iWalk: A 9-Site Before-And-After Study

Background

While underutilized, post-stroke administration of the 10-meter walk test (10mWT) and 6-minute walk test (6MWT) can improve care and is considered best practice.

Objectives

We aimed to evaluate provision of a toolkit and implementation strategy designed to increase use of the 10mWT and 6MWT by physical therapists (PTs) across acute care, and inpatient and outpatient rehabilitation settings. We also examined the influence of contextual circumstances on use of the toolkit and implementation strategy across settings

Methods

In a before-and-after study, 53 PTs and professional leaders in 9 hospitals were provided with a toolkit and access to a clinical expert over a 5-month period. The toolkit and implementation strategy were designed to support guideline recommendations to use standardized tools for evaluation of walking, education, and goal-setting post-stroke. The toolkit comprised a guide, smartphone app, and video outlining how to administer walk tests, and interpret and apply test results clinically. The guide described an implementation strategy that included setting up walkways, and implementing 3 learning sessions to learn and practice test administration and interpretation. The proportion of hospital visits for which each walk test score was documented at least once (based on abstracted health records of ambulatory patients) were compared over 8-month periods pre- and post-intervention using generalized mixed models. After completing learning sessions, 33 physical therapists and 7 professional leaders participated in focus groups or interviews. As part of a realist evaluation, we compared and synthesized site-specific context-mechanism-outcome (CMO) descriptions across sites to refine our initial theory of how the toolkit would influence practice.

Results and Outputs

Data from 347 and 375 pre- and post-intervention hospital visits, respectively, were analyzed. Compared to pre-intervention, the odds of implementing the 10mWT were 12 times greater (OR=12.4, 95% CI 5.8, 26.3), and of implementing the 6MWT were ~4 times greater (OR=3.9, 95% CI 2.3, 6.7), post-intervention, after adjusting for hospital setting, ambulation ability, presence of aphasia and cognitive impairment, and provider-level clustering. Unadjusted change in the percentage of visits for which the 10mWT/6MWT was documented at least once was smallest in acute-care settings (2.0/3.8%), and largest in inpatient and outpatient rehabilitation settings (28.0/19.9% and 29.4/23.4%, respectively). Findings from the qualitative process evaluation underscored contextual factors and activities essential to eliciting change in assessment practice in stroke rehabilitation across care settings.

Knowledge Translation

1. Salbach NM, MacKay-Lyons M, Howe J, McDonald A, Solomon P, Bayley MT, McEwen S, Nelson M, Bulmer B, Lovasi GS. Assessment of walking speed and distance post-stroke increases after providing a theory-based toolkit. Journal of Neurologic Physical Therapy. 2022;00:1-9.
2. Salbach NM, McDonald A, MacKay-Lyons M, Bulmer B, Howe J, Bayley MT, McEwen S, Nelson M, Solomon P. Experiences of physical therapists and professional leaders with implementing a toolkit to advance walking assessment post-stroke: A realist evaluation. Physical Therapy, 2021. DOI: 10.1093/ptj/pzab232.
3. Salbach NM, MacKay-Lyons M, Solomon P, Howe J, McDonald A, Bayley MT, Veitch S, Sivarajah L*, Cacoilo J*, Mihailidis A. The role of theory to develop and evaluate a toolkit to increase clinical measurement and interpretation of walking speed and distance in adults post-stroke. Disability and Rehabilitation. 2021. http://dx.doi.org/10.1080/09638288.2020.1867653.

*Trainees

Foundational Research

1. Cheng DK, Nelson M, Brooks D, Salbach NM. Validation of stroke-specific protocols for the 10-meter walk test and 6-minute walk test conducted using 15-meter and 30-meter walkways. Topics in Stroke Rehabilitation. 2020;27(4):251-261. http://dx.doi.org/10.1080/10749357.2019.1691815.
2. Cheng DK, Dagenais M, Alsbury-Nealy K, Legasto JM, Scodras S, Aravind G, Takhar P, Salbach NM. Distance-limited walk tests poststroke: a systematic review of measurement properties. NeuroRehabilitation. 2021;48(4):413-439. doi: 10.3233/NRE-210026. PMID: 33967070.
3. Salbach NM, O’Brien K, Brooks D, Irvin E, Martino R, Takhar P, Chan S, Howe J. Considerations for the selection of time-limited walk tests post-stroke: A systematic review of test protocols and measurement properties. Journal of Neurologic Physical Therapy. 2017;41:3-17. DOI: 10.1097/NPT.0000000000000159
4. Salbach NM, O’Brien K, Brooks D, Irvin E, Martino R, Takhar P, Chan S, Howe J. Reference values for standardized tests of walking speed and distance: A systematic review. Gait & Posture 2015;41(2):341-360. DOI: 10.1016/j.gaitpost.2014.10.002
5. Salbach NM, O’Brien K, Brooks D, Irvin E, Martino R, Takhar P, Chan S, Howe J. Speed and distance requirements for community ambulation: A systematic review. Archives of Physical Medicine and Rehabilitation. 2014;95:117-28. DOI: 10.1016/j.apmr.2013.06.017

Toolkit

The iWalk Toolkit was designed to facilitate clinical use of the 10-metre walk test and 6-minute walk test post-stroke by physical therapists in acute care, and inpatient and outpatient rehabilitation settings. The toolkit consists of the iWalk Guide, iWalk Videos, and the iWalkAssess app. It is freely available, click the links below to access it.

1. iWalk Guide: This describes a plan for setting up walkways and running three educational sessions to learn and practice test administration and interpretation of patient performance.
2. iWalk educational video on how to administer the 10-metre walk test and the 6-minute walk test in people post-stroke
3. iWalk video showing a person with stroke performing the 10-metre walk test
4. iWalk video showing a person with stroke performing the 6-minute walk test
5. iWalkAssess App: Download the app for free on your iOS or Android devices.
6. Webinar: Knowledge to action: How the iWalk Toolkit can improve walking assessment post-stroke. Presenter: Nancy Salbach.