SPINE Volume 35, Number 1, pp 3235
2009, Lippincott Williams & Wilkins
A New Performance Test for Cervical Myelopathy
The Triangle Step Test
Hisanori Mihara, MD, Soichi Kondo, MD, Atsushi Murata, MD, Koh Ishida, MD,
Takanori Niimura, MD, and Masashi Hachiya, MD
Study Design. Our original performance test for eval-
uating the severity of cervical myelopathy, the triangle
step test (TST), was introduced along with an assessment
of its validity.
Objective. The TST was designed to evaluate the
lower extremity motor function objectively and quanti-
tatively. This study aimed to assess the validity of the
test by analyzing the relation to the other analytic meth-
ods.
Summary of Background Data. Several rating scales
and performance tests have been proposed to evaluate
the severity of cervical myelopathy. Simple walking test is
useful; however, the test is limited for the patients who
can walk safely.
Methods. Each subject sitting on a chair was in-
structed to step on marks at each apex of a triangular
board and the number of steps in 10 seconds was
counted for each foot. The subjects were 270 cervical
myelopathy patients who had visited our hospital since
2002. As a control group, 60 healthy adults also under-
went this test. All subjects were simultaneously evalu-
ated by the Nurick score, the Japan Orthopedic Asso-
ciation score and the finger grip and release test. An
assessment of the effect of surgery was analyzed for 94
patients who underwent surgical treatments.
Results. The mean of the lower count for each subject
(TST score) in the control group was 25.4 3.7 steps,
which was superior to 18.4 5.2 steps for myelopathy
patients. TST score significantly correlated to the other
analytic measures for cervical myelopathy. Regarding the
effect of surgery, a performance of 16.7 4.5 steps before
surgery improved to 21.2 4.9 steps at follow-up. Pa-
tients who could step more than 20 times before surgery,
showed greater neurologic recovery.
Conclusion. TST score correlated with other analytic
methods for cervical myelopathy. This test is very use-
ful to quantitatively evaluate lower extremity function
and its improvement following surgical interv-
ention.
Key words: cervical myelopathy, performance test, tri-
angle step test. Spine 2010;35:3235
From the Division of Spine surgery, Department of Orthopaedic Sur-
gery, Yokohama Minami Kyosai Hospital, Yokohama, Japan.
Acknowledgment date: October 14, 2008. First revision date: May 9,
2009. Acceptance date: May 11, 2009.
The manuscript submitted does not contain information about medical
device(s)/drug(s).
No funds were received in support of this work. No benefits in any
form have been or will be received from a commercial party related
directly or indirectly to the subject of this manuscript.
The article is submitted through the recommendation of the Japanese
Society for Spine Surgery and Related Research.
Address correspondence and reprint requests to Hisanori Mihara, MD,
Division of Spine surgery, Department of Orthopaedic Surgery, Yoko-
hama Minami Kyosai Hospital, 1211 Mutuura Higashi, Kanazawa,
Yokohama, Japan 236 0037; E-mail: hmihara@ruby.ocn.ne.jp
32
The severity of cervical myelopathy has commonly
been assessed by various functional measures such as
the Nurick score or the Japan Orthopedic Association
(JOA) score.1 While, several studies have pointed out
interinstitutional or interobserver deviations in these
scoring systems which are based on ranking criteria.2,3
There are several performance tests designed to eval-
uate upper or lower extremity functions objectively
and quantitatively. The finger grip and release test
(GRT) in 10 seconds has been proven to provide a
quantitative and reliable test to evaluate upper ex-
tremity motor function.4 Because there were no safe
and simple tests for the lower extremities, we devel-
oped the triangle step test (TST), which we have used
since 2002. This study introduces our original perfor-
mance test along with an assessment of the validity of
the test.
Materials and Methods
A triangular board measuring 30 cm on each side was pre-
pared for the test and 3 stepping points were marked at each
apex (Figure 1). The board was placed in front of a subject
sitting on a chair and the subject was instructed to use their
foot to step on each mark one after another as quickly as
possible. The number of steps in 10 seconds was counted and
recorded for each foot. The number of missed steps was not
included in the total number of steps. The subjects were 270
cervical myelopathy patients who had visited our hospital
since 2002, 170 of whom were male and 100 female, with a
mean age of 64.1 years. Diagnosis according to the main
compression factor of the spinal cord showed that there were
182 patients with cervical spondylotic myelopathy (CSM),
74 with ossification of the posterior longitudinal ligament,
and 14 with cervical disc herniation. In addition, 60 healthy
adults (mean age of 57.6 years) also underwent this test as a
control group. Those with lower body motor neuron dis-
eases including lumber canal stenosis or peripheral nerve
palsy in lower extremities were excluded from the study. All
subjects including were simultaneously evaluated by Nurick
score (Table 1), JOA score (Table 2), and GRT. In order to
avoid inconsistency of criteria, the Nurick score and the JOA
score were assessed by an evaluator (H.M.). An assessment
of the effect of surgery involved the calculation of improve-
ment rates of TST, GRT, and JOA scores for 94 patients who
underwent surgical treatments, including 34 of anterior
decompression and fusion and 60 of posterior
laminoplasty.
Statistical Analysis
Comparative analysis of the measurement method was carried
out by estimation of Spearman correlation coefficients for the
acquired numerical data. Postoperative improvement was an-

30cm
30cm
Figure 1. A triangular board for the test.
alyzed by the Wilcoxon test. Statistical analyses were con-
ducted using SAS software on a personal computer.
Results
Regarding the TST results, the control group com-
pleted an average of 26.8 3.5 steps with the right
foot and 25.4 3.7 steps with the left foot. There was
on average a 1.9 steps laterality (difference in right vs.
left) in the control group and the mean of the lower
count for each subject (TST score) was 25.4 3.7.
There was not a statistically significant difference be-
tween the sexes. The TST score gradually decreased
according to age increase, though the influence was
less than 1 step per 10 years of age (Figure 2). There
was on average a 2.4 steps laterality for myelopathy
patients, and the mean of the lower count for each
patient (TST score) was 18.4 5.2, which was signif-
icantly lower than that of the control group. A statis-
tically significant correlation between Nurick grade
and TST score was observed. The mean TST score was
24.6 4.4 steps for the 38 patients of Nurick grade 1,
21.8 3.8 steps for the 61 patients of grade 2, 18.6
Table 1. Nurick Score
Grade 0 Signs or symptoms of root involvement but without evidence
of spinal cord disease
Grade 1 Signs of spinal cord disease but no difficulty in walking
Grade 2 Slight difficulty in walking that does not prevent full-time
employment
Grade 3 Difficulty in walking that prevents full-time employment or the
ability to perform housework, but that is not severe
enough to require someone elses help to walk
Grade 4 Able to walk with someone elses help or the with aid of
a frame
Grade 5 Chair bound or bedridden
Performance Test for Cervical Myelopathy Mihara et al 33
Table 2. JOA Score for Cervical Myelopathy (Disability
Scale for Lower Extremities)
Unable to walk 0
Can walk on flat floor with walking aid 1
Can walk up and/or down stairs with handrail 2
Lack of stability and smooth gait 3
No difficulties 4
4.6 steps for the 131 patients of grade 3, 12.8 3.7
steps for the 27 patients of grade 4, and 10.0 1.2
steps for the 3 patients of grade 5. Lower extremity
motor function as measured by JOA score showed a
statistically significant correlation with the TST score
as shown in Figure 3. (The mean TST score was 10.7
3.1 for the 18 patients with a JOA score (lower ex-
tremity motor function) of 1 or less, 16.5 4.2 for the
98 patients with a score of 1.5 and 2, 21.0 4.2 for
the 111 patients with a score of 2.5 and 3, and 24.8
4.1 for the 43 patients with a score of 4). The results of
the GRT were also evaluated using the lower number
for each patient. Myelopathy patients showed an av-
erage of 17.3 5.7 times, which was significantly
lower than the 23.6 4.5 times of the control group.
There was a strong correlation between the GRT re-
sults and TST score (correlation coefficient 0.55).
Regarding the effect of surgery on 94 patients, a
performance of 16.7 4.5 steps before surgery im-
proved to 21.2 4.9 steps at follow-up. The TST
score significantly increased after surgery by an aver-
age of 4.4 steps. However, 4 patients performed worse
at the final follow-up compared to before surgery. Of
them, 2 were over 75 years old and developed mild
cognition disorder. When the standard TST score was
set as 25, the recovery rate of TST score up to the
standard value was 55.7% on average, and was signif-
icantly correlated with the GRT improvement rate,
and the JOA score recovery rate (correlation coeffi-
cient 0.31 and 0.29, respectively). The mean recovery
rate of the TST score in patients who underwent ante-
rior decompression and fusion was 62.9% 37.0%,
steps
35
30
25
TST score
20
15
step=29.2 - 0.068 x Age
10
(R2 = .108)
5
0
20 30 40 50 60 70 80 90 100 y.o.
Age
Figure 2. TST score and age in control group.
34 Spine Volume 35 Number 1 2010

35 athy Disability Index,8 and others3,9,10 have been pro-

30
25
20
15
10
5 tivity in cases where medical suppliers decide how dis-
0 as the Stanford Health Assessment Questionnaire
01 1.52 2.53
Lower extremity motor function of JOA score
Figure 3. Correlation between TST score and lower extremity
motor function of JOA score.
which was greater than that of patients who under-
went laminoplasty (52.0% 42.6%), but the differ-
ence was not statistically significant.
With a retrospective analysis, there were 19 pa-
tients who could step more than 20 times before sur-
gery. These patients showed a 58.7% 26.8% of JOA
score recovery rate, which was greater than the
40.7% 26.1% of the recovery rate in the other pa-
tients who could not step more than 20 times before
surgery (Figure 4).
Discussion
Various analytic methods that evaluate clinical deficits
and surgical outcomes, and that could be applied uni-
versally, have been proposed.5 Limb spasticity is one
of the most common neurologic findings in various
disorders of the cervical spine and cord, confirming the
frequent involvement of the pyramidal tract.4 Nurick
first introduced a functional scale which was based
solely on categories of walking difficulty in CSM pa-
tients.6 Later, several rating scales including the JOA
score, the European Myelopathy Score,7 the Myelop-
% 69 patients who underwent surgical treatment in our hos-
100
JOA score improvement rate
posed to score or categorize the severity of cervical
myelopathy quantitatively and reproducibly. How-
ever, because these functional scales are based on the
ranking of disability vis-a`-vis daily activities, variation
in lifestyle or in the interpretation or definition of dis-
ability in various languages must influence their re-
sults. The lack of reliable and well validated analytic
tools has produced a situation in which it is difficult to
assess the results of treatment objectively. Further-
more, several papers have pointed out a lack of objec-
ability is categorized.11,12 Self-reporting methods such
4 (HAQ) or Short-Form 36 (SF-36) were also developed
and used to evaluate surgical benefits.9 These are prac-
tical and inexpensive, but responses reflect perceived
disability, which may over- or underestimate actual
ability.13
Alternatively, several performance tests have been
proposed for the evaluation of functional deficits in
cervical myelopathy patients. According to Ono et al,
clumsiness of the hand is one of the most common
complaints in patients with CSM. As such, they fo-
cused on the characteristic finger motion and named
myelopathy hand as assessed by the finger escape sign.
They also proposed employing the GRT in 10 seconds
as a quantitative and objective evaluation method for
upper extremity function and argued that GRT score
could be used as an indicator of the function of the
cervical spinal cord.4,14 However, many of CSM pa-
tients name difficulty walking as their chief complaint
and consider the recovery of walking ability their main
concern. As the upper motor neuron is critical in the
control of lower limb function, gait is of major impor-
tance for evaluation of cervical myelopathy.7 There-
fore, separate assessment of the function of the upper
and lower extremities seems particularly appropriate.5
There are several performance tests for the purpose of
evaluating lower extremity motor function. However,
since severe myelopathy patients are either unable to
walk at all or require support, tests based on walking
ability are impossible or dangerous to perform. In fact, 5 of
pital were unable to undergo a simple walking test, in

which walking times and the number of steps taken over a

80 30 m walk with one turn were to be measured.15
A foot tapping test is safe and easy to perform with-
60 out the need for any scaling devices,16 although it is
questionable whether simple repetitive movement of
40 the ankle joint reflects spinal cord function. The TST
we have developed requires coordination of a circular
20 motion by the whole lower extremity with a tapping
motion by the ankle and toe. Furthermore, quick step-
0
ping on the triangular board requires proprioception
15 1620 21 in 3-dimensional space. We believe that results of the
Preoperative TST score TST reflect the integrity of the pyramidal tract of the
Figure 4. Preoperative TST score and surgical outcomes. cord as well as the posterior tract, on which proprio-

ception and coordination depend.7 As this test is per-
formed in the sitting position, subjects who can hardly
walk due to severe myelopathy or joint disorders are
also able to undergo the test safely. Consequently, this
test could be performed safely on all patients suffering
from CSM.
Since neurologic deterioration often develops
rather slowly over time, the best time to perform de-
compression surgery is also difficult to determine.
Many clinical parameters are only applicable to pop-
ulations rather than to individuals.17 Current research
indicates that higher TST scores before surgery are
predictive as a better surgical outcome. Our data re-
vealed that 20 steps in 10 seconds should be consid-
ered as borderline for predicting whether surgery will
be of benefit or not. In other words, knowledge of TST
score appears to be useful for making decisions regard-
ing the timing of surgery. However, there are several
limitations when we interpret the TST score. For ex-
ample, most of elderly CSM patients have several co-
morbidities such as lumbar spinal canal stenosis, os-
teoarthritis of the knee and/or the hip joints, and
others that may influence the TST score directly. In
addition, we should consider the patients situation
such as eyesight, cooperative attitude, cognition dis-
order, and others. We need to analyze how much these
coexisting disorders and general conditions affect on
the results of TST in the future study.
Furthermore, measures of physical performance of
standardized tasks were considered more sensitive to
change following surgery.13 Such performance tests
also provide information for patient and surgeon alike
as to what to realistically expect from surgery.8 It is
quite beneficial to have a common recognition of sur-
gical efficacy. In general, performance evaluation re-
quires significant time and cost. TST, however, is quite
easy to perform without expensive instruments or
large rooms, and requires no more than 1 minute for
bilateral testing.
Conclusion
We developed the TST as a new performance test for
evaluating the severity of cervical myelopathy, focus-
ing particularly on lower extremity motor function.
TST score correlated well with Nurick grade and with
lower extremity motor function as measured by JOA
score. This test is very useful to quantitatively evaluate
lower extremity function and its improvement follow-
Performance Test for Cervical Myelopathy Mihara et al 35
ing surgical intervention without the need for expen-
sive instruments or an excessive amount of time.
Key Points
Triangle step test as a new performance test for
evaluating lower extremity motor function in
cervical myelopathy patients was proposed.
Number of step in 10 seconds significantly cor-
related to functional ranking measures such as
the Nurick score as well as results from the finger
grip and release test.
This test is very useful to evaluate the disability
of the lower extremity and its improvement fol-
lowing surgical treatments.
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