICC = 0.96), arm (ICC = 0.95), hand (ICC = 0.93), leg (ICC = 0.98) and foot (ICC = 0.94).

Inter-rater:
Gowland et al. (1993) estimated the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., at a mean age of 64 years. Participants were assessed simultaneously by two raters. The ICC for the total score showed excellent agreement (ICC = 0.97), as well as for the dimension’s shoulder pain (ICC = 0.95), postural control (ICC = 0.92), arm (ICC = 0.88), hand (ICC = 0.93), leg (ICC = 0.85) and foot (ICC = 0.96).

Gowland et al. (1993) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Impairment Inventory section of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment in 32 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., at a mean age of 64 years. Participants were re-assessed within 5 days by a second rater. The inter-rater reliabilities as calculated using ICC were excellent for the Impairment Inventory (ICC = 0.99), as well as for the gross motor function (ICC = 0.98) and walking (ICC = 0.98) indexes.

Crowe, Harmer, and Sharp (1996) assessed the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Impairment Inventory section of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment in 28 participants with Acquired Brain Injury. Participants were assessed with a 2-week interval by two therapists. Agreement between raters for the Impairment Inventory, as calculated using ICC, was excellent (r = 0.99).
Note: The severity of the Acquired Brain Injury and the reason for the 2 weeks delay when measuring inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
were not specified by the authors.

Validity

Content:
Moreland, Gowland, Van Hullenar, and Huijbregts (1993) performed a literature review to gather evidence for a theoretical basis of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment. All items from both inventories had enough scientific evidence supporting its assumptions. Thus, the authors were able to establish a theoretical basis underlying the content of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment.

Huijbregts, Gowland, and Gruber (2000) carried out a survey in 34 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 27 caregivers to verify whether the content in the Activity Inventory is representative of skills that are important to that population. On a scale where 1 is not at all important and 7 is extremely important, all items received a 7 from at least one person in each group. For most items, the mean level was above 5, except for the 2-Minute Walk Test, which had the lowest score from both clients (1.78) and caregivers (3.52). The two most important items according to clients’ and caregivers’ perspective was standing and transferring from and to bed towards the strong side.

Criterion:
Concurrent:
Gowland et al. (1993) compared the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment with the Fugl-Meyer Assessment –FMA (Fugl-Meyer, Jääskö, Leyman, Olsson, & Steglind, 1975) and the Functional Independence Measure (FIM) (Keith, Granger, Hamilton & Sherwin, 1987) in 32 participants with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Using Pearson Correlation Coefficients, the correlation between the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment total score and the FMA total score (r = 0.95) and the FIM total score (r = 0.79) were excellent.

Predictive:
Gowland (1984) examined whether the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment was able to predict sensorimotor recovery at discharge from an active rehabilitation program. Predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment was examined in 335 active strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. rehabilitation inpatients. Assessments were performed at admission to and at discharge from the rehabilitation center. The length of stay varied from 1 to 49 weeks with an average of seven weeks. At discharge, the 23 independent variables selected were able to predict 11 out of 14 outcomes. Among these independent variables, stage of recovery of the leg was found to be the most important predictive variable, followed by weeks’ post-stroke and gross motor performance.

Valach, Singer, Hartmeier, Hofer & Cox Steck (2003) examined whether scores from the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment (CMSA) were predictive of scores on the Barthel Index (BI) and vice versa, in 127 patients with vascular brain-damage. Regression analysis revealed that as few as 3 items on the CMSA disability index were needed to predict BI scores, however 6 to 8 items on the BI were needed to predict CMSA scores. Although only a few items on the CMSA were required to predict BI scores, there was still a large portion of unexplained variance and thus, it is recommended that both the BI and CMSA be performed in situations where a comprehensive evaluation of patients is desired.

Construct:
Convergent/Discriminant:
Gowland et al. (1993) evaluated the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment by comparing similar impairments between the Impairment Inventory and the Fugl-Meyer Assessment (FMA) (Fugl-Meyer et al., 1975). Correlations, as calculated using Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficients, were excellent between postural control (Impairment Inventory) and balance (FMA) (r = 0.84); arm and hand (Impairment Inventory) and shoulder, elbow, forearm, wrist and hand (FMA) (r = 0.95); leg and foot (Impairment Inventory) and hip, knee, foot and ankle (FMA) (r = 0.93); shoulder pain (Impairment Inventory) and upper limb joint pain (FMA) (r = 0.76). Furthermore, the authors compared similar activity limitations between the Activity Inventory and the Functional Independence Measure (FIM) (Keith et al., 1987). Correlations, as calculated using Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficients were excellent between the gross motor function index (Activity Inventory) and the Mobility subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the FIM (r = 0.90) and between the walking index (Activity Inventory) and the Locomotion subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of the FIM (r = 0.85).

Sacks et al. (2010) evaluated the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment Activity Inventory (AI) and the Clinical Outcomes Variable Scale (COVS) (Seaby & Torrance, 1989) in 24 geriatric inpatients (mean age 83 years) receiving care in a rehabilitation unit. Correlations between AI and COVS total scores at admission and discharge, and change in total scores from admission to discharge, as calculated by Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficients, were excellent (r=0.92, r=0.91 and r=0.84 respectively). All subscales of the AI and COVS demonstrated excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
at admission, discharge and change from admission to discharge, except for the walking subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
, which was found to have adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
for change from admission to discharge (r=0.59).

Known groups:
Crowe at al. (1996) analyzed whether the Activity Inventory was able to distinguish between subjects who changed little (<20) and those who change more (>20) on the Functional Independence Measure (FIM) (Keith et al., 1987) in 28 clients with Acquired Brain Injury. Known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured.
, as calculated using a student t-test, showed that the Activity Inventory is able to distinguish between clients with lower and higher scores on FIM.

Responsiveness

Gowland et al. (1993) estimated the responsivenessThe ability of an instrument to detect clinically important change over time.
of the Activity Inventory and the Functional Independence Measure (FIM) (Keith et al., 1987) in 32 participants with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were assessed at two points in time: at admission and discharge from the rehabilitation centre. Variance ratios were calculated. Compared to the FIM, the Activity Inventory had a greater variance ratio (0.53 for Activity Inventory vs. 0.30 for FIM) suggesting that the Activity Inventory of Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment is a more sensitive measure to detecting change.

Huijbregts et al. (2000) assessed clinically-important changes based on a global rating of change for the Activity Inventory, gross motor function index, and walking index in 34 clients. For the Activity Inventory, no change was represented by a mean change in score of 0, small changes by a mean change in score of 8, and moderate to large changes by a mean change in score of 20. For the gross motor function index, no change was represented by a mean change in score of 1, small changes by a mean change in score of 7, and moderate to large changes by a mean change in score of 7. For the walking index, no change was represented by a mean change in score of 1, small changes by a mean change in score of 5, and moderate to large changes by a mean change in score of 13. All this information suggests that for the client, a minimum change of 20 points in the Activity Inventory score is required for him to perceive a moderate to large change. Furthermore, important change as perceived by the client and the real change score of the measure have an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = 0.74).

Sacks et al. (2010) evaluated the responsivenessThe ability of an instrument to detect clinically important change over time.
of the Activity Inventory (AI) of the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment and the Clinical Outcomes Variable Scale (COVS) (Seaby & Torrance, 1989) in 24 geriatric inpatients (mean age 83 years) receiving care on a rehabilitation unit. Large effect sizes were found for both the AI and COVS (1.53 and 1.43); and a stronger standardized response meanThe standardized response mean (SRM) is calculated by dividing the mean change by the standard deviation of the change scores.
(SRM) was found for the COVS compared to that of the AI (2.30 and 1.83). Results from this study suggest that both measures are responsive to change in geriatric patients but the COVS is more responsive than the AI in this population.

References

• Crowe, J., Harmer, D., & Sharpe, D. (1996). Reliability of the Chedoke-McMaster Disability Inventory in acquired brain injury. Physiotherapy Canada, 48(1), 25.
• Finch, E., Brooks, D., Stratford, P.W, & Mayo, N.E. (2002). Physical Outcome Measures: A guide to enhance physical outcome measures. Ontario, Canada: Lippincott, Williams & Wilkins.
• Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., & Steglind, S. (1975). The post-stroke hemiplegic patient 1. A method for evaluation of physical performance. Scandinavian Journal of Rehabilitation Medicine, 7, 13-31.
• Gowland, C., Stratford, P., Ward, M., Moreland, J., Torresin, W., Van Hullenaar, S. et al. (1993). Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke, 24, 58-63.
• Gowland, C., Van Hullenaar, S., Torresin, W., et al. (1995). Chedoke-McMaster Stroke Assessment: development, validation, and administration manual. Hamilton, ON, Canada: School of Rehabilitation Science, McMaster University.
• Gowland, C. (1984). Predicting sensorimotor recovery following stroke rehabilitation. Physiotherapy Canada, 36, 313-320.
• Gowland, C. (1982). Recovery of motor function following stroke: profile and predictors. Physiotherapy Canada, 34, 77-84.
• Huijbregts, M.P., Gowland, C., Gruber, R. (2000). Measuring clinically important change with the Activity Inventory of the Chedoke-McMaster Stroke Assessment. Physiotherapy Canada, 52, 295-304.
• Keith, R.A, Granger, C.V., Hamilton, B.B., & Sherwin, F.S. (1987). The Functional Independence Measure: a new tool for rehabilitation. In: Eisenberg, M.G. & Grzesiak, R.C. (Ed.), Advances in clinical rehabilitation (pp. 6-18). New York: Springer Publishing Company.
• Moreland, J., Gowland, C., Van Hullenar, S., Huijbregts, M. (1993). Theoretical basis of the Chedoke-McMaster Stroke Assessment. Physiotherapy Canada, 45, 231-238.
• Poole, J.L. & Whitney, S.L. (2001). Assessment of motor function post stroke: A review. Physical and Occupational Therapy in Geriatrics, 19, 1-22.
• Sacks, L., Yee, K., Huijbregts, M., Miller, P.A., Aggett, T. & Salbach, N.M. (2010). Validation of the activity inventory of the Chedoke-McMaster Stroke Assessment and the Clinical Outcome Variables Scale to evaluate mobility in geriatric clients. Journal of Rehabilitation Medicine, 42, 90-92.
• Valach, L., Signer, S., Hartmeier, A., Hofer, K. & Cox Steck, G. (2003). Chedoke-McMaster Stroke Assessment and modified Barthel Index self-assessment in patients with vascular brain damage. International Journal of Rehabilitation Research, 26, 93-99.

See the measure

How to obtain the Chedoke-McMaster StrokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. Assessment

The Chedoke-McMaster can be ordered by email: djohnstn@mcmaster.ca

Purpose

The Cone Evasion Walk test (CEW) assesses fall risk in individuals in the acute phase of stroke recovery, by their ability to evade obstacles. The CEW test can be performed with or without a walking aid.

In-Depth Review

Purpose of the measure

Walking is recognized as an activity that demands attentional, perceptual, visual, neuromusculoskeletal and movement-related functions. The Cone Evasion Walk test was developed to assess fall risk by the ability to avoid obstacles.

Available versions

The Cone Evasion Walk test was developed from literature, clinical experience and in collaboration with patients and physiotherapists.

Features of the measure

Items:

The Cone Evasion Walk test is a single-item assessment. Cones are spaced over a length of 3m. The participant completes the 3m walk two times.

Scoring:

1. Record the number of cones the patient touches while completing the task two times. A cone is judged as touched regardless of whether the base or the cone itself is touched.
2. Summarise the number of cones touched on the left (possible outcomes 0-4), the right (possible outcomes 0-4) and total number of cones touched (possible outcomes 0-8).

Note: If there is any doubt regarding the participant’s performance, the cone should not be judged as touched.

For individuals using a walking aid: Record whether the cone is touched by the front wheel or the back wheel. If the participant touches a cone with both the front and the back wheel, only the front wheel is noted. If the walking device has a frame between the front and back wheels, everything behind the front wheel is judged as the back wheel.

What to consider before beginning:

Individuals who rely on a walking aid (walker, crutch, walking stick, other) should use this while performing the assessment.

If the individual requires the support of another person to walk, the individual must control the walk as much as possible.

Note whether the individual requires physical support or supervision to complete the task.

Time:

Allow approximately 5 minutes for initial set-up. The Cone Evasion Walk test takes less than 5 minutes to administer/complete.

Training requirements:

No training requirements have been specified for the Cone Evasion Walk test.

Equipment:

The Cone Evasion Walk test requires four cones, tape and a free space of 3m length.

Participants use their ordinary walking aid.

Client suitability

Can be used with:

Individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.

Should not be used with:

The Cone Evasion Walk test is not suitable for use with individuals who are not mobile nor able to mobilise safely.

The Cone Evasion Walk test has not been evaluated on individuals with subacute or chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Languages of the measure

Swedish
English

Summary

What does the tool measure?	Fall risk
What types of clients can the tool be used for?	The Cone Evasion Walk test can be used with individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms.
Time to administer	5 minutes
ICF Domain	Activity
Versions	There is one version of the Cone Evasion Walk test.
Languages	Swedish English
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have reported on internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CEW. Test-retest: No studies have reported on test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the CEW. Intra-rater: One study reported good to excellent intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings. of the CEW. Inter-rater: One study reported good to excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the CEW.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: Face validity of the CEW test was established through review and pilot-testing by clinical physiotherapists. Criterion: Concurrent: No studies have reported on concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the CEW. Predictive: One study reported significant weak correlations between number of cones touched and number of falls, and between number of cones touched and number of days from admission to first fall incident. A weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. was reported between number of cones touched and number of falls when the sample population was restricted to individuals who touched the cones during the assessment period. Construct: Convergent/Discriminant: One study reported a weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the CEW and the Timed Up and Go test, and weak to moderate negative correlations between the CEW and the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second. Categories, Montreal Cognitive Assessment Serial 7s attention task and Star Cancellation Test. Known Groups: One study reported individuals with a right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were significantly more likely to hit cones on the left side than the right; individuals with a left hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. were significantly more likely to hit cones on the right side than on the left.
Floor/Ceiling Effects	A floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect." was detected among individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. with good mobility.
Does the tool detect change?	No studies have reported on the responsivenessThe ability of an instrument to detect clinically important change over time. of the CEW.
Acceptability	The CEW is non-invasive and quick to administer. The CEW measures activity relevant to real-life.
Feasibility	The CEW is suitable for administration in various settings. The CEW is quick to administer and requires minimal specialist equipment or training.
How to obtain the tool?	Le Cone Evasion Walk test (Swedish version) Le Cone Evasion Walk test (English version)

Psychometric Properties

Overview

The Cone Evasion Walk test was developed in consultation with a convenience sample of 9 physiotherapists and occupational therapists (Sjoholm et al., 2019). A literature search was conducted to identify all relevant publications on the psychometric properties of the Cone Evasion Walk test pertinent to use with participants following strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Two studies were identified.

Floor/Ceiling Effects

Sjoholm et al. (2019) reported a floor effectThe floor effect is when data cannot take on a value lower than some particular number. Thus, it represents a subsample for whom clinical decline may not register as a change in score, even if there is worsening of function/behavior etc. because there are no items or scaling within the test that measure decline from the lowest possible score. See also "ceiling effect."
on the Cone Evasion Walk test in a sample of 221 individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., whereby 71% of participants (n=211) hit no cones.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Cone Evasion Walk test has not been measured.

Test-retest:
Test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Cone Evasion Walk test has not been measured.

Intra-rater:
Sjoholm et al. (2019) examined intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the Cone Evasion Walk test in a sample of 20 individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. using Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. with 95% Confidence Interval (CI). Ten physiotherapists viewed the video recording of participants’ performance of one run of the CEW on two occasions. Scoring consistency between the two sessions was good to excellent (ICC = 0.89-0.98) for the total scores and the four subscores. Overall percentage of agreement was 70-96%.

Inter-rater:
Sjoholm et al. (2019) examined inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Cone Evasion Walk test in a sample of 20 individuals with acute stroke using Intraclass Correlation Coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. with 95% Confidence Interval (CI). Participants’ performance of a single run of the CEW was videorecorded and viewed by ten physiotherapists. Inter-rater scoring consistency for the total score and four subscores was good to excellent (ICC = 0.88-0.97).

Validity

 Content:

Face validityA form of content validity, face validity is assessed by having 'experts' (this could be clinicians, clients, or researchers) review the contents of the test to see if the items seem appropriate. Because this method has inherent subjectivity, it is typically only used during the initial phases of test construction.
of the CEW test was established in two phases: (i) interpretations of the test instructions and assessment procedures were reviewed by nine physiotherapists practicing in the field of neurological disorders at two group meetings; and (ii) four physiotherapists subsequently pilot-tested the assessment over a 1-year period. This resulted in modified instructions regarding administration and scoring (Sjohom et al., 2019).

Criterion:

Concurrent:
Concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the Cone Evasion Walk test has not been measured.

Predictive:
Sjoholm et al. (2019) examined predictive validityA form of criterion validity that examines a measure's ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the Cone Evasion Walk test in a sample of 221 individuals with acute stroke using linear regression analysis. There were weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between number of cones touched and number of falls (r=0.18, p=0.01) and between number of cones touched and number of days from admission to first fall incident (r=-0.28, p=0.02). When only people who touched the cones were included in the analysis, the correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between number of cones touched and number of falls was weak (r=0.31, p=0.02). The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the number of cones touched and the number of falls became more robust when only those who touched the cones, in the same population, were included in the analysis.

Construct:

Convergent/Discriminant:
Sjoholm et al. (2019) examined construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the Cone Evasion Walk test by comparison with the Functional AmbulationThe ability to walk, with or without the aid of appropriate assistive devices (such as canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living (ADLs). From Perry et al (1995), functional ambulation is referred to as walking in parallell bars for exercise at a speed of about 10/cm per second.
Classification (FAC), Timed Up and Go (TUG) test and TUG Cognitive test (TUG-Cog), Montreal Cognitive Assessment Serial 7s attention task (MoCA-S7), and the Star Cancellation Test in a sample of 221 individuals with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. There was a weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the CEW test and the TUG (r=0.45, p<0.05), and weak to moderate correlations with the FAC, MoCA-S7 and SCT (r=-0.67, -0.36, -0.36 respectively, p<0.05). The total number of cones touched on the left side showed a weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the proportion of stars cancelled on the left side (r=-0.23, p<0.05), and the right side (r=0.23, p<0.05). There was no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the number of cones touched on the right side and the proportion of stars cancelled on either the left or the right. There was no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the CEW and TUG-Cog.

Known Group:
Sjoholm et al. (2019) examined known-group validityThe degree to which an assessment measures what it is supposed to measure.
of the Cone Evasion Walking test in a sample of 143 individuals with acute left hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=64) and right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=79). Differences between groups were examined using Fisher’s exact test. Among individuals with a right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., significantly more participants hit cones on the left side than the right (p=0.001). Among individuals with a left hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., significantly more participants hit cones on the right side than on the left (p<0.01).

Responsiveness:

Sensitivity & Specificity:
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
and Specificity of the Cone Evasion Walk test has not been measured.

References

Sjöholm, H., Hägg, S., Nyberg, L., Rolander, Bo, Kammerlind, A., (2019). The Cone Evasion Walk test: Reliability and validity in acute stroke. Physiotherapy Research International, 24(1), e1744. https://doi.org/10.1002/pri.1744

Sjöholm, H., Hägg, S., Nyberg, L., Rolander, Bo, Kammerlind, A., (2019). Corrigendum. Physiotherapy Research International, 24: e1801. https://doi.org/10.1002/pri.1801

Sjöholm, H., Hägg, S., Nyberg, L., Lind, J., & Kammerlind, A. (2022). Exploring possible risk factors for time to first fall and 6-month fall incidence in persons with acute stroke. SAGE Open Medicine, 10: 1-11. https://doi.org/10.1177/20503121221088093

See the measure

How to obtain the Cone Evasion Walk test

The original Swedish version of the Cone Evasion Walk test can be found here.

Test protocol in English can be found here.