Measuring community walking in stroke survivors using physiotherapists’ perspectives and the International Classification of Functioning, Health and Disability (ICF) framework

Community walking is a multifactorial task and an important functional goal for stroke survivors. Measuring community walking is challenging because there is not a good understanding of what is considered successful community walking or how this could be measured. Physiotherapists currently use a range of measures to assess community walking. Furthermore, the factors contributing to community walking that are captured by these measures are not yet well understood. This thesis, comprising two studies, explores these gaps. The first study is a qualitative exploration of physiotherapists’ perspectives of community walking measurement in stroke survivors. Physiotherapists experienced in stroke rehabilitation were recruited to participate in focus groups. Semi-structured interviews were utilised to explore physiotherapists’ perspectives on measuring community walking in stroke survivors. Interviews were transcribed verbatim and thematically analysed. Four themes were identified: successful community walking is goal-dependent, physiotherapists lack consistency in measurement of community walking, current measures don’t reflect actual community walking, and measures of community walking should be multifactorial. Physiotherapists perceived that stroke survivors’ goals related to community walking played an important role in achieving success in community walking. However, for physiotherapists, successful community walking implied stroke survivors satisfying specific criteria for gait speed, distance walked and ability to dual- task while walking. There appeared to be a range of ways in which physiotherapists measure community walking. For example, physiotherapists working in in-patient rehabilitation used more functional measurement such as observing the task of walking and commenting on assistance required. Whereas physiotherapists working in outpatient and community rehabilitation more objectively inferred community walking using measures including Berg Balance Scale, Dynamic Gait Index, 10-Meter Timed Walk and 6-Minute Walk Test. Even when using specific measures, physiotherapists reported using different values or cut-off scores as representative of stroke survivors’ community walking. Physiotherapists reported that stroke survivors’ goals were taken into account when selecting a measure. Physiotherapists noted that current measures of community walking were performed in a clinical setting, not necessarily involving situations reflective of community walking. Physiotherapists identified a range of factors that were important to be included in a measure of community walking including stroke survivors’ satisfaction and confidence in activities related to community walking. Physiotherapists’ evaluation of walking in an environment reflecting community walking, dual tasking, dynamic balance ability and stroke survivors’ safety awareness were suggested to be included in a measure of community walking. The second study, a systematic review, identified current measures of community walking and explored the content of these measures within the International Classification of Functioning, Disability and Health (ICF) framework. Search strategies were conducted in databases of CINAHL, EMBASE, PubMed, Scopus and Web of Science. Twenty measurement tools were identified from 27 studies included in the final synthesis. The identified measures of community walking were categorised as instrumented measures, patient-reported measures and therapist- reported measures. Content covered by the identified measures was then analysed within the ICF framework using an established ICF linking process. Across all measures, 169 ICF categories were linked. The majority were linked with Activity and Participation component (88%), with remaining categories linked with Environmental factors (10%) and Body functions (2%). All measures covered Activity and Participation, in which mobility categories were the most commonly linked and included walking on different surfaces, climbing, and walking around obstacles. Environmental categories were covered by half of the identified measures and included use of assistive devices for indoor and outdoor mobility and products and technology for gaining access to facilities inside buildings. Three of the identified measures covered Body functions and included categories of confidence and proprioception. Measures of community walking for stroke survivors illustrated diversity in the content covered, with most measures covering activity of walking. None of the measure comprehensively covered factors associated with community walking. Findings from Study 1 and Study 2 highlight that there is a lack of a comprehensive measurement tool of community walking in stroke survivors, as no single tool measures all of the important factors contributing to community walking. Community walking is mostly inferred based on some components of these measurement tools. Physiotherapists take into account stroke survivors’ goals when selecting a measure of community walking, at the same time relying on measures that they think best represent community walking.