Cone Evasion Walk test (CEW)

Evidence Reviewed as of before: 24-01-2023
Author(s)*: Annabel McDermott, OT
Editor(s): Annie Rochette, PhD OT
Expert Reviewer: Hanna Sjöholm, PT

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 stroke

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 stroke.

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 stroke.
Is this a screening or assessment tool? Screening
Time to administer 5 minutes
ICF Domain Activity
Versions There is one version of the Cone Evasion Walk test.
Languages Swedish
English
Measurement Properties
Reliability Internal consistency:
No studies have reported on internal consistency of the CEW.
Test-retest:
No studies have reported on test-retest reliability of the CEW.
Intra-rater:
One study reported good to excellent intra-rater reliability of the CEW.
Inter-rater:
One study reported good to excellent inter-rater reliability of the CEW.
Validity 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 validity 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 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 correlation between the CEW and the Timed Up and Go test, and weak to moderate negative correlations between the CEW and the Functional Ambulation Categories, Montreal Cognitive Assessment Serial 7s attention task and Star Cancellation Test.
Known Groups:
One study reported individuals with a right hemisphere stroke were significantly more likely to hit cones on the left side than the right; individuals with a left hemisphere stroke were significantly more likely to hit cones on the right side than on the left.
Floor/Ceiling Effects A floor effect was detected among individuals with acute stroke with good mobility.
Does the tool detect change? No studies have reported on the responsiveness 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 stroke. Two studies were identified.

Floor/Ceiling Effects

Sjoholm et al. (2019) reported a floor effect on the Cone Evasion Walk test in a sample of 221 individuals with acute stroke, whereby 71% of participants (n=211) hit no cones.

Reliability

Internal consistency:
Internal consistency of the Cone Evasion Walk test has not been measured.

Test-retest:
Test-retest reliability of the Cone Evasion Walk test has not been measured.

Intra-rater:
Sjoholm et al. (2019) examined intra-rater reliability of the Cone Evasion Walk test in a sample of 20 individuals with acute stroke using Intraclass Correlation Coefficient (ICC) 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 reliability of the Cone Evasion Walk test in a sample of 20 individuals with acute stroke using Intraclass Correlation Coefficient (ICC) 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 validity 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 validity of the Cone Evasion Walk test has not been measured.

Predictive:
Sjoholm et al. (2019) examined predictive validity of the Cone Evasion Walk test in a sample of 221 individuals with acute stroke using linear regression analysis. There were weak 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 correlation between number of cones touched and number of falls was weak (r=0.31, p=0.02). The 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 validity of the Cone Evasion Walk test by comparison with the Functional Ambulation 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 stroke, using Spearman’s rank correlation coefficient. There was a weak 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 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 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 correlation between the CEW and TUG-Cog.

Known Group:
Sjoholm et al. (2019) examined known-group validity of the Cone Evasion Walking test in a sample of 143 individuals with acute left hemisphere stroke (n=64) and right hemisphere stroke (n=79). Differences between groups were examined using Fisher’s exact test. Among individuals with a right hemisphere stroke, significantly more participants hit cones on the left side than the right (p=0.001). Among individuals with a left hemisphere stroke, significantly more participants hit cones on the right side than on the left (p<0.01).

Responsiveness:

Sensitivity & Specificity:
Sensitivity 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.

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