1582
ORIGINAL ARTICLE
Predicting Home and Community Walking Activity in People
With Stroke
George D. Fulk, PhD, Chelsea Reynolds, BS, Sumona Mondal, PhD, Judith E. Deutsch, PhD
ABSTRACT. Fulk GD, Reynolds C, Mondal S, Deutsch JE.
Predicting home and community walking activity in people
with stroke. Arch Phys Med Rehabil 2010;91:1582-6.
Objective: To determine the ability of the 6-minute walk
test (6MWT) and other commonly used clinical outcome mea-
sures to predict home and community walking activity in
high-functioning people with stroke.
Design: Cross-sectional.
Setting: Outpatient physical therapy clinic.
Participants: Participants (N⫽32) with chronic stroke
(n⫽19; ⬎6mo poststroke) with self-selected gait speed (GS)
faster than .40m/s and age-matched healthy participants
(n⫽13).
Interventions: Not applicable.
Main Outcome Measures: Independent variables: 6MWT,
self-selected GS, Berg Balance Scale (BBS), lower extremity
motor section of the Fugl-Meyer Assessment, and Stroke Im-
pact Scale. Dependent variable: average steps taken per day
during a 7-day period, measured using an accelerometer.
Results: 6MWT, self-selected GS, and BBS were moder-
ately related to home and community walking activity. The
6MWT was the only predictor of average steps taken per day;
it explained 46% of the variance in steps per day.
Conclusions: The 6MWT is a useful outcome measure in
higher functioning people with stroke to guide intervention and
assess community walking activity.
Key Words: Outcome assessment, health care; Rehabilita-
tion; Stroke; Walking.
© 2010 by the American Congress of Rehabilitation
Medicine
ECOVERY OF WALKING ability is an important goal
R 1-3
for people poststroke. People who are able to ambulate
independently after a stroke are more likely to be able to
participate in meaningful social roles and have a lower burden
of care.4 However, measuring and predicting community walk-
ing ability is difficult.5 Capacity measured in the clinic may not
reflect real-world performance.5-8
Community mobility is a multidimensional phenomenon and
can be assessed in a variety of ways. Previous studies have
identified a variety of factors, such as temporal/distance com-
ponents of a given community outing, environmental factors,
physical load, and postural transitions as having an impact on
From the Departments of Physical Therapy (Fulk, Reynolds) and Mathematics
(Mondal), Clarkson University, Potsdam, NY; and Department of Rehabilitation and
Movement Sciences, University of Medicine and Dentistry of New Jersey, Newark,
NJ (Deutsch).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Correspondence to George D. Fulk, PhD, Dept of Physical Therapy, Box 5880,
Clarkson University, Potsdam, NY 13699, e-mail: gfulk@clarkson.edu. Reprints are
not available from the author.
0003-9993/10/9110-00187$36.00/0
doi:10.1016/j.apmr.2010.07.005
Arch Phys Med Rehabil Vol 91, October 2010
community ambulation.5,9-11 Community walking activity can
be assessed by using self-report measures5,12 as well as with
more recently developed accelerometer-based sensors that pro-
vide information about steps taken during community ambula-
tion.13,14 Previous research showed that GS is able to distin-
guish between different categories of home and community
ambulation.5,12,15
Although GS commonly is used to measure walking ability
in people poststroke and to categorize people into home and
community ambulators,12 it may not reflect actual walking
activity in the community.16 An important component of com-
munity mobility is walking endurance.9 To access different
areas of the community independently, people poststroke need
to be able to maintain their walking activity for prolonged
periods. The 6MWT, a measure of walking endurance,17,18
may be able to predict home and community walking ability.
Mayo et al19 found that the 6MWT was able to predict self-
reported community reintegration in community-dwelling peo-
ple with stroke.
GS measured over a short distance, such as 10m, may not
effectively capture the endurance aspect of community walk-
ing. This may be especially true for higher functioning people
who show faster walking speeds and are classified as limited
(GS⬎.40m/s) or unlimited (GS⬎.80m/s) community ambula-
tors.12 Although these people may be categorized as commu-
nity ambulators based on GS, they may not have the walking
endurance to effectively ambulate in the community. Previous
research has shown that ambulatory people with stroke take
approximately half as many steps per day as sedentary adults.20
Given that GS may overestimate community walking ability
in high-functioning people with stroke, further research is
necessary to determine other factors that may predict commu-
nity walking ability. The 6MWT, which is predictive of com-
munity reintegration, may be a strong predictor of community
walking activity. To our knowledge, no study has examined the
ability of the 6MWT to predict home and community walking
activity. The purpose of this study was to determine whether
the 6MWT and other commonly used clinical measures were
predictive of community walking activity in high-functioning
people with stroke. A secondary purpose was to compare daily
walking activity between high-functioning people with stroke
and healthy people.
List of Abbreviations
ADL activities of daily living
BBS Berg Balance Scale
FAC Functional Ambulation Categories
FMA Fugl-Meyer Assessment
GS gait speed
LE lower extremity
SAM StepWatch Activity Monitor
SIS Stroke Impact Scale
6MWT 6-minute walk test
WAQ Walking Ability Questionnaire
 PREDICTING WALKING ACTIVITY IN STROKE, Fulk
METHODS
Community-dwelling people with chronic stroke (⬎6mo
poststroke) who were former patients at an outpatient physical
therapy clinic were recruited to participate in the study. Inclu-
sion criteria were score of 4 or 5 on the FAC, indicating an
ability to ambulate on level surfaces independently with or
without an assistive device,21 GS faster than .40m/s, and a
score higher than 24 on the Mini-Mental State Examination.
Exclusion criteria were inability to ambulate independently
before the stroke, and comorbid conditions, such as Parkin-
son’s disease, incomplete spinal cord injury, severe rheumatoid
arthritis, or other health condition that may have impacted on
the ability to ambulate. Additionally, age-matched healthy peo-
ple were recruited through flyers posted in the community. The
Clarkson University Institutional Review Board approved the
study, and all participants provided informed consent.
Outcome Measures
Independent variables. Motor function of the affected LE
was assessed using the LE motor section of the FMA of motor
recovery after stroke.22,23 Scores range from 0 to 34, with 0
indicating no reflex activity and no active movement and 34
indicating normal motor ability. The FMA LE subscale is a
valid and reliable measure of motor impairment in people with
stroke23 and is related to gait pattern and GS.24
Functional balance was measured using the BBS.25,26 The
BBS assesses balance while a person performs 14 functional
activities. The maximum score on the BBS is 56. The BBS is
commonly used across the continuum of care as a measure of
balance in people with stroke and is valid and reliable and
moderately related to GS.27
Walking ability was measured using self-selected GS and the
6MWT. Self-selected GS was measured over the middle 10m
of a 14-m walk as participants walked at their self-selected
comfortable speed with the assistive device and/or orthotic they
normally used. The mean of 2 trials was used. Self-selected GS
is a valid and reliable measure of walking ability in people with
stroke.12,28-31 For the 6MWT,32 participants were instructed to
walk as far as possible for 6 minutes around an oval course
approximately 30m in circumference. Participants were al-
lowed to stop and rest; however, the clock was running and
they were instructed to resume walking as soon as possible.
Participants used the assistive device and/or orthotic they nor-
mally used, and no verbal encouragement was provided. The
6MWT is a valid and reliable measure of walking ability in
people with stroke.19,33-35
Social participation and quality of life were measured using
the SIS. The SIS is a valid and reliable stroke-specific outcome
measure that contains 8 domains: strength, hand function,
ADL/instrumental ADL, mobility, communication, emotion,
memory and thinking, and participation/role functioning.36
Dependent variable. Home and community walking activ-
ity were measured using the StepWatch Activity Monitora
(SAM). The SAM measures steps taken per day and is worn
just above the lateral malleolus of the unaffected LE. It consists
of an accelerometer and electronic filter that detects leg move-
ments from which step counts are determined. The SAM is
75⫻50⫻20mm and weighs approximately 38g. It can be worn
for up to 2 months, but typically is calibrated so that it collects
data for 1 to 2 weeks. Data are downloaded through a docking
station to a personal computer. The SAM is a valid and reliable
measure of steps taken a day.13,14,37
Additionally, participants completed the WAQ12 to provide
a self-report of the amount of community walking activity they
performed. The WAQ is a set of 7 questions developed by
1583
Perry et al12 that were able to classify people into 1 of 6
functional walking classifications: physiologic ambulator, lim-
ited home ambulator, unlimited home ambulator, most limited
community ambulator, least limited community ambulator, and
unlimited community ambulator.
Procedure
On day 1, the independent outcome measures (FMA LE,
BBS, self-selected GS, 6MWT, SIS, and WAQ) were per-
formed. All clinical tests were performed by a physical thera-
pist with more than 10 years of experience working with people
poststroke. After these were performed, the participants were
fitted with the activity monitor. The participants walked a short
distance (30 –50 steps) wearing the activity monitor while the
investigator counted the steps walked. These data were exam-
ined to make sure the activity monitors were calibrated cor-
rectly. When confirmed, participants were instructed to wear
the activity monitor on their least affected LE for 1 week
during all waking hours, except while bathing. After 1 week,
the participants returned the activity monitor. Data were down-
loaded and reviewed with each participant to ensure that no
gross errors occurred in the activity monitors.
Age-matched healthy participants were recruited through
flyers posted in the community. These people underwent the
same testing procedure, except they did not undergo the FMA
LE examination or complete the SIS or WAQ.
Data Analysis
All data were tested for normality using the Kolmogorov-
Smirnov test. Initially, a Pearson correlation analysis was per-
formed to explore the relation between community walking
activity (measured by average steps taken per day using the
activity monitor) and clinic-based measures of body structure/
function, activity, social participation, and age. Age was in-
cluded as a potential independent variable in addition to the
clinical outcome measures because age has an impact on steps
taken a day.38
A stepwise regression analysis was used to examine the
ability of the clinic-based measures (FMA LE, BBS, self-
selected GS, 6MWT, and SIS) and age to predict home and
community walking activity in participants with stroke.
An independent t test was used to compare differences in
age, BBS, 6MWT, self-selected GS, and steps taken per day
between participants with stroke and age-matched healthy par-
ticipants. Additionally, steps taken per day by participants with
stroke who had a GS faster than .80m/s, walked farther than
367m during the 6MWT, and were classified as full community
ambulators by using the WAQ were compared with steps taken
a day by healthy participants. These values have been reported
in the literature as criterion values for unlimited community
ambulators25 and the distance walked during community trips.9
Shumway-Cook et al9 found that 367m was the average dis-
tance walked by community-dwelling elders when they went
on trips outside their homes.9 The alpha value was set at P⬍.05
for all analyses.
RESULTS
Participants with stroke (n⫽19) and age-matched healthy
participants (n⫽13) were recruited to participate in the study.
Table 1 lists mean values for descriptive data, independent
variables (age, FMA LE, BBS, self-selected GS, and 6MWT),
and mean steps per day taken during 1 week. Based on their
answers to the WAQ, 16 participants with stroke were classi-
fied as unlimited community ambulators, 2 were classified as
least limited community ambulators, and 1 was classified as a
Arch Phys Med Rehabil Vol 91, October 2010
1584 PREDICTING WALKING ACTIVITY IN STROKE, Fulk

Table 1: Participant Characteristics whose primary goal is to improve community walking ability
Participants With Healthy and may be more useful than GS, particularly in higher func-
Stroke Participants tioning people with stroke.
Characteristics (n⫽19) (n⫽13) Rehabilitation of walking of people poststroke should in-
Age (y) 65.7⫾11.9 65.3⫾8.5 clude endurance training because people with stroke often are
Time since stroke (mo) 42.1⫾36.1 NA severely deconditioned39,40 and gait after stroke has increased
FMA LE score 28.7⫾5.7 NA energy requirements.20,41 Peak oxygen consumption values for
BBS score 49.3⫾7.6* 55.7⫾1.1 many people with stroke were less than the energy expenditure
Self-selected GS (m/s) 1.01⫾0.31* 1.34⫾0.17 required for basic ADL.40 Rehabilitation interventions should
6MWT (m) 348.6⫾144.0* 560.2⫾67.6 be geared toward improving cardiovascular endurance and
SIS score 73.0⫾15.3 NA neuromuscular endurance. The ability to successfully walk a
Mean steps per day 3838.2.5⫾1963.6* 6294.0⫾1768.0 certain distance is an important factor for community mobility
Use of assistive device (yes/no) 5:14 (26) None and reintegration. The 6MWT can be used to assess cardiovas-
Use of orthotic (yes/no) 5:14 (26) None cular endurance in high-functioning people with stroke.42
Other authors have found GS5 and balance20 to be predictors
NOTE. Values expressed as mean ⫾ SD or n (%). of community walking activity. We found that although GS
Abbreviation: NA, not applicable. and balance were related to home and community walking
*Significant difference between groups, P⬍.05. activity, only the 6MWT was a significant predictor. Michael et
al20 found that BBS score predicted 30% of the variance in
community walking activity. Our results indicated that the
limited home ambulator. All data were normally distributed in 6MWT predicted 46% of the variance in walking activity. A
both groups, except for BBS score in healthy participants. possible explanation for this difference is that participants in
Independent t tests showed no significant difference in age their study had a lower level of recovery compared with par-
between participants with stroke and healthy participants ticipants in this study. Also, Michael20 measured walking
(P⬎.05). There was a significant difference in self-selected GS, activity during only a 2-day period, which may not be sufficient
6MWT, BBS score, and mean steps taken per day between the time to capture true walking activity.43,44
groups (P⬍.05) (see table 1). Mann-Whitney U test was used Lord et al5 found that GS was associated strongly with
to compare BBS scores because these data were not normally community ambulation, but gait endurance was not. Partici-
distributed in healthy participants. pants in their study were similar to ours in terms of GS, with a
In participants with stroke, there was a moderate to good mean GS of .94m/s. A possible reason why Lord5 did not find
relationship between mean steps per day and self-selected GS, that gait endurance was a predictor of community walking
6MWT, and BBS score. There was no significant relationship activity was the method by which it was measured. They
between mean steps per day and FMA LE result, SIS score, or measured gait endurance by having participants walk up to
age (table 2). 300m on a treadmill, which may have a ceiling effect. Addi-
The stepwise regression analysis to predict community and tionally, the authors reported that many study participants were
home walking activity based on 6MWT, self-selected GS, not comfortable walking on the treadmill.
BBS, FMA LE, SIS, and age in participants with stroke showed Although recovery of walking ability in the home and com-
that the 6MWT was the only significant predictor of mean steps munity is a primary goal of people with stroke, community
a day (F1,18⫽17.59; P⫽.001), with R2 of .46. Predicted mean ambulation is a complex phenomenon that is not easily mea-
steps per day is equal to 620.03⫹9.23(6MWT) (table 3). Self- sured. We used activity monitors to directly measure the
selected GS, BBS score, FMA LE result, SIS score, and age amount of steps taken per day to quantify walking activity in
were not significant predictors of mean steps per day. the home and community. Temporal and distance factors of the
Participants with stroke who were classified as unlimited community trip, postural transitions, physical load, and terrain are
community ambulators based on GS (n⫽14) took significantly important aspects of community ambulation.9 Activity monitors
fewer steps per day than healthy participants: mean ⫾ SD, may not directly measure some of these components of commu-
4479.0⫾1775.2 versus 6294.2⫾1768.0 (P⫽.013). Participants nity mobility, but they provide an accurate measure of actual
with stroke who were classified as unlimited community am- walking performance during a given time frame.13,14,37 Because
bulators based on answers to the WAQ (n⫽16) took signifi- improving walking activity is a primary goal for people with
cantly fewer steps per day than healthy participants: stroke,1,3 the amount of actual walking activity a person performs
4262.9⫾1755.2 versus 6294.2⫾1768.0 (P⫽.005). There was is an appropriate method of assessing community walking ability.
no significant difference in steps taken per day between par- Our findings supported the contention made by Lord and
ticipants with stroke who walked farther than 367m during the Rochester11 that GS should not be the sole method to measure
6MWT (n⫽10) and healthy participants (all of whom walked
⬎367m during the 6MWT): 4786.4⫾1876.5 versus 6294.2⫾
1768.0 (P⫽.062). Table 2: Relationship Between Mean Steps per Day and
Commonly Used Clinical Outcome Measures and Age in
DISCUSSION Participants With Stroke

In this study, we showed that the 6MWT predicted commu- Clinical Outcome Relationship With Mean Steps per Day
nity walking activity for high-functioning people poststroke. Measures Pearson r (P)
The 6MWT therefore is an important outcome measure for FMA LE .06 (.798)
clinicians to use to guide interventions and set goals for people BBS .54 (.016)
with stroke. Additionally, there was no significant difference in Self-selected GS .65 (.003)
steps taken per day during a 7-day period between participants 6MWT .68 (.001)
with stroke who were able to walk at least 367m during the SIS .18 (.471)
course of the 6MWT and healthy participants. The 6MWT also Age ⫺.43 (.063)
may be a useful primary outcome measure for researchers

Arch Phys Med Rehabil Vol 91, October 2010

 PREDICTING WALKING ACTIVITY IN STROKE, Fulk
Table 3: Stepwise Regression Analysis for Predicting Mean Steps per Day in Participants With Stroke
Predictor R2 R2 Adjusted Unstandardized Coefficient B
6MWT .46 .43 9.23
NOTE. Self-selected GS, BBS, FMA LE, SIS, and age were excluded from the model.
Abbreviation: CI, confidence interval.
community walking ability. In this study, although GS was
moderately related to community walking activity, it was not a
significant predictor of community walking activity. The
6MWT was the only significant predictor of community walk-
ing activity. Although the 6MWT provides insight into a per-
son’s ability to walk in the community, other factors also may
have a role. People with psychosocial support from caregivers
may be more able to access their community. Fear of falling
also may have a role in community mobility. It is interesting
that the SIS was not related to community walking in this
study. This may be because participants in this study had a
relatively high degree of motor and walking ability recovery.
Further research is necessary to explore other factors that may
impact on community walking activity in people with stroke
with varying degrees of recovery.
The participants with stroke in this study engaged in signif-
icantly less walking activity than age-matched healthy partic-
ipants and approximately half as much daily walking activity as
was reported in the literature in a recent meta-analysis.38 This
was true even for participants with stroke whose GS or self-
reported walking activity exceeded values reported in the lit-
erature as criterion values for unlimited community ambula-
tors.12 Although GS and self-report are useful methods of
measuring walking ability, caution should be used when label-
ing someone as an unlimited community ambulator who is able
to walk faster than .80m/s. Their walking activity in the home
and community may be significantly less than that for healthy
older adults. The 6MWT may be a better method of assessing
home and community walking activity than GS in higher
functioning ambulators.
Study Limitations
Our findings will not apply to all people with stroke. The
participants in this study were relatively high functioning with
good recovery of walking ability, shown by the mean self-
selected GS of .98m/s. Other factors, such as balance, may be
better able to predict home and community walking activity in
lower functioning people with stroke.20 Other limitations of our
study include the cross-sectional design and small sample size.
CONCLUSION
The 6MWT is a strong predictor of home and community
walking activity in higher functioning people with stroke. It
explained 46% of the variance in community walking activity.
The 6MWT should be used as an outcome measure to direct
interventions and set goals in people with stroke. Measures
other than the 6MWT may be needed to fully describe walking
activity in the home and community of people with stroke.
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Supplier
a. Orthocare Innovations, 840 Research Pkwy, Ste 200, Oklahoma
City, OK 73104. Oklahoma City, OK.