mobility studies lauren kark. introduction outcome measures locomotor capabilities index barthel...
TRANSCRIPT
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
Above-Knee Below-Knee
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)
Above-Knee Below-Knee
0.011 0.046 0.015
Kark, L. et al., Use of gait summary measures with lower limb amputees, Gait and Posture. 2011; (35(2): 238 – 243.
Gait Summary Measures
13121110987654
110
100
90
80
70
60
50
GPS (degrees)
GD
I
AKBK
GDI versus GPS
Kark, L. et al., Use of gait summary measures with lower limb amputees, Gait and Posture. 2011; (35(2): 238 – 243.
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
Participant Characteristics
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
Participant Characteristics
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
Participant Characteristics
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?