T ansla ion, in e - a e eliabili y, ag eemen , and in e nal consis ency o he
Spanish e sion o he cumula ed ambula ion sco e in pa ien s a e hip ac u e
“This is an o iginal manusc ip o an a icle published by Taylo & F ancis in Disabili y
and Rehabili a ion on Ma ch 2019, a ailable a : doi:
10.1080/09638288.2019.1577499.”
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T ansla ion, in e - a e eliabili y, ag eemen , and in e nal consis ency o he Spanish
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e sion o he cumula ed ambula ion sco e in pa ien s a e hip ac u e
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Au ho s
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Pa ocinio A iza-Vega.1,2, PhD, Ma a Mo a-T a e so.3, MSc, Ma iana O iz-Piña.4, MSc,
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Mau en Celes e Ashe.5,6, PhD, Mo en Tange K is ensen.7,8, PhD.
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1Rehabili a ion and T auma ology Se ice, Uni e si y Hospi al o G anada, G anada, Spain
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2Depa men o Physio he apy, Uni e si y o G anada, G anada, Spain.
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3Depa men o P e en i e Medicine and Public Heal h, Uni e si y o G anada, G anada, Spain.
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4Vis a Ne ada Nu sing Home o olde adul s, G anada, Spain.
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5The Uni e si y o B i ish Columbia, Vancou e , Canada.
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6Cen e o Hip Heal h and Mobili y, Vancou e , Canada.
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7Physical Medicine and Rehabili a ion Resea ch – Copenhagen (PMR-C),Copenhagen,
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Denma k.
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8Depa men s o Physio he apy and O hopaedic Su ge y, Copenhagen Uni e si y Hospi al,
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H ido e, Copenhagen, Denma k.
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Co esponding Au ho : Pa ocinio A iza Vega, PhD. Depa men o Physio he apy. Uni e si y
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o G anada. Rehabili a ion and T auma ology Se ice, Uni e si y Hospi al o G anada. A enida
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de la In es igación, s/n . CP 18016. G anada. Spain. Telephone: 0034 958021596, E-mail:
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[email p o ec ed]
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Abs ac
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Pu pose: To ansla e he Cumula ed Ambula ion Sco e (CAS) in o Spanish (CAS-E) and o
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examine he in e a e eliabili y and ag eemen o he CAS-E.
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Ma e ials and Me hods: Two occupa ional he apis s, independen ly e iewed 60 pa ien s
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consecu i ely admi ed o a auma ology se ice o a public hospi al wi h a hip ac u e, and
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a ed he h ee CAS ac i i ies om 0 o 2, wi hin he i s pos -su ge y week. We de e mined he
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in e nal consis ency o CAS-E using C onbach’s α coe icien . To es eliabili y, we used
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weigh ed kappa s a is ics, he s anda d e o o measu emen (SEM) and he smalles eal
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di e ence (SRD). We de e mined he sys ema ic be ween- a e bias using he McNema –Bowke
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es .
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Resul s: No be ween- a e bias was seen, and he C onbach’s α o he CAS-E was 0.89. The
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weigh ed kappa was ≥ 0.83 o he h ee indi idual ac i i ies and he o al CAS-E, while he
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obse ed ag eemen was ≥ 0.87. The SEM and he SRD o he o al CAS-E (0-6 poin s) we e
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0.18 and 0.83 poin s, espec i ely.
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Conclusions: We p esen he CAS o use in Spanish speaking coun ies and p o ide e idence
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o excellen ela i e and absolu e eliabili y o he CAS-E o assess basic mobili y o pa ien s
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wi h hip ac u e in an acu e ca e hospi al.
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Key wo ds: hip ac u e, basic mobili y, eliabili y, olde adul s, psychome ic p ope ies
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In oduc ion
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The loss o unc ional independence a e hip ac u e is widely epo ed in he li e a u e [1–3],
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and ea ly mobiliza ion is ecommended [4] o educe he isk o p olonged hospi al s ay,
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mo bidi y [5], and mo ali y [5,6]. To op imize eco e y pos -hip ac u e, ehabili a ion should
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begin soon a e su ge y [4,5], and clinicians need alid and eliable measu emen ins umen s
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(e.g., ou come measu es, such as scales o sco es) o desc ibe and e alua e changes in pa ien s'
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unc ion o guide ehabili a ion. Fo eal-wo ld up ake, ou come measu es mus also be simple o
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use and quick o adminis e wi hin he demands o daily clinical p ac ice.
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Ou come measu es equen ly used o objec i ely desc ibe olde adul s’ unc ion a e hip
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ac u e include he Func ional Independence Measu e (FIM) [7], Ba hel Index [8], Timed Up
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and Go Tes (TUG) [9] o he Tine i Pe o mance O ien ed Mobili y Assessmen (POMA) [10].
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Howe e , hese scales a e mos use ul o he assessmen o all pa ien s in he la e phases o
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ehabili a ion (some loo e ec is seen in he acu e ca e se ing) [9,10]. The FIM is ime
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consuming [7], he POMA canno be used in pa ien s wi h cogni i e impai men [10], while he
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TUG p e equisi e he abili y o ise om a chai and walk, independen o suppo om ano he
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pe son [9]. Thus, he e is a need o an e icien , easily applicable and s able ou come measu e o
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moni o all olde adul s’ basic unc ion, ac oss he mobili y spec um and con inui y o ca e.
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The Cumula ed Ambula ion Sco e (CAS ) [11] is a alid and eliable ou come measu e o
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quan i y pa ien s’ abili y o pe o m h ee basic mobili y ac i i ies: (i) ge ing in and ou o bed;
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(ii) si ing and ising om a chai (wi h a m es s); and (iii) indoo walking (wi h/wi hou walking
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aid) [11]. Each subcomponen o he CAS is g aded ou o 2 poin s and he o al CAS sco e can
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ange om 0 (dependen ) o 6 (independen ). The simplici y o he CAS makes i an ideal
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ou come o use in a busy clinical se ing. P e ious esea ch ecognized he CAS as alid o use
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wi h pa ien s wi h hip ac u e (including hose wi h cogni i e impai men ) (5), o al knee
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eplacemen [12,13] and olde adul s wi h an acu e medical hospi al admission [14,15]. O he
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li e a u e obse ed i s p edic i e abili y o hospi al leng h o s ay and sho - e m (one mon h)
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pos -ope a i e mo ali y in pa ien s hip wi h ac u e [5]. In addi ion, he CAS can de ec
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di e ences be ween g oups o pa ien s in ela ion o anemia [16], pain [17], ype o ac u e [18],
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age [16] and he p e- ac u e unc ional le el [16,18]. O e all, he CAS is an impo an clinical
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ins umen ha o e comes limi a ions o o he ou come measu es and is easy o in eg a e wi hin
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daily p ac ice [19].
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The popula i y o he CAS is gaining momen um and is adop ed o use in many coun ies [20–
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23]. In Denma k, he CAS is a manda o y componen o he na ionwide Danish Mul idisciplina y
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Hip F ac u e Da abase [24]. In his way, he CAS can p o ide popula ion le el da a o u u e
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e alua ion o change sco es ac oss se ings (acu e hospi al o communi y). Such a e sa ile
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measu e is impo an o clinical p ac ice and popula ion heal h. Fo sou he n Eu ope, he c oss-
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cul u al alidi y and eliabili y o he CAS is es ablished in I alian [20]. Spanish is he second
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mos common language spoken globally, bu he CAS is no a ailable in Spain, whe e he annual
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age-adjus ed incidence o hip ac u e in olde adul s (65 yea s and olde ) is 766 and 325
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cases/100,000 o women and men espec i ely [25]. Gi en he high a e o hip ac u e in Spain,
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i is impo an o maximize eco e y, and eliable and alid ou come measu es a e essen ial o
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e idence-based p ac ice. The e o e, he aim o his s udy was o ansla e he English e sion o
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he Cumula ed Ambula ion Sco e in o Spanish (CAS-E), and examine he in e a e eliabili y
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and ag eemen o he CAS-E.
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Me hods
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P ocedu e
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We en olled 60 consecu i e pa ien s wi h hip ac u e, admi ed o he auma se ice o he
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Hospi al o (blinded o pee - e iew), be ween Janua y 2017 and Ma ch 2017. We included all
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olde adul s aged 65 yea s and olde . Fo pa ien s wi h cogni i e impai men , he in o med
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consen was signed by hei ela i es. The s udy was app o ed by he e hics commi ee o he
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(blinded o pee - e iew), and all pa ien s, o hei p oxy, signed a consen o m be o e s a ing
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he s udy.
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We ex ac ed desc ip i e in o ma ion om he medical cha , such as, weigh and heigh , ype o
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ac u e and su ge y. Du ing an in-pe son in e iew (conduc ed be ween day 2 and 6 pos -
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su ge y) we collec ed he ollowing sociodemog aphic and clinical in o ma ion: age, gende ,
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highes le el o educa ion, esidence (p e- ac u e and discha ge), cogni i e s a us [Sho
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Po able Men al S a e Ques ionnai e (SPMSQ)] [26], sel -pe cei ed heal h (5 i em Like scale),
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p e- ac u e unc ional le el [Func ional Independence Measu e (FIM)] [7], and pain ( isual
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analogue scale (VAS)] [27].
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The Cumula ed Ambula ion Sco e (CAS)
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The CAS desc ibes h ee basic mobili y ac i i ies: (i) ge ing in and ou o bed ( he sequence o
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e en s is as ollows: pa ien is supine on he bed, hen mo es o si ing, s anding o ans e ing
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o a chai nex o he bed, hen e u ns o si ing, hen supine posi ion on he bed); (ii) si o s and
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o si om a chai wi h a m es s (wi h o wi hou aids), and (iii) walking indoo s (wi h o wi hou
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walking aids) [11]. All h ee CAS ac i i ies a e g aded ou o wo poin s and hey a e summed o
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gene a e a o al 1-day sco e om 0 (dependen [bed bound]) o 6 (independen ). Each ac i i y is
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sco ed wi h wo poin s when e bal o physical assis ance is no equi ed (independen ), e en
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o sa e y easons; 1 poin is assigned when human assis ance ( e bal o physical assis ance) is
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equi ed om one o mo e pe sons; and no poin s a e gi en when he pa ien is no able o do he
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ac i i y despi e human assis ance (dependen ) [11]. O e all, i akes 5-10 minu es (depending on
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pa ien s’ mobili y le el) o he clinician o obse e he pa ien comple e he h ee ac i i ies o
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he CAS in he clinical se ing.
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T ansla ion o he CAS
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We ollowed he ecommenda ions p o ided by Ramada-Rodilla and colleagues [28] o ansla e
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he comp ehensi e English e sion o he CAS manual [29]. Two people (un amilia wi h he
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CAS) independen ly ansla ed i om English o Spanish using he exp essions o he Spanish
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cul u e and language ( o p ese e he o iginal in en o he es ). A hi d pe son syn hesized he
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new CAS om he wo e sions desc ibed abo e. This pe son had no ead he o iginal English
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e sion o he es .
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The back ansla ion was conduc ed by a ou h pe son who was a na i e English speake . This
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English e sion was o wa ded o and app o ed by (au ho , blinded o pee - e iew), one o he
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o iginal CAS de elope s [11]. The objec i e in his phase was o iden i y possible di e ences,
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di icul ies, o e o s o he Spanish ansla ion in ela ion o he o icial English e sion. The
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inal e sion o he Spanish ansla ion o he CAS (CAS-E) is loca ed in supplemen a y da a
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(Appendix).
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In e - a e Reliabili y
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We ollowed he guide p o ided by Ko ne and colleagues [30] o exam he in e - a e
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eliabili y. One senio dual-educa ed occupa ional and physio he apis (blinded o pee - e iew)
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and one no ice CAS use (a g adua e s uden and occupa ional he apis ; blinded o pee -
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e iew) es ed in e a e eliabili y o he CAS-E. Fo ou p elimina y wo k, he a e s i s me o
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con i m he p ocedu es o he CAS-E. Following his he senio he apis (blinded o pee -
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e iew) comple ed he CAS-E wi h 15 in-pa ien s wi h hip ac u e, while he no ice CAS
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(blinded o pee - e iew) obse ed he p ocedu e. The ollowing day, he wo a e s concu en ly
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e alua ed six pa ien s wi h he CAS-E (no included in he esul s o his s udy) and discussed he
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sco es. The senio he apis was p e iously ained by one o he c ea o s o he CAS.
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In b ie , o assess he in e - a e eliabili y o he CAS-E, he a e s used se e al p ocedu es o
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add s eng h o he p ocedu e. Fi s , hey used a andom numbe gene a o o decide he o de o
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who ga e he CAS-E ins uc ions o he pa ien s. In his way, a a he p o ided he ins uc ion o
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30 pa ien s and he o he a he did he same o he o he 30 pa ien s. Second, a e s assessed
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pa ien s in he same session (concu en ly), bu hey did no discuss he a ings and eco ded hei
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sco es independen ly (a hi d pe son collec ed a ing sco es a he end o each day). Thi d, all
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es ing was comple ed be o e pa ien s’ usual daily ehabili a ion.
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Sample size
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We based he sample size o he eliabili y es ing ollowing ecommenda ions o Hopkins WG
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[31], who sugges p ecision o eliabili y es ima es equi e a minimum o 50 s udy pa ien s. We
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included 10 addi ional pa ien s ( o al n=60) o consis ency wi h he eliabili y s udy o he
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o iginal CAS [11].
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S a is ical analysis
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We p esen con inuous da a as means (s anda d de ia ion), medians (q25, q75) o numbe and
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pe cen ages depending on he da a and i s dis ibu ion. We used he Shapi o-Wilk Tes o
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examina ion o no mal dis ibu ion o con inuous da a, and Chi-squa e o Fishe 's Exac es o
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explo e di e ences o ca ego ical da a. We used C onbach’s α coe icien [32] o es o
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in e nal consis ency be ween a e s. To calcula e he in e - a e eliabili y ( o indi idual
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ac i i ies and he o al CAS-E) we used a linea weigh ed kappa and 95% con idence in e al
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[33] o o dinal scales. We calcula ed he obse ed (exac ) ag eemen be ween a e s and he
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p e alence o sco es 0–2 o he h ee ac i i ies and assessed sys ema ic be ween- a e bias using
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he McNema -Bowke es . We p o ide a Bland-Al man plo o illus a e di e ences be ween
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a e s’ sco es. We use he S anda d E o o Measu emen (SEM) o epo he absolu e
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eliabili y a g oup le el based on he s anda d de ia ion (SD) o pa ien sco es o bo h a e s
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and he In aclass Co ela ion Coe icien (ICC2.1), and calcula ed as SEM = SD x √(1-ICC) (34).
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To calcula e he smalles eal di e ence (SRD; smalles measu emen change ha can be
177
in e p e ed as a eal change o an indi idual pe son) we used he ollowing equa ion; SRD =
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SEM x √2 x 1.96 [35]. We used IBM SPSS S a is ics Ve sion 20.0 (IBM Co p., A monk, New
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Yo k) and se he le el o signi icance a P<0.05.
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Resul s
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We p o ide sociodemog aphic and clinical da a o all pa ien s in Table 1. I ook 48 days o he
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wo a e s o comple e he CAS-E on he 60 consecu i e in-pa ien s wi h hip ac u e, who we e
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e alua ed be ween day 2 and 6 pos -su ge y.
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[Table 1 nea he e]
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ac u e su ge y. Age Ageing. 2008;37(2):173–8.
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A quali a i e analysis. Disabil Rehabil. 2010;32(15):1281–90.
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[41]. Ranho AH, Hol ik K, Ma insen MI, Domaas K, Solheim LF. Olde hip ac u e
399
pa ien s: Th ee g oups wi h di e en needs. BMC Ge ia . 2010;10.
400
401
402
19
Appendix. Spanish e sion o he Cumula ed Ambula ion Sco e (CAS-E).
403
404
Escala de Mo ilidad Acumulada (CAS-E)
Ac i idad
Capaz de hace lo
independien emen e
(Sin guía e bal ni
ayuda ísica), 2 pun os
Capaz de hace lo con
guía e bal o ayuda
ísica de una o a ias
pe sonas, 1 pun os
Incapaz de hace lo
incluso con ayuda de
o as pe sonas, 0
pun os
Le an a se de la
cama y acos a se
Le an a se y sen a se
en una silla
Camina den o de
casa con o sin ayuda
écnica
Pun uación To al:
405
406
Le an a se de la cama y acos a se; (De supino en cama a sen a se en el bo de de la cama,
407
pe manece sen ado o sen a se en una silla jun o a la cama, y ol e a la posición de supino en
408
cama).
409
20
Se asignan 2 pun os cuando la ac i idad se desa olla independien emen e. Independien emen e
410
signi ica que no es necesa ia guía e bal ni ayuda ísica de una pe sona, incluso po azones de
411
segu idad. Los pacien es pueden usa ayudas écnicas.
412
Se asigna 1 pun o cuando se equie e ayuda de una pe sona. La ayuda de o a pe sona puede se
413
desde cualquie indicación e bal has a la ayuda ísica po pa e de una o a ias pe sonas. Los
414
pacien es pueden usa ayudas écnicas.
415
Se asignan 0 pun os si los pacien es no son capaces de le an a se de la cama. Es o signi ica que
416
los pacien es no pueden le an a se de la cama y sen a se en una silla incluso con la ayuda de una
417
o a ias pe sonas. Los pacien es pueden usa ayudas écnicas.
418
419
Le an a se y sen a se en una silla con eposab azos; (Le an a se, pe manece de pie y
420
sen a se).
421
Se asignan 2 pun os cuando la ac i idad se desa olla independien emen e. Independien emen e
422
signi ica que no es necesa ia guía e bal ni ayuda ísica de una pe sona, incluso po azones de
423
segu idad. Los pacien es pueden usa ayudas écnicas.
424
Se asigna 1 pun o cuando se equie e ayuda de una pe sona. La ayuda de o a pe sona puede se
425
desde cualquie indicación e bal has a la ayuda ísica po pa e de una o a ias pe sonas. Los
426
pacien es pueden usa ayudas écnicas.
427
Se asignan 0 pun os si los pacien es no son capaces de le an a se de la silla. Es o signi ica que
428
los pacien es no pueden le an a se y sen a se en una silla incluso con la ayuda de una o a ias
429
pe sonas. Los pacien es pueden usa ayudas écnicas.
430
431
Camina den o de casa
432

21
Se asignan 2 pun os cuando se consigue camina independien emen e usando una ayuda écnica.
433
Independien emen e signi ica que no es necesa ia guía e bal ni ayuda ísica de una pe sona,
434
incluso po azones de segu idad. Los pacien es pueden usa ayudas écnicas.
435
Se asigna 1 pun o cuando se equie e ayuda de una pe sona. La ayuda de o a pe sona puede se
436
desde cualquie indicación e bal has a la ayuda ísica po pa e de una o a ias pe sonas. Los
437
pacien es pueden usa ayudas écnicas.
438
Se asignan 0 pun os a aquellos pacien es que no son capaces de camina . Es o hace e e encia a
439
aquellos pacien es que no son capaces de camina incluso siendo ayudados po una o a ias
440
pe sonas al mismo iempo que usan una ayuda écnica pa a camina .
441
442
La pun uación o al es de 0 a 6 pun os. Cada una de las es ac i idades iene una pun uación
443
en e 0 y 2 pun os.
444
445
446
22
Tables
447
448
Table 1. Cha ac e is ics o pa ien s (N=60). Values a e p esen ed as median (q25-q75);
numbe o pa ien s (%) and mean (s anda d de ia ion) [minimum-maximum]
depending on he a iable.
Age, y mean (SD); min-max
81.6 (6.8); 64-96
Gende
Women
46 (77)
Men
14 (23)
Body Mass Index, (BMI) kg/m2
Unde weigh , BMI < 18.5
1 (2)
No mal, BMI =18.5-24.9
18 (30)
O e weigh , BMI > 25
41 (68)
Highes le el o Educa ion, n (%)
Canno ead and w i e
16 (27)
Can ead and w i e
25 (42)
P ima y school
13 (22)
High School
3 (5)
College (Uni e si y)
3 (5)
Type o ac u e
In acapsula
40 (67)
Ex acapsula
20 (33)
Type o Su ge y
23
Dynamic Hip Sc ew / In a Medulla Hip Sc ew
32 (53)
Hemia h oplas y
28 (47)
Cogni i e S a us
No cogni i e impai men
27 (45)
Mild cogni i e impai men
14 (23)
Mode a e cogni i e impai men
10 (17)
Se e e cogni i e impai men
9 (15)
Sel -pe cei ed heal h
Ve y good
1 (2)
Good
21(35)
A e age
23 (38)
Bad
12 (20)
Ve y bad
3 (5)
P e- ac u e Func ional Le el (measu ed by FIM) Median
(q25-q75)
102 (79-124)
Pain du ing ac i i y (measu ed by VAS), mean (SD)
5.15 (2.41)
P e- ac u e esidence
Home, li es alone
17 (28)
Home, li es wi h someone
28 (47)
Rela i e´s home
9 (15)
Nu sing home
6 (10)
Discha ge des ina ion
Home, li es alone
4 (7)
24
Home, li es wi h someone
30 (50)
Rela i e´s home
18 (30)
Nu sing home
8 (13)
To al CAS-E, mean (SD); min-max
no ice he apis
3.32 (1.86); 0-6
senio he apis
3.30 (1.91); 0-6
CAS-E. Cumula ed Ambula ion Sco e-Spanish e sion; FIM. Func ional Independence
Scale; VAS. Visual Analogue Scale
449