Mobility Studies Lauren Kark. Introduction Outcome Measures Locomotor Capabilities Index Barthel...

Mobility Studies Lauren Kark

Introduction

Outcome Measures

Locomotor Capabilities Index

Barthel Index

Functional Independence Measure

Office of Population Consensus and Surveys Scale

Amputee Activity Score

Functional Measure for Amputees

Houghton Scale

Prosthetic Profile of the Amputee

Frenchay Activities Index

Patient Generated Index

Short Form 36

Short Form 12

Sickness Impact Profile

Attitude to Artificial Limb Questionnaire

Amputation Related Body Image Scale

Body Image Questionnaire

Prosthesis Evaluation Questionnaire

Perceived Social Stigma Scale

Questionnaire for Persons with Transfemoral Amputation

Trinity Amputation and Prosthesis Experience Scale

Russek’s Code

Special Interest Group in Amputee Medicine

Rivermead Mobility Index

Orthotics and Prosthetics National Outcome Tool

Amputee Mobility Predictor

Timed-Up-and-Go Test

L-Test

2-Minute Walk Test

6-Minute Walk Test

10-Metre Walk Test

Energy Expenditure

Temporospatial Data

Kinematics

Kinetics

Outcome Measures

FunctionalCertain TS datae.g. walking speed

Functional measurese.g. TUG test, TWT

Time, money, clinical impracticality

PerceptionSelf-report measurese.g. questionnaires

Gait AnalysisKinematicsKinetics Energy Expenditure

TUG, timed-up-and-go; TWT, timed walk test

Hypothesis

Relationships exist between self-report data, functional outcome measures and quantitative gait analysis.

Complex gait parameters can be predicted using simpler, cheaper and faster outcome measures such as questionnaires and functional ability assessments.

Hypothesis

Perception

Functional

Gait Analysis

Parameters

Aims

To develop a clinical tool that enables perceptive and functional outcome measures to provide insights into quantitative gait parameters.

To use self-report questionnaires to obtain quality-of-life related information from a well represented proportion of lower limb amputees.

To conduct biomechanical analysis on a number of lower limb amputees. To explore relationships between perception, functional outcome measures and quantitative gait

analysis.

Experimental Design

Vis

it

UN

SW

?Yes

Ethics Approval

(HREC 07247)

Subject recruitment

Mail-out questionnaire study

Analysis

Subject participation

complete

No

Physical testingAnalysisSubject

participation complete

Analysis of relationships

between questionnaires and

physical testing

Part 1. Questionnaire Study

Mail-Out Questionnaire

Demographics Short-Form 36 Functional Measure for Amputees Prosthesis Evaluation Questionnaire

Participant Characteristics n (%) n (%)

Gender (135) Male Female

96 (71.1)39 (28.9)

Current Age (134) 25 – 34 35 – 44 45 – 54 55 – 64 65 – 74 75+

3 (2.2)9 (6.7)19 (14.2)32 (23.9)38 (28.4)33 (24.6)

Level (135) Transfemoral Transtibial Other

42 (31.1)66 (48.9)27 (20.0)

Time Since Amp (123) [0 – 1] (1 – 5) [5 – 10) [10 – 20] >20

13 (10.6)30 (24.4)30 (24.4)18 (14.6)32 (26.0)

Aetiology (131) Cancer Surgical Trauma Vascular

10 (7.5)19 (14.3)52 (39.1)51 (38.3)

Age at Amp (125) <35 35 – 44 45 – 54 55 – 64 65 – 74 75+

32 (25.6)14 (11.2)20 (16.0)25 (20.0)22 (17.6)12 (9.6)

Short-Form 36

Age and Gender Adjusted SF-36 (NSW, N=111)

30

35

40

45

50

55

PF RP BP GH VT SF RE MH PCS MCS

Adj

uste

d M

ean

PF, physical functioning; RP, role limitations due to physical; BP, bodily pain; GH, general health; VT, vitality; SF, social functioning; RE, role limitations due to emotional; MH, mental health; PCS, physical components scale; MCS, mental components scale

Short-Form 36 – Influence of Pain Pain Type PF RP BP GH VT SF RE MH PCS MCSPhantom sensations* Diff. in median 95% CI (median) p-value

10-5-200.15

6-6-190.35

10-2-200.23

3-5-120.51

90-190.06

70-130.57

40-80.52

-3-10-50.99

4-1-80.08

1-3-50.53

Phantom pain Diff. in median 95% CI (median) p-value

8-5-200.22

130-250.04

120-230.02

5-5-150.26

100-190.04

130-250.03

90-170.02

2-5-90.63

40-80.04

41-80.02

Residual limb pain Diff. in median 95% CI (median) p-value

8-4-200.14

130-250.04

1910-380.00

135-220.01

90-190.03

70-130.06

90-170.04

50-100.07

52-90.01

40-70.03

Intact limb pain Diff. in median 95% CI (median) p-value

100-200.13

130-250.02

100-210.09

135-200.01

90-190.01

70-130.04

80-170.09

50-100.04

40-90.03

40-80.04

Back pain Diff. in median 95% CI (median) p-value

130-250.02

130-250.1

2110-310.00

6-3-150.20

90-190.01

70-130.13

80-170.06

50-100.07

52-90.01

3-1-70.10

* Defined as an awareness of pressure and proprioception in the phantom limb (Legro et al, 1998)

Locomotor Capabilities Index NO YES

if someone helps me

YES if someone is near me

YES alone with a walking aid

YES alonewithout a walking aid

a.

Get up from a chair?

b.

Pick up an object from the floor when you are standing up with your artificial leg?

c.

Get up from the floor? (for example: if you had fallen)

d.

Walk in the house?

e.

Walk outside on EVEN ground?

f.

Walk outside on UNEVEN ground? (for example: grass, gravel, slope)

g.

Walk outside in bad weather? (for example: rain or snow)

h.

Go upstairs holding a banister?

NO YES if someone helps me

YES if someone is near me

YES alone with a walking aid

YES alonewithout a walking aid

i.

Go downstairs holding a banister?

j.

Step up onto the pavement?

k.

Step down from the pavement?

l.

Go up a few steps without a handrail?

m.

Walk down a few steps without a handrail?

n.

Walk while carrying an object? (for example: cup of tea, newspaper)

Locomotor Capabilities Index

Overall Above Knee Below Knee Other 0

10

20

30

40

50

60

Sco

re

Prosthesis Evaluation Questionnaire

AM AP FR PR RL SB SO UT WB0

10

20

30

40

50

60

70

80

90

100

Above-Knee Below-Knee

Sc

ore

( /

10

0)

** * *

*

AM, ambulation; AP, appearance; FR, frustration; PR, perceived response; RL, residual limb health; SB, social burden; SO, sounds; UT, utility; WB, well-being

Comparison to Published Results

Short-Form 36 Similar to Legro et al. (1999), Pezzin et al. (2000), Smith et al. (1995) and

Hagberg et al. (2001)

Locomotor Capabilities Index Higher than other published results

Prosthesis Evaluation Questionnaire Mixed results Frustration and social burden lower

Part 2. Physical Testing

Physical Testing

Three-dimensional gait analysis Six-minute walk test (or two-minute walk test) Timed-up-and-go test Energy expenditure Questionnaires

Participant Characteristics Lower-Limb Amputees Able-Bodied

Female Male Female Male

Number (n) 6 14 16 12

Age (yrs) 62.5 (14.0) 62.2 (11.7) 60.0 (7.7) 61.5 (8.2)

BMI 27.0 (7.6) 26.3 (5.0) 24.8 (3.4) 26.7 (2.4)

Level (n) Transtibial Transfemoral

33

95 N/A

Time Since Amp (yrs) 15.3 (14.0) 25.1 (20.5) N/A

Aetiology (n) Trauma Cancer Vascular Infection

4110

9122

N/A

Six-Minute Walk Distance

Above-Knee Below-Knee Able-Bodied0

100

200

300

400

500

600

Dis

tan

ce

(m

)

Oxygen Cost

Above-Knee Below-Knee Able-Bodied0

1

2

3

4

5

6

Ox

yg

en

Co

ns

um

pti

on

(J

/kg

.m)

Timed-Up-and-Go Test

ManualCognitivePlainBKAKABBKAKABBKAKAB

20.0

17.5

15.0

12.5

10.0

7.5

5.0

Tim

e (s

ecs)

TUG Test Summary

Self-Selected Walking Speed

Step-Length

Above-Knee Below-Knee Able-Bodied0.5

0.6

0.7

0.8

0.9

Step-Length

Average Prosthetic Intact

No

rma

lis

ed

Ste

p-L

en

gth

(-)

Gait Summary Measures – Gait Deviation Index

GDI - Limb Comparison

50

60

70

80

90

100

Prosthetic Intact Overall

GD

I


0.000 0.025 0.002

Kark, L. et al., Use of gait summary measures with lower limb amputees, Gait and Posture. 2011; (35(2): 238 – 243.

Gait Summary Measures – Gait Profile Score

GPS - Limb Comparison

0

2

4

6

8

10

12

14

Prosthetic Intact Overall

GPS (

degre

es)


0.011 0.046 0.015


Gait Summary Measures

13121110987654

110

100

90

80

70

60

50

GPS (degrees)

GD

I

AKBK

GDI versus GPS


Gait SymmetrySL GDI GPS GVSHF GVSKF GVSADP GVSHA GVSFPA

TranstibialBFCBFSBFVBMGBMKBMLBMM1BMM2BMOBMPBMSBMWTransfemoralAFC1AFC2AFKAMGAMMAMPAMRAMW

SL, step length; GDI, gait deviation index; GPS, gait profile score; GVS, gait variable score; HF, hip flexion/extension; KF, knee flexion/extension; ADP, ankle dorsi/plantarflextion; HA, hip adduction/abduction; FPA, foot progression angle

Part 3. Relationships

Outline

1. Predicting gait deviation

2. The role of gait deviation in patient satisfaction

1. Predicting Gait Deviation

Participant Characteristics

Summary Statistic Transtibial Transfemoral Able-Bodied


Number Count 12 8 28

Age (yrs) Mean (SD) 61.7 (12.6) 63.3 (12.0) 60.6 (7.8)

BMI (kg.m-2) Mean (SD) 27.3 (6.5) 25.4 (4.4) 25.6 (3.1)

Ageamp (yrs) Mean (SD) 40.9 (19.2) 38.9 (23.0) N/A

Time (yrs) Median (IQR) 17.0 (27.3) 22.5 (38.5) N/A

Use (hrs/day) Median (IQR) 15.5 (1.0) 13.0 (10.0) N/A

Types of Predictors


Age

Time since amputation Level of amputationGender

BMI

Questionnaires

- PEQ -

Ambulation

Appearance

Frustration

Perceived ResponseResidual Limb HealthSocial Burden

Sounds

Utility

Well-Being

Functional Outcomes

Step Length

Walking SpeedTUG Test

6MWD

Quantitative Gait

Parameters

Univariate Analysis

GDI

Age -0.13

Time 0.14

BMI -0.27

nSL 0.78

WS 0.76

TUGT -0.60

TWD 0.74

PF 0.38

AM 0.47

ρ = 0.70

BMI, body mass index; nSL, normalised step-length; WS, self-selected walking speed; TUG, timed-up-and-go test; TWD, timed walk distance; PF, physical functioning scale; AM, ambulation scale.

Multivariate Analysis – Regression Analysis 90

80

70

60

50

40

30

20

10

0

R2

One Type of Predictor Two Types of Predictors All

A B C A-B A-C B-C A-B-C

Predictor TypesA Demographics B Questionnaire Scales (PEQ) C Functional Outcome Measures

Multivariate Analysis

50

55

60

65

70

75

80

85

90

95

100R

2

i

AB

nSL

nSL

i

AB

nSL

nSL

tstand

i

AB

nSL

nSL

tstand

AM_C

i

AB

nSL

nSL

tstand AM_C

UT_G

AM_C: Rate your ability to walk in close spaces when using your prosthesisUT_G: Rate how much energy it took to use your prosthesis for as long as you needed it.

Summary

The gait deviation index could be predicted by: The distance walked in six minutes The patient’s perception of their own ability to ascend stairs The time taken to stand Chronological age

2. The Role of Gait Deviation in Patient Satisfaction

Kark and Simmons, Patient satisfaction following lower-limb amputation: the role of gait deviation. Prosthetics and Orthotics International, 2011. 35(2): 225 - 233


Characteristic Statistic Overall TF TT p

Number Count, n (%) 20 (100) 8 (40) 12 (60)

Aetiology

Trauma

Vascular

Count, n (%)

Count, n (%)

17 (85)

3 (15)

7 (35)

1 (5)

10 (50)

2 (10)

Gender

Male

Female

Count, n (%)

Count, n (%)

14 (70)

6 (30)

5 (25)

3 (15)

9 (45)

3 (15)

Age, years Mean (SD) 62.3 (12.1) 63.3 (12.0) 61.7 (12.6) 0.78

Ageamp , years Mean (SD) 40.1 (20.2) 38.9 (23.0) 40.9 (19.2) 0.83

Timeamp, years Median (IQR) 18.5 (34.3) 22.5 (38.5) 17.0 (27.3) 0.66

Satisfaction in the Prosthesis Evaluation Questionnaire

Abbreviation Question

SAhapyprosOver the past four weeks, rate how happy you have been with your current prosthesis.

SAsatprosOver the past four weeks, rate how satisfied you have been with your current prosthesis.

SAsatwalkOver the past four weeks, rate how satisfied you have been with how you are walking.

WBsincampOver the past four weeks, rate how satisfied you have been with how things have worked out since your

amputation.

WBqolOver the past four weeks, how would you rate your quality of life?

PCprostistHow satisfied have you been with the person who fit your current prosthesis?

PCcurtrainHow satisfied are you with the training you have received on using your current prosthesis?

PCalltrainOverall, how satisfied are you with the gait and prosthetic training you have received since your

amputation?

Patient Satisfaction

Satisfaction Measures Min Q1 Median Q3 Max p

SAhapypros7.7 47.8 82.1 90.8 100 0.85

SAsatpros3.9 48.7 80.1 95.8 100 0.16

SAsatwalk1.3 48.7 85.3 97.8 100 0.05

WBsincamp18.0 48.7 84.0 95.8 100 0.22

WBqol18.0 40.7 82.7 97.1 100 0.17

PCprostist14.1 51.9 91.7 98.7 100 0.49

PCcurtrain and PCalltrain were omitted from further analysis because 25% of respondents reported that they had not received gait training.

Correlates of Satisfaction

Participant demographics did not correlate significantly with any of the satisfaction measures

Level of amputation showed small correlation with satisfaction with walking

Self-report measures showed the strongest correlation Ambulation with: walking, well-being and quality of life Frustration with: happiness with prosthesis and satisfaction with prosthetist Perceived response with: quality of life Social burden with: walking, well-being, and quality of life

Performance-based and gait deviation did not correlate significantly with any of the satisfaction measures

Summary

In this cohort, gait deviation was relatively unimportant to the amputee

Self-reported functional ability in a variety of areas (including physical, mental and social domains) had the greatest influence on patient satisfaction

Further advocates for multidisciplinary rehabilitation

Future Work

Development of a standardised set of outcome measures, which will facilitate comparison between rehabilitation facilities, and ultimately result in improved outcomes for individuals with lower-limb amputation.

Thank you.Questions?

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