Cone Evasion Walk test (CEW)
Purpose
The Cone Evasion Walk test (CEW) assesses fall risk in individuals in the acute phase of stroke
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:
- 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.
- 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 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 |
Floor/Ceiling Effects | A floor effect was detected among individuals with acute stroke |
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
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
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. More:
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. More 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. More 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 reliability
of the Cone Evasion Walk test in a sample of 20 individuals with acute stroke
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 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. More 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. More, 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 validity
of the Cone Evasion Walking test in a sample of 143 individuals with acute left hemisphere stroke
Responsiveness:
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).
:
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 SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
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.