Feasibility of using low-cost markerless motion capture for assessing functional outcomes after lower extremity musculoskeletal cancer surgery.

BACKGROUND: Physical limitations are frequent and debilitating after sarcoma treatment. Markerless motion capture (MMC) could measure these limitations. Historically expensive cumbersome systems have posed barriers to clinical translation. RESEARCH QUESTION: Can inexpensive MMC [using Microsoft KinectTM] assess functional outcomes after sarcoma surgery, discriminate between tumour sub-groups and agree with existing assessments? METHODS: Walking, unilateral stance and kneeling were measured in a cross-sectional study of patients with lower extremity sarcomas using MMC and standard video. Summary measures of temporal, balance, gait and movement velocity were derived. Feasibility and early indicators of validity of MMC were explored by comparing MMC measures i) between tumour sub-groups; ii) against video and iii) with established sarcoma tools [Toronto Extremity Salvage Score (TESS)), Musculoskeletal Tumour Rating System (MSTS), Quality of life-cancer survivors (QoL-CS)]. Statistical analysis was conducted using SPSS v19. Tumour sub-groups were compared using Mann-Whitney U tests, MMC was compared to existing sarcoma measures using correlations and with video using Intraclass correlation coefficient agreement. RESULTS: Thirty-four adults of mean age 43 (minimum value-maximum value 19-89) years with musculoskeletal tumours in the femur (19), pelvis/hip (3), tibia (9), or ankle/foot (3) participated; 27 had limb sparing surgery and 7 amputation. MMC was well-tolerated and feasible to deliver. MMC discriminated between surgery groups for balance (p<0.05*), agreed with video for kneeling times [ICC = 0.742; p = 0.001*] and showed moderate relationships between MSTS and gait (p = 0.022*, r = -0.416); TESS and temporal outcomes (p = 0.016* and r = -0.0557*), movement velocity (p = 0.021*, r = -0.541); QoL-CS and balance (p = 0.027*, r = 0.441) [* = statistical significance]. As MMC uncovered important relationships between outcomes, it gave an insight into how functional impairments, balance, gait, disabilities and quality of life (QoL) are associated with each other. This gives an insight into mechanisms of poor outcomes, producing clinically useful data i.e. data which can inform clinical practice and guide the delivery of targeted rehabilitation. For example, patients presenting with poor balance in various activities can be prescribed with balance rehabilitation and those with difficulty in movements or activity transitions can be managed with exercises and training to improve the quality and efficiency of the movement. SIGNIFICANCE: In this first study world-wide, investigating the use of MMC after sarcoma surgery, MMC was found to be acceptable and feasible to assess functional outcomes in this cancer population. MMC demonstrated early indicators of validity and also provided new knowledge that functional impairments are related to balance during unilateral stance and kneeling, gait and movement velocity during kneeling and these outcomes in turn are related to disabilities and QoL. This highlighted important relationships between different functional outcomes and QoL, providing valuable information for delivering personalised rehabilitation. After completing future validation work in a larger study, this approach can offer promise in clinical settings. Low-cost MMC shows promise in assessing patient's impairments in the hospitals or their homes and guiding clinical management and targeted rehabilitation based on novel MMC outcomes affected, therefore providing an opportunity for delivering personalised exercise programmes and physiotherapy care delivery for this rare cancer.

A feasibility study into the use of the tilt table in the early postoperative rehabilitation of patients undergoing sacrectomy surgery with plastic reconstruction within the Orthopaedic Oncology Service.

PURPOSE: Standard post-operative care following sacrectomy requiring plastic surgical reconstruction limits hip flexion and avoids wound pressure. Extended bed rest adversely affects patient function, strength and range of movement. This feasibility study assessed whether early postoperative use of the tilt table was possible and promoted faster mobilisation. METHODS: Data from 10 patients were collected; five from a "standard tilt table group" and five from an "early tilt table group". Number of days post-operatively patients stood, walked, and were discharged was recorded. RESULTS: Patients had undergone partial or sub-total sacrectomy with wound closure using a variety of plastic surgical techniques. The "early tilt table" group started on the tilt table at 4.8 ± 2.8 days whereas the "standard tilt table" group started at 13 ± 5.1 days (p = 0.01*). Patients in the "early tilt table group" walked significantly earlier [10.6 ± 2.7*] than the standard group (28 ± 13) (p = 0.02*). LOS in the "early" group was 37.11 ± 11.9 days compared to 58.2 ± 21.8 days in the standard group (p = 0.10). No difference in complications between the groups. CONCLUSIONS: Early tilt table use after sacrectomy was safe and enabled a faster achievement of functional goals, thereby reducing LOS. This highlights the need for further evaluation of rehabilitation practice for this group of patients.IMPLICATIONS FOR REHABILITATIONMultidisciplinary discussion between the plastic surgeon, the tissue viability nurse and the physiotherapist about post-operative precautions and their impact on rehabilitation is essential and may enable earlier use of the tilt table.Early use of the tilt table can enable quicker mobilisation leading to the faster achievement of functional milestones and potentially a reduced length of stay (LOS) without detriment to patient outcomes/complications.The early use of the tilt table can support the central goal of surgery of enabling independence, especially as with such extensive surgery there is a big risk of institutionalisation and prolonged disability.There are potential mental health benefits to earlier mobilisation; however, this needs further investigation.

Return to sports following lower limb musculoskeletal tumor surgery-A systematic review.

BACKGROUND: Survivors of primary malignant musculoskeletal tumors often face long-term disability. Clinicians at present are unable to provide evidence-based advice about returning to sports, which is important for active patients. PURPOSES: Identify patients returning to sports. Describe the sporting activities in which patients participate. Identify the outcome measures used to assess return to sport. Identify barriers preventing return to sports. STUDY DESIGN: Systematic review. METHODS: A comprehensive search strategy was used to identify relevant studies combining the following concepts: (1) Bone/Soft tissue tumor, (2) Lower limb, (3) Surgical interventions, and (4) Sports. Studies were selected according to eligibility criteria with the consensus of three authors (MTB, FS, and CG). RESULTS: Twenty-two studies were selected, published between 1985 and 2020, including 1005 patients. Fifteen of the 22 studies had valid data on return to sports, with 705 participants, of which 412 (58.4%) returned to some form of sport such as swimming and cycling, at a mean follow-up period of 7.6 years. Four studies directly compared limb sparing surgery and amputation; none of these were able to identify a difference in sports participation or ability. CONCLUSION: There is insufficient published research to provide guidance for patients with respect to return to sports following musculoskeletal tumors. Future prospective studies are needed to collect better pre- and post-treatment data at multiple time intervals. Validated clinical and patient sports participation outcomes such as type of sports, level, frequency, and validated sports-specific outcome scores should be recorded. In particular, more comparison between limb sparing surgery and amputation would be welcome.

Free-living monitoring of ambulatory activity after treatments for lower extremity musculoskeletal cancers using an accelerometer-based wearable - a new paradigm to outcome assessment in musculoskeletal oncology?

PURPOSE: Ambulatory activity (walking) is affected after sarcoma surgery yet is not routinely assessed. Small inexpensive accelerometers could bridge the gap. Study objectives investigated, whether in patients with lower extremity musculoskeletal tumours: (A) it was feasible to conduct ambulatory activity assessments in patient's homes using an accelerometer-based wearable (AX3, Axivity). (B) AX3 assessments produced clinically useful data, distinguished tumour sub-groups and related to existing measures. METHODS: In a prospective cross-sectional pilot, 34 patients with musculoskeletal tumours in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) participated. Twenty-seven had limb-sparing surgery and seven amputation. Patients were assessed using a thigh-worn monitor. Summary measures of volume (total steps/day, total ambulatory bouts/day, mean bout length), pattern (alpha), and variability (S2) of ambulatory activity were derived. RESULTS: AX3 was well-tolerated and feasible to use. Outcomes compared to literature but did not distinguish tumour sub-groups. Alpha negatively correlated with disability (walking outside (r=-418, p = 0.042*), social life (r=-0.512, p = 0.010*)). Disability negatively predicted alpha (unstandardised co-efficient= -0.001, R2=0.186, p = 0.039*). CONCLUSIONS: A wearable can assess novel attributes of walking; volume, pattern, and variability after sarcoma surgery. Such outcomes provide valuable information about people's physical performance in their homes, which can guide rehabilitation. Implications for rehabilitationRoutine capture of ambulatory activity by sarcoma services in peoples' homes can provide important information about individuals "actual" physical activity levels and limitations after sarcoma surgery to inform personalised rehabilitation and care needs, including timely referral for support.Routine remote ambulatory monitoring about out of hospital activity can support personalised care for patients, including identifying high risk patients who need rapid intervention and care closer to home.Use of routine remote ambulatory monitoring could enhance delivery of evidence-based care closer to peoples' homes without disrupting their daily routine and therefore reducing patient and carer burden.Collection of data close to home using questionnaires and objective community assessment could be more cost effective and comprehensive than in-hospital assessment and could reduce the need for hospital attendance, which is of importance to vulnerable patients, particularly during the Covid-19 pandemic.

Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?

BACKGROUND: Aspects of physical functioning, including balance and gait, are affected after surgery for lower limb musculoskeletal tumors. These are not routinely measured but likely are related to how well patients function after resection or amputation for a bone or soft tissue sarcoma. Small, inexpensive portable accelerometers are available that might be clinically useful to assess balance and gait in these patients, but they have not been well studied. QUESTIONS/PURPOSES: In patients treated for lower extremity musculoskeletal tumors, we asked: (1) Are accelerometer-based body-worn monitor assessments of balance, gait, and timed up-and-go tests (TUG) feasible and acceptable? (2) Do these accelerometer-based body-worn monitor assessments produce clinically useful data (face validity), distinguish between patients and controls (discriminant validity), reflect findings obtained using existing clinical measures (convergent validity) and standard manual techniques in clinic (concurrent validity)? METHODS: This was a prospective cross-sectional study. Out of 97 patients approached, 34 adult patients treated for tumors in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) were included in this study. Twenty-seven had limb-sparing surgery and seven underwent amputation. Patients performed standard activities while wearing a body-worn monitor on the lower back, including standing, walking, and TUG tests. Summary measures of balance (area [ellipsis], magnitude [root mean square {RMS}], jerkiness [jerk], frequency of postural sway below which 95% of power of acceleration power spectrum is observed [f95 of postural sway]), gait [temporal outcomes, step length and velocity], and TUG time were derived. Body-worn monitor assessments were evaluated for feasibility by investigating data loss and patient-reported acceptability and comfort. In addition, outcomes in patients were compared with datasets of healthy participants collected in parallel studies using identical methods as in this study to assess discriminant validity. Body-worn monitor assessments were also investigated for their relationships with routine clinical scales (the Musculoskeletal Tumour Society Scoring system [MSTS], the Toronto Extremity Salvage Score [TESS], and the Quality of life-Cancer survivors [QoL-CS)] to assess convergent validity and their agreement with standard manual techniques (video and stopwatch) to assess concurrent validity. RESULTS: Although this was a small patient group, there were initial indications that body-worn monitor assessments were well-tolerated, feasible to perform, acceptable to patients who responded (95% [19 of 20] of patients found the body-worn monitor acceptable and comfortable and 85% [17 of 20] found it user-friendly), and produced clinically useful data comparable with the evidence. Balance and gait measures distinguished patients and controls (discriminant validity), for instance balance outcome (ellipsis) in patients (0.0475 m/s [95% confidence interval 0.0251 to 0.0810]) was affected compared with controls (0.0007 m/s [95% CI 0.0003 to 0.0502]; p = 0.001). Similarly gait outcome (step time) was affected in patients (0.483 seconds [95% CI 0.451 to 0.512]) compared with controls (0.541 seconds [95% CI 0.496 to 0.573]; p < 0.001). Moreover, body-worn monitor assessments showed relationships with existing clinical scales (convergent validity), for instance ellipsis with MSTS (r = -0.393; p = 0.024). Similarly, manual techniques showed excellent agreement with body-worn monitor assessments (concurrent validity), for instance stopwatch time 22.28 +/- 6.93 seconds with iTUG time 21.18 +/- 6.23 seconds (intraclass correlation coefficient agreement = 0.933; p < 0.001). P < 0.05 was considered statistically significant. CONCLUSIONS: Although we had a small, heterogeneous patient population, this pilot study suggests that body-worn monitors might be useful clinically to quantify physical functioning in patients treated for lower extremity tumors. Balance and gait relate to disability and quality of life. These measurements could provide clinicians with useful novel information on balance and gait, which in turn could guide rehabilitation strategies. LEVEL OF EVIDENCE: Level III, diagnostic study.

Patient experience after lower extremity amputation for sarcoma in England: a national survey.

PURPOSE: After amputation, rehabilitation and limb fitting services are critically important to optimise outcomes. We investigated the reported patient experience and variation in limb fitting services after amputation for musculoskeletal tumours in England. METHODS: A postal survey instrument was developed following literature review, patient and clinician consultation and piloting. The survey was sent from each of the five bone tumour surgical centres in England. RESULTS: One hundred and five responses were received from 250 patients (42%). The number of limb fitting centres accessed by each surgical centre varied from 2 to 28. Many patients reported care falling short of national standards in areas including pre-amputation counselling, information provision, meeting someone with a similar amputation before surgery, psychological support and falls management. Patients were seen sooner where limb fitting services were on site. Many patients rely on being driven, ambulance and public transport to access services. CONCLUSION: This study demonstrates variation in the reported experience of limb fitting services by sarcoma patients. Areas for improvement include information provision, pre-amputation counselling, psychological support and falls management. Clinicians should be aware services are highly variable, and this may impact on outcomes. Patients treated in sarcoma centres with limb fitting services on site may experience better care. Implications for Rehabilitation Rehabilitation services should strive to meet agreed national standards consistently. Where preamputation counselling involving meeting someone with a similar amputation is not possible, good information including video could be helpful. Services should support rehabilitation in the form of early walking aids and efficient prosthetic repair and maintenance. Psychological support, occupational therapy and physiotherapy support must be provided in the acute and chronic phases, including access to long-term rehabilitation care. Rehabilitation programmes must include training to patients and families on reporting, prevention and management of falls. On site services may support better care. Mechanisms for delivering expert specialist care close to home are needed.