ORIGINAL

Translation into Brazilian Portuguese, cross-cultural

adaptation, reliability and validation of the Functional
Ambulation Classification for the categorization of ambulation
following a stroke in a clinical setting
Cíntia Elord, Fernanda I. Corrêa, Gabriela S. Pereira, Soraia M. Silva, João C. Corrêa

Introduction. The Functional Ambulation Classification (FAC) is the only scale that classifies the gait of individuals with University Nove de Julho.
São Paulo, SP, Brazil.
multiple sclerosis and stroke victims into ambulation categories. However, the FAC is only available in English and studies
conducted in Brazil have used the FAC without an adequate translation and analysis of its measurement properties. Corresponding author:
Cíntia Elord Júlio MD. University
Aim. To translate, cross-culturally adapt the FAC to Brazilian Portuguese, test its reliability and concurrent validity on stroke Nove de Julho. Rua Vergueiro,
survivors. 235/249. Liberdade. CP 01504-001.
São Paulo, SP, Brazil.
Patients and methods. The translation and cross-cultural adaptation involved six steps. Inter-observer reliability was
E-mail:
tested with five physiotherapists who watched videos of the gait of the stroke survivors and watched a second time after at cintia_elord@hotmail.com
least one week for the determination of intra-observer reliability. Concurrent validity was determined by correlating the
FAC with the result of the 10-meter Walk Test (10mWT). Note:
Preliminary results presented at the
Results. Intra-observer reliability ranged from kappa 0.680 to 0.952 (p = 0.001) and inter-observer reliability ranged Fifth International Conference on
Health, July 2018, 10-13, University
from kappa 0.517 to 0.794 (p = 0.001). The correlation between the FAC and 10mWT was rs = 0.771 (p = 0.001). of Minho, Braga, Portugal.
Conclusion. The translation, cross-cultural adaptation and measurement properties demonstrated that the FAC is a valid,
Acknowledgments:
reliable clinical measure for the categorization of ambulation in the Brazilian population of stroke survivors in a clinical Coordination for the Advancement
setting. of Higher Education Personnel
(CAPES) and University Nove de
Key words. Functional Ambulation Classification. Reproducibility of results. Stroke. Translations. Validation studies. Walking. Julho.

Accepted:
10.02.20.

Introduction ity tests, functional scales, and kinetic and kine- How to cite this paper:
Elord C, Corrêa FI, Pereira GS,
matic analyses. Such assessment tools are complex, Silva SM, Corrêa JC. Translation
According to the World Health Organization, stroke time consuming, costly and often difficult to en- into Brazilian Portuguese, cross-
is considered the second major cause of death in counter in outpatient clinical practice. Moreover, cultural adaptation, reliability
and validation of the Functional
the world and the third major cause of functional the administration of these instruments requires Ambulation Classification for the
disability [1]. It is estimated that 25-74% of the 50 training on the part of the therapist. categorization of ambulation
following a stroke in a clinical setting.
million stroke survivors throughout the world are Therefore, it is important to have a low-cost, Rev Neurol 2020; 70: 365-71. doi:
dependent on others regarding activities of daily simple, fast, accessible method for evaluating in- 10.33588/rn.7010.2019400.
living [2,3]. dividuals with different degrees of ambulation ca- Versión española disponible
Motor impairment is highly prevalent following pacity. The Functional Ambulation Classification en www.neurologia.com
a stroke. Affected individuals have functional limi- (FAC) was developed by Holden et al in 1984 [7]
© 2020 Revista de Neurología
tations that can restrict their activities and social and has been widely used as an assessment tool for
participation [4,5], with locomotion is one of the measuring walking capacity. This predictive, evalu-
most affected aspects [6]. According to the con- ative, discriminative scale can be used in a small
cepts of the International Classification of Func- environment, which facilitates its use in clinical
tioning, Disability and Health (ICF), locomotion is practice.
defined as the capacity to move effectively through The FAC distinguishes six levels of ambulation
the surrounding environment and is classified in according to the amount of physical support re-
the activity domain [6]. As an important functional quired. During the test, ambulation capacity is
outcome, diverse assessment tools have been devel- evaluated on flat and uneven surfaces for at least
oped for the analysis of human locomotion, such as three meters as well as walking on ramps and going
the analysis of spatiotemporal variables, gait veloc- up and down stairs. Previous studies have demon-

www.neurologia.com Rev Neurol 2020; 70 (10): 365-371 365

C. Elord, et al

strated that the FAC is correlated with spatiotem- following the guidelines proposed by Beaton et al
poral gait variables [7-9]. [15]. Sixty-one individuals were involved in the
Specifically regarding the concepts addressed phase for the determination of reliability and con-
by the ICF, a recent study reports that the FAC is current validity, as proposed the guidelines, who
correlated with persistent disability regarding ac- suggest evaluating a minimum of 50 individuals for
tivities of daily living that limits the independence an adequate analysis of reliability [16,17].
of stroke survivors [10]. The FAC also has adequate The sample was composed of stroke survivors
reliability and statistically significant concurrent recruited from the physical therapy clinic of Uni-
validity and reproducibility [9] and serves as a versity Nove de Julho. To be included, the individu-
means of following up the progression of gait in re- als needed to have a diagnosis of stroke in the
habilitation processes. chronic phase (> 6 months) [18] and preserved cog-
The FAC is the only scale that classifies the gait nition, evaluated using the Mini Mental State Ex-
of individuals with multiple sclerosis and stroke amination (MMSE), with cutoff points based on
victims into ambulation categories [7]. In the study schooling: ≥ 13 points for illiterate individuals; 18
by Mudge and Stott [11], one of the objectives was points for those with low to mid-level schooling;
to investigate the frequency of use of 61 gait assess- and 26 for those with high schooling [19]. Individu-
ment tools (clinical and laboratory methods) on als with orthopedic or neurological conditions oth-
stroke victims. The authors found that the FAC was er than stroke that altered gait and those with no
the sixth most used method in general and the motor impairment were excluded from the study.
fourth when considering only clinical methods. This study received approval from the Human
However, the FAC is only available in English. Research Ethics Committee of University Nove de
Moreover, its psychometric properties (concurrent Julho in São Paulo, Brazil (certificate no. 79057817.4.
validity, predictive validity, intra-observer and in- 0000.5511). All participants and legal guardians of
ter-observer reliability) for stroke survivors have the volunteers received clarifications regarding the
only been tested in the acute and sub-acute phases objectives and procedures of the study and those
of the rehabilitation process in the hospital setting who agreed to participate signed a statement of in-
[9], with no determination of these properties in formed consent. An attempt was made to contact
the clinical setting. the author of the scale to request authorization for
Studies conducted in Brazil have used the FAC the translation, cross-sectional adaptation and
without an adequate translation and analysis of its analysis of the measurement properties, but we re-
measurement properties [12-14]. Several factors can ceived no response. However, as the scale is in the
affect the administration of a scale, such as the cul- public domain and widely used in clinical practice,
ture of the target population, the reliability, repro- the decision was made to proceed with the study,
ducibility and validation of the measure, the training considering its clinical relevance.
and skill of the examiner, and the functional status
of the individual being evaluated. In the case of the Translation and cross-cultural adaptation
FAC, issues such as its application in the clinical set-
ting and cultural issues, such as the type of irregular The translation and cross-cultural adaptation of the
ground and unit of measurement regarding the dis- original English-language version of the FAC [8] to
tance travelled during the test, can exert an influ- Brazilian Portuguese was performed following the
ence on the results in different populations. guidelines proposed by Beaton et al [15], which
Therefore, the aim of the present study was to consists of six stages:
translate and cross-culturally adapt the FAC to Bra- – Stage 1. The first stage consists of performing two
zilian Portuguese and test its measurement proper- independent translations from the language of
ties (reliability and validity) in a clinical setting. origin to the target language (English to Brazilian
Portuguese). For such, two bilingual translators
whose native language was Portuguese perfor-
Patients and methods med the translations independently. translator 1
(T1) was aware of the concepts of the question-
Study design naire and translator 2 (T2) was ‘naïve’ (unaware
of the concepts of the questionnaire) [15].
A methodological cross-sectional study was con- – Stage 2. The second stage consisted of the syn-
ducted. Forty individuals were involved during the thesis of the two translations into a single, com-
translation and cross-cultural evaluation process, bined translation (T-12), forming a translated ver-

366 www.neurologia.com Rev Neurol 2020; 70 (10): 365-371

 Translation into Brazilian Portuguese of the Functional Ambulation Classification

sion based on the two previous translations (T1 followed for the analysis of intra-observer and in-
and T2) and the original version of the question- ter-observer reliability. For, such 61 individuals
naire [15]. were recruited. Each participant was video record-
– Stage 3. The third stage consisted of back-trans- ed walking. The video recording followed the same
lating the T-12 version into the language of ori- specifications used in the article on the develop-
gin (English) to verify the validity, point out ment and validation of the original version of the
gross or conceptual mistakes and determine FAC.
whether the translated version adequately reflec- For the intra-observer analysis, five physiothera-
ted the original version. Two back-translations pists with at least five years of experience in neuro-
(BT1 and BT2) were performed by two indepen- logical rehabilitation analyzed the videos indepen-
dent translators whose native language was En- dently and classified the patients.
glish. Neither of these translators was aware of After at least seven days, the examiners analyzed
the concepts of the questionnaire [15]. the videos a second time in a random order to avoid
– Stage 4. In this stage, all translations (T1, T2, the effect of memorization [7,9]. The classifications
T12, BT1 and BT2) and reports explaining all of the examiners were compared for the determina-
the decisions made during the previous stages of tion of inter-observer agreement.
the translation process were submitted to a
board of specialists composed of all health pro- Concurrent validity
fessionals and researchers who were involved in
the translation and cross-cultural adaptation pro- The same 61 individuals recruited for the reliability
cess. The committee made decisions to ensure analysis performed the 10-meter walk test (10mWT),
semantic, idiomatic, experiential and conceptual which is significantly correlated with measures of
equivalence, giving rise to the pre-final version gait capacity. Moreover, gait speed tests are widely
of the translated scale to be tested [15]. used in both rehabilitation programs and research
– Stage 5. The pre-final version of the scale was tes- and are indicators of progress in gait performance
ted. The classification of the ambulation of each [9,20,21].
patient based on the FAC levels was performed
using videos of individual patients (front and Statistical analysis
side views). When the participant was capable, a
three-meter walk on a level surface and another The Kolmogorov-Smirnov test was used to deter-
on a non-level surface (mats with different den- mine the normality of the data. Descriptive statis-
sities) were also recorded. Also when possible, tics were used for the characterization of the sam-
the volunteer was recorded going up and down ple and distribution of the data. Parametric vari-
at least seven steps and going up and down a ables were expressed as mean ± standard deviation
ramp with a 30° inclination or more. The pa- values, nonparametric variables were expressed as
tients could use braces, the handrail on the stairs median and interquartile range and categorical vari-
and ramp and receive assistance or supervision ables were expressed as frequencies.
from the physiotherapists when necessary. Two The weighted quadratic kappa statistic was used
physiotherapists with at least five years of expe- for the analysis of intra-observer and inter-observer
rience in adult neurological rehabilitation were reliability, which is considered the best method for
recruited separately to watch the videos of 40 the determination of agreement between examin-
stroke survivors and classify each individual ba- ers and/or evaluations. Kappa coefficients were in-
sed on the FAC levels. At the end of the classifi- terpreted as follows: κ ≤ 0.20 = weak agreement;
cation, the physiotherapists reported their do- 0.21 to 0.40 = acceptable agreement; 0.41 to 0.60 =
ubts regarding the scale [15]. moderate agreement; 0.61 to 0.80 = good agree-
– Stage 6. The final stage involved the presentation ment and > 0.80 = excellent agreement. The level of
of all reports to the expert committee that ac- significance was set to 5% (p < 0.05) [22].
companied the translation process. The commit- Spearman’s correlation coefficient (rs) was used
tee verified that the reports reflected the entire for the analysis of concurrent validity (correlation
process and that all stages had been fulfilled [15]. between FAC and 10mWT). The coefficients were
interpreted as follows: 0.10 to 0.39 = weak correla-
Intra-observer and inter-observer reliability tion; 0.40 to 0.69 = moderate correlation; and > 0.70
= strong correlation [23]. The SPSS v. 22 was used
The guidelines proposed by Terwee et al [16] were for the statistical analysis.

www.neurologia.com Rev Neurol 2020; 70 (10): 365-371 367

C. Elord, et al

Table I. Changes in translation and cross-cultural adaptation process. Table II. Demographic and clinical characteristics of participants in re-
liability study (n = 61).
First translation Final version
Men 37 (60.7%)
FAC level 2 ‘Requer ajuda de uma pessoa durante a ‘Requer ajuda de uma pessoa durante Sex
deambulação em superfícies niveladas’ a deambulação em superfícies niveladas Women 24 (39.3%)
para prevenir quedas’
Age (years) a 57.3 ± 12.7
FAC level 3 ‘Requer ajuda de uma pessoa durante a ‘Requer ajuda de uma pessoa durante a
deambulação em superfícies niveladas’ deambulação em superfícies niveladas Time since stroke (months) b 24 (12-54)
‘O contato manual é contínuo ou para prevenir quedas’
intermitente leve para ajudar no equilíbrio ‘O contato manual é leve, contínuo ou Right 30 (49.2%)
ou na coordenação’ intermitente para ajudar no equilíbrio
ou na coordenação’ Affected side of body Left 30 (49.2%)

FAC level 4 ‘A deambulação ocorre em superfícies de ‘A deambulação ocorre em superfície do Both 1 (1.6%)
mesmo nível sem ajuda de outra pessoa’ mesmo nível sem ajuda de outra pessoa,
‘Requer uma pessoa do lado por causa mas por segurança, requer uma pessoa Ischemic 46 (75.4%)
do mau julgamento, status cardíaco ao lado por causa do comprometimento Type of stroke
questionável, ou da necessidade de da capacidade de decisão, status cardíaco Hemorrhagic 15 (24.6%)
verbalização para completar a tarefa’ questionável ou da necessidade de
verbalização para completar a tarefa’ Schooling (years) b 12 (4.5-12)

FAC level 5 ‘to ‘Subir escadas’ ‘Deambular em escadas’ Mini Mental State Examination (points) b 25 (22-27.5)
negotiate stairs’
a Mean ± standard deviation; b Median (interquartile range).
Non-level ‘Sujeira’ ‘Terra’
surface: ‘dirt’

The words ‘snow’ and ‘ice’ (literally ‘neve’ and ‘gelo’) were adapted to ‘colchonete’. FAC: Functional Ambulation Intra-observer reliability of the five examiners
Classification.
ranged from good to excellent, whereas inter-ob-
server reliability among the five examiners ranged
from moderate to good (Table II).
Results
Concurrent validity
Translation and cross-cultural adaptation
The correlation between the FAC and 10mWT was
Divergences were found between the two translators positive, strong and statistically significant (rs = 0.771;
(T1 and T2) and the synthesis stage (T12) (Table I). p = 0.001).
In the fifth stage, the pre-final version was ad-
ministered to forty stroke survivors and two phys-
iotherapists individually performed the classifica- Discussion
tion of the ambulation of each participant. The
physiotherapists had no questions regarding the in- During translation process, the definition of some
terpretation of the scale. FAC levels was the object of discussion. For exam-
Therefore, the final version was concluded in the ple, on levels 2 and 3, the version on the first trans-
sixth stage (Figure). lation was ‘Requer ajuda de uma pessoa durante a
deambulação em superficies niveladas’ [Requires
Reliabilty help from a person during ambulation on level sur-
faces]. After discussion with the expert committee,
Seventy-three individuals were recruited for the re- however, the decision was made to use ‘Requer aju-
liability analysis. However, four were excluded for da de uma pessoa durante a deambulação em su-
cognitive deficit (< 11 points on the MMSE), six for perficies niveladas para prevenir quedas’ [Requires
orthopedic conditions that affected walking ability help from a person during ambulation on level sur-
and two for having suffered a stroke less than six faces to prevent falls], as it was necessary to clarify
months earlier. Thus, 61 individuals participated in that the patient is accompanied throughout the en-
this analysis. The demographic and clinical charac- tire evaluation as a safety precaution to avoid pos-
teristics of the sample are listed in table II. sible complications, such as a fall.

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 Translation into Brazilian Portuguese of the Functional Ambulation Classification

Table III. Intra-observer and inter-observer reliability. Figure. Translated version of Functional Ambulation Classification (instruction manual and scale).

κ p

Intra-observer 1 (J.A) 0.952 < 0.001

Intra-observer 2 (P.F) 0.708 < 0.001

Intra-observer 3 (D.B) 0.816 < 0.001

Intra-observer 4 (R.B) 0.680 < 0.001

Intra-observer 5 (G.C) 0.876 < 0.001

Inter-observers 1 and 2 0.699 < 0.001

Inter-observers 1 and 3 0.772 < 0.001

Inter-observers 1 and 4 0.729 < 0.001

Inter-observers 1 and 5 0.568 < 0.001

Inter-observers 2 and 3 0.704 < 0.001

Inter-observers 2 and 4 0.616 < 0.001

Inter-observers 2 and 5 0.517 < 0.001

Inter-observers 3 and 4 0.794 < 0.001

Inter-observers 3 and 5 0.747 < 0.001

Inter-observers 4 and 5 0.727 < 0.001

On level 3, the second part of the first transla-

tion was: ‘O contato manual é continuo ou intermi-
tente leve para ajudar no equilíbrio ou na coordena-
ção’ [Manual contact is a continuous or intermit-
tent light touch to help balance or coordination]. In
the final version, this was changed to ‘O contato
manual é leve, continuo ou intermitente para aju-
dar no equilíbrio ou na coordenação’ [Manual con-
tact is a light, continuous or intermittent to help
balance or coordination], which would be easier for
the examiner to understand when classifying indi-
viduals who need light contact during ambulation,
whether for a particular moment or throughout the
entire evaluation.
In the description of level 4, the first translation
was: ‘A deambulação ocorre em superf ícies de mes-
mo nível sem ajuda de outra pessoa’ [Ambulation
occurs on surfaces of the same level without help
from another person] and ‘Requer uma pessoa do
lado por causa do mau julgamento, status cardiac
questionável, ou da necessidade de verbalização
para completar a tarefa’ [Requires a person along-

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C. Elord, et al

side due to poor judgment, questionable heart sta- examiners was excellent (κ = 0.905). These differ-
tus or the need for verbalization to complete the ences may be due to the analysis of videos for the
task]. In the final version, these two descriptions evaluation of reliability. Although the reference for
were united: ‘A deambulação ocorre em superf ície this technique was Mehrholz et al [9], it may not be
de mesmo nível sem ajuda de outra pessoa, mas, por the most reliable method, since it is difficult to
segurança, requer uma pessoa ao lado por causa do gauge the amount of physical support the patient
comprometimento da capacidade de decisão, status requires on levels 2 (manual contact is continuous
cardiac questionável, ou da necessidade de verbal- to support and/or maintain balance or help coordi-
ização para completar a tarefa’ [Ambulation occurs nation) and 3 (continuous or intermittent light touch
on a surface of the same level without help from an- to assist in balance or coordination) through video
other person, but, for safety, requires a person images, which may have influenced the perception
alongside due to the impairment of the decision- of the examiners during the classification.
making capacity, questionable heart status or the Mehrholz et al [9] tested predictive validity of
need for verbalization to complete the task], as a the FAC and concluded that this scale is sensitive
way to facilitate the examiner’s understanding and and specific enough to predict gait performance in
clarify that, on this level, the individual will not have the community. In the present study, a significant
contact from another person during ambulation on association was found between the classification of
a level surface, but rather supervision (a person who ambulation given by the FAC and the gait speed cat-
accompanies the patient during the evaluation as a egories, considering the performance on the 10mWT
safety precaution due to a compromised decision- test for the assessment of concurrent validity.
making capacity, questionable heart status or the The present study demonstrates that the FAC can
need for verbalization to complete the task). be used in clinical practice and research on rehabili-
On level 5, the first translation for ‘negotiating tation for the evaluation and follow up of patients in
stairs’ was ‘subir escadas’ [going up stairs] and was the chronic phase of a stroke. Brief training is need-
changed to ‘deambular em escadas’ [ambulating on ed to familiarize the examiners with the scale and
stairs] in the final version, since the individual must one should bear in mind the compensations stroke
go up and down at least seven steps. survivors can develop. Nonetheless, the FAC is a
Regarding the description of uneven ground in valid, reliable assessment tool for the evaluation of
the user’s manual of the FAC, the first translation of this specific population. The intra-examiner and in-
the word ‘dirt’ was ‘sujeira’ [filth], but the expert ter-examiner data should be interpreted with cau-
panel decided that ‘terra’ [unpaved ground] was tion considering the variations found in the reliabil-
more appropriate and more easily standardized for ity analysis. However, the results were acceptable.
the evaluation of outdoor environments, since su- The present findings are relevant to the field of
jeira is a broad, non-specific term, whereas terra is rehabilitation, demonstrating that the translation
easier to be reproduced. and cross-cultural adaptation were successful, en-
In the cross-cultural adaptation process, the ma- abling the use of the FAC on the Brazilian popula-
jor change discussed by the expert committee regard- tion. Moreover, the measurement properties (reli-
ed uneven ground, which the original version de- ability and validation) were similar to those found
scribes as grass, gravel, dirt, snow and ice. However, for the original English-language version of the
due to climatic and cultural characteristics in Brazil, scale. These findings contribute to the standardized
the decision was made to standardize uneven ground use of the FAC adapted to the Brazilian population
using an unstable surface, such as a mat, rather than in a clinical setting.
snow and ice. A mat is a low-cost instrument that is
easy to handle and can be used in the clinical set-
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Traducción al portugués brasileño, adaptación transcultural, fiabilidad y validación de la Functional

Ambulation Classification para la categorización de deambulación postictus en un entorno clínico

Introducción. La Functional Ambulation Classification (FAC) es la única escala que clasifica la marcha de individuos con es-
clerosis múltiple e ictus en categorías de deambulación. Sin embargo, la FAC sólo está disponible en la versión en inglés y
los estudios realizados en Brasil la han utilizado sin una traducción y análisis adecuados de propiedades psicométricas.
Objetivo. Traducir y adaptar culturalmente la FAC para el portugués brasileño y probar su fiabilidad y validez concurrente
en individuos afectados por ictus.
Pacientes y métodos. La traducción y la adaptación transcultural implicaron seis pasos. La fiabilidad interevaluador se
probó con cinco fisioterapeutas que vieron vídeos de la marcha de las personas afectadas por ictus y, después de un inter-
valo mínimo de una semana, los vieron por segunda vez para determinar la fiabilidad intraevaluador. La validez concu-
rrente se determinó correlacionando la FAC con el resultado de la prueba de marcha de 10 metros (PM10m).
Resultados. La fiabilidad intraevaluador varió entre un valor kappa de 0,68-0,95 (p = 0,001), y la fiabilidad interevalua-
dor, un valor kappa de 0,517-0,794 (p = 0,001). La correlación entre la FAC y la PM10m fue rs = 0,771 (p = 0,001).
Conclusión. La traducción, la adaptación transcultural y el análisis de las propiedades psicométricas demostraron que la
FAC es una medida clínica válida y fiable para clasificar la deambulación de los individuos brasileños afectados por ictus en
un entorno clínico.
Palabras clave. Estudios de validación. Functional Ambulation Classification. Ictus. Marcha. Reproducibilidad de los resul-
tados. Traducción.

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