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Outcome Measurement Tools

Use of the Prosthesis Evaluation Questionnaire (PEQ)

Boone, David Alan BS, CP, MPH, PhD; Coleman, Kim Lisa BA, MS

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JPO Journal of Prosthetics and Orthotics: January 2006 - Volume 18 - Issue 6 - p P68-P79
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The perspective of the user of a prosthesis or orthosis is generally acknowledged to be an important part of defining the function of the devices they use. Even with optimal biomechanical action, the user could have very strong negative reaction due to other matters of importance to them. Because of this, practitioners and researchers will ask questions of users to elicit such information, but these are rarely developed in a formal way. While still providing important insight for the researcher or clinician, such informal questioning must be analyzed with great care because it has an unknown degree of content validity (does it measure what we think it measures?) and stability (would it measure the same under similar circumstances but at a different time, or with a different subject?). These limitations are particularly significant when we wish to compare the results of different studies.

Use of previously validated questionnaires is one way to gather the users’ perceptions in a way that allows such comparisons to be made. It is not practical for anyone interested in functional outcomes in prosthetics and orthotics to develop and validate a questionnaire. It requires rigorous development and statistical testing. In the case of the Prosthesis Evaluation Questionnaire (PEQ), the team at Prosthetics Research Study in Seattle undertook the challenge to create a general outcomes measurement tool specific to lower limb prosthesis use. The PEQ has been shown to have a high degree of content validity and temporal stability. The statistical validation of the PEQ has been described previously.1,2 As noted above, this effort was not trivial. Development of the PEQ took about 4 years, participation of a large number of subjects with amputations, full-time staff dedicated to the project, the time of many researchers and clinicians, and hundreds of thousands of dollars in project costs.

The original goal has been accomplished. The PEQ is a relatively simple-to-use instrument that can be used to answer a wide variety of questions pertaining to the functional outcomes of lower limb prostheses. Questions specific to upper limb prosthesis use are not included, though some relevant sections may be used. It continues to be used by many research groups and clinicians.


A key rationale behind the development of the PEQ was a desire for an instrument that would be sensitive to changes specific to prosthesis function. For example, a prosthesis that was quieter may have been very significant to the user, but this important effect probably would not be detected by any of the existing rehabilitation outcomes measurement instruments such as the SF-36 Short Form Physical Function, Functional Independence Measure (FIM), Sickness Impact Profile (SIP), Barthel Index for Activities of Daily Living (ADL), Frenchay Activities Index for Instrumental Activities of Daily Living (IADL), Functional Status Questionnaire (FSQ), Nottingham Health Profile (NHP), Duke Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire (Duke OMFAQ) or Quality of Well Being Scale (QWB). Smith et al.3 used the SF-36 with 20 unilateral transtibial amputees.3 The subjects scored similarly to age-matched control subjects except in the areas of physical function, pain, and role limitations due to physical health problems. The results indicated that amputees differ from nonamputees but did not provide information that specifically identified limitations caused by their prostheses.

To aid in creation of the PEQ, prosthesis users participated in focus group meetings and online solicitations to determine what issues are important to users. These specific items were delineated, combined into groups of related questions and refined in an iterative process. Following this user-centered approach, the PEQ was designed as a self-report visual analog scale (VAS) style questionnaire. The respondent is free to answer each question on a continuum that relates to his or her perception of how ultimately good or poor prosthetic function may be.

The 54 questions of the PEQ are organized into nine functional domain scales, each reflecting a major area of concern for persons with amputations, such as “utility” and “appearance.” Each domain scale can be used and scored independent of the others. This provides considerable flexibility for the investigator or clinician to focus the content of the questionnaire to the topic(s) of interest. In turn, this minimizes the burden on the subject and reduces data analysis to only the most relevant questions. The domains and the issues addressed by each scale are listed in Table 1.

Table 1
Table 1:
Contents of the PEQ domain scales

The PEQ also contains items that are not included in the nine computed scales. These questions are scored individually. The topics concern satisfaction, pain, transfers, prosthetic care, self-efficacy, and importance to the user of particular issues.4


The PEQ is being used in a broad range of prosthetics research studies and clinical evaluations.5–18 Some specific uses of the PEQ have been: general status of prosthetic patient cohorts,6,9,11,13,14,16,17 elastomeric prosthetic liners,8 feet,7 microprocessor-controlled knees,12–18 and shock-absorbing pylons.5 Several translations of the PEQ have been undertaken, including French, German, Spanish, Japanese, Chinese, and Khmer. Tables 2–10 summarize the reported findings of several studies using the PEQ to measure prosthesis-related outcomes.

Table 2
Table 2:
Summary of PEQ ambulation scale results: Multiple studies
Table 3
Table 3:
Summary of PEQ appearance scale results: Multiple studies
Table 4
Table 4:
Summary of PEQ frustration scale results: Multiple studies
Table 5
Table 5:
Summary of PEQ perceived response scale results: Multiple studies
Table 6
Table 6:
Summary of PEQ residual limb health scale results: Multiple studies
Table 7
Table 7:
Summary of PEQ social burden scale results: Multiple studies
Table 8
Table 8:
Summary of PEQ sounds scale results: Multiple studies
Table 9
Table 9:
Summary of PEQ utility scale results: Multiple studies
Table 10
Table 10:
Summary of PEQ well being scale results: Multiple studies


The PEQ is one of only a few detailed instruments for measuring prosthesis-related quality of life and functional outcomes. It has been validated for content and temporal stability in a group of lower limb amputees. The PEQ has been used in many different settings, from hospital clinics to biomechanical research studies. The findings have been reported to be useful and have shown significant differences with changes in prostheses tested. Several translations of the validated questionnaire are being used but have not been individually revalidated in their new translations.

The PEQ and instructions for its use are freely available from Prosthetics Research Study in Seattle for anyone who is interested in using it ( Any of the domain scales may be used independently and the PEQ scales may be asked in conjunction with specific questions posed to address the problem at hand. This makes for flexible focused use.

It must be stressed that “validated measures” do not replace good experimental design or relevant questioning. The PEQ can be a useful tool in measuring outcomes, but as with any tool, it must be used appropriately.


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2. Legro MW, Reiber GD, Smith DG, et al. Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life. Arch Phys Med Rehabil 1998;79:931–938.
3. Smith DG, Horn P, Malchow D, et al. Prosthetic history, prosthetic charges, and functional outcome of the isolated, traumatic below-knee amputee. J Trauma Injury Infect Crit Care 1995;38:44–47.
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© 2006 American Academy of Orthotists & Prosthetists