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The Cumulated Ambulation Score (CAS)_English version_manual and score-sheet_updated with more references 2019.pdf

Authors:
Nicolai Bang Foss at Hvidovre Hospital, Copenhagen University
Nicolai Bang Foss
  • Hvidovre Hospital, Copenhagen University
Morten Tange Kristensen at Bispebjerg and Frederiksberg Hospital - University of Copenhagen
Morten Tange Kristensen
  • Bispebjerg and Frederiksberg Hospital - University of Copenhagen
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Abstract

The Cumulated Ambulation Score (CAS) was developed by Dr. Nicolai Bang Foss & Physical Therapist, Morten Tange Kristensen at time of start of a specialized hip fracture unit at Hvidovre Hospital September, 2002. The CAS was used to monitor the basic mobility status of all patients with hip fracture on a daily basis following surgery, and until independence was reached. Since then it has been used in a large number of research studies in patients with hip fracture and its being used in both the Danish and Irish hip fracture database. Also, the CAS has been used in several other patient groups with a low ambulatory level. As such the CAS is considered a generic test, that can be used in all patient groups, not independent in the 3 basic activities: getting in and out of bed, sit to stand to sit in a chair with armrests and walking with or without an assistive device, that forms the score. Answers to frequently asked questions: The three activities can be tested in a non-prioritized order (i.e. if a patient is sitting in a chair, testing of this activity can be started). Assessment of the individual activities can also be split up so that i.e. getting up from a chair is followed by an assessment of walking and ends with an assessment of "sitting in a chair". The same can be done for the activity of getting out of bed and getting into bed. Out of bed and into bed: - Both the patient's physical, cognitive and general level/condition are important for the score. Use of aids will often vary and depend on who is in charge of testing. This means that a patient if general condition allows mobilization to standing or sitting in a chair is given 1 point regardless of how many people or which aid (including lift) is used. - To obtain 2 points, the activity must be carried out independently from supine (without raised headboard or use of the other functions of the bed) and back to supine. - In outpatient clinics/clinics where there is no bed, a couch can be used. Sit to stand in a chair with armrests (seat height 44-47cm): -Chair raisers are considered an aid, except for particularly tall people. Walking indoors: - A patient who can walk a few steps with a walking aid and personal support is given 1 point, but to achieve the score 2 the patient must independently, i.e., be able to go to and from the toilet and out into the hallway The goal is to expand the worldwide knowledge and use of the CAS in any patient group or person with a reduced basic mobility level, both in-hospital and in municipalities. At present the CAS is available in more than 15 languages, all available here at ResearchGate. If not able to find or not available in your language, and interested in collaborating on a version for your country, please contact: mortentange@hotmail.com
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English version of the CAS manual by Derek Curtis, PT, MSc, PhD-student and Morten Tange Kristensen PT, PhD, Hvidovre
Hospital (HH), 2014 after Danish version by Morten Tange Kristensen (HH), Christina Weirum Andersen, Glostrup Hospital,
Anders Vinther, Herlev Hospital and Carsten Juhl, Gentofte Hospital, November 2006. Further info: Morten Tange
Kristensen, Senior Researcher, PMR-C, Departments of Physiotherapy and Orthopedic Surgery, Amager-Hvidovre Hospital,
University of Copenhagen, Denmark. Further info, Email: mortentange@hotmail.com
The Cumulated Ambulation Score (CAS) – English manual.
Description and application:
The CAS [1] is a score that can be used for daily assessment of developments in basic mobility until
independent ambulation is reached, defined as:
• Getting in and out of bed
• Sit to stand to sit from a chair with armrests
• Indoors walking
Each of the three activities is scored from 0-2, resulting in a daily score of 0-6 (One-day CAS) [2-8].
CAS has proved reliable and useful as a tool to make an early prediction of rehabilitation /
hospitalization. For the purposes of this a cumulated score for the first three postoperative days gives a
CAS of 0-18 points (Three-day CAS) [1].
A CAS > 9 points for postoperative day 1-3 has proven predictive for discharge within 14 days,
discharge directly to own home, not experiencing major medical complications and 30 days survival
in patients with hip fracture [1].
Scoring of the CAS follows description in the appendix of the 2009 reliability study of the CAS [2]:
Getting in and out of bed: (From supine in bed to sitting on the side of the bed, to standing or
transfer to sitting in chair placed beside the bed and return to the supine position in bed).
2 points are given when the activity is performed independently. Independently means that verbal
cueing or human assistance are not necessary, even for safety reasons. All walking aids can be used.
1 point is given when human assistance is needed. Human assistance can be anything from verbal
guiding to extensive help from one or more persons and includes aids.
0 points is given for patients who are unable to leave the bed. This means that patients cannot stand
up or sit up in a chair, despite extensive help from one or more persons, including the use of aids.
Sit-to-stand from a chair with armrests: (From sitting to standing to sitting).
2 points are given when the activity is performed independently. Independently means that verbal
cueing or human assistance are not necessary, not even for safety reasons.
1 point is given when human assistance is needed. Human assistance can be anything from verbal
cueing to extensive help from one or more persons and includes the use of aids.
0 points is given for patients who are unable to sit up in a chair. This refers to patients who are not
able to sit up in a chair in spite of the massive help of one or more persons, including the use of aids.
English version of the CAS manual by Derek Curtis, PT, MSc, PhD-student and Morten Tange Kristensen PT, PhD, Hvidovre
Hospital (HH), 2014 after Danish version by Morten Tange Kristensen (HH), Christina Weirum Andersen, Glostrup Hospital,
Anders Vinther, Herlev Hospital and Carsten Juhl, Gentofte Hospital, November 2006. Further info: Morten Tange
Kristensen, Senior Researcher, PMR-C, Departments of Physiotherapy and Orthopedic Surgery, Amager-Hvidovre Hospital,
University of Copenhagen, Denmark. Further info, Email: mortentange@hotmail.com
Indoors walking:
2 points are given when independency with a walking aid is obtained. Independently means that
verbal cueing or human assistance are not necessary, even for safety reasons. All walking aids can be
used.
1 point is given when human assistance is needed. Human assistance can be anything from verbal
cueing to extensive help from one or more persons, including the use of walking aids.
0 points is given for patients who are unable to walk. This refers to patients who are unable to walk in
spite of massive help from one or more persons, and the use of walking aids.
CAS references (selected):
1. Foss NB, Kristensen MT, Kehlet H. Prediction of postoperative morbidity, mortality and rehabilitation in
hip fracture patients: the cumulated ambulation score. Clin.Rehabil. 2006; 20: 701-8.
2. Kristensen MT, Andersen L, Bech-Jensen R et al. High intertester reliability of the cumulated ambulation
score for the evaluation of basic mobility in patients with hip fracture. Clin.Rehabil. 2009; 23: 1116-23.
3. Kristensen MT, Jakobsen TL, Nielsen JW, Jorgensen LM, Nienhuis RJ, Jonsson LR. Cumulated
Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture. Dan
Med J 2012; 59: A4464.
4. Kristensen MT, Kehlet H. Most patients regain prefracture basic mobility after hip fracture surgery in a
fast-track programme. Dan.Med.J. 2012; 59: A4447.
5. Grana E, Verzellotti S, Grassi FA, Ferriero G, Kristensen MT, Cisari C, Invernizzi M. Cross-
cultural validation of the Italian version of the Cumulated Ambulation Score. Int J Rehabil Res.
2016; 39: 160-4.
6. Fitzgerald M, Blake C, Askin D, Quinlan J, Coughlan T, Cunningham C. Mobility one week after
a hip fracture - can it be predicted? Int J Orthop Trauma Nurs. 2018; 29: 3-9.
7. Kristensen MT, Öztürk B, Röck ND, Ingeman A, Palm H, Pedersen AB. Regaining pre-fracture
basic mobility status after hip fracture and association with post-discharge mortality and
readmission-a nationwide register study in Denmark. Age Ageing. 2019; 48: 278-284.
8. Ariza-Vega P, Mora-Traverso M, Ortiz-Piña M, Ashe MC, Kristensen MT. Translation, inter-rater
reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation
score in patients after hip fracture. Disabil Rehabil. 2019; 24:1-6. [Epub ahead of press]
9. Ferriero G, Kristensen MT, Invernizzi M, Salgovic L, Bravini E, Sartorio F, Vercelli S.
Psychometric properties of the Cumulated Ambulation Score: a systematic review. Eur J Phys
Rehabil Med. 2018; 54: 766-771. Review.
CAS rating-sheet developed by Morten Tange Kristensen, PT and Nicolai Bang Foss, MD at Hvidovre Hospital, Denmark 2002.
Further information: Morten Tange Kristensen, Senior Researcher, PT, PhD, Physical Medicine and Rehabilitation Research – Copenhagen (PMR-C),
Departments of Physiotherapy and Orthopaedic surgery, Copenhagen University Hospital Hvidovre, Denmark Email: mortentange@hotmail.com
Name
Admitted due to:
Rating-sheet for the Cumulated Ambulation Score (CAS)
CAS-score (0-2 points) – Please see CAS manual for details.
(2) Able to safely, without human assistance or verbal cueing
(1) Able to, with human assistance and / or verbal cueing from one or more persons.
(0) Not able to, despite human assistance and verbal cueing (e.g. not able to leave the bed).
Date
/
/
/
/
/
/
/
/
/
/
Day of
discharge
Getting in and
out of bed
Sit to stand to
sit from a chair
with arms
Walking with:
High walker on
wheels
Walker
Rollator
Stick / Crutches
Walking
without aids
Daily CAS-score (0-6 points)
Stairs walking
The daily one-day CAS-score (0–6 points) of basic mobility is the cumulated score of the three
activities; getting in and out of bed (0-2), sit-to-stand-to-sit from a chair with arms (0-2) and the score
for walking (0-2) using a walking aid (if necessary) that gives the highest rating on a particular day.
In addition, ascending/descending stairs can be assessed with the system, but this is not included in the
total score, not being part of the basic mobility definition.
Three-day CAS-score (0-18 points) = Postoperative day 1 + 2 + 3=__________________

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Cross-cultural validation of the Italian version of the Cumulated Ambulation Score
Article
Full-text available
  • Mar 2016
  • INT J REHABIL RES
Hip fractures are common in elderly patients, and walking impairment is a frequent complication. The Cumulated Ambulation Score (CAS) is a validated functional scale used to monitor easily three basic mobility activities in patients with hip fracture. The aim of this study was to translate, cross-cultural adapt, and validate the CAS in the Italian language (CAS-I). The translation was carried out according to recommended guidelines. The final version of the CAS-I was administered to 80 geriatric patients with hip fracture admitted to a Traumatology Unit, and allowed full weight-bearing after treatment with hemiarthroplasty. Two raters evaluated each patient 2 days after surgery and then after 3 months. Statistical methods included Cronbach's [alpha] coefficient for the scale's internal consistency; the total agreement; and the [kappa] coefficient for the inter-rater reliability. The concurrent validity of the scale was determined by comparing the total CAS-I (0-6 points) with the Index of Independence in Activities of Daily Living score (0-4 points). Internal consistency and inter-rater reliability of the CAS, evaluated with Cronbach's [alpha] and [kappa], respectively, were above 0.84 and 0.94. The SE of measurement for the total CAS-I (0-6 points) 2 days and 3 months after surgery were 0.03 and 0.13 points, respectively. The CAS-I showed a significant correlation with the first four items of the Activities of Daily Living score scale (r>=0.85, P<0.001). This study confirms the validity of the CAS-I for patients with a hemiarthroplasty after hip fracture and provides additional evidence of the psychometric properties of the scale. We suggest that the official CAS-I version be used in other settings to evaluate the basic mobility in patients with hip fracture. Copyright
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Cumulated Ambulation Score to evaluate mobility is feasible in geriatric patients and in patients with hip fracture
Article
Full-text available
  • Jul 2012
Regaining basic mobility independence is considered important for elderly hospitalised patients. The Cumulated Ambulation Score (CAS) is a valid tool for evaluating these patients' basic mobility (getting in and out of bed, sit-to-stand from a chair and walking) in orthopaedic wards, and its use is recommended in Denmark for patients with hip fracture. The aims of the present study were to evaluate the feasibility of the CAS in a geriatric ward and to describe its use after hip fracture in Denmark. A total of 101 consecutive patients (with a mean age of 84.9 (standard deviation 7.2) years) were evaluated with the CAS upon admission and at discharge from a geriatric ward, while data concerning the use of the CAS after hip fracture were collected from national Danish reports. All geriatric patients could be evaluated with the CAS. A total of 41% were independent in terms of basic mobility at admission and 83% of patients at discharge from the ward (p < 0.001). Patients who were not independent in basic mobility upon admission died more often during admission or were more often not discharged to their own home than patients who were independent in basic mobility. National data from the year 2010 showed that the CAS was reported by 21 (78%) of the 27 hospitals and used in 92% of the hospitals that will be treating patients with hip fracture in the future. In geriatric wards, the CAS is a feasible tool for evaluating all patients' basic mobility, and we recommend that it be used in other settings and at all hospitals treating patients with hip fracture.
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Most patients regain prefracture basic mobility after hip fracture surgery in a fast-track programme
Article
Full-text available
  • Jun 2012
Treatment of patients with hip fracture has improved over the past decade. Still, some patients do not regain independent mobility within their primary hospital stay even if they follow a multimodal fast-track surgical programme. The aim of the present article was to examine the validity of the preliminary prefracture New Mobility Score (NMS), age and fracture type as independent predictors of in-hospital outcome after hip fracture surgery. The study comprised a total of 213 consecutive patients with a median age of 82 years who were admitted from their own home to a special hip fracture unit. Outcome variables were the regain of independency in basic mobility as evaluated by the Cumulated Ambulation Score, and discharge destination in the community. Multiple logistic regression analysis revealed that patients with a low prefracture NMS and/or an intertrochanteric fracture were 6.5 and four times more likely to not regain independency in basic mobility during admittance than patients with a high prefracture NMS level and a cervical fracture, respectively. In addition, the odds of not regaining independent mobility increased with age by 5% per year. The same three variables significantly increased the odds of patients not being discharged to their own home. Prefracture NMS, age and fracture type were confirmed as independent predictors of in-hospital outcome in patients with hip fracture who followed a multimodal rehabilitation concept.
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Regaining pre-fracture basic mobility status after hip fracture and association with post-discharge mortality and readmission - A nationwide register study in Denmark
Article
  • Mar 2019
Background: early mobilization after hip fracture (HF) is an important predictor of outcome, but knowledge of the consequences of not achieving the pre-fracture basic mobility status in acute hospital recovery is sparse. Objective: we examined whether the regain of pre-fracture basic mobility status evaluated with the cumulated ambulation score (CAS) at hospital discharge was associated with 30-day post-discharge mortality and readmission. Design: this is a population-based cohort study. Measures: using the nationwide Danish Multidisciplinary HF Database from January 2015 through December 2015, 5,147 patients 65 years or older undergoing surgery for a first-time HF were included. The pre-fracture and discharge CAS score (0-6 points with six points indicating an independent basic mobility status) were recorded. CAS was dichotomized as regained or not and entered into adjusted Cox regression overall analysis and stratified by sex, age, body mass index, Charlson comorbidity index, type of fracture, residential status and length of acute hospital stay. Outcome measures were 30-day post-discharge mortality and readmission. Results: overall mortality and readmission were 8.3% (n = 425) and 17.1% (n = 882), respectively. Mortality was 3.5% (n = 71) among patients who regained their pre-fracture CAS score compared with 11.4% (n = 354) among those who did not. Adjusted hazard ratios for 30-day mortality and readmission were 2.76 (95% confidence interval [CI] = 2.01-3.78) and 1.26 (95% CI = 1.07, 1.48), respectively, for patients who did not regain their pre-fracture CAS compared with those who did. Conclusions: we found that the loss of pre-fracture basic mobility level upon acute hospital discharge was associated with increased 30-day post-discharge mortality and readmission after a first time HF.
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Translation, inter-rater reliability, agreement, and internal consistency of the Spanish version of the cumulated ambulation score in patients after hip fracture
Article
Purpose: To translate the Cumulated Ambulation Score into Spanish, and to examine its inter-rater reliability, agreement and internal consistency. Materials and methods: Two occupational therapists independently used the Spanish version of the Cumulated Ambulation Score (three activities scored from 0-2 points) to assess 60 consecutive patients with hip fracture within the first post-surgery week at a traumatology service of a public hospital. We used linear weighted kappa (κ) statistics to determine inter-rater reliability, percent agreement to assess measurement error, Cronbach's α coefficient to establish the internal consistency, and the McNemar-Bowker test to evaluate for systematic between-rater differences. Results: The κ was ≥ 0.83 for the three individual activities and the total score, the percent agreement was ≥ 0.87, and Cronbach's α was 0.89 with no observed systematic between-rater difference. Conclusions: This study provides evidence for almost perfect inter-rater reliability, excellent internal consistency, and high percent agreement of the Spanish version of the Cumulated Ambulation Score. Due to the strong psychometric properties, and its ease of use, we suggest it be used in Spanish speaking countries to assess early basic mobility status of patients with hip fracture until independence is reached. Implications for rehabilitation The Spanish version of the Cumulated Ambulation Score is a reliable outcome measure to assess basic mobility of patients with hip fracture. We suggest the Spanish version of the Cumulated Ambulation Score be used in Spanish speaking settings to indicate small changes in basic mobility of patients with hip fracture until an independent level is reached. The Spanish version of the Cumulated Ambulation Score can be used with a high reliability by experienced and inexperienced occupational therapists, corresponding to the already established reliability when used by physicians and physiotherapists.
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Psychometric properties of the Cumulated Ambulation Score: A systematic review
Article
  • Mar 2018
  • Eur J Phys Rehabil Med
Introduction: In the geriatric population, independent mobility is a key factor in determining readiness for discharge following acute hospitalization. The Cumulated Ambulation Score (CAS) is a potentially valuable score that allows day-to-day measurements of basic mobility. The CAS was developed and validated in older patients with hip fracture as an early postoperative predictor of short-term outcome, but it is also used to assess geriatric in-patients with acute medical illness. Despite the fast- accumulating literature on the CAS, to date no systematic review synthesizing its psychometric properties has been published. Therefore, we aimed to provide a comprehensive review of the psychometric properties of the CAS, summarizing the present evidence on this measure as a basis for further research to investigate its applicability across a wider range of functional abilities and care settings. Evidence acquisition: A literature search was conducted on research articles published between 2006 and June 2016 in journals indexed by MEDLINE and Scopus databases using as search item: "Cumulated Ambulation Score"[All Fields], and selecting studies that presented a psychometric analysis of the scale. Of 49 studies identified, 17 examined the psychometric properties of the CAS. Evidence synthesis: Most papers dealt with patients after hip fracture surgery, and only 4 studies assessed the CAS psychometric characteristics also in geriatric in-patients with acute medical illness. Two versions of CAS (CAS1 and the more detailed CAS2 version) and two different methods to calculate the total score (1-day and 3-day CAS score) were used in the selected papers. Most of the papers assessed reliability and validity, using different statistics, and only one showed evidence of sensitivity to change of the score. Conclusions: This systematic review shows international interest of researchers in the CAS, despite the short time frame since its first publication in 2006. The results support the reliability, validity, and sensitivity to change of the tool. Since different versions of CAS are available and two scores are commonly used, we suggest that clinicians and researchers in the future choose the more detailed CAS2 version, already used by the large majority of studies, and report whether they used the 1- or 3-day score.
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Mobility one week after a hip fracture – Can it be predicted?
Article
  • Dec 2017
Objective: Better patient outcomes and more efficient healthcare could be achieved by predicting post hip fracture function at an early stage. This study aimed to identify independent predictors of mobility outcome one week post hip fracture surgery. Methods: All hip fracture inpatients (n=77) were included in this 6 month prospective observational cohort study. Predictor variables were obtained on the first postoperative day and included premorbid function using the New Mobility Score (NMS). Mobility outcome measures one week postoperatively included the Cumulated Ambulatory Score (CAS). Data were analysed with SPSS using binary multiple logistic regression analysis RESULTS: Patients who fell outdoors (OR 3.848; 95% CI, 1.053-14.061), had no delay to surgery (OR 5.472; 95% CI, 1.073-27.907) and had high pre-fracture function (OR3.366; 95% CI, 1.042-10.879) were predicted to achieve independent mobility (CAS = 6) one week postoperatively. Conclusion: Fall location, time to surgery and baseline function predict independent mobility one week after hip fracture, and can be used for early rehabilitation stratification. The NMS and CAS are recommended as standardised hip fracture clinical measures. Orthogeriatric and physiotherapy service initiatives may improve early functional outcome.
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High intertester-reliability of the Cumulated Ambulation Score for the evaluation of basic mobility in patients with hip fracture
Article
  • Nov 2009
  • CLIN REHABIL
To examine the intertester reliability of the three activities of the Cumulated Ambulation Score (CAS) and the total CAS, and to define limits for the smallest change in basic mobility that indicates a real change in patients with hip fracture. An intertester reliability study. An acute 20-bed orthopaedic hip fracture unit. Fifty consecutive patients with a median age of 83 (25-75% quartile, 68-86) years. The CAS, which describes the patient's independency in three activities - (1) getting in and out of bed, (2) sit to stand from a chair, and (3) walking ability - was assessed by two independent physiotherapists at postoperative median day 3. Each activity was assessed on a three-point ordinal scale from 0 (not able to) to 2 (independent of human assistance). The cumulated score for each activity provides a total CAS from 0 to 6, with 6 indicating independent ambulation. Reliability was evaluated using weighted kappa statistics, the standard error of measurement (SEM) and the smallest real difference (SRD). The kappa coefficient, the SEM and the SRD in the three activities and the total CAS were >or=0.92, <or=0.20 and <or=0.55 CAS points, respectively. The intertester reliability of the CAS is very high, and a change of more than 0.20 and 0.55 CAS points for the total CAS indicates a real change in basic mobility, at group level and for an individual patient, respectively.
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Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: The cumulated ambulation score
Article
  • Aug 2006
To validate the cumulated ambulation score as an early postoperative predictor of short-term outcome in hip fracture patients. Prospective, descriptive study. An orthopaedic hip fracture unit in a university hospital. Four hundred and twenty-six consecutive hip fracture patients with an independent walking function admitted from their own home. Rehabilitation followed a well-defined multimodal rehabilitation regimen and discharge criteria. Admission tests with a new mobility score to assess prefracture functional mobility and a short mental score for cognitive dysfunction were performed. On the first three postoperative days patients were assessed with the cumulated ambulation score consisting of a cumulated assessment of simple ambulation characteristics with a score from 0 to 18 (fully mobile). The three assessments were correlated to short-term outcome parameters. The cumulated ambulation score was a highly significant predictor for length of hospitalization, time to discharge status, 30-day mortality and postoperative medical complications (P < 0.001 for all). The cumulated ambulation score was superior in its association with all postoperative outcome parameters to both the New Mobility Score and the mental score. A cumulated ambulation score of > or = 10 correlated with a 99% survival at one month and 93% discharge to own home. The cumulated ambulation score is a potentially valuable score for early prediction of short-term postoperative outcome after hip fracture surgery.
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Linked Research

Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: The cumulated ambulation score
Article
August 2006
Nicolai Bang Foss · Morten Tange Kristensen · Henrik Kehlet