The modified Gait Abnormality Rating Scale for recognizing the risk of recurrent falls in community-dwelling elderly adults.[VanSwearingen JM, Paschal KA, Bonino P, Yang yang (yang) [Chinese] in Chinese philosophy, the active, positive, masculine principle that is complementary to yin; see yin, under principle. JF. The modified Gait Abnormality Rating Scale "Gait Abnormality Rating Scale (GARS) (Wolfson et al., 1990); this is a videotape-based analysis of 16 facets of gait. The scale comprises three categories: • five general categories • four lower extremity categories • seven trunk, head and upper extremity categories. for recognizing the risk of recurrent falls in community-dwelling elderly adults. Phys Ther. 1996;76:994-1002.] Key Words: Accidental falls, Assessment, Gait analysis gait analysis Rehab medicine Evaluation of the gait of Pts with a neurologic or orthopedic condition affecting the motor control system–eg, brain injury, spinal cord injury, cerebral palsy, stroke, multiple sclerosis, musculoskeletal actuator systems, post , Geriatrics geriatrics (jĕrēă`trĭks), the branch of medicine concerned with conditions and diseases of the aged. Many disabilities in old age are caused by or related to the deterioration of the circulatory system (see arteriosclerosis), e.g. . For community-dwelling older adults, mobility is a major factor contributing to independence.[1,2] Loss of independence frequently follows a fall or injury associated with a fall.[3] The more frequently falls occur, the greater the likelihood of mortality and morbidity for the older adult. Thus, a primary objective of geriatric assessment geriatric assessment, n the evaluation of the physical, mental, and emotional health of elderly patients. is identifying the older person with a history of falls.[4] Researchers[5-9] have assessed the mobility of older adults by studying distance and temporal characteristics of gait gait (gat) the manner or style of walking. antalgic gait a limp adopted so as to avoid pain on weight-bearing structures, characterized by a very short stance phase. . Changes in gait have been related to a history of falls among frail older adults (adults over 60 years of age with difficulty in one to three activities of daily living[10] and decreased physiologic reserve increasing their risk of disability[11]). Among frail older adults, an increased risk for falling has been associated with decreased walking speed, decreased step or stride length stride length Biomechanics The distance between 2 successive placements of the same foot, consisting of 2 step lengths; SL measured between successive positions of the left foot is always the same as that measured by the right foot, unless the subject is walking in a curve ,[12-14] increased step width,[15] and increased variability of stride length and width.[16] Wolfson et al[12] developed a videotaped system for rating qualitative abnormalities of gait that may be representative of older individuals who have an increased risk for falling, the Gait Abnormality Rating Scale (GARS GARS Gilliam Autism Rating Scale GARS Glycinamide Ribonucleotide Synthetase GARS Geological Applications of Remote Sensing GARS Groningen Activity Restriction Scale GARS Government Administrative Rate Supplement GARS Global Area Reference System ). The GARS was designed to provide a simple clinical assessment of gait abnormalities Persons suffering from peripheral neuropathy experience numbness and tingling in their hands and feet. This can cause difficulty in walking, climbing stairs and maintaining balance. and for implementation in a nursing home setting where there are time constraints In law, time constraints are placed on certain actions and filings in the interest of speedy justice, and additionally to prevent the evasion of the ends of justice by waiting until a matter is moot. , limited instrumentation, and minimal financial resources for assessment. The GARS is supposed to include variables that are intended to provide a description of gait associated with an increased risk of falling. The variables in the original GARS were variability of stepping and arm movements, guardedness (de, a lack of propulsion Propulsion The process of causing a body to move by exerting a force against it. Propulsion is based on the reaction principle, stated qualitatively in Newton's third law, that for every action there is an equal and opposite reaction. or commitment to stepping), weaving weaving, the art of forming a fabric by interlacing at right angles two or more sets of yarn or other material. It is one of the most ancient fundamental arts, as indicated by archaeological evidence. , waddling, staggering, percentage of time in the swing phase of the gait cycle, foot contact, hip range of motion (ROM), knee ROM, elbow extension, shoulder extension, shoulder abduction Abduction Balfour, David expecting inheritance, kidnapped by uncle. [Br. Lit.: Kidnapped] Bertram, Henry kidnapped at age five; taken from Scotland. [Br. Lit. , arm-heel-strike synchrony synchrony /syn·chro·ny/ (-krah-ne) the occurrence of two events simultaneously or with a fixed time interval between them. atrioventricular (AV) synchrony , head held forward, shoulder held elevated, and upper trunk flexed forward. The developers of the GARS suggested that the original 16-item scale be "streamlined" to 7 items by eliminating items that (1) appeared to demonstrate little difference between groups of fallers and nonfallers, (2) appeared to be difficult to rate visually, (3) generally had the lowest interrater reliabilities, and (4) were redundant with other variables.[12] To be useful, a measure of risk for falling among community-dwelling, frail older adults should (1) be usable in settings where geriatric assessments normally take place and (2) yield reliable and valid measurements. A streamlined version of the GARS appears to be appropriate for assessment of the elderly patient if the reliability and validity for predicting falls are acceptable. Concurrent validity concurrent validity, n the degree to which results from one test agree with results from other, different tests. with walking speed and stride length and interrater reliability of measurements obtained with the original GARS have been demonstrated for a nursing home population of older adults but not for communitydwelling older persons.[12] We chose to study the clinical use of a seven-item version of the OARS OARS See Opening Automated Reporting Service (OARS). , the modified Gait Abnormality Rating Scale (GARS-M), to determine the reliability and validity of the scale for assessing fall risk among a sample of community-dwelling, frail older adults. We expected the shortened scale to have acceptable reliability because only the variables previously found to be most reliable are scored[12] in the OARS-M and the reduction in the number of items lessens the time for scoring and the number of opportunities for errors in scoring. In addition to testing the modified scale on a communitydwelling population, we also determined the intrarater reliability for multiple raters and the concordance concordance /con·cor·dance/ (-kord´ins) in genetics, the occurrence of a given trait in both members of a twin pair.concor´dant con·cor·dance n. of individual variable scores between raters (Kappa statistic statistic, n a value or number that describes a series of quantitative observations or measures; a value calculated from a sample. statistic a numerical value calculated from a number of observations in order to summarize them. ). The purpose of our study was to assess the reliability and validity of measurements obtained with the GARS-M. Interrater and intrarater reliability were determined for OARS-M scores obtained by three physical therapist raters. Concurrent validity of the OARS-M was demonstrated by comparison with quantitative measures of gait speed and stride length. Finally, construct validity construct validity, n the degree to which an experimentally-determined definition matches the theoretical definition. of the OARS-M in the assessment of recurrent fall risk was suggested by the ability of the OARS-M score to distinguish between community-dwelling, frail older persons with a history of falls and frail older persons without a history of falls. Method Subjects Participants in the study were veterans referred to the Geriatric geriatric /ger·i·at·ric/ (jer?e-at´rik) 1. pertaining to elderly persons or to the aging process. 2. pertaining to geriatrics. ger·i·at·ric adj. 1. Evaluation and Management (GEM) Program of the University Drive Veterans Administration Medical Center (Pittsburgh, Pa) for evaluation. In the GEM Program, an interdisciplinary team interdisciplinary team, n a group that consists of specialists from several fields combining skills and resources to present guidance and information. approach is used to assess and manage community-dwelling, frail older veterans. The target population for the GEM Program has been community-dwelling older veterans who are experiencing difficulty managing daily activities and responsibilities needed for community dwelling. Nonambulatory older veterans and those with severe dementia or acute terminal illness are generally not seen by the GEM Program team.[13,14] The Biomedical bi·o·med·i·cal adj. 1. Of or relating to biomedicine. 2. Of, relating to, or involving biological, medical, and physical sciences. Institutional Review Board of the University of Pittsburgh approved the study of the physical assessment of ambulation am·bu·late intr.v. am·bu·lat·ed, am·bu·lat·ing, am·bu·lates To walk from place to place; move about. [Latin ambul and fall risk among frail older veterans and waived the requirement of informed consent, as the assessments are part of the typical evaluation of the GEM Program in which the subject had agreed to participate. Fifty-two community-dwelling, frail older veterans referred to the GEM Program team for evaluation from December 1991 through December 1993 participated. Veterans referred to the GEM Program who demonstrated the ability to follow verbal requests for movement or tasks, had sufficient strength of the ankle dorsiflexor and planter-flexor muscle groups to move against gravity, and ambulated without assistive devices assistive device Public health Any device designed or adapted to help people with physical or emotional disorders to perform actions, tasks, and activities. See Americans with Disabilities Act, Architectural barriers, Assistive technology. other than a straight cane participated. Because the population seen was predominantly male and because of the difficulty of obtaining a meaningful number of female veterans (in the time period indicated, only 1 female veteran was evaluated by the GEM Program team but was excluded from the analyses in the study), subjects were male veterans only. Characteristics of the subjects, including fall status, are presented in Table 1. The subjects' mean age was 74.8 xcars (SD=6.75, range=61-95), their mean height was 148.0 cm (SD=8.03, range=115.5-160.6), and their mean weight was 80.6 kg (SD= 15.40, range=48.2-119.1). No differences were noted for age, height, or weight between the subjects with a history of falls and the subjects without a history of falls. Measurements History of falls. Each subject or the caregiver accompanying the subject reported the number of times the subject had fallen in the past year to the GEM Program clinical nurse specialist clinical nurse specialist n. A nurse who has advanced knowledge and competence in a particular area of nursing practice, such as in cardiology, oncology, or psychiatry. in a structured interview. A fall was defined as any unexpected loss of balance resulting in coming to rest on the ground or floor.[2,17] This definition, previously used by investigators studying community-dwelling older adults,[2,17] was used because we assessed fall history by self-report or proxy report from memory and the definition is amenable AMENABLE. Responsible; subject to answer in a court of justice liable to punishment. to data collection by self-report or proxy report. Two or more falls a year represents a substantially greater risk of falling than that of the older person who fell once or not at all in the previous year.[2,17] Gait analysis. Determination of the GARS-M score involved using a standard camcorder for recording the subject walking at a self-selected pace on the smooth tile surface of the hallway of an outpatient clinic. Subjects walked past the camcorder, turned around, and walked back past the camera so that anterior anterior /an·te·ri·or/ (an-ter´e-or) situated at or directed toward the front; opposite of posterior. an·te·ri·or adj. 1. Placed before or in front. 2. , posterior posterior /pos·ter·i·or/ (pos-ter´e-er) directed toward or situated at the back; opposite of anterior. pos·te·ri·or adj. 1. Located behind a part or toward the rear of a structure. , and lateral views from both sides of the subject could be recorded for scoring purposes.[12] The distance walked was approximately 76 m (25 ft) in each direction, for a total distance of about 152 m (50 ft). Videotapes of the walks were replayed on standard video-monitoring equipment, allowing for repeated playback and slow-action and stop-action viewing of the walk. This method was designed to make use of the gait rating system easy and quick to perform, as Wolfson et al[12] noted in describing the development of the scale. Scoring from the videotape videotape Magnetic tape used to record visual images and sound, or the recording itself. There are two types of videotape recorders, the transverse (or quad) and the helical. record also saves the time and energy of the frail older person during the clinical evaluation clinical evaluation Medtalk An evaluation of whether a Pt has symptoms of a disease, is responding to treatment, or is having adverse reactions to therapy . Each of the seven items of the GARS-M was scored on the criterion-based rating scale (0-3) reported for the original GARS[12] (Appendix, page 1002). In scale order, the GARS-M consisted of the following items: (1) variability, (2) guardedness, (3) staggering, (4) foot contact, (5) hip ROM, (6) shoulder extension, and (7) arm-heel-strike synchrony. Gait characteristics were recorded as described by Wolfson et al[12] and Cerny.[18] The participants wore permanent markers A permanent marker is a type of marker pen that is used to create permanent writing on an object. Generally the liquid is water resistant, contains the toxic chemical xylene or toluene, and is capable of writing on a variety of surfaces from paper to metal to stone. attached with masking mask·ing n. 1. The concealment or the screening of one sensory process or sensation by another. 2. An opaque covering used to camouflage the metal parts of a prosthesis. tape to the back of the heel of the shoe, with the tip of the marker just touching the floor, during a timed walk on a 6-m brown-paper walkway walkway Rehabilitation medicine An instrument used to measure the timing of foot contact and or position of the foot on the ground . Stride length and walking speed were determined from the measures of three central strides of the walk to avoid any acceleration or deceleration deceleration /de·cel·er·a·tion/ (de-sel?er-a´shun) decrease in rate or speed. early deceleration effects of initiating or stopping a walk. The physical therapists were unaware of the subjects' fall status prior to recording gait performance. Thus, scoring of the GARS-M and measurement of gait characteristics occurred without the potential of rater rat·er n. 1. One that rates, especially one that establishes a rating. 2. One having an indicated rank or rating. Often used in combination: a third-rater; a first-rater. bias because of knowledge of the subjects' history of falling. Reliability of the GARS-M scoring. The GARS-M score was determined independently by three physical therapist raters (three of the authors: JMVS, KAP, and JFY JFY Just for You JFY Jobs for Youth JFY Japanese Fiscal Year ), on two separate occasions, for a subset of the subjects, the first 23 veterans included in the study. One of the physical therapist raters (rater l) had less than 2 years of clinical experience, whereas the other two raters had greater than 14 years of experience each and specific experience in geriatric performance-based physical assessments. Approximately 7 to 10 days separated the first and the second trials of scoring the GARS-M, with the second trial occurring at least 7 days after the first trial. Raters participated in a training session prior to the independent ratings to facilitate the consistency of scoring. The videotapes of five pilot subjects were played, using the slow-action and stop-action modes frequently while the raters discussed scoring of each of the seven variables. Training continued until agreement among all raters was reached on the scoring of each variable for all of the pilot subjects. No discussion of scoring the GARS-M occurred after completion of the training session. Data Analysis Intrarater and interrater reliability of the GARS-M scoring were determined by two statistical methods. Cohen's Kappa Cohen's kappa coefficient is a statistical measure of inter-rater reliability. It is generally thought to be a more robust measure than simple percent agreement calculation since κ takes into account the agreement occurring by chance. statistic (K) for determining proportion of nonchance agreement[19] was used to describe the extent of agreement for scores of each of the seven individual items. Total scores were considered aggregate data, and the reliability was described using the intraclass correlation In statistics, the intraclass correlation (or the intraclass correlation coefficient[1]) is a measure of correlation, consistency or conformity for a data set when it has multiple groups. coefficient (ICC ICC See: International Chamber of Commerce [2,1]).[20] The total GARS-M score is a sum of the seven individual items, and the total score represents a rank ordering of risk for falling based on the number of gait abnormalities recognized and the severity of any abnormality abnormality /ab·nor·mal·i·ty/ (ab?nor-mal´i-te) 1. the state of being abnormal. 2. a malformation. ab·nor·mal·i·ty n. identified. The rank ordering of the original GARS total score was previously demonstrated by the association of greater GARS scores with more abnormal gait.[12] The ICC is an appropriate reliability coefficient for demonstrating the extent to which raters indicate similar rank orderings.[21] The Kappa was designed as an index of assessment, indicating the concordance between individual ratings, and loses the ordering information contained in a scale when used for ordered data.[22] The ratings for the GARS-M by the three raters were compared using the Kappa statistic in three ways: determination of intrarater reliability (agreement between two trials of the same rater), determination of interrater reliability (agreement among three raters for the same trial), and analysis of individual item scores (agreement of scores for an item, by all raters, for both trials). The Kappa values for each of the seven gait variables rated were averaged into a generalized Kappa[23] across the entire GARS-M for the determinations of intrarater and interrater reliability. Concurrent validity was indicated by comparison of the GARS-M scores with a "gold standard," quantitative gait characteristics (stride length and walking speed) previously associated with an increased risk of falls among older adults.[5-7] Spearman spear·man n. A man, especially a soldier, armed with a spear. rank-order correlation coefficients Noun 1. rank-order correlation coefficient - the most commonly used method of computing a correlation coefficient between the ranks of scores on two variables rank-difference correlation, rank-difference correlation coefficient, rank-order correlation (r) of the GARS-M score and stride length and the GARS-M score and walking speed were calculated to characterize the relationship between the gait measures. For the determinations of concurrent and construct validity in this study, one of the physical therapist raters (JMVS) with experience in geriatric assessment, the use of physical performance measures, and clinical gait assessment (including the GARS-M) rated all of the videotaped walks using the GARS-M criteria. Construct validity was evaluated by the ability of the GARS-M to distinguish between older individuals with and without a history of falls, as indicated by self-report or proxy report, previously shown to be an indication of relative risk of falling again.[1,2,15] An independent t test was used to determine whether a difference existed between the GARS M scores of older adults with a history of falls and the GARS-M scores of older adults without a history of falls. Result Intrarater Reliability Comparison of the individual scores for the seven items of the GARS-M by the same rater for two trials using the Kappa statistic yielded generalized Kappa values of agreement of .493, .583, and .676 for the three raters. The physical therapist rater (JMVS) who scored the GARS-M for the validity determinations in this study demonstrated a Kappa coefficient of agreement of .676 for intrarater reliability. According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. Landis and Koch,[24] the Kappa values reported would be interpreted as an indication of moderate agreement (K=.41-.60) to substantial agreement (K=.61-.80) . A Kappa value near zero is considered chance agreement. Very high Kappa values are frequently restricted, particularly with limited variability of the data.23 Comparison of the first and second trial scores for each of the three raters yielded ICCs for intrarater reliability for the GARS-M total scores of .968, .950, and .984. Interrater Reliability Comparison of the three raters' individual scores for all seven GARS-M items yielded generalized Kappa measures of agreement for interrater reliability of .577 for the first trial and .603 for the second trial. Clinical experience in observational gait analysis may have been a factor influencing interrater reliability. The two more experienced physical therapists (raters 2 and 3) demonstrated higher interrater reliability for the first and second trials (K=.789 and .886) compared with the least experienced physical therapist (rater 1). The generalized Kappa values for the same comparison between the rater 1 and either of the other raters ranged from .417 to .457 for the four comparisons (Tab. 2). The ICCs for comparison of the GARS-M total scores for the three raters were .968 and .975 for the two trials. The ICCs for comparison of total GARS-M scores were highly reliable, regardless of the rater's clinical experience (Tab. 2). Table 2. Interrater Reliability for the Modified Gait Abnormality Rating Scale (GARS-M) Generalized Across Individual Variables Scores and for the Total GARS-M Score
Individual Varibale Total
Score GARS-M
Observed Score
Raters Trial Agreement K(a) ICC(b)
1 and 2 1 .610 .417 .932
1 and 2 2 .625 .431 .944
1 and 3 1 .644 .457 .974
1 and 3 2 .641 .447 .943
2 and 3 1 .861 .789 .951
2 and 3 2 .991 .886 .993
1, 2 and 3 1 .721 .577 .968
1, 2 and 3 2 .739 .603 .975
(a) Kappa for individual variables averaged into a generalized Kappa for the entire scale. (b) ICC = intraclass correlation coefficient. Individual item scores determined by three raters for both the first and second trials were compared to describe the reliability of scoring any specific, individual item of the scale. Based on the comparison of six scores for each item, Kappa values were within the moderate agreement range for all variables, with the exception of the variable staggering. The Kappa value for staggering (K= - .490) indicated less than chance agreement for scoring of this item. Of the 138 individual scores for the variable staggering (de, ratings of three raters, for two trials, for 23 participants), a score of zero occurred for 124 of 138 individual ratings. The low amount of variability for scores for staggering may have contributed to the poor agreement of scores for this GARS-M variable (Tab. 3). Table 3. Reliability of Scoring Individual Variables of the Modified Gait Abnormality Rating Scale (GARS-M)(a)
Observed
Variable Agreement K
Variability .812 .635
Guardedness .758 .587
Staggering .471 -.490
Foot contact .641 .451
Hip range of motion .708 .533
Shoulder extension .753 .613
Arm-heel-strike synchrony .656 .485
(a) Comparison of 138 scores for each item (ie, three raters, two trials, 23 participants). Concurrent Validity Mean stride length, walking speed, and GARS-M scores are shown in Table 4. Subjects with a history of falls took shorter strides ([bar X]=72.12 cm) than did subjects without a history of falls ([bar X]=97.24 cm). Subjects with a history of falls also walked slower ([bar X]=47.19 cm/s) than did subjects without a history of falls ([bar X]=71.55 cm/s). The relationship between stride length and the GARS-M scores illustrated that the subjects with shorter stride lengths showed more characteristics of risk for recurrent falls (r= - .754) (Fig. 1). A similar relationship between walking speed and the GARS-M scores existed, with slower walking speed associated with increased characteristics of the risk for falling (r= - .679) (Fig. 2).
Table 4.
Gait Characteristics of Participants
No
Recurrent Recurrent
Falls (n=36) Falls (n=16) All (N=52)
[bar]X SD [bar]X SD [bar] SD
Stride length (cm) 72.12 23.44 97.24 20.45 79.85 25.24
Walking speed
(cm/s) 47.19 23.52 71.55 24.40 54.69 26.15
GARS-M(a) score 9.0 4.59 3.8 3.37 7.42 4.87
(a) GARS-M = modified Gait Abnormality Rating Scale.
Construct Validity The GARS-M score distinguished between the subjects with and without a history of more than one fall in the year preceding the study. The mean GARS-M score for subjects with a history of falling ([bar X]=9.0) was higher than the mean GARS-M score of subjects without a history of falling ([bar X]=3.8) (t=4.583; df=2,50; P<.000). Discussion The results of the study indicate that GARS-M scores are reliable and provide a valid measure of some gait variables and the abnormalities associated with an increased risk of falling among community-dwelling older adults. Like the GARS[12] in the nursing home setting, the GARS-M is the first visually referenced measure of qualitative characteristics of gait with an acceptable level of reliability and validity for the evaluation of gait of community-dwelling older adults. Although observational gait-analysis methods, including videotaped methods, are the most widely used measures of gait assessment in the clinic,[25] the reliability and validity of measurements obtained with observational methods are lacking. Unlike the findings among community-dwelling older adults reported by Wolfson et al,[12] the community-dwelling, frail older subjects at risk for falling in our study could be distinguished from those not at risk by stride length, walking speed, and GARS-M scores (t= - 3.905; df=2,50; P<.000; t= - 3.359; df=2,50; P<.002; t=4.583; df=2,50; P<.000, respectively). The ability to distinguish between persons at risk for falling and those not at risk for falling may be due in part to the relative frailty frailty Vox populi A state of delicacy or weakness which, which encompasses age-related fragility, in particular osteoporosis. See FICSIT, Osteoporosis. of the community-dwelling older persons studied. Our subjects generally demonstrated a shorter stride length and a slower walking speed than did subjects in other studies of gait abilities of community-dwelling older adults. The stride and speed measurements recorded for our subjects (Tab. 4) are generally between the previously reported values for community-dwelling older adults (stride length=66-83 cm, walking speed=100-120 cm/s) and nursing home residents (stride length=53-82 cm, walking speed=37-64 cm/s).[12] The interrater reliability demonstrated for the GARS-M scores in our study was higher than the interrater reliability previously demonstrated by Eastlack et al[25] for ratings of spatiotemporal spa·ti·o·tem·po·ral adj. 1. Of, relating to, or existing in both space and time. 2. Of or relating to space-time. [Latin spatium, space + temporal1. variables of gait (K=.11-.52, ICC=.19-.69). The inclusion of a training session for raters prior to data collection may be an important factor contributing to the improved reliability. In two similar studies of videotaped observational gait analysis[12,26] (including the study of the original GARS) in which training sessions for raters were conducted before data collection, the ICCs[26] and Spearman coefficientst[12] for interrater reliability demonstrated were interpreted to be in the fair-to-good range, similar to the reliability demonstrated for the GARS M scoring in our study. The opportunity to slow and stop the action and to play back the videotape repeatedly may be essential to obtain better accuracy in scoring the observational gait analysis scales. Scoring in this way from the videotape, however, does not preclude the use of the GARS-M in clinical practice. In our experience, scoring the GARS M requires about 1 to 3 minutes per subject and can be done in the environs of the clinical setting. Various factors contributed to the level of reliability for GARS-M scores. Scoring from a videotape of a walk reduces the potential for variance in the task that might occur if participants had to repeat the walk for the observer to complete the scoring. Therefore, we cannot project how reliability would be affected in practice by change in subject performance. Further research is needed in this area. The GARS-M consists of largely exclusive and exhaustive categories of variables. Scorings within each item are primarily criterion-based, making the differences between scores more clear to the rater. For example, the four levels of scoring foot contact each defined criteria for how the foot meets the ground, which do not overlap the other levels of scoring. Likewise, the scoring of one variable did not limit or cross over the scoring of other variables of the scale. For instance, a score of 2 in hip ROM (eg, thigh in line with the vertical) does not exclude any score for another variable, such as a score of 0 for variability (eg, fluid and predictably placed limb movements). In our ongoing experience using the GARS M, the most difficult variable to make a score decision for is "guardedness," particularly the poorer performance ratings See benchmark. of the variable. Clinically, the criteria for the scores of 2 and 3 for guardedness do not always represent mutually exclusive Adj. 1. mutually exclusive - unable to be both true at the same time contradictory incompatible - not compatible; "incompatible personalities"; "incompatible colors" categories of gait performance. The lack of agreement for the scoring of the variable staggering compared with the moderate strength of agreement for the other six GARS-M variables may have occurred because of the low degree of variability of the ratings (eg, 90% of all ratings were scored zero for staggering), leading to increased chance of agreement and a low Kappa, which corrects for chance agreement.[24] The older subjects studied rarely demonstrated the gait abnormality of staggering. Reasons for the lack of staggering may include (1) the walking distance may have been insufficient for the event to occur with any frequency, (2) the smooth tile floors may have reduced the usual risk for staggering, or (3) staggering may not be common among these persons. Errors in scoring the variable are also a potential factor, but the criterion for scoring (de, number of lurches) and the act of staggering are unlikely to be missed by raters. Although removing the variable of staggering from the scale to improve the reliability of GARS-M scores may seem warranted, in our experience, when subjects demonstrated staggering in the GARS-M assessment, they also reported having a history of falls. The validity of this variable staggering for distinguishing older adults with a history of falls encourages us to recommend including this variable in future investigations. Conclusion The GARS-M for rating qualitative aspects of ambulation appears to provide reliable measurements that may be valid for predicting the risk of falling in community-dwelling older adults. Because subject variability was not examined in this study, reliability of the measure when subjects are examined still needs to be determined. Using the GARS-M, older subjects known to be at risk for recurrent falls by report of fall history were distinguished from the subjects considered not at risk for falling based on self-reported fall history. Data suggest the use of the GARS-M for measuring gait qualities of older individuals and the use of these measurements for predicting the risk for recurrent falls. Further research will be needed to demonstrate whether these measurements are reliable when subjects are asked to repeat their performance and when different rater training protocols are used. Further research on the GARS-M is warranted, and further evaluation of clinimetric qualities such as responsiveness[27,28] (the ability of the GARS-M to detect a change in fall risk after intervention when clinically meaningful change has occurred) is needed. The GARS-M provides a simple way of directly observing and documenting abnormalities of gait, which may be useful in guiding interventions to reduce the risk of recurrent falls. Acknowledgment acknowledgment, in law, formal declaration or admission by a person who executed an instrument (e.g., a will or a deed) that the instrument is his. The acknowledgment is made before a court, a notary public, or any other authorized person. All of the members of the interdisciplinary GEM Program team, University Drive Veterans Administration Medical Center, Pittsburgh, Pa, were an important part of the program from which the data for this report were drawn. Their support and interest as colleagues and clinicians are appreciated. [Figures 1 to 2 ILLUSTRATION OMITTED] References [1] Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly people living in the community. N Engl J Med. 1988;319:17011707. [2] Nevitt MC, Cummings SR, Kidd S, et al. Risk factor for recurrent nonsyncopal falls. JAMA JAMA abbr. Journal of the American Medical Association . 1989;261:2663-2668. [3] Studenski S, Duncan PW, Chandler J, et al. Predicting falls: the role of mobility and nonphysical factors. J Am Geriatr Soc. 1994;42:297-302. [4] Robbins AS, Rubenstein LZ, Josephson KR, et al. Predictors of falls among elderly people. Arch Intern intern /in·tern/ (in´tern) a medical graduate serving in a hospital preparatory to being licensed to practice medicine. in·tern or in·terne n. Med. 1989;149:1628-1633. [5] Bendall AJ, Bassey EJ, Pearson MB. Factors affecting walking speed of elderly people. Age Ageing. 1989;18:327-332. [6] Imms FJ, Edholm OG. Studies of gait and mobility in the elderly. Age Ageing. 1981;10:147-156. [7] Guimaraes RM, Isaacs B. Characteristics of gait in old people who fall. International Rehabilitation Medicine rehabilitation medicine Physiatry, physiotherapy A field of therapeutics that bridges the gap between conventional and nonconventional medicine; rehabilitation physicians may adminsiter or prescribe mechanical–eg, massage, manipulation, exercise, movement, . 1980;2:177-180. [8] Gehlsen GM, Whaley MH. Falls in the elderly, part I: gait. Arch Phys Med Rehabil. 1990;71:735-738. [9] Gabell A, Nayak USL (UNIX System Laboratories, Inc.) An AT&T subsidiary formed in 1990, responsible for developing and marketing Unix. In 1993, USL was acquired by Novell and merged into Novell's UNIX Systems Group (USG). See Univel. 1. . The effect of age on variability in gait. J Gerontol. 1984;39:662-666. [10] Guralnik JM, Simonsick EM. Physical disability in older Americans. J Gerontol. 1993;48(Special Issue):3-10. [11] Buchner DM, Wagner EH. Preventing frail health. Clin Geriatr Med. 1992;8;1-l7. [12] Wolfson I, Whipple R, Amerman P, Tobin JN. Gait assessment in the elderly: a gait abnormality rating scale and its relation to falls. J Gerontol. 1990;45:M12-MI9. [13] Williams TF. Geriatric assessment methods for clinical decision making. Presented at the Consensus Development Conference, 1987, Bethesda, Md. [14] Winograd CH. Targeting strategies: an overview of criteria and outcomes. J Am Geriatr. Soc. 1991;39:25S-35S. [15] Rubenstein LZ. Documenting impacts of geriatric consultation. J Am Geriatr Soc. 1987; 35:829-830. [16] Rubenstein LZ, Stuck AK, Siu AL, Weiland D. Impact of geriatric evaluation and management programs on the defined outcomes: overview of the evidence. J Am Geriatr Soc. 1991 ;39:8S-16S. [17] Cumming RG, Miller JP, Kelsey JL, et al. Medications and multiple falls in elderly people: The St Louis OASIS Study. Age Ageing. 1991 ;20: 455-461. [18] Cerny K. A clinical method of quantitative gait analysis. Phys Ther. 1983;63:1125-1126. [19] Cohen cohen or kohen (Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male. I. A coefficient of agreement for nominal scales See: principal scale; scale. . Educational and Psychological Measurement. 1960;20:37-46. [20] Shrout PE, Fleiss JJ.. Intraclass correlations: uses in assessing rater reliability. Psychol Bull. 1979;S6:420-428. [21] Bartko JJ. The intraclass correlation coefficient as a measure of reliability. Psychol Rep. 1966;19:3-11. [22] McClure M, Willett WC. Misinterpretation and misuse of the Kappa statistic. Am J Epidemiol. 1987;126:161-169. [23] Haley SM, Osherg JS. Kappa coefficient calculation using multiple ratings per subject: a special communication. Phys Ther. 1989;69:970-974. [24] Landis JR, Koch GG. The measurement of observer agreement for categorical data categorical data data relating to category such as qualitative data, e.g. dog, cat, female. It may be nominal when a name is used, e.g. location, breed, or ordinal when a range of categories is used, e.g. calf, yearling, cow. . Biometrics. 1977;33:159-174. [25] Eastlack ME, Arvidson J, Snyder-Mackler L., et al. Interrater reliability of videotaped observational gait-analysis assessment. Phys Ther. 1991;71:465-472. [26] Krebs DE, Edelstein JE, Fishman S Fishman may refer to:
n. (used with a sing. verb) The branch of mechanics that studies the motion of a body or a system of bodies without consideration given to its mass or the forces acting on it. gait analysis. Phys Ther. 1985;65:1027-1033. [27] Guyatt G, Walter S Wal·ter , Bruno 1876-1962. German conductor noted for his interpretations of Mozart and Mahler. Noun 1. Walter - German conductor (1876-1962) Bruno Walter , Norman G. Measuring change over time: assessing the usefulness of evaluative instruments. J Chronic Dis. 1987; 40:171-178. [28] Kane RA, Kane RL. Assessing; the Elderly. Lexington, Mass: Lexington Book; 1981. (Appendix follows on Modified Gait Abnormality Rating Scale (GARS-M))(a) Appendix. Modified Gait Abnormality Rating Scale (GARS-M)(a) 1 Variability--a measure of inconsistency in·con·sis·ten·cy n. pl. in·con·sis·ten·cies 1. The state or quality of being inconsistent. 2. Something inconsistent: many inconsistencies in your proposal. and arrhythmicity of stepping and/or arm movements 0 = fluid and predictably paced limb movements 1 = occasional interruptions (changes in speed) approximately 25% oF the time 2 = unpredictability of rhythm approximately 25%-75% of the time 3 = random timing of limb movements 2. Guardedness--hesistancy, slowness, diminished propulsion, and lack of commitment in stepping and arm swing 0 = good forward momentum and lack of apprehension in propulsion 1 = center of gravity of head, arms, and trunk (HAT) projects only slightly in front of push-off, but still good arm-leg coordination 2 = HAT held over anterior aspect of foot and some moderate loss of smooth reciprocation reciprocation /re·cip·ro·ca·tion/ (re-sip?ro-ka´shun) 1. the act of giving and receiving in exchange; the complementary interaction of two distinct entities. 2. an alternating back-and-forth movement. 3 = HAT held over rear aspect of stance-phase foot and great tentativeness in stepping 3. Staggering--sudden and unexpected laterally directed partial losses of balance 0 = no losses of balance to side 1 = a single lurch Lurch Addams’s zombielike, extremely tall butler. [TV: “The Addams Family” in Terrace, I, 29] See : Butler to side 2 = two lurches to side 3 = three or more lurches to side 4. Foot contact--the degree to which heel strikes heel strike Heel contact The beginning of stance phase, at the point of heel strike there is zero reaction. Immediately after contact there is an ↑ in ground reaction, known as heel strike transient, which pre-empts the major ↑ in ground reaction the ground before the forefoot forefoot /fore·foot/ (-foot) 1. one of the front feet of a quadruped. 2. the fore part of the foot. 0 = very obvious angle of impact of heel on ground 1 = barely visible contact of heel before forefoot 2 = entire foot lands flat on ground 3 = anterior aspect of foot strikes ground before heel 5. Hip ROM--the degree of loss of hip range of motion seen during a gait cycle 0 = obvious angulation angulation /an·gu·la·tion/ (ang?gu-la´shun) 1. formation of a sharp obstructive bend, as in the intestine, ureter, or similar tubes. 2. deviation from a straight line, as in a badly set bone. of thigh backward during double support (10[degrees]) 1 = just barely visible angulation backward from vertical 2 = thigh in line with vertical projection from ground 3 = thigh angled forward from vertical at maximum posterior excursion excursion /ex·cur·sion/ (eks-kur´zhun) a range of movement regularly repeated in performance of a function, e.g., excursion of the jaws in mastication. 6. Shoulder extension--a measure of the decrease of shoulder range of motion 0 = clearly seen movement of upper arm anterior (15[degrees]) and posterior (20[degrees]) to vertical axis of trunk 1 = shoulder flexes slightly anterior to vertical axis 2 = shoulder comes only to vertical axis or slightly posterior to it during flexion flexion /flex·ion/ (flek´shun) the act of bending or the condition of being bent. flex·ion n. 1. The act of bending a joint or limb in the body by the action of flexors. 2. 3 = shoulder stays well behind vertical axis during entire excursion 7. Arm-heel-strike synchrony--the extent to which the contralateral contralateral /con·tra·lat·er·al/ (-lat´er-al) pertaining to, situated on, or affecting the opposite side. con·tra·lat·er·al adj. movements of an arm and leg are out of phase 0 = good temporal conjunction of arm and contralateral leg at apex of shoulder and hip excursions all of the time 1 = arm and leg slightly out of phase 25% of the time 2 = arm and leg moderately out of phase 25%-50% of the time 3 = little or no temporal coherence coherence, constant phase difference in two or more Waves over time. Two waves are said to be in phase if their crests and troughs meet at the same place at the same time, and the waves are out of phase if the crests of one meet the troughs of another. of arm and leg (a) Adapted from Wolfson et al.[11] JM VanSwearingen, PhD, PT, is Assistant Professor, Department of Physical Therapy, School of Health and Rehabilitation rehabilitation: see physical therapy. Sciences, University of Pittsburgh, 6035 Forbes Tower Forbes Tower is a building of the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania, United States. Located directly behind the historic Iroquois Building, Forbes Tower was designed by the architectural firm Tasso Katselas Associates [1] and was , Pittsburgh, PA 15260 (USA) (jessievs+@pitt.edu), and Consulting Physical Therapist, Geriatric Evaluation and Management Program, University Drive Veterans Administration Medical Center, Pittsburgh, PA 15261. Address all correspondence to Dr VanSwearingen. KA Paschal, PT, is Assistant Professor and Director of Clinical Education, Department of Physical Therapy, School of Pharmacy and Allied Health, Creighton University Sitting on a 108-acre campus just outside Omaha's downtown business district in the Near North Side neighborhood, the University currently enrolls about 6,800 students. Creighton is one of 28 member institutions of the Association of Jesuit Colleges and Universities. , 2500 California Plaza The name California Plaza may refer to one of the following locations in Los Angeles:
P Bonino, MD, is Associate Professor of Medicine and Epidemiology and Associate Chief of Staff for Geriatrics and Extended (.are, University of Pittsburgh School of Medicine The University of Pittsburgh School of Medicine is the medical school of the University of Pittsburgh, located in Pittsburgh, PA. As of 2007, the University of Pittsburgh School of Medicine consists of 589 medical students - 53% men and 47% women. and University Drive Veterans Administration Medical Center. JF Sang, PT, holds a teaching position in Department of Rehabilitation Medicine, Medical College, National Cheng-Kung University, Tainan, Taiwan He was completing the Master of Science degree, Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, when he participated in this study. This study was approved by the Biomedical Institutional Review Board of the University of Pittsburgh. Portions of this article were presented at the Combined Sections Meeting of the American Physical Therapy Association The American Physical Therapy Association (APTA) is a national professional organization representing more than 66,000 members. Its goal is to foster advancements in physical therapy practice, research, and education. ; February 2-6, 1994; New Orleans New Orleans (ôr`lēənz –lənz, ôrlēnz`), city (2006 pop. 187,525), coextensive with Orleans parish, SE La., between the Mississippi River and Lake Pontchartrain, 107 mi (172 km) by water from the river mouth; founded , LA. This article was submitted July 5, 1995, and was accepted March 27, 1996. |
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