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RehabMeasures Instrument

Walking While Talking Test

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Purpose

The WMT is a dual-task measure of divided attention to examine cognitive-motor interactions, especially for identifying fallers.

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Instrument Details

Acronym WWT

Area of Assessment

Attention & Working Memory
Balance – Non-vestibular
Functional Mobility
Gait
Life Participation

Assessment Type

Performance Measure

Cost

Free

Diagnosis/Conditions

  • Brain Injury
  • Parkinson's Disease & Neurologic Rehabilitation

Key Descriptions

  • Verghese J, Buschke H, Viola L, Katz M, Hall C, Kuslansky G, Lipton R. Validity of divided attention tasks in predicting falls in older individuals: a preliminary study. JAGS. 2002;50:1572-1576.

  • Ambulate 20 ft, turn, and return (40 ft total).
  • Individuals are instructed to:
    1) WWT-simple: walking while reciting the alphabet aloud
    2) WWT-complex: walking while reciting alternate letters of the alphabet aloud

  • Scoring: time needed to complete the distance

  • Brandler et al, 2012; n = 145 community dwelling older adults without dementia, 49% female, 82% white, mean age 79.2 years

  • Subjects are instructed to pay equal attention to both walking and talking.
  • The initial letter option on WWT task included ‘a’, ‘b’, ‘m’, and ‘n’. Each subject performed four WWT trials; one trial with each of the four initial letters. The order of each trial was random

Number of Items

1

Equipment Required

  • Stopwatch
  • Tape measure to measure the 40ft required to perform the test
  • Markings on floor (or cones) to indicate pathway
  • May choose to use GAITRite

Time to Administer

10 minutes

Less than 1 minute, but 3-10 minutes including instructions to participant and warm up trial

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Irene Ward, PT, DPT, NCS and the TBI EDGE task force of the Neurology Section of the APTA in 8/2012 and Rosemary Gallagher, PT, DPT, GCS and the PD EDGE task force of the Neurology Section of the APTA in 4/2013.

Body Part

Lower Extremity

ICF Domain

Activity
Participation

Measurement Domain

Activities of Daily Living
Cognition
Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

 

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

Recommendations Based on Parkinson Disease Hoehn and Yahr stage: 

 

I

II

III

IV

V

PD EDGE

LS/UR

LS/UR

LS/UR

LS/UR

NR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

LS

LS

LS

LS

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

LS

LS

NR

NR

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

PD EDGE

No

No

No

Not reported

TBI EDGE

No

Yes

No

Not reported

Considerations

  • Caution should be taken in comparing and interpreting literature on the Walking While Talking test because several variations of this test have been reported in the literature (variations in ambulation distance and cognitive tasks performed). Also, there are other measures with similar names that may also result in confusion when reviewing the literature i.e. Stops Walking While Talking (SWWT) test and Talking While Walking test (TWWT). During the SWWT test, the tester initiates a conversation with the person being tested during a 100 meter to 200 meter walk and documents whether a person completely stops walking during the conversation. During the TWWT, patients ambulate 5 meters, turn and walk back again with a concurrent verbal fluency task of reciting names. 
  • Brandler et al reported that by varying the initial letter for the WWT-complex between ‘a’, ‘b’, ‘m’, ‘n’, may reduced a learning effect. 
  • The abilities of the individual should be considered as they may impact the utility of the WWT test. For example, McCulloch (2007) reports that “cognitive task difficulty varies based on education level and ability to inhibit responses (complex task).” 

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Alzheimer's Disease and Progressive Dementia

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Cut-Off Scores

Community dwelling older adults without dementia: (Verghese et al, 2002; = 60 individuals aged 65 to 98; mean age = 79.6 (6.3) years; Cut-off scores were chosen at one standard deviation from the group mean)

  • 20 seconds or longer for WWT-simple (16.3 ± 4)
    • High Specificity 89.4%- for identifying falls
    • Modest Sensitivity 46.1%- for ruling out falls
    • Positive predictive value 54.5%
  • 33 seconds or longer for WWT-complex (22 ± 11.4) 
    • High Specificity 95.6%- for identifying falls 
    • Modest Sensitivity 38.5%- for ruling out falls 
    • Positive predictive value 71.4%
  • Specificity is the proportion of individuals without falls that have a negative result.
  • Sensitivity is the proportion of individuals with falls who have a positive test result. 
  • Positive predictive value is the proportion of individuals who have a positive test result have the disease. 

 

Healthy Community Dwelling Elderly:

(Verghese et al, 2012. 594 healthy CDOA mean age 79.9 ± 5.3yrs. Study outcomes were frailty, disability and all-cause mortality)

WWT Cutscores and Risk of Frailty and Disability (HR 95% CI and P-Value):

 

Cutscore, cm/s 

Frailty 

Disability 

70 

1.93 (1.47-2.55), < 0.001 

1.82 (1.15-2.86), 0.01 

60 

1.79 (1.35-2.36), < 0.001 

1.35 (0.88-2.01), 0.17 

50 

1.46 (1.06-2.99), < 0.001 

1.51 (0.96-2.37), 0.07 

*WWT cutscores did not predict mortality 

 

*WWT speed of < 70cm/s had a 93% greater risk of developing frailty and an 82% greater risk of developing disability that individuals with a WWT speed > 70 cm/s.

Normative Data

Older adults without dementia:

(Verghese et al, 2007; =189; mean age= 80.2 (4.9) years)

Quantitative Gait and Verbal Parameters during Normal Walking

 

 

 

WWT Variables

Normal Walking Median

WWT-C (paying attention to both walking and talking)

WWT-T (paying attention only to talking)

Velocity (cm/s)

104.7 (92.3-115.8)

76.7 (58.1-94.5)

72.2 (54.5-92.5)

Cadence (steps/min)

104.0 (96.4-110.4)

87.9 (68.2-101.2)

87.2 (76.3-100.0)

Step length right (cm)

60.1 (54.8-65.5)

53.2 (47.0-59.6)

53.1 (47.0-58.3)

Stride length right (cm)

119.3 (106.4-131.5)

105.7 (95.2-118.9)

106.0 (93.9-116.7)

Double support time (%)

26.1 (24.2-28.1)

27.9 (24.4-32.5)

27.9 (23.5-31.8)

WWT errors (total)

 

2 (0-4)

1 (0-4)

WWT letters (total)

 

14 (12-18)

14 (12-18)

Note: Values are median with interquartile range from the 25th to 75th quartile

 

 

 

Interrater/Intrarater Reliability

Community dwelling older adults without dementia:

(Verghese et al, 2002)

  • Adequate reliability (r = 0.602, P < 0.001) on the WWT-simple test

Criterion Validity (Predictive/Concurrent)

Community dwelling older adults without dementia 

(Verghese et al, 2002)

  • Poor performance on WWT-simple (OR = 7.02, 95% CI = 1.7-29.4) and WWT-complex tasks (OR = 13.7, 95% CI = 2.3-83.6) was strongly predictive of falls over 12 months.
    • WWT-simple: 55% of subjects scoring over the WWT-simple cutoff (20 seconds or longer ) fell, compared with 15% of older people who did not exceed this score.
    • WWT-complex: 71% of subjects scoring over the cutoff of the WWT-complex (33 seconds or longer ) fell, compared with 15% of older people who did not exceed this score. 
  • Combining the Tinetti Balance and Mobility Scale with WWT-simple improves the sensitivity to 71% with specificity of 70%. 

(Verghese et al, 2008; = 539 (60.5% female) Mean age 80.1 ± 5.2 yrs, participated in the Physical Performance Battery (PPB). The PPB was analyzed as an aggregate (including the WWT), and the WWT analyzed separately)

  • WWT Velocity not associated with frailty (OR 1.00, 95% CI 0.99-1.01) 

(Verghese et al, 2012; n = 594 healthy CDOA (61% female), mean age 79.9 ± 5.3yrs. Study outcomes were frailty, disability and all-cause mortality)

  • WWT Speed predicted frailty (n = 473) (HR per 10-cm/s change = 1.12, 95% CI = 1.06-1.18)
  • WWT Speed predicted disability (n = 594) (HR = 1.13, 95% CI = 1.03-1.24)
  • WWT is associated with the risk of mortality (n = 545) (HR = 1.14, 95% CI = 1.01-1.28)
  • Each 10-cm/s change in WWT speed was associated with a 12% greater risk of developing frailty, 13% greater risk of developing disability, and 13% greater risk of mortality.

Construct Validity

Community dwelling older adults without dementia:

(Verghese et al, 2002)

  • Timed gait (same distance traversed by the subject as the WWT) was used in this study. The progressive increase in positive predictive value (PPV) from 42% for timed gait (Odds Ratio (OR) = 4.3) to 55% for WWT-simple (OR = 7), and 71% for WWT-complex (OR = 13.7), demonstrates the incremental validity of WWT test over timed gait.
  • The authors felt that the process involved in the WWT was relevant to the causation of falls.

Community dwelling older adults:

(Hall et al, 2011; = 77 community-dwelling older adults with a mean (SD) age of 75.5 (5.8) years )

  • Regardless of the specific cognitive task, participants walked slower (ie, took longer and DTCs, therefore, were positive) under dual-task conditions than under single-task conditions.

SD of Gait and Cognitive Dual-Task Costs for Each Condition 

 

 

 

 

Variable

WWT with alphabet

WWT with alternate letters

FGT with count

FGT with verbal

Gait DTCs (%)

4 (12) n = 76

29 (34) n = 76

18 (24) n = 77

30 (33) n = 75

Cognitive DTCs (%)

17 (20) n = 63

4 (30) n = 61

 

-24 (46) n = 61

-44 (58) n = 58

Wilcoxon signed rank tests were used to examine differences among conditions. The ratio values have been multiplied by 100 to convert to a percentage for ease in interpretation. A positive value indicates percentage of decrement in performance from single-task condition; a negative value indicates percentage of improvement in performance from single-task condition. WWT_Walk While Talk Test, FGT_Functional Gait Test, DTCs_dual-task costs.

 

 

 

 

Older Adults and Geriatric Care

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Construct Validity

Geriatrics:

(Liu-Ambrose et al, 2009; = 140 healthy senior females aged 65-75 yrs (mean 69.6(3.0), Balance confidence assessed by ABC. Dual task gait performance assessed by WWT test under 2 conditions: simple (recite alphabet consecutively) and complex (recite alphabet alternately)

Pearson Product Moment Coefficient between Simple WWT completion time, Complex WWT completion time; and Age, MMSE and ABC Scale

 

 

 

 

 

 

Variable

Age

MMSE

ABC Scale

Simple WWT Completion Time (sec)

0.25 (p </= 0.01)

-0.11 (p > 0.8)*

-0.55 (p </= 0.01)

Complex WWT Completion Time (sec)

0.25 (p </= 0.05)

-0.12 (p > 0.08)*

-0.054 (p </= 0.001)

*Balance confidence is independently associated with dual task gait performance (WWT), and was more strongly than the MMSE.  Executive function does not play a role in dual-task gait when the concurrent cognitive load is low. This is in disagreement with Verghese et al 2002 above.

 

 

 

(Verghese et al, 2012)

  • Moderate correlation between WWT and gait speed (r = 0.32) Low correlation between WWT and Short Physical Performance Battery (SPPB

Responsiveness

Sedentary older adults

(Verghese et al, 2010, = 24) 

  • Participants in the intervention group (n = 10) demonstrated a change in WWT- complex over the 8 week period
  • Change: 19.9 ± 14.9-2.5 ± 20.1cm/s, p = 0.05

Parkinson's Disease

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Normative Data

Parkinson's Disease: 

(O’Shea et al 2002= 15 subjects with PD (12 M/3F, mean age 68.33 ± 6.59, range 52-76 yrs, H&Y not provided) and 15 Healthy controls (age sex and height matched- mean age 67.73 ± 6.97, range 52-79 yrs). Subjects walked along a 14m walkway (middle 10m used for data collection), spatiotemporal (time and distance) measures were recorded. Pressure sensors in footswitches. Secondary motor and cognitive task performed. Cognitive task: digit subtraction (count backward by 3’s from a randomly selected target number). No practice trials. 

Statistics for unitask and dual task (digit subtraction) walking in subjects with PD (n = 15) and controls (n = 15):

 

 

PD

 

Controls

 

Variable

Unitask

Dual-Task

Unitask

Dual Task

Speed m/min: (Mean/SD)

71.74(11.66)

58.06(13.26)

87.29(6.35)

81.25(7.17)

Stride length (m): (Mean/SD)

1.29(0.19)

1.13(0.21)

1.51(0.07)

1.45(0.11)

Cadence (steps/min): Mean/SD)

110.79(7.44)

102.61(10.01)

115.81(7.37)

112.11(7.33)

Duration of double-limb support (% gait cycle): Mean/SD)

33.38(5.43)

35.44(5.36)

31.21(2.08)

32.06(2.56)

 

PD responded slower than controls in dual task than controls (t28 = -4.41, P < 0.0001)PD committed more errors in dual task than controls (t 28 =3.19, P < 0.005) 

 

(La Point et al, 2010; n = 25 PD (19M/6F, mean age 67.44 range 41-91 yrs, H&Y stage II: 18 ppl, stage III: 4 ppl, stage IV: 3 ppl) and 13 controls (mean age 68.07 yrs) completed gait tasks while conducting tasks of low (counting by ones) middle 9serial subtraction of 3’s) and high load (alpha-numeric sequencing)

  • No significant difference between PD and controls for Stride length (F 1,38= 3.64, p = 0.065) or Step velocity (F1,38 = 4.09, p = 0.051) 
  • Significant difference bet PD and control in double support time ((F 1,38 = 4.42, p = 0.04) with a significant interaction. *control group sig increased double support time while Pd did not. 

 

(Camicioli et al, 1998; n = 19 subjects with PD (Freezers(n = 9): 4M/5F, mean age 72 (4.7) mean dz duration 7.8 (4.1) yrs, UPDRS 9.2 (4.7)/44; Non-Freezers(n = 10): 5M/5F, mean age 67.3 (9.3) yrs, mean dz duration 11 (4.4) yrs, UPDRS 12.1 (5.8)/44) and 19 healthy controls: 11M/8F, mean age 71.7 (3.8)yrs) 

  • PD-F significantly increased the number of steps taken (mean ± SD: PD-F, 4.2 ± 4.6; PD-NF, 0.11 ± 1/62 as compared to controls (1.53 ± 1.54; F[2,35] = 5.8, P = 0.007). The PD-F group changed more than both the PF = NF group (p = 0.002) and controls (P = 0.02). The PD-NF group did not differ from the controls (P = 0.20). 
  • Increase in time (seconds) to walk 30 feet did not differ significantly between groups (PD-F, 2.00 ± 1.41 sec; PD-NF, 0.44 +/-1.51 sec; controls 1.53 ± 2.04 sec; F[2,35]+1.9, P = 0.16)
  • With anti-PD medications, PD-F significantly decreased # steps (F = 14.1, P < 0.001), and decreased time (F = 10.6, P < 0.0002) but PD-NF did not sig decrease steps or time. 

 

Effect of Anti PD meds on # steps and time to walk 30 feet in PD-F:

 

Pre-Medication 

Post-Medication 

# Steps with dual task (digit subtraction) 

44.1 (40.4) p > 0.05 

21.2 99.3) p < 0.05 

Time (sec) with dual task (digit subtraction) 

46.0 (68.0) p > 0.05 

14.1 (5.8) p < 0.05 

Brain Injury

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Floor/Ceiling Effects

Floor Effect: 

Acquired Brain Injury

(McCulloch et al, 2007; = 18; aged 24-58; residents of a supported living environment (n = 14), community dwellers (n = 2), and patients in acute rehabilitation (n = 2), able to ambulate unaided (with or without an assistive device))

  • Single task condition of WWT: All subjects completed the walking portion
  • Single task condition of WWT: 87% of the subjects could perform the simple cognitive task of the WWT-simple
  • Single task condition of WWT: 44% of the subjects could perform the complex cognitive task of the WWT-complex
  • Dual task condition: Several subjects refused to complete the WWT-complex because it was too difficult to do

Bibliography

Brandler, T. C., Oh-Park, M., et al. (2012). "Walking while talking: investigation of alternate forms." Gait and Posture 35(1): 164-166. Find it on PubMed

Camicioli, R., Howieson, D., et al. (1997). "Talking while walking: the effect of a dual task in aging and Alzheimer's disease." Neurology 48(4): 955-958. Find it on PubMed

Camicioli, R., Oken, B., et al. (1997). "Verbal fluency task affects gait in Parkinson's disease with motor freezing." Journal of geriatric psychiatry and neurology 11(4): 181-185. 

de Hoon, E. W., Allum, J. H., et al. (2003). "Quantitative assessment of the stops walking while talking test in the elderly." Archives of Physical Medicine and Rehabilitation 84(6): 838-842. Find it on PubMed

Deshpande, N., Metter, E. J., et al. (2009). "Gait speed under varied challenges and cognitive decline in older persons: a prospective study." Age and Ageing 38(5): 509-514. Find it on PubMed

Hall, C. D., Echt, K. V., et al. (2011). "Cognitive and motor mechanisms underlying older adults' ability to divide attention while walking." Physical Therapy 91(7): 1039-1050. Find it on PubMed

LaPointe, L. L., Stierwalt, J. A., et al. (2010). "Talking while walking: Cognitive loading and injurious falls in Parkinson's disease." Int J Speech Lang Pathol 12(5): 455-459. Find it on PubMed

Liu-Ambrose, T., Katarynych, L. A., et al. (2009). "Dual-task gait performance among community-dwelling senior women: the role of balance confidence and executive functions." J Gerontol A Biol Sci Med Sci 64(9): 975-982. Find it on PubMed

McCulloch, K. (2007). "Attention and dual-task conditions: physical therapy implications for individuals with acquired brain injury." J Neurol Phys Ther 31(3): 104-118. Find it on PubMed

O'Shea, S., Morris, M. E., et al. (2002). "Dual task interference during gait in people with Parkinson disease: effects of motor versus cognitive secondary tasks." Physical Therapy 82(9): 888-897. 

Pettersson, A. F., Olsson, E., et al. (2007). "Effect of divided attention on gait in subjects with and without cognitive impairment." J Geriatr Psychiatry Neurol 20(1): 58-62. Find it on PubMed

Pohl, P. S., Kemper, S., et al. (2011). "Older adults with and without stroke reduce cadence to meet the demands of talking." J Geriatr Phys Ther 34(1): 35-40. Find it on PubMed

Verghese, J., Buschke, H., et al. (2002). "Validity of divided attention tasks in predicting falls in older individuals: a preliminary study." Journal of the American Geriatrics Society 50(9): 1572-1576. Find it on PubMed

Verghese, J., Holtzer, R., et al. (2012). "Mobility stress test approach to predicting frailty, disability, and mortality in high-functioning older adults." J Am Geriatr Soc 60(10): 1901-1905. Find it on PubMed

Verghese, J., Kuslansky, G., et al. (2007). "Walking while talking: effect of task prioritization in the elderly." Archives of Physical Medicine and Rehabilitation 88(1): 50-53. Find it on PubMed

Verghese, J., Mahoney, J., et al. (2010). "Effect of cognitive remediation on gait in sedentary seniors." J Gerontol A Biol Sci Med Sci 65(12): 1338-1343. Find it on PubMed

Verghese, J. and Xue, X. (2010). "Identifying frailty in high functioning older adults with normal mobility." Age Ageing 39(3): 382-385. Find it on PubMed

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