Single-step test for unilateral limb ability following total knee arthroplasty

Abstract

Study design: Secondary analysis of a cohort enrolled in a prospective, randomized, longitudinal clinical trial.

Objectives: The single-step test (SST) was evaluated to assess its intertester reliability, validity as a test of activity limitation, and responsiveness to change for patients after unilateral total knee arthroplasty (TKA). The SST was also examined to determine whether it could differentiate between the surgical and nonsurgical lower limbs of patients after unilateral TKA and between the surgical limbs of patients after TKA and the limbs of healthy controls.

Background: Tests of functional ability for patients recovering from TKA cannot differentiate the contribution of each limb to performance outcome. A test of unilateral limb ability would provide a metric for assessing the surgical lower extremity, without the confounder of the status of the contralateral lower extremity.

Methods: Intertester reliability was assessed between clinicians and between a clinician and a switch mat. Patients who underwent unilateral TKA were tested at initial outpatient physical therapy evaluation, at 3 months after TKA, and at 1 year after TKA.

Results: The assessment of function with the SST was determined to be reliable between testers when using a stopwatch. SST times were significantly correlated with other measures of lower extremity functional performance, providing evidence of its validity in patients after TKA. The SST was responsive to treatment in patients after TKA, with improvements in time for test completion. Performance on the SST also differed between limbs of patients after TKA and when comparing the limbs of healthy controls to those of patients after TKA.

Conclusion: The SST is a reliable measure between testers and a valid and responsive test of activity limitations when assessing unilateral lower extremity impairments in patients after TKA.

FIGURE 1

Schematic depicting the single-step test. The test leg is on a 15-cm block and the other leg is in a knee immobilizer to minimize its contribution to the task. Subjects were asked to touch the heel of the nontest leg to the floor, then back to the block 20 times, as fast as possible.

FIGURE 2

Effect-size index for changes from IE to 3 months after surgery and to 1 year after surgery, with 95% confidence intervals, for the SST, SCT, TUG, and 6MW. The effect size for the 6MW was negative; for comparison among measures, the absolute effect size is presented. Abbreviations: 6MW, 6-minute walk; IE, initial postoperative physical therapy evaluation; SCT, stair-climbing test; SST, single-step test; TUG, timed up-and-go.

FIGURE 3

Changes in single-step-test performance (n = 102) between limbs and across time for patients who underwent unilateral total knee arthroplasty. Testing was completed at IE and at 3 months and at 1 year after surgery. The broken line indicates mean performance time for the control subjects. Blue lines indicate differences in the operated limb and orange lines indicate differences in the nonoperated limb. *Significant difference between limbs (P = .004). ^†Significant difference between limbs (P<.001). ^‡Significant difference over time (P<.001). Abbreviation: IE, initial postoperative physical therapy evaluation.