Gait & Posture 77 (2020) 118–124

Contents lists available at ScienceDirect

Gait & Posture

journal homepage: www.elsevier.com/locate/gaitpost

Full length article

Assessing gait efficacy in older adults: An analysis using item response T

theory
Subashan Pereraa,b,*, Jessie VanSwearingenc, Valerie Shumanc, Jennifer S. Brachc
a
Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213, USA
b
Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
c
Department of Physical Therapy, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Suite 210, Pittsburgh, PA 15219, USA

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Assessing confidence in walking in older adults is important, as mobility is a critical aspect of
Confidence in walking independence and function, and self-report provides complementary information to performance-based mea-
Gait efficacy sures. The modified Gait Efficacy Scale (mGES) is a self-report measure used to examine confidence in walking.
Item response theory Research Question: : What are the psychometric properties of the mGES at the item level? Are there opportunities
Rasch
for improvement?
Psychometric properties
Methods: We performed a secondary analysis of baseline data from a cluster randomized trial of 424 community-
dwelling older adults and reliability data from 123 participants. We fitted a graded response model to dissect the
mGES to the item and individual response level and examined opportunities to improve and possible shorten the
mGES. We examined psychometric characteristics such as internal consistency, test-retest reliability and con-
struct validity with respect to other relevant measures.
Results: Mobility tasks such as navigating stairs and curbs with separate items for going up and down largely
provide the same information on confidence, with downward direction providing slightly more. It may be
reasonable to consider removal of walking 1/2 mile, stepping down and/or stair tasks with railings items due to
little or duplicate information contributed compared to other items. The shortened scales proposed by removing
the above items had similar psychometric properties to mGES.
Significance: The mGES has good psychometric properties, but can be potentially shortened to substantially
reduce responder burden. The upward direction curb and stairs items can be removed to result in a 7-item scale
with virtually no loss of desirable psychometrics. An alternative 3-item version, level surface walking, stepping
down curb and climbing up stairs without a railing items, entails only a minimal loss in psychometric properties.

1. Background
Mobility is an important aspect of function in older adults and a key
determinant of independence in old age. While physical performance
measures are essential in mobility assessment, an individual’s percep-
tion of their mobility ability provides additional complementary in-
formation beyond performance-based measures [1]. According to social
cognitive theory, one important related construct assessed by self-re-
port is efficacy, one’s level of confidence in engaging in behaviors [2].
Moreover, efficacy is modifiable [3]. Efficacy assessment must be nar-
rowly focused on the activity of interest [4]. The Gait Efficacy Scale
(GES) was developed specifically for self-rating confidence in carrying
out 10 common mobility tasks such as walking up/down stairs with/
without handrails, walking/stepping over obstacles and using an
escalator [5]. Similar instruments such as the Self-Efficacy for Walking
Scale have mainly focused on the pace and endurance aspects of
walking [6,7]. The GES was initially revised by removing the 4 esca-
lator items and adding two items for stepping up on and down from a
curb to result in a scale with 8 items [8].
Others have highlighted the important role of gait efficacy in
functional limitations in older adults. Gait and balance efficacy has a
mediating role in the pathway from physical activity to physical per-
formance to functional limitations [9]. Further, the said role extends to
longitudinal changes in physical activity being partially mediated by
changes in both balance and exercise self-efficacy in older women [10].
Objectively measured better physical performance is associated with
both less pessimism and greater self-efficacy. However, the association
with pessimism attenuates after controlling for self-efficacy, raising the

⁎
Corresponding author at: Medicine and Biostatistics, Division of Geriatric Medicine, University of Pittsburgh, 3471 Fifth Avenue, Suite 500, Pittsburgh, PA 15213,
USA.
E-mail addresses: ksp9@pitt.edu (S. Perera), jessievs@pitt.edu (J. VanSwearingen), vls40@pitt.edu (V. Shuman), jbrach@pitt.edu (J.S. Brach).

https://doi.org/10.1016/j.gaitpost.2020.01.028
Received 5 July 2019; Received in revised form 19 November 2019; Accepted 27 January 2020
0966-6362/ © 2020 Elsevier B.V. All rights reserved.
S. Perera, et al.
possibility that gait efficacy plays an important mediating role, or that
it is a more encompassing/relevant and specific/proximal measure than
pessimism with respect to physical performance [11]. The said med-
iating role makes gait efficacy a potential target for interventions
seeking to improve functional limitations of older adults, and study of
measurement characteristics of gait efficacy metrics is an essential
component of the groundwork needed for evaluating such interven-
tions.
More recently, the further-modified GES (mGES) was developed by
adding walking on a level surface, on grass, and over a long distance
such as 1/2 mile and consolidating the two walking/stepping over
obstacle items into one to result in a 10-item scale [12]. The mGES has
excellent internal consistency (Chronbach’s α = 0.94), and construct
validity with respect to confidence and fear (Falls Efficacy Scale, Survey
of Activities and Fear of Falling in the Elderly, Activities-Specific Bal-
ance Confidence Scale), function and disability (Late-Life Function and
Disability Instrument), and performance measures (gait speed, 6-
Minute Walk Test, Figure of 8 Walk Test, Timed Up & Go Test, narrow
and obstacle walk tests, simple and complex walking while talking tests,
Physical Performance Test, Senior Fitness Test) in community-dwelling
older adults [12–15]. The mGES has been translated to Japanese with
excellent test-retest reliability and concurrent validity in older in-
dividuals living at home [16].
However, despite the relevance of gait efficacy, no formal in-
vestigation has been completed using classical or modern test theoretic
treatment of any of the versions of GES. The initial development and
modifications appear to have been based on reasonable ad hoc deci-
sions derived from content expertise and face validity. While the pro-
cess has led to an instrument with favorable internal consistency, re-
liability and validity, it is not clear whether the mGES is optimal in
some sense, or whether it could be improved; and if so, in what manner.
We sought to address this gap via a secondary analysis of a large data
set using item response theory. We examine the mGES at the item level,
consider shortening the mGES in an informed manner guided by the
findings of the item analysis, and examine the effect of shortening on its
psychometric properties.
2. Methods
2.1. Setting and participants
We conducted a secondary analysis of data from the On the Move
trial. Study methods and main results appear elsewhere [17–19].
Briefly, this cluster randomized trial of a timing and coordination group
exercise program to improve mobility was conducted in 32 independent
living facilities, senior apartment complexes and senior community
centers. Inclusion criteria were age ≥ 65, independence in ambulating
household distances with a gait speed ≥ 0.60 m/s, English speaking,
ability to follow a 2-step command and understand the informed con-
sent process, no acute/unstable medical conditions, ability to safely
complete the 6-minute walk test, and plans to stay the area for study
duration. We use baseline data from all 424 participants, and baseline
and 3-month follow-up data from a subset of 123 participants waiting
to start exercise interventions (reliability subsample). The University of
Pittsburgh Institutional Review Board approved the study and all par-
ticipants provided informed consent.
2.2. Measures
mGES-The 10-item mGES [12] was used in the parent study. On a
scale of 1 (no confidence) to 10 (complete confidence) in increments of
1, participants rated their level of confidence in walking on a level
surface such as a hardwood floor, walking on grass, walking over an
obstacle, stepping down from and up onto a curb, walking up and down
stairs with and without holding onto a railing, and walking a long
distance such as 1/2 mile. The responses were summed to obtain a
119
Gait & Posture 77 (2020) 118–124
composite score with range 10-100.
Other Measures-We used the following measures to characterize the
study sample and to examine construct validity of the mGES based on
others’ prior work, availability of data in the parent trial and our per-
ception of the plausibility of a variable being associated with gait ef-
ficacy. For measures of mobility ability, we considered gait speed and
mean and standard deviations of stance time, step length, and double
support time from 6 trials on an instrumented walkway (ZenoWalkway,
Zenometrics, LLC, Peekskill, New York). For endurance in walking, we
considered six-minute walk distance (6MWD) [20–22]. For challenged
walking, we considered ability to safely complete the walk (yes/no) and
time to complete narrow and obstacle walks [23]. For motor skill of
walking, we considered Figure-of-8 walk test [14] time, step count and
smoothness category. For physical function, we considered Short Phy-
sical Performance Battery (SPPB) [24]. For fall risk, we considered self-
reported fear of falling (Are you afraid of falling? yes/no), and (mul-
tiple) falls during the prior year (Have you had a fall in the past year?
yes/no; Have you fallen more than once in the past year? yes/no). For
global ratings of mobility and balance, we used 5-level Likert scale
responses to questions “Would you say your mobility in general is ex-
cellent, very good, good, fair, or poor?” and “Would you say your
balance in general is excellent, very good, good, fair, or poor?” For
function and disability measures, we considered the Late-Life Function
and Disability Index (LLFDI) domains of overall functioning, and basic
and advanced lower extremity functioning [25,26]. Participants’ co-
morbid burden was assessed with the Duke Comorbidity Index [27].
2.3. Statistical analysis
We used appropriate descriptive statistics to summarize the char-
acteristics of the whole sample and the reliability subsample. First, we
fitted a graded response model to the ordinal responses for items in the
mGES [28]. The graded response model is an extension of the basic item
response model from educational testing for dichotomous responses (ie.
the one-parameter Rasch model) which models the probability of a
correct response to a question only on the difference between a person’s
ability and the question’s difficulty, measured on the same scale re-
presenting the latent trait the test aims to quantify [29]. With ordinal
responses, the model is extended by adding parameters to accom-
modate probability of responding at a certain level as opposed to the
one below (thresholds), and the discriminating ability of an item. In the
mGES, where each item has an ordinal score from 1 to 10 in increments
of 1, we fitted the specific graded response model
* *
Pijk = e λj (ηi − αjk ) /(1 + e λj (ηi − αjk ) ), k = 2, 3, …, 10 , where Pijk is the prob-
ability of participant i responding at level k or greater for item j ; αjk are
the threshold parameters for item j ; λj is the slope or discrimination
parameter for item j ; and ηi is the normally distributed latent trait of the
i th participant that the mGES aims to capture. Item category probability
Pijk , the probability of participant i responding at level k item j, can then
*
be estimated by taking differences Pijk − Pij* (k − 1) of adjacent categories,
* *
where Pij1 = 1 and Pij10 = 0 . We estimated the parameters, and used
them to plot item characteristic, item category probability, item in-
formation and test information curves against the estimated latent trait
representing the underlying construct of gait efficacy. Briefly, item
characteristic curves for an item show how the cumulative probability
of responding at a certain level or higher (as opposed to lower than that
level) for the item changes with the underlying trait of gait efficacy.
Item category probability curves show how the probability of re-
sponding at a certain level for an item changes with the underlying trait
of gait efficacy, with the highest region of a curve indicates the extent of
gait efficacy most likely to select that level to respond. Item/test in-
formation curves show the regions in the underlying gait efficacy
continuum where greatest amount of information is provided by the
item/test for discrimination among individuals. We also constructed a
histogram of estimated latent trait scores. Second, guided by item
curves, we judiciously and methodically removed items from mGES to
S. Perera, et al. Gait & Posture 77 (2020) 118–124

arrive at successively shorter scales. Specifically, we searched for items Table 1

providing less or duplicate information compared to other items in the Participant characteristics and measures: mean ± standard deviation or N (%).
same latent trait regions and less separation among item characteristic Characteristic Entire Reliability
curves (see details in Results section). The process continued until it Sample Subsample
appeared removal of items would entail a deterioration of psychometric N = 424 N = 123
properties of mGES, resulting in four shorter scales each with 9, 7, 6 and
Intervention setting
3 items. The same scoring strategy was used for the derived shorter Community senior center 92 (21.7) 28 (22.8)
scales as for the original mGES. Third, we computed Cronbach’s α for Independent living facility 176 (41.5) 67 (54.5)
internal consistency of the mGES and the shorter derivative scales, 3- Senior apartment complex 156 (36.8) 28 (22.8)
month test-retest reliability using intra-class correlation coefficients Age (years) 80.7 ± 7.8 82.4 ± 6.7
Female gender 349 (82.3) 95 (77.2)
within the subsample, and Pearson correlation between the mGES and
White race 352 (83.0) 100 (81.3)
the shorter scale derivatives. Finally, we examined construct validity of Duke comorbidity index (possible range 2.84 ± 1.40 2.96 ± 1.28
both the mGES and the shorter derivatives against other measures. For 0–8)
continuous measures, we used simple linear regression and report Six-minute walk distance (m) 276.8 ± 281.5 ± 86.8
89.6
standardized regression (equivalently correlation) coefficients and R2;
Able to complete narrow walk 323 (76.2) 100 (81.3)
for dichotomous measures, standardized odds ratios (OR) and area Narrow walk time (s) 6.45 ± 2.72 6.57 ± 2.63
under receiver operator characteristic curves (c-statistic). The R Able to complete obstacle walk 320 (75.5) 92 (74.8)
package ltm [30] and SAS® version 9.3 (SAS Institute, Inc., Cary, North Obstacle walk time (s) 9.19 ± 2.60 9.22 ± 2.71
Carolina) were used for analysis. Figure of 8 walk test
Walk time (s) 10.45 ± 10.40 ± 3.35
3.29
3. Results Number of steps 17.9 ± 4.2 18.0 ± 4.8
Smoothness Score:0 14 (3.3) 6 (4.9)
Participant characteristics for the whole and reliability samples 1 131 (31.2) 33 (26.8)
appear in Table 1. From the 32 facilities, 424 individuals were re- 2 85 (20.2) 30 (24.4)
3 191 (45.4) 53 (43.1)
cruited, of which 123 underwent a waiting period of 3 months before Modified Gait efficacy scale (mGES) 81.0 ± 16.8 82.5 ± 15.4
interventions began. Characteristics of the subsample were not mate- (possible range 10–100)
rially different from those of the entire sample. Participants had Short physical performance battery (SPPB) 9.40 ± 1.81 9.59 ± 1.68
(mean ± standard deviation) age of 80.7 ± 7.8 years, were 83 % white (possible range 0–12)
Fear of falling 148 (34.9) 36 (29.3)
and 82 % women. Participants, on average, had comorbidities in ap-
Fall prior year 128 (30.2) 41 (33.3)
proximately 3 affected physiologic systems. Participants ranged widely Multiple falls prior year 35 (8.3) 9 (7.3)
in their mobility function. A third reported fear of falling, 30 % re- Self-reported global mobility
ported a history of falls during the prior year and 8 % had multiple falls Excellent 68 (16.0) 21 (17.1)
on multiple instances. Only 60 % reported their mobility as excellent/ Very good 179 (42.2) 43 (35.0)
Good 139 (32.8) 51 (41.5)
very good and 31 % reported similarly for balance. The 6MWD was Fair/poor 38 (9.0) 8 (6.5)
276.8 ± 89.6 m and mean gait speed was 0.91 ± 0.20 m/s. Self-reported global balance
Graded response model parameter estimates are in eTable 1 (in Excellent 23 (5.4) 7 (5.7)
Supplementary material) which were used to generate plots for item Very good 108 (25.4) 27 (22.0)
Good 162 (38.2) 51 (41.5)
category probability (eFig. 1 (in Supplementary material)), item char-
Fair/poor 131 (30.9) 38 (30.9)
acteristic (eFig. 2 (in Supplementary material)), item information Late Life Function and Disability Index
(Fig. 1) and test information (Fig. 2) curves, as well as the histogram of (possible range 0–100)
latent trait scores (eFig. 3 (in Supplementary material)). From eFig. 3 Overall function 59.5 ± 9.4 60.0 ± 9.3
(in Supplementary material), we observed evidence of minor ceiling Basic lower extremity function 73.0 ± 14.1 73.9 ± 13.9
Advanced lower extremity function 47.9 ± 15.0 48.8 ± 15.3
effects indicated by a distorted right side of the bell curve. Compared to Instrumented walkway gait speed (m/s) 0.91 ± 0.20 0.91 ± 0.19
other items, walking 1/2 mile generally contributed little information Stance time mean (s) 0.783 ± 0.777 ± 0.092
for discriminating among different levels of gait efficacy (Fig. 1), as 0.105
indicated by the low height of the curve in the same regions where Step length mean (cm) 51.3 ± 8.9 51.6 ± 9.0
Double support time mean (s) 0.405 ± 0.403 ± 0.081
other curves were higher. Although walking on a level surface also
0.091
generally contributed little discriminative information indicated by a Stance time standard deviation (s) 0.044 ± 0.044 ± 0.025
lower height curve, it contributed more than any other item in the 0.022
leftmost region of the graph for those with very low levels of gait ef- Step length standard deviation (cm) 3.49 ± 1.05 3.44 ± 1.08
ficacy (Fig. 1). The directional pairs of items for the same activity (e.g. Double support time standard deviation (s) 0.028 ± 0.028 ± 0.014
0.014
up curb/down curb; up stairs/down stairs) contributed a greater
amount of information as indicated by taller curves but with substantial
duplication of the information for the same range of abilities as in- Supplementary material)) than corresponding up items. In some items,
dicated by almost superimposed curves. The down items generally regardless of the level of gait efficacy, almost no participants chose
provided slightly more information than up as indicated by graphs that certain categories of response (e.g. eFig. 1f (in Supplementary mate-
stayed slightly above those of the up items, except for walking upstairs rial)) and the utility of these categories is questionable.
without a railing (Fig. 1). Item characteristic curves (eFig. 2 (in Sup- Guided by the above observations, it is logical to consider 4 po-
plementary material)) show how the probability of responding at a tential alternative shorter versions of the mGES: (A) 9-item scale: ex-
certain level or above increases as one’s gait efficacy increases. The item clude the 1/2 mile item; (B) 7-item scale: exclude duplicate up items;
category probability curves (eFig. 1 (in Supplementary material)) show (C) 6-item scale: exclude both the 1/2 mile and duplicate up items; and
how the probability of responding at a certain level first increases and (D) 3-item scale: include only level surface walking, stepping down a
then decreases with one’s gait efficacy, where the highest region of the curb, and walking up stairs without a railing items. Peak-normalized
graph corresponds to those with a range of gait efficacy likely to self- test information curves in Fig. 2 shows that when all items are con-
report that category. Down items generally show a more desirable sidered together, abbreviated 9-item and 7-item versions entail
greater level of separation in item characteristic curves (eFig. 2 (in

120
S. Perera, et al.
Fig. 1. Item information curves for the modified gait efficacy scale versus gait
efficacy trait. The curves show how much information about gait efficacy (y-
axis) each item provides for individuals with varying levels of gait efficacy (x-
axis). The peak corresponds to the point where the item has the highest dis-
crimination.
Fig. 2. Peak-normalized item information curves for original and abbreviated
versions of the modified gait efficacy scale versus gait efficacy trait. The curves
show how much total information about gait efficacy (y-axis) each scale pro-
vides (sum of information provided by items in scale) for individuals with
varying levels of gait efficacy (x-axis). The peak corresponds to the point where
the scale has the highest discrimination. The height depends on the number of
items in scale, and thus normalized by peak height for a fairer comparison.
virtually no loss of psychometric properties and the 3-item version re-
sulting in a minor loss of information among those with lower gait ef-
ficacy.
Psychometric characteristics of the mGES and its shorter derivatives
are in Table 2. All considered potential alternatives have extremely
high (≥0.96) Pearson correlations with the mGES. The mGES internal
consistency (Cronbach’s α) of 0.91 is unaffected by removing walking
1/2 mile (9-item scale), slightly reduced to 0.87 by excluding the du-
plicate up items (7-item scale) and further reduced to 0.72 in the
121
Gait & Posture 77 (2020) 118–124
shortest 3-item version. Three-month test-retest reliability (ICC) of 0.77
in the mGES slightly decreases to 0.75 by excluding the duplicate up
items (7-item scale) and to 0.72 when considering only 3 items.
In Table 3 are the standardized regression coefficients and R2 for
examining construct validity with respect to continuous measures, and
in Table 4 are the standardized odds ratios and c-statistics for dichot-
omous variables that should be plausibly related to gait efficacy. Me-
trics of construct validity did not materially decrease and even slightly
improved when duplicate up items were removed (7-item scale). For
example, the standardized regression coefficient (β) for LLFDI advanced
lower extremity changed from 0.734 to 0.731 (R2 from 0.54 to 0.53)
and mean double support time increased from -0.454 to -0.465 (R2 from
0.21 to 0.22); and ORs for fear of falling decreased from 0.59 to 0.50 (c
from 0.756 to 0.757), multiple falls during prior year increased from
0.65 to 0.66 (c from 0.745 to 0.748), and report of excellent/very good
mobility increased from 1.80 to 1.85 (c from 0.759 to 0.766). Minor
losses to construct validity occurred when only 3 items were con-
sidered, with the standardized regression coefficient (β) for LLFDI ad-
vanced lower extremity decreasing to 0.685 (R2 = 0.47) and double
support time to -0.400 (R2 = 0.16); and ORs for fear of falling to 0.61 (c
= 0.746), multiple falls during prior year to 0.67 (c = 0.730), and
report of excellent/very good mobility 1.68 (c = 0.738).
4. Discussion
Using a large sample of older adults, we performed a rigorous
psychometric analysis of the mGES using item response theory. We
observed that the mGES generally has good psychometric properties.
However, it also has minor ceiling effects, some items provide only a
low level of information, and some items duplicate information pro-
vided by other items. In theory, the mGES could be augmented with
additional items to ameliorate its minor ceiling effects, although we
argue that may not be necessary. Regardless of underlying level of gait
efficacy, certain categories of certain items are rarely endorsed.
Opportunities exist to shorten the mGES without a material sacrifice of
the desirable psychometric properties. Considering similar psycho-
metric properties yet less responder burden of a shorter scale, we pro-
pose that of the 10 items in mGES, a subset of 7 or possibly 3 items
should be considered.
Patient-reported and performance-based outcome measures provide
complementary information about physical function. In this case, the
mGES may help identify individuals at risk of mobility decline that are
not otherwise readily classified through physical measures. In a busy
clinical setting, there is no time for lengthy questionnaires. The benefits
of a shortened mGES are lower responder burden for the patient, lower
analytic burden for the clinician and saving time for both. While 10
questions may not appear to be excessive, in both clinical and research
settings there is little room for redundancy. If the information gathered
from two questions that could direct the clinician’s choice of inter-
ventions (e.g. our data support confidence in descending stairs likely
has the same information as ascending) is sufficiently similar that there
is no additional benefit from asking both questions. Moreover, clin-
icians may be more likely to use a shorter version in the clinic, if one
were available, compared to not assessing gait efficacy at all due to the
length of the questionnaire.
While self-efficacy measures have been used for initial assessment
and the identification a person’s beliefs in abilities, less often in clinical
practice has it been incorporated to determine therapeutic outcomes or
appropriate time to terminate a care episode. For example, is the end-
point of a therapeutic regimen in clinical practice when the clinician
observes performance to be adequate, treatment goals achieved or
when the individual also perceives their performance meets the func-
tional goals? Despite the actual performance ability, if the person does
not believe their performance is adequate for the challenges of daily
physical functioning, the behavior is unlikely to occur or continue after
discharge from therapy. Therefore, a short form mGES could be useful
S. Perera, et al. Gait & Posture 77 (2020) 118–124

Table 2
Some psychometric Characteristics of mGES and its shorter derivatives.
Psychometric Characteristic Gait Efficacy Measure

mGES mGES w/o 1/2 Excluding Duplicate Excluding Duplicate Up Level Surface, Down Curb, & Up
Mile Item Up Items Items & 1/2 Mile Stairs w/o Railing Items Only
(10-item) (9-item) (7-item) (6-item) (3-item)

Internal consistency by Cronbach’s α 0.91 0.91 0.87 0.86 0.72

(95 % CI) (0.90-0.93) (0.90-0.93) (0.85-0.89) (0.84-0.89) (0.66-0.78)
Pearson Correlation with mGES α ——— 0.99 0.99 0.98 0.96
(95 % CI) (0.99-0.99) (0.98-0.99) (0.97-0.98) (0.95-0.96)
3-Month Test- Retest Reliability by Intraclass 0.77 0.74 0.75 0.71 0.72
Correlation Coefficient or ICC α (N = 123)
(95 % CI) (0.69-0.83) (0.65-0.81) (0.67-0.82) (0.62-0.79) (0.63-0.80)

CI = Confidence interval.

Table 3
Construct validity: standardized coefficients (β; first number in each cell) and proportion of explained variability (R2; second number in each cell) from regressing
continuous measures on gait efficacy measures.
Other Concurrent Continuous Gait Efficacy Measure
Measures
mGES mGES w/o 1/2 Mile Excluding Duplicate Up Excluding Duplicate Up Items Level Surface, Down Curb, & Up Stairs
Item Items & 1/2 Mile w/o Railing Items Only
(9-Item) (7-Item) (6-Item) (3-Item)

Six-minute walk distance (m) β = 0.507 0.465 0.516 0.457 0.460

R2 = 0.26 0.22 0.27 0.21 0.21
Narrow walk time (s) −0.349 −0.332 −0.359 −0.337 −0.305
0.12 0.11 0.13 0.11 0.09
Obstacle walk time (s) −0.45 −0.428 −0.454 −0.426 −0.412
0.20 0.18 0.21 0.18 0.17
Figure 8 walk time (s) −0.512 −0.506 −0.516 −0.511 −0.479
0.26 0.26 0.27 0.26 0.23
Figure 8 number of steps −0.489 −0.483 −0.489 −0.481 −0.462
0.24 0.23 0.24 0.23 0.21
Short physical performance battery 0.447 0.434 0.446 0.428 0.410
0.20 0.19 0.20 0.18 0.17
LLFDI overall function 0.699 0.681 0.695 0.671 0.663
0.49 0.46 0.48 0.45 0.44
LLFDI basic lower extremity function 0.681 0.672 0.679 0.668 0.648
0.46 0.45 0.46 0.45 0.42
LLFDI advanced lower extremity 0.734 0.707 0.731 0.692 0.685
function 0.54 0.50 0.53 0.48 0.47
Instrumented walkway gait speed (m/ 0.523 0.500 0.529 0.498 0.482
s) 0.27 0.25 0.28 0.25 0.23
Stance time mean (s) −0.366 −0.341 −0.374 −0.339 −0.319
0.13 0.12 0.14 0.11 0.10
Step length mean (cm) 0.508 0.489 0.513 0.488 0.475
0.26 0.24 0.26 0.24 0.23
Double support time mean (s) −0.454 −0.425 −0.465 −0.425 −0.400
0.21 0.18 0.22 0.18 0.16
Stance time standard deviation (s) −0.277 −0.258 −0.289 −0.264 −0.247
0.08 0.07 0.08 0.07 0.06
Step length standard deviation (cm) −0.070* −0.067* −0.075* −0.072* −0.068*
0.00 0.00 0.01 0.01 0.00
Double support time standard −0.294 −0.275 −0.305 −0.281 −0.268
deviation (s) 0.09 0.08 0.09 0.08 0.07

* Not statistically significant at α = 0.05. All other cells are statistically significant at α = 0.05.

in clinical practice to facilitate patient-centered, shared clinician-client
decision-making.
Estimated latent trait (gait efficacy) plotted in eFig. 3 (in
Supplementary material) ideally should be approximately normally
distributed. The compressed right tail of the distribution demonstrates
some ceiling effect, indicating the mGES may not be able to sufficiently
discriminate among those with a very high level of gait efficacy. The
ceiling effects seen are not as severe as other reported instances such as
with the Barthel Index in stroke survivors [31], and in principle, could
be mitigated by including items that are more difficult to respond to at
high levels. However, more difficult walking tasks may be irrelevant to
large portions of the target population depending on the climate and
rural/urban nature of where they live, and whether such mobility tasks
are frequently undertaken by older adults. Most importantly, we note
that our participants had to meet inclusion criterion of ability to in-
dependently ambulate with no more assistance than a cane. Therefore,
our sample was skewed towards the higher end of function than the
general population of community-dwelling older adults, and perhaps
the minor ceiling effects observed should have been expected as a result
of the inclusion criterion rather than a measurement characteristic of
mGES. Moreover, if certain participants have very high level of gait
efficacy, they are likely not a subpopulation of clinical interest.
Therefore, we do not feel adding items to mitigate ceiling effects is
warranted at this stage.
The walking a 1/2-mile item was more recently added by Newell
and colleagues based on content expertise [12]. We notice that it does

122
S. Perera, et al. Gait & Posture 77 (2020) 118–124

Table 4 single greater metropolitan area, potentially limiting the general-

Construct validity: standardized odds ratios and area under receiver operator izability of findings. Our analysis is limited by the availability of data
characteristic curve (c-statistic) from logistic regressing dichotomous measures from the parent trial, which had only included the mGES as a gait ef-
on gait efficacy measures. ficacy measure. Most rating scales in health sciences have fewer re-
Other Concurrent Gait Efficacy Measure sponse categories per item, commonly 4-5. It is unclear whether par-
Dichotomous ticipants can reliably respond on a 10-level scale at the item level, or
Measures mGES mGES Excluding Excluding Level whether all 10 levels are needed for adequate discrimination of re-
w/o 1/ Duplicate Duplicate Surface,
2 Mile Up Items Up Items & Down Curb,
sponse. For example, at no level of gait efficacy did a nontrivial per-
Item 1/2 Mile & Up Stairs centage of responders felt it was appropriate to select category 3 for
w/o Railing going up stairs with a railing item, as indicated by the near zero
(B) Items Only probability curve in eFig. 1(f) (in Supplementary material). However,
(C) (D)
we were unable to examine such nuances rigorously with the available
(A)
data. We could have operationally collapsed adjacent response cate-
Fear of falling 0.59 0.59 0.59 0.59 0.61 gories to 5 levels, but such extrapolations are based on excessive as-
0.756 0.760 0.757 0.763 0.746 sumptions on how a responder may view a 5-level scale.
Fall prior year 0.74 0.75 0.74 0.76 0.75
In conclusion, the ten-item mGES can be shortened to 7 items with
0.647 0.643 0.646 0.643 0.644
Multiple falls prior 0.65 0.67 0.66 0.68 0.67
virtually no loss of its psychometric properties and to 3 items with only
year 0.745 0.739 0.748 0.731 0.730 a minimal loss of psychometrics. Both shortened versions could de-
Excellent/very 1.80 1.69 1.85 1.71 1.68 crease responder burden and increase the likelihood of the scale being
good mobility 0.759 0.741 0.766 0.741 0.738 used by clinicians and researchers to elicit important patient perspec-
Excellent/very 2.61 2.48 2.62 2.47 2.24
tives to be incorporated into therapeutic approaches to reduce mobility
good balance 0.812 0.807 0.813 0.805 0.790
Figure of 8 walk 1.46 1.47 1.44 1.45 1.44 disability among older adults.
smoothness (3 0.691 0.692 0.690 0.690 0.686
vs < 3) Declaration of Competing Interest
Able to complete 1.64 1.63 1.64 1.63 1.63
narrow walk 0.758 0.755 0.754 0.752 0.751
Able to complete 1.86 1.85 1.85 1.83 1.79
None of the authors has a conflict of interest.
obstacle walk 0.790 0.786 0.788 0.784 0.773
Acknowledgements
*Not significant at α = 0.05.
This study was supported by grants from Patient Centered Outcomes
provide information for discrimination among individuals with a wide Research Institute (CE-1304-6301) and National Institute on Aging
range of gait efficacy as indicated by the width of the graph, but only a (P30 AG024827; K24 AG057728). Funding agencies played no role and
low amount of information (Fig. 1). The range covered by the item is investigators retained complete independence in conducting the parent
also covered by other items such as curb on the lower end and stairs study and the present secondary analysis.
without railing on the upper end, and with much greater level of in-
formation (Fig. 1). Thus, while a reasonable addition, it also appears to Appendix A. Supplementary data
be redundant. Removing it from mGES entails virtually no loss in
construct validity (Tables 3-4) and other psychometric characteristics Supplementary material related to this article can be found, in the
(Table 2). On the other hand, the addition of curb items in the same online version, at doi:https://doi.org/10.1016/j.gaitpost.2020.01.028.
work proved extremely beneficial, as they provide the greatest amount
of information of all items. References
Historically, separate items have been included for going up and
down directions in escalator, curb and stair tasks based on differences [1] D.B. Reuben, A.L. Siu, S. Kimpau, The predictive validity of self-report and per-
from a biomechanical perspective [8]. However, in terms of contribu- formance-based measures of function and health, J. Gerontol. 47 (July (4)) (1992)
M106–10.
tion to confidence in gait, it appears that direction matters only a little,
[2] A. Bandura, Social Foundations of Thought and Action, Prentice Hall, Englewood
as indicated by nearly superimposed curves (Fig. 1) for up and down Cliffs, New Jersey, 1986.
directions of the same tasks. Moreover, moving downward may be a [3] J.M. VanSwearingen, S. Perera, J.S. Brach, R. Cham, C. Rosano, S.A. Studenski, A
greater challenge than upward potentially secondary to utilizing ec- randomized trial of two forms of therapeutic activity to improve walking: effect on
the energy cost of walking, J. Gerontol. Med. Sci. 64A (November (11)) (2009)
centric muscle control, or the realization that downward motion has the 1190–1198.
potential to continue down to the ground or bottom of the steps. [4] A. Bandura, Self-Efficacy: The Exercise of Control, W. H. Freeman, New York, 1977.
Therefore, the greater level of information in down items is to be ex- [5] E. McAuley, S.L. Mihalko, K. Rosengren, Self-efficacy and balance correlates of fear
of falling in the elderly, J. Aging Phys. Act. 5 (1997) 329–340.
pected, and it is reasonable to consider only retaining the downward [6] E. McAuley, B. Blissmer, J. Katula, T.E. Duncan, Exercise environment, self-efficacy,
items of the same task. Indeed, construct validity (Tables 3-4) and other and affective responses to acute exercise in older adults, Psychol. Health 15 (2000)
psychometric properties (Table 2) are virtually unchanged or even 341–357.
[7] E. McAuley, K.S. Courneya, J. Lettunich, Effects of acute and long-term exercise on
slightly improved when upward items are removed. self-efficacy responses in sedentary, middle-aged males and females, Gerontologist
Strengths and limitations of our study need mention. Compared to 31 (August (4)) (1991) 534–542.
previous studies of the scale, the sample size was the largest and most [8] K.S. Rosengren, E. McAuley, S.L. Mihalko, Gait adjustments in older adults: activity
and efficacy influences, Psychol. Aging 13 (3) (1998) 375–386.
representative of older adults in independent living facilities, senior
[9] E. McCauley, J.F. Konopack, K.S. Morris, Hu L. Motl RW, S.E. Doerksen,
apartments and community centers. Our findings were only possible K. Rosengren, Physical activity and functional limitations in older women: influence
through a rigorous analysis using item response theory afforded by the of self-efficacy, J. Gerontol. B Psychol. Sci. Soc. Sci. 61B (5) (2006) 270–277.
[10] E. McAuley, K.S. Morris, S.E. Doerksen, R.W. Motl, L. Hu, S.M. White, T.R. Wojcicki,
large sample size. As indicated by an average age over 80 years and
K. Rosengren, Effects of change in physical activity on physical function limitations
comorbidities in nearly 3 physiologic systems, the sample is re- in older women: mediating roles of physical function performance and self-efficacy,
presentative of community-dwelling older adults with some health and J. Am. Geriatr. Soc. 55 (2007) 1967–1973.
function difficulties. Nonetheless, the parent trial did have certain in- [11] M.R. Umstattd, E. McAuley, R.W. Motl, K.S. Rosengren, Pessimism and physical
functioning in older women: influence of self-efficacy, J. Behav. Med. 30 (2) (2007)
clusion/exclusion criteria such as ability to independently ambulate 107–114.
with no more assistance than a straight cane and was conducted in a [12] A.M. Newell, J.M. VanSwearingen, E. Hile, J.S. Brach, The modified gait efficacy

123
S. Perera, et al.
scale: establishing the psychometric properties in older adults, Phys. Ther. 92 (2)
(2012) 318–328.
[13] Wert D. Talkowski JB, J. VanSwearingen, J. Brach, Validation of the Late Life
Function and Disability Index (LLFDI) and Gait Efficacy Scale (GES) with perfor-
mance based measures of function and mobility in community dwelling older
adults, J. Geriatr. Phys. Ther. 30 (3) (2007) 136.
[14] R.J. Hess, J.S. Brach, S.R. Piva, J.M. VanSwearingen, Walking skill can be assessed
in older adults: validity of the Figure-of-8 walk Test, Phys. Ther. 90 (1) (2010)
89–99.
[15] A. Goldberg, S.A. Talley, D.E. Adamo, Construct validity of the modified gait effi-
cacy scale in older females, Physiother. Theory Pract. 32 (4) (2016) 307–314.
[16] H. Makizako, H. Shimada, D. Yoshida, Y. Anan, T. Ito, T. Doi, K. Tsutsumimoto,
K. Uemura, J.S. Brach, T. Suzuki, Reliability and validity of the Japanese version of
the modified gait efficacy scale, Phys. Ther. Jpn. 17 (1) (2014) 45, https://doi.org/
10.1298/jjpta.Vol17_012.
[17] J.S. Brach, S. Perera, S. Gillmore, J.M. VanSwearingen, D. Brodine, D. Wert,
N. Nadkarni, E. Ricci, Stakeholder involvement in the design of a patient-centered
comparative effectiveness trial of the "On the Move" group exercise program in
community-dwelling older adults, Contemp. Clin. Trials 50 (September) (2016)
135–142, https://doi.org/10.1016/j.cct.2016.08.003.
[18] J.S. Brach, S. Perera, S. Gillmore, J.M. Vanswearingen, D. Brodine, N.K. Nadkarni,
E. Ricci, Effectiveness of “on the move” group exercise program to improve mobility
in community-dwelling older adults: a randomized trial, JAMA Intern. Med. 177
(October (10)) (2017) 1437–1444, https://doi.org/10.1001/jamainternmed.2017.
3609.
[19] D.M. Wert, S. Perera, J.F. Nutini, E.M. Ricci, L. Coffman, R. Turnquist, J. Brach,
Motor control-based group exercise: can it be delivered as effectively by lay leaders?
Transl. J. Am. Coll. Sports Med. 3 (February (3)) (2018) 19–27.
[20] B.E. Maki, Gait changes in older adults: Predictors of falls or indicators of fear? J.
Am. Geriatr. Soc. (1997), https://doi.org/10.1111/j.1532-5415.1997.tb00946.x.
[21] M.E. Chamberlin, B.D. Fulwider, S.L. Sanders, J.M. Medeiros, Does fear of falling
124
Gait & Posture 77 (2020) 118–124
influence spatial and temporal gait parameters in elderly persons beyond changes
associated with normal aging? J. Gerontol. – Ser. A Biol. Sci. Med. Sci. (2005),
https://doi.org/10.1093/gerona/60.9.1163.
[22] R.J. Butland, J. Pang, E.R. Gross, A.A. Woodcock, D.M. Geddes, Two-, six-, and 12-
minute walking tests in respiratory disease, Br. Med. J. (Clin Res Ed) 284 (6329)
(1982) 1607–1608.
[23] A. Shumway-Cook, J.M. Guralnik, C.L. Phillips, et al., Age-associated declines in
complex walking task performance: the walking in Chianti toolkit, J. Am. Geriatr.
Soc. 55 (1) (2007) 58–65.
[24] J.M. Guralnik, E.M. Simonsick, L. Ferrucci, et al., A short physical performance
battery assessing lower extremity function: association with self-reported disability
and prediction of mortality and nursing home admission, J. Gerontol. 49 (2) (1994)
M85–M94.
[25] A.M. Jette, S.M. Haley, W.J. Coster, et al., Late life function and disability instru-
ment: I. development and evaluation of the disability component, J. Gerontol. A
Biol. Sci. Med. Sci. 57 (4) (2002) M209–M216.
[26] S.M. Haley, A.M. Jette, W.J. Coster, et al., Late life function and disability instru-
ment: II. Development and evaluation of the function component, J. Gerontol. A
Biol. Sci. Med. Sci. 57 (4) (2002) M217–M222.
[27] S.K. Rigler, S. Studenski, D. Wallace, D.M. Reker, P.W. Duncan, Co-morbidity ad-
justment for functional outcomes in community-dwelling older adults, Adv. Clin.
Neurosci. Rehabil. 16 (June (4)) (2002) 420–428.
[28] F. Samejima, Estimation of Latent Ability Using a Response Pattern of Graded
Scores, Psychometrika Monograph Supplement, No 17 (1969).
[29] G. Rasch, Probabilistic Models for Some Intelligence and Attainment Tests, The
University of Chicago Press, Chicago, IL, 1980.
[30] D. Rizopoulos, ltm: an R package for latent variable modeling and item response
analysis, J. Stat. Softw. 17 (5) (2007) 1–25.
[31] S.M. Lai, S. Studenski, P. Duncan, S. Perera, Persisting consequences of stroke
measured by the stroke impact scale, Stroke 33 (July (7)) (2002) 1840–1844.