Application of Rasch analysis to examine psychometric aspects of the activities-specific balance confidence scale when used in a new cultural context

Revisiting the Concept of Minimal Detectable Change for Patient-Reported Outcome Measures

Interpreting change is a requisite component of clinical decision making for physical therapists. Physical therapists often interpret change using minimal detectable change (MDC) values. Current MDC formulas are informed by classical test theory and calculated with group-level error data. This approach assumes that measurement error is the same across a measure's scale and confines the MDC value to the sample characteristics of the study. Alternatively, an item response theory (IRT) approach calculates separate estimates of measurement error for different locations on a measure's scale. This generates a conditional measurement error for someone with a low, middle, or high score. Error estimates at the measure-level can then be used to determine a conditional MDC (cMDC) value for individual patients based on their unique pre- and post-score combination. cMDC values can supply clinicians with a means for using individual score data to interpret change scores while providing a personalized approach that should lower the threshold for change compared with the MDC and enhance the precision of care decisions by preventing misclassification of patients. The purpose of this Perspective is to present how IRT can address the limitations of MDCs for informing clinical practice. This Perspective demonstrates how cMDC values can be generated from item-level psychometrics derived from an IRT model using the patient-reported Activities-specific Balance Scale (ABC) commonly used in stroke rehabilitation and also illustrates how the cMDC compares to the MDC when accounting for changes in measurement error across a scale. Theoretical patient examples highlight how reliance on the MDC value can result in misclassification of patient change and how cMDC values can help prevent this from occurring. This personalized approach for interpreting change can be used by physical therapists to enhance the precision of care decisions.

Measurement Precision and Efficiency of Computerized Adaptive Testing for the Activities-specific Balance Confidence Scale in People With Stroke

OBJECTIVE

Administrative burden often prevents clinical assessment of balance confidence in people with stroke. A computerized adaptive test (CAT) version of the Activities-specific Balance Confidence Scale (ABC CAT) can dramatically reduce this burden. The objective of this study was to test balance confidence measurement precision and efficiency in people with stroke with an ABC CAT.

METHODS

We conducted a retrospective, cross-sectional, simulation study with data from 406 adults approximately 2 months post-stroke in the Locomotor-Experience Applied Post-Stroke trial. Item parameters for CAT calibration were estimated with the Rasch model using a random sample of participants (n = 203). Computer simulation was used with response data from the remaining 203 participants to evaluate the ABC CAT algorithm under varying stopping criteria. We compared estimated levels of balance confidence from each simulation to actual levels predicted from the Rasch model (Pearson correlations and mean standard error [SE]).

RESULTS

Results from simulations with number of items as a stopping criterion strongly correlated with actual ABC scores (full item, r = 1, 12-item, r = 0.994; 8-item, r = 0.98; 4-item, r = 0.929). Mean SE increased with decreasing number of items administered (full item, SE = 0.31; 12 item, SE = 0.33; 8 item, SE = 0.38; 4 item, SE = 0.49). A precision-based stopping rule (mean SE = 0.5) also strongly correlated with actual ABC scores (r = 0.941) and optimized the relationship between number of items administrated with precision (mean number of items 4.37, range [4-9]).

CONCLUSION

An ABC CAT can determine accurate and precise measures of balance confidence in people with stroke with as few as 4 items. Individuals with lower balance confidence may require a greater number of items (up to 9) which could be attributed to the Locomotor-Experience Applied Post-Stroke trial excluding more functionally impaired persons.

IMPACT

Computerized adaptive testing can drastically reduce the ABC test's administration time while maintaining accuracy and precision. This should greatly enhance clinical utility, facilitating adoption of clinical practice guidelines in stroke rehabilitation.

LAY SUMMARY

If you have had a stroke, your physical therapist will likely test your balance confidence. A CAT version of the ABC scale can accurately identify balance with as few as 4 questions, which takes much less time.

Falls efficacy instruments for community-dwelling older adults: a COSMIN-based systematic review

Background

Falls efficacy is a widely-studied latent construct in community-dwelling older adults. Various self-reported instruments have been used to measure falls efficacy. In order to be informed of the choice of the best measurement instrument for a specific purpose, empirical evidence of the development and measurement properties of falls efficacy related instruments is needed.

Methods

The Consensus-based Standards for the Selection of Health Measurement Intruments (COSMIN) checklist was used to summarise evidence on the development, content validity, and structural validity of instruments measuring falls efficacy in community-dwelling older adults. Databases including MEDLINE, Web of Science, PsychINFO, SCOPUS, CINAHL were searched (May 2019). Records on the development of instruments and studies assessing content validity or structural validity of falls efficacy related scales were included. COSMIN methodology was used to guide the review of eligible studies and in the assessment of their methodological quality. Evidence of content validity: relevance, comprehensiveness and comprehensibility and unidimensionality for structural validity were synthesised. A modified GRADE approach was applied to evidence synthesis.

Results

Thirty-five studies, of which 18 instruments had been identified, were included in the review. High-quality evidence showed that the Modified Falls Efficacy Scale (FES)-13 items (MFES-13) has sufficient relevance, yet insufficient comprehensiveness for measuring falls efficacy. Moderate quality evidence supported that the FES-10 has sufficient relevance, and MFES-14 has sufficient comprehensibility. Activities-specific Balance Confidence (ABC) Scale–Simplified (ABC-15) has sufficient relevance in measuring balance confidence supported by moderate-quality evidence. Low to very low-quality evidence underpinned the content validity of other instruments. High-quality evidence supported sufficient unidimensionality for eight instruments (FES-10, MFES-14, ABC-6, ABC-15, ABC-16, Iconographical FES (Icon-FES), FES–International (FES-I) and Perceived Ability to Prevent and Manage Fall Risks (PAPMFR)).

Conclusion

Content validity of instruments to measure falls efficacy is understudied. Structural validity is sufficient for a number of widely-used instruments. Measuring balance confidence is a subset of falls efficacy. Further work is needed to investigate a broader construct for falls efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-020-01960-7.

Validation of the Activities-Specific Balance Confidence Scale With 5-Option Response Format in Slovene Lower-Limb Prosthetic Users

OBJECTIVE

To examine the psychometric properties of the Activities-specific Balance Confidence (ABC) scale administered in the Slovene version with a simplified 5-option response format (ABC-5/SLO) using Rasch analysis.

DESIGN

Methodological research on data gathered in a cross-sectional study.

SETTING

Outpatient university rehabilitation clinic.

PARTICIPANTS

A convenience sample of adults with unilateral lower-limb amputation (N=138; 75% men) longer than 6 months who regularly wear a prosthesis.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

We evaluated functioning of rating scale categories, internal construct validity, reliability indices, and dimensionality using the ABC-5/SLO (0=no confidence to 4=complete confidence).

RESULTS

The ABC-5/SLO rating scale fulfilled the category functioning criteria. All items fit the underlying scale construct (balance confidence) except item 8 ("walk outside the house to a car parked in the driveway"), which was overfitting. The person abilities-item difficulty matching (targeting) was good. The person separation reliability was .92, and the item separation reliability was .99. Analysis of the standardized Rasch residuals showed the scale's unidimensionality and absence of high item dependency (residual correlations, <.30). The correlation between the ABC-5/SLO and the Prosthetic Mobility Questionnaire (Rasch measures) was high (ρ=.84), as expected. Minor signs of item redundancy were found.

CONCLUSIONS

The simplified ABC-5/SLO scale is a valid and reliable measure of balance confidence for individuals with lower-limb amputation. It is possible to transform the ordinal summed raw scores of the ABC-5/SLO into interval-level measurements using a nomogram.

Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study

Background

Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors. Caregivers are often able and willing to assist with home-based exercise and physical activity but lack the knowledge and resources to do so. ActivABLES was established to promote home-based exercise and physical activity among community-dwelling stroke survivors, with support from their caregivers. The aim of our study is to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality.

Methods

A convergent design of mixed methods research in which quantitative results were combined with personal experiences of a four-week use of ActivABLES by community-dwelling stroke survivors with support from their caregivers. Data collection before, during and after the four-week period included the Berg Balance Scale (BBS), Activities-Specific Balance Confidence Scale (ABC), Timed-Up-and-Go (TUG) and Five Times Sit to Stand Test (5xSST) and data from motion detectors. Semi-structured interviews were conducted with stroke survivors and caregivers after the four-week period. Descriptive statistics were used for quantitative data. Qualitative data was analysed with direct content analysis. Themes were identified related to the domains of feasibility: acceptability, demand, implementation and practicality. Data was integrated by examining any (dis)congruence in the quantitative and qualitative findings.

Results

Ten stroke survivors aged 55–79 years participated with their informal caregivers. Functional improvements were shown in BBS (+ 2.5), ABC (+ 0.9), TUG (− 4.2) and 5xSST (− 2.7). More physical activity was detected with motion detectors (stand up/sit down + 2, number of steps + 227, standing + 0.3 h, hours sitting/lying − 0.3 h). The qualitative interviews identified themes for each feasibility domain: (i) acceptability: appreciation, functional improvements, self-initiated activities and expressed potential for future stroke survivors; (2) demand: reported use, interest in further use and need for follow-up; (3) implementation: importance of feedback, variety of exercises and progression of exercises and (4) practicality: need for support and technical problems. The quantitative and qualitative findings converged well with each other and supported the feasibility of ActivABLES.

Conclusions

ActivABLES is feasible and can be a good asset for stroke survivors with slight or moderate disability to use in their homes. Further studies are needed with larger samples.

Validity and reliability of the Brazilian activities-specific balance confidence scale and determinants of balance confidence in community-dwelling older adults

Introduction: The Activities-specific Balance Confidence scale is the most used tool to quantify balance confidence, a psychological factor related to balance impairment among older adults. Objective: To investigate the validity and reliability of the original and short versions of the Brazilian Activities-specific Balance Confidence scales, to determine cutoff points for balance impairments and to identify the determinants of balance confidence of community-dwelling older adults.Methods: The validity of both versions of the scales was verified by correlating its results with postural balance, fear of falling and mobility (n = 105). Both scales were administered with a 30 min (interrater reliability, n = 158) and 1-week intervals (intrarater reliability, n = 105). Receiver operating characteristic curve was used to determine the cutoff points, and linear regression was applied to identify the determinants of balance confidence.Results: The Brazilian versions of the scale correlated to postural balance, fear of falling and mobility (p < .05). Excellent interrater (α = 0.946, 95% CI: 0.902-0.976; α = 0.932, 95% CI: 0.918-0.960) and intrarater reliability (α = 0.946, 95% CI: 0.905-0.960; α = 0.952, 95% CI: 0.921-0.965) were found for the original and short versions.  Values of ≤67% (sensitivity: 81%, specificity: 77.4%) and ≤44% (sensitivity: 87.5%, specificity: 82.1%) were observed to identify balance impairments for the original and short versions of the scale. Physical inactivity, fear of falling, imbalance sensation, and number of falls are the main determinants of balance confidence.Conclusion: Both scales are valid and reliable to assess balance confidence. Cutoff points to identify balance impairments were determined and some factors may act as possible predictors of balance confidence.

The Prosthetic Mobility Questionnaire, a tool for assessing mobility in people with lower-limb amputation: validation of PMQ 2.0 in Slovenia

The aim of this study was to examine the metric properties of the Prosthetic Mobility Questionnaire, an outcome measure of mobility following lower-limb amputation, in Slovene outpatients undergoing rehabilitation. The 12-item Prosthetic Mobility Questionnaire was administered to 148 Slovene adults (74% men) with unilateral lower-limb amputation since >12 months and regularly wearing a prosthesis. The psychometric analysis included classical test theory methods and Rasch models. Rasch analysis disclosed two pairs of locally dependent items (same task but in opposite directions: walk up/down stairs; walk up/down a hill). Thus, we devised a new version (PMQ 2.0) assessing all 12 Prosthetic Mobility Questionnaire items but calculating the global score on only 10, i.e. considering-for each pair of locally dependent items-just the item with worst performance. The PMQ 2.0 demonstrated correct functioning of rating scale categories, construct validity (item fit, hierarchy of item difficulties), convergent validity, high-reliability indices and unidimensionality. In conclusion, the new 10-item PMQ 2.0 shows good reliability and validity, and an excellent overall metric quality for measuring perceived mobility capabilities in people with lower-limb amputation.

Rasch Analysis of the Activities-Specific Balance Confidence Scale in Individuals Poststroke

Objective

To examine the psychometric properties of the Activities-specific Balance Confidence (ABC) scale using Rasch analysis for individuals poststroke.

Design

Retrospective cohort.

Setting

Data was extracted from the Locomotor Experience Applied Post-Stroke phase 3, multisite, randomized controlled clinical trial.

Participants

Community-dwelling, ambulatory, older adults (N = 406) (mean age ± SD, 61.97±12.76y; 45.07% female) approximately 2 months poststroke.

Intervention

None.

Main Outcome Measures

We examined unidimensionality, local dependence, rating-scale structure, item and person fit, person-item match, and separation index of the ABC scale.

Results

Confirmatory and exploratory factor analysis showed the ABC scale was adequately unidimensional and 3-item pairs had local dependence. A collapsed 5-category rating scale was superior to the 101-category scale. The hardest item was "walking outside on an icy sidewalk," the easiest item was "getting into or out of a car," and no items misfit. The ABC scale had high person reliability (0.93), despite 10.5% of individuals misfitting the expected response pattern. Mean ability level of the sample was slightly lower (-0.56 logits) than the mean item difficulty indicating that the ABC scale adequately matched our sample's balance confidence. The ABC scale did not have a floor or ceiling effect and separated individuals into 5 statistically distinct strata (separation index = 3.71).

Conclusions

The Rasch model supports the use of the ABC scale to measure balance confidence in individuals poststroke. The consistency of our results with previous Rasch analyses on the ABC scale demonstrates the instrument responds similarly across multiple populations; community-dwelling older-adults, outpatient orthopedic physical therapy, stroke, Parkinson disease, and lower-limb amputation. Recommendations include collapsing the rating scale and developing a computerized-adaptive test version of the scale to enhance clinical utility.

Rasch Analysis of the Activities-Specific Balance Confidence Scale in Older Adults Seeking Outpatient Rehabilitation Services

Background The Activities-specific Balance Confidence (ABC) scale measures confidence in performing various ambulatory activities without falling or experiencing a sense of unsteadiness. Objectives This study (1) examined the ABC scale (0-100) using Rasch analysis, (2) assessed statistically reliable change, and (3) developed a functional staging to guide clinical interpretation of a patient's improvement. Methods The authors examined rating-scale structure, item difficulty hierarchy, item fit, person-item match, separation index, differential item functioning, test precision, and unidimensionality. Additionally, this cross-sectional study of 5012 older patients seeking outpatient rehabilitation therapy in 123 clinics estimated the minimal detectable change and developed a functional staging. Results The item "walk outside on icy sidewalks" was the most difficult item, while the item "reach for a small can off a shelf at eye level" was the easiest item. Overall, average patient ability estimates of 56.2 ± 20.3 were slightly higher than the average item difficulty estimates of 45.9 ± 7.8. With a separation index equal to 3.65, the ABC scale items can differentiate individuals into 5.2 statistically distinct strata. Most ABC scale items were free of differential item functioning. For example, "walk outside on icy sidewalks" was easier for patients who were underweight. Results supported unidimensionality of the ABC scale, with the first factor explaining 77% of the total variance. The estimated minimal detectable change was 15 points. The authors provided an example of functional staging application. Conclusion Results supported sound psychometric properties and clinical usage of the ABC scale for older adults seeking outpatient rehabilitation therapy. J Orthop Sports Phys Ther 2018;48(7):574-583. Epub 30 Mar 2018. doi:10.2519/jospt.2018.8023.

Rasch analyses of the wheelchair use confidence scale

OBJECTIVES

To compare the functioning of the 101-point response format of the Wheelchair Use Confidence Scale (WheelCon) with shortened 11-point formats, and to evaluate the scale's measurement properties using principal components and Rasch analyses.

DESIGN

Secondary analysis of cross-sectional data.

SETTING

Community.

PARTICIPANTS

Volunteer participants were manual wheelchair users (N=220) ≥19 years of age, with ≥6 months' experience with daily wheelchair use and no cognitive impairment.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

65-item WheelCon.

RESULTS

The 11-point response format outperformed the original 101-point format. Principal component analyses confirmed the presence of 2 dimensions: mobility efficacy and self-management efficacy. Thirteen items in the mobility efficacy subscale and 8 items in the self-management efficacy subscale fit the Rasch Rating Scale model. Five items misfit the model developed using the 21 items from both subscales. In each of the 13- and 8-item subscales, and the 21-item short form, the 2 lowest and highest scores had internal consistency reliability estimates <.70; all other scores had reliability estimates >.70.

CONCLUSIONS

The WheelCon is composed of 2 dimensions. The recoded measurements using a 0-to-10 response scale from the 13-item mobility and 8-item self-management efficacy subscales have good reliability, as do the measurements from the 21-item WheelCon Short Form. The use of the subscales, the short form, or both, depends on the context in which they are being considered. Research to establish the reliability and validity of the measurements using the 0-to-10 response format is warranted.

Validity and Reliability of the Swedish Version of the Activities-specific Balance Confidence Scale in People with Chronic Stroke

PURPOSE

To evaluate the validity and reliability of the Swedish version of the Activities-specific Balance Confidence (ABC) scale in people >1 year after stroke.

METHOD

In a multi-centre study design, using initial cross-sectional data collection with follow-up, the timed up-and-go (TUG) test, 10 m timed walk (10TW), and 6-Minute Walk Test (6MWT) were performed; ABC scale and Short Form 36 Health Survey (SF-36) were completed; and falls history data were collected during one session. One week later, the ABC scale was sent to participants for a second rating. Spearman correlation coefficients were calculated, and reliability was assessed via the intra-class correlation coefficient (ICC) and Cronbach alpha.

RESULTS

A convenience sample of 67 people was included (mean age 68 y). The median score for the ABC scale changed from 57 at the first rating to 43 at the second; 19 participants (28%) reported falls during the previous 3 months. Scores on the ABC scale were moderately correlated with the TUG (r=-0.48), 10TW (r=-0.52), 6MWT (r=0.45), and SF-36 physical component summary score (r=0.43). Internal consistency was high for the ABC scale at test and retest (α=0.95-0.97). The ICC was 0.82 (95% CI, 0.72-0.88).

CONCLUSIONS

The Swedish version of the ABC scale is a valid and reliable measure for investigating balance confidence in people >1 year after stroke.

Activities-specific balance confidence in people with multiple sclerosis

Objective. To evaluate the validity of the Activities-specific Balance Confidence scale (ABC) in people with multiple sclerosis (PwMS). Design. A multicentre, cross-sectional study. Setting. Six rural and urban Swedish sites, including specialized units at hospitals and primary care centers. Participants. A sample of 84 PwMS with subjective gait and balance impairment but still able to walk 100 m (comparable with EDSS 1–6). Outcome Measures. Timed Up and Go, Timed Up and Go^cog, 25-foot Timed Walk Test, Four Square Step Test, Dynamic Gait Index, Chair Stand Test, 12-item MS Walking Scale, self-reported falls, and use of assistive walking device were used for validation. Results. The concurrent convergent validity was moderate to good (0.50 to −0.75) with the highest correlation found for the 12-item MS Walking Scale. The ABC discriminated between multiple fallers and nonfallers but not between men and women. Ecological validity is suggested since ABC discriminated between users of assistive walking device and nonusers. The internal consistency was high at α = 0.95, and interitem correlations were between 0.30 and 0.83. Conclusion. This study supports the validity of the ABC for persons with mild-to-moderate MS. The participants lacked balance confidence in many everyday activities, likely restricting their participation in society.

Determinants of self-rated health in old age: a population-based, cross-sectional study using the International Classification of Functioning

BACKGROUND

Self-rated health (SRH) is a widely used indicator of general health and multiple studies have supported the predictive validity of SRH in older populations concerning future health, functional decline, disability, and mortality. The aim of this study was to use the theoretical framework of the International Classification of Functioning, Disability and Health (ICF) to create a better understanding of factors associated with SRH among community-dwelling older people in urban and rural areas.

METHODS

The study design was population-based and cross-sectional. Participants were 185 Icelanders, randomly selected from a national registry, community-dwelling, 65-88 years old, 63% urban residents, and 52% men. Participants were asked: "In general, would you say your health is excellent, very good, good, fair, or poor?" Associations with SRH were analyzed with ordinal logistic regression. Explanatory variables represented aspects of body functions, activities, participation, environmental factors and personal factors components of the ICF.

RESULTS

Univariate analysis revealed that SRH was significantly associated with all analyzed ICF components through 16 out of 18 explanatory variables. Multivariate analysis, however, demonstrated that SRH had an independent association with five variables representing ICF body functions, activities, and personal factors components: The likelihood of a better SRH increased with advanced lower extremity capacity (adjusted odds ratio [adjOR] = 1.05, p < 0.001), upper extremity capacity (adjOR = 1.13, p = 0.040), household physical activity (adjOR = 1.01, p = 0.016), and older age (adjOR = 1.09, p = 0.006); but decreased with more depressive symptoms (adjOR = 0.79, p < 0.001).

CONCLUSIONS

The results highlight a collection of ICF body functions, activities and personal factors associated with higher SRH among community-dwelling older people. Some of these, such as physical capacity, depressive symptoms, and habitual physical activity are of particular interest due to their potential for change through public health interventions. The use of ICF conceptual framework and widely accepted standardized assessments should make these results comparable and relevant in an international context.

Rasch analyses of the Activities-specific Balance Confidence Scale with individuals 50 years and older with lower-limb amputations

OBJECTIVES

To explore shortened response formats for use with the Activities-specific Balance Confidence (ABC) Scale and then evaluate the unidimensionality of the scale, the item difficulty, the scale for redundancy and content gaps, and the item standard error of measurement (SEM) and internal consistency reliability among aging individuals with a lower-limb amputation living in the community.

DESIGN

Secondary analysis of cross-sectional survey and chart review data.

SETTING

Outpatient amputee clinics, Ontario, Canada.

PARTICIPANTS

Community living adults (N=448; ≥50y; mean, 68y) who have used a prosthesis for at least 6 months for a major unilateral lower-limb amputation. Of the participants, 325 (72.5%) were men.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

ABC Scale.

RESULTS

A 5-option response format outperformed 4- and 6-option formats. Factor analyses confirmed a unidimensional scale. The distance between response options is not the same for all items on the scale, evident by the Rasch Partial Credit Model (PCM) having a better fit to the data than the Rasch Rating Scale Model. Two items, however, did not fit the PCM within statistical reason. Revising the wording of the 2 items may resolve the misfit and improve the construct validity and lower the standard error of measurement. Overall, the difficulty of the scale's items is appropriate for use with aging individuals with lower-limb amputation, and is most reliable (Cronbach α=0.94) for use with individuals with moderately low balance confidence levels.

CONCLUSIONS

The ABC Scale with a simplified 5-option response format is a valid and reliable measure of balance confidence for use with individuals aging with a lower-limb amputation.

Participation frequency and perceived participation restrictions at older age: applying the International Classification of Functioning, Disability and Health (ICF) framework

PURPOSE

To identify variables from different components of International Classification of Functioning, Disability and Health (ICF) associated with older people's participation frequency and perceived participation restrictions.

METHOD

Participants (N = 186) were community-living, 65-88 years old and 52% men. The dependent variables, participation frequency (linear regression) and perceived participation restrictions (logistic regression), were measured using The Late-Life Function and Disability Instrument. Independent variables were selected from various ICF components.

RESULTS

Higher participation frequency was associated with living in urban rather than rural community (β = 2.8, p < 0.001), physically active lifestyle (β = 4.6, p < 0.001) and higher cognitive function (β = 0.3, p = 0.009). Lower participation frequency was associated with being older (β = -0.2, p = 0.002) and depressive symptoms (β = -0.2, p = 0.029). Older adults living in urban areas, having more advanced lower extremities capacity, or that were employed had higher odds of less perceived participation restrictions (adjusted odds ratio [OR] = 5.5, p = 0.001; OR = 1.09, p < 0.001; OR = 3.7, p = 0.011; respectively). In contrast, the odds of less perceived participation restriction decreased as depressive symptoms increased (OR = 0.8, p = 0.011).

CONCLUSIONS

Our results highlight the importance of capturing and understanding both frequency and restriction aspects of older persons' participation. ICF may be a helpful reference to map factors associated with participation and to study further potentially modifiable influencing factors such as depressive symptoms and advanced lower extremity capacity.