Translation, reliability, and validation of the Dutch Safe Use of Mobility Aid Checklist (SUMAC-NL) for walker use in people living with dementia

Jesper Kroesen; Hans Hobbelen; Susan Hunter; Helen Bruinsma; Hans Drenth

doi:10.12688/f1000research.132762.1

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Research Article

Translation, reliability, and validation of the Dutch Safe Use of Mobility Aid Checklist (SUMAC-NL) for walker use in people living with dementia

[version 1; peer review: 2 approved with reservations]

Jesper Kroesen ¹, Hans Hobbelen^2-4, Susan Hunter⁵, Helen Bruinsma⁶, Hans Drenth^3,4,7

Jesper Kroesen ¹, Hans Hobbelen^2-4, [...] Susan Hunter⁵, Helen Bruinsma⁶, Hans Drenth^3,4,7

PUBLISHED 14 Sep 2023

Author details Author details

¹ Physical Therapy Sciences, Universiteit Utrecht, Utrecht, Utrecht, The Netherlands
² Department of General Practice & Elderly Care Medicine, Rijksuniversiteit Groningen, Groningen, Groningen, The Netherlands
³ Research Group Healthy Ageing, Allied Health Care and Nursing, Hanzehogeschool Groningen, Groningen, Groningen, The Netherlands
⁴ FAITH research, Groningen/Leeuwarden, The Netherlands
⁵ School of Physical Therapy, Faculty of Health Sciences, University of Western Ontario, Ontario, Ontario, Canada
⁶ Treant, Emmen, 7285, The Netherlands
⁷ ZuidOostZorg, Drachten, Friesland, The Netherlands

Jesper Kroesen
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Hans Hobbelen
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Susan Hunter
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Helen Bruinsma
Roles: Resources

Hans Drenth
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Global Public Health gateway.

This article is included in the Dignity in Aging collection.

Abstract

Background: People with dementia have a yearly risk of falling of 60 to 80 percent. Therefore, a walker is often recommended. However, the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers. Better advice and training could reduce fall risk. Therefore, a tool to assess functional walking skills with a walker is needed. The SUMAC was developed to fill this gap. So far, there is no Dutch instrument available that can assess functional walking skills with a walker in people with dementia.
Methods: Reliability was evaluated by scoring videos of people with dementia (n = 9) using a walker performing the SUMAC-NL. ICC was used to assess inter-rater and test-retest reliability. An expert panel (n = 8) evaluated the content validity using the content validity index (CVI) and the content validity ratio (CVR).
Results: Inter-rater reliability of the SUMAC-NL was statistically significant for the PF domain (ICC = 0.94, 95%CI (0.84, 0.98, p < 0.001) and for the EQ domain (ICC = 0.79, 95%CI (0.49 – 0.95), p < 0.001). Test-retest reliability was statistically significant for both the PF domain (ICC = 0.95, 95%CI (0.89, 0.99), p < 0.001) and EQ domain (ICC = 0.92, 95%CI (0.82, 0.98), p < 0.001). The SUMAC-NL shows content validity with a CVI >0.79 for both domains and a CVR of 0.53 on the PF domain and 0.78 on the EQ domain.
Conclusions: The SUMAC-NL shows good to excellent reliability and content validity for both the PF and the EQ domain. The SUMAC-NL seems to be a promising tool to assess walking with a walker in people with dementia in the Netherlands.

Keywords

dementia, walker, geriatric evaluation, fall risk, walking, translation, validity, reliability

Corresponding author: Jesper Kroesen

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Kroesen J et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Kroesen J, Hobbelen H, Hunter S et al. Translation, reliability, and validation of the Dutch Safe Use of Mobility Aid Checklist (SUMAC-NL) for walker use in people living with dementia [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:1150 (https://doi.org/10.12688/f1000research.132762.1) First published: 14 Sep 2023, 12:1150 (https://doi.org/10.12688/f1000research.132762.1) Latest published: 30 Jun 2025, 12:1150 (https://doi.org/10.12688/f1000research.132762.3)

Introduction

Dementia is a neurocognitive disorder in which mental abilities as associative memory, reasoning and perceptual speed are severely reduced.¹ It is estimated that there are approximately 290,000 people with dementia in the Netherlands and it is the fastest-growing cause of death in the Netherlands.¹^–³ Dementia is characterized by a cognitive decline related to memory and in at least one of the other domains: perceptual-motor function, language, executive function, attention, and social cognition.⁴^,⁵

People with dementia have a high risk of falling and the cause is multifactorial. Intrinsic and extrinsic factors such as vision or balance problems and the use of medication can play a role in falling.⁶ Also, impairments in attention and executive functions are prominent risk factors for falls among people living with dementia.⁷ Importantly, balance and gait problems are common and progressive in dementia as well. People with dementia have a yearly risk to fall of sixty to eighty percent. This is twice as high as in their cognitively healthy peers.⁷^,⁸ Moreover, people with dementia have a high risk of admission to a long-care setting.⁷^,⁸

To compensate for deficits in balance, gait and strength that accompany dementia, the use of a walker is often recommended. A walker is known for improving stability during walking in cognitively healthy adults.⁹^,¹⁰ However, the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers who walk with a walker.⁶^,¹¹ Lindemann et al. identified obstacles and opening a door towards a person as the main problems for older adults using a walker.¹²

Many standardized scales for balance and gait developed for cognitively healthy older adults have been evaluated for reliability and validity in people living with dementia.¹³ The existing measures provide only partial information regarding mobility and few target elements that become relevant as dementia progresses.¹³ In addition, none of these instruments can assess the functional skills for safe walking when using a walker in people with dementia.

The high frequency of falls among people with dementia and the absence of a measurement instrument to assess walking skills in walker use led Hunter et al. to develop the Safe Use of Mobility Aid Checklist (SUMAC) in 2020.¹⁴ The SUMAC was generated by a focus group (N = 12) consisting of one geriatrician, two registered nurses, five physiotherapists, and four occupational therapists.¹⁴ The generated tasks were scored for relevance by an independent panel of five healthcare professionals. This resulted in a final selection of nine tasks in two domains (physical functioning (PF) and interaction with equipment (EQ) that form the SUMAC. The SUMAC can evaluate the skills of walking with a walker in people with dementia who walk with a walker independently or assess the success of training when the walker has been identified as an appropriate level of gait aid to compensate for deficits.¹⁴ The SUMAC has a good test-retest and inter-rater reliability (ICC = 0.89 for PF and ICC = 0.88 for EQ) and shows good construct validity (r_s = 0.92 for the PF score and r_s = 0.82 for the EQ score).¹⁴ This makes it a promising tool to give specific advice and training in walker use and to reduce the risk of falling in people with dementia.

Currently, there is no Dutch assessment instrument that can assess walking skills in people with dementia who need a walker. Therefore, a Dutch measuring instrument must be developed that can assess the safety of walking with a walker in people with dementia. This will lead to better advice and training regarding the use of a walker and thereby reduce the risk of falls in people with dementia in the Netherlands.

Therefore, the primary objective of this study is to 1) translate the SUMAC from English to Dutch and 2) determine the inter-rater reliability, the test-retest reliability, and the content validity of the SUMAC-NL to assess walking skills in older people with dementia living in the Netherlands who walk with a walker.

Methods

Study design

This study has an observational clinimetric design and involved two phases. The first part of this study consisted of the translation of the English version of the SUMAC into Dutch (SUMAC-NL). In the second part of this study, the reliability and validity evaluation of the SUMAC-NL was performed. The second part of the study was a replication study of the work by Hunter et al. (2020).¹⁴

Dutch translation of the SUMAC

The SUMAC was translated into Dutch between July and August 2021. The tasks and domains in the SUMAC remained the same. The translation was done according to the Beaton guideline¹⁵ and consisted of five phases. The first phase was the forward translation from English to Dutch by two Dutch native speakers with a medical background. The first translator knew the purpose of the instrument. The second translator did not know the instrument to keep the translation as objective as possible. The second phase was the synthesis of the two translations by the Dutch native translators. The third phase was the backward translation from Dutch to English by two English native speakers. The first translator had a medical background and the second translator did not. Both translators were unaware of the purposes of the SUMAC. The fourth phase consisted of a review of the translations by the researcher, two experts, and the developer of the SUMAC. The fifth phase consisted of getting an understanding of the items. For the feasibility of this study, the last step has been replaced by the evaluation of the content validity (Figure 1). This last step of the Beaton guideline consists of testing the prefinal version of the translated test. This involves administering the translated test to 30 to 40 people and then conducting interviews to ask participants what they thought was meant by the questions and the chosen response.¹⁵

Figure 1. Translation process.

▽ = translated version; △ = step in translation.

Reliability and validity evaluation

Participants

Older people with dementia who walk with a walker, living in an intramural setting were recruited by their physiotherapist between 1 December 2021 and 28 February 2022 by convenience sampling. The recruiter selected potential participants from the institution’s patient database. Potential participants and their families were informed about the study through the information letter and through verbal explanations. They were then asked for their participation.

The inclusion criteria were: 1) diagnosed with dementia 2) walking with a walker, 3) Dutch-speaking, 4) able to follow simple instructions, 5) able to walk 60 meters without the supervision of another person, 6) able to perform the SUMAC-NL and 7) having someone available who can make decisions (e.g. on participation) if necessary.¹⁶ Exclusion criteria for this study were: 1) comorbidities that limit mobility, such as Multiple Sclerosis (MS), a past Cerebro Vascular Accident (CVA), or (poly) neuropathy, and 2) people who have recently undergone surgery that limits mobility. All participants provided written informed consent. The legal representative of the participant was asked to give informed consent if the participant was deemed unable to do so.

Data collection

The demographic data requested from the participants were age, sex, amount of medication use, number of comorbidities, level of activities of daily living, and fear of falling. The 6-item Katz ADL scale was used to assess the participants’ ability to perform ADL activities and the short-FES-I is administered to determine the fear of falling of the participants. The Katz ADL (ICC = 0.82, p < 0.05) and short-FES-I (α = 0.84) are both reliable instruments to measure these parameters.¹⁷^–¹⁹

The assessment of the performed tasks by the participants was done by a group of raters consisting of a convenience sample of five physiotherapists who were recruited by one of the researchers (JK). All physiotherapists provided written informed consent for using their demographic data at the start of data collection. The physiotherapists were all legally registered therapists working in the physical therapy primary practice.

The participants were asked to perform the tasks of the SUMAC-NL while being filmed. Filming took place on 25 February and 4 March 2022 in a corridor with sufficient space in the institution where the participants live. Participants were asked if they wanted to be recognised in the video. If they did not agree, their faces were blurred in the videos so that the participants are unrecognisable in the video. The videos were stored in a 2FA-protected digital location, according to the data management plan and were deleted after the raters finished rating the videos. These videos were only used for the reliability assessment.

Ethical considerations

This study was conducted following the Declaration of Helsinki and the FAIR principle and was approved by the Hanze University of Applied Sciences Groningen’s Ethical Review Board (HEAC), with approval number heac.2021.026. Participants gave informed consent for understanding the information letters and that participating in the study was voluntary. In addition, they gave permission to contact their GP in case of unexpected findings, the collection and use of data and longer storage of the data as well as whether or not they wanted to be contacted again for follow-up studies.

Reliability

Each of the raters was asked to watch the provided instruction video and to read the instruction manual of the SUMAC-NL before starting the evaluation of the participants. The instruction video consisted of a detailed instruction of the components and items within the SUMAC-NL and an example of the evaluation with the SUMAC-NL. The videos of the participants performing the SUMAC-NL were sent to the raters on 11 March 2022. The evaluations of the participants was done twice at an interval of one week. The ratings were collected by the researcher on 8 April 2022.

The order of the tasks in the videos was the same as in the SUMAC-NL. The videos were offered in a random order. This order differed between the first and second evaluation session. Each rater evaluated all participants. The raters could evaluate the videos digitally at a location of their choice.

Validity

The expert panel consisted of six master of science trained geriatric physiotherapists, one master of science geriatric physiotherapist student, and one master of science trained physiotherapist. The experts in the panel have a mean age of 31.5 ± 2.7 years. Each of them has experience in working with older people with dementia (3.5 ± 3.2 years).

Before determining content validity, the expert panel received an instructional video explaining how to score the content of the SUMAC-NL. In addition, the expert panel received a digital score sheet in Microsoft Office Word in which the assessment of the SUMAC-NL was recorded. The scores of the experts were compared with each other and the content validity ratio (CVR) and content validity index (CVI) were calculated. Scoring of the SUMAC-NL by the expert panel to determine content validity took place between 18 February 2022 and 25 March 2025.

Statistical analysis

IBM SPSS statistical package version 28 (IBM Corp, Armonk, NY) was used for descriptive analysis and reliability analysis. Microsoft Office Excel 2019 was used in the content validity calculation.

Reliability

An a priori sample size calculation for the reliability study was done using the formula of Shoukri et al. (2004).²⁰ This formula showed that a sample consisting of nine participants and five raters making two evaluations is required to determine the desired ICC of >0.9 (CI ± 0.1). An ICC of >0.90 is considered excellent reliability.²¹ The demographic characteristics of the participants are presented using descriptive statistics.

Continuous data (SUMAC-NL subscores) were used and presented quantitatively. Missing data were considered ‘missing completely at random’ (MCAR) and imputed by the Expectation-Maximization (E-M) algorithm.²² Normality checks were done by the Shapiro-Wilk test and using histograms and Q-Q plots.

The absolute reliability was calculated using the standard error of the measurement (SEM) and minimal detectable change with a 95% confidence interval (MDC₉₅) for the PF and EQ domains of the SUMAC-NL. A smaller SEM means higher absolute reliability.²³ The SEM was estimated using the pooled standard deviation and the ICC for each group. The following formula was used: SE_measurement = s √(1-r_xx).²⁴^,²⁵ The MDC₉₅ was calculated using the SEM by the following formula: MDC₉₅ = (1.96)*(√2)*(SEM).²⁵^,²⁶

The relative values of inter-rater and test-retest reliability were calculated using ICC. An average measurement, absolute agreement, 2-way random-effects model (ICC 2,k) was used for determining the ICC.²¹ An ICC value less than 0.5 is indicative of poor reliability, values between 0.5 and 0.75 indicate moderate reliability, values between 0.75 and 0.9 indicate good reliability and values greater than 0.9 indicate excellent reliability.²¹

Content validity

Content validity was determined using CVR and the CVI and was calculated separately for both domains of the SUMAC-NL. The CVR was used to show the acceptance of tasks in the instrument and the CVI was used to determine the content validity of both the entire domains.²⁷

For CVR, the expert panel separately scored each item of the SUMAC-NL on a three-point Likert scale where a score of one is essential, a score of two is useful but not essential and a score of three is not essential. After obtaining the scores of the assessments of the experts, the CVR was calculated based on the following formula in Microsoft Office Excel 2019, where n_e represents the number of panel members who have chosen the item of ‘essential’, and N is the number of panel members:

CVR = \frac{n_{e} - (\frac{N}{2})}{\frac{N}{2}}

The CVR varies between -1 and 1. A higher score indicates further agreement of members of the panel on the necessity of an item in the instrument. The CVR of each domain is compared with the values in Lawshe’s table, and if the CVR is equal to or higher than the value (0.75) in Lawshe’s table, the item is preserved.²⁷

To determine the CVI, all items of the instrument have been scored on three parameters by the experts: relevance, simplicity, and clarity. Each parameter was scored on a 4-point Likert scale from disagree to totally agree. The average of the total scores was taken from the table and the CVI of each item was calculated with the following formula:

CVI = \frac{(the number of experts giving a rating of either 3 or 4)}{the number of experts}

The CVI of both domains of the SUMAC-NL was determined by dividing the sum of the CVI scores per item by the number of items.²⁸^,²⁹ A CVI of >0.79 was considered appropriate.²⁹

Results

Nine participants with dementia participated in this study. The sample consisted of five women (55.6%) and four men with a mean age of 85.56 (± 7.49). See Table 1 for the demographic characteristics of the participants.

Table 1. characteristics of people with dementia participating in reliability study (N = 9).

Variable	Mean ± SD, or n %
Age (years)	85.56 ± 7.49
Sex n (% female)	5 (55.6%)
FES-I score	12.11 ± 4.26
Katz ADL score	4.44 ± 2.00
Number of prescribed Medications	5.13 ± 1.13
Number of Comorbidities	3.33 ± 1.50

Reliability

The absolute reliability values were: SEM for the PF domain was 1.20 and for the EQ domain was 2.22; the MDC₉₅ was 3.33 for the PF domain and was 6.15 for the EQ domain (Table 2).

Table 2. Reliability values and scores for the two categories of the SUMAC-NL.

Domains of the Dutch Safe Use of Mobility Aid Checklist
	Physical functioning (PF)	Interaction with walker (EQ)
Mean (SD), range
Assessment 1	26.75 (4.83), 18-37	41.83 (7.76), 23-56
Assessment 2	26.13 (4.98), 16-36	40.78 (7.03), 28-55
Intraclass correlation coefficients (95%CI), p-value
Assessment 1: inter-rater reliability	0.85 (0.63, 0.96), p < 0.001	0.86 (0.64, 0.96), p < 0.001
Assessment 2: inter-rater reliability	0.90 (0.74, 0.97), p < 0.001	0.75 (0.41 – 0.94), p < 0.001
Test-retest reliability	0.94 (0.86, 0.99), p < 0.001	0.91 (0.79, 0.98), p < 0.001
Absolute reliability
Standard Error of Measurement (SEM)	1.20	2.22
Minimal Detectable Change (MDC₉₅)	3.33	6.15

A good to excellent inter-rater reliability in both evaluation moments in the PF domain (ICC = 0.85 (0.63, 0.96), p < 0.001 for assessment 1 and ICC = 0.90 (0.74, 0.97), p < 0.001 for assessment 2) and EQ domain (ICC = 0.86 (0.64, 0.96), p < 0.001 for assessment 1 and ICC = 0.75 (0.41 – 0.94), p < 0.001 in assessment 2) was found (Table 2). In addition, we found excellent test-retest reliability in the PF (ICC = 0.94, 95%CI (0.86, 0.99), p < 0.001) and EQ (ICC = 0.91 95%IC (0.79, 0.98), p < 0.001) domains (Table 2). The full raw data can be found under Underlying data.³⁰

Validity

The evaluation of the content validity was done by an expert panel (N =8) with experience in working with older people with dementia.

In the evaluation of the content validity, we calculated a CVI of 0.86 on the PF domain and 0.96 on the EQ domain. In addition, we calculated the CVR of 0.53 on the PF domain and 0.78 on the EQ domain (Table 3).

Table 3. CVI and CVR of the SUMAC-NL.

Domains of the Dutch Safe Use of Mobility Aid Checklist
	Physical functioning (PF)	Interaction with walker (EQ)
CVI	0.86	0.96
CVR	0.53	0.78

The CVI of all individual tasks was >0.79. The CVR of tasks 4 and 5 in the PF domain were both 0, of task 7 it was 0.5, and of tasks 8 and 9, it was 0.25. The other tasks showed a CVR >0.75. In the EQ domain, task 4 had a CVR of 0 and task 5 had a CVR of 0.5. The other tasks had a CVR >0.75.

Discussion

This replication study of the study from Hunter et al.¹⁴ includes the translation of the English SUMAC into Dutch and the determination of the test-retest reliability, inter-rater reliability, and validity of the Dutch SUMAC (SUMAC-NL) for people with dementia who walk with a walker. This study found a good to excellent inter-rater reliability and test-retest reliability, and strong support for content validity.

Small differences were found between our results and the results of the study by Hunter et al.¹⁴ The inter-rater reliability of the SUMAC-NL seems to be higher than the English version. The test-retest reliability of the SUMAC-NL seems higher for both the PF domain and the EQ domain (0.94 vs. 0.89 and 0.91 vs. 0.88, respectively). The SEM is smaller for the PF domain (1.20 vs. 1.31) and higher for the EQ domain (2.22 vs. 1.93) in the SUMAC-NL. The MDC₉₅ for the PF domain of the SUMAC-NL is smaller than that of the English-language SUMAC (3.33 vs. 3.64) and greater for the EQ domain (6.15 vs. 5.35). These differences could be explained by the differences in the way the raters were instructed. In the study by Hunter et al.,¹⁴ the raters received a one-hour one-on-one training session while, in this study, an online education via an instructional video was chosen due to the COVID-19 pandemic.¹⁴ As a result, the interpretation of the scoring method may differ slightly between the two raters’ groups.

The content validity index (CVI) shows that both the PF domain and the EQ domain are considered valid by the expert panel. However, the content validity ratio (CVR) shows that tasks 4, 5, 7, 8, and 9 are not valid (CVR <0.75) tasks for determining physical function (PF domain) for walking with a walker in people with dementia. This finding is not in line with the results from the study by Hunter et al.¹⁴ The content validity was determined by two sets of experts to include these tasks important for observing physical functioning.¹⁴ In addition, it appears that walking through a doorway causes serious problems for older people who use a walker, which is observed in tasks 7, 8, and 9.¹² Because of the results from previous research and a good CVR (>0.75) for tasks 7, 8, and 9 in the EQ domain, it seems appropriate to keep these tasks in the FF domain of the SUMAC-NL.¹²

The expert panel in this study determined tasks 4 and 5 as not valid for both the PF and EQ domain. These tasks involve walking with a double task (horizontal head turns) and a cognitive task. The expert panel scored lower for these tasks on the simplicity parameter within the CVI. One of the reasons given is that the wording of the tasks can be interpreted in different ways. However, different studies show that gait performance decreases and fall risk increases with increasing task complexity with the addition of a second cognitive task in community-dwelling adults or cognitively impaired older adults.³¹^–³⁴ Therefore, it seems appropriate to observe these performances and keep tasks 4 and 5 in the SUMAC-NL but the formulation may have to be modified in the future.

Other measuring instruments can score balance and physical performance to interpret a risk of falls. A commonly used measuring instrument for evaluating physical performance and walking in older adults is the Berg Balance Scale (BBS).³⁵^,³⁶ The BBS measures the balance of participants through transfers and static postures, without a walker. The BBS is a reliable instrument for determining the risk of falling and has good reliability in older people with dementia to assess physical functioning.³⁵^,³⁷^,³⁸ This measuring instrument can have value in determining walking safety but is not specified for determining walking safety in older people with dementia who walk with a walker. The SUMAC-NL seems to be an appropriate tool to fill this gap because of its good reliability in people with dementia and the functional items that are included for walking with a walker. The SUMAC-NL provides professionals a standardised assessment tool to assess safe walking with a walker in people with dementia.

Previous research shows that people with dementia are well able to learn tasks both implicitly and explicitly, making possible therapy effective.³⁹^,⁴⁰ The SUMAC-NL could be performed in people living with dementia who already walk with a walker or in people who have received training in walking with a walker so that the walking skills and/or the success of the training can be evaluated.

Strengths and limitations

The translation of the English-language SUMAC into Dutch was carried out systematically using the Beaton guideline.¹⁵ This increases the comparability between different cultures.⁴¹ For the feasibility of this study, the last step in the guideline has not been reviewed. We have overcome this by determining the content validity and reliability, which also includes the comprehensibility of the instrument.

Another strength of this study is that the experts involved in the validation assessment of the SUMAC-NL were all master trained physiotherapists who are experts in the field of physical activity who have experience in geriatrics and work with people living with dementia.⁴²

This study also has some limitations. For the power and feasibility of this study, the reliability phase of this study consisted of several assessors (N = 5) and nine participants. Although the sample size is appropriate to achieve power in the analysis, research with a larger sample size (n >50) is recommended.⁴³ After data collection, there was missing data (<10%). This data was assumed to be missing completely at random (MCAR). After imputation, we did calculations on the imputed data and the raw data. The results of both calculations were similar to each other.

This study was done in older people with dementia who were able to perform the SUMAC-NL. Therefore, the results cannot be generalised to people with dementia who may not be able to complete the SUMAC-NL. The people in our sample show no severe fear of falling on the FES-I and are largely independent in ADL following the Katz ADL scores. The results are therefore not generalizable to people with severe fear of falling and are more dependent in ADL. Further research is needed on the psychometric properties of the SUMAC-NL in people who are less likely to be able to perform the SUMAC-NL, have a greater fear of falling and are more dependent in ADL.

Implications for practice and research

The inter-rater reliability, test-retest reliability, and validity support the use of the SUMAC-NL in practice. The SUMAC-NL should be considered to assess the walking skills in people living with dementia who use a walker independently and/or to evaluate the training success of walking with a walker. With the help of the SUMAC-NL, more specific training, education, and advice can be given for walker use.

Future research must determine whether the use of the SUMAC-NL can improve the walking safety of older people with dementia who walk with a walker and thus can reduce the risk of falling in this population. Because of the lack of generalizability of this study to older people with dementia with more severe fear of falling and are more dependent in ADL, further research into the psychometric properties of the SUMAC-NL in people with dementia is advised.

Conclusion

In this study, the English-language SUMAC was translated into the Dutch SUMAC-NL. The SUMAC-NL seems to have good to excellent inter-rater reliability, test-retest reliability, and content validity. The SUMAC-NL seems to be a promising instrument for the assessment of walking with a walker in older people with dementia.

Data availability

Underlying data

DataverseNL: Safe Use of Mobility Aid Checklist (SUMAC) for walker use in people living with dementia. https://doi.org/10.34894/RUKZQP ³⁰

This project contains the following underlying data:

Dataset of the reliability study

- DatastetreliabilitySUMACNL_15-5-2022_raw (.cvs and.sav)
- Syntax1reliabilitySUMAC (.sps)

Dataset of the validity study

- Validityworksheet_CVI_CVR-SUMAC-NL (.xlsx)

Extended data

This project contains the following extended data:

- README_ENG_ SUMAC_NL_translation_relibility_validation 27-1-2023.pdf
- informatiebrief SUMAC-NL studie 2-12-2021.docx (participant information sheet)
- Handleiding SUMAC-NL_final.docx (manual for using the SUMAC-NL)
- SUMAC-NL_final.docx (The official SUMAC-NL tool for clinical use)
- Dataset definitions.pdf
- The English version of the SUMAC can be found via: http://www.mobility-in-aging-lab.ca/#publications

Data are available under the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication).

Acknowledgments

This research is part of the graduation phase of the Physiotherapy Sciences programme at Utrecht University. Our thanks go to the supervisors and fellow students who helped in the process of the research.

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Version 3

VERSION 3 PUBLISHED 14 Sep 2023

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Helen Bruinsma
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No competing interests were disclosed.

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The author(s) declared that no grants were involved in supporting this work.

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Published: 30 Jun 2025, 12:1150

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Kroesen J, Hobbelen H, Hunter S et al. Translation, reliability, and validation of the Dutch Safe Use of Mobility Aid Checklist (SUMAC-NL) for walker use in people living with dementia [version 1; peer review: 2 approved with reservations]. F1000Research 2023, 12:1150 (https://doi.org/10.12688/f1000research.132762.1)

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Reviewer Report 29 Jan 2025

Brittney Muir, University of Washington, Seattle, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.145710.r351635

This article is a replication study of the work by Hunter et al. (2020).¹⁴ However, the authors have translated the instrument into Dutch, and evaluated its use. The study found that SUMAC-NL shows good to excellent reliability and content validity, and seems to be a promising tool to assess walking with a walker in people with dementia in the Netherlands.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?
Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: aging, mobility, device evaluation and translation.

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 26 Feb 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

26 Feb 2025

Author Response

Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Competing Interests: No competing interests were disclosed.
Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Competing Interests: No competing interests were disclosed. Close
Report a concern
Author Response 15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

15 Apr 2025

Author Response

Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

... Continue reading Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?

Author Response: We adapted and refined the introduction to make clear and substantiate the importance of translating the SUMAC into Dutch and why a reliability study is necessary after translation. This strengthened the scientific value of the study. In the discussion, we also addressed the robustness of the original SUMAC.

Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.
Author Response: Thanks for the compliments and the effort taken to provide feedback on our study!
Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?

Author Response: We adapted and refined the introduction to make clear and substantiate the importance of translating the SUMAC into Dutch and why a reliability study is necessary after translation. This strengthened the scientific value of the study. In the discussion, we also addressed the robustness of the original SUMAC.

Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.
Author Response: Thanks for the compliments and the effort taken to provide feedback on our study!
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 26 Feb 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

26 Feb 2025

Author Response

Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Competing Interests: No competing interests were disclosed.
Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Dear Brittney,

Thank you for your valuable feedback. We will work on it and then upload a new version after that.

Kind regards, Jesper Kroesen
Competing Interests: No competing interests were disclosed. Close
Report a concern
Author Response 15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

15 Apr 2025

Author Response

Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

... Continue reading Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?

Author Response: We adapted and refined the introduction to make clear and substantiate the importance of translating the SUMAC into Dutch and why a reliability study is necessary after translation. This strengthened the scientific value of the study. In the discussion, we also addressed the robustness of the original SUMAC.

Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.
Author Response: Thanks for the compliments and the effort taken to provide feedback on our study!
Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?

Author Response: We adapted and refined the introduction to make clear and substantiate the importance of translating the SUMAC into Dutch and why a reliability study is necessary after translation. This strengthened the scientific value of the study. In the discussion, we also addressed the robustness of the original SUMAC.

Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.
Author Response: Thanks for the compliments and the effort taken to provide feedback on our study!
Competing Interests: No competing interests were disclosed. Close
Report a concern

Views

Reviewer Report 10 May 2024

Jodie Marquez, The University of Newcastle, Callaghan, New South Wales, Australia

Approved with Reservations

https://doi.org/10.5256/f1000research.145710.r270411

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: rehabilitation, ageing, exercise, physiotherapy

CITE

Report a concern

Author Response 13 Jun 2024

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

13 Jun 2024

Author Response

Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of ... Continue reading Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of F1000research, we will do so after a second review by another researcher.

Kind regards,

Jesper Kroesen
Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of F1000research, we will do so after a second review by another researcher.

Kind regards,

Jesper Kroesen
Competing Interests: No competing interests were disclosed. Close
Report a concern
Author Response 15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

15 Apr 2025

Author Response

Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

... Continue reading Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?
Response : We agree that the concept could be introduced more clearly. We have made a textual addition to a sentence in the abstract to clarify this. In addition, the abbreviations mentioned have been removed and replaced with full words. It was not mentioned in the abstract, but the discussion substantiated that implicit learning is still possible with the target audience.

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Response :The introduction has been revised and refinedto more clearly justify the necessity of translaing the SUMAC into Dutch and the rationale for subsequently conducting a reliability check on the translated SUMAC. We agree that this could be stated more clearly in the introduction

Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Response : We recognize that the absence of scores from a cognitive survey of people with dementia is an important oversight. Unfortunately, we are unable to revisit participants as their cognitive state has changed since 3 years ago. Following the review, we have given this issue additional paid attention in the discussion.
Reading back, we understand that the distinction between the group of raters and the expert group for the validity assessment was not clearly delineated. We formulated this more clearly in the new version in the methods section under: data collection.
The limitations of a homogeneous expert group have also been incorporated into the discussion

Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Response :We clarified the explanation in the difference in scores in the discussion.
Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?
Response : We agree that the concept could be introduced more clearly. We have made a textual addition to a sentence in the abstract to clarify this. In addition, the abbreviations mentioned have been removed and replaced with full words. It was not mentioned in the abstract, but the discussion substantiated that implicit learning is still possible with the target audience.

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Response :The introduction has been revised and refinedto more clearly justify the necessity of translaing the SUMAC into Dutch and the rationale for subsequently conducting a reliability check on the translated SUMAC. We agree that this could be stated more clearly in the introduction

Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Response : We recognize that the absence of scores from a cognitive survey of people with dementia is an important oversight. Unfortunately, we are unable to revisit participants as their cognitive state has changed since 3 years ago. Following the review, we have given this issue additional paid attention in the discussion.
Reading back, we understand that the distinction between the group of raters and the expert group for the validity assessment was not clearly delineated. We formulated this more clearly in the new version in the methods section under: data collection.
The limitations of a homogeneous expert group have also been incorporated into the discussion

Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Response :We clarified the explanation in the difference in scores in the discussion.
Competing Interests: No competing interests were disclosed. Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 13 Jun 2024

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

13 Jun 2024

Author Response

Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of ... Continue reading Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of F1000research, we will do so after a second review by another researcher.

Kind regards,

Jesper Kroesen
Dear Jodie,

Thank you for taking the time to review our study. We find your suggestions very valuable and will incorporate them into the article. On the advice of F1000research, we will do so after a second review by another researcher.

Kind regards,

Jesper Kroesen
Competing Interests: No competing interests were disclosed. Close
Report a concern
Author Response 15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

15 Apr 2025

Author Response

Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

... Continue reading Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?
Response : We agree that the concept could be introduced more clearly. We have made a textual addition to a sentence in the abstract to clarify this. In addition, the abbreviations mentioned have been removed and replaced with full words. It was not mentioned in the abstract, but the discussion substantiated that implicit learning is still possible with the target audience.

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Response :The introduction has been revised and refinedto more clearly justify the necessity of translaing the SUMAC into Dutch and the rationale for subsequently conducting a reliability check on the translated SUMAC. We agree that this could be stated more clearly in the introduction

Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Response : We recognize that the absence of scores from a cognitive survey of people with dementia is an important oversight. Unfortunately, we are unable to revisit participants as their cognitive state has changed since 3 years ago. Following the review, we have given this issue additional paid attention in the discussion.
Reading back, we understand that the distinction between the group of raters and the expert group for the validity assessment was not clearly delineated. We formulated this more clearly in the new version in the methods section under: data collection.
The limitations of a homogeneous expert group have also been incorporated into the discussion

Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Response :We clarified the explanation in the difference in scores in the discussion.
Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?
Response : We agree that the concept could be introduced more clearly. We have made a textual addition to a sentence in the abstract to clarify this. In addition, the abbreviations mentioned have been removed and replaced with full words. It was not mentioned in the abstract, but the discussion substantiated that implicit learning is still possible with the target audience.

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Response :The introduction has been revised and refinedto more clearly justify the necessity of translaing the SUMAC into Dutch and the rationale for subsequently conducting a reliability check on the translated SUMAC. We agree that this could be stated more clearly in the introduction

Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Response : We recognize that the absence of scores from a cognitive survey of people with dementia is an important oversight. Unfortunately, we are unable to revisit participants as their cognitive state has changed since 3 years ago. Following the review, we have given this issue additional paid attention in the discussion.
Reading back, we understand that the distinction between the group of raters and the expert group for the validity assessment was not clearly delineated. We formulated this more clearly in the new version in the methods section under: data collection.
The limitations of a homogeneous expert group have also been incorporated into the discussion

Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Response :We clarified the explanation in the difference in scores in the discussion.
Competing Interests: No competing interests were disclosed. Close
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Version 3

VERSION 3 PUBLISHED 14 Sep 2023

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Jodie Marquez, The University of Newcastle, Callaghan, Australia
Brittney Muir, University of Washington, Seattle, USA

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3 Views

22 Jul 2025 | for Version 3

Jodie Marquez, The University of Newcastle, Callaghan, New South Wales, Australia

3 Views Cite this report Responses(0)

Approved

Thank you to the editorial team for this robust and transparent process.

Much gratitude to the authors for their respectful and considered responses. I have no further comments and am pleased with indexing.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

healthy aging, stroke, rehabilitation, falls

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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11 Views

28 Apr 2025 | for Version 2

Jodie Marquez, The University of Newcastle, Callaghan, New South Wales, Australia

11 Views Cite this report Responses(1)

Approved With Reservations

Thank you for the opportunity to review the response made by the authors.
I appreciate that they have addressed my comments. One point remains outstanding.
The authors have clarified the aim of the study, to validate a tool to assess functional walking abilities - this has merit. However. the authors take this further to state:
in the abstract: Better advice and training could reduce fall risk;
in the intro: a promising tool to give specific advice and training in walker use and to reduce the risk of falling in people with dementia.
The ability to educate and train this population to reduce falls needs validation from the literature. This is a statement that is far reaching in this population with cognitive/STM impairments that worsen with time.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

healthy aging, stroke, rehabilitation, falls

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Author Response

11 Sep 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

Dear Jodie,
Thank you once again for reviewing our study, we appreciate it. You provided us with the following feedback:

In the abstract: Better advice and training could reduce fall risk;
In the introduction: a promising tool to give specific advice and training in walker use and to reduce the risk of falling in people with dementia.
The ability to educate and train this population to reduce falls needs validation from the literature. This is a statement that is far reaching in this population with cognitive/STM impairments that worsen with time.

We agree that these statements were too strong, and we have therefore revised them to be more nuanced in both the abstract and the introduction.

Kind regards,

Jesper Kroesen

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No competing interests were disclosed.

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7 Views

26 Apr 2025 | for Version 2

Brittney Muir, University of Washington, Seattle, USA

7 Views Cite this report Responses(1)

Approved

The authors have addressed my concerns. Thank you

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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20 Views

29 Jan 2025 | for Version 1

Brittney Muir, University of Washington, Seattle, USA

20 Views Cite this report Responses(2)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

No source data required
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

aging, mobility, device evaluation and translation.

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Author Response

15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

Dear Brittney,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Major comments:

I find the science to be sound, as it is by design a replication of previous work. I have major concerns about the value this study adds to science. While validating the tool in another language is an important step, there is little support on why this is novel publishable scientific work.
Towards this, I am requesting the authors revise the introduction and discussion to explain why it is important to evaluate and publish this work on the translated device. Points that could be considered in this revision include: 1) Were you expecting the Dutch version to not be as valid/ reliable? 2) What value does this study bring other than having the tool in Dutch? Does it speak to the robustness of the original tool?

Author Response: We adapted and refined the introduction to make clear and substantiate the importance of translating the SUMAC into Dutch and why a reliability study is necessary after translation. This strengthened the scientific value of the study. In the discussion, we also addressed the robustness of the original SUMAC.

Minor comments:

I have no minor comments, I thought the paper was well-written, scientifically sound, and rigorous work was conducted and documented.
Author Response: Thanks for the compliments and the effort taken to provide feedback on our study!

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

33 Views

10 May 2024 | for Version 1

Jodie Marquez, The University of Newcastle, Callaghan, New South Wales, Australia

33 Views Cite this report Responses(2)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Yes
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

rehabilitation, ageing, exercise, physiotherapy

Respond to this report

Responses (2)

Author Response

15 Apr 2025

Jesper Kroesen, Physical Therapy Sciences, Universiteit Utrecht, Utrecht, The Netherlands

Dear Jodie,

First of all, we would like to thank you for your effort in reviewing our study. Below is a response to the feedback and its incorporation.

Abstract:
The abstract needs to be revised to clearly outline the reason for the study and the primary aims. Concepts need to be introduced more clearly. For example:
“the use of a walker in people with dementia is associated with a threefold increased odds of falls compared to their healthy peers”. This point is misleading – it suggests that walker use is associated with falls, yet it may be that if they didn’t use a walker the falls rate may be much higher. Please revise for clarity.
Please reconsider ‘Better advice and training could reduce falls risk – is this true in this population where short term memory is problematic? It would seem that the assessment tool would be used to warrant the prescription of the walker rather than to inform education. Please re consider the purpose of this tool. If this point is to be presented, please provide evidence in the introduction of evidence of the use of training /education to improve mobility in this population.
The SUMAC was developed but why was the Dutch version required?
Don’t use abbreviations not introduced eg PF domain, EQ
Was intra-rater/ test-retest reliability assessed?
Response : We agree that the concept could be introduced more clearly. We have made a textual addition to a sentence in the abstract to clarify this. In addition, the abbreviations mentioned have been removed and replaced with full words. It was not mentioned in the abstract, but the discussion substantiated that implicit learning is still possible with the target audience.

Introduction:
The background needs to describe what assessments are currently used to determine the need for a mobility aid, such as a walker, in the general population – and why these tools are not suitable for those with dementia Why is a dementia specific tool required?
What makes the Dutch population any different to the global population – why is a Dutch specific tool required?
Response :The introduction has been revised and refinedto more clearly justify the necessity of translaing the SUMAC into Dutch and the rationale for subsequently conducting a reliability check on the translated SUMAC. We agree that this could be stated more clearly in the introduction

Methods:
Not clear why a cognitive assessment score was not included in the demographic information –it would seem this information would be very important in determining what level of cognitive functioning is appropriate for clinical application of the tool
In the ‘data collection’ section it states ‘ a convenience sample of five physiotherapist who were recruited’ else where it states “8 experts” please clarify.
The expert panel are very homogenous with regard to age and experience - this is a potential limitation to widespread adoption of the tool whereby reliability may differ for those outside of this age/experience range
Response : We recognize that the absence of scores from a cognitive survey of people with dementia is an important oversight. Unfortunately, we are unable to revisit participants as their cognitive state has changed since 3 years ago. Following the review, we have given this issue additional paid attention in the discussion.
Reading back, we understand that the distinction between the group of raters and the expert group for the validity assessment was not clearly delineated. We formulated this more clearly in the new version in the methods section under: data collection.
The limitations of a homogeneous expert group have also been incorporated into the discussion

Discussion:
The authors conclude that the difference in reliability with the previous study may be due to the difference in the format in which the training was provided ( in person vs online) please clarify this. Was the content different? How would this affect the scoring?
There were differences in findings but no recommendation to modify the tool for the Dutch population therefore the impact of the study is reduced

Response :We clarified the explanation in the difference in scores in the discussion.

View more View less

Competing Interests

No competing interests were disclosed.

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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Translation, reliability, and validation of the Dutch Safe Use of Mobility Aid Checklist (SUMAC-NL) for walker use in people living with dementia

Abstract

Keywords

Introduction

Methods

Study design

Dutch translation of the SUMAC

Figure 1. Translation process.

Reliability and validity evaluation

Statistical analysis

Results

Table 1. characteristics of people with dementia participating in reliability study (N = 9).

Reliability

Table 2. Reliability values and scores for the two categories of the SUMAC-NL.

Validity

Table 3. CVI and CVR of the SUMAC-NL.

Discussion

Strengths and limitations

Implications for practice and research

Conclusion

Data availability

Underlying data

Extended data

Acknowledgments

References

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