November 2012

Self-selected gait speed: A critical clinical outcome

When treating patients who are going through rehabilitation, clinicians may be overemphasizing gait distance and over­looking the importance of gait speed. Clinical assessment of gait speed is sim­ple and inexpensive but can be a signifi­cant indicator of functional recovery.

By Heather Braden, PT, MPT, PhD, GCS

Gait speed, a useful measure that clinicians can use to guide the inpatient stay and discharge process and evaluate current and future health status, is emerging as the “sixth vital sign” in healthcare settings.1

Clinicians currently measure gait distance, but gait speed is not routinely noted.2 According to the Guide to Physical Therapy Practice, gait is defined as the manner in which a person walks, characterized by rhythm, cadence, step length, stride length, and speed.3 Documenting components of gait (such as speed), demonstrating how slowed gait speed limits function (e.g., not being able to walk with sufficient speed to cross a street with a controlled traffic light), and implementing appropriate interventions to improve patients’ functional mobility illustrate the advanced skills of the physical therapist. Practitioners will benefit from understanding the importance of measuring gait speed, in addition to distance, to describe a patient’s mobility.

Gait speed may be referred to as a “self-selected” comfortable speed or a safe “maximum” speed. In this article, the term “gait speed” refers to self-selected gait speed, indicating that patients walk at their normal pace rather than as fast as safely possible. Gait speed is a practical test that takes only minutes to complete and uses inexpensive equipment such as a stopwatch and a facility hallway.4 It can be recorded as the patient walks with or without an assistive device. Patients may start with a necessary assistive device and progress to a lesser device, or undergo gait speed measure­ment in the same manner throughout the course of therapy.

Figure 1. Gait speed test design: Patient is instructed to walk at a comfortable speed down corridor unaware of start-and-stop timing points.

Clinicians can adapt gait speed measures for various settings and reliably compare speeds across varying distances.5 For example, gait speed measured over shorter distances of 8 or 10 feet may be best for acute care, due to patient acuity levels, or in home health care, due to limited home space. Longer distances of 10 m may be appropriate in skilled nursing and inpatient rehabili­tation settings, health fairs that include wellness screens, schools, or outpatient settings.6,7 Gait speed has been studied in single trials8,9 and by averaging multiple trials10,11 and normative values have been established with high reliability. This is important in the clinic because physical therapists do not always have time to measure a patient’s gait speed multiple times in one session.

If measuring gait speed over a distance of 4 meters, the patient is commonly instructed to walk at a normal pace (self-selected speed) down a hallway through a 1-m zone for acceleration, a central 4-m “testing” zone that is timed with a stopwatch, and a 1-m zone for deceleration. The central 4-m testing zone is bounded by a starting line and a finish line that are not visible to the patient; assessment of gait speed begins when the patient’s lead leg crosses the starting line and ends when the patient’s lead leg crosses the finish line (Figure 1).

Medical facilities could benefit from using valid and reliable performance measures such as gait speed within discharge proto­cols to help identify patient trends for safe discharge destinations and minimized risk of rehospitalization. In 2004, 20% of Medicare beneficiaries who were discharged from a hospital were rehospitalized within 30 days and the total cost of rehospital­izations for Medicare patients was $17.4 billion.12 Beginning in fiscal year 2013, the Medicare Hospital Value-Based Purchasing Program will reward hospitals for quality care and decreased rehospitalizations.13 Including gait speed measures as criteria for discharge may help decrease rehospitalization rates.

Number crunching

We performed a study14 to determine whether gait speed could be measured and whether gait speed times improved during a short acute care stay. The study included 46 hospital inpatients (mean age, 75 years) who were referred to physical therapy and were able to walk at least 20 feet. Patients were asked to walk down a facility corridor at their normal pace at both initial evaluation and discharge. All participants received the same bed mobility training and transfer practice at bedside, followed by gait training in the hallway.

Our preliminary results indicate that measuring walking speed in this setting is feasible and that speed improved significantly during patients’ hospitalization, from an initial speed of 0.33 m/s (SD=0.21; 95% CI: 0.27-0.39) to a final gait speed of 0.37 m/s (SD=0.20; 95% CI: 0.31-0.43). The Wilcoxon test, which evaluates differences between paired scores, showed a significant increase in gait speed of 0.04 m/s (P = 0.005) during a mean therapy period of just two days (SD=1.4) and a total hospitalization period of 5.5 days (SD = 3.6).14

Gait speeds, however, continue to be limited at hospital discharge, so identifying a proper discharge destination is war­ranted. Prior studies have shown that patients with gait speeds of less than 0.6 m/s rely on caregivers in their home for activities of daily living (ADLs) such as grooming, dressing, transfers, and ambu­lation, and instrumental ADLs such as housework, shopping, tech­nology use, and transportation.15 Those with speeds less 0.4 m/s are likely to have a discharge destination other than their home.16 And individuals with gait speeds less than 0.15 m/s tend to be institutionalized in nursing homes or other facilities17 (Figure 2). Ongoing studies in this area will identify further trends for discharge from acute care, skilled nursing, and inpatient rehabilitation facilities that will facilitate safe placement of patients with minimized rehospitalization.

Established normative values for gait speed provide meaningful references for a patient’s functional status. Researchers have documented age-based self-selected walking speeds.18 Normative data indicate that healthy community-dwelling men aged 60 to 69 years walk at an average of 1.34 m/s; healthy women walk 1.24 m/s (Table 1). By the time individuals reach 80 to 99 years, average gait speed has slowed to 0.97 m/s for men and to 0.94 m/s for women.19

The term “household ambulator” describes those who walk at 0.2 to 0.4 m/s; these individuals typically require assistance entering and exiting structures and have difficulty climbing stairs in the home.20 A patient who has undergone a cerebrovascular accident or stroke, for example, has an average gait speed of 0.29 m/s and thus falls into this category21 along with seniors with acute hip fracture, who have an average gait speed of 0.23 to 0.26 m/s.22

Patients with gait speeds of 0.4 to 0.6 m/s, such as those with chronic stroke,20 are considered limited community ambulators. Limited community ambulators can complete a direct, unobstructed path to one destination but may have difficulty in crowds. Seniors who walk at least 0.67 m/s tend to be able to complete self-care tasks such as dressing and toileting.23

Patients who walk faster than 0.8 m/s are characterized as community ambulators and can maneuver through crowds and shopping centers.22 Gait speed prior to total joint replacement surgery ranges from 0.68 to 1.36 m/s24 and most patients regain or exceed their original gait speed one year after surgery.25 Host et al, for example, demonstrated that, after strength and functional training, patients who had experienced a hip fracture walked an average of 1.1 m/s.26

Those with gait speeds of at least 0.89 m/s are typically able to complete household chores, individuals who can walk 1.11 m/s or faster are able to carry groceries and complete light yard work, and those who can ambulate at a speed of at least 1.33 m/s are commonly able to climb several flights of stairs.23

Therapeutic applications

Where a patient’s self-selected gait speed falls within this spectrum depends upon overall health status and the extent to which multiple organ systems within the body are working in collaboration to regulate energy expenditure and motor control.27,28 Motor control and muscle performance affect gait speed,29,30  as do sensation, perception,31 endurance levels,7 and environmental charateristics.32 Motivation,33 mental health,34 and cognitive status35 also contribute to self-selected gait speed. A deficit in any of these systems typically has a negative effect on gait speed.36 Physical therapists, however, can improve gait speed by assessing patients to identify such impairments and activity related challenges and initiating inte­rventions that target specific deficits and result in higher functioning levels of mobility.

A physical therapist can utilize established gait speed norms to evaluate each patient’s functional capabilities in the home environment. Reimbursement by third party payers tends to be linked to a physical therapist’s ability to help patients achieve pro­gressive gains in function and to document that progress. Progress occurs more gradually with some patients than others and is dependent on a patient’s current diagnosis, comorbidities, motivation, and stage of rehabilitation. Thus, the concept of a minimum clinical difference value is important for documenting the small gains and achievement of short-term goals that, with time, will lead to more substantial func­tional gains.

The minimum detectable change value of gait speed in patients who lack normal gait speed is 0.1 m/s. This value can be included in patient goals and can help demonstrate progress toward more functional well be­ing.4,14,17 A long-term clinical goal regarding gait speed is the patient’s ability to achieve higher levels of community ambulation. Progressions from household am­bu­lation to limited community ambulation (when a patient can attend a doctor’s appointment) to full community ambulation (when a patient can maneuver stairs, crowds, and shop­ping centers) represent signifi­cant im­prove­ments in functional mobility that are defined by the patient’s gait speed.

Gait speed can predict future health status in numerous populations, includ­ing frail elderly veterans,4 patients with hemi­plegia,37 and patients in the home setting.10 Gait speed changes may even help identify medical disturbances that can affect survival before patients notice symptoms.8 Gait speed has also been shown to predict healthcare costs.2 In hospitalized patients, every 0.1 m/s decline in gait speed results in poorer health status and physical functioning; increases in disability, days of rehabilitation, and days of medical-
surgical visits; longer overall hospital stays; and higher inpatient costs. Likewise, every 0.1 m/s of gait speed improvement results in improved health status, less physical disability, fewer hospitalization days, and a one-year reduction in medical costs of $1188.4

Gait speed can help physical therapists and other clinicians forecast rehabilitation outcomes,38 fear of falling,6 and gait behavior, such as how successfully an elderly individual can enter the com­munity and cross the street.7,39 It can also predict functional decline.40 Patients who ambulate at speeds slower than 1 m/s benefit from fall prevention training3 and those who walk slower than 0.6 m/s have a high risk of physical disability.41 Gait speeds less than 0.6 m/s are also predictive of a future risk of hospitalization and a decline in health and function.8

Gait speed even predicts future survival and mortality rates.9 For example, men aged 85 years who walk 0.85 m/s have a five-year survival rate of 85% while their same-age counterparts who walk 0.4 m/s have a 40% chance of living five years.8 Afilalo et al42 studied the use of gait speed in predicting mortality and major morbidity in older patients undergoing cardiac surgery. They reported that slow gait speed prior to surgery, defined as 0.83 m/s or less, is a primary independent predictor of mortality and major morbidity after coronary artery bypass or valve replacement or repair. The study also found that slow walkers were more likely to be women and have diabetes.

As noted, gait distances, use of assistive devices, and assistive levels are already commonly documented in patients’ medical charts.1 However, the quantitative observation that gait distance is  longer than when the patient began rehabilitation does not support the need for a skilled physical therapist.43,44 For therapy documentation to support gait training as a medical necessity of care, quality-related gait components such as speed, rhythm, cadence, step length, and stride length3 need to be included. Gait as it relates to function is more meaningful than just the distance covered, and skilled intervention may be required to enable a patient to maneuver from the bedroom to the bathroom, to the driveway for car transfers, across the street at a traffic signal, or the distance from the front door of a facility to a physician’s office. Together, gait speed and distance, as they relate to function, paint a more comprehensive picture of gait improvements throughout the course of therapy, especially if used in conjunction with other appropriate mobility assessment measures.

Although gait speed is a simple measure and clinicians can test ambulatory patients’ gait speed in any setting, its beauty is that it provides so much information on a patient’s current condition as well as his or her potential future status.

Conclusion

In summary, gait speed can help the physical therapist describe gait components, contributing more objective measures than gait distance alone. Gait speed has the potential to assist in safe discharge planning of patients with the goal of minimized rehospi­talizations. Established normative data on gait speed can provide objective measures so a clinician can assess current health status and document results for continuity of care.

Because changes in self-selected gait speed may indicate a new health problem is arising, gait speed assessment may serve to predict future health status, thus justifying preventive interventions targeted at patients’ modifiable risk factors.45

Since documenting gait distance alone is insufficient, the addition of gait speed strengthens medical documentation by describing components of gait, linking resulting functional limitations to appropriate interventions, and providing objective data that confirm progress while offering a glimpse of the patient’s future health status.

Heather Braden, PT, MPT, PhD, GCS, is an assistant professor in the Department of Nursing and Rehabilitation Sciences, Doctor of Physical Therapy Program, at Angelo State University in San Angelo, TX.

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2 Responses to Self-selected gait speed: A critical clinical outcome

  1. Steve Throner says:

    I am wondering if any of the gait-speed analysts in the above article have any recommendations for foot drop braces. I am an ex-athlete with CMT seeking appliances that will enable me to become more athletic. Currently, I do without braces and just kind of gut it out. Standing and walking are both very tiring. Falling is downright disturbing.

    Thanks,

    Steve

  2. Marina Makarova says:

    Dear colleges, thank you very much for your interesting, elegant review. I,m a physical therapist and docent in medical university in Moscow,Russia. I hope you will not mind if I use this material in educational programm. Thank you

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