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Inter-rater Reliability, Test-retest Reliability, and Internal Consistency of the Persian Version of Dynamic Gait Index in Patients With Multiple Sclerosis

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Introduction: Dynamic Gait Index (DGI) has been used as a valid and reliable tool to assess balance performance in various populations. However, it has been translated into the Persian language and has shown perfect psychometric properties in the
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  245  Journal of Modern Rehabilitation Research Paper:  Inter-rater Reliability, Te-rete Reliability, and Internal Consiency of the Persian Version of Dynamic Gait Index in Patients With Multiple Sclerosis Hossein Soltanpour 1  , Minoo Kalantari 1   , Meysam Rooaei 2*   1. Department of Occupational Therapy, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran.2. Department of Occupational Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran. * Corresponding Author:    Meysam Rooaei   , MSc.  Address:  Department of Occupational Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran. Tel:  +98 (938) 1207484  E-mail:  m-rooaei@razi.tums.ac.ir  Introduction: Dynamic Gait Index (DGI) has been used as a valid and reliable tool to assess  balance performance in various populations. However, it has been translated into the Persian language and has shown perfect psychometric properties in the elderly population. The Persian version in Multiple Sclerosis (MS) population was validated, but its reliability has not been examined. The aim of the current udy was to inveigate the inter-rater reliability, te-rete reliability, and internal consiency of the Persian version of DGI in MS patients. Materials and Methods: A total of 62 participants took part in the reliability process. The sample included 51 females and 11 males. Inter-rater reliability was assessed by the agreement of the results obtained by two occupational therapis. We considered a 3-day interval for the r and second data collection. Te-rete and inter-rater reliability were measured with the Intraclass Correlation Coecient (ICC2, 1) and internal consiency was evaluated with the Cronbach alpha. Results: The Persian version of DGI showed excellent inter-rater reliability (ICC for total score was 0.98 and ICC for the items ranged from 0.83 to 0.96) and te-rete reliability (ICC for the overall score was 0.97 and ICC for the items ranged from 0.82 to 0.96). The Cronbach alpha of the Persian version of DGI was 0.87. Conclusion: The Persian version of DGI can be used as a reliable tool for dynamic balance measurement of MS patients in clinical settings and research udies.  A B S T R A C T  Keywords: Multiple sclerosis, Gait, Poural balance, Psychometrics Citation :  Soltanpour H, Kalantari M, Rooaei M. Inter-rater Reliability, Te-rete Reliability, and Internal Consiency of the Persian Version of Dynamic Gait Index in Patients With Multiple Sclerosis . Journal of Modern Rehabilitation. 2018; 12(4):245-252. http://dx.doi.org/10.32598/JMR.V12.N4.245  :   http://dx.doi.org/10.32598/JMR.V12.N4.245 Use your device to scan and read the arcle online Article info: Received:  24 Apr 2018 Accepted:  08 Aug 2018 Available Online:  01 Oct 2018 October 2018, Volume 12, Number 4  246  Journal of Modern Rehabilitation 1. Introduction ultiple Sclerosis (MS) is a neurode - generative disease as a result of demy - elination in anywhere of the Central  Nerve Syem (CNS), creating several neurological impairments such as par  -ehesia, spaicity, numbness, poor motor control, fa-tigue, diculty walking, cognitive problems, bowel and  bladder problems, vision problems, dizziness or vertigo,  pain, and balance decits [1, 2]. Balance dysfunction in dynamic and atic activities, as well as walking per- formance, is common among people with MS. Several cross-sectional udies show that the participants with any type or severity of MS indicated signicant atic and dynamic balance dysfunction compared with typical age-matched control groups [3,  4]. A syematic review and meta-analysis by Comber et al. reviewed gait parameters in the people with MS, and their results showed that MS has a signicant eect on ride length, ep length, cadence, velocity, and swing  phase duration. [5]. In spite of applying compensatory rategies, these impairments may increase the rate of falling, fear of falling, low quality of life, and dependen - cy in the activity of daily living [6-9] . Previous udies suggeed that the involvement of the infratentorial area, insucient connectivity of cor-ticocerebellar circuit, cerebellar and brainem impair- ment, and lower gray matter volume damage the bal - ance of MS patients [10-13] . Therefore, balance control may become more dependent on well-functioning in cerebellar-regulated proprioceptive controls syem, the veibular syem, and the visual syem [14]. In addition, Jones demonrated that one of the essential aspects of eablishing balance control is the somato-sensory syem [15]. However, brain damage can lead to various diculties in functional tasks that occur as a result of balance dysfunction. Physical evaluation is the mo crucial component in clinical reasoning. Physical and occupational therapis and other practitioners are looking for valid and reli - able tools for assessment in the clinical setting. A com -  prehensive evaluation of balance may lead to a clear underanding of walking performance and assi the therapis in developing therapeutic goals and interven- tion planning [3] . Dynamic Gait Index (DGI) may be a more proper functional te for people with MS because of easy implementation, and that is a co-eective measurement. DGI was introduced in 1995 by Shumway-Cook et al. [16, 17]. It has 8 items and was designed to evaluate gait quality and balance dysfunction during a walking  performance. It has been widely used in several neuro -logical diseases and conditions such as roke, veibu- lar disorder, brain injury, and elderly [18-20] . DGI is a valid and reliable te for the MS population [21, 22]. It has been translated into the Persian language and has shown perfect psychometric properties in the elderly  population [23] . Also, the Persian version in MS pop - ulation was validated, but its reliability has not been examined. [24] . Therefore, the current udy aimed to inveigate the inter-rater reliability, te-rete reliabil-ity, and internal consiency of the Persian version of DGI in MS patients. 2. Materials and Methods Guidelines for Reporting Reliability and Agreement Studies (GRRAS) have 15 helpful inructions for re- porting a reliability udy [25] . We used GRRAS method for reporting all parts of the article. Study participants The participants were selected from Iranian MS Society (IMSS), Imam Hossein Hospital, and Sina Hospital, using the convenience sampling method. The inclusion criteria for MS patients were: 1. Being 20 years or older; 2. Hav - ing disability between 2.0 and 6.0 based on the Expanded Disability Status Scores (EDSS); 3. Being in remission  period of MS and consiency in medication; 4. Experi - encing balance dysfunction and gait deviation; 5. Being able to walk 10m or more and 6. H aving a score of Mini- Mental Status Examination (MMSE) higher than 22. The exclusion criteria consied of having one or more co-morbid diseases and insucient collaboration during the te completion. Study procedure Initially, all participants were examined by a neurolo -gi, and after diagnosis, he assigned the EDSS score to the participants. An occupational therapi evaluated MMSE score and considered the inclusion and exclu -sion criteria. At the r session, the patients completed a demographic queionnaire; also, the occupational therapi exclusively observed all participations during  performing the Persian version of DGI items and graded their function according to manual inructions. The re-te for the Persian version of DGI was fullled three days after the r session. Also, inter-rater reliability was inveigated by the agreement of the results obtained M Soltanpour H, et al. Gait Index in Patients With Multiple Sclerosis. JMR. 2018; 12(4):245-252. October 2018, Volume 12, Number 4  247  Journal of Modern Rehabilitation  by the r and second occupational therapis for the total scores of the Persian version of DGI. All therapis had at lea two years of clinical experi-ence in the eld of neurological rehabilitation. Observa-tions were made simultaneously by the therapis in the same situation (the same weather, time of year, time of day, and environment), and they were blinded to their scoring process. Dynamic gait index DGI includes eight items, and each item has a four-  point rating scale (zero to three). All items are related to the balance function during gait performance. Items consi of gait level surface, change in gait speed (fa to slow), gait with horizontal head turns, gait with vertical head turns, gait and pivot turn, ep over the obacle, ep around obacles, and eps. This survey takes ten minutes or less to be completed [26]. The items are scored on a 4-point scale according to the therapi’s evaluation of the participant’s performance in each item, where 0= Extremely decit, 1= Medium decit, 2= Mild decit, and 3= Typical performance. The total score of the DGI range from 0-24. A higher score shows a better degree of balance competency and scores less than 19 are dened as a fall risk in MS population [22]. Statistical analysis The data were analyzed using SPSS V. 20. Descriptive atiics present The characteriics of the participants and demographic information (age, gender, married situation, etc.) Te-rete and inter-rater reliability were determined by calculating two-way random eects of the Intraclass Correlation Coecient (ICC2, 1) because DGI was lled out by the same therapis. ICC <0.4 is interpreted as a poor agreement; ICC ≥0.75 is excellent agreement, and ICC between these ranges is identied moderate to good [27]. The Cronbach alpha was used for calculating the internal consiency. If the Cronbach alpha is >0.80, the internal consiency will be excellent. If it is between 0.70 and 0.80, the internal consiency will be adequate, and if it is <0.70, the internal consis- tency will be low or inadequate [27]. 3. Results A total of 62 patients with MS participated in this udy; 41(66%) were recruited from IMSS, and 21(34%) were in outpatient wards of Imam Hossein and Sina hospitals. The sample included 51(82%) females and 11(18%) males. The Mean±SD age of the participants was 38.32±11.32, ranging from 20-63; their Mean±SD EDSS score was 3.43±1.34 and Mean±SD MMSE score was 27.82±2.31. Table 1 presents the descriptions of the  participants. Inter-rater reliability The agreement between the two therapis was checked. The Mean±SD score of DGI was 19.13±3.63 for the r therapi and 19±3.70 for the second thera- pi. The inter-rater reliability in the total score of DGI was 0.98(95% condence interval), and Table 2 presents the result of ICC for each item. All items had excellent reliability. Test-retest reliability The rete data collection session was performed on the same occasion; 26 patients did not participate in the re -te procedure because they did not devote their time to  participate in the rete session. ICC for the total score of DGI was 0.97(95% condence interval). Table 3  pres - ents ICC for the item scores. ICC for all items shows an excellent agreement. Internal consistency The homogeneity of the items was evaluated by inter  -nal consiency. Finding are demonrated in Table 4. Total Cronbach alpha value was 0.87. Therefore, the re -sult shows that all items have excellent consiency and measure similar objectives. 4. Discussion The evaluation of dynamic balance in fundamental motor skills like walking is the essential component related to the rehabilitation services. The assessment of  balance with a reliable tool is critical for Iranian patients with MS. The present udy aimed to evaluate the inter-rater reliability, te-rete reliability, and internal con-siency of the Persian version of DGI in patients with MS. The nding of the present udy indicated that the Persian version of DGI showed excellent inter-rater re-liability, te-rete reliability, and internal consiency when assessed in a mild to moderate disabled sample of  patients with MS. The agreement between dierent assessors is in ac-cordance with the ndings reported by McConvey et al. [21] . They inveigated inter-rater reliability for DGI scores in patients with MS. Inter-rater reliability was conducted by 11 physical therapis, and they used re- Soltanpour H, et al. Gait Index in Patients With Multiple Sclerosis. JMR. 2018; 12(4):245-252. October 2018, Volume 12, Number 4  248  Journal of Modern Rehabilitation cording videotape of participant’s performance for reli-ability process. The results of this udy indicated that ICC for total scores in intra-rater reliability of DGI was 0.98. Also, their nding showed that ICC for items ranged from 0.91-0.97. These results are similar to another udy conducted by Cattaneo et al. [28]; their results demon - Table 1. Descriptive characteristics (n=62) Variables No. (%) GenderMale11(17.7)Female51(82.3)Type of MS Relapsing-reming 48(77.4)Secondary progressive11(17.7)Primary progressive3(4.8) Married situaon Married48(77.4)Single14(22.6) The inial symptom of the disease Visual impairments25(40.3)Sensory impairments19(30.6)Weakness7(11.3) Balance dysfuncon 1(1.6)Dizziness1(1.6)Several symptoms9(14.5) Usage of outpaent rehabilitaon programs Yes18(29)No44(71) Table 2. Item ICC for inter-rater reliability (n=62) ItemsICC 95% Confdence Interval Lower BoundUpper Bound Gait level surface0.840.740.90Change in gait speed 0.930.880.95Gait with horizontal head turns0.920.870.95 Gait with vercal head turns 0.830.730.89Gait and pivot turn0.940.900.96 Step over obstacle 0.960.940.97 Step around obstacles 0.960.940.98Steps0.930.890.96Total0.980.970.99 Soltanpour H, et al. Gait Index in Patients With Multiple Sclerosis. JMR. 2018; 12(4):245-252. October 2018, Volume 12, Number 4  249  Journal of Modern Rehabilitation rated that ICC in intra-rater reliability was 0.94 and ex-  pressed that DGI was a reliable tool for patients with MS. Te-rete reliability is a valuable factor that indicates the ability of result at over time. We considered a three- day interval without rehabilitation and pharmacological interventions for the r and second data collection. The result of this udy shows that ICC for te-rete reliabil- ity of the Persian version of DGI in patients with MS is 0.97. This nding was 0.85 and 0.76-0.98 (for 11 physi-cal therapi) in Cattaneo et al. and McConvey et al.’s udies, respectively [21, 28]. Table 3. Item ICC for test-retest reliability (n=36) ItemsICC 95% Confdence Interval Lower BoundUpper Bound Gait level surface111Change in gait speed 0.940.890.97Gait with horizontal head turns0.940.890.97 Gait with vercal head turns 0.920.850.96Gait and pivot turn0.820.850.96 Step over obstacle 0.950.910.97 Step around obstacles 0.960.930.98Steps0.950.920.97Total0.970.940.98 Table 4. Cronbach alpha for the eight items in DGI Items Inter Item Correlaon Matrix  C  o r  r  e c  t   e d  I   t   e m- T  o t   a l   C  o r  -  r  e l   a   o n C  r  o n b  a c  h  a l   p h  a i   f   I   t   e mD e l   e t   e d  T  o t   a l   C  r  o n b  a c  h  A  l   p h  a G  a i   t  L  e v e l   S  u r  f   a c  e C  h  a n g e i   n G  a i   t   S  p e e d  G  a i   t   W i   t   h  H o r  i  z  o n t   a l    H  e a d  T  u r  n s   G  a i   t   W i   t   h  V  e r    c  a l    H  e a d  T  u r  n s  G  a i   t   a n d  P  i   v o t   T  u r  n  S  t   e p O v e r  O b  s  t   a c  l   e S  t   e p A  r  o u n d  O b  -  s  t   a c  l   e s  S  t   e p s  Gait level surface1.00 0.680.850.87Change in gait speed 0.531.000.640.85Gait with horizontal head turns0.590.491.00 0.710.84 Gait with vercal head turns0.560.490.701.000.680.85Gait and pivot turn0.560.570.580.511.00 0.750.84 Step over obstacle 0.430.460.460.430.531.000.580.86 Step around obstacles 0.510.450.560.500.650.421.00 0.650.85Steps0.290.380.250.310.430.300.261.000.410.87 Soltanpour H, et al. Gait Index in Patients With Multiple Sclerosis. JMR. 2018; 12(4):245-252. October 2018, Volume 12, Number 4
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