Walking Index for Spinal Cord Injury

Last Updated

January 11, 2013

Purpose

The WISCI & WISCI II assess the amount of physical assistance needed, as well as devices required, for walking following paralysis that results from Spinal Cord Injury (SCI). They are designed to be a more precise measure of improvement in walking ability specific to SCI.

Link to Instrument

Instrument Details

Acronym WISCI, WISCI II

Area of Assessment

Functional Mobility
Gait

Assessment Type

Observer

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Spinal Cord Injury

Spinal Injuries

Rank orders the ability of a person to walk 10m after a spinal cord injury from most to least severe impairment (Ditunno & Dittuno, 2001).
Considers:
1) Amount of assistance: two persons, defined as moderate to maximum assist; 1 person, defined as minimal assist; no assist; assistve device, such as parallel bars, walker, crutches(axillary or forearm), canes
2) Braces: 1 or 2; short or long
Of note, the original scale, WISCI, consisted of items 1-20; scale revised to WISCI II to include 0-20.
Levels and descriptions of the scales are included in the Considerations section below.
WISCI II Is the current used and accepted scale.

Number of Items

5 minutes

Required Training

No Training

Adolescent

13 - 17

years

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team in 2011; Updated by Jennifer H Kahn, PT, DPT, NCS, Candy Tefertiller, PT, DPT, APT, NCS, and the SCI EDGE task force of the Neurology Section of the APTA in 2012.

ICF Domain

Activity

Measurement Domain

Motor

Professional Association Recommendation

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 (Vestibular EDGE) 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)

SCI EDGE

Recommendations based on SCI AIS Classification:

	AIS A/B	AIS C/D
SCI EDGE	R	HR

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)
SCI EDGE	No	Yes	Yes	Not reported

Considerations

Level	Description
0	Client is unable to stand and/or participate in assisted walking.
1	Ambulates in parallel bars, with braces and physical assistance of two persons, less than 10 meters.
2	Ambulates in parallel bars, with braces and physical assistance of two persons, 10 meters.
3	Ambulates in parallel bars, with braces and physical assistance of one person, 10 meters.
4	Ambulates in parallel bars, no braces and physical assistance of one person, 10 meters.
5	Ambulates in parallel bars, with braces and no physical assistance, 10 meters.
6	Ambulates with walker, with braces and physical assistance of one person, 10 meters.
7	Ambulates with two crutches, with braces and physical assistance of one person, 10 meters.
8	Ambulates with walker, no braces and physical assistance of one person, 10 meters.
9	Ambulates with walker, with braces and no physical assistance, 10 meters.
10	Ambulates with one cane/crutch, with braces and physical assistance of one person, 10 meters.
11	Ambulates with two crutches, no braces and physical assistance of one person, 10 meters.
12	Ambulates with two crutches, with braces and no physical assistance, 10 meters.
13	Ambulates with walker, no braces and no physical assistance, 10 meters.
14	Ambulates with one cane/crutch, no braces and physical assistance of one person, 10 meters.
15	Ambulates with one cane/crutch, with braces and no physical assistance, 10 meters.
16	Ambulates with two crutches, no braces and no physical assistance, 10 meters.
17	Ambulates with no devices, no braces and physical assistance of one person, 10 meters.
18	Ambulates with no devices, with braces and no physical assistance, 10 meters.
19	Ambulates with one cane/crutch, no braces and no physical assistance, 10 meters.
20	Ambulates with no devices, no braces and no physical assistance, 10 meters.

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Standard Error of Measurement (SEM)

See Burn's et al (2011) SRD data below

Minimal Detectable Change (MDC)

Chronic SCI: (Burns et al, 2011; n = 63; mean age = 43.3 (13.8) years; mean time since injury = 6.32 (5.99) years)

SRD for WISCI Level and Walking Speed
		SEM	SRD
SS WISCI	Level	0.283	0.785
	Speed	0.091	0.254 m/s
Max WISCI	Level	0.215	0.597
	Speed	0.059	0.163 m/s
WISCI = Walking Index for Spinal Cord Injury SS = Self-Selected Max = Maximum SEM = Standard Error of Measurement SRD = Smallest Real Difference

These results suggest that a change of 1 WISCI level can be considered a real difference in a clinical context

Normative Data

Acute SCI : (Scivoletto et al, 2004; n = 183 males and 98
females; mean age = 50.4 (19.3) years)

SCI Outcome Data by Sex:
Admission	Females	Males
Age (years)	52 (19.1)	50.8 (19)
Lesion to admission time (days)	54.1 (43)	52.6 (39)
Length of stay (days)	103.6 (73.9)	103.4 (79.3)
Motor scores	58.4 (14.3)	56.9 (16.8)
WISCI	0.6 (2.7)	1.8 (5.4)
Motor scores at discharge	67.3 (19.2)	65 (22.3)
WISCI at discharge	7.9 (8.2)	7.8 (8.5)
No significant differences between male and female scoresWISCI = Walking Index for Spinal Cord Injury

Test/Retest Reliability

Chronic SCI: (Burns et al, 2011; n = 63; mean age = 43.3 (13.8) years; mean time since injury = 6.32 (5.99) years); mean time between tests 35 days (0-437)

Self selected WISCI Excellent, ICC =0.994
Max WISCI, Excellent, ICC = 0.995

Interrater/Intrarater Reliability

Chronic SCI: (Marino et al, 2010; n = 26; sample included participants from the US and Italy)

Excellent Intrarater reliability (maximum) = 1.0
Excellent Interrater reliability = 0.98

Acute SCI: (Ditunno et al, 2000, 24 raters assessed 40 video clips, multicenter)

Excellent interrater reliability 100%

Acute SCI: (Morganti et al, n= 249 (sub sample from 284), Italy)

Excellent (1.0) interrater reliability for assignment of WISCI II scores via retrospective collection of data from charts

Criterion Validity (Predictive/Concurrent)

Concurrent Validity for Original WISCI: (Ditunno et al, 2000 sample included participants from Australia, Brazil, Canada, Korea, Italy, the UK and US)

Excellent WISCI and FIM score correlations (r = 0.765)

Predictive validity for Acute SCI: (Ditunno et al, 2007; n =142; the best predictor of WISCI scores at baseline entrance into multicenter RCT was LEMS, r = 0.73).

Predictors of WISCI at 12months
	Baseline	3mo	6mo
LEMS	0.73	0.81	0.86
BBS	0.47	0.84	0.89
LFIM	0.30	0.79	0.85
Total FIM	0.12	0.63	0.69
Speed		0.71	0.81
6MWT		0.77	0.80

Construct Validity

Chronic SCI (>6months): (Burns et al, 2011; n = 63; mean age = 43.3 (13.8) years; mean time since injury = 6.32 (5.99) years; mean time between tests 35 days (0-437))

Convergent Validity:
		MMT		LEMS			UEMS
		Combined	Tetraplegic	Combined	Tetraplegic	Paraplegic	Tetraplegic
SS WISCI	WISCI Level	0 .647**	0.812**	0.704**	0.852**	0.479*	0.496**
	Speed	0.494**	0.715**	0.509**	0.752**	0.104	0.491*
MAX WISCI	WISCI Level	0.663**	0.798**	0.717**	0.816**	0.533*	0.502**
	Speed	0.539**	0.753**	0.572**	0.813**	0.149	0.469**

Results suggest that LE motor function contributes more to walking function following tetraplegia vs. paraplegia.

Correlation Strength:
> .60 = Excellent
.31 to .59 = Adequate
< .30 = Poor

*p < .05
**p < .0001
WISCI = Walking Index for Spinal Cord Injury
SS = Self-Selected
Max = maximum
MMT = manual muscle test
LEMS = lower-extremity motor score
UEMS = upper-extremity motor score

Acute SCI: (van Hedel et al, 2005; mean age = 54 (20) years; AIS A = 5%, B = 4%, C = 9% and D = 81%)

Validity was investigated for the 10MWT, TUG, and 6MWT via correlations with the WISCI II. The authors completed an analysis of overall WISCI II scores as well as sub groups, dividing the WISCI II, based on walking ability.
- Overall correlations (n=67)
  - Excellent WISCI II vs TUG (r= -0.76)
  - Excellent WISCI II vs 10MWT (r= -0.68)
  - Excellent WISCI II vs 6MWT (r= 0.60)
- WISCI II score of 0 to 10 (n = 13 to 20)
  - Poor, WISCI II vs TUG (r = 0.16)
  - Poor, WISCI II vs 10MWT (r =- 0.24)
  - Poor, WISCIII vs 6MWT (r = -0.22)
- WISCI II score of 11 to 20 (n = 47)
  - Excellent, WISCI II vs TUG (r = -0.65)
  - Adequate, WISCI II vs 10MWT (r = -0.49)
  - Excellent, WISCI II vs 6MWT (r = 0.64)
- WISCI II (0-8, 10, 11, 14, 17 ), dependent walkers (n=15 to 24)
  - Poor, WISCI II vs TUG (r=-0.22)
  - Adequate, WISCI II vs 10MWT (r =-0.35)
  - Poor, WISCI II vs 6MWT (r =0.21)
- WISCI II (9, 12, 13, 15, 16, 18-20), independent walkers (n=43 to 45)
  - Excellent, WISCI II vs TUG (r =-0.66)
  - Adequate, WISCI II vs 10MWT (r =-0.48)
  - Excellent, WISCI II vs 6MWT (r =0.65)

Overall, improved validity in individuals who are less impaired, higher walking ability, and do not require assistance.

Acute SCI: (Morganti 2005, n=76(subset of 284), Italy)

Excellent WISCI vs Rivermead Mobility Index( r =0.67)
Excellent WISCI vs Barthel Index ( r =0.67)
Excellent WISCI vs Spinal Cord Independence Measure ( r =0.97)
Excellent WISCI vs Functional Independence Measures ((r =0.7)

Acute to chronic incomplete SCI: (van Hedel et al 2006, n=22, incomplete SCI who could ambulate within the 1^st month post SCI, measured at 1mo, 3mo, 6mo, and 12 mo post, middle 10m of 14m walk used)

	LEMS	10MWT	6MWT
Within 1 month
WISCI II	Adequate r= 0.49**	Excellent r= -0.79*	Excellent r= -0.78*
After 3 months
WISCI II	Adequate r= 0.50	Poor r=-0.21	Poor r=0.28
After 6 months
WISCI II	Adequate r=0.38	Adequate r=-0.37	Adequate r=0.36
After 12 months
WISCI II	Adequate r=0.32	Adequate r=-0.37	Adequate r=0.36
p<.001; * p = 0.02 ; Spearman’s correlations

Acute SCI: (Ditunno, 2007; n= 146 data collected as part of a multicenter randomized controlled trial looking at locomotor training methods and improved ambulation)

WISCI vs:	LEMS N=107-121	Speed N=80-88	6MWT n=76-78	LFIM	Total FIM	BBS
3mo	0.85	0.78	0.76	0.92	0.73	0.91
6mo	0.85	0.85	0.68	0.89	0.77	0.89
12mo	0.88	0.77	0.69	0.88	0.74	0.92
Change from baseline
to 3mo	0.55 (A)			0.87	0.54 (A)	0.85
to 6mo	0.60			0.88	0.48 (A)	0.87
to12mo	0.64			0.87	0.51 (A)	0.85
LEMS = Lower extremity motor scores; 6MWT= 6minute walk test; LFIM = locomotor score on FIM; BBS = Berg Balance Scale; All values significant p<.01; All results Excellent, with exception of those noted (A) = Adequate

Content Validity

SCI Measure Review: (Jackson et al, 2006, review of 5 SCI measures; based on 54 votes)

Expert ratings:

Valid or Useful = 52%
Useful but requires validation or changes = 43%
Not Useful or valid for research in SCI = 6%

Ditunno 2001, International, multicenter group of experts utilizing the Modifed Delphi technique to construct the measure

Face Validity

Ditunno 2000, A group consensus process, Modified Delphi technique was utilized. Experts (a clinical investigator, a physician, and a physical therapist) at eight international spinal cord injury facilities were asked to rank 20 items in order from least impaired to most impaired. This gave a total of 24 individuals and 8 teams of data.

Excellent Kendall coefficient for individual ranking = 0.860, for team rankings = 0.872
Excellent agreement/correlations among participants in each team (investigator, physician, PT, =0.960, 0.944, 0.974)

Floor/Ceiling Effects

Acute incomplete SCI: (Morganti et al, 2005, n=249 (subset of 284), Italy, AIS A, B, C, D)

17% subjects, 42/249, reached WISCI II score of 20 by the time of discharge from inpatient rehabilitation
53% (131/249) had a WISCI score of 0 at discharge from inpatient rehab; however, 82 of these individuals were classified as AIS A or B.

Acute SCI (inpatient AIS D, Canada): Lemay 2010, n=32

44.8 % of subjects reached the highest score on the WISCI II indicating a ceiling effect.

Chronic SCI: (Kim 2007, n=50, >1 year post)

48% (24/50) subjects at greater than 1 year post injury has WISCI =20 at entry into the study

Responsiveness

Acute incomplete SCI: (Morganti et al, 2005, n=249 (subset of284), Italy)

Found the WISCI II to be a more precise and sensitive scale for documenting changes in levels of walking over the FIM, SCIM, RMI, BI. WISCI II scores had greater distribution at discharge (12 levels) versus FIM (4), SCIM(5), RMI(2), BI(3).

Acute to chronic incomplete SCI: (van Hedel et al 2006, n=22, incomplete SCI who could ambulate within the 1^st month post SCI, measured at 1mo, 3mo, 6mo, and 12 mo post)

Looked at change between different time intervals post SCI of WISCI II, 10m, and 6minute walk tests, and ASIA LEMS. The WISCI II and LEMS showed change between 1mo and 3mo, but not after that, while the 10m and 6min continued to show change at 6 months post injury.
Bottom line – The WISCI II is less responsive in assessing walking ability in those who are at a higher level of walking.

	1mo vs. 3mo post	3mo vs. 6mo post	6mo vs 12 mo post
WISCI II	*	Not a significant change	Not a significant change
10M	*	*	Not a significant change
6min	*	*	Not a significant change
LEMS	*	Not a significant change	Not a significant change
Results of Friedman’s test to assess change between time intervals post SCI. *= significant change, p<0.025 10M = 10m walk test 6min = 6minute walk test LEMS = lower extremity motor scores

Acute SCI: (comparisons 1 to 3 months post injury and 3 to 6 months post injury, incomplete SCI, reported in Lam 2008 calculated from data in van Hedel 2007. Note, calculated from median data.

Effect size 2.05, moderate change – discrimination between 1 and 3 months post injury
Effect size 0.73, small change – discrimination between 3 and 6 months post injury

Bibliography

Burns, A. S., Delparte, J. J., et al. (2011). "The reproducibility and convergent validity of the Walking Index for Spinal Cord Injury (WISCI) in chronic spinal cord injury." Neurorehabil Neural Repair 25(2): 149-157. Find it on PubMed

Dittuno, P. L. and Ditunno, J. F., Jr. (2001). "Walking index for spinal cord injury (WISCI II): scale revision." Spinal Cord 39(12): 654-656. Find it on PubMed

Ditunno, J. F., Jr., Barbeau, H., et al. (2007). "Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial." Neurorehabil Neural Repair 21(6): 539-550. Find it on PubMed

Ditunno, J. F., Jr., Ditunno, P. L., et al. (2000). "Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study." Spinal Cord 38(4): 234-243. Find it on PubMed

Jackson, A. B., Carnel, C. T., et al. (2008). "Outcome measures for gait and ambulation in the spinal cord injury population." J Spinal Cord Med 31(5): 487-499. Find it on PubMed

Kim, M. O., Burns, A. S., et al. (2007). "The assessment of walking capacity using the walking index for spinal cord injury: self-selected versus maximal levels." Arch Phys Med Rehabil 88(6): 762-767. Find it on PubMed

Lam, T., Noonan, V. K., et al. (2008). "A systematic review of functional ambulation outcome measures in spinal cord injury." Spinal Cord 46(4): 246-254. Find it on PubMed

Lemay, J. F. and Nadeau, S. (2010). "Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale." Spinal Cord 48(3): 245-250. Find it on PubMed

Marino, R. J., Scivoletto, G., et al. (2010). "Walking Index for Spinal Cord Injury Version 2 (WISCI-II) with Repeatability of the 10-m Walk Time: Inter-and Intrarater Reliabilities." American Journal of Physical Medicine & Rehabilitation 89(1): 7. Find it on PubMed

Morganti, B., Scivoletto, G., et al. (2005). "Walking index for spinal cord injury (WISCI): criterion validation." Spinal Cord 43(1): 27-33. Find it on PubMed

Scivoletto, G., Romanelli, A., et al. (2008). "Clinical factors that affect walking level and performance in chronic spinal cord lesion patients." Spine 33(3): 259-264. Find it on PubMed

van Hedel, H. J., Dietz, V., et al. (2007). "Assessment of walking speed and distance in subjects with an incomplete spinal cord injury." Neurorehabil Neural Repair 21(4): 295-301. Find it on PubMed

van Hedel, H. J., Wirz, M., et al. (2006). "Improving walking assessment in subjects with an incomplete spinal cord injury: responsiveness." Spinal Cord 44(6): 352-356. Find it on PubMed

van Hedel, H. J., Wirz, M., et al. (2005). "Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests." Arch Phys Med Rehabil 86(2): 190-196. Find it on PubMed

van Hedel, H. J., Wirz, M., et al. (2008). "Standardized assessment of walking capacity after spinal cord injury: the European network approach." Neurol Res 30(1): 61-73. Find it on PubMed

Last Updated

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Criterion Validity (Predictive/Concurrent)

Construct Validity

Content Validity

Face Validity

Floor/Ceiling Effects

Responsiveness

Bibliography

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