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A Nationwide Initiative to Develop and Use a Standing and Walking Assessment Tool for Spinal Cord Injury Rehabilitation

The SWAT is a guide for the progressive staging and assessment of standing and walking ability in individuals with SCI. It combines staging of mobility status with established measures of balance and walking in order to standardize walking assessment after SCI.

This article was originally featured in Synapse (November 2018, Vol. XXXVI, No 1) published by the Neurosciences Division of the Canadian Physiotherapy Association.

A Nationwide Initiative to Develop and Use a Standing and Walking Assessment Tool for Spinal Cord Injury Rehabilitation

Written by: Kristen Walden, PT

Why was it developed?

Spinal cord injury (SCI) often causes sensorimotor impairments of the lower extremities making standing and walking an important rehabilitation goal. Many tools for assessing standing and walking in SCI exist;1,2 however, there is no consensus nationally or internationally on which instruments to use during the rehabilitation process. More importantly, there is no consensus on what stage of functional recovery to initiate specific assessments for standing and walking.

The Rick Hansen Institute engaged a group of expert researchers and physiotherapists practicing in the area of SCI rehabilitation across Canada to address this issue. The objective of the project was to develop and implement a Canadian Standing and Walking Assessment Tool (SWAT) for inpatient rehabilitation at Canadian rehabilitation centers participating in the Rick Hansen Spinal Cord Injury Registry (RHSCIR) to inform evidence-based physical therapy practice and start to use the combined information collected by the centers participating to start to track walking outcomes on a more national level. RHSCIR is a pan-Canadian prospective patient registry that collects information about individuals who sustain a traumatic SCI (tSCI). It is used to support data collection and reporting for patients with a traumatic SCI for this project.

How was it developed?

Twelve expert researchers and eight physical therapists (PTs) from eight Canadian inpatient rehabilitation centers formed the SWAT development team. Development included a review of existing evidence, standing and walking assessment practices, and clinical feasibility. A new functional Staging Tool was designed outlining different stages of standing and walking recovery. Walking stages were determined using a consensus-based approach, incorporating regular feedback from frontline clinicians. The Staging Tool captures a wide range of function from those who cannot sit independently with no lower extremity function to those who can independently ambulate long distances.

SWAT Fig1Figure 1: Centers participating in the SWAT development and/or implementation

What is included in the SWAT?

The SWAT includes the Staging Tool, Berg Balance Scale, 10 Meter and 6 Minute Walk Tests, Timed Up and Go, and the Activities Specific Balance Confidence Scale. Two optional measures can also be collected: Spinal Cord Injury Functional Ambulation Profile ('Advanced SWAT'), and the mini-Balance Evaluation Systems Test ('Research SWAT'). (Figure 2) Measures appropriate for each Stage (based on the floor and ceiling effects for each measure) are indicated and completed during inpatient rehabilitation at admission and discharge if the patient is at or above the defined threshold Stage for that measure.

SWAT fig 2Figure 2: Assessment guideline for Canadian SCI Standing and Walking Assessment Tool (SWAT).

How has it been implemented?

During the development, the team also created a variety of implementation support tools (including a Standing and Walking Measures Toolkit4, instructional videos5, etc.) and developed a set of clinical and research questions they felt would be important to answer with this data. The PTs from the development team each received standardized training and became clinical champions for implementation at their centers. The RHSCIR provides each center with ongoing reports of their walking data completion to support ongoing collection, as well as data reports which show patient outcomes and progress over the course of their rehab stay both locally and from a more national perspective to inform PT practice at a center. Both development and implementation were informed by the Consolidated Framework for Implementation Research (CFIR) Model6. Centers began SWAT data collection in 2014; currently over 670 patient data sets have been collected and the SWAT has been implemented at ten Canadian Rehabilitation Centers (Figure 1).
The most identified implementation barriers have been: staff time and conflicting priorities, the perception that the project was just for research, therapist agreement with threshold stages defined in the SWAT (which shows the diversity in terms of when PTs choose to use these measures currently), and the fact that as RHSCIR only supports the collection of information on patients with tSCI not all patient information is being reported back to clinicians. The key facilitators identified were: having an individual to provide support at each local center, having the ability to customize implementation methods and tools, and the fact that the SWAT contains outcome measures that were familiar to clinicians.

What are the next steps for the SWAT?

The development team has become an integrated community of research and practice which continue to meet to address clinical issues and discuss priorities for the project. Formal testing of content and construct validation and responsiveness of SWAT are underway along with additional evaluation of the implementation process. Next steps for the project include providing ongoing workshops and webinars on how to use the SWAT and the clinical utility of the measures, inclusion of patients with non-traumatic SCI in RHSCIR data collection & reporting, and data use to answer clinical and research questions outlined in the development phase.

How do I get more information?

More information is available on the Spinal Cord Injury Rehabilitation Evidence website or contact the Rick Hansen Institute Clinical Team at .


1Lam, T., Noonan, V.K., Eng, J.J., and SCIRE Research Team, the S.R. (2008). A systematic review of functional ambulation outcome measures in spinal cord injury. Spinal Cord. 46, 246–54.
2van Hedel, H.J., Wirz, M., and Dietz, V. (2005). Assessing walking ability in subjects with spinal cord injury: validity and reliability of 3 walking tests. Arch. Phys. Med. Rehabil. 86, 190–6.
3Craven, C., Verrier, M., Balioussis, C., Wolfe, D., Hsieh, J., Noonan, V., Rasheed, A., and Cherban, E. (2012). Rehabilitation Environmental Scan Atlas: Capturing Capacity in Canadian SCI Rehabilitation. Rick Hansen Institute.
4Rick Hansen Institute. (2014). Stand & Walk. Available from: http://sci2.rickhanseninstitute.org/standing-walking.
5SCIRE https://scireproject.com/videos/outcome-measures-group/lower-limb-walking/
6Damschroder, L.J., Aron, D.C., Keith, R.E., Kirsh, S.R., Alexander, J.A., and Lowery, J.C. (2009). Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement. Sci. 4, 50.