Transcript Slide 1

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
Perception
Functional
Gait Analysis
Self-report measures
Certain TS data
e.g. questionnaires
e.g. walking speed
Kinematics
Kinetics
Energy Expenditure
Functional measures
e.g. TUG test, TWT
Time, money, clinical impracticality
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
Ethics Approval
(HREC 07247)
Subject recruitment
UNSW?
Mail-out questionnaire study
Visit
Analysis
No
Subject
participation
complete
Yes
Analysis
Physical testing
Analysis of relationships
between questionnaires
and physical testing
Subject
participation
complete
Part 1. Questionnaire Study
Mail-Out Questionnaire
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Demographics
Short-Form 36
Functional Measure for Amputees
Prosthesis Evaluation Questionnaire
Participant Characteristics
n (%)
Gender (135)
Male
Female
96 (71.1)
39 (28.9)
n (%)
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)
Time Since Amp (123)
Level (135)
Transfemoral
Transtibial
Other
42 (31.1)
66 (48.9)
27 (20.0)
Aetiology (131)
Cancer
Surgical
Trauma
Vascular
10 (7.5)
19 (14.3)
52 (39.1)
51 (38.3)
[0 – 1]
(1 – 5)
[5 – 10)
[10 – 20]
>20
Age at Amp (125)
<35
35 – 44
45 – 54
55 – 64
65 – 74
75+
13 (10.6)
30 (24.4)
30 (24.4)
18 (14.6)
32 (26.0)
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)
55
Adjusted Mean
50
45
40
35
30
PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
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
Phantom sensations*
Diff. in median
95% CI (median)
p-value
PF
RP
BP
GH
VT
SF
RE
MH
PCS
MCS
10
-5-20
0.15
6
-6-19
0.35
10
-2-20
0.23
3
-5-12
0.51
9
0-19
0.06
7
0-13
0.57
4
0-8
0.52
-3
-10-5
0.99
4
-1-8
0.08
1
-3-5
0.53
Phantom pain
Diff. in median
95% CI (median)
p-value
8
-5-20
0.22
13
0-25
0.04
12
0-23
0.02
5
-5-15
0.26
10
0-19
0.04
13
0-25
0.03
9
0-17
0.02
2
-5-9
0.63
4
0-8
0.04
4
1-8
0.02
Residual limb pain
Diff. in median
95% CI (median)
p-value
8
-4-20
0.14
13
0-25
0.04
19
10-38
0.00
13
5-22
0.01
9
0-19
0.03
7
0-13
0.06
9
0-17
0.04
5
0-10
0.07
5
2-9
0.01
4
0-7
0.03
Intact limb pain
Diff. in median
95% CI (median)
p-value
10
0-20
0.13
13
0-25
0.02
10
0-21
0.09
13
5-20
0.01
9
0-19
0.01
7
0-13
0.04
8
0-17
0.09
5
0-10
0.04
4
0-9
0.03
4
0-8
0.04
Back pain
Diff. in median
95% CI (median)
p-value
13
0-25
0.02
13
0-25
0.1
21
10-31
0.00
6
-3-15
0.20
9
0-19
0.01
7
0-13
0.13
8
0-17
0.06
5
0-10
0.07
5
2-9
0.01
3
-1-7
0.10
* Defined as an awareness of pressure and proprioception in the phantom limb (Legro et al, 1998)
Locomotor Capabilities Index
NO
YES
YES
YES
YES alone
if someone helps
me
if someone is near
me
alone with a
walking aid
without 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?





Get up from the floor?
(for example: if you had fallen)





d.
Walk in the house?
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


e.
Walk outside on EVEN ground?
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



f.
Walk outside on UNEVEN ground? (for example: grass, gravel, slope)











NO

YES

YES

YES

YES alone
if someone helps me
if someone is near
me
alone with a walking
aid
without a walking aid
c.
g.
h.
Walk outside in bad weather?
(for example: rain or snow)
Go upstairs holding a banister?
i.
Go downstairs holding a banister?





j.
Step up onto the pavement?
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k.
Step down from the pavement?
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
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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
70
60
Score
50
40
30
20
10
0
Overall
Above Knee
Below Knee
Other
Prosthesis Evaluation
Questionnaire
100
90
*
Score ( /100)
80
70
*
*
*
*
UT
WB
60
50
40
30
20
10
0
AM
AP
FR
PR
Above-Knee
RL
SB
SO
Below-Knee
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
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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
3
3
9
5
N/A
Time Since Amp (yrs)
15.3 (14.0)
25.1 (20.5)
N/A
Aetiology (n)
Trauma
Cancer
Vascular
Infection
4
1
1
0
9
1
2
2
N/A
Six-Minute Walk Distance
700
600
Distance (m)
500
400
300
200
100
0
Above-Knee
Below-Knee
Able-Bodied
Oxygen Cost
Oxygen Consumption (J/kg.m)
7
6
5
4
3
2
1
0
Above-Knee
Below-Knee
Able-Bodied
Timed-Up-and-Go Test
TUG Test Summary
20.0
Time (secs)
17.5
15.0
12.5
10.0
7.5
5.0
AB
AK
Plain
BK
AB
AK
BK
Cognitive
AB
AK
Manual
BK
Self-Selected Walking Speed
Step-Length
Step-Length
Normalised Step-Length (-)
1
0.9
0.8
0.7
0.6
0.5
Above-Knee
Below-Knee
Average
Prosthetic
Intact
Able-Bodied
Gait Summary Measures – Gait
Deviation Index
GDI - Limb Comparison
0.000
0.025
0.002
100
GDI
90
80
70
60
50
Prosthetic
Intact
Above-Knee
Overall
Below-Knee
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
GPS (degrees)
14
0.011
0.046
0.015
12
10
8
6
4
2
0
Prosthetic
Intact
Above-Knee
Overall
Below-Knee
Kark, L. et al., Use of gait summary measures with lower limb amputees, Gait and Posture. 2011; (35(2): 238 – 243.
Gait Summary Measures
GDI versus GPS
110
100
GDI
90
80
70
60
AK
BK
50
4
5
6
7
8
9
GPS (degrees)
10
11
12
13
Kark, L. et al., Use of gait summary measures with lower limb amputees, Gait and Posture. 2011; (35(2): 238 – 243.
Gait Symmetry
SL
Transtibial
BFC
BFS
BFV
BMG
BMK
BML
BMM1
BMM2
BMO
BMP
BMS
BMW
Transfemoral
AFC1
AFC2
AFK
AMG
AMM
AMP
AMR
AMW
GDI
GPS
GVSHF
GVSKF
GVSADP
GVSHA
GVSFPA
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
Age
Participant
Characteristics
Time since amputation
Level of amputation
Gender
BMI
Ambulation
Appearance
Frustration
Questionnaires
- PEQ -
Perceived Response
Residual Limb Health
Social Burden
Sounds
Utility
Well-Being
Functional
Outcomes
Step Length
Walking Speed
TUG 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.
Predictor Types
A Demographics
B Questionnaire Scales (PEQ)
C Functional Outcome Measures
Multivariate Analysis – Regression
One Type of Predictor
Two Types of Predictors
All
Analysis
90
80
70
60
50
40
30
20
10
0
A
B
C
A-B
A-C
B-C
A-B-C
AM_C: Rate your ability to walk in close spaces when using your prosthesis
UT_G: Rate how much energy it took to use your prosthesis for as long as you needed it.
Multivariate Analysis
100
95
90
85
80
75
70
65
60
55
50
nSLAB
nSLi
nSLAB
nSLi
tstand
nSLAB
nSLi
tstand
AM_C
nSLAB
nSLi
tstand
UT_G
AM_C
Summary
𝐺𝐷𝐼 = 24.8 + 0.14(6𝑀𝑊𝐷) − 0.22(𝐴𝑀𝐶 ) + 4.70(𝑡𝑠𝑡𝑎𝑛𝑑 ) + 0.21(𝑎𝑔𝑒)
2
2
𝑅𝑎𝑑𝑗
= 90.2%; 𝑅𝑝𝑟𝑒𝑑
= 86.2%
 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)
Trauma
Count, n (%)
17 (85)
7 (35)
10 (50)
Vascular
Count, n (%)
3 (15)
1 (5)
2 (10)
Male
Count, n (%)
14 (70)
5 (25)
9 (45)
Female
Count, n (%)
6 (30)
3 (15)
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
Aetiology
Gender
Satisfaction in the Prosthesis
Evaluation
Questionnaire
Abbreviation
Question
SAhapypros
Over the past four weeks, rate how happy you have been with your current prosthesis.
SAsatpros
Over the past four weeks, rate how satisfied you have been with your current prosthesis.
SAsatwalk
Over the past four weeks, rate how satisfied you have been with how you are walking.
WBsincamp
Over the past four weeks, rate how satisfied you have been with how things have worked out since your
amputation.
WBqol
Over the past four weeks, how would you rate your quality of life?
PCprostist
How satisfied have you been with the person who fit your current prosthesis?
PCcurtrain
How satisfied are you with the training you have received on using your current prosthesis?
PCalltrain
Overall, 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
SAhapypros
7.7
47.8
82.1
90.8
100
0.85
SAsatpros
3.9
48.7
80.1
95.8
100
0.16
SAsatwalk
1.3
48.7
85.3
97.8
100
0.05
WBsincamp
18.0
48.7
84.0
95.8
100
0.22
WBqol
18.0
40.7
82.7
97.1
100
0.17
PCprostist
14.1
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?