Limitations of self-reported estimates of functional capacity using the Walking Impairment Questionnaire

The “Walking Estimated Limitation Stated by History” (WELSH) visual tool is applicable and accurate to determine walking capacity, even in people with low literacy level

Determination of the self-reported walking capacity by interview or standardized questionnaire is important. However, the existing questionnaires require the patient to be able to read and write in a specific language. We recently proposed the WELSH (Walking Estimated Limitation Stated by History) tool to be administrable to illiterate people. The main objective was to assess the applicability of WELSH tool in the community and in a large group. We performed a prospective study in the city of Bobo-Dioulasso in Burkina Faso during June 2020. We recruited 630 interviewers among medical students. They were trained to administer the WELSH, and to conduct a 6-minute walk test. We performed a Pearson’s “r” correlation between the WELSH and maximal walking distance (MWD). Of the 1723 participants available for the analysis, 757 (43.9%: 41.6–46.3) never went to school or attended only elementary school. The percentage of questionnaires with participant filling-in errors corrected by the investigator decreased with the decrease in educational level (p<0.001). The average WELSH score was 53 ± 22 and the average MWD was 383 ±142 meters. The Spearman correlation coefficient between the WELSH score and the MWD was r = 0.567 (p<0.001). Correlations ranged from 0.291 to 0.576 in males and females, (all p values < 0.05) and in different levels of education, with the highest coefficients found in illiterate people. The WELSH is feasible on the community by a wide variety of interviewers. It correlates with the MWD estimated by the 6-minutes’ walk test even for people with little or no schooling.

Using wearable monitors to assess daily walking limitations induced by ischemic pain in peripheral artery disease

PURPOSE

To develop, assess the feasibility of, and determine the clinical validity of an event-based analysis method using wearable monitors to quantify walking pain manifestations (WPMs) and stops induced by walking pain (SIWPs) during daily life walking in people with peripheral artery disease (PAD).

METHODS

The following two conditions were studied: a standardized outdoor walking session (OWS) and a seven-day free-living measurement (FLM) period. The PAD participants (n = 23) wore an accelerometer and a watch. They were asked to press the event marker button on the watch to indicate events related to WPMs and SIWPs. To assess the clinical validity of the method, the computed pain-free walking time (PFWT) and maximal walking time (MWT) were compared with the PFWT and MWT assessed using standard treadmill walking protocols, respectively.

RESULTS

Following OWSs, the PFWT^[OWS] and MWT^[OWS] were significantly correlated with the PFWT^[Strandness] (r = .955, P < .001) and MWT^[Strandness] (r = .821, P < .001), respectively. During the FLM, PAD participants experienced only 2 WPMs/day and 1 SIWP/day, although severely limited on the treadmill and during the OWS. The average WPMs/day were moderately correlated with the PFWT^[Strandness] (r = -.54, P = .016). The PFWT^[FLM] was on average 12 times longer than the PFWT^[Strandness] . Interestingly, the intensity of the walking bouts as assessed by the accelerometer counts during the FLM was significantly lower than that during the OWS (45 ± 15 vs 66 ± 20 counts/s, P < .001).

CONCLUSION

This new method offers opportunities for studies investigating the experience of living with PAD and the assessment of daily life walking capacity for both diagnostic and therapeutic purposes.

Treadmill Measured vs. Questionnaire Estimated Changes in Walking Ability in Patients With Peripheral Artery Disease

OBJECTIVE

Determining the maximum walking time (MWT) using the treadmill test is the gold standard method for evaluating walking capacity and treatment effect in patients with peripheral arterial disease (PAD). However, self reported functional disability is important when assessing quality of life. Changes in the Walking Estimated Limitation Calculated by History (WELCH) questionnaire scores were compared with the MWT.

METHODS

A cross sectional study was performed in patients with intermittent claudication. The treadmill test (3.2 km/h; 10% gradient) and WELCH questionnaire were administered to all patients for objective evaluation of walking capacity. Given the log normal distribution of these parameters in patients with PAD, a log transformation was applied to the WELCH score (LnW) and maximum walking time (LnT). The responsiveness of the WELCH score was determined using mean changes and correlation coefficients of LnW and LnT changes. The effect of time on the "estimated minus real" (E - R) changes (LnW - change minus LnT - change) was assessed after categorisation of patients into various test-retest intervals. Patients who underwent lower limb revascularisation between the two tests and those who underwent medical treatment only were analysed.

RESULTS

Correlation coefficients between LnW and LnT for tests 1 and 2 were r = 0.514 and r = 0.503, respectively (p < .001, for both). Correlation for LnW change vs. LnT change was 0.384 (p < .001). E - R was positive only early after surgery. E - R was negative for all test-retest intervals >1 year in revascularised and non-revascularised patients.

CONCLUSION

Changes in WELCH scores correlated with changes observed on the treadmill in patients with intermittent claudication. For long test-retest intervals, WELCH changes tended to overestimate the worsening of walking impairment as compared with the measured difference observed in both revascularised and non-revascularised patients. A shortlived "honeymoon" (overestimation of the benefit for the shortest test-retest interval) was observed only in revascularised patients.

Google Maps offers a new way to evaluate claudication

BACKGROUND

Accurate determination of walking capacity is important for the clinical diagnosis and management plan for patients with peripheral arterial disease. The current "gold standard" of measurement is walking distance on a treadmill. However, treadmill testing is not always reflective of the patient's natural walking conditions, and it may not be fully accessible in every vascular clinic. The objective of this study was to determine whether Google Maps, the readily available GPS-based mapping tool, offers an accurate and accessible method of evaluating walking distances in vascular claudication patients.

METHODS

Patients presenting to the outpatient vascular surgery clinic between November 2013 and April 2014 at the Ottawa Hospital with vasculogenic calf, buttock, and thigh claudication symptoms were identified and prospectively enrolled in our study. Onset of claudication symptoms and maximal walking distance (MWD) were evaluated using four tools: history; Walking Impairment Questionnaire (WIQ), a validated claudication survey; Google Maps distance calculator (patients were asked to report their daily walking routes on the Google Maps-based tool runningmap.com, and walking distances were calculated accordingly); and treadmill testing for onset of symptoms and MWD, recorded in a double-blinded fashion.

RESULTS

Fifteen patients were recruited for the study. Determination of walking distances using Google Maps proved to be more accurate than by both clinical history and WIQ, correlating highly with the gold standard of treadmill testing for both claudication onset (r = .805; P < .001) and MWD (r = .928; P < .0001). In addition, distances were generally under-reported on history and WIQ. The Google Maps tool was also efficient, with reporting times averaging below 4 minutes.

CONCLUSIONS

For vascular claudicants with no other walking limitations, Google Maps is a promising new tool that combines the objective strengths of the treadmill test and incorporates real-world walking environments. It offers an accurate, efficient, inexpensive, and readily accessible way to assess walking distances in patients with peripheral vascular disease.

Predicting long-term prognosis in stable peripheral artery disease with baseline functional capacity estimated by the Duke Activity Status Index

BACKGROUND

The ability of a simple self-assessment tool for estimated functional capacity to predict long-term prognosis in patients with established peripheral artery disease (PAD) is unknown. We investigate whether subjective measurement of functional capacity estimated by using the Duke Activity Status Index (DASI) questionnaire predicts long-term prognosis in patients with established PAD.

METHODS

We administered the DASI questionnaire to 771 stable patients with established PAD who underwent elective diagnostic coronary angiography with 5-year follow-up all-cause mortality.

RESULTS

Two hundred ten patients (27%) died over a 5-year follow-up. The lowest DASI score was associated with a 3.2-fold increased risk of 5-year all-cause mortality (unadjusted hazard ratio 3.23, 95% CI 2.19-4.75, P<.001). After adjustments for traditional risk factors, estimated glomerular filtration rate, high-sensitivity C-reactive protein, and lowest DASI score remained predictive of 5-year all-cause mortality (adjusted hazard ratio 2.09, 95% CI 1.36-3.23, P<.001). Interestingly, the lowest DASI score remained to predict 5-year all-cause mortality regardless of each PAD diagnosis subtype (including lower extremity, non-lower extremity, or carotid artery PAD), although the mortality risk was attenuated when incorporating heart disease severity in the non-lower extremity group.

CONCLUSIONS

A simple self-assessment tool of functional capacity provides an independent and incremental prognosis value for long-term adverse clinical events in stable patients with established PAD beyond each PAD diagnostic subtype.

Patient-reported outcome measures in patients with peripheral arterial disease: a systematic review of psychometric properties

Background

Peripheral arterial disease (PAD) is generally associated with considerable morbidity and reduced quality of life. Patient-reported outcome measures (PROMs) provide important information about the burden of disease and impact of treatment in affected patients.

Objectives

The objective of the review was to identify and appraise studies reporting the psychometric evaluation of PROMs administered to a specified population of patients with PAD with a view to recommending suitable PROMs.

Methods

A systematic review of peer-reviewed English language articles was undertaken to identify primary studies reporting psychometric properties of PROMs in English-speaking patients with various stages of PAD. Comprehensive searches were completed up until January 2015. Study selection, data extraction and quality assessment were undertaken independently by at least two researchers. Findings were presented as tabular and narrative summaries based on accepted guidance.

Results

Psychometric evaluation of 6 generic and 7 condition-specific PROMs reported in 14 studies contributed data to the review. The frequently reported measure was the SF-36 (n = 11 studies); others included the Walking Impairment Questionnaire (n = 8 studies), EQ-5D (n = 5 studies) and the Vascular Quality of Life Questionnaire (n = 3 studies). Studies included a diverse PAD population and varied in methodology, including approach to validation of PROMs.

Conclusions

Various PROMs have been validated in patients with PAD but no study provided evidence of a full psychometric evaluation in the patient population. Careful selection is required to identify reliable and valid PROMs to use in clinical and research settings.

Electronic supplementary material

The online version of this article (doi:10.1186/s12955-016-0563-y) contains supplementary material, which is available to authorized users.

All Cause Chronic Widespread Pain is Common in Patients with Symptomatic Peripheral Arterial Disease and is Associated with Reduced Health Related Quality of Life

OBJECTIVE

Invasive treatment of peripheral arterial disease (PAD) does not always lead to improvement, as concomitant diseases might affect walking ability and health related quality of life (HRQoL). Patients with chronic widespread pain (CWP) report worse outcome when treated for cancer and rheumatic diseases. The aim of the present study was to evaluate the prevalence of CWP and its potential association with reduced HRQoL in patients treated for PAD.

METHOD

This was a longitudinal cohort study conducted between May 2011 and April 2014, including patients with planned invasive treatment of symptomatic PAD at two vascular clinics in Sweden. In 240 patients with planned treatment of PAD, HRQoL and pain distribution were assessed using the Short Form 36 Health Survey (SF-36), EuroQoL 5 dimensions (EQ5D), Walking Impairment Questionnaire (WIQ), and a questionnaire concerning musculoskeletal pain (Epipain manikin) before and 12 months after treatment. HRQoL was compared in patients with no chronic pain (NCP), with chronic regional pain (CRP), and with CWP. The SF-36 subscales PF, VT, and MH, representing important aspects of HRQoL (physical function, vitality, and mental health), were the main outcome measures.

RESULTS

Before treatment 22 (10%) patients reported NCP, 133 (61%) CRP, and 64 (29%) CWP. These proportions did not differ between patients with intermittent claudication (IC) and critical limb ischemia (CLI, p = .150). CWP was more common in women than in men (36% vs. 24%, p = .035.) HRQoL improved significantly after treatment in all groups, but was still significantly reduced in CWP patients. CWP predicted worse outcome in HRQoL after treatment.

CONCLUSION

CWP is common and is strongly associated with reduced HRQoL in patients with PAD. Treatment led to significant improvement, but patients with CWP still had significantly reduced HRQoL after treatment. CWP measured by a pain manikin should therefore be taken into account when evaluating disease severity, treatment options, and effect of treatment in PAD.

Self-administered versus interview-based questionnaires among patients with intermittent claudication: Do they give different results? A cross-sectional study

CONTEXT AND OBJECTIVE

Many clinical investigations use generic and/or specific questionnaires to obtain information about participants and patients. There is disagreement about whether the administration method can affect the results. The aim here was to determine whether, among patients with intermittent claudication (IC), there are differences in the Walking Impairment Questionnaire (WIQ) and European Quality of Life-5 Dimension (EQ-5D) scores with regard to: 1) the questionnaire administration method (self-administration versus face-to-face interview); and 2) the type of interviewer (vascular surgeon, VS, versus general practitioner, GP).

DESIGN AND SETTING

Cross-sectional observational multicenter epidemiological study carried out within the Spanish National Health Service.

METHODS

1,641 evaluable patients with IC firstly completed the WIQ and EQ-5D questionnaires and then were interviewed by their doctor on the same day. Pearson correlations and Chi-square tests were used.

RESULTS

There was a strong correlation (r > 0.800; P < 0.001) between the two methods of administering the WIQ and EQ-5D questionnaires, and between the VS and GP groups. Likewise, there was a high level of concordance (P > 0.05) between the different dimensions of the WIQ-distance and EQ-5D (self-administration versus face-to-face) in the VS and GP groups.

CONCLUSION

There was no difference between the different methods of administering the WIQ and EQ-5D questionnaires, among the patients with IC. Similarly, the two types of interviewers (VS or GP) were equally valid. Therefore, it seems unnecessary to expend effort to administer these questionnaires by interview, in studies on IC.

Validation of a Brazilian Portuguese Version of the Walking Estimated-Limitation Calculated by History (WELCH)

Background

The Walking Estimated-Limitation Calculated by History (WELCH) questionnaire has been proposed to evaluate walking impairment in patients with intermittent claudication (IC), presenting satisfactory psychometric properties. However, a Brazilian Portuguese version of the questionnaire is unavailable, limiting its application in Brazilian patients.

Objective

To analyze the psychometric properties of a translated Brazilian Portuguese version of the WELCH in Brazilian patients with IC.

Methods

Eighty-four patients with IC participated in the study. After translation and back-translation, carried out by two independent translators, the concurrent validity of the WELCH was analyzed by correlating the questionnaire scores with the walking capacity assessed with the Gardner treadmill test. To determine the reliability of the WELCH, internal consistency and test-retest reliability with a seven-day interval between the two questionnaire applications were calculated.

Results

There were significant correlations between the WELCH score and the claudication onset distance (r = 0.64, p = 0.01) and total walking distance (r = 0.61, p = 0.01). The internal consistency was 0.84 and the intraclass correlation coefficient between questionnaire evaluations was 0.84. There were no differences in WELCH scores between the two questionnaire applications.

Conclusion

The Brazilian Portuguese version of the WELCH presents adequate validity and reliability indicators, which support its application to Brazilian patients with IC.

Effect of physical activity assessment on prognostication for peripheral artery disease and mortality

OBJECTIVE

To examine whether a simple question about the performance of regular vigorous activity is associated with peripheral artery disease (PAD) and mortality.

METHODS

A total of 1288 individuals undergoing nonemergency coronary angiography were assessed for participation in regular vigorous activity by questionnaire. Data on demographic characteristics, ankle-brachial indexes, and cardiovascular outcomes were prospectively collected.

RESULTS

Compared with those who denied participation in regular vigorous activity, those who reported participation were less likely to have PAD (odds ratio, 0.58; 95% CI, 0.39-0.86), had higher ankle-brachial indexes, had better Walking Impairment Questionnaire scores (P<.001), and experienced reduced all-cause mortality rates (hazard ratio, 0.48; 95% CI, 0.31-0.74). When added to the Framingham Risk Score, the response improved the net reclassification index for all-cause (32.6%) and cardiovascular (32.0%) mortality.

CONCLUSION

Among at-risk individuals, regular vigorous activity is associated with decreased PAD and all-cause mortality. Simple and readily available, a single yes/no query about participation in regular vigorous exercise could be used to improve risk stratification.

The correlation of the "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire with treadmill maximal walking time is not impaired by age, in patients with claudication

PURPOSE

The "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire is a short four-item questionnaire that estimates the walking capacity of a patient in comparison with relatives, friends or people the same age. As such, it should be relatively insensitive to age, yet this has never been tested.

METHODS

A prospective study was performed among 525 patients presenting vascular-type claudication. Patients were grouped into quintiles of age-from quintile 1 for the youngest patients to quintile 5 for the oldest ones. Patients completed a self-administered questionnaire and then had their maximal walking time (MWT) measured on a treadmill. We estimated the coefficient of correlation, the slope and the intercept of the relationship between the WELCH score and the MWT, then the accuracy of a WELCH score under 25 to predict the ability to walk for 5 min on a treadmill.

RESULTS

The slopes of the relationships and the correlation coefficients were not significantly different in each quintile, but a significant shift in the intercept of regressing lines was found with age. Nevertheless, the accuracy in predicting treadmill results from the WELCH score with a cut-off point of 25 was, respectively, 68.6, 72.4, 80.0, 72.4 and 73.3 % in quintiles 1, 2, 3, 4 and 5 (p = 0.45).

CONCLUSIONS

The relationship of MWT on a treadmill and the WELCH score is slightly influenced by age, but a score superior to 25 seems to be of equal discriminatory performance in different quintiles of age to predict the ability to walk for 5 min on a treadmill. This makes this cut-off limit of interest for routine use, regardless of age.

Feasibility and validity of self-reported walking capacity in patients with intermittent claudication

OBJECTIVE

The primary aim of this study was to assess if self-reported measures of walking limitation correlate better with a community-based assessment of maximum walking distance (MWD) than they do with laboratory-based tests in patients with intermittent claudication. A secondary aim was to examine the effect of prior objective testing on these correlations.

METHODS

Thirty-one patients completed three self-report tools (self-reported MWD; Walking Impairment Questionnaire [WIQ]; Estimation of Ambulatory Capacity by History-Questionnaire [EACH-Q]) immediately before and approximately 1 week after a series of objective tests (incremental treadmill walking test, 6-minute walk test, 1-hour global positioning system [GPS] recording of a community walk). We analyzed the feasibility of the self-report tools in terms of number of errors and their correlation (r) with objective measures.

RESULTS

The correlations of self-report tests to GPS-MWD (range, .579-.808) were consistently higher than with the treadmill test (range, .310-.584) and 6-minute walk test (range, .414-.613). The WIQ had the highest proportion of errors, both at first and second completion (58% and 42%, respectively), compared with self-reported MWD (23% and 13%, respectively) and the EACH-Q (6.5% and 13%, respectively). Correlations were improved with the second set of self-report tests (range, .310-.595 to .414-.808).

CONCLUSIONS

The fact that all self-report tools correlated better with a community-based measure of MWD using GPS than with laboratory results confirms that they measure what they aim to: community-based MWD. In addition, prescription of a community walk might help patients to better estimate their walking limitation.

Further clinical validation of the walking impairment questionnaire for classification of walking performance in patients with peripheral artery disease

The purpose of this study was to further validate the Walking Impairment Questionnaire (WIQ) as a self-report tool to aid in the clinical identification of walking ability of patients with peripheral artery disease (PAD). 132 patients with PAD and an ankle brachial index (ABI) ≤0.90 were enrolled; 123 provided complete data for the WIQ and standardized graded treadmill test. The WIQ scores were consistent with reported scores in other studies. The absolute claudication distance (ACD) ranged from 42.3 to 1589.2 meters; the peak walking time (PWT) ranged from 68 to 1800 seconds. Adjusted WIQ scores were positively and moderately associated with the log transformed ACD and PWT (r > .53, P < .001). Based on the area under the curve analysis, an overall WIQ score of 42.5 or less identified low performers (sensitivity 0.90, specificity 0.73); the combined subscale score of distance and stair of 75.5 or more identified high performers (sensitivity 0.41, specificity 0.90). We conclude that WIQ cut-offs appropriately classify walking performance in PAD patients, making this a potentially useful clinical tool. Consideration needs to be given to incorporating a standardized WIQ version into practice guidelines and the use of innovative strategies to facilitate clinical uptake.