Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation

BACKGROUND

Dysvascularity accounts for 75% of all lower limb amputations in the UK. Around 37% of these procedures are done at the transfemoral level (mid-thigh), with most patients over the age of 60 and having existing comorbidities. A significant number of these amputees are prescribed a lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. This is the third update of the review first published in 2005.

OBJECTIVES

To identify and summarise the evidence evaluating prosthetic rehabilitation interventions for prosthetic ambulation following unilateral transfemoral or transgenicular amputation in older dysvascular people, whether community dwelling or institutionalised.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register and CENTRAL, MEDLINE, Embase, and CINAHL databases; the World Health Organization International Clinical Trials Registry Platform; and the ClinicalTrials.gov trials registry to 14 June 2018. We performed additional searches by handsearching citations of studies identified by the electronic search. We applied no restrictions on language or publication status.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or older) dysvascular people.

DATA COLLECTION AND ANALYSIS

Two review authors independently scanned the search results for potentially eligible studies and, on obtaining full reports of these, selected studies for inclusion and exclusion. Two review authors independently assessed the methodological quality of studies and extracted data. We used GRADE to assess the overall quality of evidence supporting the outcomes assessed in this review.

MAIN RESULTS

We identified no new studies for inclusion in this update. In total we included one trial, excluded 18 trials, classed one trial as ongoing, and classed another as awaiting classification. The total number of participants in the included trial was 10, and the methodological quality of this trial was moderate because of high risk of bias in relation to two domains (random sequence generation and allocation concealment) but low risk of bias for the four remaining domains (blinding, incomplete outcome data, selective reporting, and any other bias). The included trial was a short-term cross-over randomised trial undertaken in Canada, which tested the effects of adding three seemingly identical prosthetic weights (150 g vs 770 g vs 1625 g) to the prostheses of a total of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. Trial authors found that four participants preferred the addition of the lightest weight (150 g), five preferred the middle weight (770 g), and one preferred the heaviest weight (1625 g). Researchers interpreted this as equating to user satisfaction (success) and reported no adverse effects.

AUTHORS' CONCLUSIONS

The limited evidence presented in this review is of very low quality and is insufficient to inform the choice of prosthetic rehabilitation, including the optimum weight of the prosthesis, after unilateral transfemoral amputation in older dysvascular people. A programme of research that includes randomised controlled trials to examine key interventions is urgently required in this area.

Physical activity behavior change for older veterans after dysvascular amputation

OBJECTIVE

Determine the feasibility of using a physical-activity behavior-change (PABC) intervention for increasing physical activity and reducing disability in Veterans 1-5years following dysvascular lower-limb amputation (LLA).

DESIGN

Cross-over, feasibility trial SETTING: VA Geriatric Research Education and Clinical Center and Veterans Homes PARTICIPANTS: 32 Veterans with dysvascular LLA (1-5years after major LLA) INTERVENTION: The home-based study, using telerehabilitation technology, is intended to reduce participant burden by removing transportation and time barriers. Participants will be randomized into two participation periods of three months (Months 1-3 and 4-6). PABC intervention will occur Months 1-3 for GROUP1 and Months 4-6 for GROUP2. During PABC Intervention, participants engage in weekly video interaction with a physical therapist, who uses a collaborative approach to develop self-monitoring, barrier identification, problem solving and action planning skills to improve physical activity. GROUP2 will participate in a no physical activity intervention, attention control in Months 1-3. GROUP1 will have a no contact, intervention "wash-out" period in Months 4-6.

MAIN OUTCOME MEASURES

Feasibility will be determined using measures of 1) participant retention, 2) dose goal attainment, 3) participant acceptability, 4) safety, and 5) initial effect size. Effect size will be based on accelerometer-based physical activity and self-report disability using the Late-Life Function and Disability Index.

CONCLUSIONS

This study focuses on a prevalent and understudied population with low physical activity and high levels of disability due to dysvascular LLA. The results of this study will guide future development of targeted rehabilitation research to improve long term physical activity and disability outcomes.

Explaining modified 2-min walk test outcomes in male Veterans with traumatic or nontraumatic lower-limb amputation

Little evidence exists to support the presence of differences in spatiotemporal gait parameters and ambulation ability between those individuals with traumatic and nontraumatic lower-limb amputation (LLA). We conducted an exploratory study of 81 male Veterans with unilateral amputation to quantify differences in spatiotemporal gait parameters and ambulatory mobility between Veterans with traumatic and nontraumatic LLA. Furthermore, we identified variables that significantly contributed to the explanation of variability in modified 2-min walk test distance. All participants completed the modified 2-min walk test and a spatiotemporal gait analysis using an instrumented walkway during a routine physical therapy visit. Veterans with nontraumatic LLA walked significantly shorter mean distances during a modified 2-min walk test than Veterans with traumatic LLA. Variables identified as significant contributors to modified 2-min walk test variability were amputated limb stance time, amputated limb step length, and percentage of the gait cycle spent in double support. These findings demonstrate that differences in spatiotemporal gait parameters and ambulatory mobility exist between Veterans with traumatic and nontraumatic LLA and identify important spatiotemporal parameters of gait contributing to this decline. These parameters should be considered as targets for intervention and future investigation.

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation

BACKGROUND

Dysvascularity accounts for 75% of all lower limb amputations in the UK. Around 37% of these are at transfemoral level (mid-thigh), with the majority of people being over the age of 60 and having existing co-morbidities. A significant number of these amputees will be prescribed a lower limb prosthesis for walking. However, many amputees do not achieve a high level of function following prosthetic rehabilitation. This is the second update of the review first published in 2005.

OBJECTIVES

We aimed to identify and summarise the evidence from randomised controlled trials evaluating rehabilitation interventions for prosthetic ambulation following unilateral transfemoral amputation in older dysvascular people, whether community dwelling or institutionalised.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched July 2014) and Cochrane Register of Studies (CRS) (last searched 2014 Issue 6). No language restrictions were applied.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials testing prosthetic rehabilitation interventions following a unilateral transfemoral or transgenicular amputation in older (aged 60 years or above) dysvascular people.

DATA COLLECTION AND ANALYSIS

Two authors independently scanned the search results for potentially eligible studies and on obtaining full reports of these, selected studies for inclusion and exclusion. Two authors independently assessed methodological quality and extracted data. No data pooling was possible.

MAIN RESULTS

No new studies were identified for inclusion in this update. Of the full reports obtained for consideration, one trial was included and four excluded. The included trial was a short-term crossover randomised trial which tested the effects of adding three seemingly identical prosthetic weights (150 g versus 770 g versus 1625 g) to the prostheses of 10 participants with unilateral dysvascular transfemoral amputation. Eight participants were over 60 years of age. The trial found that four participants preferred the lightest weight (150 g), five preferred the middle weight (770 g) and one preferred the addition of the heaviest weight (1625 g).

AUTHORS' CONCLUSIONS

There is a lack of evidence from randomised controlled trials to inform the choice of prosthetic rehabilitation, including the optimum weight of prosthesis, after unilateral transfemoral amputation in older dysvascular people. A programme of research, including randomised controlled trials to examine key interventions, is urgently required in this area.

Test-retest reliability of the Sensory Organization Test in older persons with a transtibial amputation

OBJECTIVE

To determine the test-retest reliability of the Sensory Organization Test (SOT) in older persons with a unilateral transtibial amputation.

DESIGN

Cross-sectional observational study with repeated measures.

SETTING

A University balance laboratory.

PARTICIPANTS

Fifteen participants (12 men and 3 women) who had undergone a unilateral transtibial amputation that was performed as a result of either trauma or complications of diabetes or peripheral vascular disease were recruited from a patient database. The mean age of the participants was 69.53 years (SD, 6.60), with 11.94 mean years of prosthetic use.

INTERVENTION

All participants completed 3 trials of the 6 balance testing conditions in the standard SOT protocol with use of the NeuroCom SMART Equitest system on 2 occasions approximately 2 weeks apart.

MAIN OUTCOME MEASURES

Reliability of the mean equilibrium and strategy scores for the 6 SOT conditions and the overall composite score was evaluated using intraclass correlation coefficients.

RESULTS

The test-retest reliability coefficients (intraclass correlation coefficient model 2,1) for the equilibrium scores ranged from 0.67-0.90 for conditions 1 to 4 and 6, indicating fair-to-good reliability. The coefficients obtained for the strategy scores of all the conditions and the composite score showed excellent reliability (intraclass correlation coefficients >0.75).

CONCLUSIONS

This study suggests that the majority of outcome measurements associated with the SOT protocol on the SMART Equitest provide a reliable measure of dynamic balance performance in older persons with a unilateral transtibial amputation, even in the presence of comorbidities. The equilibrium, strategy, and composite scores obtained from the testing protocol with the exception of condition 5, can be used reliably in clinical practice to monitor for changes in balance with rehabilitation or to monitor the effects of a specific intervention and/or in patients with comorbidities that could potentially affect their balance capacities.

The effectiveness of inpatient rehabilitation in the acute postoperative phase of care after transtibial or transfemoral amputation: study of an integrated health care delivery system

OBJECTIVE

To compare outcomes between lower-extremity amputees who receive and do not receive acute postoperative inpatient rehabilitation within a large integrated health care delivery system.

DESIGN

An observational study using multivariable propensity score risk adjustment to reduce treatment selection bias.

SETTING

Data compiled from 9 administrative databases from Veterans Affairs Medical Centers.

PARTICIPANTS

A national cohort of veterans (N=2673) who underwent transtibial or transfemoral amputation between October 1, 2002, and September 30, 2004.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

One-year cumulative survival, home discharge from the hospital, and prosthetic limb procurement within the first postoperative year.

RESULTS

After reducing selection bias, patients who received acute postoperative inpatient rehabilitation compared to those with no evidence of inpatient rehabilitation had an increased likelihood of 1-year survival (odds ratio [OR]=1.51; 95% confidence interval [CI], 1.26-1.80) and home discharge (OR=2.58; 95% CI, 2.17-3.06). Prosthetic limb procurement did not differ significantly between groups.

CONCLUSIONS

The receipt of rehabilitation in the acute postoperative inpatient period was associated with a greater likelihood of 1-year survival and home discharge from the hospital. Results support early postoperative inpatient rehabilitation following amputation.