1. Mobility Studies Lauren Kark

2. Introduction

3. 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

4. Outcome Measures Functional Certain TS data e.g. walking speed Functional measures e.g. TUG test, TWT Time, money, clinical impracticality Perception Self-report measures e.g. questionnaires Gait Analysis Kinematics Kinetics Energy Expenditure TUG, timed-up-and-go; TWT, timed walk test

5. 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.

6. Hypothesis Perception Functional Gait Analysis Parameters

7. 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.

8. Experimental Design Visit UNSW? Yes Ethics Approval (HREC 07247) Subject recruitment Mail-out questionnaire studyAnalysis Subject participation complete No Physical testingAnalysis Subject participation complete Analysis of relationships between questionnaires and physical testing

9. Part 1. Questionnaire Study

10. Mail-Out Questionnaire  Demographics  Short-Form 36  Functional Measure for Amputees  Prosthesis Evaluation Questionnaire

11. Participant Characteristics 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) 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)

12. 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

13. Short-Form 36 – Influence of Pain Pain TypePFRPBPGHVTSFREMHPCSMCS Phantom sensations* Diff. in median 95% CI (median) p-value 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)

14. Locomotor Capabilities Index NOYES if someone helps me YES if someone is near me YES alone with a walking aid YES alone 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?      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?      NOYES if someone helps me YES if someone is near me YES alone with a walking aid YES alone without 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)     

15. Locomotor Capabilities Index

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

17. 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

18. Part 2. Physical Testing

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

20. Participant Characteristics Lower-Limb AmputeesAble-Bodied FemaleMaleFemaleMale Number (n)6141612 Age (yrs)62.5 (14.0)62.2 (11.7)60.0 (7.7)61.5 (8.2) BMI27.0 (7.6)26.3 (5.0)24.8 (3.4)26.7 (2.4) Level (n) Transtibial Transfemoral 3333 9595 N/A Time Since Amp (yrs)15.3 (14.0)25.1 (20.5)N/A Aetiology (n) Trauma Cancer Vascular Infection 41104110 91229122 N/A

21. Six-Minute Walk Distance

22. Oxygen Cost

23. Timed-Up-and-Go Test

24. Self-Selected Walking Speed

25. Step-Length

26. 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.

27. 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.

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

29. Gait Symmetry SLGDIGPSGVS HF GVS KF GVS ADP GVS HA GVS FPA Transtibial BFC BFS BFV BMG BMK BML BMM1 BMM2 BMO BMP BMS BMW Transfemoral AFC1 AFC2 AFK AMG AMM AMP AMR AMW 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

30. Part 3. Relationships

31. Outline 1.Predicting gait deviation 2.The role of gait deviation in patient satisfaction

32. 1. Predicting Gait Deviation

33. Participant Characteristics Summary StatisticTranstibialTransfemoralAble-Bodied Participant Characteristics NumberCount12828 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) Age amp (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

34. Types of Predictors Participant Characteristics Age Time since amputation Level of amputation Gender BMI Questionnaires - PEQ - Ambulation Appearance Frustration Perceived Response Residual Limb Health Social Burden Sounds Utility Well-Being Functional Outcomes Step Length Walking Speed TUG Test 6MWD Quantitative Gait Parameters

35. Univariate Analysis GDI Age-0.13 Time0.14 BMI-0.27 nSL0.78 WS0.76 TUGT-0.60 TWD0.74 PF0.38 AM0.47 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.

36. Multivariate Analysis – Regression Analysis 90 80 70 60 50 40 30 20 10 0 One Type of PredictorTwo Types of PredictorsAll ABCA-BA-CB-C A-B-C Predictor Types A DemographicsB Questionnaire Scales (PEQ)C Functional Outcome Measures

37. Multivariate Analysis t stand AM_C t stand AM_C UT_G 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.

38. Summary

39. 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

40. Participant Characteristics CharacteristicStatisticOverallTFTTp NumberCount, n (%)20 (100)8 (40)12 (60) Aetiology Trauma Vascular Count, n (%) 17 (85) 3 (15) 7 (35) 1 (5) 10 (50) 2 (10) Gender Male Female Count, n (%) 14 (70) 6 (30) 5 (25) 3 (15) 9 (45) 3 (15) Age, yearsMean (SD)62.3 (12.1)63.3 (12.0)61.7 (12.6)0.78 Age amp­, yearsMean (SD)40.1 (20.2)38.9 (23.0)40.9 (19.2)0.83 Time amp, yearsMedian (IQR)18.5 (34.3)22.5 (38.5)17.0 (27.3)0.66

41. Satisfaction in the Prosthesis Evaluation Questionnaire AbbreviationQuestion SA hapypros Over the past four weeks, rate how happy you have been with your current prosthesis. SA satpros Over the past four weeks, rate how satisfied you have been with your current prosthesis. SA satwalk Over the past four weeks, rate how satisfied you have been with how you are walking. WB sincamp Over the past four weeks, rate how satisfied you have been with how things have worked out since your amputation. WB qol Over the past four weeks, how would you rate your quality of life? PC prostist How satisfied have you been with the person who fit your current prosthesis? PC curtrain How satisfied are you with the training you have received on using your current prosthesis? PC alltrain Overall, how satisfied are you with the gait and prosthetic training you have received since your amputation?

42. Patient Satisfaction Satisfaction Measures MinQ1MedianQ3Maxp SA hapypros 7.747.882.190.81000.85 SA satpros 3.948.780.195.81000.16 SA satwalk 1.348.785.397.81000.05 WB sincamp 18.048.784.095.81000.22 WB qol 18.040.782.797.11000.17 PC prostist 14.151.991.798.71000.49 PC curtrain and PC alltrain were omitted from further analysis because 25% of respondents reported that they had not received gait training.

43. 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

44. 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

45. 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.

46. Thank you. Questions?