assessing the degree of walking independence among inpatients is one of the important roles 
 of physical therapists .
overestimation of a patient s ability to walk can result in falls , 
 whereas underestimation can lead to disuse syndrome due to a decrease in physical activity . 

preliminary research investigating cutoff values for parameters of walking independence in 
 patients with stroke has reported the efficacy of physical performance examinations such as 
 assessments of walking speed1 .
however , 
 preliminary studies often exclude stroke patients with cognitive disorders in order to 
 increase the rate of identifying patients with walking independence and improve the 
 reliability of examinations .
stroke patients with cognitive disorders are often examined in 
 the clinical setting2 , 3 , where the cutoff value for excluding stroke patients with cognitive 
 disorders in preliminary research can not be used to evaluate those with cognitive disorders . 
 as a result ,
walking independence in stroke patients with cognitive disorders is presently 
 being assessed on the basis of subjective assessment by a physical therapist , and no clear 
 protocol exists regarding this issue .
therefore , determination of the cutoff values for 
 parameters of walking independence in patients with stroke and cognitive disorders is 
 necessary .
but there have been few studies so far that have evaluated the reference values 
 associated with walking independence in stroke patients with a cognitive impairment4 .
the purpose of this study was to determine the threshold for classifying walking 
 independence in stroke patients with and without cognitive disorders .
the subjects included 130 patients with initial stroke hemiplegia admitted to the 
 rehabilitation unit at koseinenkin kochi rehabilitation hospital in japan from april 2007 
 through december 2012 .
patients were eligible for inclusion if they met the following 
 criteria : ( 1 ) age 40  years ; ( 2 ) more than one month had passed since stroke onset ; ( 3 ) 
 ability to complete the mini - mental state examination ( mmse ) ( total score : > 1)5 ; ( 4 ) first stroke , i.e. , no previous history 
 of stroke ; ( 5 ) ability to walk a minimum of 10  m using mobility aids such as a cane or a 
 brace ; and ( 6 ) a history of independent activities of daily living before the onset of 
 stroke .
we investigated basic information in addition to walking status , physical function , and 
 performance of the patients during physical therapy based on their medical records .
the 
 survey items included gender , age , side of paralysis , functional independence measure ( fim ) 
 for walking6 , mmse score , lower limb 
 brunnstrom stage7 , one - leg standing time 
 on the paralytic side , one - leg standing time on the non - paralytic side , and 10-m walking 
 speed .
for measuring the one - leg standing time , we measured the duration for which the patients 
 were able to maintain one leg in the air without touching the floor8 , 9 .
we excluded the 
 measurements of one - leg standing time in the following cases : swaying while balancing , using 
 the arms for balancing , hopping to maintain balance , and putting the foot down on the floor . 

the maximum measurement time was 60 s. the time before falling over was measured , and the 
 maximum time of two repetitions was determined .
the 10-m walking speed was used to quantify the ambulatory status in terms of a fast gait 
 speed10 .
the time from the starting line to a line marking 10  m was measured using a 
 stopwatch .
the participants performed two trials at each speed , and the calculated walking 
 speed ( m / min ) was recorded .
we conducted the statistical analysis according to the presence or absence of cognitive 
 disorders .
we classified the patients with mmse scores of 24 points into the high - score 
 group and those with mmse scores of 23 points into the low - score group11 .
the mmse 
 measures various domains of cognitive functioning including memory , orientation to place and 
 time , naming , reading , visuospatial orientation / construction ability , writing , and the 
 ability to follow a 3-stage command .
it is difficult to diagnose inattention and 
 accomplishment dysfunction in patients with stroke using the mmse .
therefore , patients with 
 a deteriorated cognitive function may have been included in the high - score group .
the statistical analysis was conducted to investigate the main factors associated with 
 walking independence using a logistic regression analysis .
the cutoff levels for the main 
 factors used to distinguish walking independence were determined according to the 
 compatibility of the regression models using the area under the curve ( auc ) of the receiver 
 operating characteristic ( roc ) curve and the youden index12 .
we calculated test diagnostics ( sensitivity , specificity , positive 
 predictive value , negative predictive value , positive likelihood ratio , and negative 
 likelihood ratio ) for a series of cutoff points .
subjects were included after obtaining informed consent , and the study protocol was 
 approved by the ethics committee of seirei christopher university .
the high - score group included 69 subjects ( 53.1% ) , and the low - score group included 61 
 subjects ( 46.9% ) ( table 1table 1.characteristics of the high - score group and low - score groupvariablewalking statusdependentindependenthigh - score groupno . of patients2940age ( years)72.4 ( 11.8 ) 68.9 ( 11.3)female ( % ) 62.140.0left - sided hemiplegia 
 ( % ) 58.652.5time after stroke onset to 
 measurement ( m)3.5 ( 2.4)2.4 ( 2.2)brunnstrom stage ( 16)0.0.11.3.10.50.0.0.2.5.33*one - leg standing time on the 
 paralytic side(s)0.4 ( 1.3)10.4 ( 15.4)*one - leg standing time on the 
 non - paralytic side(s)2.3 ( 5.3)13.6 ( 18.2)*10-m walking speed 
 ( m / min)23.9 ( 21.5)82.2 ( 47.5)*low - score groupno . of patients4021age ( years)79.4 ( 6.9)76.4 ( 7.9)female ( % ) 62.533.3*left - sided hemiplegia 
 ( % ) 50.019.0*time after stroke onset to 
 measurement ( m)3.1 ( 0.9)2.3 ( 0.7)*brunnstrom stage ( 16)0.0.3.6.16.150.0.0.1.1.19*one - leg standing time on the 
 paralytic side(s)0.38 ( 0.74)3.8 ( 3.5)*one - leg standing time on the 
 non - paralytic side(s)0.9 ( 1.7)4.8 ( 3.3)*10-m walking speed 
 ( m / min)24.5 ( 17.6)71.7 ( 21.0)**p<0.05
the incidence of walking independence was 40 of 69 
 ( 58.0% ) patients with maintained cognitive function . according to the logistic regression 
 analysis ,
the main factor associated with walking independence in the high - score group was 
 the 10-m walking speed ( odds ratio , 1.076 ; 95% confidence interval , 1.0421.111 ) ( table 2table 2.results of the logistic regression analysisvariablebodds ratio95% confidence intervalhigh - score group10-m walking speed*0.0731.076
1.0421.111constant3.044identification rate87.0low - score group10-m walking speed*0.1071.1131.0451.186one - leg standing time on the 
 non - paralytic side0.4951.6400.9692.777constant7.146identification rate88.5dependent variable : walking status ( dependent , 0 ; independent , 1 ) independent 
 variable : 10-m walking speed and one - leg standing time on the non - paralytic side . 

odds ratio for a 1-second increase ) . as for the compatibility of the regression models of the roc curve , the auc 
 was 0.921 . using a cutoff level for the 10-m walking speed of 41.4 m / min resulted in a 
 sensitivity of 87.5% , specificity of 86.2% , positive predictive value of 90.0% , negative 
 predictive value of 83.3% , positive likelihood ratio of 6.3 , and negative likelihood ratio 
 of 0.2 ( fig .
1 . the auc was 0.921 in the high - score group . using a cutoff level for the 10-m walking 
 speed of 41.4
the 
 auc was 0.953 in the low - score group . using a cutoff level for the 10-m walking speed 
 of 48.0 m / min resulted in a sensitivity of 95.2% and a specificity of 87.5% . ) .
mann - whitney test dependent variable : walking status ( dependent , 0 ; independent , 1 ) independent 
 variable : 10-m walking speed and one - leg standing time on the non - paralytic side . 
 * odds ratio for a 1 m / min increase .
odds ratio for a 1-second increase the auc was 0.921 in the high - score group . using a cutoff level for the 10-m walking 
 speed of 41.4
the 
 auc was 0.953 in the low - score group . using a cutoff level for the 10-m walking speed 
 of 48.0 m / min resulted in a sensitivity of 95.2% and a specificity of 87.5% .
the incidence of walking independence in the low - score group was 21 of 61 ( 34.4% ) patients 
 with impaired cognitive function . according to the logistic regression analysis ,
the main 
 factor associated with walking independence in the low - score group was the 10-m walking 
 speed ( odds ratio , 1.113 ; 95% confidence interval , 1.0451.186 ) ( table 2 ) .
with regard to the compatibility of the regression 
 models of the roc curve , the auc was 0.953 . using a cutoff level for the 10-m walking speed 
 of 48.0 m / min resulted in a sensitivity of 95.2% , specificity of 87.5% , positive predictive 
 value of 89.5% , negative predictive value of 80.6% , positive likelihood ratio of 7.6 , and 
 negative likelihood ratio of 0.1 ( fig .
the patients in the low - score group based on the examinations for the presence of cognitive 
 disorders accounted for 50% of all subjects .
the subjects of this study included patients 
 with initial stroke hemiplegia who had been treated in the rehabilitation unit at 
 koseinenkin kochi rehabilitation hospital . on the basis of preliminary research
it has become clear that patients with a history of several 
 strokes can not be evaluated using the cutoff values employed in preliminary research that 
 excludes patients with cognitive disorders .
the results of this study showed that the primary factor associated with walking 
 independence in the high - score group of stroke patients was the 10-m walking time .
preliminary 
 studies have found that the walking speed can be used to classify patients according to the 
 degree of walking independence in the community15 .
investigated the cutoff value of walking speed 
 for community walkers with stroke and reported a positive predictive value of 93% and a 
 negative predictive value of 57% for a cutoff value of 0.66 m / s , with an auc of 0.8515 .
it is clear from these results that there 
 is a standard value for classifying walking independence with walking speed .
this study 
 demonstrated the 10-m walking speed to be an effective parameter for identifying walking 
 independence in the hospital . in the present study ,
the main factor associated with walking independence in the low - score 
 group of stroke patients was the 10-m walking time .
therefore , the 10-m walking speed is an 
 effective parameter for classifying stroke patients with cognitive disorders according to 
 the degree of walking independence in the hospital .
examinations using complicated 
 instructions decrease the reliability of assessments of physical function in patients with 
 deteriorated cognitive function .
it is therefore necessary to use simple examinations in 
 patients with cognitive function disorders .
we used the 10-m maximal walking speed to 
 examine the walking independence status in this study . cognitive impairment in patients with 
 stroke results in significant inattention and accomplishment dysfunction16 .
patients with cognitive function 
 disorders have difficulty in maintaining attention during long examinations and performing 
 the required movements in assessments with complicated instructions17 .
measuring the 10-m walking speed is an effective 
 laboratory procedure due to its simplicity and allows for the determination of walking 
 independence in patients evaluated with the mmse .
 [ purpose ] the aim of this study was to determine the threshold for classifying walking 
 independence in stroke patients with and without cognitive disorders . [ subjects ] the 
 subjects were 130 patients with initial stroke hemiplegia . [ methods ] the following factors 
 were analyzed for associations with walking independence : brunnstrom stage , one - leg 
 standing time on the paralytic side , one - leg standing time on the non - paralytic side , and 
 10-m walking speed . 
 we classified the patients with mini - mental state examination ( mmse ) 
 scores 24 points into the high - score group and those with mmse scores of 23 points into 
 the low - score group and examined the main factors and cutoff values associated with 
 walking independence in each group . 
 [ results ] the high - score group included 69 subjects 
 ( 53.1% ) , and the low - score group included 61 subjects ( 46.9% ) . 
 the primary factor 
 associated with high mmse scores among the stroke patients was the 10-m walking time . 
 using a cutoff level for the 10-m walking speed of 41.4 m / min resulted in a positive 
 likelihood ratio of 6.3 . 
 the primary factor associated with low mmse scores among the 
 stroke patients was the 10-m walking time . 
 using a cutoff level for the 10-m walking speed 
 of 48.0 m / min resulted in a positive likelihood ratio of 7.6 . 
 [ conclusion ] the cutoff 
 value for the 10-m walking speed can be used to evaluate walking independence in patients 
 with stroke among patients with high or low mmse scores . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION