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.

Management of Upper Limb Amputation Rehabilitation: Synopsis of the 2022 US Department of Veterans Affairs and US Department of Defense Clinical Practice Guideline for Acquired Amputation

ABSTRACT

Upper limb amputation can result in significant functional impairment necessitating a comprehensive rehabilitation approach throughout the continuum of care. In 2022, the Departments of Veteran Affairs and Defense completed an updated clinical practice guideline for the management of upper limb amputation rehabilitation. This practice guideline was developed by a workgroup of subject-matter experts from a variety of disciplines. Twelve key questions were developed by the workgroup using the PICOTS (population, intervention, comparator, outcomes, timing of outcomes measurement, and setting) format to establish the scope of the literature review. Eighteen recommendations were developed through extensive review of the available literature and use of the Grading of Recommendations, Assessment, Development and Evaluation criteria. The strength of each recommendation was determined based on the quality of the research evidence and the additional domains of the Grading of Recommendations, Assessment, Development and Evaluation criteria. Of the 18 recommendations, 4 were found to have sufficient evidence to suggest for use of a particular rehabilitation management strategy. Thus, the 2022 Department of Veteran Affairs and Department of Defense clinical practice guideline provides updated, evidence-based information on the care and rehabilitation of persons with upper limb amputation. However, a significant lack of high-quality evidence in upper limb amputation rehabilitation limited evidence-based clinical guidance to assist healthcare providers in managing this population.

Understanding Implications of Residual Limb Length, Strength, and Range-of-Motion Impairments of Veterans With Upper Limb Amputation

OBJECTIVE

The aim of the study was to describe and quantify the relationship between limb impairment variables to key functional outcomes.

DESIGN

This was an observational study of 107 participants with unilateral above/at-elbow or below-elbow/wrist amputation. Demographics, prosthesis characteristics, residual limb length, and prevalence of passive range-of-motion restrictions, and strength impairments were described. Correlations between impairment variables were estimated. Linear regressions examined associations between impairment variables and activity performance, health-related quality of life, disability, and prosthesis satisfaction.

RESULTS

Prevalence of short/very short below- and above-elbow residua was 25.7% and 12.5%, respectively. Shorter below-elbow/wrist residual limb length was correlated with elbow flexion weakness (r = 0.30) and prevalence of passive range of motion (r = 0.25). Shoulder prevalence of passive range-of-motion restrictions were correlated with shoulder (r = 0.27-0.51) and elbow weakness (r = 0.25-0.46). In regressions, activity performance was worse for those with shoulder flexion prevalence of passive range-of-motion restrictions (B = -5.0, P = 0.03) and better for those with flexion restrictions (B = 3.3, P = 0.04) compared with normal prevalence of passive range of motion. Prosthetic satisfaction was lower for those with limited elbow prevalence of passive range of motion.

CONCLUSIONS

Short below-elbow residual limb length was correlated with impairment of elbow flexion strength and prevalence of passive range of motion. Prevalence of passive range-of-motion restrictions were most prevalent at the shoulder and were strongly correlated with weakness in the same planes of motion. Few significant associations were found between impairment variables and outcomes.

Contemplating Health Economics, Coding and Reimbursement in Orthotics, Prosthetics and Pedorthics

Reimbursement to U.S. healthcare service providers is largely transitioning from fee for service to fee for value for those clinicians who code using current procedural terminology and through their coding, describe their professional services. The Orthotic, Prosthetic and Pedorthic profession (O&P), currently codes using a system that describes the devices they evaluate for, fabricate, fit and maintain and their professional services are incorporated into their codes. These O&P codes, in contrast to those for other healthcare disciplines, are predominantly product based rather than service based, focusing on product features and function more than clinical service. This editorial manuscript provides a brief overview of the system the US O&P profession uses currently, particularly in the context of other healthcare professions transitioning to value based coding and reimbursement and culminates in a call to action for the profession to academically consider the strengths and weaknesses of the current system relative to alternative systems.

Amputation Care Quality and Satisfaction With Prosthetic Limb Services: A Longitudinal Study of Veterans With Upper Limb Amputation

Purpose

This study sought to measure and identify factors associated with satisfaction with care among veterans. The metrics were colelcted for those receiving prosthetic limb care at the US Department of Veterans Affairs (VA) and US Department of Defense (DoD) care settings and at community-based care providers.

Methods

A longitudinal cohort of veterans with major upper limb amputation receiving any VA care from 2010 to 2015 were interviewed by phone twice, 1 year apart. Care satisfaction was measured by the Orthotics and Prosthetics User's Survey (OPUS) client satisfaction survey (CSS), and prosthesis satisfaction was measured by the OPUS client satisfaction with device (CSD), and the Trinity Amputation and Prosthetic Experience Scale satisfaction scales. The Quality of Care index, developed for this study, assessed care quality. Bivariate analyses and multivariable linear regressions identified factors associated with CSS. Wilcoxon Mann-Whitney rank tests and Fisher exact tests compared CSS and Quality of Care items at follow-up for those with care within and outside of the VA and DoD.

Results

The study included 808 baseline participants and 585 follow-up participants. Device satisfaction and receipt of amputation care in the prior year were associated with greater satisfaction with care quality. Persons with bilateral amputation were significantly less satisfied with wait times. Veterans who received amputation care in the VA or DoD had better, but not statistically different, mean (SD) CSS scores: 31.6 (22.6) vs 39.4 (16.9), when compared with those who received care outside the VA or DoD. Those with care inside the VA or DoD were also more likely to have a functional assessment in the prior year (33.7% vs 7.1%, P = .06), be contacted by providers (42.7% vs 18.8%, P = .07), and receive amputation care information (41.6% vs 0%, P =.002). No statistically significant differences in CSS, Quality of Care scores, or pain measures were observed between baseline and follow-up. In regression models, those with higher CSD scores and with prior year amputation care had higher satisfaction when compared to those who had not received care.

Conclusions

Satisfaction with prosthetic limb care is associated with device satisfaction and receipt of care within the prior year. Veterans receiving amputation care within the VA or DoD received better care quality scores than those receiving prosthetic care outside of the VA or DoD. Satisfaction with care and quality of care were stable over the 12 months of this study. Findings from this study can serve as benchmarks for future work on care satisfaction and quality of amputation rehabilitative care.

Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE): Protocol for a Multisite Pragmatic Clinical Trial

BACKGROUND

Physical therapy (PT) is frequently used for the management of low back pain (LBP) within the US Departments of Defense (DOD) and Veterans Affairs (VA). However, variations in PT practice patterns and use of ineffective interventions lower the quality and increase the cost of care. Although adherence to the clinical practice guidelines (CPGs) can improve the outcomes and cost-effectiveness of LBP care, PT CPG adherence remains below 50%. The Resolving the Burden of Low Back Pain in Military Service Members and Veterans (RESOLVE) trial will evaluate the effectiveness of an active PT CPG implementation strategy using an education, audit, and feedback model for reducing pain, disability, medication use, and cost of LBP care within the DOD and VA health care systems.

DESIGN

The RESOLVE trial will include 3,300 to 7,260 patients with LBP across three DOD and two VA medical facilities using a stepped-wedge study design. An education, audit, and feedback model will be used to encourage physical therapists to better adhere to the PT CPG recommendations. The Oswestry Disability Index and the Defense and Veterans Pain Rating Scale will be used as primary outcomes. Secondary outcomes will include the LBP-related medication use, medical resource utilization, and biopsychosocial predictors of outcomes. Statistical analyses will be based on the intention-to-treat principle and will use linear mixed models to compare treatment conditions and examine the interactions between treatment and subgrouping status (e.g., limb loss).

SUMMARY

The RESOLVE trial will provide a pragmatic approach to evaluate whether better adherence to PT CPGs can reduce pain, disability, medication use, and LBP care cost within the DOD and VA health care systems.

The effect of the transfemoral prosthetic socket interface designs on skeletal motion and socket comfort: A randomized clinical trial

BACKGROUND

The most crucial aspect of a prosthesis is the socket, as it will directly determine gait stability and quality. The current standard of care ischial ramus containment socket is reported to increase coronal stability through gait; however, socket discomfort is the primary complaint among prosthetic users.

OBJECTIVES

The purpose of this study is to compare ischial ramus containment to alternatives in the transfemoral amputee population. All subjects were fit with three different sockets: traditional ischial ramus containment, a dynamic socket, and a sub-ischial. In this study, authors hypothesized socket skeletal motion would be equivalent across interventions.

STUDY DESIGN

Single-blind, repeated-measures, three-period randomized crossover clinical trial.

METHODS

Outcome measures were socket comfort score and skeletal motion, viewed coronally with X-ray measuring the position of the skeleton in relationship to the socket in full weight-bearing and full un-loading.

RESULTS

The mean age was 38.2 and mean Amputee Mobility Predictor score was 40. Mean vertical movement, horizontal movement, single limb prosthetic stance, mean femoral adduction in swing and stance, and median socket comfort score were not statistically different.

CONCLUSION

The socket design did not significantly effect skeletal motion and socket comfort. All socket designs are suitable depending on the patient-centric preferences and prosthetist skill set.

CLINICAL RELEVANCE

The comfort of the standard of care transfemoral amputation socket has been widely reported as problematic. A comparison of alternative designs in a controlled clinical trial environment will assist the clinician in understanding the impact of design regarding skeletal motion and comfort. Users could benefit from alternatives applied in clinical practice.

Histopathologic Concordance of Mohs Micrographic Surgery: A Systematic Review

Mohs micrographic surgery is dependent upon accurate interpretation of frozen section slides to ensure complete tumor removal and high cure rates. The objective of this study was to determine an aggregate concordance of histologic frozen section interpretation between the Mohs surgeon and dermatopathologists as available in the literature. The study sought to assess the bias risk, applicability, and level of evidentiary support for studies of histologic accuracy between these two provider groups. A systematic literature review of three medical databases was conducted. The Quality Assessment of Diagnostic Accuracy Studies instrument was used to determine bias risk and applicability. The level of evidence was then determined by using the Center for Evidence-Based Medicine (CEBM) model. According to the literature, the concordance rate for frozen slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists was 99.4% after reviewing 5,566 cases with CEBM Level 2 evidence. This study confirms a high level of correlation of histologic frozen section slide interpretation between fellowship-trained Mohs surgeons and dermatopathologists, which is supported by Level 2 evidence with low bias risk and low applicability concerns.

Low back pain in persons with lower extremity amputation: a systematic review of the literature

BACKGROUND CONTEXT

Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life.

PURPOSE

The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research.

STUDY DESIGN/SETTING

Systematic review of the literature.

METHODS

A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs.

RESULTS

Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES.

CONCLUSIONS

Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

FUNCTIONAL DIFFERENCES OF BILATERAL TRANSFEMORAL AMPUTEES USING FULL-LENGTH AND STUBBY-LENGTH PROSTHESES

Many unilateral amputations are followed by a contralateral amputation within three years, sometimes presenting as bilateral transfemoral amputations. Bilateral transfemoral amputees that successfully use prostheses are an understudied patient population. This study establishes reference values for this population in users of short non-articulating (stubby) or full-length articulating prostheses. Anthropometric and demographic information was collected from participants. Additionally, participants completed a self-reported Prosthesis Evaluation Questionnaire-Mobility Subscale 12/5 (PEQ-MS) and performed multiple physical mobility tests, including walking tests and the multi-directional Four Square Step Test (FSST). Full-length users rated their abilities to complete the PEQ-MS tasks as less difficult than stubby users in eight of the 12 items. Gait analysis revealed a greater amount of time is spent in stance phase with a greater portion in double limb support for both user groups, and a greater percentage in stance phase for the subject-reported dominant limb. Stubby users' gait velocity had a significant reduction from that of their full-length peers; however, cadence was similar between groups. Both user groups completed the FSST at comparable times. These outcomes may be of benefit for identifying tasks bilateral transfemoral prosthetic users may find to be most difficult as well as for identifying normal ambulation patterns within this population. Future studies with a greater number of subjects would enable these results to be further generalized.

The role of exercise testing in predicting successful ambulation with a lower extremity prosthesis: a systematic literature review and clinical practice guideline

BACKGROUND

Growing discontent with the k-level system for functional classification of patients with limb loss and movement of healthcare toward evidence-based practice has resulted in the need for alternative forms of functional classification and development of clinical practice guidelines to improve access to quality prosthetic interventions. The purpose of this project was to develop and present a clinical practice recommendation for exercise testing in prosthetic patient care based on the results and synthesis of a systematic literature review.

METHODS

Database searches of PubMed, Google Scholar, Web of Science, and Cochrane were conducted and articles reviewed. Of the potential 1386 articles 10 met the criteria for inclusion. These articles were assessed using the critical appraisal tool of the United Kingdom National Service Framework for Long-Term Conditions. Of the 10 included articles eight were of high, one of medium, and one of low, quality. Data from these articles were synthesized into 6 empirical evidence statements, all qualifying for research grade A. These statements were used to develop the proposed clinical practice guideline.

RESULTS

While the results of this systematic review were not able to support the direct connection between cardiorespiratory performance and K-levels, the literature did support the ability of exercise testing results to predict successful prosthetic ambulation in some demographics. Both continuous maximum-intensity single lower extremity ergometer propelled by a sound limb and intermittent submaximal upper extremity ergometer protocols were found to be viable evaluation tools of cardiorespiratory fitness and function in the target population.

CONCLUSION

The ability to sustain an exercise intensity of ≥50% of a predicted VO2max value in single leg cycle ergometry testing and achievement of a sustained workload of 30 W in upper extremity ergometry testing were found to be the strongest correlates to successful ambulation with a prosthesis. VO2 values were found to increase in amputee subjects following a 6-week exercise program. These synthesized results of the systematic literature review regarding exercise testing in patients with loss of a lower extremity were used to develop and a present a clinical treatment pathway.

Functional performance differences between the Genium and C-Leg prosthetic knees and intact knees

Microprocessor prosthetic knees (MPKs) have advanced technologically, offering new features to decrease impairment and activity limitations for persons with transfemoral amputation (TFA). The Genium knee is functionally untested, and functional differences between it and intact knees are unknown. This study sought to determine whether Genium use improves functional performance compared with the C-Leg. A randomized experimental crossover design was used, with a cross-section of five nonamputee controls for comparison to normal. Twenty community-ambulating persons with TFA were trained and tested for accommodation with study components. All subjects (n = 25) were assessed using the Continuous-Scale Physical Functional Performance-10 (CS-PFP10) assessment. Subjects with TFA used both MPK systems. Genium use improved upper-body flexibility, balance, and endurance domain scores (7.0%-8.4%, p </= 0.05) compared with the C-Leg. Only in the endurance domain did Genium users score significantly lower than nonamputees (22.4%, p = 0.05). Comparing the C-Leg with nonamputees, CS-PFP10 total (2.0%-24.4%, p = 0.03) and all domains except upper-body strength were lower than nonamputees (-13.4% to -28.9%, p </= 0.05). Nonetheless, regardless of knee condition, subjects with TFAs did not equal or surpass nonamputees in any functional domain, suggesting room for improvements in TFA functional performance.

Prosthetic interventions for people with transtibial amputation: Systematic review and meta-analysis of high-quality prospective literature and systematic reviews

Considering transtibial amputation (TTA) rehabilitation costs and complexity, high-quality literature should inform clinical practice. Systematic reviews (SRs) suggest this is not the case. This article's purpose was to review the highest-quality evidence available to guide clinical practice for TTA regarding five prosthetic intervention areas. Six databases were searched for high-quality SRs and prospective clinical trials (randomized clinical trials [RCTs]). Reviewers screened, sorted, rated (i.e., methodologic quality, bias risk), and extracted article data. Meta-analyses were conducted when possible. Thirty-one references were included (25 RCTs and 6 SRs). Five topical areas emerged (alignment, feet and ankles, interface, postoperative care, pylons). Twenty-three evidence statements were supported by level 2 evidence and eight by level 1 evidence. All RCTs reported randomization and reasonable data presentation. Concealed allocation and blinding were not widely used. Mean attrition was 11%. SRs included no meta-analyses. Functional level was poorly reported. Grouping feet and ankle components by functional classification enabled meta-analyses, though variance was considerable given the small sample sizes. Prosthetic interventions are generally safe for TTAs. High-quality literature enabled formulation of evidence statements to support select clinical practice areas, though quantity was lacking. Thus, numerous topics related to TTA care lack rigorous evidence. Although blinding in prosthetic research requires increased funding and effort, it could greatly improve the methodologic quality of prosthetic research.

Crossover study of amputee stair ascent and descent biomechanics using Genium and C-Leg prostheses with comparison to non-amputee control

This study was a randomized crossover of stair ambulation of Transfemoral Amputees (TFAs) using the Genium and C-Leg prosthetic knees. TFAs typically have difficulty ascending and descending stairs, limiting community mobility. The objective of this study was to determine the relative efficacy of the Genium and C-Leg prostheses for stair ascent and descent, and their absolute efficacy relative to non-amputees. Twenty TFAs, and five non-amputees participated in the study. TFAs were randomized to begin the study with the Genium or C-Leg prosthesis. Informed consent was obtained from all participants prior to data collection and the study was listed on clinicaltrials.gov (#NCT01473662). After fitting, accommodation, and training, participants were asked to demonstrate their preferred gait pattern for stair ascent and descent and a step-over-step pattern if able. TFAs then switched prosthetic legs and repeated fitting, accommodation, training, and testing. An eight camera Vicon optical motion analysis system, and two AMTI force plates were used to track and analyze the participants' gait patterns, knee flexion angles, knee moment normalized by body weight, and swing time. For stair descent, no significant differences were found between prostheses. For stair ascent, Genium use resulted in: increased ability to use a step-over-step gait pattern (p=0.03), increased prosthetic side peak knee flexion (p<0.01), and increased swing duration (p<0.01). Changes in contralateral side outcomes and in knee moment were not significant. Overall the Genium knee decreased deficiency in gait patterns for stair ascent relative to the C-Leg, by enabling gait patterns that more closely resembled non-amputees.

Energy costs and performance of transfemoral amputees and non-amputees during walking and running: A pilot study

BACKGROUND

Limited information is available concerning the effects of prosthetic foot components on energy costs and ambulatory performance for transfemoral amputees.

OBJECTIVES

Compare energy costs (VO₂; gait economy) and ambulatory performance (self-selected walking speeds, self-selected running speeds, peak running speeds) differences during walking and running for transfemoral amputees and matched, non-amputee runners.

STUDY DESIGN

Repeated measures.

METHODS

Transfemoral amputees were accommodated and tested with three prosthetic feet: conventional foot, solid-ankle cushioned heel (SACH); energy storing and return foot, Renegade; and running-specific energy storing and return foot, Nitro.

RESULTS

During walking, VO₂ was similar between transfemoral amputees but was increased compared to controls. Self-selected walking speeds were slower for SACH compared to Renegade and Nitro. For transfemoral amputees, gait economy was decreased and self-selected walking speeds were slower compared to controls. During fixed running speeds, transfemoral amputees ran using Nitro, and VO₂ was greater compared to controls. Transfemoral amputees ran at self-selected running speeds using Renegade and Nitro. Self-selected running speeds were slower for Renegade compared to Nitro. For transfemoral amputees, gait economy was decreased and self-selected running speeds were slower compared to controls. VO₂ peak was similar between transfemoral amputees and controls, but controls achieved greater peak running speeds and % grade.

CONCLUSION

Energy costs were greater and ambulatory performance was lower for transfemoral amputees compared to matched, non-amputee controls for all prosthetic foot conditions. Clinical relevance Both types of energy storing and return feet may improve walking performance for transfemoral amputees by providing faster self-selected walking speeds. For transfemoral amputees interested in performing vigorous running (exercise and running competition), clinicians should recommend a running-specific energy storing and return foot.

The effectiveness of the bone bridge transtibial amputation technique: A systematic review of high-quality evidence

BACKGROUND

This literature review was undertaken to determine if commonly held views about the benefits of a bone bridge technique are supported by the literature.

METHODS

Four databases were searched for articles pertaining to surgical strategies specific to a bone bridge technique of the transtibial amputee. A total of 35 articles were identified as potential articles. Authors included methodology that was applied to separate topics. Following identification, articles were excluded if they were determined to be low quality evidence or not pertinent.

RESULTS

Nine articles were identified to be pertinent to one of the topics: Perioperative Care, Acute Care, Subjective Analysis and Function. Two articles sorted into multiple topics. Two articles were sorted into the Perioperative Care topic, 4 articles sorted into the Acute Care topic, 2 articles into the Subjective Analysis topic and 5 articles into the Function topic.

DISCUSSION

There are no high quality (level one or two) clinical trials reporting comparisons of the bone bridge technique to traditional methods. There is limited evidence supporting the clinical outcomes of the bone bridge technique. There is no agreement supporting or discouraging the perioperative and acute care aspects of the bone bridge technique. There is no evidence defining an interventional comparison of the bone bridge technique.

CONCLUSION

Current level III evidence supports a bone bridge technique as an equivalent option to the non-bone bridge transtibial amputation technique. Formal level I and II clinical trials will need to be considered in the future to guide clinical practice. Clinical relevance Clinical Practice Guidelines are evidence based. This systematic literature review identifies the highest quality evidence to date which reports a consensus of outcomes agreeing bone bridge is as safe and effective as alternatives. The clinical relevance is understanding bone bridge could additionally provide a mechanistic advantage for the transtibial amputee.

Predictors of success on the American Board for Certification's prosthetics certification examination

BACKGROUND

Many factors can potentially impact pass or fail performance of a certification examination. While studies regarding predictors of success have been conducted in other professions, no such studies have been conducted in prosthetics and orthotics.

OBJECTIVES

Determine whether there are significant differences in prosthetics certification examination success or failure based on gender, Carnegie ranking of the institution from where the candidate received the degree, and whether the candidate is extending credential from orthotics to include prosthetics.

STUDY DESIGN

Retrospective study.

METHODS

Data of candidates who completed prosthetics residency in 2011 and 2012 were evaluated for relationships with the dependent variables.

RESULTS

Only credential extension showed a statistically significant relationship with written multiple choice ( p = 0.000), written simulation ( p = 0.006), and clinical patient management examinations ( p = 0.005) as well as with success or failure in obtaining prosthetics certification ( p < 0.001).

CONCLUSIONS

Currently available data for analysis regarding predictors of success are limited. Collection of additional variables (i.e. pre-requisite grade point average) in the future will permit analysis of more robust information. Presently available data reveal that candidates seeking to extend credential are more successful in obtaining certified prosthetist status compared with those testing for the first time. Clinical relevance Understanding factors contributing to attaining licensure is important as the prosthetic/orthotic practitioner population ages. This is the first study to investigate this dimension of prosthetics and orthotics training, which upholds professional standards and protects patients. It helps the profession develop best educational and clinical practices in managing patients who utilize prosthetic technologies.

EFFECTS OF THE GENIUM MICROPROCESSOR KNEE SYSTEM ON KNEE MOMENT SYMMETRY DURING HILL WALKING

Use of the Genium microprocessor knee (MPK) system reportedly improves knee kinematics during walking and other functional tasks compared to other MPK systems. This improved kinematic pattern was observed when walking on different hill conditions and at different speeds. Given the improved kinematics associated with hill walking while using the Genium, a similar improvement in the symmetry of knee kinetics is also feasible. The purpose of this study was to determine if Genium MPK use would reduce the degree of asymmetry (DoA) of peak stance knee flexion moment compared to the C-Leg MPK in transfemoral amputation (TFA) patients. This study used a randomized experimental crossover of TFA patients using Genium and C-Leg MPKs (n = 20). Biomechanical gait analysis by 3D motion tracking with floor mounted force plates of TFA patients ambulating at different speeds on 5° ramps was completed. Knee moment DoA was significantly different between MPK conditions in the slow and fast uphill as well as the slow and self-selected downhill conditions. In a sample of high-functioning TFA patients, Genium knee system accommodation and use improved knee moment symmetry in slow speed walking up and down a five degree ramp compared with C-Leg. Additionally, the Genium improved knee moment symmetry when walking downhill at comfortable speed. These results likely have application in other patients who could benefit from more consistent knee function, such as older patients and others who have slower walking speeds.

CONCURRENT VALIDITY OF THE CONTINUOUS SCALE-PHYSICAL FUNCTIONAL PEFORMANCE-10 (CS-PFP-10) TEST IN TRANSFEMORAL AMPUTEES

The Continuous Scale-Physical Functional Performance-10 (CS-PFP-10) test consists of 10 standardized daily living tasks that evaluate overall physical functional performance and performance in five individual functional domains: upper body strength (UBS), upper body flexibility (UBF), lower body strength (LBS), balance and coordination (BAL), and endurance (END). This study sought to determine the concurrent validity of the CS-PFP-10 test and its functional domains that involve the lower extremities (LBS, BAL, or END) in comparison to measures that have established validity for use in persons with transfemoral amputation (TFA). Ten TFA patients functioning at K3 or higher (Medicare Functional Classification Level) completed the study. Participants were assessed performing the CS-PFP-10, Amputee Mobility Predictor (AMP), 75 m self-selected walking speed (75 m SSWS) test, timed down stair walking (DN stair time), and the limits of stability (LOS) balance test. Concurrent validity was assessed using correlation analysis. The AMP, 75 m SSWS, LOS, and the DN stair time tests were strongly correlated (r = ± 0.76 to 0.86) with their paired CS-PFP-10 domain score (LBS, BAL, or END) and CS-PFP-10 total score. These findings indicate that the lower limb and balance domains of the CS-PFP-10 are valid measures to assess the physical functional performance of TFA patients.

The dead spot phenomenon in prosthetic gait: Quantified with an analysis of center of pressure progression and its velocity in the sagittal plane

BACKGROUND

The "dead spot" phenomenon in prosthetics is a disruption in forward progression observed in the rearfoot of passive prosthetic foot-ankle systems which results in a compensatory and inefficient gait pattern by amputees. A metric to quantify the dead spot as a kinetic event has not yet been introduced. The present study implements a three-part metric to evaluate the dead spot in terms of time, magnitude, and total area using center of pressure velocity and a novel threshold value calculation.

METHODS

The metrics are implemented for proof of efficacy using a convenient sample of four amputees (2 transtibial, 2 transfemoral) who walked in a 3D motion capture system with integrated force plates over five foot conditions.

FINDINGS

"Continuous-lever" feet designs showed the most favorable metric results between subjects (p<0.05) and in an ad hoc analysis compared to an ideal foot condition within subjects (p>0.05). Ten of 18 (55.6%) foot conditions found to be similar to the ideal were continuous-lever feet. Lack of significant similarity between the feet and ideal conditions (1 of 18, 5.6%) were found in transfemoral subjects.

INTERPRETATION

The metric calculations were able to show statistical difference among foot conditions between subjects. One foot (continuous-lever, glass composite) had no detectable dead spot in the transtibial subjects. The lack of significant findings in transfemoral subjects indicates a different coefficient in threshold calculations may be more appropriate for these subjects versus transtibial subjects. Further research with larger sample is needed to determine clinically significant findings among feet and between transtibial and transfemoral subjects.

RADIOGRAPHIC ASSESSMENT OF EXTREMITY OSSEOINTEGRATION FOR THE AMPUTEE

Osseointegration (OI) is a bone-anchoring procedure that allows the direct skeletal attachment of a prosthesis through the use of an implant. Transcutaneous OI implants are similar to subcutaneous intramedullary joint implants with some exceptions. Particularly, OI implants are inserted at the distal aspect of the femur, while intramedullary implants are inserted at the proximal aspect of the femur. In this report, an additional adaptation of the radiographic zonal analysis used for intramedullary implants, known as Gruen zones, is introduced to include OI implants of extremity prosthetics. Radiographic zonal analyses and interpretations are proposed. Gruen zones are used for intramedullary implants, which are generally inserted from the proximal aspect of the bone. OI extremity implants are inserted from the distal end of the bone. Therefore, the zonal analysis is inverted. A radiographic zonal analysis has been introduced by the Osseointegration Group of Australia (OGA). This analysis is needed specifically for the clinical evaluation of extremity OI, as significant changes to the bone and OI implant have been reported and need to be clinically described. A classification technique is necessary for establishing treatment guidelines for the extremity osseointegrated implant. The OGA Zonal analysis addresses this need by adapting a common reference standard to osseointegration of the extremity amputee.

PLAY HANDS PROTECTIVE GLOVES: TECHNICAL NOTE ON DESIGN AND CONCEPT

Cerebral Palsy (CP) is the leading cause of childhood motor disability, with a global incidence of 1.6 to 2.5/1,000 live births. Approximately 23% of children with CP are dependent upon assistive technologies. Some children with developmental disabilities have self-injurious behaviors such as finger biting but also have therapeutic needs. The purpose of this technical note is to describe design considerations for a protective glove and finger covering that maintains finger dexterity for children who exhibit finger and hand chewing (dermatophagia) and require therapeutic range of motion and may benefit from sensory stimulation resulting from constant contact between glove and skin. Protecting Little and Adolescent Youth (PLAY) Hands are protective gloves for children with developmental disorders such as CP who injure themselves by biting their hands due to pain or sensory issues. PLAY Hands will be cosmetically appealing gloves that provide therapeutic warmth, tactile sensory feedback, range of motion for donning/ doffing, and protection to maximize function and quality of life for families of children with developmental disorders. The technology is either a per-finger protective orthosis or an entire glove solution designed from durable 3D-printed biodegradable/bioabsorbable materials such as thermoplastics. PLAY Hands represent a series of protective hand wear interventions in the areas of self-mutilating behavior, kinematics, and sensation. They will be made available in a range of protective iterations from single- or multi-digit finger orthoses to a basic glove design to a more structurally robust and protective iteration. To improve the quality of life for patients and caregivers, they are conceptualized to be cosmetically appealing, protective, and therapeutic.

BIOENERGETIC DIFFERENCES DURING WALKING AND RUNNING IN TRANSFEMORAL AMPUTEE RUNNERS USING ARTICULATING AND NON-ARTICULATING KNEE PROSTHESES

Transfemoral amputation (TFA) patients require considerably more energy to walk and run than non-amputees. The purpose of this study was to examine potential bioenergetic differences (oxygen uptake (VO₂), heart rate (HR), and ratings of perceived exertion (RPE)) for TFA patients utilizing a conventional running prosthesis with an articulating knee mechanism versus a running prosthesis with a non-articulating knee joint. Four trained TFA runners (n = 4) were accommodated to and tested with both conditions. VO₂ and HR were significantly lower (p ≤ 0.05) in five of eight fixed walking and running speeds for the prosthesis with an articulating knee mechanism. TFA demonstrated a trend for lower RPE at six of eight walking speeds using the prosthesis with the articulated knee condition. A trend was observed for self-selected walking speed, self-selected running speed, and maximal speed to be faster for TFA subjects using the prosthesis with the articulated knee condition. Finally, all four TFA participants subjectively preferred running with the prosthesis with the articulated knee condition. These findings suggest that, for trained TFA runners, a running prosthesis with an articulating knee prosthesis reduces ambulatory energy costs and enhances subjective perceptive measures compared to using a non-articulating knee prosthesis.

COMPARATIVE EFFECTIVENESS OF AN ADJUSTABLE TRANSFEMORAL PROSTHETIC INTERFACE ACCOMMODATING VOLUME FLUCTUATION: CASE STUDY

The socket-limb interface is vital for functionality and provides stability and mobility for the amputee. Volume fluctuation can lead to compromised fit and function. Current socket technology does not accommodate for volume fluctuation. An adjustable interface may improve function and comfort by filling this technology gap. The purpose of this study was to compare the effectiveness of the standard of care (SOC) ischial ramus containment to an adjustable transfemoral prosthetic interface socket in the accommodation of volume fluctuation. A prospective experimental case study using repeated measures of subjective and performance outcome measures between socket conditions was employed. In the baseline volume condition, the adjustable socket improved subjective and performance measures 19% to 37% over SOC, whereas the two-minute walk test demonstrated equivalence. In the volume loss condition, the adjustable socket improved all subjective and performance measures 22% to 93%. All aggregated data improved 16% to 50% compared with the SOC. In simulated volume gain, the SOC socket failed, while the subject was able to complete the protocol using the adjustable socket. In this case study, the SOC socket was inferior to the comparative adjustable transfemoral amputation interface in subjective and performance outcomes. There is a lack of clinical trials and evidence comparing socket functional outcomes related to volume fluctuation.

THE EFFECT OF TRANSFEMORAL INTERFACE DESIGN ON GAIT SPEED AND RISK OF FALLS

Falls and diminished walking capacity are impairments common in persons with transfemoral amputation (TFA). Reducing falls and optimizing walking capacity through such means as achieving a more normal gait speed and community ambulation should be considered when formulating the prosthetic prescription. Because walking capacity and balance confidence are compromised with TFA, these outcomes should be considered when evaluating interfaces for transfemoral prosthetic users. The purpose of this study was to compare the effect of TFA interface design on walking capacity and balance confidence A retrospective cohort design was utilized involving unilateral TFA patients who used ischial ramus containment (IRC) and High-Fidelity (HiFi) interfaces (independent variables). Dependent variables included the Activity-specific Balance Scale (ABC) and the two-minute walk test (2MWT). Complete records were available for 13 patients (n = 13). The age range was 26 to 58 years. Three patients functioned at the K4 activity level, whereas all others functioned at the K3 level. Mean ABC scores were significantly different (p ≤ 0.05) at 77.2 (±16.8; 35.6 to 96.9) for IRC and 90.7 (±5.7; 77.5 to 98.7) for HiFi. The mean distance walked on the 2MWT was 91.8 m (±22.0, 58.3 to 124.7) for IRC compared to 110.4 m (±28.7; 64.7 to 171.1) for the HiFi socket (p ≤ 0.05). Alternative transfemoral interface design, such as the HiFi socket, can improve walking capacity and balance confidence in higher-functioning TFA patients.

BIOPSY 1-2-3 in Dermatologic Surgery: Improving Smartphone use to Avoid Wrong-Site Surgery

The smartphone has become a ubiquitous tool in modern culture. Given the current high quality of smartphone cameras, they should be considered a valuable tool for the dermatologic surgeon in the pre-operative consultation. The purpose of this technical note is to describe a methodology using smartphone camera technology to improve the process for capturing biopsy site photographs and including those photos in decision making to maximize cutaneous surgical outcomes. This technical note describes a three-step procedure (BIOPSY 1-2-3) to simplify and standardize the protocol for capturing a biopsy site photograph using the patient's own smartphone. The steps are also intended to improve the resolution and value of the image. A case example is provided. Using the steps of BIOPSY 1-2-3, the case example biopsy site image is clearly identified compared to a less structured image. Using BIOPSY 1-2-3, biopsy site images taken by patient-owned smartphone cameras can empower and involve patients in their care, improve image quality, and reduce medical errors.

EFFECTS OF THE GENIUM KNEE SYSTEM ON FUNCTIONAL LEVEL, STAIR AMBULATION, PERCEPTIVE AND ECONOMIC OUTCOMES IN TRANSFEMORAL AMPUTEES

Compared to non-microprocessor knees, the C-Leg microprocessor knee (MPK) is bioenergentically and economically more efficient and safer for transfemoral amputation (TFA) patients. The Genium MPK has demonstrated improvements in perceived function, knee kinematics, and physical functional performance compared to C-Leg. Clinical and health economic analyses have not been conducted with the Genium knee system. The purpose of this study was to determine if laboratory determined benefits of Genium are detectable using common clinical assessments and if there are economic benefits associated with its use. This study utilized a randomized AB crossover study with 60 d follow-up including cost-effectiveness analysis. Twenty TFA patients tested with both knees in mobility and preference measures. Incremental cost-effectiveness ratios (ICER) were calculated based on performance measures. Stair Assessment Index scores improved with Genium. Mean stair completion times and descent stepping rate were not different between knees. Stair ascent stepping rate for C-Leg was greater compared with Genium (p = 0.04). Genium use decreased Four square step test completion time and increased functional level and step activity (p ≤ 0.05). Further, Genium use improved (p ≤ 0.05) function and safety in three out of five Activities of Daily Living (ADL) survey domains. Finally, more subjects preferred Genium following testing. Functional measures were used to calculate ICERs. ICER values for Genium fall within established likely-to-accept value ranges. Compared with C-Leg, Genium use improved stair walking performance, multi-directional stepping, functional level, and perceived function. In this group of community ambulators with TFA, Genium was preferred, and, while more costly, it may be worth funding due to significant improvements in functional performance with ADLs.

PSYCHOMETRIC EVALUATION OF THE HILL ASSESSMENT INDEX (HAI) AND STAIR ASSESSMENT INDEX (SAI) IN HIGH-FUNCTIONING TRANSFEMORAL AMPUTEES

The hill assessment index (HAI) and stair assessment index (SAI) were developed to objectively evaluate ramp and stair gait. This study's purpose was to determine the validity and reliability of these tests in a sample of persons with unilateral transfemoral amputation (TFA) using microprocessor prosthetic knee systems. All subjects were fit with a microprocessor knee system. After accommodation, subjects performed three trials ascending and descending a 5° ramp and a flight of stairs while being recorded on video. Sensitivity and specificity for the HAI was calculated against degree of asymmetry in step length using Dartfish video analysis software. Reliability was assessed using intraclass correlational coefficients calculated using Spearman's Rho (rs). A priori significance level was set at p ≤ 0.05. Twenty (n = 20) individuals with TFA completed the study protocol. Sensitivity and specificity of the HAI were calculated at 88.0% and 75.0% during ascending conditions and 94.0% and 67.0% during descending conditions, respectively. Significant correlations for the HAI included rs = 0.87 and rs = 0.73 within raters uphill and downhill, respectively. Corresponding coefficients of rs = 0.80 and rs = 0.67 were calculated between raters. For the SAI, significant correlations included rs = 1.00 for both comparisons within raters and in the comparison between raters in the ascending condition. A correlation of rs = 0.89 was calculated for the between-rater comparison in the descending condition. The HAI showed moderate to excellent sensitivity and specificity but good to adequate reliability. The SAI showed excellent to good reliability.

ECONOMIC EVALUATIONS OF INTERVENTIONS FOR TRANSTIBIAL AMPUTEES: A SCOPING REVIEW OF COMPARATIVE STUDIES

Transtibial amputation (TTA) is life-altering emotionally, functionally, and economically. The economic impact to all stakeholders is largely unknown, as is the cost-effectiveness of prosthetic intervention. This scoping report's purpose was to determine if there is sufficient evidence to conduct a formal systematic review or meta-analysis in any particular prosthetic intervention area and to determine if any evidence statements could be synthesized relative to economic evaluation of interventions provided to patients with TTA. The scoping review revealed six articles representing three topical areas of transtibial care: Care Models, Prosthetic Treatment, and Prosthetic Sockets. All six articles were cost-identification or cost-consequence design and included a total of 704 subjects. Presently, it can be concluded with moderate confidence that specific weight-bearing and total-contact sockets for transtibial amputees are functionally and economically equivalent in the short term when costs, delivery time, and all stakeholder perspectives are considered. Long-term socket outcomes are relatively unexplored. Further primary research is needed beyond this to determine cost-effectiveness for other areas of transtibial prosthetic care although clinical outcomes are somewhat established through systematic review and meta-analysis in other areas of care. Conversely, evaluation of narrative economic reports relative to transtibial care may be sufficient to warrant further analysis. Guidance from the profession may also be useful in devising a strategy for how to assure economic analyses are a routine element of future prosthetic science.

INTERVENTIONS TO MANAGE RESIDUAL LIMB ULCERATION DUE TO PROSTHETIC USE IN INDIVIDUALS WITH LOWER EXTREMITY AMPUTATION: A SYSTEMATIC REVIEW OF THE LITERATURE

Patients with lower extremity amputation (LEA) experience 65% more dermatologic issues than non-amputees, and skin problems are experienced by ≈75% of LEA patients who use prostheses. Continuously referring LEA patients to a dermatologist for every stump related skin condition may be impractical. Thus, physical rehabilitation professionals should be prepared to recognize and manage common non-emergent skin conditions in this population. The purpose of this study was to determine the quantity, quality, and strength of available evidence supporting treatment methods for prosthesis-related residual limb (RL) ulcers. Systematic literature review with evidence grading and synthesis of empirical evidence statements (EES) was employed. Three EESs were formulated describing ulcer etiology, conditions in which prosthetic continuance is practical, circumstances likely requiring prosthetic discontinuance, and the consideration of additional medical or surgical interventions. Continued prosthetic use is a viable option to manage minor or early-stage ulcerated residual limbs in compliant patients lacking multiple comorbidities. Prosthetic discontinuance is also a viable method of residual limb ulcer healing and may be favored in the presence of severe acute ulcerations, chronic heavy smoking, intractable pain, rapid volume and weight change, history of chronic ulceration, systemic infections, or advanced dysvascular etiology. Surgery or other interventions may also be necessary in such cases to achieve restored prosthetic ambulation. A short bout of prosthetic discontinuance with a staged re-introduction plan is another viable option that may be warranted in patients with ulceration due to poor RL volume management. High-quality prospective research with larger samples is needed to determine the most appropriate course of treatment when a person with LEA develops an RL ulcer that is associated with prosthetic use.

PREDICTING WALKING ABILITY FOLLOWING LOWER LIMB AMPUTATION: AN UPDATED SYSTEMATIC LITERATURE REVIEW

There is not a clear clinical recommendation for the determination of prosthetic candidacy. Guidelines do not delineate which member(s) of the multidisciplinary team are responsible for prosthetic candidacy decisions and which factors will best predict a positive outcome. Also not clearly addressed is a patient-centered decision-making role. In a previous systematic review (SR), Sansam et al. reported on the prediction of walking ability following lower limb amputation using literature up to 2007. The search strategy was designed from the previous Sansam SR as an update of previously valuable predictive factors of prosthetic candidacy. An electronic literature search was executed from August 8, 2007, to December 31, 2015, using MEDLINE (Pubmed), Embase, The Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid), and Cochrane. A total of 319 studies were identified through the electronic search. Of these, 298 were eliminated, leaving a total of 21 for full evaluation. Conclusions from this updated study are drawn from a total recruited sample (n) of 15,207 subjects. A total of 12,410 subjects completed the respective studies (18% attrition). This updated study increases the size of the original Sansam et al. report by including 137% more subjects for a total of 21,490 between the two articles Etiology, physical fitness, pre-amputation living status, amputation level, age, physical fitness, and comorbidities are included as moderate to strongly supported predictive factors of prosthetic candidacy. These factors are supported in an earlier literature review and should be strongly considered in a complete history and physical examination by a multidisciplinary team. Predictive factors should be part of the patient's healthcare record.

Gait Training Interventions for Lower Extremity Amputees: A Systematic Literature Review

Lower extremity (LE) amputation patients who use prostheses have gait asymmetries and altered limb loading and movement strategies when ambulating. Subsequent secondary conditions are believed to be associated with gait deviations and lead to long-term complications that impact function and quality of life as a result. The purpose of this study was to systematically review the literature to determine the strength of evidence supporting gait training interventions and to formulate evidence statements to guide practice and research related to therapeutic gait training for lower extremity amputees. A systematic review of three databases was conducted followed by evaluation of evidence and synthesis of empirical evidence statements (EES). Eighteen manuscripts were included in the review, which covered two areas of gait training interventions: 1) overground and 2) treadmill-based. Eight EESs were synthesized. Four addressed overground gait training, one covered treadmill training, and three statements addressed both forms of therapy. Due to the gait asymmetries, altered biomechanics, and related secondary consequences associated with LE amputation, gait training interventions are needed along with study of their efficacy. Overground training with verbal or other auditory, manual, and psychological awareness interventions was found to be effective at improving gait. Similarly, treadmill-based training was found to be effective: 1) as a supplement to overground training; 2) independently when augmented with visual feedback and/or body weight support; or 3) as part of a home exercise plan. Gait training approaches studied improved multiple areas of gait, including sagittal and coronal biomechanics, spatiotemporal measures, and distance walked.

Correlations between residual limb length and joint moments during sitting and standing movements in transfemoral amputees

BACKGROUND AND AIM

Longer residual limb lengths provide an increased lever arm. Longer residual limbs may produce increased joint moments; the two may be correlated. These correlations have not been evaluated in transfemoral amputees during transitional movements. Correlations between residual limb length and involved side joint moment could contribute to justification supporting maximal residual limb length preservation. This study investigated possible correlations between hip or knee moment and residual limb length.

TECHNIQUE

Hip and knee joint moments were determined while 21 transfemoral amputees performed sitting and standing movements and then evaluated for correlation with residual limb length.

DISCUSSION

Residual limb length was not correlated with either knee or involved side hip moments during sit to stand or stand to sit. Conversely, weak inverse correlations (p < 0.05) existed between sound hip moment magnitude and residual limb length. These correlations suggest that in community ambulating transfemoral amputees, longer residual limb length could decrease sound hip kinetic burden during transitional movement. Beyond correlations between residual limb length and sound hip transitional movement kinetics, there are other considerations in determining residual limb length during amputation.

CLINICAL RELEVANCE

This study examines relationships between lower limb joint moments and residual limb length related to sit-to-stand and stand-to-sit activities. The results have implications for amputation surgery and rehabilitation.

Delivery of cosmetic covers to persons with transtibial and transfemoral amputations in an outpatient prosthetic practice

BACKGROUND

Limb loss negatively impacts body image to the extent that functional activity and societal participation are affected. Scientific literature is lacking on the subject of cosmetic covering for prostheses and the rate of cosmetic cover utilization by cover type, gender, amputation level, and type of healthcare reimbursement.

OBJECTIVES

To describe the delivery of cosmetic covers in lower limb prostheses in a sample of people with lower extremity amputation.

STUDY DESIGN

Cross-sectional design

METHODS

Patient records from an outpatient practice were reviewed for people who received a transtibial or transfemoral prosthesis within a selected 2-year period.

RESULTS

A total of 294 records were reviewed. Regardless of the amputation level, females were significantly (p ≤ 0.05) more likely to receive a cover. Type of insurance did not affect whether or not a cover was used, but Medicare reimbursed more pull-up skin covers.

CONCLUSION

There were differences regarding cosmetic cover delivery based on gender, and Medicare reimbursed for more pull-up skin covers at the transtibial level than other reimbursors did. This analysis was conducted in a warm, tropical geographic region of the United States. Results may differ in other parts of the world based on many factors including climate and local views of body image and disability.

CLINICAL RELEVANCE

Cosmetic covering rates are clinically relevant because they provide insight into which gender is utilizing more cosmetic covers. Furthermore, it can be determined which type of covers are being utilized with greater frequency and which insurance type is providing more coverage for them.

Differences in myoelectric and body-powered upper-limb prostheses: Systematic literature review

The choice of a myoelectric or body-powered upper-limb prosthesis can be determined using factors including control, function, feedback, cosmesis, and rejection. Although body-powered and myoelectric control strategies offer unique functions, many prosthesis users must choose one. A systematic review was conducted to determine differences between myoelectric and body-powered prostheses to inform evidence-based clinical practice regarding prescription of these devices and training of users. A search of 9 databases identified 462 unique publications. Ultimately, 31 of them were included and 11 empirical evidence statements were developed. Conflicting evidence has been found in terms of the relative functional performance of body-powered and myoelectric prostheses. Body-powered prostheses have been shown to have advantages in durability, training time, frequency of adjustment, maintenance, and feedback; however, they could still benefit from improvements of control. Myoelectric prostheses have been shown to improve cosmesis and phantom-limb pain and are more accepted for light=intensity work. Currently, evidence is insufficient to conclude that either system provides a significant general advantage. Prosthetic selection should be based on a patient's individual needs and include personal preferences, prosthetic experience, and functional needs. This work demonstrates that there is a lack of empirical evidence regarding functional differences in upper-limb prostheses.

Golf hand prosthesis performance of transradial amputees

BACKGROUND

Typical upper limb prostheses may limit sports participation; therefore, specialized terminal devices are often needed. The purpose of this study was to evaluate the ability of transradial amputees to play golf using a specialized terminal device.

CASE DESCRIPTION AND METHODS

Club head speed, X-factor, and elbow motion of two individuals with transradial amputations using an Eagle Golf terminal device were compared to a non-amputee during a golf swing. Measurements were collected pre/post training with various stances and grips.

FINDINGS AND OUTCOMES

Both prosthesis users preferred a right-handed stance initially; however, after training, one preferred a left-handed stance. The amputees had slower club head speeds and a lower X-factor compared to the non-amputee golfer, but increased their individual elbow motion on the prosthetic side after training.

CONCLUSION

Amputees enjoyed using the device, and it may provide kinematic benefits indicated by the increase in elbow flexion on the prosthetic side.

CLINICAL RELEVANCE

The transradial amputees were able to swing a golf club with sufficient repetition, form, and velocity to play golf recreationally. Increased elbow flexion on the prosthetic side suggests a potential benefit from using the Eagle Golf terminal device. Participating in recreational sports can increase amputees' health and quality of life.

Differences in knee flexion between the Genium and C-Leg microprocessor knees while walking on level ground and ramps

BACKGROUND

Microprocessor knees have improved the gait and functional abilities of persons with transfemoral amputation. The Genium prosthetic knee offers an advanced sensor and control system designed to decrease impairment by: allowing greater stance phase flexion, easing transitions between gait phases, and compensating for changes in terrain. The aim of this study was to determine differences between the knee flexion angle of persons using the Genium knee, the C-Leg knee, and non-amputee controls; and to evaluate the impact the prostheses on gait and level of impairment of the user.

METHODS

This study used a randomized experimental crossover of persons with transfemoral amputation using the Genium and C-Leg microprocessor knees (n=25), with an observational sample of non-amputee controls (n=5). Gait analysis by 3D motion tracking of subjects ambulating at different speeds on level ground and on 5° and 10° ramps was completed.

FINDINGS

Use of the Genium resulted in a significant increase in peak knee flexion for swing (5°, p<0.01, d=0.34) and stance (2°, p<0.01, d=0.19) phases relative to C-Leg use. There was a high degree of variability between subjects, and significant differences still remain between the Genium group and the control group's knee flexion angles for most speeds and slopes.

INTERPRETATION

The Genium knee generally increases flexion in swing and stance, potentially decreasing the level of impairment for persons with transfemoral amputation. This study demonstrates functional differences between the C-Leg and Genium knees to help prosthetists determine if the Genium will provide functional benefits to individual patients.

Biomechanical characteristics, patient preference and activity level with different prosthetic feet: a randomized double blind trial with laboratory and community testing

Providing appropriate prosthetic feet to those with limb loss is a complex and subjective process influenced by professional judgment and payer guidelines. This study used a small load cell (Europa™) at the base of the socket to measure the sagittal moments during walking with three objective categories of prosthetic feet in eleven individuals with transtibial limb loss with MFCL K2, K3 and K4 functional levels. Forefoot stiffness and hysteresis characteristics defined the three foot categories: Stiff, Intermediate, and Compliant. Prosthetic feet were randomly assigned and blinded from participants and investigators. After laboratory testing, participants completed one week community wear tests followed by a modified prosthetics evaluation questionnaire to determine if a specific category of prosthetic feet was preferred. The Compliant category of prosthetic feet was preferred by the participants (P=0.025) over the Stiff and Intermediate prosthetic feet, and the Compliant and Intermediate feet had 15% lower maximum sagittal moments during walking in the laboratory (P=0.0011) compared to the Stiff feet. The activity level of the participants did not change significantly with any of the wear tests in the community, suggesting that each foot was evaluated over a similar number of steps, but did not inherently increase activity. This is the first randomized double blind study in which prosthetic users have expressed a preference for a specific biomechanical characteristic of prosthetic feet: those with lower peak sagittal moments were preferred, and specifically preferred on slopes, stairs, uneven terrain, and during turns and maneuvering during real world use.

Transfemoral sockets with vacuum-assisted suspension comparison of hip kinematics, socket position, contact pressure, and preference: ischial containment versus brimless

The objective of this study was to investigate the effect of brimless compared with ischial ramus containment (IRC) prosthetic sockets when using vacuum-assisted suspension (VAS) on persons with a unilateral transfemoral amputation (TFA). A randomized crossover design with a 2 d accommodation was used. People with unilateral TFA (n = 9 analyzed) were enrolled. Interventions were IRC VAS and brimless VAS sockets. Main outcome measures included coronal hip angle and vertical and lateral socket movement as measured by X-ray, skin pressure measured by Tekscan, and preference measured subjectively. The brimless design was statistically equivalent to IRC in all measured coronal hip angles and vertical and lateral socket displacement. The peak/stance mean pressure in the medial proximal aspect of the socket was 322 mmHg in the IRC compared with 190 mmHg in the brimless condition. Except for medial proximal pressure, no other measures reached statistical significance. All subjects reported the brimless design to be more comfortable than the IRC in short-term preference. Brimless VAS socket design may be a clinically viable choice for people with TFA.

Comparison of the metabolic demands of dance performance using three mobility devices for a dancer with spinal cord injury and an able-bodied dancer

Mobility devices for dancers with physical mobility impairments have previously been limited to traditional manual or power wheelchairs. The hands-free torso-controlled mobility chair is a unique powered mobility device which allows greater freedom and expression of movement of the trunk and upper extremities. This study compared differences in energy expenditure during a standardized dance activity using three mobility devices: the hands-free torso-controlled mobility chair, a manual sports wheelchair with hand-arm control, and an electric power chair with hand-joystick control. An experienced dancer with C7 incomplete spinal cord injury (SCI) and an experienced able-bodied dancer were recruited for testing. Three measurement trials were obtained for each chair per subject. Oxygen uptake (VO2) and heart rate (HR) were measured continuously during the dance activity. Immediately following the dance activity, subjects rated perceived exertion. Significant differences (p ≤ 0.05) and similar linear patterns in VO2 and HR responses were observed between chairs for both dancers. When the hands-free mobility chair was used, the dance activity required a moderate level of energy expenditure compared to the manual sports chair or electric power chair for both dancers. Higher ratings of perceived exertion were observed in the manual chair compared to the other chairs for the dancer with SCI, but were similar between chairs for the able-bodied dancer. These results suggest that for a dancer with high-level SCI, the hands-free torso-controlled mobility chair may offer improved freedom and expressive movement possibilities and is an energy-efficient mobility device.

Energy costs & performance of transtibial amputees & non-amputees during walking & running

This study compared energy costs and performance differences of walking and running for transtibial amputee (TTA) and matched non-amputee runners. TTA were tested with 3 prosthetic feet: traditional foot, SACH; general purpose, energy storing and return (ESAR) foot, Renegade; running-specific ESAR foot, Nitro. During walking, VO2 and gait efficiency (GE) were similar between prosthetic feet. VO2 was increased (21-33%) and GE was decreased for TTA compared to controls. Self-selected walking speed (SSWS) was slower for SACH (4-6%) compared to Renegade and Nitro but SSWS for TTA was slower (16-22%) than controls. During running, VO2 was increased (8-18%) and GE was decreased using SACH and Renegade, compared to Nitro. During running, VO2 was greater (9-38%), GE was decreased and SSRS was slower (17-30%) for TTA, than controls. VO2 peak was similar for controls and TTA using Nitro, but peak running speed was slower for TTA. In conclusion, during walking energy costs are mostly similar between prosthetic feet, but ESAR feet likely provide faster SSWS for TTA. During running, energy costs and performance are improved for TTA using Nitro. Nonetheless, for all prosthetic feet conditions, TTA demonstrated an energy cost and performance disadvantage during walking and running compared to non-amputee runners.

Transfemoral interfaces with vacuum assisted suspension comparison of gait, balance, and subjective analysis: ischial containment versus brimless

OBJECTIVE

Investigate the effect of a brimless interface design compared with ischial ramus containment (IRC) of interfaces when using vacuum-assisted suspension (VAS) on transfemoral amputees (TFAs).

DESIGN

Randomized experimental crossover.

SETTING

Household, community, and clinic.

PARTICIPANTS

Unilateral TFAs (N=12 enrolled, N=10 analyzed). Mean age: 42.9 years. Mean residual limb length: 60.3% of the sound side femur length. Participants' mean time as an amputee: 8.3 years and median AMP score: 43.

INTERVENTIONS

(1) IRC VAS interface, and (2) brimless VAS interface. Average medial wall height for IRC interfaces was 0.7cm proximal to the distal-most aspect of the ischial tuberosity (IT). The medial wall on the brimless design was an average of 3.3cm distal to the distal-most aspect of the IT.

MAIN OUTCOME MEASURES

Spatiotemporal gait parameters, limits of stability, four square step test, and subjective perception using the prosthetic evaluation questionnaire (PEQ).

RESULTS

Step length was significantly improved towards the IRC (p=0.04), when calculating degree of asymmetry. Base of support was significantly narrowed toward the brimless (p=0.03). All subjective measures reached statistical significance in favor of improvement with the brimless design, compared to the IRC.

CONCLUSIONS

The brimless design was equivalent to IRC in most gait and balance outcome measures. However, step length was more symmetrical toward the IRC while base of support was narrowed toward the brimless demonstrating mixed inconsistent performance changes. Further, the PEQ demonstrated significant subjective improvements in prosthetic related function and quality of life when participants used the brimless design. Brimless interface design may be a clinically viable choice.