Image of Speed Walker Falls Gets Up Falls Again

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J Aging Phys Human action. Author manuscript; bachelor in PMC 2016 Apr one.

Published in terminal edited form as:

PMCID: PMC4254896

NIHMSID: NIHMS642780

Walking Speed: The Functional Vital Sign

Abstract

Walking speed (WS) is a valid, reliable, sensitive measure advisable for assessing and monitoring functional status and overall health in a wide range of populations. These capabilities take led to its designation as the "6^th vital sign". By synthesizing the available prove on WS, this scholarly review article provides clinicians with a reference tool regarding this robust measure. Recommendations on testing procedures for assessing WS, including optimal altitude, inclusion of acceleration/deceleration phases, instructions, and instrumentation are given. After assessing an individual'south WS, clinicians demand to know what this value represents. Therefore, WS cut-off values and the corresponding predicted outcomes, also equally minimal detectable change values for specific populations and settings are provided.

Groundwork

The White Paper: "Walking Speed: the Sixth Vital Sign" published in 2009 consolidated available evidence on a robust mensurate, walking speed (Adell, Wehmhorner, & Rydwik, 2013; Afilalo et al., 2010; Castell et al., 2013; Graham, Fisher, Berges, Kuo, & Ostir, 2010; Peters, Fritz, & Krotish, 2013; Quach et al., 2011; Rydwik, Bergland, Forsen, & Frandin, 2012; Shimada et al., 2013; Verghese, Wang, & Holtzer, 2011). Since publication of the original commodity, evidence has emerged regarding updated recommendations on testing protocols. Additional cut-off values and minimal detectable change values have also been reported in the interim. For this reason, the authors decided to follow-up the original white paper with recent show regarding this robust tool. As a valid (Rydwik et al., 2012; Verghese et al., 2011), reliable (Peters, Fritz, et al., 2013; Rydwik et al., 2012), and sensitive (Goldberg & Schepens, 2011; van Iersel, Munneke, Esselink, Benraad, & Olde Rikkert, 2008) measure, WS tests accept found a dwelling in both clinical (Skin, Kuys, & Klein, 2013) and enquiry (Graham, Ostir, Fisher, & Ottenbacher, 2008) settings. Not only is WS indicative of an individual's functional capacity (Verghese et al., 2011) and general health status (Cesari et al., 2005; Studenski et al., 2011), the measure has been shown to exist predictive of a range of outcomes, including response to rehabilitation (Goldie, Matyas, & Evans, 1996), functional dependence (Purser et al., 2005; Shimada et al., 2013; Shinkai et al., 2000), frailty (Castell et al., 2013), mobility disability (Cesari et al., 2005) (Rosano, Newman, Katz, Hirsch, & Kuller, 2008), cerebral decline (Alfaro-Acha, Al Snih, Raji, Markides, & Ottenbacher, 2007) (Inzitari et al., 2007), falls (Montero-Odasso et al., 2005) (Chu, Chi, & Chiu, 2005), institutionalization (Woo, Ho, & Yu, 1999), hospitalization (Montero-Odasso et al., 2005) (Cesari et al., 2005), cardiovascular-related events and mortality (Dumurgier et al., 2009; Matsuzawa et al., 2013), also equally all-cause bloodshed (Studenski et al., 2011) (Blain et al., 2010). An clan has been observed between tedious self-selected WS and lower quality of life (Ekstrom, Dahlin-Ivanoff, & Elmstahl, 2011), decreased participation (Ekstrom et al., 2011), and presence of depressive symptoms (Brandler, Wang, Oh-Park, Holtzer, & Verghese, 2012). Due to the measure's extensive predictive capabilities, besides as ease of assistants, the original article proposed WS be considered the "6th vital sign". Inquiry findings go along to back up this designation (Afilalo et al., 2010; Castell et al., 2013; Elbaz et al., 2013; Matsuzawa et al., 2013; Studenski et al., 2011).

Predictive Capabilities of Walking Speed

Just as with the other vital signs, WS has "cut-off" values that are indicative of specific outcomes. Figure one provides visual representation of the various cutting-off values and the corresponding predicted outcomes from across the literature. The respective tabular array (Table i) provides details regarding the studies included in Figure 1.

Depiction of walking speeds and the associated outcomes. chiliad/s, meters per second; ↑, increased; LE, lower extremity; indep, independent; ADL, activities of daily living; AD, Alzheimer's affliction; 2x, two times; yo, years old; d/c, discharge

* Able to climb several flights of stairs

**More than probable to require long term hospital care than d/c domicile or nursing abode 1. (Studenski et al., 2003), two. (Montero-Odasso et al., 2005), three. (Cesari et al., 2005), 4. (Shimada et al., 2013), 5. (Ainsworth et al., 2011), half dozen. (Studenski, 2009), seven. (Inzitari et al., 2007), 8. (Atkinson et al., 2005), nine. (Ostir, Kuo, Berges, Markides, & Ottenbacher, 2007), x. (Abellan van Kan et al., 2012), eleven. (Friedman, Richmond, & Baskett, 1988), 12. (Graham, Fisher, Berges, Kuo, & Ostir, 2010), xiii. (Perry, Garrett, Gronley, & Mulroy, 1995), xiv. (Salbach et al., 2013)

Table 1

	Population(s)	Blueprint	Sample Size	Historic period, years (mean ± SD)	WS, yard/s†
Studenski et al., 2003	Customs-habitation older adults (age >65 years)	Prospective (1 year)	north = 487	74.ane ± 5.7	0.88 ± 0.22
Montero-Odasso et al., 2005	Community-habitation older adults (age >75 years)	Prospective (2 years)	northward = 102	79.6 ± four	0.27 – 1.33 (range)
Cesari et al., 2005	Community-domicile older adults (age seventy – 79 years)	Prospective (4.9±0.9 years)	n = three,047	74.ii ± 2.9	ane.17 ± 0.24
Shimada et al., 2013	Older adults (historic period >65 years)	Cross-sectional	due north = 10,351	78.8 ± eight	Personal care: 0.7 ± 0.iii No personal intendance: 1.2 ± 0.two
Inzitari et al., 2007	Customs-dwelling older adults (age lxx – 79 years)	Prospective (5 years)	n = 2,276	73.5 ± 2.8	Quartiles*: <one.05, ane.06–one.19, one.20–i.34, ≥1.35
Atkinson et al., 2005	Older women with moderate to astringent disability	Prospective (iii years)	n = 558	78.0 ± viii.i	No decline: 0.83±0.25 Physical decline: 0.68±0.25 Cognitive decline: 0.75±0.16 Combined turn down: 0.62±0.fifteen
Ostir et al., 2007	Mexican-American older adults (age >65 years)	Prospective (7 years)	n = ane,630	72.0 ± 6.1	5 categories based on viii′ walk time*: unable, ≥9.0, half-dozen.0–8.ix, four.0–5.9, ≤3.ix sec
Abellan van Kan et al., 2012	Older women (historic period >75 years)	Prospective (7 years)	n = 647	NR for group(southward)	Dementia complimentary: 0.9±0.two Dementia: 0.eight±0.2
Friedman et al., 1988	Patients in geriatric rehabilitation ward	Prospective (length of stay)	due north = 125	Abode lonely: 74.0±8.5 Abode-carer: 76.3±vii.8 Rest-home: 83.7±viii.5 Hospital: fourscore.v±7.6	Dwelling lone: 0.55±0.28 Home-carer: 0.43±0.23 Rest-home: 0.34±0.19 Hospital: 0.nineteen±0.18
Graham et al., 2010	Acute care older adults (age >65 years)	Cross-sectional	north = 174	75.27 ± 6.91	0.43 ± 0.23
Perry et al., 1995	Individuals >three months postal service-stroke	Cross-sectional	n = 147	55.five ± 12.ii	Functional walking categories: Physiological 0.i±0.05, Limited Household 0.23±0.17, Unlimited Household 0.27±0.12, Nigh-limited Community 0.40±0.18, Least-limited Community 0.58±0.18, Customs 0.80±0.18

Responsiveness of Walking Speed

Walking speed tests can be performed in a variety of settings (Adell et al., 2013; Barthuly, Bohannon, & Gorack, 2012; Bohannon, 2009; Braden, Hilgenberg, Bohannon, Ko, & Hasson, 2012; Fulk et al., 2011; Puthoff & Saskowski, 2013) and are appropriate for apply with a wide range of diagnoses (Chrysagis, Skordilis, Stavrou, Grammatopoulou, & Koutsouki, 2012; Fulk et al., 2011; Hass et al., 2012; Hollman et al., 2008; Horemans, Beelen, Nollet, & Lankhorst, 2004; Kon et al., 2012; Motyl, Driban, McAdams, Price, & McAlindon, 2013; Nair, Hornby, & Behrman, 2012; Nogueira, Dos Santos, Sabino, Alvarenga, & Santos Thuler, 2013; Peel et al., 2013; Puthoff & Saskowski, 2013; Working Grouping on Wellness Outcomes for Older Persons with Multiple Chronic, 2012) making information technology a universal measure out. Refer to Table 2 for further information regarding specific populations and settings. The breadth of information provided by this assessment tool is non limited to inferences made based on a single time point. Every bit a responsive measure (Barthuly et al., 2012; Goldberg & Schepens, 2011; Puthoff & Saskowski, 2013), repeated WS tests can be used to monitor patients over time. For example, in a clinical setting a patient'due south WS at initial evaluation can be compared to their WS at reassessment and discharge; or in a inquiry setting WS may be used to determine changes over the form of a written report and maintenance at follow upwardly. In guild to exist confident that true alter in WS has occurred, the difference between testing sessions needs to exceed the measurement error and natural variability that can occur with repeated measurements. A value that reflects this is the measure's minimal detectable change value (MDC). If an individual'south change in WS between testing sessions exceeds the MDC₉₅, we can exist 95% confident that a true change in WS has occurred. MDC values for self-selected and fast WSs by diagnosis are presented in Table 2. As this is a scholarly, rather than systematic review, the selected studies represent the most recently published values not a consolidation of all high-quality testify. Therefore, clinicians and researchers should exert caution when using the values to determine if true change has occurred. In that location may be more applicative values available in the literature for your specific patients or participants.

Table two

Minimal Detectable Change Values and Testing Protocols by Diagnosis and Setting

DIAGNOSIS	Sample Characteristics†	MDC95		Timed*	Acceleration*
		SS WS	Max WS
Community-home older adultsi	n = 30
All participants	Age threescore+ y	0.14	n/a	4	2
SS WS 0.6–1.0 m/due south	33.3% AD apply	0.xi		iv	two
SS WS >ane.0 m/s	13.3% AD utilise	0.fourteen		four	2
Chronic stroke2 **	n = 61
All participants	Age 63.5±10.0 y	0.18	0.13	ten	ii
MAS=0	25% Ad use	0.2	0.thirteen	10	two
MAS ane-one+	69% Advert utilize	0.18	0.15	10	2
MAS ≥2	59% Advertisement use	0.09	0.07	10	two
Incomplete spinal string injury3	n = 16	0.17	n/a	3.84	0.6 – 0.9
	3–88 mo post-injury
	75% Ad use
Following hip fracture4	n = 16	0.08	north/a	10	one
	Age 77.9±9.0 y
	south/p 4.vii±2.0 d
Multiple Sclerosis5	n = 120	0.26	0.26	10	NR
	MAS LE 1.6±ii.nine
	6MWT 484.1±181.2m
Parkinson's Illness6	n = 88	0.09	0.13	10	2
	47% H&Y Stage one
	25% H&Y Stage ii
	28% H&Y Phase 3/four
Huntington's Diseaseseven	n = 81
Pre-manifest	UHDRS TMS 2±2	0.23	due north/a	10	2
Manifest	UHDRS TMS 39±xviii	0.34		10	ii
Early-Phase	UHDRS TMS 28±eighteen	0.xx		ten	2
Middle-Phase	UHDRS TMS 40±fifteen	0.46		10	two
Late-Stage	UHDRS TMS 48±17	0.29		x	2
Alzheimer's Illness8	n = 51	0.16	n/a	4.57	NR
	Historic period 80.71±8.77 y
	76.v% living at habitation
	<50% Advertising use
Dementia9	n = 58	0.27	due north/a	six	NR
	Historic period 82.47±5.31 y
	34% Nursing Domicile
	44.8% AD use
SETTING
Short term rehabilitation10	northward = 136	0.xiii	due north/a	5.two	1
	TKA (36)
	Infection (13)
	THA (10)
	Fracture (x)
	Stroke (vii)
	Cardiopulmonary (22)
	Other (38)
Acute careeleven	northward = 46	0.18	northward/a	3	one.v
	Orthopedic (18)
	Cardiopulmonary (13)
	GI/Genitourinary (6)
	CNS (3)
	Other (6)
Cardiac rehabilitation12	n = 49	0.sixteen	north/a	4	ane
	PCI (19)
	CABG (16)
	MI (7)
	Other (7)
Residential Care Unit13	n = 31	n/a	0.31	10	2
	Age 74–100 y
	77% Advertising use

The absolute change is non the only variable of interest; an individual'south WS trajectory has health implications too. Walking speed trajectories demonstrating rapid reject are associated more strongly with mortality than trajectories that are more stable (White et al., 2013). Therefore, determining rate of modify, in add-on to corporeality of change, of an individual's WS may be of value.

Recommendations on Assessment Procedures

A variety of testing protocols are available for assessing WS. Procedures differ in regards to altitude (2 meters to 40 meters) (Rydwik et al., 2012), beginning (static versus dynamic) (Phan-Ba et al., 2012), path (directly versus turn) (van Herk, Arendzen, & Rispens, 1998), speed (self-selected versus maximal) (Rydwik et al., 2012), instruction (eastward.1000. "walk at a comfortable pace" versus " walk every bit if yous are taking a stroll through the park") (Nascimento et al., 2012), and timing instrument (due east.yard. stopwatch, automatic timer, instrumented walkway) (Peters, Fritz, et al., 2013; Youdas et al., 2010). Although a standardized protocol has non been adopted, there is evidence available to help guide WS test selection. Clinicians may want to consider administering WS tests of 10 meter distances and less equally they are more clinically feasible than longer walkways. When selecting a distance within this range, the psychometric properties of the various tests must exist taken into account. A study conducted by Ng, et al (2013) found no significant differences betwixt WSs calculated via 5, 8, or 10 meter walkways in older adults (Ng et al., 2013) or individuals with stroke (Ng, Ng, Lee, Ng, & Tong, 2012). These results held for both self-selected and maximal WS tests (Ng et al., 2013). Since findings betoken that walkways ranging in length from 5 to ten meters produce similar results, the distance in that range most suited to the environment can be used. Caution may demand to exist exercised, yet, if considering a walkway shorter than v meters.

Although the original White newspaper indicated that distances every bit short every bit three meters (approximately 10′) could be used, recommendations take been revised based on recent evidence. Results from a study conducted by Peters, et al, signal that while a 4 meter walk test is a reliable option for older adults, WSs calculated via this method do non demonstrate sufficient concurrent validity with the 10 meter walk test to be used interchangeably (Peters, Fritz, et al., 2013). Therefore, WSs calculated via the 4 meter walk examination can be compared across testing sessions, but should not be compared to x meter walk test results for determining changes over time. Like results were found in a written report comparing a 3 meter walk test to the GAITRite^® electronic walkway in individuals with chronic stroke (Peters, Middleton, Donley, Blanck, & Fritz, 2013). Lack of concurrent validity with longer WS tests is a potential limitation of 4 meter assessments and those of fifty-fifty shorter distances. To maximize clinical feasibility, while maintaining psychometric soundness, clinicians may desire to select WS tests ranging from 5 to 10 meters in length.

The recommended 5 to x meter length refers to the timed altitude. Clinicians may also want to contain acceleration and deceleration phases. Standardized dispatch and deceleration distances are not established and some uncertainty exists over whether or not these phases are necessary (Graham et al., 2008). However, assuasive acceleration and deceleration to occur outside of the timed portion may allow for a more accurate assessment of cocky-selected and maximal WSs (Macfarlane & Looney, 2008). WSs calculated without an dispatch phase (static get-go) are slower than WSs calculated via dynamic start protocols (Phan-Ba et al., 2012). Exclusion of an acceleration phase may innovate greater variability into WS measurement, which hinders the ability for the test to capture true change (Macfarlane & Looney, 2008). Recommended acceleration stage distances range from 2.17 (salubrious) (Macfarlane & Looney, 2008) to 2.5 (frail) (Lindemann et al., 2008) meters for older adults. A greater altitude is required to reach steady land maximal WS. For maximal tests, recommended acceleration phase distances are 3.23 meters (Macfarlane & Looney, 2008) for healthy older adults and 3 meters (Phan-Ba et al., 2012) for individuals with Multiple Sclerosis. As acceleration and deceleration during the timed portion of WS tests tin can increase variability, the use of a straight path protocol has advantages over a path that includes a plow (east.m. 10 meter path rather than 5 meter 10 ii path) (Graham et al., 2008; van Herk et al., 1998). Turning non simply requires adjustments in speed, it also increases the complexity of the test making it harder to standardize over multiple cess sessions and between individuals.

Administering both self-selected and maximal WS tests may provide a more than complete picture of a patient than either test in isolation (Dobkin, 2006). While an private's self-selected or usual WS is indicative of electric current functional condition (Verghese et al., 2011) and numerous health outcomes (Abellan van Kan et al., 2009; Castell et al., 2013; Dumurgier et al., 2009), maximal WS provides information regarding an individual'south capabilities in the customs (Dobkin, 2006; Salbach et al., 2013). For example, in the United States WSs of i.32 m/south or greater are required to ensure condom street crossing (Salbach et al., 2013). During testing, method of instruction to achieve actual maximum speed may demand to be taken into business relationship. In individuals with chronic stroke, instructions including the addition of a "real life" example (east.1000. "accomplish a charabanc that is most to pull out") or demonstration by the clinician were found to upshot in greater maximal WSs compared to traditional simple instructions (e.grand. "walk as fast as possible and safely, but without running") (Nascimento et al., 2012). These results may hold for other populations besides. Regardless of arroyo decided upon, instructions should exist consequent beyond testing sessions every bit differing methods have been shown to produce significantly different results (Nascimento et al., 2012). Being able to increase WS in response to ecology demands is an important aspect of functional mobility and prophylactic. Therefore, maximal WS should exist assessed in addition to cocky-selected WS equally function of a comprehensive evaluation (Nascimento et al., 2012).

A variety of instruments are available for measurement of cocky-selected and maximal WSs including cease watches, automatic timers, and instrumented walkways. While use of a stopwatch requires the assessor to start/end the stopwatch as a patient crosses into and out of the timed department, automatic timers are electronic devices triggered to start/stop timing as an individual walks by. Another electronic option is an instrument walkway. Evidence suggests that WSs captured via instrumented walkways are less variable than those calculated using a stopwatch and marked walkway (Youdas et al., 2010). Withal, the expense of instrumented walkways limits their clinical feasibility. Use of a stopwatch and a marked walkway remains a valid (Shimada et al., 2013) and reliable (Adell et al., 2013; Phan-Ba et al., 2012; Puthoff & Saskowski, 2013) option. Non only is this option more than clinically feasible, it has been shown to be every bit reliable equally automatic timers for assessing WS in older adults (Peters, Fritz, et al., 2013).

Clinical Message

Consolidation of evidence supports the use of WS tests to assess and monitor a wide range of populations (Chrysagis et al., 2012; Fulk et al., 2011; Hass et al., 2012; Hollman et al., 2008; Horemans et al., 2004; Kon et al., 2012; Motyl et al., 2013; Nair et al., 2012; Nogueira et al., 2013; Puthoff & Saskowski, 2013; Working Group on Health Outcomes for Older Persons with Multiple Chronic, 2012). Clinicians should consider administering tests with timed distances of 5 to 10 meters (Ng et al., 2012; Ng et al., 2013) and dispatch phases of approximately 2.5 meters for cocky-selected speeds (Lindemann et al., 2008; Macfarlane & Looney, 2008) and 3.25 meters for maximal WSs (Macfarlane & Looney, 2008). A straight path should be used in order to capture steady state WS rather than including a turn (van Herk et al., 1998). Hand held stopwatches can exist used for timing (Peters, Fritz, et al., 2013) and the path can exist marked with tape. If working in an surround where record cannot be applied to surfaces, some other easy option is for clinicians to deport a thin rope that is the length of the unabridged distance (including dispatch/deceleration phases) and clearly marked with the timed section. The rope tin can then exist temporarily laid out during performance of the test. This easily transportable option allows for testing anywhere within the setting, so may be useful in home wellness, acute intendance, skilled nursing, or long term care facilities where clinicians perform evaluations and treatments in multiple areas. For maximal WS tests, improver of "real life" examples or demonstration to uncomplicated instructions may effect in greater, and therefore more than accurate, speeds. The recommendations regarding WS assessment presented in this review are provided as a guide for clinicians to help them select the about appropriate protocol for their specific patient and environment. Regardless of protocol called, the important take home message is that consistency across testing sessions must exist maintained in guild for accurate conclusions to be drawn.

Assessment of a patient'due south WS can exist used to guide clinical controlling. Equally a screening tool, WS can identify those at-risk of agin outcomes or in demand of intervention (Cesari et al., 2005; Montero-Odasso et al., 2005). Walking speed is the result of a complex interplay of multiple torso structures and functions; proactive and reactive postural control (Woollacott & Tang, 1997), lower extremity force (Bohannon, 1997) (Clark, Manini, Fielding, & Patten, 2013), aerobic capacity (Fiser et al., 2010), proprioception (Park, Kim, & Lee, 2013), and vision (Aartolahti et al., 2013) all contribute to WS. Therefore, patients who nowadays with WSs indicative of harm warrant further testing to determine the crusade(s) of their decreased speed. Depending on the assessors' scope of practice, the results tin can then be used as targets of intervention or reasons for referral to appropriate healthcare professionals.

Evidence continues to validate the prognostic and predictive values of WS, and accordingly, the measure's popularity as the "6th vital sign" has not waned over time. As with any other vital sign, WS is a simple assessment that provides a wealth of information about underlying physiological processes. The value far out ways the price, and clinicians should consider incorporating this vital sign into all comprehensive evaluations.

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Recommendations for cess of walking speed

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