Activities-specific Balance Confidence Scale (ABC Scale)

Evidence Reviewed as of before: 30-11-2020
Author(s)*: Annabel Wildschut
Editor(s): Annie Rochette
Expert Reviewer: Johanne Filiatrault, erg., Ph.D.
Content consistency: Gabriel Plumier

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 activities 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 activities 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 activities, and if so, which ones?’ (Powell & Myers, 1995). Items were chosen to include a number of difficult activities 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 consistency (reliability index 0.86) and good convergent validity (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 stroke population.

A 6-item version of the ABC Scale (ABC-6) was also developed for clinical and research use. It includes 6 activities 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 stroke 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 activities:

  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 activities 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 stroke 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 stroke.
Is this a screening or assessment tool? Screening 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
Reliability Internal consistency:
– Two studies have reported high internal consistency of the ABC Scale in a stroke population (Botner et al, 2005; Salbach et al, 2006).
– One study reported high internal consistency of the ABC-CF Scale in a stroke population (Salbach et al, 2006).
– One study reported high internal consistency of a Swedish translation of the ABC Scale in a stroke population (Nilsagard & Forsberg, 2012).
Test-retest:
One study examined test-retest reliability of the ABC Scale within a stroke population and reported excellent test-retest reliability of the overall score and adequate to excellent item level test-retest reliability (Botner et al, 2005).
Intra-rater:
Intra-rater reliability of the ABC Scale has not been examined.
Inter-rater:
Inter-rater reliability of the ABC Scale has not been examined.
Validity Content:
One study conducted factor analysis of the ABC Scale within a stroke population and results revealed two factors: perceived low-risk activities and perceived high-risk activities (Botner et al, 2005).
Criterion:
Concurrent:
Concurrent validity of the ABC Scale has not been examined within a stroke population.
Predictive:
Predictive validity of the ABC Scale has not been examined within a stroke population.
Construct:
Convergent/Discriminant:
– Three studies (Botner et al., 2005; Salbach et al., 2006; Nilsagard & Forsberg, 2012) have examined convergent validity of the ABC Scale within a stroke population and reported : an adequate correlation with the Berg Balance Scale (BBS), gait speed, 6 Minute Walk Test (6MWT), Barthel Index (BI), Functional Ambulation 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 subscale (SF-36 PF) ranged from excellent to poor among studies.
– Two studies (Salbach et al., 2006; Nilsagard & Forsberg, 2012) have examined divergent validity of the ABC Scale within a stroke population and reported: an adequate correlation with the EQ-5D visual analog scale (EQ VAS); an adequate negative correlation with the Geriatric Depression Scale (GDS); and a low correlation with the SF-36 Mental component score.
– One study (Salbach et al., 2006) examined convergent / divergent validity of the ABC-CF Scale and reported: an excellent correlation with the EQ VAS; an excellent negative correlation with the GDS; adequate correlations with the SF-36 PF, BBS, walking speed, 6MWT and BI; and an adequate negative correlation with the TUG.
Known Groups:
Known-group validity of the ABC Scale has not been examined within a stroke 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 stroke, but noted a floor effect for 3 items and a ceiling effect for 8 items of both scales.
Sensitivity / Specificity Not reported.
Does the tool detect change in patients? No studies have reported on the responsiveness of the ABC Scale within a stroke population.
Acceptability The ABC Scale is non-invasive and quick to administer. The items are considered reflective of real-life activities.
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 stroke. 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 stroke 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 stroke and residual walking deficits. The authors reported a floor effect (whereby more than 20% of participants reported ‘no confidence’ or 0%) for 3 items of both scales; and a ceiling 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 stroke) 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 consistency:
Powell & Myers (1995) examined 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 consistency (a = 0.96). Stepwise deletion of each item did not alter internal consistency.

Botner et al. (2005) examined internal consistency of the ABC Scale in a sample of 77 participants with chronic stroke, using Cronbach’s alpha. Results revealed high internal consistency (a=0.94). Stepwise deletion did not alter internal consistency (a=0.93 – 0.94).

Salbach et al. (2006) examined internal consistency of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic stroke and residual walking deficit. The authors reported high 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 consistency of either scale.

Nilsagard & Forsberg (2012) examined internal consistency of a Swedish translation of the ABC Scale in a sample of 37 patients with acute/subacute stroke, using Cronbach’s alpha. Participants were retested 3 months later (n=31). The authors reported high internal consistency at both time points (a= 0.97, 0.94 respectively).

Absolute reliability:
Salbach et al. (2006) examined absolute reliability of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic stroke 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 reliability (Rho coefficient = 0.95).

Test-retest:
Powell & Myers (1995) examined 2-week test-retest reliability of the ABC Scale with a sample of 21 community-dwelling seniors. Results revealed excellent overall test-retest reliability (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 reliability of the ABC Scale with a sample of 24 participants with chronic stroke, using intra-class correlation coefficients. Results indicated excellent test-retest reliability of the overall score (ICC = 0.85; 95% CI 0.68-0.93), and adequate to excellent item level test-retest reliability (ICC ranged from 0.53 – 0.93).

Intra-rater:
No studies have reported on the intra-rater reliability 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 reliability 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 stroke, using principal component analysis with Varimax rotation. Results revealed two components:
Factor 1: perceived low-risk activities (9 items; 55.7% of the variance); and
Factor 2: perceived high-risk activities (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 validity 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 correlation between scales (r=0.84, p<0.001).

Predictive:
No studies have reported on the predictive validity of the ABC Scale.

Construct:
Convergent/Discriminant:
Powell & Myers (1995) examined convergent validity 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 validity was measured by comparison with the Physical Self-Efficacy Scale (PSES). There was an adequate correlation (r=0.49, p<0.001) between the ABC Scale and the PSES score, and an excellent correlation between the ABC scale and the PSES physical abilities subscale (r=0.63, p<0.001). There was no significant correlation between the ABC Scale and the PSES general self-presentation subscale (r=0.03).

Powell & Myers (1995) examined discriminant validity 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 validity 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 validity of the ABC Scale with a sample of 77 participants with chronic stroke, using Spearman’s correlation coefficient. Convergent validity was measured by comparison with the Berg Balance Scale (BBS) and gait speed. Results showed an adequate correlation with both measures (BBS: r=0.36, p<0.001; gait speed: r=0.48, p<0.001).

Salbach et al. (2006) examined convergent validity of the ABC Scale and the ABC-CF Scale in a sample of 86 participants (n=51, 35 respectively) with subacute/chronic stroke and residual walking deficit, using Spearman correlation coefficients and associated 95% confidence intervals. Convergent validity was measured by comparison with the BBS, 5-m walking test (comfortable/maximal gait 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 subscale (SF-36 PF), Geriatric Depression Scale (GDS), and the EQ-5D visual analog scale (EQ VAS). The ABC Scale showed an excellent 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 correlation with perceived health status (EQ VAS: r=0.68), an excellent negative 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 correlation with functional mobility (TUG: r=-0.52).

Nilsagard & Forsberg (2012) examined convergent and divergent validity of the ABC Scale in a sample of 37 participants with acute/subacute stroke, using Kendall’s coefficient. Participants were retested 3 months later (n=31). Convergent validity was measured by comparison with the Functional Ambulation 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 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 validity was measured using the SF-36 Mental component score (SF-36 MF), with which the ABC Scale showed a low correlation at both time points (r=0.22, 0.12).

Known Group:
Powell & Myers (1995) examined known group validity 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 responsiveness 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).

Sensitivity & Specificity:
Powell & Myers (1995) examined item specificity 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.

Table of contents

Chedoke-McMaster Stroke Assessment

Evidence Reviewed as of before: 19-08-2008
Author(s)*: Sabrina Figueiredo, BSc; Katie Marvin, MSc, PT Candidate
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc; Lisa Zeltzer, MSc OT

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 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. It is recommended that measures of motor impairment, such as the Chedoke-McMaster Stroke 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 Stroke 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 Stroke 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 Stroke 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 – spasticity is present and felt as a resistance to passive movement; 3 – marked spasticity but voluntary movement present within synergistic patterns; 4 – spasticity decreases; 5 – spasticity 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 stroke 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 Stroke 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 stroke will typically take longer to accomplish all tasks when compared to clients with mild stroke.

Subscales:
The Chedoke-McMaster Stroke 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 stroke.
  • 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 Stroke Assessment measures specific changes in limb function among individuals who sustained cortical damage resulting in hemiplegia.
What types of clients can the tool be used for? The Chedoke-McMaster Stroke Assessment can be used with, but is not limited to clients with stroke.
Is this a screening or assessment tool? Screening and assessment.
Time to administer An average of 45 to 60 minutes.
Versions There are no alternative versions.
Other Languages French.
Measurement Properties
Reliability Internal consistency:
No studies have examined the internal consistency of the Chedoke-McMaster Stroke Assessment.
Test-retest:
One study has examined the test-retest reliability of the Chedoke-McMaster Stroke Assessment and reported excellent test-retest reliability using ICC.
Intra-rater:
One study has examined the intra-rater reliability of the Chedoke-McMaster Stroke Assessment and reported excellent intra-rater reliability using ICC.
Inter-rater:
Three studies have examined the inter-rater reliability of the Chedoke-McMaster Stroke Assessment and reported excellent inter-rater reliability using ICC.
Validity Content:
Two studies have examined the content validity of the Chedoke-McMaster Stroke Assessment.
Criterion:
Concurrent:
One study has examined the concurrent validity of the Chedoke-McMaster Stroke Assessment and reported excellent correlation between the Chedoke-McMaster Stroke Assessment total score and the Fugl-Meyer Assessment total score and the Functional Independence Measure (FIM) total score, using Pearson correlation.
Predictive:
One study has examined the predictive validity of the Chedoke-McMaster Stroke Assessment and reported it is a predictor of functional ability and sensorimotor recovery after stroke.
Construct:
Convergent:
Two studies examined convergent validity of the Chedoke-McMaster Stroke 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 Correlation. The other reported excellent 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 validity of the Chedoke-McMaster Stroke 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 Stroke Assessment.
Sensitivity/ Specificity No studies have examined the sensitivity/specificity of the Chedoke-McMaster Stroke Assessment.
Does the tool detect change in patients? Two studies have examined the responsiveness of the Chedoke-McMaster Stroke 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 Stroke 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 therapist. 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 Stroke Assessment in individuals with stroke. We identified six studies. The Chedoke-McMaster Stroke Assessment appears to be responsive in clients with stroke.

Floor/Ceiling Effects

No studies have examined the floor/ceiling effects of the Chedoke-McMaster Stroke Assessment.

Reliability

Test-retest:
Gowland, Stratford, Ward, Moreland, Torresin, Van Hullenar, et al. (1993) examined the test-retest reliability of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, at a mean age of 64 years. Participants were re-assessed with a 5-day interval. The test-retest reliability for the Activity Inventory, as calculated using Intraclass Correlation Coefficient (ICC), 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 reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, 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 reliability, 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 reliability of the Activity Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, 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 reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke Assessment in 32 clients with stroke, 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 reliability of the Impairment Inventory section of the Chedoke-McMaster Stroke 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 reliability 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 Stroke 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 Stroke Assessment.

Huijbregts, Gowland, and Gruber (2000) carried out a survey in 34 clients with stroke 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 Stroke 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 stroke. Using Pearson Correlation Coefficients, the correlation between the Chedoke-McMaster Stroke 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 Stroke Assessment was able to predict sensorimotor recovery at discharge from an active rehabilitation program. Predictive validity of the Chedoke-McMaster Stroke Assessment was examined in 335 active stroke 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 Stroke 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 validity of the Chedoke-McMaster Stroke 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 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 Correlation Coefficients were excellent between the gross motor function index (Activity Inventory) and the Mobility subscale of the FIM (r = 0.90) and between the walking index (Activity Inventory) and the Locomotion subscale of the FIM (r = 0.85).

Sacks et al. (2010) evaluated the construct validity of the Chedoke-McMaster Stroke 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 Correlation Coefficients, were excellent (r=0.92, r=0.91 and r=0.84 respectively). All subscales of the AI and COVS demonstrated excellent correlation at admission, discharge and change from admission to discharge, except for the walking subscale, which was found to have adequate 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 validity, 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 responsiveness of the Activity Inventory and the Functional Independence Measure (FIM) (Keith et al., 1987) in 32 participants with stroke. 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 Stroke 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 correlation (r = 0.74).

Sacks et al. (2010) evaluated the responsiveness of the Activity Inventory (AI) of the Chedoke-McMaster Stroke 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 mean (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 Stroke Assessment

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

Table of contents

Functional Ambulation Categories (FAC)

Evidence Reviewed as of before: 23-06-2011
Author(s)*: Katie Marvin, MSc. (Candidate)
Editor(s): Nicol Korner-Bitensky, PhD OT; Annabel McDermott, OT

Purpose

The Functional Ambulation Categories (FAC) is a functional walking test that evaluates ambulation ability. This 6-point scale assesses ambulation status by determining how much human support the patient requires when walking, regardless of whether or not they use a personal assistive device (Teasdall, Foley & Salter, 2011). The FAC can be used with, but is not limited to, patients with stroke.

In-Depth Review

Purpose of the measure

The Functional Ambulation Categories (FAC) is a functional walking test that evaluates ambulation ability. This 6-point scale assesses ambulation status by determining how much human support the patient requires when walking, regardless of whether or not they use a personal assistive device (Teasell et al., 2011). The FAC does not evaluate endurance, as the patient is only required to walk approximately 10 ft (Holden, Gill, Magliozzi, Nathan & Piehl-Baker, 1984). The FAC can be used with, but is not limited to, patients with stroke.

Available versions

The FAC was developed at Massachusetts General Hospital and first described by Holden et al. in 1984.

Features of the measure

Items:
There are no actual items to the FAC.

To use the FAC, an assessor asks the subject various questions (Mehrholz et al., 2007) and briefly observes their walking ability to provide a rating from 0 to 5 (Collen, Wade and Bradshaw, 1990).

  • A score of 0 indicates that the patient is a non-functional ambulator (cannot walk);
  • A score of 1, 2 or 3 denotes a dependent ambulator who requires assistance from another person in the form of continuous manual contact (1), continuous or intermittent manual contact (2), or verbal supervision/guarding (3)
  • A score of 4 or 5 describes an independent ambulator who can walk freely on: level surfaces only (4) or any surface (5=maximum score) (Holden et al., 1984)

What to consider before beginning:
To prepare for the FAC, the client should be encouraged to:

  • Wear comfortable clothing
  • Wear appropriate footwear
  • Use their usual walking aides during the test (cane, walker, etc.)

To prepare for the FAC, clinicians should be aware that provision of human support to the patient may be required.

Scoring and Score Interpretation:

Score Category Interpretation
0 Nonfunctional ambulator
1 Ambulator, dependent on physical assistance – level I Indicates a patient who requires continuous manual contact to support body weight as well as to maintain balance or to assist coordination.
2 Ambulator, dependent on physical assistance – level II Indicates a patient who requires intermittent or continuous light touch to assist balance or coordination.
3 Ambulator, dependent on supervision Indicates a patient who can ambulate on level surface without manual contact of another person but requires standby guarding of one person either for safety or verbal cueing.
4 Ambulator, independent level surface only Indicates a patient who can ambulate independently on level surface but requires supervision to negotiate (e.g. stairs, inclines, nonlevel surfaces).
5 Ambulator, independent Indicates a patient who can walk everywhere independently, including stairs.

(Mehrholz et al., 2007)

Time:
The average completion time has not been reported, however, it is estimated that the FAC takes approximately 1 to 5 minutes to complete.

Training requirements:
No special training is required to administer the FAC but the administrator should be familiar with the scale prior to its use.

Subscales:
None typically reported.

Equipment:
The FAC does not require any specialized equipment and can therefore be accomplished in community as well as institutional settings.

  • Ten feet path free from obstruction
  • Stairs and uneven terrain in order to evaluate category 5 (Ambulator, independent)

Alternative Forms of the assessment

Also known as Functional Ambulation Classification.
There are no alternative forms of the FAC.

Client suitability

Can be used with:

Patients with stroke/hemiplegia (acute, subacute, and chronic) (Holden et al., 1984, 1986; Hesse et al. 1994)

Other groups tested with this measure:

  • Multiple Sclerosis (Holden et al., 1984, 1986)
  • Cerebral Palsy (Schindl et al., 2000).

Should not be used with:

  • A proxy – because the FAC is administered through direct observation, a proxy respondent cannot be used.

In what languages is the measure available?

No information available. As it is not a measure with specific items that are asked of the patient it is likely the scale can be used by any clinician who understands English sufficiently well to differentiate the coding structure.

Summary

What does the tool measure? It is a functional walking test that assesses ambulation status by determining how much human support the patient requires.
What types of clients can the tool be used for? Clients with stroke, Multiple Sclerosis and Cerebral Palsy.
Is this a screening or assessment tool? Assessment
Time to administer Approximately 1 to 5 minutes.
Versions Also referred to as Functional Ambulation Classification.
There are no alternative versions.
Other Languages None reported.
Measurement Properties
Reliability Test-retest:
One study examined the test-retest reliability of the FAC and found the test to have excellent test-retest reliability (k=.950).

Inter-rater:
Two studies examined the inter-rater reliability of the FAC and found the test to have poor to excellent inter-rater reliabilities (k=.36 and k=.905).

Validity Criterion:
Concurrent:
One study examined the concurrent validity of the FAC and reported excellent correlations with Rivermead Mobility Index, 6 Minute Walk Test, walking velocity and stride length.
Predictive:
One study examined the predictive validity of the FAC in patients with stroke and found it to be an adequate predictor of functional community ambulation 6 months after stroke.
Does the tool detect change in patients? Earlier studies suggested that the FAC may lack responsiveness, especially if using it to distinguish between groups at lower levels of functioning (Teasdall et al., 2011), however, a recent study reported moderates to larges effect sizes when the FAC was used to evaluate change in ambulation over a period of 6-months (Mehrholz et al., 2007). Future research is required to determine the responsiveness of the FAC in assessing patients at various levels of functioning.
Acceptability Administration of the FAC is simple, requiring only brief questioning and observation, thereby creating minimal patient burden.
Feasibility The FAC is quick and easy to use and the scale can be obtained at no cost. Also, there is no equipment that needs to accompany administration of the scale. No formal training is required to administer the FAC but the user should be familiar with the scale prior to its use.
How to obtain the tool? Please visit:
http://www.rehabmeasures.org

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the FAC in individuals with stroke. We identified four studies. More studies are required before definitive conclusions can be drawn regarding the reliability, validity and responsiveness of the FAC.

Floor/Ceiling Effects

No studies have reported on the floor/ceiling effects of the FAC with patients with stroke. However given that it measures the full range of functional walking floor/ceiling effects are not expected.

Reliability

Internal Consistency:
No studies have reported on the internal consistency of the FAC with patients with stroke.

Test-retest:
Mehrholz et al. (2007) examined the test-retest reliability (one week apart) of the FAC by administering the measure to a sample of 55 clients with stroke (< 60 days since onset). The correlation between the two evaluations was excellent (k=.950), indicating that the FAC has excellent test-retest reliability.

Intra-rater:
No studies have reported on the intra-rater reliability of the FAC in patients with stroke.

Inter-rater:
Collen, Wade and Bradshaw (1990) investigated the inter-rater reliability of the FAC in 25 patients with chronic stroke (2 to 6 years of stroke with residual impaired mobility). Inter-rater reliability between examiners, as measured using kappa statistics was found to be be poor (k=0.36).

Mehrholz et al. (2007) examined the inter-rater reliability of the FAC in 55 clients with subacute stroke admitted to a rehabilitation hospital. Clients were within 2-months post stroke. Inter-rater reliability was found to be excellent (k.905). Researchers believe that the use of key questions, video recordings and experienced examiners improved the inter-rater reliability in this study.

Validity

Content:
No studies have reported on the content validity of the FAC with patients with stroke.

Criterion:
No studies have reported on the criterion validity of the FAC with patients with stroke.

Concurrent:
Mehrholz et al. (2007) examined the concurrent validity of the FAC and commonly used measures of gait performance, the Rivermead Mobility Index (RMI), 6 Minute Walk Test (6MWT), walking velocity and stride length in 55 patients with stroke. Evaluations were performed at admission, 2 and 4 weeks, and 6 months. Concurrent validity was measured using Spearman correlations. Correlations between the FAC and RMI, 6MWT, walking velocity and stride length from baseline to 6-months were excellent (k=.841; k=.795; k=767; k=.805 respectively).

Predictive:
Mehrholz et al. (2007) examined whether FAC scores assessed following a 4-week rehabilitation program could predict functional community ambulation at 6-month follow-up in 55 patients with subacute stroke. Community ambulation was defined as the ability to walk faster than 73m/min, longer than 332m, climb stairs and curbs; patients that met all three community ambulation criteria were deemed community ambulators. Predictive validity, as calculated using a Receiver Operating Characteristic (ROC) curve, was highest for ROC cut-off scores ≥ 4 (AUC = 0.89). Thus scoring ≥ 4 on the FAC following a 4-week rehabilitation program is predictive of community ambulation at 6-months.

Sensitivity/Specificity:
No studies have reported on the sensitivity or the specificity of the FAC with patients with stroke.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent/discriminant validity of the FAC with patients with stroke.

Known Groups:
No studies have reported on the known groups validity of the FAC with patients with stroke.

Responsiveness

Earlier studies have suggested that the FAC may lack responsiveness, especially when being used to differentiate between groups at lower levels of functioning (Teasdall et al., 2011). However, a recent study reported moderates to larges effect sizes when the FAC was used to evaluate change in ambulation over a period of 6-months (Mehrholz et al., 2007). Future research is required to determine the responsiveness of the FAC in assessing patients at various levels of functioning.

Mehrholz et al. (2007) assessed the responsiveness of the FAC in evaluating recovery of walking ability in 55 patients with stroke who could not walk without assistance prior to initiating inpatient rehabilitation. The mean score at baseline was 0.44 +/- 0.69 and the mean score at discharge was 2.79 +/- 2.12. The responsiveness to change as measured by the standard response mean (SRM) was was moderate to large: FAC scores changed significantly within the first 2 weeks of the study (SRM=1.016) and between week 4 and study end date at 6 months (SRM=.699); and adequately within weeks 2 and 4 (SRM=.842). The results of this study suggest that the FAC can be used to measure change and outcome in gait performance in patients with stroke.

References

  • Brock, J.A., Goldie, P.A. & Greenwood, K.M. (2002). Evaluating the effectiveness of stroke rehabilitation: Choosing a discriminative measure. Archives of Physical Medicine Rehabilitation, 83, 92-99.
  • Collen, F.M., Wade, D.T. & Bradshaw, C.M. (1990). Mobility after stroke: Reliability of measures of impairment and disability. International Disability Studies, 12, 6-9.
  • Cunha, I.T., Lim, P.A., Henson, H., Monga, T., Qureshy, H. & Protas, E.J. (2002). Performance-based gait tests for acute stroke patients. American Journal of Physical Medicine Rehabilitation, 81, 848-856.
  • Hesse, S., Bertelt, C., Schaffrin, A., Malezic, M. & Mauritz, K.H. (1994). Restoration of gait in nonambulatory hemiparetic patients by treadmill training with partial body-weight support. Archives of Physical Medicine Rehabilitation, 75, 1087-1093.
  • Holden, M.K., Gill, K.M., Magliozzi, M.R., Nathan, J. & Piehl-Baker, L. (1984). Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness. Physical Therapy, 64, 35-40.
  • Holden, M.K., Gill, M.K. & Magliozzi, M.R. (1986). Gait and assessment for neurologically impaired patients. Standards for outcome assessment. Physical Therapy, 66, 1530-1539.
  • Lord, S.E., McPherson, K., McNaughton, H.K., Rochester, L., Weatherall, M. (2004). Community ambulation after stroke: How important and obtainable is it and what measures appear predictive? Archives of Physical Medicine Rehabilitation, 85, 234-239.
  • Mehrholz, J., Wagner, K., Rutte, K., Meiner, D. and Pohl, M. (2007). Predictive validity and responsiveness of the Functional Ambulation Category in hemiparetic patients after stroke. Archives of Physical Medicine Rehabilitation, 88, 1314-1319.
  • Schindl, M.R., Forstner, C., Kern, H. & Hesse, S. (2000). Treadmill training with partial body weight support in nonambulatory patients with cerebral palsy. Archives of Physical Medicine Rehabilitation, 81, 301-306.
  • Simondson, J.A., Goldie, P., Greenwood, K.M. (2003). The Mobility Scale for Acute Stroke Patients: Concurrent validity. Clinical Rehabilitation, 17, 558-564.
  • Stevenson, T.J. (1999). Using impairment inventory scores to determine ambulation status in individuals with stroke. Physiotherapy Canada, 51, 168-174.
  • Teasell, R., Foley, N. C., & Salter K. (2011). EBRSR: Evidence-Based Review of Stroke Rehabilitation. 13th ed. London (ON): EBRSR.

See the measure

How to obtain the Functional Ambulation Categories?

Please visit: http://www.rehabmeasures.org and search “Functional Ambulation Classification” or “Functional Ambulation Categories”.

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