As part of a case study recently submitted to the Journal of Prosthetics and Orthotics, I conducted three clinical outcome measures to objectify the results of treating a ligament laxity disease with bilateral custom knee orthoses. The outcome measures used were a timed up and go (TUG) test, the Locomotor Capabilities Index (LCI), and the Prosthetic Evaluation Questionnaire (PEQ). Admittedly, the TUG test was the only one that had been used with orthoses in the past, and its use with orthoses has been limited. The LCI was originally developed for prostheses, but it is just as clinically applicable to patients using orthoses, and the only reference in the LCI to prostheses is a parenthetical clarification. It reads, “Pick up an item from the floor (when you are standing up with your prosthesis).” All of the tasks are easily imaginable, transferable, and possible for a person with an orthosis to complete. Therefore, the LCI was included in the article. My explanation in the article stated,
The LCI has been used only with prostheses and has not been used or validated for use with an orthosis; however, the author proposes that the LCI translates well to orthoses because 1) the questions do not specifically reference the function of a prosthesis but rather activities of daily living and 2) the purpose of the LCI is to assess the patient’s self-perceived ability to perform a task with the assistance of a device that replaces a physical functional deficit—and both orthoses and prostheses accomplish this purpose.
The PEQ, on the other hand, took significantly more modification to shape it to be clinically relevant for orthotics, and therefore, the PEQ was not included in the article. Some questions were left out entirely because after restructuring the questions, there were some redundancies, especially for a bilateral user. I believe that the results from the PEQ with an orthotic user are relevant, but they require validation. Here, I will present the modifications made to the PEQ to make it relevant for orthoses, the results of the PEQ with a bilateral orthotic user, and the comparison of those results to the more valid TUG test and LCI. My hope is that we may eventually be able to use and validate the PEQ for orthoses so that we may also have an Orthotic Evaluation Questionnaire (OEQ).
The orthotic patient was given the same instructions and was told to fill out the OEQ the same as a prosthetic patient would be instructed with the PEQ. The OEQ was scored the same as the PEQ. The modifications made to the PEQ required reprinting of significant portions of many of the questions. To maintain the integrity of the layout of the PEQ and to reprint the questions, an office label maker with a similar font and size was used to print over the original questions. Some questions were easy to restructure; others required only one word to be crossed out to make them relevant to orthoses. A simple question would read, “Over the past 4 weeks, rate your comfort while standing when using your prosthesis.” Here, only the word prosthesis was substituted with orthosis. Other questions require more restructuring. A complicated question would read, “Over the past 4 weeks, rate how often you have been aware of nonpainful sensations in your phantom limb.” This question does not easily transfer to orthoses. The goal of the question seemed to be rating abnormal sensations during the time the device was meant to be worn. Thus, the question was changed to read, “Over the past 4 weeks, rate how often you have been aware of nonpainful abnormal sensations in your knees.” The word sensations was modified to abnormal sensations to maintain the continuity of questioning. The anatomical location was changed from “phantom limb” to “in your knees” because an orthotic user would obviously not have phantom sensation. However, together, both of these changes maintain the underlying discovery of abnormal/phantom sensations while using the device being studied. Figure 1 is a copy of all of the changes made to transform the PEQ into the OEQ.
The results with the OEQ reflected the positive outcomes noted in the TUG test and the LCI. Over a 15-week period, the patient showed a 21.7% improvement in the TUG test and a 105.6% improvement in the LCI score. The OEQ reported a total satisfaction of 93% (a score of 100% would be the highest and most positive response (see Figs. 2 and 3 for additional scoring; in Figure 3, some of the individual scores have been averaged. Although the mean is not valid for individual scores, it does provide some interesting clinical insight). The grouped and individual scores represent an overall positive benefit of using the bilateral knee orthoses to treat the patient’s ligament laxity syndrome and further add to the body of knowledge that support medical necessity for orthotic intervention in similar cases.
My transformation of the PEQ to the OEQ has not been perfected, but I believe these results show that with further modifications and validation, the PEQ can be adjusted to be clinically relevant for orthoses.
Keith R. Sardó CPO, BS
Rehab Systems Inc,
Boise, ID, USA