A systematic review of validity and reliability assessment of measuring balance and walking at the level of International Classification of Functioning, Disability and Health (ICF) in people with spinal cord injury

Abstract

Context: A spinal cord injury (SCI) is associated with a wide range of impairments in functioning, many limitations in activity, and restrictions for patients.

Objectives: The present study aimed to systematically review the psychometric properties (reliability and validity) of outcome measures used to assess walking and balance in people with spinal cord injury.

Methods: Databases such as PubMed, Embase, Scopus, and Web of Sciences were searched for relevant articles using various terms (title and abstract). Articles including the outcome measures of spinal cord injury patients and published in English from 2010 until 2021 were selected, and the quality of the selected studies was determined by applying the COSMIN checklist. Reliability and validity values were extracted, and conclusions were drawn about the psychometric quality of each measure.

Results: A total of 1253 records were retrieved, and among them 22 potentially eligible articles were identified, 15 of which were included in the present study. The COSMIN tool (Consensus-based Standards for the selection of health status Measurement Instruments) was used to evaluate the quality level of imported articles based on the inclusion criteria.

Conclusions: One consideration for testing people with disabilities is to observe the reliability and validity of the instrument, which was addressed in this study in various fields. In our study, seven tools for assessing SCI were evaluated, and it was found that the 10-meter walk (10MWT) tool performs better and more easily than other tools. The Mini-BESTest tool was suggested as a reliable tool for assessing standing balance in SCI subjects.

Introduction

A spinal cord injury (SCI) is associated with a wide range of impairments in functioning, many limitations in activity, and restrictions for patients (1). The first published population-based study in Tehran, Iran, estimated the prevalence of traumatic SCI to be in the range of 1.2-11.4 per 10,000 individuals (2). Causes included fractures, road accidents, work-related falls, acts of violence, and sports/recreation activities. Non-traumatic injuries were related to insufficient blood supply, infection, cancer, and osteoarthritis (3). Etiologically, more than 90% of SCI cases are traumatically caused by incidences such as traffic accidents, violence, sports, or falls (4).

Males across all age groups are consistently at a greater risk of morbidity and mortality from SCI. The average age of injury increased from 29 years in 1970 to 42 years in 2015 (5). Damage to the spinal cord occurs at the time of injury, known as a primary injury, and results in a secondary injury. A primary cord injury involves disruption or pressure on the cord itself, the blood supply, or the surrounding supportive structures, such as ligaments and vertebrae. Four main mechanisms were established for primary injury: impact with transient or persistent compression of the cord, distraction injury, direct laceration, and transaction. A secondary injury is the exacerbation of the primary injury because of local or systemic processes, such as hypotension, hypoxemia, hemorrhage, or cord edema (6).

In patients with SCI, partial or complete loss of somatosensory perception of voluntary motor control is the leading cause of balance disorders (7). Balance control during quiet standing depends on integrating sensory information from the somatosensory, visual, and vestibular systems. However, individuals with SCI suffer from sensory and motor impairments below the lesion level, causing an alteration in the integration of sensory inputs to maintain balance (8). One other critical outcome measure is the recovery of walking ability among SCI patients. Based on the World Health Organization (WHO) definition, walking capacity aims to indicate the highest possible level of functioning that a person may reach in a given domain at a given time (9).

The biopsychosocial model, including the international classification of functioning, disability, and health (ICF), provides a unified, international, and standardized language to describe and classify ICF with all health conditions, including SCI. This model is accepted all over the world (13). ICF may serve as a comprehensive and universally accepted framework to classify and describe functioning, disability, and health in people with all kinds of disorders or conditions, including SCI (10). After chronic SCI and the completion of rehabilitation courses, evaluations consider daily life activities and participation in physical activity and exercise. In the clinical arena and research areas, Kirschner and Guyatt's (1985) framework delineated that the assessment of impairment in SCI should preferably be proper for descriptive and evaluative purposes (11). In this regard, “valid” refers to the ability of a tool to assess what it is intended to measure; “reliable” refers to the reproducibility of measurements, which indicates the consistency of replicated measurements (11).

Studies have revealed that timed measures, such as walking tests, showed excellent reliability, construct validity, and responsiveness to change. The psychometric properties of the categorical scales were more variable; however, those developed specifically for the SCI population had excellent reliability and validity (12). The assessments considered covered neuro-musculoskeletal, sensory and pain, mental and skin structures functions, activity, participation, and quality of life (13). Based on previous studies, 12 tools were identified and analyzed for measuring unsupported sitting balance showing limited and incomplete measurement properties. Among them, 10 addressed activities, one addressed structure/body functions, and one addressed both activity and structure/body functions domains in the ICF (14). The results of previous research on balance identified 11 evaluated biomechanical constructs and 20 balanced scales. All balance scales had high clinical utility. The Berg Balance Scale and Functional Reach Test were valid and reliable, while the mini-BES test was the most comprehensive one (15).

According to the available literature reviews, clinical tests evaluating the performance of individuals with SCI use physiotherapy and occupational therapy. Studies have determined the subject’s ability after the acute period of the lesion or to what extent occupational therapy and physiotherapy exercises have increased the performance of the SCI subjects. After the medical team completes its work, an adapted physical educator is provided for a patient to improve their quality of life, longevity, and participation in physical activity. Adapted physical education, as defined by the National Consortium for Physical Education and Recreation for Individuals with Disabilities (NCPERID), is physical education that may be adapted to meet the specific needs of children who may have delays in gross motor development. Adapted physical education teachers are physical education (PE) teachers that are trained to evaluate and assess motor competency, physical fitness, play, recreation, leisure, and sports skills (16).

To determine the functional status of SCI and develop an appropriate exercise program, it is necessary to evaluate the required factors such as walking and balance. Therefore, evaluating the performance of the patient using the mentioned tools results in the collection of the required information, which can effectively help physical educators. It also makes it easier for researchers to identify tools by arranging the measurement results in the ICF model. In addition, studies have aimed to identify a tool with good validity and reliability to assess walking and balance of SCI. Confirming the validity of the tests associated with each section and result in assessing accurately and comprehensively valid and accurate tests by the instructors or coaches, lead to an appropriate training program and ultimately offer exercise designs for individuals suffering from SCI. Therefore, it was necessary to conduct a systematic review in the field of health and the assessment tools in this group with the following objectives: 1. Assess the validity and reliability of evaluation tests for people with SCI; 2. Recommend valid and reliable tests in gait and balance sections to use in upcoming research and assessments of SCI. Therefore, the present study reviewed assessments commonly used for measuring walking and balance in individuals with SCI.

Methods

The current study was registered in the “International Prospective Register of Systematic Reviews” (PROSPERO) in 2022 (CRD42022331360), and the detailed prespecified protocol is available upon request.

Search strategy

The results of the measurements were identified using a keyword search of electronic databases (PubMed, Scopus, EMBASE and Web of Science) from 2010 to 2021. The following keywords were used in the search: “spinal cord injury,” “tetraplegia,” “paraplegia,” “reliability,” “validity,” and the name of the instrument. The search strategy used in the PubMed database is attached. The search strategy was performed in four databases on May 31, 2021, and again on November 5, 2022. Then, the identified articles were entered into Endnote software, and they were screened such that duplicate articles were first removed, and then, based on the originality of second-hand sources which included systematic reviews and meta-analyses, irrelevant studies were excluded. In the next step, the articles that were written in a language other than English were excluded.

Eligibility criteria

Inclusion criteria included publications with research-related test validity or reliability, studies comparing multiple tests simultaneously, cross-sectional, prospective, and experimental studies published in English. Studies not performed on people with spinal cord injury, not evaluating a person with spinal cord injury, and not evaluating the validity and reliability of the test were excluded.

Data extraction

Reliability is the degree to which the measurement is free from measurement error, and by extension, it refers to the extent to which scores for patients who have not changed are the same for repeated measurement under several conditions. Validity is the degree to which an health-related patient reported outcomes (HR-PRO) instrument measures the construct(s) it purports to measure (17). Persons with SCI perceived reduced strength in lower limbs, balance loss, and environmental barriers as contributing factors to falls. It is essential to use an evaluation tool that can help assess and predict the risk of falls in this population to develop a customized rehabilitation program to address the problem of balance loss. The Berg Balance Scale (18), a widely used clinical assessment tool, is a 14-item test that requires an individual to perform static and dynamic everyday tasks of diverse difficulties (19). The only clinical scale that includes an evaluation of reactive postural control is the mini-Balance Evaluation Systems Test (mini-BESTest). The mini-BESTest assesses balance control in four areas (i.e. subscales): anticipatory postural adjustments, reactive postural control, sensory orientation, and dynamic gait. It consists of 14 standing and walking tasks scored on a three-point ordinal scale (20). The Functional Reach Test (FRT) is used as a valid measure of dynamic balance stability and is reliable for assessing the limits of stability and balance strategies (21). The 10-Meter Walk Test (10MWT) reflects walking speed that relates to motor function and overall quality of walking (22). The Walking Index for Spinal Cord Injury II (WISCI II) is an ordinal scale (0–20) consisting of 21 items. It reflects various levels of walking ability, taking into account the use of assistive devices, orthotic devices, and physical assistance (23). The 6-Min Walk Test (6MWT) measures how far (in meters) a patient can walk within 6 min (24). Both 10MWT and 6MWT have been utilized in previous studies on SCI patients (25) (see table 1).

Table 1.

Characterization of eligible studies.

number	Instrument	Country	Sample size	Study design	Sex	Age (year / average)	Chronic / acute / subacute	Type of SCI	Injury level/AIS
(37)	10MWT	Thailand	20	pilot study	15 Men 5 women	10/59 ± 51/05	Chronic	Tetraplegia paraplegia	C_2 D_18
(38)	10MWT 6MWT	Thailand	94	cross-sectional	Men	FIM-L 5 = 45.2 ± 13.2 FIM-L 6 = 51.9 ± 13.2 FIM-L 7 = 49.2 ± 10.0	Chronic	tetraplegia	D
(39)	10MWT 6MWT		37	test-retest analysis	28 Men 9 women	19_77	Chronic & subacute		D_35 C_2
(40)	10MWT	Thailand	16	cross-sectional	11 Men women	50/8 ± 10/3	-	Tetraplegia paraplegia	C_2 D_15
(41)	10MWT	India	25	_	22Men 3 women	18_60	Chronic	paraplegia	A_24 B_1
(42)	10MWT	Thailand	83	prospective cohort study	83 Men	Non-multiple faller = 52.68 ± 11.21 Multiple faller = 44.21 ± 10.72	Chronic	tetraplegia	C
(43)	WISCI II		76	cohort study	79% Men	43/3	Chronic	Tetraplegia paraplegia	A_3% B_1% C_8% D_88%
(44)	WISCI II	Italy	26	reliability study	16 Men 10women	46/4 ± 19/3	Chronic		D_23 A_2 C_1
(45)	WISCI II		33	test-retest analysis	28 Men 5 women	28_69	acute	Tetraplegia paraplegia	D_32 C_1
(46)	WISCI-II		10	pilot study	8 Men 2 women	5_13	Chronic	Tetraplegia paraplegia	D_5 A_3 B_1 C_1
(47)	BBS	Spain	20	Cross sectional	14 Men 6women	48/2	incomplete		C_1 D_19
(48)	BBS	Switzerland	42		33 Men 9women	49/3	Incomplete &complete		A_ 2 B_ 2 C_ 35 D_ 3
(49)	BBS	Canada	32	Longitudinal and correlational	25 Men 7 women	47/9	incomplete	Tetraplegia paraplegia	D
(42)	BBS FRT TUG	Thailand	83	prospective cohort study	83 Men	Non-multiple faller = 52.68 ± 11.21 Multiple faller = 44.21 ± 10.72	Chronic	tetraplegia	C
(40)	TUG	Thailand	16	Cross-sectional	11 Men 5 women	10/3 50/8±	Incomplete &complete	Tetraplegia paraplegia	C_2 D_15
(37)	TUG	Thailand	20	pilot study	15 Men 5 women	10/59 51/05±	Chronic Incomplete	Tetraplegia paraplegia	C_2 D_18
(50)	mini-BESTest	United States	18	Cross-sectional	7 Men 14women	14/0 56/8±	Chronic Incomplete		C D
(51)	mini-BESTest	Canada	23	Prospective observational	17 Men 6 women	52/2	Incomplete	Tetraplegia paraplegia	B_1 D_22
(52)	mini-BESTest BBS	Norway	46	Cross-sectional	6 Men	54/5	Incomplete		A,B,C_7 D_39

Quality of evidence

The present study used the COSMIN tool (Consensus-based Standards for the selection of health status Measurement Instruments) to evaluate the quality level of imported articles based on the inclusion criteria. The COSMIN checklist focuses on evaluating the methodological quality of studies on measurement properties of HR-PROs. Because of their complexity, HR-PROs were evaluated in the current study. These instruments measure constructs that are both multidimensional and not directly measurable. The checklist contains 12 boxes, ten of which can be used to assess whether a study meets the standard for good methodological quality. Nine of these boxes contain standards for the included measurement properties (internal consistency, reliability, measurement error, content validity, structural validity, hypotheses testing, cross-cultural validity, criterion validity, and responsiveness), and one box contains standards for studies on interpretability (26). Each item is scored on a 4-point rating scale (poor, fair, good, or excellent), and an overall score for the methodological quality of a study is determined separately for each measurement property by taking the lowest rating of any of the items in a box. Using the COSMIN checklist allows the critically appraisal of the quality of studies about a single measurement instrument and the comparison of measurement instruments (27).

An alternative method that was considered less optimal was to calculate a ‘‘mean score’’ per box. With this method, each response option is scored (e.g. poor = 0, fair = 1, good = 2, and excellent = 3), and a total score is calculated by summarizing the scores of the completed items and dividing it by the number of completed items. An advantage of this method is that the total score is not dependent on the number of items in the box (28).

Evaluation of reliability of tests

In health measurement scales, the intraclass correlation coefficient (ICC) has been integrated into the Consensus-based Standards for the selection of the health status measurement instruments (COSMIN) checklist, which was developed to assess the methodological quality of studies based on measurement attributes. One of the major boxes on the COSMIN checklist is reliability, in which it is recommended that the ICC be used as a measurement of inter-rater reliability. One of the driving factors of the use of the ICC in many fields is its ease of interpretation. The ICC is a value between 0 and 1, and values below 0.5 indicate poor reliability, values between 0.5 and 0.75 demonstrate moderate reliability, values between 0.75 and 0.9 represent good reliability, and values above 0.9 indicate excellent reliability (29).

Evaluation of validity of tests

Pearson correlation coefficient was used to evaluate the validity of the tests. Pearson’s correlation is commonly used to verify the intensity of the existing linear association between variables and to measures the linear association between quantitative variables. This coefficient is a number between −1 and 1. A negative value indicates that one variable decreases as the other increases, while a positive value indicates that one variable increases as the other increases. R values are defined as follows: r = 0–0.25, very low correlation; r = 0.26–0.49, low correlation; r = 0.5–0.69, moderate correlation; r = 0.7–0.89, high or strong correlation; r = 0.9–1.0, very high or very strong correlation. Pearson’s correlation was employed in this study, because the instrument presents a linear association between the criteria presented (30).

Results

A total of 2553 potentially eligible studies were retrieved from four databases. Moreover, 26 additional records were identified through the screening of reference lists using the ancestry method. A total of 1326 duplicate studies were excluded, and the remaining 1253 potentially relevant titles and abstracts were screened, from which an additional 1224 abstracts were excluded after the screen title and abstract. The remaining 29 full-text studies were retrieved for complete review. Another 14 studies were excluded because they did not meet the eligibility criteria. Finally, 15 studies involving a total of 720 participants were included in the systematic review. The main characteristics of the selected studies are shown in Tables 1–4 (Figure 1).

Table 2.

Methodological Quality of Validation Studies based on COSMIN.

First Author	year	Instrument	Assessed Psychometric Property	Methodological Quality Rating	Average scores in the table
Puttipong Poncumhak	2014	10MWT	inter-tester reliability	Good	2.16
Amatachaya	2014	10MWT 6MWT	concurrent validity	Good	2.42
Scivoletto	2011	10MWT 6MWT	inter- and intra-rater reliabilities	Good	2.16
Poncumhak	2013	10MWT	concurrent validity and inter-tester reliability	Good	2.16
Dhairiamani Rini	2017	10MWT	test-retest reliability	Good	2.66
Kitiyawadee Srisim	2014	10MWT	inter-reliabilities	Good	2.25
Anthony	2011	WISCI-II	Test-retest reliability	Excellent	2.88
Anthony	2011	WISCI-II	Convergent Validity	Good	1
Ralph	2010	WISCI-II	inter- and intra-rater reliabilities	Good	1.90
Scivoletto	2014	WISCI-II	inter- and intra-rater reliabilities	Excellent	2.33
Scivoletto	2014	WISCI-II	Measurement error	Excellent	2.66
Christina	2012	WISCI-II	inter- and intra-rater reliabilities	Good	2.16
Orestes Freixes	2019	BBS	inter- and intra-rater reliabilities	Good	2.08
Markus Wirz	2010	BBS	inter-reliabilities	Good	2.25
J-F Lemay	2010	BBS	concurrent validity	Good	2
Kitiyawadee Srisim	2014	TUG FRT BBS	inter-reliabilities	Good	2.25
Poncumhak	2013	TUG	concurrent validity and inter-tester reliability	Good	2.16
Puttipong Poncumhak	2014	TUG	inter-tester reliability	Good	2.16
Katherine Chan	2019	mini-BESTest	Test-retest reliability	Good	2
Katherine Chan	2019	mini-BESTest	Concurrent validity and Convergent validity	Good	1.8, 0.75
Audrey Roy	2019	mini-BESTest	Test-retest reliability	Excellent	2.66
Audrey Roy	2019	mini-BESTest	inter-rater reliability	Excellent	2.66
Vivien Jørgensen	2017	mini-BESTest	internal consistency	Good	1.75
Vivien Jørgensen	2017	BBS	construct validity	Good	1.25

Table 3.

Reliability.

First Author	Instrument	ICF domain	Reliability: internal consistency/ test-retest/ inter_ rater reliability/ intra_rater reliabilities/ Measurement error
Puttipong Poncumhak	10MWT	activity	inter_ rater reliability ICC = 0/994	Measurement error SEM = 0/03
Poncumhak	10MWT	activity	inter_ rater reliability ICC = 0/999 ICC = 1/000
Dhairiamani Rini	10MWT	activity	test-retest ICC = 0/98_0/99	Measurement error SEM = 0/01 MCD = 0/02_0/03
Kitiyawadee Srisim	10MWT	activity	inter_ rater reliability ICC = 0/997	Measurement error ICC = 0/20
Scivoletto	10MWT	activity	inter_ rater reliability ICC = 0/95 ICC = 0/98	intra-rater reliabilities ICC = 0/98 ICC = 0/99
Scivoletto	6MWT	activity	inter_ rater reliability ICC = 0/99 ICC = 1/00	intra-rater reliabilities ICC = 0/98 ICC = 0/99
Christina	WISCI-II	activity	inter_ rater reliability ICC = 0/97	intra-rater reliabilities ICC = 0/98
Anthony	WISCI-II	activity	test-retest SS WISCI Level:0/994 Speed:0/930 Max WISCI Level:0/995 Speed:0/971	Measurement error SS WISCI Level:0/283 Speed:0/091 Max WISCI Level:0/215 Speed:0/059
Ralph	WISCI-II	activity	inter_ rater reliability SS WISCI ICC = 1/00 Max WISCI ICC = 0/98	intra-rater reliabilities SS WISCI ICC = 1/00 Max WISCI ICC = 1/00
Scivoletto	WISCI-II	activity	test-retest ICC = 0/996 inter_ rater reliability rater 1:0/996 rater 2:0/975	intra-rater reliabilities rater 1:0/999 rater 2:0/979 Measurement error SRD = 0/883 SEM = 0/318
Orestes Freixes	BBS	activity	inter_ rater reliability ICC = 0/99	intra-rater reliabilities ICC = 1/00
Markus Wirz	BBS	activity	inter_ rater reliability ICC = 0/953
Kitiyawadee Srisim	TUG	activity	inter_ rater reliability ICC = 0/999	Measurement error SEM = 0/19
Kitiyawadee Srisim	FRT	activity	inter_ rater reliability ICC = 1/000	Measurement error SEM = 0/19
Poncumhak	TUG	activity	inter_ rater reliability ICC = 0/998
Puttipong Poncumhak	TUG	activity	inter_ rater reliability ICC = 0/998	Measurement error ICC = 0/41
Katherine Chan	mini-BESTest	Activity and body function	test-retest ICC = 0/98
Audrey Roy	mini-BESTest	Activity and body function	test-retest ICC = 0/94	Measurement error SEM = 1/40
Vivien Jørgensen	mini-BESTest	Activity and body function	Cronbach's alpha:0/95
Vivien Jørgensen	BBS	activity	Cronbach's alpha:0/94

SEM: standard error of the mean; MCD: Minimal clinically important differences.

Table 4.

Validity.

First Author	Instrument	ICF domain	Validity: convergent/ construct/ concurrent/ criterion
Puttipong Poncumhak	10MWT	Activity	Criterion Validity r = 0/778
Amatachaya	10MWT 6MWT	Activity	Criterion Validity FIM-L 5 =  0/31 = r FIM-L 6 =  0/74 = r FIM-L 7 =  0/83 = r
Anthony	WISCI-II	Activity	construct Validity r = 0/717 r = 0/704
J-F Lemay	BBS	Activity	Criterion Validity 0/60-0/98 = r
Poncumhak	TUG	Activity	Criterion Validity r = 0/692
Katherine Chan	mini-BESTest	Activity and body function	concurrent validity r = 0/48-0/71	construct validity r = 0/73
Vivien Jørgensen	BBS	Activity	r = 0/74
Vivien Jørgensen	mini-BESTest	Activity and body function	r = 0/74

Figure 1.

Flow diagram of systematic literature search.

Evaluating the quality of research studies

Table 2 presents the results of the selected studies, and the evaluation of the quality of the selected studies is reported in two ways as follows: “average scores of each table” and qualitatively (excellent and good). Evaluation of the selected studies showed that 10 studies focused on the walking of people with SCI. Out of these ten studies, three were scored as “excellent,” and the rest were scored as “good” on tests of the studies’ reliability and validity. A search in the balance studies section found nine studies related to the intended exams, of which all studies were of “good” quality and two articles were of “excellent” quality, with average scores. Table 2 shows the the results of each study.

Results of reliability of tests

Table 3 reports the reliability of the used tools. Six studies examined the validity and reliability of the 10MWT instrument, and five studies examined the reliability between the testers, within the tester, and the measurement error. Table 3 presents the results of the data and the inter-group correlation coefficient, which are clear. Only one study examined inter-rater and intra-rater reliabilities of the 6MWT. Four studies related to evaluating the reliability of the WISCI-II instrument were included in the study. In the balance discussion, eight studies reported the reliability of the tests, among which three examined the BBS, three examined the reliability of the TUG, and three examined the reliability of the mini-BESTest; one study evaluated the reliability of the FRT test. All tests had “excellent” reliability. In examining the validity of walking tests, a concurrent validity study examined the 10MWT and 6MWT tests.

Results of validity of tests

Table 4 shows the structural validity evaluation of the WISCI-II test and the 10MWT criterion validity. Pearson correlation coefficient was used to evaluate the validity of the tests. The data showed that all three tests have high validity (above 0.90 = excellent reliability). In the discussion of test validity, the validity of BBS, mini-BESTest, and TUG has been reported as being highly correlated in studies.

Discussion

This review evaluated the reliability and validity properties of available measures for assessing walking and balance in the SCI population. Fifteen articles were found to have examined the two mentioned variables, 10 of which were related to walking, and nine were related to balance. SCI was assessed and ranked at the “activity,” “body function,” and other levels of the International Classification of Function, Disability, and Health (ICF); one tool was placed at the “body function” level, and the rest of the “activity” tools were placed according to the background literature. Our selected studies reported only the validity and reliability of the instruments and did not examine the interpretability and responsiveness. The study samples were at different levels according to the ASIA classification (A, B, C, and D).

In the current study, three instruments (10MWT, 6MWT, and WISCI) were investigated to evaluate the gait of SCIs, their validity, and their reliability. Ten studies examined these instruments. Among them, six examined 10MWT, four evaluated the WISCI instruments, and only two studies evaluated the 6MWT test. On the other hand, four instruments, namely TUG, BBS, FRT, and mini-BES Test, were selected to evaluate the balance of SCI patients. The validity and reliability of the instruments were reported. Nine studies examined these instruments; four BBS studies reviewed three studies of TUG instruments, only 3 evaluated the mini-BESTest test, and one study evaluated the FRT.

The 10MWT and 6MWT tests are recommended as valid indicators to assess the gait of SCI patients. The results of 6MWT represent general and integrated responses of the pulmonary, cardiovascular, and muscular systems. Thus, this test reflects the functional status of daily activities. However, the area assessment process is time-consuming (at least 6 minutes). In addition, it is more difficult to standardize the 6MWT than the 10MWT, as it is highly dependent on features. Some studies measured 6MWT by asking individuals to go up and down a path of a certain length, which allowed the experiment to be performed in a restricted environment (31). Scivoletto et al. showed high inter-rater and intra-rater reliabilities and had comparable results with a dynamic and static start. However, regarding the 6MWT, our data showed that different test conditions of the route and turns make significant differences, and they should be standardized for use in future experiments (25).

According to the review conducted on the discussion of walking and the tools used in the studies, the 10MWT test is more feasible for the SCI person, because it allows the person to use assistive devices, and the calculation method is easier. Less time allows the examinee and the examiner to achieve their goal while evaluating easily. The results of a review by T. Lam et al. are in line with the results of our research; the WISCI-II index does not measure walking speed or energy expenditure and does not show any signs of endurance, because the distance traveled is only 10 meters. Because of its shorter and easier implementation, 10MWT is recommended as a gait test for people with SCI, and it is suggested that a combination of WISCI-II and a timed test (e.g. 10MWT) be used to assess functional displacement in people with SCI (12). Srisim et al. conducted a comparative study between the BBS, TUG, and FRT tools and the 10MWT to investigate the fear of falling SCI. They ultimately suggested that FRT may be used as a screening tool to predict risk. Multiple falls are used on these people. Given the ability to better differentiate FRT from the number of people who can complete the test, the test method is proposed. Anyone can complete the BBS, TUG, 10MWT, and FRT, but only the FRT can assess people's gaits without using a device. Thus, the findings may indicate a limit of stability, which is critical in recognizing the ability to balance when changing position (32).

Markus Wirz et al. found BBS to be reliable and well correlated with other motor actions, fear of falling, and muscle strength, although they did not distinguish between those who fell and those who did not (33). In a study by Freixes et al., the results showed that the Spanish version of BBS is a reliable tool for assessing the balance of SCI patients (19). Both Audrey Roy and Chan reported excellent mini-BES Test reliability in their studies (20, 34). Lemay et al. evaluated and compared individuals using the BBS, WISCI, SCI-FAI, 10MWT, and TUG (35). People with SCI often have impaired muscle strength, especially in the hip, knees, and ankles, which are important for balance control; as a result, the BBS and Mini-BESTest are valid scales to assess balance control in people with lesions. A person with a chronic spinal cord injury is unable to walk. It seems that the Mini-BESTest may be more appropriate for people with moderate to good walking ability and people with poorer walking performance (36).

According to the studies reviewed in this section, the BBS test was accepted in three studies, but it has not been suggested in a comparative study with FRT and TUG. BBS can be performed with less time and without the need for an auxiliary device, and because of these advantages, we recommend this test for assessing balance in people with SCI in a static position. The TUG test was not suggested in any of the studies as an evaluation of balance in the SCI group, but the Mini-BESTest and BBS tests were suggested in three studies. Ultimately, these tests had more acceptable reliability in most studies than other measuring instruments, and we propose these tests for assessing balance. The results of our study are consistent with those of a review by Arora et al., who proposed the Mini-BESTest test, which has higher psychometric properties than other tests for assessing balance (15).

Limitations

The present study had some limitations. First, only the validity and reliability of studies were evaluated. Most of the studies evaluated the reliability related to the instrument. A smaller number discussed the validity, considering that the COSMIN checklist could review studies related to responsiveness. Out of 15 studies, only three were of excellent quality. Differences in the level of lesion (chronic or acute), sample size, and age of subjects may have affected the study results, and more research is needed to confirm this study.

Conclusions

This review study has contributed to current knowledge by comprehensively examining motor tools for use in people with SCI. Ethical issues, safety, and psychological issues were considered during the test for people with disabilities. One of the considerations for testing people with disabilities is to observe the reliability and validity of the instrument, which was addressed in this study in various fields. In the current study, seven tools for assessing SCI were discussed, and it was found that the 10-meter walk (10MWT) tool is better and easier to perform than the other tools. The Mini-BESTest tool was suggested as a reliable tool for assessing standing balance in SCI subjects.

Appendix.

(TITLE-ABS-KEY (“spinal cord injury” OR “spinal cord disease” OR “spinal cord lesion” OR “spinal cord injuries” OR “spinal cord injured” OR “spinal cord trauma” OR “SCI” OR “paralysis”)) AND TITLE-ABS-KEY (“10mwt” OR “10 meter walk test”) OR (“10 m walk test” OR “10 m test”) AND TITLE-ABS-KEY (“validity” OR “valid” OR “validation” OR “reliability” OR “reliable” OR “reliabilities”).

Funding Statement

No funding was obtained for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).