Zanesljivost klinične analize hoje med preiskovalci pri bolnikih po transtibialni amputaciji: Inter-rater reliability of clinical gait analysis in people after transtibial amputation

Background: Patients after lower limb amputation fitted with prosthesis have to learn how to walk and control the movement of prosthesis. In spite of modern prosthetic components, gait deviations in this population are still frequent. The physiotherapists (PTs) performing gait training have to be able to observe different gait abnormalities, understand their causes and try to improve them by using appropriate physiotherapeutic methods. Clinical gait analysis is part of the standard procedure of fitting a new prosthesis. It is therefore important that there is inter-rater agreement between different PTs. Methods: Fifty subjects after transtibial amputation, who had been amputated at least one year ago were recruited from our outpatient clinic. They had no other neurological or musculoskeletal disorders that might influence their gait, had to be able to walk independently with their prosthesis (walking aids were allowed) and had no problems with the prosthesis. Five PTs performed gait assessment; three of them were randomly selected to observe each patient when they got a new prosthesis. Randomisation was balanced so that each PT observed an equal number of subjects. The percentage of agreement between raters was calculated for each gait parameter (which were all dichotomous). Results: The subjects (43 men, 7 women) were on average 65 years old (range 17-91, median 67 years). The mean time since amputation was 11 years (range 1-66, median 4 years); 18 amputations were due to sequelae of diabetes mellitus, 16 due to injury, nine due to peripheral vascular disease, one due to tumour and six due to other reasons. In six minutes, the subjects walked 40 to 760 metres (mean 287 m, median 280 m). Only in five of the 13 observed gait parameters was the percentage of agreement higher than 80%. There was 100% agreement about functionality of gait and 98% of initial contact, 92% about knee hyperextension, 80% about not loading the prosthesis and 78% about loading it. Agreement about whether there was knee valgus during stance phase was better (88%) than about knee varus (62%). The lowest agreement was about gait rhythm (60%) and equality of step length (54%). Conclusions: Inter-rater reliability of clinical gait analysis in people after transtibial amputation between our PTs is not very satisfactory. It is necessarily to define more precisely what the observed parameters mean; it would also be beneficiary to adjust the assessment form accordingly. Izhodišče: Ljudje z amputacijo spodnjega uda, ki so oskrbljeni s protezo, se morajo naučiti hoje in obvladovanja proteze. Kljub sodobnim protetičnim komponentam so pri tej populaciji nepravilnosti hoje pogoste. Fizioterapevti, ki izvajajo učenje in vadbo hoje, morajo biti sposobni opaziti različne nepravilnosti v vzorcu hoje, poznati njihove vzroke ter poskušati izboljšati vzorec hoje z različnimi fizioterapevtskimi metodami. Klinična analiza hoje je del standardnih postopkov ob predpisu nove proteze. Zato je pomembno, da je zanesljivost med ocenjevalci čim boljša. Metode: V preiskavo smo vključili 50 oseb po transtibialni amputaciji enega spodnjega uda, ki so že vsaj eno leto hodili s protezo, niso imeli nevroloških ali drugih mišično-skeletnih okvar, ki bi lahko vplivale na hojo, so dobili novo protezo in so bili pripravljeni sodelovati. Izključili smo tudi osebe z bolečinami ali ranami na krnu. Ob prejemu nove proteze smo naključno izbrani trije od petih fizioterapevtov Oddelka za rehabiltiacijo bolnikov po amputaciji hkrati opazovali njihovo hojo in vsak na svoj obrazec zabeležili opažene nepravilnosti. Na vsakih 10 bolnikov znotraj vsake skupine smo uporabili vse kombinacije treh terapevtov. Rezultati: V raziskavo smo vključili 50 bolnikov (43 moških in sedem žensk) po transtibialni amputaciji, starih od 17 do 91 let (povprečje 65 let, mediana 67 let). Pri bolnikih je bila amputacija opravljena v obdobju od enega leta do 66 let (povprečje 11 let, mediana 4 leta) pred vključitvijo v študijo. Pri 18 bolnikih je bila amputacija posledica zapletov sladkorne bolezni, 16 bolnikov je bilo amputiranih zaradi poškodbe, devet zaradi perifernega žilnega obolenja, eden zaradi tumorja in šest zaradi drugih vzrokov. V šestih minutah so prehodili od 40 do 760 metrov (povprečje 287 m, mediana 280 m). Trideset jih ni moglo stati na protezi (test stoje na eni nogi % protezi), pet jih je na protezi stalo eno sekundo, po sedem dve oziroma tri sekunde (povprečje je dve sekundi). Skladnost med petimi terapevti je bila zadovoljiva le v petih od 13 opazovanih značilnosti, kljub uporabi dvojiškega točkovanja. Fizioterapevti smo se povsem (100 %) strinjali v tem, ali je hoja funkcionalna ali ni, dobra je bila tudi skladnost glede dostopa na podlago in morebitne prisotnosti hiperekstenzije kolena. Skladnost je bila najslabša glede dolžine korakov, ritma hoje in nagiba trupa na stran amputacije. Zaključek: Skladnost ocenjevanja in prepoznavanja nepravilnosti hoje bolnikov po transtibialni amputaciji med fizioterapevti ni najboljša. Potrebno je bolj natančno opisati, kaj pomenijo posamezne ocene, dobro pa bi bilo tudi prilagoditi obrazec za ocenjevanje.