Outcome measurement is crucial to assuring high-quality patient services and improving the quality of services provided by prosthetists. This article summarizes recent evidence on the measurement properties of outcome measures, and updates previously published summaries of outcome instruments. The review focuses on measures of mobility, functional status, quality of life, and patient satisfaction, and includes both performance-based and patient-reported outcomes. Amputation-specific and general measures that are suitable for patients served by prosthetists are discussed. It is encouraging that responsiveness of measures is often reported, as this information is needed to improve clinical utility.
Key points
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Accreditors expect prosthetists to monitor patient outcomes as part of routine clinical practice.
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Outcomes of patient care can be performance-based or reported by patients.
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Important aspects of care to be monitored include mobility, functional status, quality of life, and satisfaction with services.
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Instruments may be developed specifically for adults with amputations or for general populations; several general-purpose instruments are suitable for adults with amputations.
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Routine monitoring of outcomes allows clinicians to address patient concerns in a timely manner and to implement quality-improvement initiatives while fulfilling accreditation requirements.
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Emerging information about responsiveness of outcome measures improves their clinical utility.
Introduction: nature of the problem
The American Board for Certification in Prosthetics, Orthotics and Pedorthics (ABC) accreditation standards are designed to enhance the quality of health care in prosthetic and orthotic practice, and to help increase efficiency and support initiatives that improve patient outcomes. Facility accreditation helps ABC achieve specific goals, including promoting the welfare of persons with disabilities by establishing standards for those engaged in the fitting of prostheses and orthoses. ABC defines 6 categories of standards including quality assessment and improvement. However, provider enthusiasm for quality improvement through routine outcomes monitoring is diminished by the time and expense required as well as limitations in the psychometric properties of many instruments, in particular the validation of generic instruments with prosthesis users, availability of norms, and evidence of responsiveness or sensitivity of measures to change. This review is designed to provide up-to-date information on the psychometric properties of outcome instruments, allowing prosthetists to select instruments to improve the quality of their services.
In recent years, the American Academy of Orthotists and Prosthetists (AAOP) have published findings from a series of state-of-the-science conferences, 2 of which address lower and upper limb prosthetic outcome instruments. The review of lower limb prosthetic outcome measures by Condie and collegues identified 25 instruments that assess mobility, function, and quality of life. Wright’s review of upper limb prosthetic outcome measures identified 7 outcome measures for adults in 4 categories: hand function, upper limb functional abilities, overall functional abilities and participation, and quality of life.
Several other recent reviews of lower and upper limb outcome measures for prosthesis users have been organized using the International Classification of Functioning, Disability and Health (ICF). Hebert and colleagues reviewed measures of body function applicable to lower limb amputation and identified 12 measures of global mental function, 1 measure of sensory function and pain, 1 measure of cardiovascular and respiratory function, and 2 measures of neuromuscular and movement function. Deathe and colleagues reviewed measures of activity applicable to lower limb amputees and identified 4 walking tests, 1 mobility grading, 5 generic activity of daily living (ADL) and mobility measures, and 7 amputee-specific measures. Lindner and colleagues reviewed outcome measures applicable for upper limb amputees, including 1 measure for subjects of all ages, 5 pediatric measures, and 2 adult measures. Most upper limb instruments measured activity and participation, while 2 measures also measured quality of life. These reviews all highlighted the lack of information about instrument responsiveness. Table 1 summarizes the recommendations made by the authors of these reviews.
| Instrument | Lower Limb Prostheses | Upper Limb Prostheses | This Review | |||
|---|---|---|---|---|---|---|
| Condie et al, 1996 | Hebert et al, 2009 | Deathe et al, 2009 | Wright, 2009 | Lindner et al, 2010 | ||
| Lower Limb Mobility/Function | ||||||
| Activity-Specific Balance Confidence Scale (ABC Scale) | — | R | — | — | — | N |
| Amputee Activity Score (AAS) | R | — | N | — | — | — |
| Amputee Body Image Scale (ABIS) | — | R | — | — | — | — |
| Amputee Mobility Predictor (AMPPRO) | R | — | N | — | — | R |
| Barthel Index | N | — | R (older dysvascular amputees only) | — | — | — |
| Berg Balance Scale (BBS) | — | — | — | — | — | N |
| Clinical Outcome Variables Scale (COVS) | — | — | N | — | — | — |
| Engagement in Everyday Activities Involving Revealing the Body (EEARB) | — | N | — | — | — | — |
| Functional Mobility Assessment (FMA) | R | — | — | — | — | — |
| Frenchay Activities Index (FAI) | N | — | — | — | — | — |
| Functional Independence Measure (FIM) | N | — | N | — | — | — |
| Houghton Scale | R | — | R | — | — | — |
| Locomotor Capabilities Index (LCI) | R (LCI & LCI-5) | — | R | — | — | N |
| Multidimensional Body-Self Relations Questionnaire (MBSRQ) | — | N | — | — | — | — |
| Office of Population Census and Survey Scale (OPCS) | N | — | — | — | — | — |
| Orthotics and Prosthetics Users’ Survey Lower Extremity Functional Status (OPUS-LEFS) | — | — | — | — | — | N |
| Patient-Specific Functional Scale (PSFS) | — | — | — | — | — | R |
| Prosthetic Profile of the Amputee (PPA) | r | — | — | — | — | — |
| Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) | — | — | N | — | — | — |
| Rivermead Mobility Index (RMI) | N | — | N | — | — | — |
| Russek’s Code | N | — | — | — | — | — |
| Special Interest Group in Amputee Mobility (SIGAM) | R | — | R (classification measure only) | — | — | — |
| L Test of Functional Mobility (L Test) | — | — | R | — | — | R |
| Timed Up and Go (TUG) | R | — | R | — | — | R |
| 10 Meter Walk Test (10mWT) | R | — | R | — | — | N |
| 2 Minute Walk Test (2MWT) | R | — | R | — | — | R |
| 6 Minute Walk Test (6MWT) | R | — | — | — | — | R |
| Wheelchair Skills Test (WST) | — | — | N | — | — | — |
| Quality of Life | ||||||
| Amputation-Related Body Image Scale (ARBIS) | N | — | — | — | — | — |
| Attitudes to Artificial Limbs Questionnaire (AALQ) | N | N | — | — | — | — |
| Body Image Questionnaire (BIQ) | N | N | — | — | — | — |
| Patient Generated Index (PGI) | N | — | — | — | — | — |
| Short-Form Healthy Survey (SF36/SF12) | N | — | — | N | — | — |
| Sickness Impact Profile (SIP) | N | — | — | — | — | — |
| Orthotics and Prosthetics National Outcomes Tool (OPOT) | r | — | — | — | — | — |
| Orthotics and Prosthetics Users’ Survey Health-Related Quality of Life (OPUS-HRQOL) | — | — | — | — | — | N |
| Orthotic and Prosthetic User’s Survey Satisfaction with Device and Services | — | — | — | — | — | N |
| Prosthesis Evaluation Questionnaire (PEQ) | r | — | — | — | — | — |
| Prosthesis Evaluation Questionnaire Mobility Scale (PEQ-MS) | — | — | R | — | — | R |
| Perceived Social Stigma Scale (PSSS) | N | — | — | — | — | — |
| Trinity Amputation and Prosthesis Experience Scales (TAPES) | N | — | — | R (a) | R | R |
| Adult Upper Limb Function | ||||||
| Activities Measure for Upper Limb Amputees (AM-ULA) | — | — | — | — | — | R |
| Assessment of Capacity for Myoelectric Control (ACMC) | — | — | — | R (a,c) | R | N |
| Box and Block Test (BBT) | — | — | — | — | — | R |
| Disabilities of Arm, Shoulder, and Hand (DASH) | — | — | — | R (a) | — | — |
| Jebsen-Taylor Test of Hand Function (JTHF) | — | — | — | — | — | R |
| Nottingham Health Profile (NHP) | — | — | — | N | — | — |
| Orthotics and Prosthetics Users’ Survey Upper Extremity Functional Status (OPUS-UEFS) | — | — | — | R (a) | R | N |
| Southampton Hand Assessment Profile (SHAP) | — | — | — | N | — | — |
| Pediatric Upper Limb Function | ||||||
| ABILHAND-KIDS | — | — | — | R (c) | — | — |
| Assisting Hand Assessment (AHA) | — | — | — | R (c) | — | — |
| Child Amputee Prosthetic Project–Functional Status Inventory (CAPP–FSI) | — | — | N | N | N | N |
| Pediatric Quality of Life Inventory (PedsQL) | — | — | — | N | — | — |
| Pediatric Orthopedic Data Collection Outcomes Instrument (PODCI) | — | — | — | N | — | — |
| Prosthetic Upper Extremity Functional Index (PUFI) | — | — | — | R (c) | R | — |
| Unilateral Below Elbow Test (UBET) | — | — | — | N | N | — |
| University of New Brunswick (UNB) Test | — | — | — | R (c) | N | — |
| Global Mental Function: Depression or Emotional Status | ||||||
| Beck Depression Inventory (BDI) | — | N | — | — | — | — |
| Center for Epidemiological Studies–Depression Scale (CES-D) | — | R | — | — | — | — |
| General Health Questionnaire (GHQ-28) | — | R | — | — | — | — |
| Geriatric Depression Survey (GDS) | — | N | — | — | — | — |
| Hospital Anxiety and Depression Scale (HADS) | — | N | — | — | — | — |
| Sensory Function and Pain | ||||||
| Socket Comfort Score (SCS) | — | R | — | — | — | R |
| Cardiovascular and Respiratory | ||||||
| One-leg cycling test (V o 2max , Anaerobic Threshold) | — | r | — | — | — | — |
| Neuromusculoskeletal and Movement | ||||||
| Walking speed (instrumented assessment) | — | r | — | — | — | — |
| Postural sway (instrumented assessment) | — | r | — | — | — | — |
This article provides an update on the development of outcome instruments that are suitable for prosthetic practice, focusing on instruments published in English that are suitable for adult populations. The authors highlight recently published information about the psychometric properties of these instruments, especially responsiveness, and provide updated recommendations as to their suitability for clinical practice.
Introduction: nature of the problem
The American Board for Certification in Prosthetics, Orthotics and Pedorthics (ABC) accreditation standards are designed to enhance the quality of health care in prosthetic and orthotic practice, and to help increase efficiency and support initiatives that improve patient outcomes. Facility accreditation helps ABC achieve specific goals, including promoting the welfare of persons with disabilities by establishing standards for those engaged in the fitting of prostheses and orthoses. ABC defines 6 categories of standards including quality assessment and improvement. However, provider enthusiasm for quality improvement through routine outcomes monitoring is diminished by the time and expense required as well as limitations in the psychometric properties of many instruments, in particular the validation of generic instruments with prosthesis users, availability of norms, and evidence of responsiveness or sensitivity of measures to change. This review is designed to provide up-to-date information on the psychometric properties of outcome instruments, allowing prosthetists to select instruments to improve the quality of their services.
In recent years, the American Academy of Orthotists and Prosthetists (AAOP) have published findings from a series of state-of-the-science conferences, 2 of which address lower and upper limb prosthetic outcome instruments. The review of lower limb prosthetic outcome measures by Condie and collegues identified 25 instruments that assess mobility, function, and quality of life. Wright’s review of upper limb prosthetic outcome measures identified 7 outcome measures for adults in 4 categories: hand function, upper limb functional abilities, overall functional abilities and participation, and quality of life.
Several other recent reviews of lower and upper limb outcome measures for prosthesis users have been organized using the International Classification of Functioning, Disability and Health (ICF). Hebert and colleagues reviewed measures of body function applicable to lower limb amputation and identified 12 measures of global mental function, 1 measure of sensory function and pain, 1 measure of cardiovascular and respiratory function, and 2 measures of neuromuscular and movement function. Deathe and colleagues reviewed measures of activity applicable to lower limb amputees and identified 4 walking tests, 1 mobility grading, 5 generic activity of daily living (ADL) and mobility measures, and 7 amputee-specific measures. Lindner and colleagues reviewed outcome measures applicable for upper limb amputees, including 1 measure for subjects of all ages, 5 pediatric measures, and 2 adult measures. Most upper limb instruments measured activity and participation, while 2 measures also measured quality of life. These reviews all highlighted the lack of information about instrument responsiveness. Table 1 summarizes the recommendations made by the authors of these reviews.
| Instrument | Lower Limb Prostheses | Upper Limb Prostheses | This Review | |||
|---|---|---|---|---|---|---|
| Condie et al, 1996 | Hebert et al, 2009 | Deathe et al, 2009 | Wright, 2009 | Lindner et al, 2010 | ||
| Lower Limb Mobility/Function | ||||||
| Activity-Specific Balance Confidence Scale (ABC Scale) | — | R | — | — | — | N |
| Amputee Activity Score (AAS) | R | — | N | — | — | — |
| Amputee Body Image Scale (ABIS) | — | R | — | — | — | — |
| Amputee Mobility Predictor (AMPPRO) | R | — | N | — | — | R |
| Barthel Index | N | — | R (older dysvascular amputees only) | — | — | — |
| Berg Balance Scale (BBS) | — | — | — | — | — | N |
| Clinical Outcome Variables Scale (COVS) | — | — | N | — | — | — |
| Engagement in Everyday Activities Involving Revealing the Body (EEARB) | — | N | — | — | — | — |
| Functional Mobility Assessment (FMA) | R | — | — | — | — | — |
| Frenchay Activities Index (FAI) | N | — | — | — | — | — |
| Functional Independence Measure (FIM) | N | — | N | — | — | — |
| Houghton Scale | R | — | R | — | — | — |
| Locomotor Capabilities Index (LCI) | R (LCI & LCI-5) | — | R | — | — | N |
| Multidimensional Body-Self Relations Questionnaire (MBSRQ) | — | N | — | — | — | — |
| Office of Population Census and Survey Scale (OPCS) | N | — | — | — | — | — |
| Orthotics and Prosthetics Users’ Survey Lower Extremity Functional Status (OPUS-LEFS) | — | — | — | — | — | N |
| Patient-Specific Functional Scale (PSFS) | — | — | — | — | — | R |
| Prosthetic Profile of the Amputee (PPA) | r | — | — | — | — | — |
| Questionnaire for Persons with a Transfemoral Amputation (Q-TFA) | — | — | N | — | — | — |
| Rivermead Mobility Index (RMI) | N | — | N | — | — | — |
| Russek’s Code | N | — | — | — | — | — |
| Special Interest Group in Amputee Mobility (SIGAM) | R | — | R (classification measure only) | — | — | — |
| L Test of Functional Mobility (L Test) | — | — | R | — | — | R |
| Timed Up and Go (TUG) | R | — | R | — | — | R |
| 10 Meter Walk Test (10mWT) | R | — | R | — | — | N |
| 2 Minute Walk Test (2MWT) | R | — | R | — | — | R |
| 6 Minute Walk Test (6MWT) | R | — | — | — | — | R |
| Wheelchair Skills Test (WST) | — | — | N | — | — | — |
| Quality of Life | ||||||
| Amputation-Related Body Image Scale (ARBIS) | N | — | — | — | — | — |
| Attitudes to Artificial Limbs Questionnaire (AALQ) | N | N | — | — | — | — |
| Body Image Questionnaire (BIQ) | N | N | — | — | — | — |
| Patient Generated Index (PGI) | N | — | — | — | — | — |
| Short-Form Healthy Survey (SF36/SF12) | N | — | — | N | — | — |
| Sickness Impact Profile (SIP) | N | — | — | — | — | — |
| Orthotics and Prosthetics National Outcomes Tool (OPOT) | r | — | — | — | — | — |
| Orthotics and Prosthetics Users’ Survey Health-Related Quality of Life (OPUS-HRQOL) | — | — | — | — | — | N |
| Orthotic and Prosthetic User’s Survey Satisfaction with Device and Services | — | — | — | — | — | N |
| Prosthesis Evaluation Questionnaire (PEQ) | r | — | — | — | — | — |
| Prosthesis Evaluation Questionnaire Mobility Scale (PEQ-MS) | — | — | R | — | — | R |
| Perceived Social Stigma Scale (PSSS) | N | — | — | — | — | — |
| Trinity Amputation and Prosthesis Experience Scales (TAPES) | N | — | — | R (a) | R | R |
| Adult Upper Limb Function | ||||||
| Activities Measure for Upper Limb Amputees (AM-ULA) | — | — | — | — | — | R |
| Assessment of Capacity for Myoelectric Control (ACMC) | — | — | — | R (a,c) | R | N |
| Box and Block Test (BBT) | — | — | — | — | — | R |
| Disabilities of Arm, Shoulder, and Hand (DASH) | — | — | — | R (a) | — | — |
| Jebsen-Taylor Test of Hand Function (JTHF) | — | — | — | — | — | R |
| Nottingham Health Profile (NHP) | — | — | — | N | — | — |
| Orthotics and Prosthetics Users’ Survey Upper Extremity Functional Status (OPUS-UEFS) | — | — | — | R (a) | R | N |
| Southampton Hand Assessment Profile (SHAP) | — | — | — | N | — | — |
| Pediatric Upper Limb Function | ||||||
| ABILHAND-KIDS | — | — | — | R (c) | — | — |
| Assisting Hand Assessment (AHA) | — | — | — | R (c) | — | — |
| Child Amputee Prosthetic Project–Functional Status Inventory (CAPP–FSI) | — | — | N | N | N | N |
| Pediatric Quality of Life Inventory (PedsQL) | — | — | — | N | — | — |
| Pediatric Orthopedic Data Collection Outcomes Instrument (PODCI) | — | — | — | N | — | — |
| Prosthetic Upper Extremity Functional Index (PUFI) | — | — | — | R (c) | R | — |
| Unilateral Below Elbow Test (UBET) | — | — | — | N | N | — |
| University of New Brunswick (UNB) Test | — | — | — | R (c) | N | — |
| Global Mental Function: Depression or Emotional Status | ||||||
| Beck Depression Inventory (BDI) | — | N | — | — | — | — |
| Center for Epidemiological Studies–Depression Scale (CES-D) | — | R | — | — | — | — |
| General Health Questionnaire (GHQ-28) | — | R | — | — | — | — |
| Geriatric Depression Survey (GDS) | — | N | — | — | — | — |
| Hospital Anxiety and Depression Scale (HADS) | — | N | — | — | — | — |
| Sensory Function and Pain | ||||||
| Socket Comfort Score (SCS) | — | R | — | — | — | R |
| Cardiovascular and Respiratory | ||||||
| One-leg cycling test (V o 2max , Anaerobic Threshold) | — | r | — | — | — | — |
| Neuromusculoskeletal and Movement | ||||||
| Walking speed (instrumented assessment) | — | r | — | — | — | — |
| Postural sway (instrumented assessment) | — | r | — | — | — | — |
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