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Rehab Measures: Functional Gait Assessment

Link to instrument

FGA is available in the appendix of the original article (external link) 

Title of Assessment

Functional Gait Assessment 

Acronym

FGA

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team in 2010; Updated with references from the SCI and PD populations by Tamara Alie, SPT and Stephanie Austin, SPT in 2011; Updated by Candy Tefertiller, PT, DPT, ATP, NCS, Jennifer Kahn, PT, DPT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 2012; Updated with references for Stroke and PD populations by Marissa Gruber, SPT, Sally Stelsel, SPT, and Laura Vazquez, SPT in 2012; Updated by Cathy Harro PT, MS, NCS and the PD EDGE task force of the Neurology Section of APTA in 2013; Updated by Diane Wrisley, PT, PhD, NCS and Elizabeth Dannenbaum MScPT for Vestibular EDGE task force 2013

Summary Date

11/14/2013 

Purpose

Assesses postural stability during various walking tasks

Description

  • This test is a modification of the Dynamic Gait Index developed to improve reliability and decrease the ceiling effect.
  • 10-item test that comprises 7 of the 8 items from the original DGI
    • Eliminated 1 item from original DGI, ambulation around obstacles
    • Added 3 new items to the original DGI, including gait with narrow base of support, ambulating backwards, and gait with eyes closed were added
  • Each item is scored on an ordinal scale from 0 - 3, with
    • 0 = severe impairment
    • 1 = moderate impairment
    • 2 = mild impairment
    • 3 = normal ambulation
  • Highest score = 30
  • Assessment may be performed with or without an assistive device

Area of Assessment

Balance Vestibular; Balance Non-Vestibular; Gait 

Body Part

Not Applicable 

ICF Domain

Activity 

Domain

Motor 

Assessment Type

Observer 

Length of Test

05 Minutes or Less 

Time to Administer

5 - 10 minutes

Number of Items

10 

Equipment Required

  • Stopwatch
  • Marked walking area: Length = 20 feet (6.1 meters); width 12 inches (30.5 cm)
  • Obstacle of 9 inch height (22.86 cm) using at least 2 stacked shoe boxes
  • Set of steps with railings

Training Required

No training

Type of training required

No Training 

Cost

Free 

Actual Cost

Free

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Geriatrics; Parkinson’s Disease; Stroke; Vestibular Disorders 

Populations Tested

  • Older adults ranging from 40-80 years
  • Parkinson's Disease
  • Spinal Cord Injury
  • Stroke
  • Vestibular populations

Standard Error of Measurement (SEM)

Stroke:

(Lin et al, 2010; n = 45; mean age = 60.0 (12.6) years; median time since stroke = 9 months (range 3 to 36 months); tested while undergoing OP PT at 1 week, 2 months, and 5 months; Taiwanese sample, Stroke)

  • SEM = 1.52 (calculated from MDC - 4.2 points)

Minimal Detectable Change (MDC)

Stroke:

(Lin et al, 2010; n = 45; mean age = 60.0 (12.6) years; median time since stroke = 9 months (range 3 to 24 months); tested while undergoing OP PT at 1 week, 2 months, and 5 months; Taiwanese sample, Acute and Chronic Stroke)

  • MDC = 4.2 points (clinically: 5 point change)
  • Percent change = 14.1%

Minimally Clinically Important Difference (MCID)

Vestibular Disorders:
(Marchette and Lin, article in press; Vestibular Disorders)
  • 8 points from admission to follow-up

Cut-Off Scores

Community-dwelling Older Adults:

(Wrisley & Kumar, 2010; n = 35; aged 60 to 90, Older Adults)

  • Scores of ≤ 22/30 on the FGA were found to be effective in predicting falls, Sensitivity 85%, Specificity 86%
  • Scores of ≤ 20/30 on the FGA were optimal to predict older adults residing in community dwellings who would sustain unexplained falls in the next 6 months, Sensitivity 100%, Specificity 76%

Parkinson's Disease:

(Leddy et al, 2011; n = 80; mean disease duration = 6.9 years (3.38), Parkinson's Disease)

  • Scores of 15/30 on the FGA indicate predictive ability to clinically identify fallers in parkinson’s patients when sensitivity and specificity was maximized

Normative Data

Stroke:        

(Lin et al, 2010, Acute and Chronic Stroke)

1 week

N = 45

2 months

N = 39

5 months

N = 35

Median score

13

12

12

Range: 1st to 3rd quartile

8 - 18

9 - 20

9 - 19

 

Healthy Adults:

(Walker et al, 2007; n = 200, aged 40 to 89. Unimpaired Adults)

 

Age

n

Min score

Max score

Mean

SD

95% CI

40-49

27

24

30

28.9

1.5

28.3-29.5

50-59

33

25

30

28.4

1.6

27.9-29.0

60-69

63

20

30

27.1

2.3

26.5-27.7

70-79

44

16

30

24.9

3.6

23.9-26.0

80-89

33

10

28

20.8

4.7

19.2-22.6

Total

200

10

30

26.1

4.0

25.5-26.6

  • Mean total FGA scores demonstrate an overall decrease with increased age
  • Increased variability in scores noted with each decade increase in age (increased SD’s)

Test-retest Reliability

Community Dwelling Adults with Parkinson’s Disease:

(Leddy et al, 2011; FGA and BEST; subset of subjects n = 24, MDS-UPDRS = 71 (21.9), disesase duration mean = 6.9 (3.38), 21% fallers)

  • Excellent test-retest reliability administered by PT (ICC = 0.91; 95% CI = 0.80 - 0.96)
  • Excellent test-retest reliability administered by student (ICC = 0.80; 95% CI = 0.58 - 0.91)

 

Stroke:

(Lin et al, 2010; n = 45; mean age = 54.9 (10.2) years, Acute and Chronic Stroke)

  • Excellent test-retest reliability (ICC = 0.95, 95%CI)

Interrater/Intrarater Reliability

Community Dwelling Adults:

(Walker et al, 2007, Community Dwelling Adults)

  • Excellent interrater reliability (ICC = 0.93; p < 0.001)

Community Dwelling Adults with Parkinson’s Disease:

(Leddy, et al, 2011; n =15 people with PD; mean disease duration = 6.8 (3.26) years; MDS-UPDRS mean score = 74.2 (18.6); H&Y scale stage 1 = 2, stage 2 = 7, stage 2.5 = 3, stage 3 = 2, and stage 4 = 1)

  • Excellent interrater reliability (ICC = 0.93; 95% CI = 0.84 - 0.98

Stroke:

(Thieme et al, 2009; n = 28; mean age 69.9 (9.5) years; max 6 months post CVA, Subacute Stroke, German version) 

  • Excellent interrater reliability (ICC = 0.94) (individual items Kendall's W = 0.77-0.96) 
  • Excellent intrarater reliability (ICC = 0.97) (individual items Kendall's W = 0.88-0.98)

Vestibular Disorders:

(Wrisley et al, 2004, n = 6, mean age 58.7 + 12.4, 10 raters - 3 students, 7 experienced PTs)

  • Excellent interrater reliability (ICC = 0.84) (individual items k = 0.34-0.78) 
  • Excellent intrarater reliability (ICC = 0.83) (individual items k = 0.16-0.83) 

Internal Consistency

Vestibular Disorders:

(Wrisley et al, 2004, Vestibular Disorders)

  • Excellent internal consistency (Cronbach's alpha = 0.79)

Criterion Validity (Predictive/Concurrent)

Older Adult Community Dwelling:

(Wrisley et al, 2010, aged 60-90 years, Older Adult Community Dwelling)

  • Excellent concurrent validity and statistical significance with:
    • Berg Balance Scale r = 0.84 (P < 0.000)
    • Timed Up and Go Test r = 0.84 (P < 0.000)
  • Adequate concurrent validity and statistical significant with:
    • Activities-specific Balance Confidence Scale r = 0.53 (P < 0.001)
  • Predictive Validity: FGA correctly identified 6/7 unexplained falls in the 6 months following testing

Stroke:

(Lin et al, 2010, Stroke)

  • Excellent correlation with 10MWT and PASS (r = -0.66 - 0.83)

Stroke:

(Thieme et al, 2009)

  • Excellent correlation with Functional Ambulatory Category (r = 0.83), gait speed (r = 0.82), Berg Balance Scale (r = 0.93), Rivermead Mobility Index (r = 0.85) and Barthel Index (r = 0.71)

Vestibular Disorders:

(Wrisley et al, 2004, Vestibular Disorders)

  • Excellent concurrent validity with:
    • Perception Dizziness Symptoms (r = -0.70)
    • Dizziness Handicap Inventory (r = -0.64)
    • Activities-specific Balance Confidence Scale (r = 0.64)
    • Number of falls in previous 4-weeks (r = -0.66)
    • Dynamic Gait Index (r = 0.80)
  • Adequate concurrent validity with Timed Up and Go Test (r = -0.50)

Parkinson Disease:

(Ellis et al, 2011; n = 263 with idiopathic PD; mean age = 67.7 (9.2); mean duration of PD = 6.22 (4.8) years, H& Y stages (1-16, 1.5 = 4, 2 = 113, 2.5 - 62, 3 = 52, 4 = 15). Mean FGA score for cohort = 20.5 (6.4)

  • Excellent concurrent validity between FGA scores and the following: Berg Balance Scale (r =0.77), PDQ-39 mobility subsection (r = -0.66), postural instability gait disorder score (r = -0.68)
  • Adequate concurrent validity between FGA scores and the following: PDQ_39 total score (r = -0.57), age (r = -0.44), bradykinesia composite score (r = -0.55), freezing of gait score (r = -0.54),functional reach (r = 0.52), 9 hole peg test (r = -0.52)
  • FGA scores were significant contributor to PDQ-39 motor score in stepwise regression analysis (R2change = 0.06, p < 0.001)

Construct Validity (Convergent/Discriminant)

Older Adults:

(Wrisley & Kumar, 2010; n = 35; aged 60 to 90, Older Adults)

  • FGA correctly classified fall risk based on the DGI 93% of the time (DGI ≤ 19/24)
    • Individuals scoring ≤ 22 on FGA are 4.5 times more likely to fall based on the DGI
  • FGA correctly classified fall risk based on the TUG 87% of the time (TUG: ≥ 11 seconds)
    • Individuals scoring ≤ 22 on FGA are 6 times more likely classified as a fall risk based on TUG

Stroke:

(Lin et al, 2010, Acute and Chronic Stroke)

  • Excellent convergent validity with 10MWT (r = -0.66, -0.85, -0.81) and PASS (r = 0.83, 0.75, 0.83) during 1st week of therapy, 2 months and 5 months after therapy

(Thieme et al, 2009; n = 28; mean age 69.9 (9.5) years; max 6 months post CVA)

  • Excellent correlations between FGA and FAC (ρ = 0.83, p < 0.001)
  • Excellent correlations between FGA and Gait speed (ρ = 0.82, p < 0.001)
  • Excellent correlations between FGA and BBS (ρ = 0.93, p < 0.001)
  • Excellent correlations between FGA and RMI (ρ = 0.85, p < 0.001)
  • Excellent correlations between FGA and BI (ρ = 0.71, p < 0.001)

Parkinson Disease:

(Duncan et al, 2012; 6-month prospective group n = 51; mean age = 67.5 (8.8) years; mean duration of PD = 7.7 (3.9) years, mean UPDRS-motor score = 39.3 (13.3), mean H&Y stage = 2.4 (0.6); 12-month prospective group n = 40; mean age = 67.3 (9.5), mean duration of PD = 7.2 (4.1); mean UPDRS-motor score = 37.8 (13.1;, mean H&Y stage = 2.3 (0.6))

  • Adequate predictive validity of FGA to identify fall risk with cutoff score < 15/30 is as follows:
    • 6-month prospective falls (AUC = 0.80 (95% CI, 0.62-0.90), Sensitivity = 0.64, specificity = 0.81, +LR = 3.37 (CI, 2.19-5.18), -LR = 0.44 (CI, 0.34-0.59), Posttest probability with test < cutoff value = 0.56, with test score > cut off value = 0.15
    • 12 month prospective falls {AUC = 0.70 (95% CI, 0.50-0.83), sensitivity = 0.46, specificity = 0.81, +LR = 2.42 (CI, 1.53-3.82), -LR = 0.67 (CI, (0.54-0.82), Post test probability with test < cutoff value = 0.54, with test score > cutoff value= 0.24
    • FGA was inferior to BESTest in predictive validity and AUC (6- and 12-months)

(Foreman et al, 2011a; n = 36 persons with PD who were ambulatory but clinical signs of gait hypokinesia; Grouped as, Fallers = 22 & non-fallers = 14; Fallers characteristics {14 male/8 female, mean age = 70.95 (11.4), mean duration of PD = 8.18 (4.58) mean UPDRS motor score on/off medications = 17.0 (8.07)/27.29 (7.96), mean H&Y stage = 2.5/3 range 1.5 - 4} Non-fallers characteristics {10 male/4 female, mean age 66.64 (10.05), mean duration PD 4.64 (3.25), mean UPDRS-motor score on/off meds = 11.57 (6.43) / 25.36(9.9), mean H&Y score 2.25/2.5 range 1.5 - 3)

  • FGA scores were significantly different on vs. off medications (on meds 18.77 (8.38), off meds 13.67 (6.93), p < 0.006. Effect size = 0.47
  • FGA has better predictive validity for identifying fallers when scored “off meds” as compared to “on meds” {Adequate responsiveness AUC = 0.81 (0.66-0.95) on meds; 0.89 (0.78 - 0.99) off meds. FGA scores were better at predicting fallers than TUG or pull test both on and off meds

(Foreman et al 2011b; n = 15, 9 male/6 female, mean age 67 (13) years, mean duration of PD = 7.5 (5.0) years, mean H&Y stage = 2.5 (range 2 - 4) on meds, mean UPDRS-motor on meds = 13.7 (6.8) and off meds mean H&Y stage 3.0 (2.5 - 4) and mean UPDRS-motor = 27.6 (7.0), 8 fallers)

  • Significantly higher FGA scores on meds = 23.67 (4.59) 95% CI 21.1-26.21 as compared to off meds = 18.8 (4.8), 95% CI 16.4-21.46, p < 0.008

(Leddy et al, 2011; community dwelling adults with PD)

  • Scores < 15/30 identified subjects with a history of falling (Sensitivity 0.72, Specificity 0.78, AUC 0.80)

Content Validity

Not Established

Face Validity

Not Established

Floor/Ceiling Effects

Stroke:

(Lin et al, 2010, Acute and Chronic Stroke)

  • Excellent floor and ceiling effects

Time Point

Floor Effect %

 Ceiling Effect %

1st week of  PT

2.0

0

2 months after PT

0

0

5 months after PT

0

5.7

Responsiveness

Parkinson’s Disease:

(Duncan et al., 2012; n = 51; mean age for fallers in 6 months = 67.5 (8.8); disease duration: 7.7 (3.9) years; mean Hoehn & Yahr score = 2.4 (0.6)(range 1-4); also assessed at 12 months: n = 40; mean age for fallers at 12 months = 67.3 (9.5); disease duration: 7.2 (4.1) years; mean H & Y score = 2.3 (0.6), Parkinson’s Disease)

  • At 6 months:
    • AUC = 0.80
    • Sensitivity = 64%
    • Specificity = 81%
  • At 12 months:
    • AUC = 0.70
    • Sensitivity = 46%
    • Specificity = 81%

(Foreman, 2011; n = 36; mean age of fallers = 70.95(11.41) years and of non-fallers = 66.64(10.05) years, Parkinson’s Disease)

  • ROC curve (Sensitivity vs. 1-Specificity)
    • AUC = 0.8052 (subjects on meds)
    • AUC = 0.8861 (subjects off meds)

(Foreman et al, 2011a)

  • Moderate effect size in response to measure mobility functions on vs. off PD meds (ES = 0.47)

(Foreman et al, 2011b)

  • Effect of dopamine replacement meds, large effect size on total FGA score = 1.07. FGA items that were more reponsive to dopamine replacement (effect size > 0.7) were gait on level surface, change in gait speed, gait with vertical head turns, gait with narrow base. FGA items that were less responsive were walk with head turns, pivot turn, walk with eyes closed and steps.

Stroke:

(Lin et al 2010, Acute and Chronic Stroke)

  • FGA: Moderate responsiveness in detecting change at the 2 and 5 months of rehabilitation

Periods of Follow-Up

Effect Size d

Wilcoxon Z

2 months

0.50

3.0*

5 months

0.54

2.8*

*P < 0.01

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

SCI EDGE

LS

LS

NR

VEDGE

LS

 

HR

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

HR

HR

HR

HR

NR

 

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

UR

UR

UR

UR

UR

TBI EDGE

LS

LS

LS

LS

LS

 

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

LS

LS

 

 

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

LS

LS

NR

NR

 

 

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

UR

UR

NR

NR

 

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

HR

HR

LS

LS

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

No

No

No

Yes

PD EDGE

Yes

Yes

Yes

Not reported

SCI EDGE

No

Yes

No

Not reported

TBI EDGE

Yes

Yes

Yes

Not reported

VEDGE

Yes

Yes

Yes

Yes

Considerations

Position of therapist did not make difference in interrater reliability (Wrisley et al, 2004)
 
Addressed the ceiling effect of the DGI in persons with vestibular dysfunction. (Wrisley et al, 2004)
 
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Duncan, R. P., Leddy, A. L., et al. (2012). "Accuracy of fall prediction in Parkinson disease: six-month and 12-month prospective analyses." Parkinsons Dis 2012: 237673. Find it on PubMed

Ellis, T., Cavanaugh, J. T., et al. (2011). "Which measures of physical function and motor impairment best predict quality of life in Parkinson's disease?" Parkinsonism Relat Disord 17(9): 693-697. Find it on PubMed

Foreman, K. B., Addison, O., et al. (2011). "Testing balance and fall risk in persons with Parkinson disease, an argument for ecologically valid testing." Parkinsonism Relat Disord 17(3): 166-171. Find it on PubMed

Foreman, K. B., Wisted, C., et al. (2012). "Improved Dynamic Postural Task Performance without Improvements in Postural Responses: The Blessing and the Curse of Dopamine Replacement." Parkinsons Dis 2012: 692150. Find it on PubMed

Leddy, A. L., Crowner, B. E., et al. (2011). "Functional gait assessment and balance evaluation system test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall." Phys Ther 91(1): 102-113. Find it on PubMed

Lin, J. H., Hsu, M. J., et al. (2010). "Psychometric comparisons of 3 functional ambulation measures for patients with stroke." Stroke 41(9): 2021-2025. Find it on PubMed

Thieme, H., Ritschel, C., et al. (2009). "Reliability and validity of the functional gait assessment (German version) in subacute stroke patients." Arch Phys Med Rehabil 90(9): 1565-1570. Find it on PubMed

Walker, M., Austin, A., et al. (2007). "Reference group data for the functional gait assessment." Physical Therapy 87(11): 1468. Find it on PubMed

Wrisley, D. M. and Kumar, N. A. (2010). "Functional gait assessment: concurrent, discriminative, and predictive validity in community-dwelling older adults." Physical Therapy 90(5): 761-773. Find it on PubMed

Wrisley, D. M., Marchetti, G. F., et al. (2004). "Reliability, internal consistency, and validity of data obtained with the functional gait assessment." Physical Therapy 84(10): 906-918. Find it on PubMed

Wrisley, D. M., Walker, M. L., et al. (2003). "Reliability of the dynamic gait index in people with vestibular disorders." Arch Phys Med Rehabil 84(10): 1528-1533. Find it on PubMed

Year published

1998 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 10/30/2010 11:36 AM  by Dawood Ali 
Last modified at 9/24/2014 1:36 PM  by Jason Raad