Clinical Rehabilitation 2006; 20: 413-420

Gait analysis and WOMAC are complementary in

assessing functional outcome in total hip
replacement
U Lindemann Robert-Bosch-Hospital, Department of Geriatric Rehabilitation, Stuttgart and Bethesda Geriatric Hospital Ulm,
Academic Centre at the University of Ulm, Ulm, C Becker Robert-Bosch-Hospital, Department of Geriatric Rehabilitation,
Stuttgart, I Unnewehr Bethesda Geriatric Hospital Ulm, Academic Centre at the University of Ulm, Ulm, R Muche University
of Ulm, Department of Biometry and Medical Documentation, Ulm, Germany, K Aminian, H Deinabadi Ecole Polytechnique
F6derale de Lausanne (EPFL), Division for Research in Orthopaedics, Laboratory of Movements Analysis and Measurement,
Lausanne, Switzerland, Th Nikolaus Bethesda Geriatric Hospital Ulm, Academic Centre at the University of Ulm, Ulm,
W Puhl, K Huch and KE Dreinhofer Department of Orthopaedics, Rehabilitationskrankenhaus, University of Ulm, 89081
Ulm, Germany
Received 25th March 2005; returned for revisions 8th August 2005; revised manuscript accepted 21st September 2005.

Objective: To investigate the correlation between objective and subjective evaluation

of patients with total hip replacement.
Design: Prospective preliminary trial comparing the Western Ontario and McMaster
University questionnaire (WOMAC) and gait analysis preoperatively and three
months postoperatively.
Setting: A German academic orthopaedic centre specializing in total hip replacement
surgery.
Subjects: Seventeen patients (median age 70 years) with hip osteoarthritis.
Intervention: All patients had had a primary unilateral total hip replacement.
Main measures: WOMAC questionnaire to assess self-perceived health status and
gait analysis to determine objective gait parameters.
Results: Performance of walking as well as subjective judgement of health status
improved following surgery (gait speed P= 0.0222; stride length P= 0.038; stance
phase ratio P = 0.0466; WOMAC P < 0.0001). However, the correlation between gait
parameters and WOMAC was poor (r= -0.27 or less). Correlation between
changes of walking parameters and WOMAC was bad to good (r= 0.01 to
r= -0.72).
Conclusion: The WOMAC questionnaire might not reflect walking performance. The
addition of gait analysis is recommended to gain objective information about the
quality of gait.

Address for correspondence: Ulrich Lindemann, Robert-Bosch-

Krankenhaus, Geriatrische Rehabilitation, Auerbachstr. 110,
70376 Stuttgart, Germany. e-mail: ulrich.lindemann@rbk.de
CC) 2006 Edward Arnold (Publishers) Ltd 10. I 91/026921 5506cr958oa

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414 U Lindemann et al.

Introduction overlap of the pain and function items.2" WOMAC

may not be capable of distinguishing between
Osteoarthritis is one the major diseases profiled changes in pain and functional status like walking
during the World Health Organization (WHO) and when these attributes have discordant changes.
United Nations endorsed 'Bone and Joint Decade' Walking performance can objectively be as-
since it is one of the leading causes of pain and sessed by systems of biomechanical gait analy-
disability in the western world.' The prevalence of sis22'23 which are also an objective measure to
the condition increases markedly with age. The evaluate the clinical efficacy of surgical procedures
increasing number of older people and the changes of the lower extremity, especially to quantifSy the
in lifestyle throughout the world will drastically improvement after total hip replacement.24 2 The
increase the burden of osteoarthritis on patients temporal and spatial parameters of gait, such as
and societies.
gait speed, step length, stride length, width of base
Total hip replacement effectively relieves pain of support, knee flexion-extension or thigh rota-
and functional disability for patients with moder- tion angle, are estimated by gyroscopes attached to
ate to severe arthritis of the hip. It thereby the lower limbs or pressure sensors, embedded in a
improves quality of life2 and is a cost-effective walkway, respectively. From these parameters the
procedure.3 Due to the huge demand in ageing stride to stride variability expressed by the coeffi-
societies more than 260000 primary hip arthro- cient of variation, meaning the steadiness of gait,
plasties are performed annually in the US. In can be calculated. This variability of gait is
Germany more than 180000 total hip replace- discussed
risk in older
as a safety feature related to the fall
people.26-28
ments are being conducted every year.
Many publications have analysed factors related The purpose of this study was to investigate the
to outcome of total hip replacement. Originally, correlation between objective and subjective mea-
most studies looked at the influence of implant, surements in the evaluation of patients with total
cement, procedure or the qualification of the hip replacement and to analyse the validity of the
surgeon. 5 More than 20 different hip scores
4,5 physical function subscale of the WOMAC. A
were introduced,6 but the test measurement prop-
further objective was to evaluate which parameter
of gait is
erties of the different rating systems were hetero- parameters in most independent from other gait
geneous, and a lack of reliability and validity was
describing changes of performance.
described for many of the scores.7 Large discre-
pancies were demonstrated between self-reported
measures and clinical evaluation of outcome.8
More recently, research has focused on patient- Methods
related factors9"0 and quality of life issues in
particular."'1 These are now considered the The study is a prospective investigation comparing
gold standard in clinical trials in osteoarthritis. the results of pre-post measurements. The patients
At the Outcome Measures in Arthritis Clinical were screened by a physician on the day before
Trials conference, the OMERACT (Outcome surgery. Selection criteria were defined before
Measures in Rheumatology Clinical Trials) group recruitment and all patients gave written informed
identified pain and physical function as core out- consent. The study was approved by the local
come measures for patients with hip and ethical committee.
knee osteoarthritis. 14 The Western Ontario Patients between the ages of 60 and 80
and McMaster Universities Osteoarthritis Index years with a primary diagnosis of osteoarthritis
(WOMAC)'5 has been recommended as the (Kellgren and Lawrence grade 3 and 4) undergoing
standard of a self-reported measure to assess these elective unilateral total hip replacement were
items. 16,17 recruited from an orthopaedic hospital. Exclusion
The core domains of the WOMAC are pain, criteria comprised advanced generalized osteoar-
stiffness and function. However, previous studies thritis or spondylarthritis, severe osteoarthritis in
indicate that WOMAC items do not group by pain another joint of the lower extremity, rheumatoid
and function,'8 20 but rather by activities with arthritis, previous arthrodesis or arthroplasty of

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 Gait analysis and WOMAC in total hip replacement 415

the lower extremity, systemic connective tissue limbs stride length and stride velocity) were
diseases, comorbidities associated with cognitive estimated by integration of the angular rate of
impairment, patients with neurological diseases rotation of the thigh and shank.
preventing normal gait and patients using a Gait speed was estimated as mean of left and
walking aid routinely. Twenty consecutive patients right leg's velocity, and stride length as mean of left
(10 men, 10 women) were included in the study. Of and right leg's stride length. To evaluate stride-to-
these, three were excluded during the study: one stride variability of the stride length and gait speed,
man due to a hip dislocation eight weeks after for each walking trial coefficients of variation of
surgery and two women who refused to participate these parameters were calculated and presented as
in the gait analysis after three months. The re- percentage of variability (CV 100 x standard
maining 17 patients (nine men, eight women, mean deviation/mean). Stance phases were normalized
age 67.2, SD 5.25; mean body mass index 29.7; SD by gait cycle duration and presented as percentage
3.55) completed all tests. of it. As a marker of limping the quotient of mean
All patients received a primary unilateral total percentage of stance phases of the affected and the
hip replacement, performed transgluteally at a unaffected leg was calculated as the stance
German university hospital by five experienced phase ratio. In addition, mean range of thigh
hip surgeons. During their stay in hospital all flexion-extension of the affected leg was docu-
patients received 30 min physiotherapy for five mented. A change of performance after three
days a week (acute and rehab setting) as part of the months was calculated as the absolute difference
rehabilitation programme, and were advised to between pre and post measurement.
partially bear weight for the first six weeks after The gait analysis system has been validated in
surgery. patients with hip osteoarthritis, with total hip
Gait analysis and assessment of health status replacement and control subjects.29 A force-plate
were performed at the hospital on the day before and an optical motion analysis system including
hip replacement and three months later at the same four cameras have been used as a criterion
location, when the patients returned for a post- standard. The good agreement of the ambulatory
operative routine check-up. system with the reference devices has been shown
Gait was analysed over 40 seconds walking in a by the low level of errors for gait events ( < 19 ms),
hallway straight on. The subjects were instructed stride length ( < 0.4 cm) and velocity ( < 2.5 cm/s),
to walk at their preferred pace. The use of a as well as for lower limb flexion-extension
walking aid was allowed during the assessment. (< 2.40).
Lower limb movement in the sagittal plane during Health status was assessed by the self-adminis-
walking was measured using four miniature gyro- tered WOMAC questionnaire,'15 a multidimen-
scopes (ENC-03J, Murata, Kyoto, Japan) attached sional, self-administered outcome measure
on each shank and thigh. Each sensor measured developed for patients with hip and knee osteoar-
the velocity of the angular rotation of each thritis. It probes for the dimensions of pain (five
segment parallel to the medio-lateral axis items), stiffness (two items) and physical function
(flexion-extension). The signals were digitised (12 (17 items). The German version with a numeri-
bit) at a sampling rate of 200 Hz by a light portable cally gradually scaling ranging from 0 ('no symp-
data logger (Physilog, BioAGM, Ecublens, toms') to 10 ('extreme symptoms') for each
Switzerland), and stored for off-line elaboration question was used. A change of perception after
on a memory card. The method for the calculation three months was calculated as the absolute
of the spatio-temporal parameters of gait is difference between pre and post measurement.
described in detail elsewhere.22 The gait phases Mean values and standard deviation (SD) were
were determined from the precise moments of heel- calculated over all parameters. The individual
strike (initial foot contact) and toe-off (terminal differences between the pre and post measurements
foot contact). Every temporal parameter of a gait are given as mean values and SD. The Wilcoxon
cycle was computed as a percentage of this gait signed rank test was used to assess differences
cycle. Based on a mechanical model, spatial between the pre and post measurements. The
parameters (i.e. flexion-extension of the lower significance level was set to a == 5%. All P-values

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416 U Lindemann et al.

presented are two-sided. Correlations between subscore stiffness (r = 0.22) showed a poor
-

parameters were calculatedby Spearman's coeffi- association. The association between the changes
cient of correlation. Absolute values of the corre- of gait parameters and changes of WOMAC was
lation coefficients were a priori classified as poor also poor (r = 0.38 or less) for both parameters
(<0.40), fair to good (0.40-0.75) and excellent describing gait variability (Table 3).
(>0.75). The data were analysed using SAS The most independent gait parameters (statisti-
version 8.0 (SAS Institute Inc., Cary, USA). cally independent from other gait parameters)
describing changes of walking performance were
the variability of gait speed, the variability of stride
length and the stance phase ratio with their highest
Results absolute coefficients of correlation between
gait parameters of r = 0.43, r = 0.56 and r = 0.45,
No adverse events occurred during surgery. Gait respectively (Table 3). The association between
speed, stride length, variability of stride length, gait speed and these parameters was poor
and stance phase ratio improved after three (r = 0.37 or less).
months (P = 0.0466 or less, Table 1). No alteration
was documented in the gait parameters thigh
flexion-extension and gait speed variability. In
addition, an improvement of the sum-score of the Discussion
WOMAC questionnaire as well as of all of its
subscores could be demonstrated (P=0.0016 or In the presented study, the surgical intervention
less; Table 1). was successful in all patients. This is demonstrated
The association between gait parameters and by the improved rating of the self-perceived health
WOMAC, including its subscores, was remarkably status (WOMAC) in all segments and the improve-
poor at baseline and also postoperatively. Absolute ment of parameters describing the walking perfor-
coefficients of correlation of r = 0.27 or less were mance. However, the correlation between these
calculated (Table 2). The association between the tools was poor, indicating that WOMAC may not
changes of gait parameters and changes of be capable of distinguishing between changes in
WOMAC was fair to good for gait speed, stride pain and functional status as long as these para-
length, thigh flexion-extension and stance phase meters have discordant changes.
ratio (r = 0.42 0.72), except that the coefficients
- Although pain is an important reason for most
of correlation for gait speed/WOMAC subscore patients for having surgery, functional disabilities
pain (r = 0.39) and stance phase ratio/WOMAC
- associated with arthritis of the hip might be
Table 1 Gait analysis and WOMAC before and three months after total hip replacement (n = 17)
Preoperative Postoperative Differences
Mean SD Mean SD Mean SD P-value
GS (m/s) 1.06 0.2 1.16 0.13 0.1 0.17 0.0222
GS CV (%) 3.31 1.16 2.82 1.37 -0.49 1.37 0.1089
SL (m) 1.2 0.15 1.26 0.12 0.06 0.1 0.038
SL CV (%) 2.22 0.79 1.78 0.39 - 0.44 0.8 0.0348
TFE (°) 34.41 7.87 38.72 4.09 4.31 6.92 0.0466
SPR 0.96 0.04 0.98 0.04 0.02 0.04 0.0734
WOMAC 108.65 40.18 37.53 29.25 -71.12 40.23 <0.0001
Pain 21.41 9.44 5.88 6.07 - 15.53 7.77 < 0.0001
Stiffness 9.47 4.46 4.71 3.55 -4.76 5.07 0.0016
Function 76.88 28.27 25.82 22.2 -51.06 29.29 < 0.0001

GS, mean gait speed; SL, mean stride length; TFE, mean thigh flexion-extension; SPR, mean stance phase ratio; CV, coefficient
of variation; WOMAC, Western Ontario and McMaster Universities questionnaire sum-score.

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 Gait analysis and WOMAC in total hip replacement 417
Table 2 Correlation between gait parameters and WOMAC (n= 17)
WOMAC preoperative WOMAC postoperative
Sum-score Pain Stiffness Function Sum-score Pain Stiffness Function
GS 0.09 0.21 -0.2 0.09 - 0.16 0.05 - 0.06 - 0.12
GS CV -0.12 -0.14 0.15 -0.1 -0.1 -0.15 -0.23 -0.06
SL 0.01 0.11 -0.18 0.03 0.14 0.04 0.12 0.2
SL CV 0.07 -0.02 -0.09 0.1 0.02 -0.06 -0.21 -0.05
TFE -0.1 -0.02 -0.27 -0.06 0.05 -0.07 -0.1 -0.03
SPR 0.04 0.16 0.06 0.04 -0.17 0.03 -0.27 -0.21

WOMAC, Western Ontario and McMaster Universities questionnaire; GS, mean gait speed; SL, mean stride length; TFE, mean
thigh flexion-extension; SPR, mean stance phase ratio; CV, coefficient of variation.

equally or even more important to some patients. much the domains pain, stiffness and physical
Pain and physical function are usually seen to be functions are really described by the patients'
closely related, but in certain phases they develop choices. Most studies confirming the ability of
in different directions. In the early postoperative the WOMAC to detect change have a common
phase pain is reduced, while the functional cap- denominator, since pain and function were always
ability might be diminished compared with the expected to improve over the assessment period.
preoperative period. Despite expecting that the No gold standard has existed up to now for
WOMAC subscale for physical function would measuring functional status. Gait analysis is used
demonstrate this decline in functional status, it did as an objective reference, since one of the func-
not in a recent study.21 While time to complete tional goals of total hip replacement is to improve
some performance measures (40 m walk test, stair the walking capability. Parameters such as walking
test, and Timed Up and Go Test) doubled between velocity and symmetry reliably reflect changes in a
preoperative and eight days post operative, no patient's gait efficiency.
appreciable change took place in the WOMAC An analysis of quality-of-life data and objective
functional subscale and the WOMAC pain sub- clinical data in the same setting is uncommon, and
scale demonstrated a decrease in reported pain.21 only used to measure the efficiency of the
Considering that the association between the WOMAC.'5 In an earlier study Boardman evalu-
WOMAC pain and physical function score is so ated 30 osteoarthritic patients undergoing total hip
strong that it is not capable of identifying the clear replacement subjectively (WOMAC, SF-36) and
deterioration in physical function in the early objectively with regard to their functional ability to
postoperative phase, it is questionable if differen- walk with the basic stride analysis and the
tiation of even more subtle differences between six-minute walk test preoperatively and at one
change profiles in pain and physical function will year post operative.3' Improvements in the six-
be detected. Further analysis is needed on how minute walking distance and in gait velocity
Table 3 Correlation between changes of gait parameters and changes of WOMAC (n = 17)
GS CV SL SL CV TFE SPR WOMAC Pain Stiffness Function
GS - 0.23 0.78 - 0.37 0.73 0.32 - 0.6 -0.39 -0.59 -0.62
GS CV -0.43 0.25 -0.21 0.1 0.18 0.36 0.28 0.13
SL -0.56 0.68 0.32 -0.6 -0.42 -0.5 -0.62
SL CV -0.35 -0.2 0.32 0.01 0.09 0.38
TFE 0.45 -0.7 -0.55 -0.64 -0.72
SPR -0.66 -0.49 -0.22 -0.66

WOMAC, Western Ontario and McMaster Universities questionnaire sum-score; GS, mean gait speed; SL, mean stride length;
TFE, mean thigh flexion-extension; SPR, mean stance phase ratio; CV, coefficient of variation.

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418 U Lindemann et al.
correlated with improvement in the WOMAC
physical function and stiffness subscales. There
was also a good correlation between absolute
postoperative data for six-minute walking distance,
gait velocity, gait symmetry and the WOMAC
functional score.
While in the present study all parameters of the
gait analysis and all WOMAC scales improved
over the first three months after surgery, the
correlation between these parameters was poor
and the association between the changes was only
fair to good.High coefficients of correlation would
have implied that both tools (WOMAC and gait
analysis) assess the same aspect (walking perfor-
mance), but from a different perspective. Origin-
ally, we would have expected a high correlation
between gait parameters and WOMAC functional
subscales, which describe self-perceived physical
function. However, the correlation is remarkably
poor (r = - 0.21 or less). This implies that the
self-perceived physical function score does not
reflect actual performance. Nevertheless, self-per-
ceived physical function should be an important
marker of success for any surgical intervention,
because it demonstrates patient's satisfaction. The
difference between the results of our study and
the one from Boardman3' might be caused by the
different time interval between the intervention
and the measurement. While at three months the
changes in pain and functional status might still be
discordant, after 12 months they should be con-
cordant.
The improvement of physical performance and
the better results of the WOMAC score after hip
replacement show the sensitivity to change of both
Clinical messages
* Subjective perception of function, measured
by the WOMAC questionnaire, does not
reflect the actual walking performance.
* Gait analysis gives additional information
about performance and changes of consis-
tency of walking.
* Variability of gait speed and variability of
stride length as well as the stance phase ratio
are clinically relevant parameters.
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tools. However, fair to good coefficients of correla-
tion for changes were only documented between
the WOMAC score and those gait parameters that
provide a global description of performance, like
gait speed, stride length, thigh flexion-extension
and the stance phase ratio. The association be-
tween changes in the WOMAC score and those
gait parameters describing the quality (i.e. the
consistency of performance), such as the variability
of gait speed and of stride length, is poor.
Since these parameters are shown to have
relevance for the safety of walking,26-28 there is
important additional information provided by gait
analysis describing any improvement in walking.
Furthermore, poor association between these para-
meters describing quality of performance and
mean gait speed demonstrate that the assessment
of mean gait speed alone is not sufficient. A stride-
to-stride gait analysis is necessary to describe
performance of walking.
Our study has limitations due to the size of the
study group and the limited number of assess-
ments. It might be interesting to analyse these
parameters more frequently in the early rehabilita-
tion phase and in a later phase for comparison.
In the measurement of outcomes in osteoarthritis
it is desirable to include both a generic instrument
and a condition-specific instrument, such as the
WOMAC or SF-36. In a recent study assessing
physical function and quality of life before and
after total hip replacement both instruments
detected significant and clinically meaningful
changes. However, the WOMAC was a more
responsive measure in the short term compared
to SF-36, thus requiring a smaller sample size.32 In
a different study functional improvements could be
detected better by the WOMAC than the SF-36.33
Therefore, we decided to focus in this study on a
disease-specific subjective instrument (WOMAC).
Recently the WHO has approved the International
Classification of Functioning, Disability and
Health (ICF), formerly ICIDH-2. Based on the
biopsychosocial view of patient health, the ICF
forms a comprehensive instrument for measuring
functional ability, since it covers almost all human
functions and activities. Further research is neces-
sary to analyse whether the ICF core set for
osteoarthritis 4 is able to predict the functional
status of a patient with osteoarthritis over time.
 Gait analysis and WOMAC in total hip replacement 419
Acknowledgements
We acknowledge the help of Bijan Najafi for
discussing our results. Barbara Eichner and
Hannes Becker were helpful with the data manage-
ment. The study was supported by the Bethesda
Geriatrische Klinik Ulm, and the Rehabilitation-
skrankenhaus Ulm.
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