Mobility Studies Lauren Kark Introduction Outcome Measures Locomotor

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 § § 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) 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 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 Type Phantom sensations* Diff. in median 95% CI (median) p value PF 10 5 20 0. 15 RP 6 6 19 0. 35 BP 10 2 20 0. 23 GH 3 5 12 0. 51 VT 9 0 19 0. 06 SF 7 0 13 0. 57 RE 4 0 8 0. 52 MH 3 10 5 0. 99 PCS 4 1 8 0. 08 MCS 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 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 a. b. Get up from a chair? 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) Walk in the house? Walk outside on EVEN ground? Walk outside on UNEVEN ground? (for example: grass, gravel, slope) d. e. f. g. h. i. j. k. l. m. n. Walk outside in bad weather? (for example: rain or snow) Go upstairs holding a banister? Go downstairs holding a banister? Step up onto the pavement? Step down from the pavement? Go up a few steps without a handrail? Walk down a few steps without a handrail? Walk while carrying an object? (for example: cup of tea, newspaper) NO YES if someone helps me if someone is near me YES alone with a walking without a walking aid YES alone if someone helps me if someone is near me alone with a walking aid without a walking aid

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 § § § 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 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

Self-Selected Walking Speed

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

Gait Summary Measures 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 BMM 1 BMM 2 BMO BMP BMS BMW Transfemoral AFC 1 AFC 2 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 Questionnaire s PEQ Perceived Response Residual Limb Health Social Burden Sounds Utility Well Being Functional Outcomes Step Length Walking Speed TUG Test 6 MWD Quantitative Gait Parameters

Univariate Analysis GDI Age 0. 13 Time 0. 14 BMI 0. 27 n. SL 0. 78 WS 0. 76 TUGT 0. 60 TWD 0. 74 PF 0. 38 AM 0. 47 ρ = 0. 70 BMI, body mass index; n. SL, 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.

R 2 Predictor Types A Demographics B Questionnaire Scales (PEQ) C Functional Outcome Measures Multivariate Analysis – Regression Analysis 90 One Type of Predictor Two Types of Predictors All 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 R 2 80 75 70 65 60 55 50 tstand AM_C tstand UT_G AM_C

Summary

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 Count, n (%) 17 (85) 7 (35) 10 (50) Vascular Count, n (%) 3 (15) 1 (5) 2 (10) Gender Male Count, n (%) 14 (70) 5 (25) 9 (45) Female Count, n (%) 6 (30) 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 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 Measures Min Q 1 Median Q 3 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?