Role of balance ability and confidence in prosthetic use for mobility of people with lower-limb loss

Perceptions of physical activity among individuals with limb loss: A qualitative study

OBJECTIVES

Individuals with lower-limb amputations (LLA) often have deficits in balance and community walking ability. As a result, people with LLA are often sedentary. The aim of this study was to explore perceptions of physical activity from the perspective of people with LLA.

METHODS

A qualitative descriptive study situated within an interpretive research paradigm was conducted. Semistructured interviews were held by telephone or in person with adults living with major LLAs recruited from rehabilitation hospitals and advertisements on social media. Individuals were included if they were age 18 years and older with a major LLA. Purposive sampling was used to ensure variation by sex, cause, and level of amputation.

RESULTS

Thirty-three people with LLA participated (22 men/11 women; median age 63 years). The majority of individuals had a unilateral, transtibial amputation (∼50% dysvascular LLA). Three main themes were developed to characterize participants' perceptions of physical activity: (1) physical activity is perceived as important but can be challenging after amputation; (2) physical activity has physical and mental health benefits; and (3) physical activity is a means to maintain independence and engagement in community and social life.

CONCLUSIONS

Obtaining the perspectives of individuals with LLA about physical activity helps us understand how they think about it, what motivates them, and how we can optimize physical activity levels. Future research is needed to evaluate the effectiveness of interventions to enhance physical activity in this population.

Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use.

MATERIALS AND METHODS

A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed.

RESULTS

The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) (p < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization.

CONCLUSIONS

The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

A qualitative study exploring healthcare professionals' perceptions of lower limb 3D printed sockets

PURPOSE

The purpose of this study was to explore healthcare professionals' (HCPs) perceptions and experiences related to 3D scanning and 3D printing for fabricating lower limb prosthetic sockets.

MATERIALS AND METHODS

This study used a qualitative descriptive approach. Participants were recruited through HCPs' professional associations, social media posts, and snowball sampling. Purposive sampling was used to attain variation in provider type. One-on-one telephone interviews were conducted using a semi-structured interview guide. Inductive thematic analysis was performed to identify the main themes.

RESULTS

Three themes were identified: (1) 3D scanning of the residual limb for designing prosthetic sockets is perceived as clean, quick, and convenient; (2) concerns about the strength and safety of 3D printed sockets for long-term use; (3) Adoption of 3D scanning and 3D printing technology for fabricating prosthetic sockets.

CONCLUSION

We identified perceived benefits and challenges with digital technologies for fabricating prosthetic sockets. To increase adoption, more research demonstrating its efficacy compared to conventional methods, increasing 3D printing material quality, and improving software training programs are needed.Implications for Rehabilitation3D printing and 3D scanning are emerging digital technologies that can be used as alternative methods for prosthetic socket manufacturing in the field of rehabilitation.Our research identified perceived benefits of using digital technologies for fabricating prosthetics sockets (3D scanning is perceived as clean, quick, and convenient) and perceived challenges (concerns about the strength and safety of 3D printed sockets for long-term use and a prolonged learning curve).To increase adoption of these digital technologies, more training should be provided to prosthetists and support provided to integrate new processes into staff workloads.

Quantitative methods used to evaluate balance, postural control, and the fear of falling in lower limb prosthesis users: A systematic review

Problems with balance, postural control, and fear of falling are highly prevalent in lower limb prosthesis users, with much research conducted to understand these issues. The variety of tools used to assess these concepts presents a challenge when interpreting research outcomes. This systematic review aimed to provide a synthesis of quantifiable methods used in the evaluation of balance, postural control, and fear of falling in lower limb prosthesis users with an amputation level at or proximal to the ankle joint. A systematic search was conducted in CINAHL, Medline, AMED, Cochrane, AgeLine, Scopus, Web of Science, Proquest, PsycINFO, PsycArticles, and PubPsych databases followed by additional manual searching via reference lists in the reviewed articles databases. Included articles used quantitative measure of balance or postural control as one of the dependent variables, lower limb prosthesis users as a sample group, and were published in a peer-reviewed journal in English. Relevant assessment questions were created by the investigators to rate the assessment methods used in the individual studies. Descriptive and summary statistics are used to synthesize the results. The search yielded (n = 187) articles assessing balance or postural control (n = 5487 persons in total) and (n = 66) articles assessing fear of falling or balance confidence (n = 7325 persons in total). The most used test to measure balance was the Berg Balance Scale and the most used test to measure fear of falling was the Activities-specific Balance Confidence scale. A large number of studies did not present if the chosen methods were valid and reliable for the lower limb prosthesis users. Among study limitations, small sample size was common.

Association between balance confidence and basic walking abilities in people with unilateral transtibial lower-limb amputations: A cross-sectional study

INTRODUCTION

Falls are common for people with lower-limb amputations (PLLA). Low balance confidence is also prevalent, is worse in PLLA not reporting walking automaticity, and is known to negatively affect prosthesis use, social engagement, and quality of life. Moreover, walking with a prosthesis requires continuous attention. Low balance confidence may act as a distractor imposing an additional cognitive load on the already cognitively demanding task of walking with a prosthesis.

METHODS

Adults with unilateral, transtibial amputations were recruited. The Activities-specific Balance Confidence (ABC) scale quantified balance confidence. The L Test assessed basic walking abilities under single-task (ST) (usual) and dual-task (DT) (walking while counting backwards) conditions. The relative change in gait and secondary task performance between conditions (ie, DT cost) was calculated. Separate multivariable linear regressions examined the association of balance confidence on the L Test.

RESULTS

Forty-four PLLA (56.6 ± 12.6 years) participated. An independent association of the ABC to ST ( P < 0.001, R 2 = 0.56) and DT ( P = 0.008, R 2 = 0.43) L Test performance was observed. A 1% ABC increase was related with a 0.24 (95% confidence interval, 0.35-0.14) and 0.23 (95% confidence interval, 0.39-0.06) second reduction with the ST and DT L Test, respectively. No association to DT cost was observed.

CONCLUSIONS

Balance confidence influences basic walking abilities yet does not modulate the added cognitive load associated with DT. Interventions that address balance confidence may be beneficial throughout rehabilitation. This research is novel and offers the possibility for alternative avenues for focus in rehabilitation and falls prevention in a population at high risk for falls.

Clinimetrics of performance-based functional outcome measures for vascular amputees: A systematic review

BACKGROUND

Objective physical performance-based outcome measures (PerBOMs) are essential tools for the holistic management of people who have had an amputation due to vascular disease. These people are often non-ambulatory, however it is currently unclear which PerBOMs are high quality and appropriate for those who are either ambulatory or non-ambulatory.

RESEARCH QUESTION

Which PerBOMs have appropriate clinimetric properties to be recommended for those who have had amputations due to vascular disease ('vascular amputee')?

DATA SOURCES

MEDLINE, CINAHL, EMBASE, EMCARE, the Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) and Scopus databases were searched for the terms: "physical performance" or "function", "clinimetric properties", "reliability", "validity", "amputee" and "peripheral vascular disease" or "diabetes".

REVIEW METHODS

A systematic review of PerBOMs for vascular amputees was performed following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and PRISMA guidelines. The quality of studies and individual PerBOMs was assessed using COSMIN risk of bias and good measurement properties. Overall PerBOM quality was evaluated with a modified GRADE rating. Key clinimetric properties evaluated were reliability, validity, predictive validity and responsiveness.

RESULTS

A total of 15,259 records were screened. Forty-eight studies (2650 participants) were included: 7 exclusively included vascular amputees only, 35 investigated validity, 20 studied predictive validity, 23 investigated reliability or internal consistency and 7 assessed responsiveness. Meta-analysis was neither possible nor appropriate for this systematic review in accordance with COSMIN guidelines, due to heterogeneity of the data. Thirty-four different PerBOMs were identified of which only 4 are suitable for non-ambulatory vascular amputees. The Amputee Mobility Predictor no Prosthesis (AMPnoPro) and Transfemoral Fitting Predictor (TFP) predict prosthesis use only. PerBOMs available for assessing physical performance are the One-Leg Balance Test (OLBT) and Basic Amputee Mobility Score (BAMS).

CONCLUSION

At present, few PerBOMs can be recommended for vascular amputees. Only 4 are available for non-ambulatory individuals: AMPnoPro, TFP, OLBT and BAMS.

User-relevant factors influencing the prosthesis use of persons with a transfemoral amputation or knee-disarticulation: A meta-synthesis of qualitative literature and focus group results

OBJECTIVE

Persons with a transfemoral amputation or knee-disarticulation are heavily reliant on an adequate set of components for their prosthesis. To improve the process of adjusting the specific prosthetic properties to the expectations of the prosthesis users, it is of importance to first identify which factors have an influence on prosthesis use. Therefore, we aimed to identify factors that influence prosthesis use in adults with a transfemoral amputation or knee-disarticulation.

METHODS

A qualitative meta-synthesis was conducted by searching five databases (last update January 20th 2022). Studies were considered eligible if they contained qualitative data about adult persons with a transfemoral amputation or knee-disarticulation with experience in using a prosthesis and focused on the users' opinions. All eligible studies were independently screened by two reviewers. The results sections of the included studies were entered in Atlas.ti software (v8) and coded using the framework approach. The quality of the included studies was assessed using the Critical Appraisal Skills Program (CASP) qualitative research checklist. Results of the meta-synthesis were validated with prosthesis users (n = 8) in a focus group.

RESULTS

Out of 5757 articles, 14 studies were included. An overview of seven themes ('prosthesis related'; 'rehabilitation, costs and prosthetist'; 'mental'; 'physical'; 'social'; 'activities and participation' and 'walking') containing 84 factors was created. Ten factors were added during the focus group, resulting in an overview of 94 factors that may influence the prosthesis use of lower-limb prosthesis users. Participants would like more user-involvement from the rehabilitation team. The development of a patient decision aid could help this process in the future.

CONCLUSION

The large number of factors demonstrates that there is a great variety between prosthesis users and the factors that influence their prosthesis use. Therefore, it is important to take individual preferences into account for the selection of a new prosthesis.

Thoracic spine deformation may predict prosthetic rehabilitation outcome

BACKGROUND

A considerable number of patients require prosthetic ambulation, which necessitates improvements in the success rate of prosthetics.

OBJECTIVE

This study aimed to determine the association between the presence of thoracic spinal osteophyte on imaging and the patient's ability to walk with lower leg prosthetics.

STUDY DESIGN

Retrospective cohort study.

METHODS

This study included 15 patients with lower leg amputations who underwent prosthetic rehabilitation. Medical records and spine radiographs of patients with lower leg amputations between 2013 and 2019 at a private rehabilitation hospital were reviewed. The primary outcome was achieving prosthetic ambulation with a single T-cane or without a walking aid.

RESULTS

Poor outcomes were associated with the presence of thoracic spinal deformation (P = 0.007) and the lower Berg Balance Scale score at admission (P = .067) and discharge (P = .033) groups. Monte Carlo simulation results showed a ≥33% difference in walking achieving rate between patients with and without thoracic spinal deformity. In addition, an 18% probability was found for randomly selected persons with an amputation to show a difference of ≥1 point in Berg Balance Scale scores.

CONCLUSION

Thoracic spinal deformity on radiography and Berg Balance Scale score at admission are potentially associated with successful prosthetic rehabilitation. These findings potentially affect the indications for prosthetic limbs.

Mobility Analysis of AmpuTees (MAAT 7): Normative Mobility Values for Lower Limb Prosthesis Users of Varying Age, Etiology, and Amputation Level

OBJECTIVE

The aim of the study was to establish normative values of lower limb amputation mobility across primary etiologies based on age and amputation level.

DESIGN

This study is a cross-sectional observational analysis of outcomes. A total of 11,995 lower limb prosthesis users were included in the analysis. Participants were grouped by etiology into four categories: cancer, congenital, trauma, and diabetes/dysvascular. Mobility was assessed by using the Prosthetic Limb Users Survey of Mobility.

RESULTS

Mobility across seven age groups for the four etiologies was established for both above-the-knee amputation and below-the-knee amputation. Differences were found between age groups for individuals: above-the-knee amputation: cancer (χ 2 (6) = 40.97, P < 0.001), congenital (χ 2 (3) = 9.41, P = 0.024), trauma (χ 2 (6) = 18.89, P = 0.004), and dysvascular (χ 2 (5) = 39.73, P < 0.001; below-the-knee amputation: cancer (χ 2 (6) = 29.77, P < 0.001), trauma (χ 2 (6) = 28.22, P < 0.001), and dysvascular (χ 2 (6) = 144.66, P < 0.001).

CONCLUSIONS

The awareness of differences across amputation etiologies extending across the lifespan of ages can assist the goal-setting process as part of prosthetic rehabilitation. In addition, refined normative values provide the ability to benchmark new and innovative changes in clinical practice.

Near-Fall Detection in Unexpected Slips during Over-Ground Locomotion with Body-Worn Sensors among Older Adults

Slip-induced falls are a growing health concern for older adults, and near-fall events are associated with an increased risk of falling. To detect older adults at a high risk of slip-related falls, this study aimed to develop models for near-fall event detection based on accelerometry data collected by body-fixed sensors. Thirty-four healthy older adults who experienced 24 laboratory-induced slips were included. The slip outcomes were first identified as loss of balance (LOB) and no LOB (NLOB), and then the kinematic measures were compared between these two outcomes. Next, all the slip trials were split into a training set (90%) and a test set (10%) at sample level. The training set was used to train both machine learning models (n = 2) and deep learning models (n = 2), and the test set was used to evaluate the performance of each model. Our results indicated that the deep learning models showed higher accuracy for both LOB (>64%) and NLOB (>90%) classifications than the machine learning models. Among all the models, the Inception model showed the highest classification accuracy (87.5%) and the largest area under the receiver operating characteristic curve (AUC), indicating that the model is an effective method for near-fall (LOB) detection. Our approach can be helpful in identifying individuals at the risk of slip-related falls before they experience an actual fall.

Factors that Influence Time to Prosthesis Receipt after Lower Limb Amputation: A Cox Proportional Hazard Model Regression

INTRODUCTION

Early mobility, functional independence, and ambulation are associated benefits after LLA, while an increased risk of clinical complications is associated with no prosthesis.

OBJECTIVE

The aims of this study were to describe time to prosthesis receipt after amputation and to assess the impact of patient demographic and health factors on the rate of prosthesis receipt within 12 months post-LLA.

DESIGN

A retrospective cohort analysis using commercial administrative claims data. Kaplan-Meier and Cox proportional-hazards models were applied to assess time to prosthesis receipt.

SETTING

Watson/Truven administrative database 2014-2016.

PARTICIPANTS

Adults age 18-64 with LLA who maintained their current insurance enrollment for 12 months after amputation.

INTERVENTIONS

Independent variables included diabetes/vascular disease status, amputation level, age, sex, and region.

MAIN OUTCOME MEASURE

Prosthesis receipt was defined based on the presence of codes billed for prosthesis services. Time was measured in days from date of amputation surgery.

RESULTS

Among the sample, 510 individuals maintained enrollment for 12 months post-amputation, of which 443 individuals received a prosthesis within that period (79% BK and 21% AK). The adjusted average rate of time to prosthesis receipt was 138 (95% CI: 113-185) days. Individuals with diabetes/vascular disease were 22% (HR: 1.22 95% CI: 1.02-1.49) more likely to receive a prosthesis earlier than individuals without diabetes/vascular disease and females received a prosthesis later than males at 141 (95% CI: 126-162) days vs 106 (95% CI: 96-119) days, respectively.

CONCLUSION

This study expands the understanding of factors that influence the likelihood of receiving a prosthesis along with the timing of prosthesis receipt after LLA among commercially insured adults. At least half of this sample received a prosthesis within 5 months or less. Disparities in timing and access to a prosthesis based on amputation level and sex were noted, future efforts are needed to address these issues. This article is protected by copyright. All rights reserved.

A block randomised controlled trial investigating changes in postural control following a personalised 12-week exercise programme for individuals with lower limb amputation

BACKGROUND

Individuals with a lower limb amputation (LLA) have an increased risk of falls and often report lower balance confidence. They must compensate for altered mechanics and prosthetic limitations in order to execute appropriate motor responses to postural perturbations. Personalised exercise could be an effective strategy to enhance balance and reduce falls.

RESEARCH QUESTION

In this study, we investigated whether a personalised exercise programme could improve postural control and self-reported balance confidence in individuals with an LLA.

METHODS

Participants were block randomised into two groups (exercise, n = 7; control, n = 7) based on age and level of amputation. The exercise group completed a 12-week personalised exercise programme, including home-based exercise sessions, consisting of balance, endurance, strength, and flexibility training. The control group continued with their normal daily activities. All participants performed the Sensory Organization Test (SOT) and Motor Control Test (MCT) on the NeuroCom SMART Equitest, and completed the Activities-specific Balance Confidence-UK (ABC) self-report questionnaire, at baseline and post-intervention.

RESULTS AND SIGNIFICANCE

Exercise group equilibrium scores improved significantly when standing on an unstable support surface with no visual input and inaccurate somatosensory feedback (SOT condition 5, P < 0.012, d = 1.45). There were significant group*time interactions for medium (P = 0.029) and large (P = 0.048) support surface forward translations, which were associated with a trend towards increased weight-bearing on the intact limb in the control group (medium: P = 0.055; large: P = 0.087). No significant changes in ABC score were observed. These results indicate reduced reliance on visual input, and/or enhanced interpretation of somatosensory input, following an exercise programme. However, objective improvements in aspects of postural control were not associated with subjective improvements in self-reported balance confidence. More weight-bearing asymmetry in the control group suggests that a lack of targeted exercise training may have detrimental effects, with potential adverse long-term musculoskeletal consequences, that were quantifiable within a short timeframe.

Current and Emerging Trends in the Management of Fall Risk in People with Lower Limb Amputation

Purpose of Review

People living with lower limb amputation are at an increased risk of falling compared with the healthy geriatric population. Factors of increased age and increased number of comorbidities could compound the already increased risk. The purpose of this article is to highlight recent research associated with fall risk in amputees and provide the reader with evidence to help guide clinical interventions.

Recent Findings

Though research on the topic of falls in people with amputation is becoming more common, there is still a dearth of evidence regarding what contributes to increased fall risk and how to address it in this population. There are recent studies that have examined therapy and prosthetic interventions that could mitigate fall risk in people with amputation, yet there is not enough evidence to develop a consensus on the topic. More research is required to determine what contributes to increased fall rates in people with amputation, and what detriments to an amputee's function or psyche may result after incurring a fall.

Summary

Borrowing from what is known about geriatric fall risk and combining the information with novel and existing approaches to fall mitigation in amputees can offer clinicians the opportunity to develop evidence-based programs to address fall risk in their patients with lower limb amputation.

Relevance of medical comorbidities for functional mobility in people with limb loss: retrospective explanatory models for a clinical walking measure and a patient-reported functional outcome

OBJECTIVES

Various modifiable and non-modifiable factors affect functional mobility, but subjective patient-reported and objective performance-based measures are rarely combined in explanatory analyses of functional mobility in people with limb loss. This study determined separate explanatory models for patient-reported function using the Prosthetic Evaluation Questionnaire Mobility Subscale (PEQ-MS), and performance-based 2-Minute Walk Test (2MWT).

DESIGN

Retrospective cross-sectional observational analysis.

SETTING

Wellness-walking program.

PARTICIPANTS

Three hundred five volunteers with lower limb loss participated. Sixty nine percent were men, mean age 56 (15) years. Fifty two percent had vascular amputation causes, 42% had surgical levels above the knee, and 82% had medical comorbidities. Walking levels included limited-household (21%), limited-community (30%), and independent-community (49%). Outcome measures included patient-reported PEQ-MS, Activities-specific Balance Confidence (ABC) and Houghton scales; and performance-based balance and walking.

MAIN OUTCOMES

Separate PEQ-MS and 2MWT multiple regression models fit using backward deletion.

RESULTS

Modifiable (balance ability, ABC, Houghton score; P<0.05) and non-modifiable factors (sex, amputation cause, surgical level; P<0.05) explained the variance in 2MWT (adjusted R²=0.685). Patient-reported and performance-based modifiable factors (Houghton score, 2MWT; P<0.001) explained PEQ-MS variance (adjusted R²=0.660). Integumentary (P=0.022) and cardiopulmonary (P<0.001) comorbidities explained an additional 4% of PEQ-MS variance, while surgical level was insignificant.

CONCLUSIONS

Both modifiable and non-modifiable factors explained prosthetic functional mobility. Performance-based walking was explained by modifiable factors including balance ability and confidence, prosthesis and walking aid use. Patient-reported function was also explained by prosthesis and walking aid use, walking speed and medical comorbidities. Modifiable factors for objective and subjective prosthetic mobility may provide a clinical roadmap for rehabilitation.

'It's . . . forward-focused': Experiences of a mobility clinic for people with limb loss

BACKGROUND

Mobility clinics are designed to extend gait and mobility training beyond rehabilitation programmes. No research has been undertaken into participants' experiences of attending these multidisciplinary, experience-based clinics. Research in this area is needed to ensure clinics meet intended goals, including understanding the motivation and experience of attendees. Insights may improve mobility clinics and inform strategies to encourage greater participation.

OBJECTIVES

To explore the motivation of people with limb loss to attend a mobility clinic, the experience of participation and their perception of the clinic's benefits.

STUDY DESIGN

Qualitative methodology, naturalistic enquiry.

METHODS

Semi-structured interviews were conducted with nine clinic attendees during the clinic. Interviews were transcribed verbatim, data thematically analysed and emergent themes underwent member checking.

RESULTS

Three themes emerged from the data: facing the challenge captured how participants' have adapted to amputation, valuing peers highlights the important role of peers in learning and support and improving mobility described the ongoing quest to improve mobility.

CONCLUSION

The mobility clinic was attractive to those who liked challenges and was an invaluable source of learning for those wishing to improve their mobility. Future clinics should ensure that peer education is supported, and activities cater for a range of skills and fitness levels.

CLINICAL RELEVANCE

Findings of this study indicate that those who attended the mobility clinic liked to challenge themselves. Participation with peers was an important source of learning and support. Those participants who had previously attended a mobility clinic reported improvements in their overall daily function.

Functional capacity of elderly with lower-limb amputation after prosthesis rehabilitation: a longitudinal study

OBJECTIVES

Elderly amputees are a specific clientele because of the interaction of this disease with the ageing process. The objective of this study was to determine the impact of prosthesis rehabilitation on the functional capacity of elderly with lower-limb amputation (LLA) in short and long time.

MATERIALS AND METHODS

A quasi-experimental study was developed. The sample consisted of 29 elderly with LLA who finished the prosthesis rehabilitation programme. Gait capacity was evaluated by Functional Ambulation Classification Scale (FAC), ability to perform basic activities of daily living (ADL) was evaluated by Barthel Index (BI) and Pfeffer Questionnaire was used to evaluate the capacity to execute instrumental ADL. Statistical inference was done by t-test, t-student test and chi-squared test. The significance level was fixed at 5% (p < 0.05).

RESULTS

In the transtibial group (n = 15) no difference (p = 0.108) was found between BI score before amputation and after 3 months of follow up. The transfemoral group (n = 14) improved significantly (p = 0.045) the FAC before starting and after 3 months of discharge from ambulatory rehabilitation. Both groups increased the time of prosthesis use during the day after 3 months of follow up. However, no group has achieved FAC and Pfeffer Questionnaire pre-amputation performance.

CONCLUSION

Although elderly with LLA improved functional capacity after 3 months of a prosthesis rehabilitation programme, they did not achieve their pre-amputation functionality.Implications for rehabilitationLower-limb amputation causes a significant socioeconomic impact and decreases functional capacity, autonomy and quality of life. Elderly people with a lower-limb amputation impose a heavy burden on health resources, requiring extensive rehabilitation and long term care. The specific presentation of elderly persons with lower-limb amputation, with multiple physical, psychological, cognitive, and social comorbidities, imposes unique challenges to ongoing care. The potential bias from the inclusion of younger patients into a study with an elderly population with lower-limb amputation supports the need for independent investigation.In our study we verified that although elderly with transfemoral or transtibial amputation have improved their functional independence after lower-limb prosthesis rehabilitation, they could not achieve their functional capacity before amputation. This improvement especially occurred for the basic activities of daily living, however elderly patients with transfemoral amputations presented greater difficulty in improving functional capacity.These results support that being able to better select elderly by their mobility potential and environmental barriers, is an important goal for future research to aim toward those who will achieve and maintain prosthetic walking or those who could better focus on regaining nonprosthetic mobility.

The relationship between balance ability and walking ability using the Berg Balance Scale in people with transfemoral amputation

BACKGROUND

Few reports have examined the relationship between balance ability and walking ability in people with transfemoral amputation using the Berg Balance Scale.

OBJECTIVES

To assess the construct validity (known groups discrimination, convergent validity, and floor/ceiling effects) of Berg Balance Scale for people with transfemoral amputation.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty people with transfemoral amputation participated (age: 54 ± 19 years; range: 18-78 years). Outcome measures (Berg Balance Scale, Timed Up & Go test, Six-Minute Walk Test, and use of ambulatory aids) were compared between the groups requiring and not requiring ambulatory aids by the Mann-Whitney U test, Student's t-test or Welch's t-test. Correlations were assessed using Spearman's rank correlation coefficients and age-corrected Spearman's partial rank correlation coefficients.

RESULTS

The group using ambulatory aids had a significantly lower Berg Balance Scale score (41 ± 5 vs 52 ± 3). Berg Balance Scale score was correlated with Timed Up & Go test, use of aids, and Six-Minute Walk Test using Spearman's rank correlation coefficients (r =-0.85, p < 0.0001; r =-0.82, p < 0.0001; r = 0.81, p < 0.0001) and age-corrected partial rank correlation coefficients (r =-0.66, p < 0.0001; r =-0.56, p = 0.0017; r = 0.57, p = 0.0012). No ceiling effect of Berg Balance Scale was observed.

CONCLUSIONS

Balance ability in people with transfemoral amputation could be evaluated using Berg Balance Scale and is correlated with walking ability.

CLINICAL RELEVANCE

In clinical practice, using Berg Balance Scale for people with transfemoral amputation may adequately enable us to discriminate different groups based on walking ability from the perspective of balance ability. When walking ability is evaluated as low, the improvement of walking ability may be evaluated by Berg Balance Scale improvement during rehabilitation.

The development and internal consistency of the comprehensive lower limb amputee socket survey in active lower limb amputees

BACKGROUND:

Prosthetic socket fit is an important element associated with successful ambulation and use of a prosthesis. Prosthetists and rehabilitation clinicians would benefit from an assessment tool that discriminates between and quantifies the multiple determinants that influence the lower limb amputee's performance and satisfaction of a prosthetic socket.

OBJECTIVES:

To determine the internal consistency of the comprehensive lower limb amputee socket survey, a new self-report measure of prosthetic socket satisfaction that quantifies suspension, stability, comfort, and appearance.

STUDY DESIGN:

Cross-sectional sample of active amputees.

METHODS:

Interviews were conducted with prosthetists, physical therapists, and lower limb amputees to identify clinical concerns and common activities influencing socket fit. An expert panel of five clinicians reviewed the items and constructed the original version of the comprehensive lower limb amputee socket survey which was then administered to a convenience sample of 47 active lower limb amputees. Item analysis and Cronbach's alpha were used to determine the final version of the comprehensive lower limb amputee socket survey.

RESULTS:

Following item raw score-to-total score correlation with Cronbach's alpha for comprehensive lower limb amputee socket survey determinants, internal consistency improved when nine questions were eliminated.

CONCLUSION:

The comprehensive lower limb amputee socket survey is a self-report measure of prosthetic socket satisfaction with very good internal consistency.

CLINICAL RELEVANCE

When socket problems occur, the ability to determine the specific cause can reduce modification time, enhance socket fit, and promote patient satisfaction. A standardized multi-dimensional assessment measure of socket satisfaction enables prosthetists to quantify the multiple determinants of socket satisfaction, improve patient communication, and demonstrate the value of socket interventions.

Factors associated with the likelihood of fall-related injury among people with lower limb loss

Background

People with lower limb loss that live in the community fall at a rate that exceeds that of other vulnerable populations such as hospitalized elderly people. Past research in a small single state study has identified factors associated with fall-related injury. The purpose of this study was to use a larger multistate sample of people with lower limb loss living in community settings to evaluate factors associated with fall-related injury in a multivariable model.

Method

This retrospective cohort study included community-dwelling people with lower limb loss participating in wellness-walking programs in 6 states within the United States. Fall-related injury was considered injury sustained during a fall to the ground that required medical care. Pearson’s Chi-squared test and student’s t-test were used for descriptive statistics. Odds ratios and 95% confidence intervals from multivariable logistic regression modelling were used to estimate the likelihood of fall-related injuries.

Results

Of the 303 subjects recruited, 257 (84.8%) were included in the analyses. Overall, 45 subjects (17.5%) reported at least a single fall-related injury. Most subjects reported two or more falls within the previous 12 months (N = 161, 63.1%), were male (N = 177, 68.9%), and were White (N = 212, 83.8%). Most falls were associated with gait (44.5%), activities of daily living (ADL, 15.7%), or ramps and/or stairs (12%). The likelihood of fall-related injury was elevated among females versus males (OR = 2.90, 95% CI 1.35, 6.24), people of non-White versus White race (OR = 4.79, 95% CI 1.06, 21.76), people with vascular amputations due to peripheral artery disease or diabetes versus non-vascular amputations (OR = 2.22, 95% CI 1.04, 4.73) and people with transtibial versus transfemoral amputations (OR = 2.32, 95% CI 1.01, 4.89).

Discussion

Results of this study show that the likelihood of fall-related injury was significantly higher among women, non-White race, people with vascular and transtibial amputations. The results from this study were largely consistent with results from the prior multivariable fall-related injury model.

Conclusion

The results highlight the association of female sex, non-White race, vascular and transtibial amputations with the likelihood of fall-related injury. Future studies may use the study findings to develop educational fall prevention programs for women, minorities, and people with vascular etiology and transtibial amputations.

Balance-confidence is associated with community participation, perceived physical mobility, and performance-based function among individuals with a unilateral amputation

OBJECTIVE

To explore relationships between balance-confidence and: 1) community participation; 2) self-perceived mobility; and 3) performance-based physical function among individuals with a lower-limb amputation using a prosthetic. Design: Retrospective, cross-sectional study. Setting: Outpatient, multidisciplinary amputee clinic. Participants: Patients (n = 45) using a prosthesis, aged ≥ 18 years, with a unilateral transfemoral or transtibial amputation of ≥1 year, were included. Methods: Participants completed the following self-report measures: Activities-Specific Balance Confidence Scale (ABC); Community Integration Questionnaire (CIQ); Locomotor Capabilities Index (LCI); and two performance-based measures (i.e. Timed Up and Go and 6 Minute Walk Test). Linear regression modeling was used to explore relationships between balance-confidence (i.e. ABC) and self-report (i.e. CIQ and LCI) and performance-based measures (p ≤ 0.0125). Results: After controlling for potential covariates (i.e. age, sex, and body mass index), balance-confidence explained 47.4% of the variance in CIQ (p = 0.000), 53.0% of the variance in LCI (p = 0.000), 20.3% of the variance in Timed Up and Go (p = 0.001), and 18.2% of the variance in 6 Minute Walk Test (p = 0.001). Conclusion: Lower balance-confidence is associated with less community participation, lower self-perceived mobility, and poorer performance among patients with a unilateral lower-limb amputation.

[The influence of the technique for the post-isometric relaxation of the muscles of the lumbosacral region of the spine on the manifestations of the flexion contracture in the hip joint in the men at the age of 50-60 years following amputation of the lower limb at the hip level in the course of the rehabilitation process]

AIM

The objective of the present study was to evaluate the outcome the application of the technique for the post-isometric relaxation of the muscles of the lumbosacral region of the spine and of the lumbosacral junction as a component of the combined rehabilitation on the manifestations of the flexion contracture in the hip joint in the men at the age of 50-60 years following amputation of the lower limb at the hip level throughout the course of the rehabilitative process.

MATERIALS AND METHODS

A total of 243 patients who had undergone ablation of a femur available for the examination. 153 of them were treatment with the use of the technique for the post-isometric relaxation of the muscles of the lumbosacral region of the spine and of the lumbosacral junction. The control group was comprised of the remaining 90 patients treated without the application of the technique for post-isometric relaxation. The analysis of the degree of flexion contracture of the hip joint on the side of ablation was carried out by means of the Thomas test.

RESULTS

The results of the study give evidence that that use of the technique for the post-isometric relaxation of muscles of the lumbar spine and sacroiliac joint makes it possible to reduce the time needed to decrease the severity of contracture of the hip joint during the rehabilitation process.

CONCLUSION

The data obtained provide a basis for recommending the inclusion of the technique for the post-isometric relaxation of muscles of the lumbar spine and the lumbosacral junction into the program of the combined rehabilitation of the patients who had undergone ablation of a femur.

Interactions Between Transfemoral Amputees and a Powered Knee Prosthesis During Load Carriage

Machines and humans become mechanically coupled when lower limb amputees walk with powered prostheses, but these two control systems differ in adaptability. We know little about how they interact when faced with real-world physical demands (e.g. carrying loads). Here, we investigated how each system (i.e. amputee and powered prosthesis) responds to changes in the prosthesis mechanics and gravitational load. Five transfemoral amputees walked with and without load (i.e. weighted backpack) and a powered knee prosthesis with two pre-programmed controller settings (i.e. for load and no load). We recorded subjects' kinematics, kinetics, and perceived exertion. Compared to the no load setting, the load setting reduced subjects' perceived exertion and intact-limb stance time when they carried load. When subjects did not carry load, their perceived exertion and gait performance did not significantly change with controller settings. Our results suggest transfemoral amputees could benefit from load-adaptive powered knee controllers, and controller adjustments affect amputees more when they walk with (versus without) load. Further understanding of the interaction between powered prostheses, amputee users, and various environments may allow researchers to expand the utility of prostheses beyond simple environments (e.g. firm level ground without load) that represent only a subset of real-world environments.

Dynamic balance changes within three weeks of fitting a new prosthetic foot component

Balance during walking is of high importance to prosthesis users and may affect walking during baseline observation and evaluation. The aim of this study was to determine whether changes in walking balance occurred during an adaptation period following the fitting of a new prosthetic component. Margin of stability in the medial-lateral direction (MOS_ML) and an anterior instability margin (AIM) were used to quantify the dynamic balance of 21 unilateral transtibial amputees during overground walking. Participants trialled two prosthetic feet presenting contrasting movement/balance constraints; a Higher Activity foot similar to that of their own prosthesis, and a Lower Activity foot. Participants were assessed before (Visit 1) and after (Visit 2) a 3-week adaptation period on each foot. With the Higher Activity component, MOS_ML decreased on the prosthetic side, and increased on the sound side from Visit 1 to Visit 2, eliminating a significant inter-limb difference apparent at Visit 1 (Visit 1-sound=0.062m, prosthetic=0.075m, p=0.018; Visit 2-sound=0.066m, prosthetic=0.074m, p=0.084). No such change was seen with the Lower Activity foot (Visit 1-sound=0.064m, prosthetic=0.077m, p=0.007; Visit 2-sound=0.063m, prosthetic=0.080m, p<0.001). Significant changes in AIM were observed at Visit 2 (Visit 1: -0.16 (0.08) m, Visit 2: -0.17 (0.08) m; F=23.396, p<0.01). These findings suggest that changes in balance during walking can occur following the initial receipt of a device regardless of whether the component is of the same functional category as the one an individual is accustomed to using.

Perceived self-efficacy and specific self-reported outcomes in persons with lower-limb amputation using a non-microprocessor-controlled versus a microprocessor-controlled prosthetic knee

PURPOSE

To measure self-efficacy in a group of individuals who have undergone a lower-limb amputation and investigate the relationship between self-efficacy and prosthetic-specific outcomes including prosthetic use, mobility, amputation-related problems and global health. A second purpose was to examine if differences exist in outcomes based upon the type of prosthetic knee unit being used.

METHOD

Cross-sectional study using the General Self-Efficacy (GSE) Scale and the Questionnaire for Persons with a Transfemoral Amputation (Q-TFA). Forty-two individuals participated in the study. Twenty-three used a non-microprocessor-controlled prosthetic knee joint (non-MPK) and 19 used a microprocessor-controlled prosthetic knee joint (MPK).

RESULTS

The study sample had quite high GSE scores (32/40). GSE scores were significantly correlated to the Q-TFA prosthetic use, mobility and problem scores. High GSE scores were related to higher levels of prosthetic use, mobility, global scores and negatively related to problem score. No significant difference was observed between individuals using a non-MPK versus MPK joints.

CONCLUSIONS

Individuals with high self-efficacy used their prosthesis to a higher degree and high self-efficacy was related to higher level of mobility, global scores and fewer problems related to the amputation in individuals who have undergone a lower-limb amputation and were using a non-MPK or MPK knee. Implications for rehabilitation Perceived self-efficacy has has been shown to be related to quality of life, prosthetic mobility and capability as well as social activities in daily life. Prosthetic rehabilitation is primary focusing on physical improvement rather than psychological interventions. More attention should be directed towards the relationship between self-efficacy and prosthetic related outcomes during prosthetic rehabilitation after a lower-limb amputation.

Determining 1-Yr Prosthetic Use for Mobility Prognoses for Community-Dwelling Adults with Lower-Limb Amputation: Development of a Clinical Prediction Rule

OBJECTIVE

The objective of this study was to develop a prognostic clinical prediction rule to identify people not achieving community walking level prosthetic use after 1 yr.

DESIGN

This is a prospective longitudinal cohort study of community-dwelling adults with lower-limb amputations recruited from support groups and prosthetic clinics. Participants completed Activities-specific Balance Confidence and Houghton prosthetic use for mobility self-report scales and the Berg Balance Scale. The clinical prediction rule was developed using multivariate logistic regression, receiver operating curves, and probability statistics to identify people not achieving community walking level prosthetic use (Houghton scores <9) at 1 yr.

RESULTS

Forty (74.1%) of 54 participants provided follow-up data. Participants averaged 57.0 ± 11.9 yrs old, and the most recent amputation had occurred an average of 6.6 ± 11.0 yrs ago. Seventy percent had vascular amputations and 52.5% had transtibial amputations. The clinical prediction rule predicted who would not reach the community prosthetic walking level with excellent accuracy (area under the curve >0.96) using four criteria: initial Houghton, Activities-specific Balance Confidence, and Berg Balance Scale tasks 9 (retrieve object from floor) and 10 (look behind over shoulders). Failure to exceed cutoff scores in two or more criteria yielded posttest probability of not reaching community walking prosthetic use 1 yr later for 90% of participants or higher.

CONCLUSIONS

Accurate 1-yr prosthetic use for mobility prognoses can be obtained by screening prosthetic use, balance confidence, and balance ability to identify community-dwelling people with lower-limb amputations unlikely to achieve community walking prosthetic use.