PHYT 622 Clinical Gross Anatomy

11/5/2018

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University of Delaware

Department of Physical Therapy Application of Clinical Anatomy: Let Palpation

Drive your Clinical Practice


Department of Physical Therapy Measuring Outcomes in Adults with Limb Loss

Dr. J. Megan Sions, PhD, DPT, PT

J. MEGAN SIONS, PHD, DPT, PT, OCS

P RI NC I P A L I NVESTI G A TOR

DELA W A RE LI MB LOSS STU DI ES

Measuring Outcomes in Adults with Limb-Loss:

An Update for Clinicians

Lower Limb Prosthesis Prescription and Training Considerations





Objectives

After this session, you will be able to...

1. Discuss the premise & evidence for objective evaluation of adults with limb loss.

2. Select evidence-based outcome measures to support your clinical assessments.

3. Prioritize examinations of adults with limb amputations to collect the most pertinent data given the evaluation goal.






Types of Data

Subjective

Clinical Metrics e.g. strength, range-of-motion

Screening Tests*

Self-Report Outcome Measures*

Performance-Based Outcome Measures*

Activity Monitoring Accelerometers (e.g. FitBit)

*will cover in this session






Outcome Measures

Self-Report

Prosthesis Use

Houghton

Physical Function

Prosthetic Evaluation Questionnaire-mobility section

Locomotor Capabilities Index

Balance-Confidence

Activities-Specific Balance Confidence Scale

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Outcome Measures

Performance-Based

Balance

Four Square Step Test

360° Turn Test

Gait

10 Meter Walk Test

Figure-of-8 Walk Test

Functional Mobility

Timed Up and Go

5 Times Sit-to-Stand

Amputee Mobility Predictor

Endurance

6 Minute Walk Test

2 Minute Walk Test






Prosthetist Perceptions (Hafner, et al. 2017)






Use & Barriers (Hafner, et al. 2017)

75% of prosthetists support outcome measurement use (Borrenpohl, et al. 2016)

38-67% routinely use (Borrenpohl, et al. 2016; Gaunard, et al. 2015)

Barriers (Hafner, et al. 2017)

Difficult to integrate into clinical routine

Difficult to set-up/administer

Difficult to select/interpret






Goal of Evaluation

Screening Cognition*

Subsequent Amputation*

Evaluative Fall Risk*

Predict Prosthesis Use/Nonuse*

Determine or Predict Functional Level (i.e. K-Level)*

Determine Optimal Prosthetic Componentry

Justify Need for Therapy Services

Return to Sport/High Level Activities *will cover in this session

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Cognition






Cognition (Miu, et. al 2016; LCD L33787)

Whom to Screen History of brain trauma or stroke

Older age

Self-reported

Memory difficulty or difficulty with ≥2 ADLs

Justification for certain prosthetic componentry

Need to (objectively) establish:

Will remember to charge device (memory)

Will respond to error alerts/alarms indicating malfunction (follows instructions)






Mini-CogTM

(Borson, et al. 2000; Tsoi, et al. 2015; Norris, et al. 2016)

Assesses memory & ability to follow instructions

Time to complete: ≤ 5 minutes

Not influenced by education level

May not detect mild cognitive impairment

Dementia (cut-point < 3): Sensitivity: 91% (95% CI: 80-96%)

Specificity: 86% (95% CI: 74-93%)






Mini-CogTM

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Mini-CogTM




Mini CogTM Lab




Subsequent Amputation






Subsequent Amputation (Gurney, et al. 2018)

Cohort study of patients with diabetes

↑ comorbidity burden

Peripheral vascular disease

↑ independent risk

Prior amputation Minor

10-fold ↑ risk (95% CI: 7.8, 12.8)

Major

20-fold ↑ risk (95% CI: 17.8, 25.5)

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Pulse Integrity (Adams, et al. 2018)

Population Non-traumatic transmetatarsal

amputation

3 year follow-up

Non-palpable pedal pulses 3X odds of proximal amputation

(95% CI: 1.8, 5.1)

2X odds of dying (95% CI: 0.9, 2.9)

>2X odds of post-operative non-healing (95% CI: 1.4, 4.3)






Pedal Pulses

Presence/Absence (Brearley, et al. 1992)

Grading 4+ = bounding

3+ = increased

2+ = normal

1+ = weak

0 = absent






Pedal Pulses (Armstrong, et al. 2010)




Pulse Palpation Lab

Mosby's Medical Dictionary, 9th edition. ©

2009, Elsevier.

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Fall Risk






Fall Risk

>2X that of the general population (Talbot, et al. 2005)

17-50% of those that fall sustain an injury (Kulkarni, et al. 1996; Miller.

et al. 2001; Pauley, et al. 2006; Wong, et al. 2016)

Prior fall is a major risk factor for subsequent falls (Kalula, et al.

2016)

Risk factors (Hunter, et al. 2016)

o Advanced age*

o Concurrent comorbidities*

o # prescription medications*

o Lower-extremity muscle weakness*

o Dysvascular etiology

o Transfemoral amputation (post-acute phase)

*risk factors shared with

older adult population






Fall Risk (Dite, et al. 2007)

Adults with unilateral transtibial amputation

Post-discharge from rehabilitation & 6 months later

Multiple fallers (n=13) vs. Non-multiple fallers (n=27)

Performance-based outcome measures Four Square Step Test

≥ 24 seconds (Sn=92%; Sp =93%)

Timed Up and Go

≥ 19 seconds (Sn=85%, Sp=74%)

180 Degree Turn Test

≥ 3.7 seconds (Sn=85%, Sp=78%)

≥ 6 steps (Sn=100%, Sp=74%)






Four Square Step Test (Dite & Temple, 2002; Highsmith, et al. 2016; Roffman, et al. 2016; Fatone, et al. 2017;

Jefferson, Sions, et al. 2018)

“Try to complete the sequence as fast as possible without touching the canes. Face forward during the entire sequence (if possible). Ready? Begin.”

Allowed to turn if stepping over the sticks backwards or to the side is not possible

Demonstrate with instructions

Allow 1 practice

Test-retest reliability established for adults with unilateral lower-limb loss

Best/Average of 2 trials

MDC Best of 2 trials: 1.22 seconds

Average of 2 trials: .34 seconds

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Timed Up and Go (TUG) (Schoppen, et al. 1999; Miller, et al. 2001, 2004; Resnik, et al. 2011)

Standard chair with armrests seat height: 40-50 cm

Normal pace

“On the word ‘go’, stand up from the chair, walk to the line on the floor, turn, walk back to the chair and sit down.”

Stop timer when buttock hits chair

1 practice; 1 timed trial

Assistive Device prn






TUG (Schoppen, et al. 1999; Miller, et al. 2001, 2004; Resnik, et al. 2011)

Reliable & Valid

MDC: 3.6 sec

Ceiling effect (Deathe and Miller,

2005; Gremeaux, et al. 2012)






Fall Risk TAKE-HOME

Consider testing for likelihood of multiple falls FSST & TUG

What patients? Unilateral transtibial amputation

When? Within first year post-amputation




Prosthesis Use vs. Nonuse

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Prosthesis Use vs. Nonuse (Roffman, et al. 2016)






Criteria for Prosthesis Nonuse Permanent abandonment for locomotion

Wear for cosmesis only

Users (n=165) vs. Nonusers (n=36) Nonuse

Due to…

Prosthesis/Residual/Sound limb issues

Comorbidities

Pain

Falls/Fear-of-falling

↑ energy costs

↓ balance

Unable to don







Performance Tests Four Square Step Test

≥ 36.6 seconds (Sn=80%, Sp=71%)

Timed Up and Go

≥ 21.4 seconds (Sn=75%, Sp=78%)

6 Minute Walk Test

≤191 meters (Sn=80%, Sp=71%)

10 Meter Walk Test (at self-selected speed)

≤.44 meters/second (Sn=66%, Sp=75%)







6 Minute Walk Test (6MWT)

(Lin, et al. 2008; Scivoletto, et al. 2011; Harada, et al. 1990; Rikli, et al. 1998; King, et

al. 2000; Gailey, et al. 2002; Bellet, et al. 2011; Resnik, et al. 2011; Reid, et al. 2015)

• “Cover as much ground as possible in 6 minutes. While I want you to walk as fast possible, I want you to do so safely. You may rest at any point and sit if absolutely necessary, but the clock will not stop so please start walking again as soon as you are able. To avoid limiting your speed, we will refrain from conversation. I will walk with you and give you time updates. Ready? Begin.”

• Assistive device allowed

• Reliable & Valid

• MDC = 45 meters

5 yards

100 feet (30 meters)

20 yards

COURSE LAYOUT

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10 Meter Walk Test (Bohannon, et al. 1996, 1997, 1999; Franchignoni, et al. 2004; Deathe and Miller, 2005)

Reliability unknown

Average 3 trials

Self-selected/fast speeds

Assistive device allowed

2 meters

2 meters

6 meters






Prosthesis Nonuse TAKE-HOME

Consider testing for likelihood of prosthesis nonuse FSST, TUG, 6MWT, 10MWT (self-selected speed)

What patients? ≥1 major lower-limb amputation

Ambulatory prior to surgery

Community-living

When? Within first 1-2 years post-amputation




Questions?




K-Level Determination

mailto:[email protected]

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Excerpted from CMS Coverage Indications, Limitations, and Medical Necessity; printed 10/16/2014.

K0 Does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.

K1 Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of a limited and unlimited household ambulatory.

K2

Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator.

K3

Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to transverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.

K4 Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

Functional Level Classification









K2


K3









K-Level Determination

Historically Subjective assignment by single practitioner

team-based assignment

informed by objective outcome measures

6 Minute Walk Test

Amputee Mobility Predictor (AMP)

• With Prosthesis (AMPPro)

• Without Prosthesis (AMPnoPro)

Future Team based & informed by a battery of outcome measures

Self-report & performance based

Battery may vary based on patient’s functional abilities






6MWT (Gailey, et al. 2002)

May help differentiate between functional K-levels

Functional Level

Mean ± SD (m)

Range (m)

K0-1 50 ± 30 4-96

K2 190 ±111 16-480

K3 299 ± 102 48-475

K4 419 ± 86 264-624

(Gailey, et al. 2002)

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Amputee Mobility Predictor: With Prosthesis (AMPPro)

21 items

0-1/2 per item

47 point maximum

Reliable (Gailey, et al. 2002; Resnik and Borgia,

2011)

Valid (Gailey, et al. 2002)

MDC=3.4 points (Resnik and Borgia, 2011)

May help to differentiate between K-levels (Gailey, et al. 2002)

Level AMPPRO

Mean ± SD

K0-K1 25.0 ± 7.4

K2 34.7 ± 6.5

K3 40.5 ± 3.9

K4 44.7 ± 1.8






Amputee Mobility Predictor: No Prosthesis (AMPnoPro)

(Gailey, et al. 2002)

21 items

0-1/2 per item

43 point maximum

Reliable & Valid

K Level

AMPnoPRO:

Mean +/- SD

K01-K1 9.7 +/- 9.5

K2 25.3 +/- 7.3

K3 31.4 +/- 7.4

K4 38.5 +/- 3.0




K2 versus K3









K2


K3




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Houghton Scale (Wong, et al. 2016)

Classification of community-dwelling adults Aged 55±16

years

7±13 years post-amputation






Houghton Scale (Houghton, et al. 1992; Miller, et al. 2001; Devlin, et al. 2004; Condie, et al. 2006)

4 items

0-12 points

Reliable

Valid

MCID: 1 point

Floor/Ceiling Effects

Houghton Scale of Prosthetic Use

1. Do you wear your

prosthesis? 0

< than 25% of waking hours (1-3

hours)

1 25-50% of waking hours (4-8 hours)

2

> than 50% of waking hours (> 8

hours)

3 All waking hours (12-16 hours)

2. Do you use your

prosthesis to walk: 0

Just when visiting the doctor of

limb-fitting center

1 At home but not to go outside

2 Outside the home on occasion

3 Inside & outside all the time

3. When going outside

wearing your prosthesis,

do you:

0 Use a wheelchair

1 Use 2 crutches, 2 canes, or a walker

2 Use one cane

3 Use nothing

4a-4c. When walking with

your prosthesis outside, do

you feel unstable when…






Prosthetic Evaluation Questionnaire-Mobility Section (PEQ-m)

(Franchignoni, et al. 2007; Resnik & Borgia. 2011; Hafner, et al. 2005, 2016)

Over the past 4 weeks,

please rate your ability

in the following

activities when using

your prosthesis:

Unable or

hardly able at

all

(ability

<5%)

High

difficulty

(ability

5-34%)

Moderate

difficulty

(ability

35-64%)

Little difficulty

(ability

65-95%)

No

problems

or almost

fully able

(ability

> 95%)

0 1 2 3 4

1. To walk

2. To walk in confined spaces

3. To walk upstairs Reliable & Valid

2 Sub-Scales: Ambulation (8-items) & Transfers (4-items)

Average (or Total) Items; Higher Scores = Better Function

MDC (Average)= 0.3-0.6 points

Ceiling Effect

Available at: http://www1.udel.edu/PT/clinic/measures/Revised%20Prosthesis%20Evaluation%20Questionnaire_mobility%20section.pdf






Activities-Specific Balance Confidence Scale (ABC-16)

(Sakakibara, et al. 2011; Hafner, et al. 2016)

5 response options

Reliable & Valid

Average the 16 items

MDC: 0.5 points

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2 Minute Walk (2MWT) (Brooks, et al. 2002; Resnik, et al. 2011; Pin, 2014; Reid, et al. 2015; Wong et al. 2016)

May not capture endurance

Reliable & Valid

MDC=34 meters

≥113 meters = K3/K4 (community-level ambulation potential)






Potential Battery

K2 vs. ≥K3 classification Consider collection of measures (Wong, et al. 2016)

Houghton Scale


Activities-Specific Balance Confidence Scale

Timed Up and Go

2-Minute Walk Test

≥113 meters= K3 level or higher (i.e. K4)

What patients?

Community-dwelling, amputation(s) of any level(s)

When? Post-acute amputation period






Patient Case 1






Subjective

73 year-old male with right transtibial amputation

Evaluation for replacement prosthesis & componentry upgrade?

Amputation 2 years prior After unsuccessful resolution of an infection following ankle fusion

Fit with initial prosthesis 4 months following amputation

Current Complaints Blisters at distal end of residual limb; excessive sock ply

Environment/Social History Lives alone in two-story home with 12 steps within home

External environment: hilly

Consultant; 20 steps to enter work building

Recreational golfer

Pertinent Past Medical History: diabetes, peripheral vascular disease, hypertension, & hearing loss

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K2


K3









Objective

Constitutional Height: 5 ft, 10 in

Weight: 205 pounds

BMI: 29.4 kg/m2

Vital Signs Blood pressure: 148/98 mmHg

Heart rate: 88 bpm

Cardiovascular

LE edema: none

LE Pulses: palpable throughout

Skin

Blisters of residual limb

Cognition

Mini-Cog: 5/5

Socket Fit Comfort Score

2/10

Vital Signs (American Thoracic Society, 2002; ACSM, 2011)

Contraindications to Exertion: • Systolic blood pressure > 180 mmHg

• Diastolic blood pressure > 100 mmHg

• Resting Heart Rate > 120 bpm






Socket Fit Comfort Score (Hanspal, et al. 2003; Safari & Meier, 2015; Hafner, et al. 2016)

Reliable & Valid

Sensitive to change

MDC: 3 points

“If 0 represents the most uncomfortable socket fit you can imagine and 10

represents the most comfortable socket fit, how would you score the comfort of

the socket fit of your prosthesis at this moment?”

0 1 2 3 4 5 6 7 8 9 10

___________________________________________________






Outcome Measure Evaluation

Houghton Scale Community-Ambulator: ≥9 Limited-Community: 6-8

12/12

Prosthetic Evaluation Questionnaire-Mobility Section Community-Ambulator: 36.6±9.9 Limited-Community: 26.4±8.8

47/48

Activities-Specific Balance Confidence Scale Community-Ambulator: 2.9±0.8 Limited-Community: 1.7±0.7

3.8/4.0

Timed Up and Go Community-Ambulator: 9.9±3.5 sec Limited-Community: 17.7±8.1 sec

7.15 sec

Gait Speed (10MWT)-Fast Community-Ambulator: >.8-1.2 m/sec Limited-Community: .5-.8 m/sec

1.31 m/sec

Interpretation data from Wong, et al. 2016

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12/12


47/48


3.8/4.0


7.15 sec


1.31 m/sec









12/12


47/48


3.8/4.0


7.15 sec


1.31 m/sec









12/12


47/48


3.8/4.0


7.15 sec


1.31 m/sec










K2


K3




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K3 versus K4









K2


K3


K4

Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.






K3 versus K4 (Sions, et al. 2018, Arch Phys Med Rehabil)

Inclusion criteria Aged ≥ 18 years

Community-dwelling

Unilateral transfemoral or transtibial amputation

K-level determined by multidisciplinary team







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Outcome Measures

Self-Report Locomotor Capabilities Index


Performance-Based Timed Up and Go

10 Meter Walk Test

Amputee Mobility Predictor

6 Minute Walk Test






Locomotor Capabilities Index (Franchignoni, et al. 2004, 2007; Condie, et al. 2006; Gaultier-Gagnon, et al. 2006)

Perceived capability 14 items

0-4 points/response (maximum: 56)

Reliable & Valid

Responsive to Change

Available at: http://www.austpar.com/portals/gait/docs-and-presentations/LCI.doc







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Potential Battery

K3 vs. K4 classification Consider collection of performance-based measures

Timed Up and Go

10 Meter Walk Test (SS and/or F)

AMPPro

6 Minute Walk Test

What patients? Community-dwelling

Unilateral transtibial/transfemoral

When? > 5 years post-amputation




WHAT SELF-REPORT MEASURE MIGHT BE APPROPRIATE FOR

HIGHER-FUNCTIONING ADULTS WITH LOWER-LIMB LOSS

(I .E. K3 AND K4)

WHO ARE USING A PROSTHESIS?






Prosthetic Limb Users Survey of Mobility (PLUS-M)

Prosthetic users aged 18+years

Perceived ability to carry out actions that require use of both lower limbs Household ambulation to outdoor recreational activities

Available at: http://plus-m.org/about.html






PLUS-M (Hafner, et al. 2016; 2017)

Reliable & Valid

7-item & 12-item

Paper & Computer Adaptive Tests (CAT)

Percentile Ranking

T-scores 23.3-69.9 (7-item); 21.8-71.4 (12-item); 19.2-76.6 (CAT)

50 represents mean mobility of a reference sample (n=1091 lower limb prosthetic users)

↑ scores = greater mobility

MDC=4.50 (paper, 12-item) - 6.42 (CAT)

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K3 versus K4: Emerging Research






5 Times Sit-to-Stand (5XSTS) (Jefferson, Sions, et al. 2018)

Seated in chair with arms folded.

“Stand up straight and sit down as quickly as possible 5 times without stopping.”

Start stopwatch on “Begin”.

Stop stopwatch when standing 5th repetition.

2 trials (2 minute recovery between trials)

Reliable for best/average trial time in adults with unilateral lower-limb loss MDC:

Best of 2 trials: .67 sec

Average of 2 trials: .54 sec






Figure-of-8 Walk Test (Jefferson, Sions, et al. 2018)

“Walk around these cones in a figure-8 pattern. Start in the middle of the 2 cones with your toes on the line. Walk as quickly as possible while trying to complete the walk smoothly without any hesitation or stopping. Ready? Begin.”

1 demonstration; 2 timed trials

With/without assistive device

Count number of steps needed to complete the course

Reliable for best/average speed & best/average # of steps in adults with unilateral lower-limb loss

MDC Time: .35-.37 sec

# of steps: 1 step






360° Turn Test (Jefferson, Sions, et al. 2018)

Stand with toes on line on floor

“Turn 360 degrees as quickly and safely as possible (on ‘go’).

No assistive device

Stopwatch to record total time

2 trials toward the prosthetic side Reliable for best/average

MDC = .18-.20 sec

2 trials toward the sound-limb side Reliable for best/average

MDC = .15 sec

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Modified Four Square Step Test (mFSST)

(Jefferson, Sions, et al. 2018)

“Try to complete the sequence as fast as possible without touching the tape. Face forward during the entire sequence (if possible). Ready? Begin.”

Allowed to turn if stepping over the tape backwards or to the side is not possible

Less floor effect than standard FSST

Demonstrate with instructions

Allow 1 practice

Best/Average of 2 trials

Test-retest reliability established for adults with unilateral lower-limb loss

MDC Best Trial: .95 seconds

Average of 2 Trials: .31 seconds






Patient Case 2






Subjective

62 year-old male with left transtibial amputation

Evaluation for replacement prosthesis

Amputation 5 years prior 2° to wound infection

Current Complaints Socket is too big, uncomfortable, & not secure with walking

Environment/Social History Lives alone in single-story home with 4 steps to enter home

External environment: flat

Building Engineer: walks ≥ 5 miles/day, carries ≥ 50#, ascends/descends ladders

Recreational Activity: line dancing

Pertinent Past Medical History: Diabetes Mellitus, Kidney Problems









K2


K3


K4


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Objective

Constitutional Height: 6 ft, 2 in

Weight: 200 pounds

BMI: 25.3 kg/m2

Vital Signs Blood pressure: 118/78 mmHg

Heart rate: 66 bpm

Cardiovascular

LE edema: none

LE Pulses: Non-palpable

RIGHT posterior tibial & dorsalis pedis

LEFT popliteal

Skin

Unremarkable

Cognition

Mini-Cog: 5/5

Socket Fit Comfort Score

0/10

Vital Signs (American Thoracic Society, 2002; ACSM, 2011)

Contraindications to Exertion: • Systolic blood pressure > 180 mmHg

• Diastolic blood pressure > 100 mmHg

• Resting Heart Rate > 120 bpm







PLUS-M

Raw Score=56/60 T-score: 61.0

Percentile: 86.4%

Modified Four Square Step Test K3: 9.16-10.44 ; K4: 7.68-8.95 sec (unpublished)

7.80 sec

Timed Up and Go K3: 11.74-13.89; K4: 7.92-10.98 sec*

8.01 sec

Gait Speed (10MWT)-Self-Selected K3: .80-.96; K4: 1.11-1.32 m/sec*

1.30 m/sec

6 Minute Walk Test K3: 273-349; K4: 373-481 m*

475 m

*Interpretation data from Sions, et al. 2018

Objective







PLUS-M


Percentile: 86.4%

Modified Four Square Step Test K3: 9.16-10.44; K4: 7.68-8.95 sec (unpublished)

7.80 sec


8.01 sec


1.30 m/sec


475 m


Objective







PLUS-M


Percentile: 86.4%


7.80 sec


8.01 sec


1.30 m/sec


475 m


Objective

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PLUS-M


Percentile: 86.4%


7.80 sec


8.01 sec


1.30 m/sec


475 m


Objective







PLUS-M


Percentile: 86.4%


7.80 sec


8.01 sec


1.30 m/sec


475 m


Objective









K2


K3


K4





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Questions?

[email protected]


PHYT 622 Clinical Gross Anatomy

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Transcript of PHYT 622 Clinical Gross Anatomy