©

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© 2018 EDIZIONI MINERVA MEDICA European Journal of Physical and Rehabilitation Medicine 2018 October;54(5):766-71
Online version at [Link] DOI: 10.23736/S1973-9087.18.04822-0

S Y S T E M AT I C R E V I E W

Psychometric properties of the Cumulated

Ambulation Score: a systematic review
Giorgio FERRIERO 1 *, Morten T. KRISTENSEN 2, Marco INVERNIZZI 3, Ludovit SALGOVIC 4,
Elisabetta BRAVINI 5, Francesco SARTORIO 6, Stefano VERCELLI 6

1Department of Physical Medicine and Rehabilitation, Scientific Institute of Lissone, Maugeri Clinical Institutes for Research and Care,
Lissone, Italy; 2Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Departments of Physical Therapy and Orthopedic
Surgery, Copenhagen University Hospital, Hvidovre, Copenhagen, Denmark; 3Department of Health Sciences, University of Eastern
Piedmont, Novara, Italy; 4University of Ss. Cyril and Methodius, Trnava, Slovak Republic; 5Italian Society of Physiotherapy, Florence,
Italy; 6Laboratory of Ergonomics and Musculoskeletal Disorders Assessment, Department of Physical Medicine and Rehabilitation,
Scientific Institute of Veruno, Maugeri Clinical Institutes for Research and Care, Veruno, Novara, Italy
*Corresponding author: Giorgio Ferriero, Department of Physical Medicine and Rehabilitation, Scientific Institute of Lissone, Maugeri Clinical Institutes for
Research and Care, Via Monsignor Ennio Bernasconi 16, 20035 Lissone (MB), Italy. E-mail: [Link]@[Link]

ABSTRACT
INTRODUCTION: In the geriatric population, independent mobility is a key factor in determining readiness for discharge following acute
hospitalization. The Cumulated Ambulation Score (CAS) is a potentially valuable score that allows day-to-day measurements of basic mobility.
The CAS was developed and validated in older patients with hip fracture as an early postoperative predictor of short-term outcome, but it is also
used to assess geriatric in-patients with acute medical illness. Despite the fast-accumulating literature on the CAS, to date no systematic review
synthesizing its psychometric properties has been published. Therefore, we aimed to provide a comprehensive review of the psychometric prop-
erties of the CAS, summarizing the present evidence on this measure as a basis for further research to investigate its applicability across a wider
range of functional abilities and care settings.
EVIDENCE ACQUISITION: A literature search was conducted on research articles published between 2006 and June 2016 in journals indexed
by MEDLINE and Scopus databases using as a search item “Cumulated Ambulation Score”[All Fields], and selecting studies that presented a
psychometric analysis of the scale. Of 49 studies identified, 17 examined the psychometric properties of the CAS.
EVIDENCE SYNTHESIS: Most papers dealt with patients after hip fracture surgery, and only 4 studies assessed the CAS psychometric char-
acteristics also in geriatric in-patients with acute medical illness. Two versions of CAS (CAS1 and the more detailed CAS2 version) and two
different methods to calculate the total score (1-day and 3-day CAS) were used in the selected papers. Most of the papers assessed reliability and
validity, using different statistics, and only one showed evidence of sensitivity to change of the score.
CONCLUSIONS: This systematic review shows international interest of researchers in the CAS, despite the short time frame since its first pub-
lication in 2006. The results support the reliability, validity, and sensitivity to change of the tool. Since different versions of CAS are available
and two scores are commonly used, we suggest that clinicians and researchers in the future choose the more detailed CAS2 version, already used
by the large majority of studies, and report whether they used the 1- or 3-day score.
(Cite this article as: Ferriero G, Kristensen MT, Invernizzi M, Salgovic L, Bravini E, Sartorio F, et al. Psychometric properties of the Cumulated
Ambulation Score: a systematic review. Eur J Phys Rehabil Med 2018;54:766-71. DOI: 10.23736/S1973-9087.18.04822-0)
Key words: Rehabilitation - Hip fractures - Geriatrics - Validation studies - Mobility limitation.

Introduction wards. In postsurgical hip fracture rehabilitation, the post-

operative mobility level is likely to influence the prognosis

I n the geriatric population, independent mobility is a key

factor in determining readiness for discharge following
acute hospitalization.1 Evaluation of mobility status, there-
of function.4 Early evaluation of mobility status is there-
fore important to monitor functional ability and exercise
intensity, and to plan post-acute rehabilitation.3 Moreover,
fore, represents one of the cornerstones of a comprehen- being able to early predict the outcome is crucial for the
sive assessment of patients in geriatric2 and orthopedic3 management of patients after hip fracture surgery.5-8

766 European Journal of Physical and Rehabilitation Medicine October 2018

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

PSYCHOMETRIC PROPERTIES OF CUMULATED AMBULATION SCORE FERRIERO

The Cumulated Ambulation Score (CAS) is a potential- Search strategy and study selection
ly valuable score developed in Denmark that allows day-
to-day measurements of basic mobility.6, 8 Its development A literature search was conducted on research articles pub-
and validation paper for assessing the basic mobility status lished between 2006 and June 2016 in journals indexed in
of older patients after hip fracture surgery was published Medline and Scopus databases using the following search
10 years ago,6 although its use had already been reported in item: “Cumulated Ambulation Score”[All Fields]. In line
2005 in a randomized controlled trial.9 The CAS is a 3-item with the search strategy, papers written in English that in-
scale assessing activities that characterize the patient’s ba- cluded analyses of the psychometric properties of CAS
sic mobility skills: 1) getting in and out of bed (from supine were selected. Reviews, letters, commentaries, protocols,
position in bed to sitting on the edge of the bed, to standing and editorials not containing original data were excluded.
or transfer to sitting on a chair placed beside the bed, and The bibliographies of the selected articles were then ex-
return to the supine position in bed); 2) sit-to-stand from a amined for additional relevant articles with the same char-
chair with armrests (from sitting to standing to sitting); 3) acteristics. Titles, abstracts, and then the full texts of the
walking indoors with the use of appropriate walking aids retrieved papers were screened by two independent re-
(e.g. high walker on wheels, walker, rollator or crutches) viewers (G.F., S.V.), and the main psychometric properties
allowed in transfer and walking if necessary.10 Clinicians of CAS were synthesized.
are asked to objectively rate patient mobility on a 3-point Data extraction
scale, where 0 is “not able to, despite human assistance and
verbal cueing”; 1 is “able to, with human assistance and/or Data extraction was performed by the other two inde-
verbal cueing from one or more persons”; and 2 is “able to pendent authors (LS and EB) and disagreement was re-
safely, without human assistance or verbal cueing.”10 The solved by consensus. Information was extracted regarding
CAS obtained on one day (1-day score) ranges from 0 to the tool’s reliability, validity, and responsiveness. To en-
6, where 6 indicates a completely independent ambulatory hance the accuracy of data extraction, definitions of the
level. The CAS is currently available in Danish, English, psychometric properties were based on COSMIN (Table
Swedish, Norwegian (available from: [Link]. I).6, 10, 11, 13 Additional information extracted from the se-
net/publication/270888051_Cumulated_Ambulation_ lected studies included authors and publication year; scale
Score_CAS_English_version_manual_and_score-sheet), version; scoring system; and sample characteristics such
and Italian11 versions, approved by the developers. as sample size, age, disease condition.
Despite the fast-accumulating literature on the CAS, to
date no systematic review synthesizing its psychometric Results
properties has been published. Therefore, the aim of this
study was to provide a comprehensive review of the psy- The literature search produced a total of 49 items. After
chometric properties of the CAS, summarizing the present removal of duplicates, posters, and congress abstracts, 19
evidence on this measure, as a basis for further research papers were assessed for eligibility; 14 of them, which as-
examining its applicability across a wider range of patient sesses the psychometric properties of the CAS, met the
groups, functional abilities and care settings. inclusion criteria for this review. Three papers not found
through the search were added by the authors.14-16 Details
Materials and methods of the screening process are shown in Figure 1. Most of
the selected papers dealt with patients after hip fracture
The literature was systematically reviewed according to surgery. Four studies assessed the CAS psychometric
the steps of the Preferred Reporting Items for Systematic properties also in geriatric in-patients with acute medical
Review and Meta-Analysis (PRISMA) statement.12 illness.15, 17-19

Table I.—Inter-rater reliability of the Cumulated Ambulation Score after hip fracture surgery.
Study CAS version CAS score Sample size Time after surgery (days) ICC (95% CI)
Foss et al. (2006)6 CAS1 1-day 20 Within the first week* 0.97 (0.93-0.99)
Kristensen et al. (2009)10 CAS2 1-day 50 Median: 3; (IQR, 2-5) 0.99 (0.98-0.99)*
Grana et al. (2016)11 CAS2 1-day 80 2 and 90 ≥0.99 (0.99-1)
*Data requested to the authors.

Vol. 54 - No. 5 European Journal of Physical and Rehabilitation Medicine 767

 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

FERRIERO PSYCHOMETRIC PROPERTIES OF CUMULATED AMBULATION SCORE

Search in Medline and Scopus used the CAS2.3, 7, 8, 10, 11, 15-19, 23, 24 However, the more de-
(N.=49) tailed CAS2 version10 was actually the version used in the
studies conducted at the Copenhagen University Hospital
Hvidovre where the score was developed,14, 20, 21 although
After checking for duplicates CAS1 was stated as the reference, as verified by Dr. Kris-
(N.=25) tensen. Similarly, Taraldsen et al.,22 despite reporting the
use of CAS1, stated that CAS2 was the version they actu-
Excluded/irrelevant articles ally used in their study (personal communication).
based on title and abstracts: Independently of the version selected, two different
Congress abstracts (N.=5)
Reviews (N.=1) methods to calculate the total score were used: a one-day
assessment (1-day CAS) ranging from 0-6 points, and the
sum of 3 days assessments made on postoperative days 1-3
Articles selected based on title (3-day CAS), ranging from 0-18 points. Only one paper
and abstract (N.=19) validated a translation of CAS2 (from English to Italian
Excluded/irrelevant articles
language),11 but versions approved by the developers are
based on full text: also available in Swedish and Norwegian.
- Projects (N.=1)
- No psychometric data (N.=4)
Reliability
Reliability was assessed using different statistics. Three
Articles selected based on title
and abstract (N.=19) studies reported excellent inter-rater reliability using the
intraclass-correlation coefficient (ICC) (Table I). ICC val-
lncluded articles selected from ues higher than 0.75 are considered good, and those above
bibliographies and/or known
by the authors 0.90 are considered excellent.25
(N.=3) Kappa statistics were also used in three papers to assess
the agreement of the CAS. Kappa values ranging 0.61-
Total articles selected 0.80 show substantial agreement, while those higher than
(N.=17)
0.80 are considered as almost perfect agreement.26 CAS2
Figure 1.—Flow chart showing study selection process. showed an almost perfect agreement (weighted kappa val-
ues >0.94) in patients after hip fracture surgery,10, 11 while
Two different versions of the CAS are currently avail- the agreement was good in geriatric patients with acute
able: one (CAS1) described in the appendix of the initial medical illness (weighted kappa 0.76).17 The percentage of
validation study,6 and a more detailed version (CAS2) pub- agreement was reported in two studies, and it was >94%
lished later by one of the original authors of the score.10 for CAS2.10, 11
The two versions differ on four main points: 1) in CAS1 In two studies the standard error of measurement (SEM)
the bed transfer activity is described as “transfer from su- of 1-day CAS2 (0-6 points) was reported, ranging from
pine-to-sitting-to-supine,” not mentioning the requirement 0.03 to 0.20 CAS points.10, 11 A corresponding minimal de-
for scoring purposes to be standing or sitting in a chair tectable change (MDC95) of 0.55 CAS points was reported
placed beside the bed; 2) in CAS1, the chair-stand activity in one study.10
refers to the use of an “armchair” as opposed to, in CAS2, Validity
“a chair with armrests”; 3) the description of the walking
activity of CAS1 did not clearly specify that the activity The validity of CAS was demonstrated in different ways in
evaluated is indoor walking; and 4) the scoring levels in 15 studies.1, 3, 6-8, 10, 11, 16-24 Table II shows concurrent valid-
CAS1 are labelled as 1 for “able with assistance from one ity with other assessment tools in patients with hip frac-
or two people” and 0 for “unable despite assistance from ture. Spearman correlations (rs) are categorized as high if
two people,” while in CAS2 the patient is assessed accord- ≥0.70, moderate between 0.50 and 0.69, and low between
ing to not only the level of assistance, but also the need for 0.26 and 0.49.26, 27 The association between the 3-day CAS
verbal cueing. (>9 versus <10 points) and other categorical variables was
Of the 17 papers selected, 5 stated they used as a refer- assessed in one study using chi square test (χ2).6 Results
ence the CAS1 paper,6, 14, 20-22 whereas the other 12 papers showed a significant association (P≤0.01) between 3-day

768 European Journal of Physical and Rehabilitation Medicine October 2018

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
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cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

PSYCHOMETRIC PROPERTIES OF CUMULATED AMBULATION SCORE FERRIERO

Table II.—CAS validity studies in patients after hip fracture surgery.

Validity
Author, year CAS version CAS Sample size Age Second variable
rs P value
Foss et al. (2006)6 CAS1 3-day 426 82 (74-87) LOS 0.62 0.001
Foss et al. (2008)20 CAS2 1-day 487 82 (75-88) Hb 0.12/0.18 <0.02
Foss et al. (2009)21 CAS2 3-day 117 80 (67-91) VRS -0.43 0.001
Kristensen et al. (2009)14 CAS2 3-day 20 77±7 Knee-extension strength >0.56 ≤0.01
Piscitelli et al. (2012)24 CAS2 3-day 55 82 GDS -0.31 <0.05
Vukomanović et al. (2014)3 CAS2 1-day 50 76 (47-89) A-test 0.91 0.000
Grana et al. (2016)11 CAS2 1-day 80 84.98±5.88 ADL Scale >0.85 <0.001
LOS: length of stay; Hb: hemoglobin value <100 g/L; VRS: 5-point Verbal Ranking Score for pain; GDS: Geriatric Depression Scale; A-test: performance-based test
for assessing basic activities; ADL Scale: first four items only of the Katz’s Index of Independence in Activities of Daily Living.

CAS and 30-day mortality (χ2=49.1), postoperative major (American Society of Anesthesiologists’ rating >2),7, 23 and
medical complications (χ2=60.3), and discharge to home low mental status (Hindsoe’s test <7).7, 23 Thus, in patients
(χ2=97.6). Three studies assessed the content validity by with hip fracture surgery, CAS showed to have discriminant
means of analysis of ceiling and floor effects in patients validity. Correspondingly, older medical patients with an in-
with hip fracture3, 11, 19 and/or geriatric disorders.19 These dependent CAS=6 score were more physical active during
three studies all used the CAS2 version, but only the 1-day hospitalization than those with a CAS<6 points.15
0-6 CAS was evaluated. They showed that CAS had a high Only one study assessed the sensitivity to change of the
ceiling effect, with values higher than 20%.28 CAS2 version. Differences between admission and dis-
Validity can be measured also by sensitivity and speci- charge of each item were reported (using chi-square test
ficity, in terms of positive and negative predictive values. with P<0.001) after a multidisciplinary rehabilitation in-
Positive predictive value (PPV) is the proportion of patients patient intervention (mean length of stay 17±12 days) in a
with positive test results who are correctly diagnosed. Neg- geriatric ward.19
ative predictive value (NPV) is the proportion of patients
with negative test results who are correctly diagnosed.29 Discussion
At postoperative day 3 after hip fracture, a 3-day CAS >9
points (cut-off arbitrarily set) was found to be predictive This systematic review shows that the CAS is a promising
for discharge within 2 weeks postoperatively (PPV=0.76; tool for the assessment of basic mobility in different pa-
NPV=0.68), discharge home (PPV=0.94; NPV=0.32), 30- tient groups with musculoskeletal disorders and highlights
day survival (PPV=0.99; NPV=0.17), and not experienc- the continuous interest of researchers in this tool. To date,
ing major medical complications (PPV=0.93; NPV=0.47), the tool is used in studies from Italy, Norway, and Serbia,
although there was an important risk of false negatives.6 in addition to the country of origin, Denmark. According
In older medical patients, CAS2 showed low sensitivity to criteria’s by Streiner25 and Viera,26 the CAS proved to
(40.2) and high specificity (92.0) to identify patients with be a highly reliable tool in the assessment of basic mobil-
limited mobility at follow-up (PPV=77.3; NPV=69.4).18 ity of patients after hip fracture (ICC>0.96) surgery,6, 10, 11
Regression analyses are appropriate for establishing a and showed substantial agreement in geriatric in-patients
measure’s discriminant validity. Significant (P<0.05) pre- with acute medical illness (weighted Kappa 0.76).17 The
dictors of not regaining independency in basic mobility measurement error of the 1-day CAS was found to be very
(CAS<6) within the first 5 post-operative days or at the time low, with MDC values <1 CAS point.10 As MDC reflects
of discharge were: age >80 years, low pre-fracture function the smallest change in scale points on a given measure that
(New Mobility Score <7),7, 8, 23 having a trochanteric frac- represents a real change for a single person,30 this would
ture,7, 23 inability to complete physiotherapy on the first post- mean that any change in a CAS assessment is beyond the
operative day, and anemia (Hb<6 mmol/L) within the first 5 measurement error of the score. However, a ceiling ef-
post-operative days,8 while pre-fracture function, knee-ex- fect was found in three studies,3, 11, 18 probably due to the
tension strength and lower limb edema was associated with limited number of items. Thus, as the CAS was specifi-
the 3-day CAS.14 On the other side, non-significant (P>0.05) cally developed for the early assessment of basic mobility
predictors were: sex,7, 8, 23 type of osteosynthesis,8 vital signs after surgery, its usefulness is only until independency is
assessment (Early Warning Score),17 poor health status reached. Good sensitivity to change was reported only in

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

FERRIERO PSYCHOMETRIC PROPERTIES OF CUMULATED AMBULATION SCORE

geriatric inpatients.19 Therefore, the CAS is not sufficient Conclusions

on its own as an outcome measure because it is not able
to monitor any improvements in basic mobility level over Results of this review support the reliability and valid-
time in patients with higher ability after achieving basic ity of the CAS. Since different versions are available and
mobility independence. Other measurements, e.g. the two scores are commonly used, we suggest that clinicians
Timed Up-and-Go test,31 which quantifies the functional and researchers continue to use the more detailed CAS2
mobility level and changes over time, need to be used version, and report whether they used the 1-day or 3-day
jointly in patients with hip fracture.32 CAS. Further studies on the CAS are warranted to analyze
The validity of the CAS has been assessed concerning its psychometrics properties - including its responsiveness,
different aspects in geriatric patients. It showed a high cor- not only in geriatric inpatients after hip fracture surgery or
relation with other outcome measures for basic mobility with acute medical illness, but also in other fields, e.g. in
(the A-test3 and the ADL score11), high to moderate corre- neurological diseases or after general surgery, and in dif-
lation with muscle strength and thigh edema,14 moderate ferent cultural contexts.
correlation with length of stay,6 and low correlation with
other clinical aspects affecting mobility such as pain (five-
point Verbal Ranking Score [VRS] for pain)21 and depres- References
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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access
COPYRIGHT 2018 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

PSYCHOMETRIC PROPERTIES OF CUMULATED AMBULATION SCORE FERRIERO

14. Kristensen MT, Bandholm T, Bencke J, Ekdahl C, Kehlet H. Knee- 23. Kristensen MT, Kehlet H. Most patients regain prefracture basic mo-
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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
Article first published online: March 29, 2018. - Manuscript accepted: March 27, 2018. - Manuscript revised: March 19, 2018. - Manuscript received: May
17, 2017.

Vol. 54 - No. 5 European Journal of Physical and Rehabilitation Medicine 771