Finding a clinical assessment scale - Physical Medicine and Rehabilitation

Description:

The WISCI scale is a walking ability evaluation scale dedicated to the spinal cord injury patient whose incomplete neurological profile offers promise for relearning to walk.

The original version comprised 19 levels [1].

The revised WISCI II version [3] makes it possible to graduate the evolution of walking over 21 levels, taking account of the use of braces (one or both legs, long or short) and/or technical aids: axillary or Canadian crutches, canes, parallel bars, walkers, and/or human assistance (1 or 2 persons) necessary to complete a journey of 10 metres. Level 0 corresponds to inability to stand and/or walk. Level 20 corresponds to walking over 10 metres without any human or technical assistance.

Walking speed, quality of walking, and assistance required to stand from a seated position are not taken into account [12].

The WISCI II is not a questionnaire but an observation scale and is presented as a real evaluation of the ambulation abilities of the spinal cord injury patient.

The administration time does not exceed 5 minutes since it draws on the analysis of only 4 parameters (distance travelled, type of braces, type of walking aids, type of assistance).

No learning or material is required.

This scale has been translated into French, but the French version has not been validated.

> Access to the scale is free.

Psychometric properties:

General comment on reliability:

1) The validity of appearance: the organisation and choice of items of the WISCI II scale called up on the opinion of experts, whose concordance of judgement relative to the order of items 0 to 20 proved very satisfactory with a Kendall concordance coefficient (all disciplines combined) of 0.860 (p<0.001) [1].
2) Intra-observer reproducibility in chronic phase is also perfect during usual walking and during optimal walking – intraclass correlation coefficient (ICC) = 1 [5].
3) Inter-observer reproducibility is perfect with a reliability of 100% in acute phase [1] [3] [6] or chronic phase – ICC of 1 during normal walking and ICC = 0.98 in optimal walking [8]
4) The test-retest accuracy is excellent – ICC of 0.994 during usual walking and 0.995 during optimal walking [6]
5) The content validity is satisfactory, as demonstrated among the examiners, with the good adhesion rate of 52% judging the WISCI II useful and valid without the need for modification, and 43% of examiners judging the WISCI useful but with the need for modifications [12].
6) The construct validity is conveyed by many studies:
- an excellent correlation in acute phase with
  . the modified Barthel index - Spearman coefficient r = 0.67, p<0.001 [3]
  . the Rivermead Mobility Index (RMI) -r =0.67, p<0.001-[3],
  . the Spinal Cord Independence Measure (SCIM) -r=0.97, p<0.001[3]
  . the Functional Independence Measure (FIM) -r=0.7, p<0.001) [3] and r=0.78 [4]. It should be noted that 80% of items of the WISCI are found in only two FIM score levels [1].
- an excellent correlation in acute phase with
  . the 10m walking test (10MWT) (r=0.69, p<0.0001) [4]. This latter correlation is negative, meaning that the improvement in walking function is correlative to the reduction in walking speed [8].
  . the Timed Up and Go (TUG) r=0.76 [8].
- a good or excellent correlation in acute phase with
  . the lower limb motor score 3, 6 and 12 months after the spinal cord injury (respective r=0.85, 0.85 and 0.88) [4]
  . walking speed at 3, 6 and 12 months (respective r=0.78, 0.85 and 0.77) [4].
  . the 6-minute test (6MWT) at 3, 6 and 12 months (respective r=0.76, 0.68 and 0.69) [4].
- an excellent correlation in chronic phase with
  . the motor score of the lower limbs in chronic phase (r=0.81 or 0.85, p<0.0001 depending on whether it relates to routine walking or optimal walking [6].
  . the Berg Balance Scale (BBS) at 3, 6 and 12 months (respective r = 0.91, 0.89 and 0.92) [4].
- a good correlations
  . between ASIA grades A, B, C and D upon admission and the WISCI II score at the end of a primary rehabilitation cycle, making the ASIA grade a good predictor of the WISCI [3].
  . The same finding is made between the motor score of the lower limbs upon admission and the WISCI at 12 months - r=0.73 [4]. This lower extremity motor score (LEMS) upon admission explains 57% of the variance of the WISCI at 12 months. This correlation in usual and optimal walking falls sharply in chronic phase for paraplegics (r=0.479 and r=0.533) and is maintained for tetraplegics (r=0.852 and r=0.816) [6].

The correlations found over the American series are also found in the European series (Germany, Italy and Denmark) [13].

7) The discriminating validity is criticised by the fact that 71% of the 917 subjects studied are found in only 5 of the 20 categories of the WISCI II, and 11% in 11 of the 20 categories [11]. This finding suggests that some categories are redundant or scarcely representative.
8) Sensitivity to change
In acute and subacute phase, the WISCI proved more sensitive than the other evaluation scales, whether or not dedicated to walking (SCIM, FIM, modified Barthel Index, Rivermead Mobility Index) [3]. In reality, at the end of the primary stay, the WISCI II offers a much wider distribution of levels than all the above-mentioned scales.
In chronic phase:
In the case of usual walking, the sensitivity to change of the WISCI II is lower (SRD=0.785 and SEM=0.283) than that found in optimal walking (SRD=0.597 and SEM=0.215) [6]. On the other hand, the prevalence of the sensitivity of the WISCI II over that of the 6-minute test or the 10-metre walking test is nuanced by Van Hedel [7]. The sensitivity of the WISCI II appears better in subjects whose walking abilities are poor and who consequently have a margin for progression i.e. in the first 3 months (effect size = 2.05 with a confidence interval at 95% 1.57-2.53).
The sensitivity of the WISCI II is less good when the margin for progress is lower, between 3 and 6 months (effect size = 0.73 with a confidence interval at 95% 0.33-1.13).
Van Hedel and Morganti recommend the combination of the WISCI with walking speed measurements [3] [7].
9) The threshold effect: A ceiling effect has sometimes been observed – 48% of subjects walking over one year after injury [10], and 17% of subjects upon discharge from a primary stay [3] are attached to level 20 even though their walking performances are not optimal. The floor effect is observed for 53% subjects in subacute phase at the end of the first rehabilitation stay [3].

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