Gait quality assessed by trunk accelerometry after total knee arthroplasty and its association with patient related outcome measures

doi:10.1016/j.clinbiomech.2019.10.007

Clinical Biomechanics

Volume 70, December 2019, Pages 192-196

https://doi.org/10.1016/j.clinbiomech.2019.10.007 Get rights and content

Highlights

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Functional outcome after total knee arthroplasty has become increasingly relevant
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Accelerometry can give extra information on function after total knee arthroplasty.
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Patient reported outcome measures and accelerometry correlations were limited.
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Measuring functional outcome with questionnaires only appears to be insufficient.

Abstract

Background

With an increasingly younger population and more active patients, assessment of functional outcome is more important than ever in patients undergoing total knee arthroplasty. Accelerometers have been used successfully to objectively evaluate gait quality in other fields. The aim of this study was to assess gait quality with accelerometers before and after surgery, and to assess added value of resulting parameters to patient reported outcome measures scores.

Methods

Sixty-five patients (mean age 65 years (range 41–75)) who underwent primary total knee arthroplasty were evaluated using a tri-axial trunk accelerometer preoperatively and 1 year after surgery. Gait quality parameters derived from the accelerometry data were evaluated in three dimensions at both time points. Factor analysis was performed on all outcome variables and changes from before to 1 year after surgery in the most representative variable for each factor were studied.

Findings

Factor analysis identified three separate gait quality factors, with questionnaire and gait quality parameters loading on different factors. Both gait quality factor scores and questionnaire factor scores improved significantly 1 year after surgery. As expected based on the factor analysis, only weak to moderate associations were found between patient reported outcome measures and gait quality before surgery, after surgery and in change scores.

Interpretation

The independence of patient reported outcome measures and gait quality parameters measured with trunk accelerometry indicates that gait quality parameters provide additional information on functional outcome after total knee arthroplasty. Providing caretakers with objectively measurable targets using accelerometry could help improve outcome of these patients.

Introduction

Osteoarthritis (OA) of the knee is a degenerative joint disease, disabling approximately 6% of the adults of 30 years and older (Felson et al., 2000). Total knee arthroplasty (TKA) is successfully used to treat moderate to severe OA. During the last decades, the prevalence of OA and the number of TKAs has increased strongly and is expected to increase further, because of demographic trends in obesity and life expectancy and because TKAs are increasingly performed in younger patients (Inacio et al., 2017; Wallace et al., 2017). To measure clinical outcome and monitor the results of TKA, mostly patient reported outcome measures (PROMs) are used. These questionnaires allow patients to report their quality of life, level of functioning and other outcome variables, and are used because they have a high internal consistency, are relatively easy to complete, and are cost-effective (Stevens-Lapsley et al., 2011). There are indications that PROMs may not fully capture the details of limitations in patient functional performance after TKA (Abbasibafghi, 2012). This might be partially due to the fact that PROMs outcome is influenced by, amongst others: pain, patient expectations, function of the non-operated limb, and functional status before the surgery (Jacobs and Christensen, 2009; Stevens-Lapsley et al., 2011). Because of the increased number of relatively young patients undergoing TKA surgery and patients remaining active to an older age, recovery of functional abilities has become increasingly important in a patient who has undergone a TKA. It could therefore be argued that more detailed analysis of functional outcome, especially gait, could be of added value and could give a better understanding of changes in functional performance after TKA (Bolink et al., 2015; Jacobs and Christensen, 2009).

More detailed gait analysis of TKA patients using accelerometers, aimed at spatiotemporal parameters in short bouts of gait, has already provided indications that objective functional measurements can be an addition to clinical outcome measured with subjective PROMs (Kluge et al., 2018). Using accelerometers, quality of gait measurements can be assessed in a clinical or domestic setting, in larger cohorts of patients, and in a relatively inexpensive way (van der Straaten et al., 2017). These earlier studies were done in smaller groups, and did not determine the added value of gait quality to the assessment of PROMs. Also, no trunk accelerometry has been used, which has shown to be a valid and reliable method to objectively assess gait quality (van der Straaten et al., 2017). With trunk accelerometry, an accelerometer is placed at the lower lumbar spine, which allows the device to collect data on gait stability, symmetry, and smoothness, as well as spatiotemporal gait features (Rispens et al., 2014). Therefore, analysis of gait quality using trunk accelerometry in TKA patients could provide a more detailed analysis of symmetry, stability and smoothness of gait in these patients, in addition to clinical outcome assessed using PROMs.

The goal of the present study was to use trunk accelerometers for instrumented analysis of gait quality parameters (i.e. stability, symmetry, and smoothness) of patients before and 1 year after unilateral primary TKA. The associations between these parameters and several commonly used PROMs were studied, to provide insight into whether gait quality parameters contain independent information on functional outcome after TKA that could be an addition to PROMs.

Section snippets

Study design and study population

A prospective multicenter, observational study was performed in two large non-university teaching hospitals in The Netherlands between 1 July 2014 and 1 July 2017. This study was performed in accordance with the Declaration of Helsinki (JAMA, 2013). Institutional review board approval was received from the Medical Ethical Committee Zuidwest Holland (number 14-071), and the study was registered in the Dutch Trial Register (number NTR6566). Eligible patients who were planned to undergo a primary

Study population

Sixty-five patients with an average age of 65 years (range 41–75) completed the entire protocol. 54% of the patients were female, and the average BMI was 30 (range 19 to 56). Patient characteristics can be found in Table 2.

Factor analysis

The initial factor analysis on PROMS and gait quality parameters resulted in the identification of five factors with eigenvalues above 1.0 (>1.157), which in combination explained 62% of the variance. However, the fifth factor consisted of GS-VT only (with a factor loading of

Discussion

We performed a prospective cohort study to assess gait quality parameters in 65 patients before and 1 year after primary unilateral TKA and their association with (changes in) PROMs scores. To determine whether gait quality parameters contain independent information on functional outcome after TKA in addition to PROMs, and to reduce the number of variables and statistical tests, a principal factor analysis was performed. The identified factors were classified as AP/VT gait quality, PROMs,

Conclusions

Accelerometers were used to analyse gait quality in patients before and 1 year after primary unilateral TKA. Using a principal factor analysis, four factors were identified that represented AP/VT gait quality, PROMs, Symmetry, and ML gait quality. Correlations of gait quality parameters with PROMs were at most weak to moderate. This indicates that gait quality as assessed with accelerometers could provide additional and more detailed information on functional rehabilitation of TKA patients with

CRediT authorship contribution statement

Bas L. Fransen:Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing.Nina M.C. Mathijssen:Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing - original draft, Writing - review & editing.Karin Slot:Data curation, Investigation, Writing - original draft, Writing - review & editing.Nicole H.H. de Esch:Data curation, Investigation, Writing - original draft, Writing - review & editing.

Declaration of competing interest

The institution of one or more of the authors has received funding from Zimmer Biomet, Mahwah, U.S.A. They did not play a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and/or in the decision to submit the article for publication.

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Cited by (14)

Do Patient-Reported Outcomes Reflect Objective Measures of Function? Implications for Total Knee Arthroplasty
2023, Journal of Arthroplasty
Patient-reported outcomes (PROs) are used in research, clinical practice, and by federal reimbursement models to assess outcomes for patients who have knee osteoarthritis (OA) and total knee arthroplasty (TKA). We examined a large cohort of patients to determine if commonly used PROs reflect observed evaluation as measured by standardized functional tests (SFTs).
We used data from the Osteoarthritis Initiative, a 10-year observational study of knee osteoarthritis patients. Two cohorts were examined: 1) participants who received TKA (n = 281) and 2) participants who have native OA (n = 4,687). The PROs included Western Ontario and McMaster Osteoarthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS), 12-Item Short Form Health Survey (SF-12), and Intermittent and Constant Pain Score (ICOAP). The SFTs included 20 m and 400 meter (m) walks and chair stand pace. Repeated measures correlation coefficients were used to determine the relationship between PROs and SFTs.
The PROs and SFTs were not strongly correlated in either cohort. The magnitude of the repeated measures correlation (r_rm) between KOOS, WOMAC, SF-12, and ICOAP scores and SFT measurements in native knee OA patients ranged as follows: 400 m walk pace (0.08 to 0.20), chair stand pace (0.05 to 0.12), and 20 m pace (0.02 to 0.21), all with P < .05. In the TKA cohort, values ranged as follows: 400 M walk pace (0.00 to 0.29), chair stand time (0.02 to 0.23), and 20 M pace (0.03 to 0.30). Due to the smaller cohort size, the majority, but not all had P values < .05.
There is not a strong association between PROs and SFTs among patients who have knee OA or among patients who received a TKA. Therefore, PROs should not be used as a simple proxy for observed evaluation of physical function. Rather, PROs and SFTs are complementary and should be used in combination for a more nuanced and complete characterization of outcome.
Evaluation of gait recovery after total knee arthroplasty using wearable inertial sensors: A systematic review
2023, Knee
This study aimed to conduct a systematic review of the recent research output to present more evidence of the current clinical applications of wearable sensors to determine the change and the recovery in gait function pre- and post-total knee arthroplasty (TKA).
A systematic search of the PubMed, ScienceDirect, and Scopus databases was conducted in October 2022. Inclusion criteria consisted of applying acceleration wearable sensors for pre- and post-arthroplasty assessment of the gait cycle. Studies reporting gait analysis using wearable sensors in patients with knee osteoarthritis at any time after total or partial knee arthroplasty (KA) were also included. Each included study was assessed using the Joanna Briggs Institute Critical Appraisal Tool for Quasi-Experimental studies.
Twelve articles were finally considered. The extracted data included essential characteristics of participants, KA studies and their characteristics, sensor technology characteristics and the clinical protocols, gait parameter changes, and various clinical outcome scores at different follow up times after KA. Postoperative examinations were performed from 5 days to 1 year after KA. Clinical outcome scores and gait variables for all patient groups, with or without postoperative rehabilitation, showed various recovery profiles. A variety of wireless sensor devices for gait analysis were recorded. Also, different types of KA were found in the studies.
The study’s findings showed that acceleration-based gait analysis has notable clinical use in monitoring patients after KA. This application provides objective information on the functional outcome beyond the use of clinical outcome scores. More extensive prospective studies are required to investigate gait function further with the help of wearable sensors in patients with knee osteoarthritis.
Objective gait assessment in individuals with knee osteoarthritis using inertial sensors: A systematic review and meta-analysis
2022, Gait and Posture
Citation Excerpt :
Multiple studies have investigated other (non-linear) parameters to assess gait in individuals with knee OA with inertial sensors (Table 3). Examples of this include symmetry/regularity parameters based on autocorrelation procedures [20,29,35], harmonic ratios [2,39,68], sample entropy [69], turning velocity [18], tibial/femoral acceleration [70,71], hip/ankle kinematics [15,30,33,37], and dual-task cost [18]. In addition, development of more advanced algorithms may enable the assessment of joint kinetics [72] and balance related measures, such as the margin of stability [73].
Objective assessment of gait using inertial sensors has shown promising results for functional evaluations in individuals with knee osteoarthritis (OA). However, the large number of possible outcome measures calls for a systematic evaluation of most relevant parameters to be used for scientific and clinical purposes.
This systematic review and meta-analysis aimed to identify gait parameters derived from inertial sensors that reflect gait deviations in individuals with knee OA compared to healthy control subjects (HC).
A systematic search was conducted in five electronic databases (Medline, Embase, Web of Science, CINAHL, IEEE) to identify eligible articles. Risk of bias was assessed using a modified version of the Downs and Black scale. Data regarding study population, experimental procedures, and biomechanical outcomes were extracted. When a gait parameter was reported by a sufficient number of studies, a random-effects meta-analysis was conducted using the inverse variance method.
Twenty-three articles comparing gait between 411 individuals with knee OA and 507 HC were included. Individuals with knee OA had a lower gait speed than HC (standardized mean difference = −1.65), driven by smaller strides with a longer duration. Stride time variability was slightly higher in individuals with knee OA than in HC. Individuals with knee OA walked with a lower range of motion of the knee during the swing phase, less lumbar motion in the coronal plane, and a lower foot strike and toe-off angle compared to HC.
This review shows that inertial sensors can detect gait impairments in individuals with knee OA. Large standardized mean differences found on spatiotemporal parameters support their applicability as sensitive endpoints for mobility in individuals with knee OA. More advanced measures, including kinematics of knee and trunk, may reveal gait adaptations that are more specific to knee OA, but compelling evidence was lacking.
Usefulness of gait parameters obtained from inertial sensors attached to the lower trunk and foot for assessment of gait performance in the early postoperative period after total knee arthroplasty
2022, Knee
Citation Excerpt :
For example, Mandeville et al. [43] showed that movements of the center of mass and trunk inclination angle during gait at 6 months postoperatively were decreased compared with those of controls. Additionally, several studies showed that gait regularity or smoothness assessed by inertial sensors attached to the lower trunk improved from the preoperative to postoperative period [26,28]. Nevertheless, the values of the gait parameters at 6 months or 1 year postoperatively reported in these studies were lower than those of community-dwelling healthy older adults that we reported in a previous study as a Ref. [15].
This study was performed to (i) compare gait parameters obtained from inertial sensors attached to the lower trunk and foot between patients in the early postoperative period after total knee arthroplasty (TKA) and healthy age- and sex-matched controls and (ii) elucidate the association between the gait parameters and patient-reported outcome measures (PROMs).
The gait performance of 19 patients who had undergone TKA was assessed using inertial sensors and PROMs obtained from the Knee Injury and Osteoarthritis Outcome Score (KOOS) 1 week before hospital discharge. The patients walked along a 15-m walkway and we calculated the following gait parameters: walking speed, coefficient of variation (CV) of stride time, unbiased autocorrelation coefficient (AC), harmonic ratio (HR), and symmetry index (SI). The same gait parameter data from 19 age- and sex-matched healthy adults (controls) were obtained from our past study.
The TKA group demonstrated slower walking speed, larger CV of stride time, lower HR in all three directions, lower AC in the vertical direction, and higher SI in the vertical direction than the healthy control group (all p < 0.05). Correlation analysis revealed that the SI in the anteroposterior direction was significantly correlated with the KOOS symptoms subscore and ADL subscore (p < 0.05).
Patients in the early postoperative period after TKA exhibited worse gait performance as assessed by inertial sensors compared with healthy controls. Gait symmetry was correlated with PROMs. These results indicate the usefulness of assessing gait parameters after TKA.
Sex differences in the regularity and symmetry of gait in older adults with and without knee osteoarthritis
2022, Gait and Posture
Citation Excerpt :
Moreover, they have been shown to be sensitive to improvements following surgical interventions for hip [14] and knee OA [12]. While gait speed and functional assessments were also shown to increase following these interventions, Fransen et al. [12] demonstrated that ML regularity metrics may provide additional information on the functional improvements above gait speed and self-report outcomes alone. Therefore, we would argue that the regularity metrics examined here remain important markers of gait health which could be implemented clinically but must be viewed within the context of spatiotemporal parameters, self-report data, and other clinical assessments to provide a more comprehensive and holistic profile of individual gait and functional changes overtime.
Three-dimensional (3D) motion measured at the lower back during walking can describe the regularity and symmetry of gait that may be related to osteoarthritis (OA) and functional status. However, gait speed and inherent sex differences, regardless of the presence of OA, may confound these measures. Therefore, there is a need to understand the effect of OA separately among males and females, without the confounding influence of gait speed.
To investigate the difference in 3D gait regularity and symmetry measures between gait speed-matched males and females with and without knee OA.
Gait regularity and symmetry were computed as autocorrelations of pelvic accelerations during treadmill walking in four groups of older adults: healthy asymptomatic females (AsymF; n = 44), healthy asymptomatic males (AsymM; n = 45), females diagnosed with knee OA (OAF; n = 44), and males diagnosed with knee OA (OAM; n = 45). Data were obtained from a larger research database, allowing for the matching of gait speed between groups. The main effect of OA, sex, and interaction effect between them was examined for the 3D gait regularity and symmetry measures at an alpha level of 0.05.
There was no main effect of OA on any variable, but there was a significant main effect of sex on mediolateral and anteroposterior gait regularity measures. Specifically, females demonstrated significantly greater gait regularity, most notably in the mediolateral directions compared to males.
Older adult females were found to display significantly greater mediolateral gait regularity as compared to males, regardless of the presence of OA. Further, this difference exists among matched gait speeds, suggesting it is not the result of gait speed. Overall, these results highlight the importance of sex-specific analyses and considering gait speed when examining gait acceleration patterns near the center of mass for both cross sectional and longitudinal gait assessments.
Osteoarthritis year in review 2020: mechanics
2021, Osteoarthritis and Cartilage
Citation Excerpt :
Nevertheless, there remains a need for further development and validation before this type of system can provide a viable measure of joint loading in a clinical setting. We have also seen a continued trend78 in the use of IMU-based measurement of gait symmetry and variability as outcomes of knee and hip arthroplasty surgery89–93. Specifically, Nelms et al.92 found IMU-based measures of gait symmetry were more sensitive than PROMs at assessing early recovery from THA.
The mechanical environment of the joint during dynamic activity plays a significant role in osteoarthritis processes. Understanding how the magnitude, pattern and duration of joint-specific loading features contribute to osteoarthritis progression and response to treatment is a topic of on-going relevance. This narrative review synthesizes evidence from recent papers that have contributed to knowledge related to three identified emerging subthemes: 1) the role of the joint mechanical environment in osteoarthritis pathogenesis, 2) joint biomechanics as an outcome to arthroplasty treatment of osteoarthritis, and 3) methodological trends for advancing our knowledge of the role of biomechanics in osteoarthritis. Rather than provide an exhaustive review of a broad area of research, we have focused on evidence this year related to these subthemes. New research this year has indicated significant interest in using biomechanics investigations to understand structural vs clinical progression of osteoarthritis, the role and interaction in the three-dimensional loading environment of the joint, and the contribution of muscle activation and forces to osteoarthritis progression. There is ongoing interest in understanding how patient variability with respect to gait biomechanics influences arthroplasty surgery outcomes, and subgroup analyses have provided evidence for the potential utility in tailored treatment approaches. Finally, we are seeing a growing trend in the application of translational biomechanics tools such as wearable inertial measurement units for improved integration of biomechanics into clinical decision-making and outcomes assessment for osteoarthritis.

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Gait quality assessed by trunk accelerometry after total knee arthroplasty and its association with patient related outcome measures

Highlights

Abstract

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Study design and study population

Study population

Factor analysis

Discussion

Conclusions

CRediT authorship contribution statement

Declaration of competing interest

Knee

Gait Posture

Osteoarthr. Cartil.

Gait Posture

Gait Posture

Gait Posture

Knee

PM&R

Gait Posture

Thesis: Walking with Knee Osteoarthritis

Gait patterns in parkinsonian patients with or without mild cognitive impairment

Mov. Disord.

Statistical Power Analysis for the Behavioural Sciences

Osteoarthritis: new insights. Part 1: the disease and its risk factors

Ann. Intern. Med.