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

Abstract

WHAT THIS PAPER ADDS In patients with peripheral artery disease, the Walking Estimated Limitation Calculated by History (WELCH) questionnaire score correlates with the maximum treadmill walking time. Changes in WELCH score tend to decrease more than the objective changes in walking impairment, particularly with a longer a testeretest interval. After revascularisation, a shortlived "honeymoon" (overestimation of the objectively measured change on the treadmill) is observed. For long testeretest intervals, self reported worsening according to the WELCH score should probably be confirmed on the treadmill before a decision to revascularise is taken. Whether other questionnaires estimating walking impairment face the same issue remains to be determined. 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 À R) changes (LnW À change minus LnT À change) was assessed after categorisation of patients into various testeretest 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 ¼ 0.514 and r ¼ 0.503, respectively (p < .001, for both). Correlation for LnW change vs. LnT change was 0.384 (p < .001). E À R was positive only early after surgery. E À R was negative for all testeretest 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 testeretest 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 testeretest interval) was observed only in revascularised patients.

Measuring walking impairment in patients with intermittent claudication: psychometric properties of the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire

“…The limited responsiveness found here is also comparable to the responsiveness of the WELCH after performing revascularization, where a moderate correlation with treadmill maximum walking distance was shown (Henni et al, 2019). In addition, the 12-month time interval between the measurements may have also reduced the WELCH's ability to detect improvements after exercise therapy, as the WELCHs responsiveness tends to decrease over time (Henni et al, 2019). Despite the promising results reported, the responsiveness of the WELCH in relation to other walking impairment measures (i.e., other PROMs, functional testing), and whether it depends on the time interval between measurements (i.e., short-term, long-term change), mode of intervention (i.e., invasive, non-invasive) and degree of change (i.e., small, medium, large intervention effects) still remains to be conclusively determined in further studies.…”

“…The WELCH may therefore be better suited to capture improvements after combined therapies of IC (i.e., exercise therapy plus lower extremity revascularization), as greater improvements in walking performance are usually achieved than after either therapy alone (Biswas et al, 2021). The limited responsiveness found here is also comparable to the responsiveness of the WELCH after performing revascularization, where a moderate correlation with treadmill maximum walking distance was shown (Henni et al, 2019). In addition, the 12-month time interval between the measurements may have also reduced the WELCH's ability to detect improvements after exercise therapy, as the WELCHs responsiveness tends to decrease over time (Henni et al, 2019).…”

“…To date, only few PROMs for PAD patients have been studied in terms their responsiveness, which is a major shortcoming since PROMs are frequently used for measuring the effect of treatment in research and clinical practice (Conijn et al, 2015), raising doubts on the validity of results. Likewise, evidence on the responsiveness of the WELCH is sparse (Henni et al, 2019). In agreement with the construct validity results, the WELCH was found capable to detect large clinically important improvements observed in walking distance and speed following a home-based training regimen, suggesting that the WELCH may be considered responsive to exercise interventions, whereas small to moderate improvements did not generate sufficient change on the WELCH.…”

“…The 'Walking Estimated-Limitation Calculated by History' (WELCH) questionnaire is a brief patient-reported outcome measure (PROM) instrument that requires minimal completion time for assessing walking capacity, with the intention to be used routinely in clinical practice (Ouedraogo et al, 2013). The WELCH has been translated and cross-validated into various languages (Ouedraogo et al, 2013;Abraham et al, 2014a;Cucato et al, 2016;Abraham et al, 2014b;Tew et al, 2014), has shown good feasibility results as it is easy to score and, compared to other PROMs, considered less prone to errors when self-administered by the patient (Ouedraogo et al, 2013;Ouedraogo et al, 2011), while correlating well with treadmill walking (Ouedraogo et al, 2013;Tew et al, 2014;Henni et al, 2019;Fouasson-Chailloux et al, 2015). To be proposed as a routine tool in the future, however, further external validation in larger samples and other languages are required.…”

Simple assessment of quality of life and lower limb functional capacity during cilostazol treatment – results of the SHort-tERm cIlostazol eFFicacy and quality of life (SHERIFF) study

“…While more data are available on the validity of these specific questionnaires, experience regarding the power to detect changes due to treatment is only scarcely available. It is limited to examine the effect of supervised exercise therapy (EQ-5D-3L) [27] or lower limb revascularization (EQ-5D-3L, WELCH) [28,29]. No data on the change of quality of life or walking capacity assessed by these two PROMs is known regarding the effect of cilostazol treatment.…”