Low Back Pain in People With Lower Limb Amputation: A Cross-Sectional Study

STUDY DESIGN

A cross-sectional study based on an online questionnaire.

OBJECTIVE

The aim was to investigate the prevalence and intensity of low back pain (LBP) in people with lower limb amputation (LLA) and to analyze the association factors that can influence the genesis of LBP.

SUMMARY OF BACKGROUND DATA

It is still unclear whether LBP is more prevalent in the amputated population than in its nonamputated counterpart. Given the multifactorial nature of LBP, it is necessary to explore possible factors that can influence its presence and intensity, to build a solid background to define a better rehabilitation pathway for the management of these people.

METHODS

The online questionnaire included six sections: informed consent of the study, demographic information, comorbid conditions, history of LLA, history of LBP, and acceptance of the amputation.

RESULTS

Between March and June 2021, 239 participants [mean age (SD): 49.2 (11.5); female 11%] completed the survey (response rate: 32%). From the results of this study, LBP in LLA showed a prevalence of 82% postamputation and 70% in the last year. A logistic regression with a backward method showed that participants who had problems in the not affected leg presented 1.58 (95% confidence interval: 0.70; 2.45) times higher odds to have LBP after the amputation.

CONCLUSION

This study shows that the prevalence of LBP in lower limb amputees appears to be higher than in the general population, with similar levels of pain intensity and frequency. The highest percentage of people with a sedentary lifestyle not practicing any kind of sports emphasizes the importance of educating this population on the importance of physical activity. New strategies to invest in the education of this population in terms of physical activity are needed.

LEVEL OF EVIDENCE

Level 4.

Osseointegration for Lower-Extremity Amputees: Operative Considerations from the Plastic Surgeon's Perspective

➢

Osseointegration for lower-extremity amputees, while increasing in frequency, remains in its relative infancy compared with traditional socket-based prostheses.

➢

Ideal candidates for osseointegration have documented failure of a traditional prosthesis and should be skeletally mature, have adequate bone stock, demonstrate an ability to adhere to a longitudinal rehabilitation protocol, and be in an otherwise good state of health.

➢

Lowering the reoperation rate for soft-tissue complications depends heavily on surgical technique and on the implant device itself; the current gold standard involves a smooth implant surface for dermal contact as well as maximal skin resection to prevent skin breakdown against the prosthesis. This may include the need for thighplasty to optimize skin reduction.

➢

Interdisciplinary peripheral nerve management, such as targeted muscle reinnervation, performed in tandem with a plastic surgery team can treat existing and prevent future symptomatic neuromas, ultimately improving pain outcomes.

Monitoring Osseointegration Process Using Vibration Analysis

Osseointegration implant has attracted significant attention as an alternative treatment for transfemoral amputees. It has been shown to improve patients' sitting and walking comfort and control of the artificial limb, compared to the conventional socket device. However, the patients treated with osseointegration implants require a long rehabilitation period to establish sufficient femur-implant connection, allowing the full body weight on the prosthesis stem. Hence, a robust assessment method on the osseointegration process is essential to shorten the rehabilitation period and identify the degree of osseointegration prior to the connection of an artificial limb. This paper investigates the capability of a vibration-related index (E-index) on detecting the degree of simulated osseointegration process with three lengths of the residual femur (152, 190 and 228 mm). The adhesive epoxy with a setting time of 5 min was applied at the femur-implant interface to represent the stiffness change during the osseointegration process. The cross-spectrum and colormap of the normalised magnitude demonstrated significant changes during the cure time, showing that application of these plots could improve the accuracy of the currently available diagnostic techniques. Furthermore, the E-index exhibited a clear trend with a noticeable average increase of 53% against the cure time for all three residual length conditions. These findings highlight that the E-index can be employed as a quantitative justification to assess the degree of osseointegration process without selecting and tracing the resonant frequency based on the geometry of the residual femur.

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.

Symmetry Function: The Differences between Active and Non-Active Above-the-Knee Amputees

The number of patients with unilateral above-knee amputation (AKA) due to non-vascular causes has remained stable over the years, at 0.92 per 1000 people per year. Post-AKA individuals are at risk of experiencing a higher incidence of chronic pain. Post rehabilitation, it is estimated that between 16−62% of patients with musculoskeletal disabilities fail to meet the minimum criteria for physical activity in comparison to a healthy population. The current study included 14 participants (11 men and 3 women) with a mean age of 46.1 ± 14.2 years, body height of 1.76 ± 0.09 m, and weight of 79.6 ± 18.3 kg, who were all post-unilateral above-the-knee amputees. Patients in the study were divided into two groups: active (AC) and non-active (NAC). This study was conducted in a certified Laboratory of Biomechanical Analysis using the BTS Smart-E system (BTS Bioengineering). In order to investigate the symmetry function (SF) of gait, the only measurements included were the time series assessment of gait variables defining pelvic and lower limb joint motion and ground reaction forces (GRF). Both groups had an asymmetrical gait pattern with a different magnitude and relative position in the gait cycle, which was revealed by SF. The differences in terms of median, minimum, and maximum were statistically significant (p < 0.05), with SF ranging from −25 to 24% for the AC group and from 43 to 77% (59% on average) for the NAC group. The AC’s pattern was more symmetrical compared to the NAC’s pattern, especially in the case of pelvic and hip joint motion.

On the use of virtual reality for individuals with upper limb loss: a systematic scoping review

INTRODUCTION

Virtual reality has recently become a popular application for rehabilitation and motor control research. This technology has emerged as a valid addition to conventional therapy and promises a successful rehabilitation. This study describes recent research related to the use of virtual reality applications in the rehabilitation of individuals with upper limb loss and to see whether this technology has enough proof of its applicability.

EVIDENCE ACQUISITION

Searches were conducted with the Web of Science, Google Scholar, IEEE Xplore, and PubMed databases from inception up to September 2020. Articles that employed virtual reality in the rehabilitation of individual with upper limb loss were included in the research if it is written in English, the keyword exists in the title and abstract; it uses visual feedback in nonimmersive, semi-immersive, or fully immersive virtual environments. Data extraction was carried out by two independent researchers. The study was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols (PRISMA).

EVIDENCE SYNTHESIS

A total of 38 articles met the inclusion criteria. Most studies were published between 2010 and 2020. Thirty-nine percent of the studies (N.=15), originates from North America; 55% of the studies (N.=21), were publicly funded; 61% of the studies (N.=24), was without disclosure of conflict of interest; 82% of the studies (N.=31), were cited in other studies. All the studies were published in journals and conference proceedings. Sixty-six percent of the studies (N.=25) has come out with positive outcome. The design studies were mostly case reports, case series, and poorly designed cohort studies that made up 55% (N.=21) of all the studies cited here.

CONCLUSIONS

The research conducted on the use of virtual reality in individual with upper limb loss rehabilitation is of very low quality. The improvements to the research protocol are much needed. It is not necessary to develop new devices, but rather to assess existing devices with well-conducted randomized controlled trials.

Amputation-specific and generic correlates of participation among Veterans with lower limb amputation

Participation in valued interpersonal and community activities is a key component of rehabilitation for Veterans with amputation. The purpose of this study was to identify specific factors that promote or inhibit participation to inform development of interventions that may facilitate participation in desired life activities. A convenience sample of 408 Veterans with at least one lower limb amputation and who had received outpatient care from the Regional Amputation Center (RAC) completed a mailed survey. Participation was measured using the Community Participation Indicators (CPI) Importance, Control, and Frequency scales and the Patient Reported Outcome Measurement Information System (PROMIS) Ability to Participate in Social Roles and Satisfaction with Social Participation scales. Multiple imputation procedures were used to address missing data. Correlates of participation were examined through multiple linear regression. A total of 235 participants completed the survey, a response rate of 58%. Levels of participation, measured with the PROMIS instruments, were 43.2 (SD = 8.1) for Ability and 46.4 (SD = 8.6) for Satisfaction. Regression analyses found robust amputation-specific correlates for participation, including body image and balance confidence. Generic (non-amputation specific) correlates for participation included depression and pain interference. Development of treatment approaches and devices that can address body image, balance confidence, pain, and mental health concerns such as depression have the potential to enhance the participation and rehabilitation of Veterans with lower limb amputation.

Self-reported health condition severity and ambulation status postmajor dysvascular limb loss

BACKGROUND

Individuals with dysvascular lower limb amputations (LLA) secondary to complications of peripheral arterial disease (PAD) and/or diabetes have high rates of co-morbidities.

OBJECTIVES

To describe self-reported health condition severity and their association with sociodemographic factors and ambulations status among individuals with major dysvascular LLA.

STUDY DESIGN

Cross sectional telephone and in person survey with adults with major dysvascular LLA living in the community setting in Ontario, Canada.

METHODS

Survey by phone/in person, and completion of the Dysvascular Conditions Scale and Special Interest in Amputee Medicine Mobility (SIGAM) Grade by each participant.

RESULTS

Two hundred thirty-one individuals with major dysvascular LLAs participated in the study. Most of them were male individuals (80.5%) and had undergone a transtibial amputation (74%). On average, participants were 3.4 years postlimb loss and had five identified Dysvascular Conditions Scale health conditions. The top five reported health conditions were diabetes, hypertension, phantom limb pain, musculoskeletal pain, and back pain. With the exclusion of hypertension, these conditions were also perceived by respondents to be quite severe for their impact. Vision impairment was also rated as being severe in nature. Lower mobility Special Interest Group in Amputee Medicine grades were associated with higher health condition severity scores.

CONCLUSIONS

Individuals with dysvascular limb loss experience high multimorbidity with perceived negative impact on their overall wellness and function. Rehabilitation and self-management strategies to help patients with dysvascular LLAs to manage chronic health conditions may improve outcomes.

Extended Reality "X-Reality" for Prosthesis Training of Upper-Limb Amputees: A Review on Current and Future Clinical Potential

The rejection rates of upper-limb prosthetic devices in adults are high, currently averaging 26% and 23% for body-powered and electric devices, respectively. While many factors influence acceptance, prosthesis training methods relying on novel virtual reality systems have been cited as a critical factor capable of increasing the likelihood of long-term, full-time use. Despite that, these implementations have not yet garnered widespread traction in the clinical setting, and their use remains immaterial. This review aims to explore the reasons behind this situation by identifying trends in existing research that seek to advance Extended Reality "X-Reality" systems for the sake of upper-limb prosthesis rehabilitation and, secondly, analyzing barriers and presenting potential pathways to deployment for successful adoption in the future. The search yielded 42 research papers that were divided into two categories. The first category included articles that focused on the technical aspect of virtual prosthesis training. Articles in the second category utilize user evaluation procedures to ensure applicability in a clinical environment. The review showed that 75% of articles that conducted whole system testing experimented with non-immersive virtual systems. Furthermore, there is a shortage of experiments performed with amputee subjects. From the large-scale studies analyzed, 71% of those recruited solely able-bodied participants. This paper shows that X-Reality technologies for prosthesis rehabilitation of upper-limb amputees carry significant benefits. Nevertheless, much still must be done so that the technology reaches widespread clinical use.

A functional approach towards the design, development, and test of an affordable dynamic prosthetic foot

Humanitarian actors involved in physical rehabilitation, such as the International Committee of the Red Cross (ICRC), usually provide their beneficiaries with lower-limb prostheses comprising Solid Ankle Cushion Heel (SACH) feet as these are considered appropriate (price, durability, low profile to fit a majority of patients, appearance) and reliable for all ambulation levels. However, individuals in low-resource settings having higher ambulation abilities would greatly benefit from dynamic prosthetic feet with improved biomechanics and energy storage and release. Some attempts tried to address this increasing need (e.g. Niagara Foot) but most products proposed by large manufacturers often remain unaffordable and unsuitable to the context of low-resource settings. The design requirements and a price target were defined in partnership with the ICRC according to their initial assessment and used as a starting point for the development process and related technological choices. Numerical simulation and modeling were used to work on the design and to determine the required materials properties (mechanical, chemical, wear), and a cost modeling tool was used to select suitable materials and relevant processing routes (price vs. performance). A prosthetic foot comprising an internal keel made of composite materials, a filling foam, and a cosmetic shell with a foot shape was developed. Manufacturing processes meeting the cost criteria were identified and prototype feet were produced accordingly. These were successfully tested using a compression testing system before gait analyses were performed in the laboratory with non-amputees wearing testing boots. After validation in laboratory conditions, the prototype foot was tested in the field (Vietnam) with 11 trans-tibial unilateral amputees, who showed an increased mobility compared with the SACH foot. The collaboration of different research fields led to the development of a prosthetic foot which met the technical requirements determined by the ICRC’s specific needs in its field of operation. The materials and selected production processes led to a manufacturing cost of less than 100 USD per part.

[Randomized Controlled Trial of the Effects of Repetitive Transcranial Magnetic Stimulation and Mirror Therapy on Phantom Limb Pain in Amputees]

Objective

To investigate the effect of repetitive transcranial magnetic stimulation (rTMS) on phantom limb pain (PLP) in amputees, and to compare the therapeutic effect with that of mirror therapy (MT).

Methods

The study was designed as a randomized controlled trial. The evaluators were blinded, while the subjects and the therapists were unblinded. Subjects were randomly assigned to either the rTMS group or the MT group with a computer-generated random number table. From June 2018 to December 2020, from out of 45 amputee patients screened for the study, 30 who met the inclusion criteria were recruited for the study. All patients were recruited from the Rehabilitation Medicine Center, West China Hospital, Sichuan University. In the end, 4 patients withdrew from the study and 26 patients (12 in the rTMS group and 14 in the MT group) completed the prescribed treatment and evaluation. The rTMS group was given rTMS (1 Hz, 15 min, 5 d/week) for 2 weeks in addition to conventional rehabilitation therapy, while the MT group received MT (corresponding movements of limbs, 15 min, 5 d/week) for 2 weeks in addition to conventional rehabilitation therapy. PLP was evaluated by the Visual Analogue Scale (VAS) and Douleur Neuropathique 4 Questions (DN-4). Subjects were assessed before treatment ( t 0), immediately after the completion of the treatment ( t 1) and 3 months after the completion of the treatment ( t 2).

Results

The mean age of the 26 patients was 39.73±12.64. There were 15 males and 11 females. According to the reported description of the characteristics of the PLP by the patients, the characteristics with the highest incidence were tingling, stabbing, numbing, electric shocks and burning in descending order. There was no significant difference in the incidence of PLP characteristics between the two groups ( P>0.05). The two groups had comparable baseline data, showing no significant difference in VAS and DN-4 between the two groups at t 0 ( P>0.05). At t 1 and t 2, the VAS and DN-4 scores were decreased from those of t 0, showing statistically significant difference in both groups ( P<0.01 for both scores). In the rTMS group, there was no significant difference between VAS and DN-4 scores at t 1 and those at t 2 ( P>0.05). In the MT group, the VAS and DN-4 scores at t 2 were significantly lower than those of t 1 ( P<0.05). There was no statistically significant difference between the rTMS group and MT group in the changes in pain measurements, i.e., VAS and DN-4 scores, before and after the intervention ( P>0.05). The 26 patients who completed the experiment showed no dizziness, headache, or other abnormalities during the study.

Conclusion

The results of this study indicate that repetitive transcranial magnetic stimulation could improve PLP in amputees, and the improvement effect was comparable to that of mirror therapy.

Prosthetic walking after bilateral transfemoral amputation in a patient with dilated cardiomyopathy: a case report

In this study, we present a case of a 14-year-old adolescent boy who developed rhabdomyolysis and underwent bilateral transfemoral amputation after cardiopulmonary resuscitation for cardiac arrest because of dilated cardiomyopathy (DCM). Patients with bilateral transfemoral amputation have slower walking velocity and greater oxygen consumption during walking. Rehabilitation of such patients may be demanding especially if they have DCM, one of the major causes of advanced heart failure. The patient was admitted to our hospital on postoperative day (POD) 206. At first, we started with residuum compression. Simultaneously, resistance training and range-of-motion exercise were performed. He started the walking training with short stubbies prostheses on POD 262. Then, we used two types of knee joint prostheses, microprocessor-controlled prosthetic knee (MPK) and non-MPK. We chose MPK for his bilateral knee joints because it was easier for him to walk with MPK than with non-MPK. MPK also has the advantage of high stability and less burden on the heart. He achieved to walk with the prosthesis using T-canes with both hands on POD 374. Furthermore, he was able to return to school after discharge. In patients with transfemoral amputations and DCM with exercise restrictions, MPK is preferred because it reduces cardiac load during physical activity.

Experimental Investigation of Vibration Analysis on Implant Stability for a Novel Implant Design

Osseointegrated prostheses are widely used following transfemoral amputation. However, this technique requires sufficient implant stability before and during the rehabilitation period to mitigate the risk of implant breakage and loosening. Hence, reliable assessment methods for the osseointegration process are essential to ensure initial and long–term implant stability. This paper researches the feasibility of a vibration analysis technique for the osseointegration (OI) process by investigating the change in the dynamic response of the residual femur with a novel implant design during a simulated OI process. The paper also proposes a concept of an energy index (the E–index), which is formulated based on the normalized magnitude. To illustrate the potential of the E–index, this paper reports on changes in the vibrational behaviors of a 133 mm long amputated artificial femur model and implant system, with epoxy adhesives applied at the interface to simulate the OI process. The results show a significant variation in the magnitude of the colormap against curing time. The study also shows that the E–index was sensitive to the interface stiffness change, especially during the early curing process. These findings highlight the feasibility of using the vibration analysis technique and the E–index to quantitatively monitor the osseointegration process for future improvement on the efficiency of human health monitoring and patient rehabilitation.

Survey of transfemoral amputee experience and priorities for the user-centered design of powered robotic transfemoral prostheses

BACKGROUND

Transfemoral amputees experience a complex host of physical, psychological, and social challenges, compounded by the functional limitations of current transfemoral prostheses. However, the specific relationships between human factors and prosthesis design and performance characteristics have not yet been adequately investigated. The present study aims to address this knowledge gap.

METHODS

A comprehensive single-cohort survey of 114 unilateral transfemoral amputees addressed a broad range of demographic and clinical characteristics, functional autonomy, satisfaction and attitudes towards their current prostheses, and design priorities for an ideal transfemoral prosthesis, including the possibility of active assistance from a robotic knee unit. The survey was custom-developed based on several standard questionnaires used to assess motor abilities and autonomy in activities of daily living, prosthesis satisfaction, and quality of life in lower-limb amputees. Survey data were analyzed to compare the experience (including autonomy and satisfaction) and design priorities of users of transfemoral prostheses with versus without microprocessor-controlled knee units (MPKs and NMPKs, respectively), with a subsequent analyses of cross-category correlation, principal component analysis (PCA), cost-sensitivity segmentation, and unsupervised K-means clustering applied within the most cost-sensitive participants, to identify functional groupings of users with respect to their design priorities.

RESULTS

The cohort featured predominantly younger (< 50 years) traumatic male amputees with respect to the general transfemoral amputee population, with pronounced differences in age distribution and amputation etiology (traumatic vs. non-traumatic) between MPK and NMPK groups. These differences were further reflected in user experience, with MPK users reporting significantly greater overall functional autonomy, satisfaction, and sense of prosthesis ownership than those with NMPKs, in conjunction with a decreased incidence of instability and falls. Across all participants, the leading functional priorities for an ideal transfemoral prosthesis were overall stability, adaptability to variable walking velocity, and lifestyle-related functionality, while the highest-prioritized general characteristics were reliability, comfort, and weight, with highly variable prioritization of cost according to reimbursement status. PCA and user clustering analyses revealed the possibility for functionally relevant groupings of prosthesis features and users, based on their differential prioritization of these features-with implications towards prosthesis design tradeoffs.

CONCLUSIONS

This study's findings support the understanding that when appropriately prescribed according to patient characteristics and needs in the context of a proactive rehabilitation program, advanced transfemoral prostheses promote patient mobility, autonomy, and overall health. Survey data indicate overall stability, modularity, and versatility as key design priorities for the continued development of transfemoral prosthesis technology. Finally, observed associations between prosthesis type, user experience, and attitudes concerning prosthesis ownership suggest both that prosthesis characteristics influence device acceptance and functional outcomes, and that psychosocial factors should be specifically and proactively addressed during the rehabilitation process.

Deleterious Musculoskeletal Conditions Secondary to Lower Limb Loss: Considerations for Prosthesis-Related Factors

Significance: The intent of this work was to summarize the existing evidence of, and highlight knowledge gaps specific to, prosthetic devices/componentry and training regimes, particularly in the context of the human-device interaction and deleterious musculoskeletal conditions secondary to lower limb loss. Recent Advances: With the recent and evolving technological advancements in prostheses, there are numerous devices available to individuals with lower limb loss. Current literature demonstrates the importance of expanding the knowledge of all prosthetic device-specific factors and the significance of proper prescription, fit, and alignment, along with adequate device-/activity-specific training, to enhance human-device interaction, reduce gait abnormalities and compensatory motions, and as a result, mitigate risk for secondary musculoskeletal conditions. Critical Issues: Inadequate device prescription, fit, alignment, and training are evident owing to the lack of knowledge or awareness of the many device-specific properties and factors, leading to suboptimal use, as well as, biomechanical compensations, which collectively and adversely affect the function, activity level, and overall health of the prosthesis user. Future Directions: To maximize optimal outcomes after lower limb loss, it is essential to better appreciate the factors that affect both prosthesis use and satisfaction, particularly any modifiable factors that might be targeted in rehabilitation interventions such as device prescription, fit/alignment, and training regimes. A better understanding of such device-specific factors will help enhance the human-device interaction and resulting functional performance, thereby reducing secondary musculoskeletal conditions, allowing for the readiness of the fighting force (return-to-duty/redeployment) and/or improved reintegration into civilian society/work, and overall enhancing quality of life after lower limb loss.

Error-Manipulation Gait Training for Veterans With Nontraumatic Lower Limb Amputation: A Randomized Controlled Trial Protocol

OBJECTIVE

he purpose of this study will be to determine the efficacy of error-manipulation gait training (error-augmentation or error-correction) to improve step length symmetry and secondary health outcomes in veterans with unilateral nontraumatic transtibial amputation (TTA).

METHODS

This will be a 3-arm, parallel, assessor-blinded, randomized controlled trial, with baseline, postintervention, and 3-month follow-up assessments in a VA Geriatric Research Education and Clinical Center. Participants are 54 US military veterans ranging in age from 50 to 85 years with a unilateral transtibial nontraumatic amputation. Participants will be randomized into 1 of 3 groups: error-augmentation training (EAT), error-correction training (ECT), or supervised walking (CTL). Each group will complete 8 split-belt treadmill walking training sessions of 25 minutes each over 4 weeks. The EAT group will walk with belts moving at asymmetrical speeds. The ECT group will walk to the cadence of a metronome and the split belts moving at symmetrical speeds. The CTL group will walk with symmetrical belt speeds and without feedback. Step length symmetry is the primary outcome and will be assessed using an asymmetry index during overground walking. Secondary outcomes include lower extremity joint work during treadmill walking, 6-Minute Walk Test performance, daily step count, participant-perceived disability, and residual-limb integumentary health. Outcomes will be assessed at preintervention, 1-week postintervention (primary endpoint), and 13 weeks postintervention.

IMPACT

This study protocol focuses on an understudied area of rehabilitation for patients with nontraumatic unilateral TTA who have high levels of spatiotemporal gait asymmetry and mobility impairment. The results of this study will inform future implementation of clinical gait training interventions to improve spatiotemporal gait symmetry and long-term health and disability outcomes in patients with nontraumatic unilateral TTA.

Prosthetic Disuse Leads to Lower Balance Confidence in a Long-Term User of a Transtibial Prosthesis

Residual limb wounds or ulcers are one of the most frequent skin problems reported by lower extremity prosthesis users. Healing often requires prosthesis disuse, which can logically impair physical functioning. However, there are limited data available to support this idea. We report the impact of prosthesis disuse by presenting assessments of balance, gait, physical activity, and balance confidence obtained on a case subject before experiencing a wound and following reintroduction to a well-fit prosthesis after wound-related prosthesis disuse. The case subject was a 76-year-old male who suffered a unilateral, transtibial amputation due to synovial sarcoma 13 years before. After presenting with a history of pain in the area of a chronic skin plaque, he received a punch biopsy, which resulted in 4 weeks of prosthesis disuse followed by 12 weeks of limited use before a final well-fitting socket was received. The following data were collected 24 weeks before the biopsy and 4 weeks after receiving the final well-fitting socket: Berg Balance Scale, L-test of walking, quantitative gait analysis, Activity-specific Balance Confidence Scale, and 1 week of community-based activity. Balance confidence decreased nearly 19%, walking speed decreased by 12%, and steps/day decreased by 19% following ∼4 months of prosthesis disuse/limited use; functional measures were not impacted. Lower balance confidence is not trivial as it can lead to activity avoidance and increased fall risk. Interventions to target balance confidence changes following prosthesis disuses may be important to minimize the impact of disuse on physical and mental well-being.

Residual limb volume fluctuations in transfemoral amputees

This study constitutes the first attempt to systematically quantify residual limb volume fluctuations in transfemoral amputees. The study was carried out on 24 amputees to investigate variations due to prosthesis doffing, physical activity, and testing time. A proper experimental set-up was designed, including a 3D optical scanner to improve precision and acceptability by amputees. The first test session aimed at measuring residual limb volume at 7 time-points, with 10 min intervals, after prosthesis doffing. This allowed for evaluating the time required for volume stabilization after prosthesis removal, for each amputee. In subsequent sessions, 16 residual limb scans in a day for each amputee were captured to evaluate volume fluctuations due to prosthesis removal and physical activity, in two times per day (morning and afternoon). These measurements were repeated in three different days, a week apart from each other, for a total of 48 scans for each amputee. Volume fluctuations over time after prosthesis doffing showed a two-term decay exponential trend (R2 = 0.97), with the highest variation in the initial 10 min and an average stabilization time of 30 min. A statistically significant increase in residual limb volume following both prosthesis removal and physical activity was verified. No differences were observed between measures collected in the morning and in the afternoon.Clinical Trials.gov ID: NCT04709367.

Joint speed feedback improves myoelectric prosthesis adaptation after perturbed reaches in non amputees

Accurate control of human limbs involves both feedforward and feedback signals. For prosthetic arms, feedforward control is commonly accomplished by recording myoelectric signals from the residual limb to predict the user's intent, but augmented feedback signals are not explicitly provided in commercial devices. Previous studies have demonstrated inconsistent results when artificial feedback was provided in the presence of vision; some studies showed benefits, while others did not. We hypothesized that negligible benefits in past studies may have been due to artificial feedback with low precision compared to vision, which results in heavy reliance on vision during reaching tasks. Furthermore, we anticipated more reliable benefits from artificial feedback when providing information that vision estimates with high uncertainty (e.g. joint speed). In this study, we test an artificial sensory feedback system providing joint speed information and how it impacts performance and adaptation during a hybrid positional-and-myoelectric ballistic reaching task. We found that overall reaching errors were reduced after perturbed control, but did not significantly improve steady-state reaches. Furthermore, we found that feedback about the joint speed of the myoelectric prosthesis control improved the adaptation rate of biological limb movements, which may have resulted from high prosthesis control noise and strategic overreaching with the positional control and underreaching with the myoelectric control. These results provide insights into the relevant factors influencing the improvements conferred by artificial sensory feedback.

[The necessity for treatment paths for lower limb prosthetics : All that glitters is not gold!]

BACKGROUND

Frequently occurring problems in the fitting of leg prostheses are either, for a prosthetic fitting, insufficiently resilient leg stumps or insufficiently adapted prostheses. For this reason, there has been a demand at the political level to establish treatment pathways and a quality standard for the care of people after leg amputations.

QUESTION

How can a joint, interdisciplinary approach to the provision of aids be developed? Does interdisciplinary care of amputees lead to an improvement in the quality of care?

MATERIAL AND METHOD

A compendium "Quality standard in the field of lower extremity prostheses" was compiled and presented at the OT World in Leipzig in 2018. The basic principle is treatment pathways for the interdisciplinary care of all amputation levels of the lower extremities.

RESULTS

The result is a compendium that represents the current "gold standard" in orthopaedic care after lower limb amputations. The compendium not only describes the treatment paths in detail but also makes demands on the quality of the result of the surgical amputation, as well as the goals of residual limb conditioning and the demands on the quality of the fitting of the prosthesis. A traffic light system is used to make recommendations, restrictions and rejections, thus defining the gold standard.

CONCLUSIONS

If all the professions involved (doctors, CPOs, physiotherapists) do not work separately but rather together with the necessary expertise and routine, the quality of care for amputees will improve, and at the same time, the health care system will become more cost efficient.

Community ambulation in people with lower limb amputation: An observational cohort study

Lower limb amputation (LLA) is still a health issue requiring rehabilitation and long-term care even in industrial societies. Several studies on subjects with LLA have been focused on the efficacy of rehabilitation and factors influencing the use of prosthesis. However, literature data on the recovery of ability to walk outdoors, and thus to participate in social life in this population is limited.To investigate potential correlations between socio-demographic and clinical factors, and the use of the prosthesis for indoor and/or outdoor walking referred to as community ambulation (CA) in subjects with LLA.An observational cohort study on 687 LLA subjects was conducted. Socio-demographic and clinical characteristics of 302 subjects who received similar rehabilitative treatment with respect to the standard protocol were collected by a telephone survey with a structured questionnaire. The CA recovery, in terms of patient's autonomy and participation, assessed by Walking Handicap Scale, was considered as the main outcome.The univariate analysis demonstrated statistical significant positive correlation between CA and gender (χ2 = 3.901, P = .048); amputation level (χ2 = 24.657, P < .001); pre-LLA (χ2 = 6.338, P = .012) and current work activity (χ2 = 25.192, P < .001); prosthesis use (χ2 = 187.037, P < .01); and time from LLA (r = 0.183, P < .001); increasing age was negatively correlated with the outcome (r = -0.329, P < .001), while pain intensity was not significant. Being male (75.4%); trans-tibial (TT) amputation level (9.79%); working before (3.81%) and after LLA (7.68%); and the prosthesis use (24.63%) increased the probability of CA recovery. Multivariate binary logistic regression analysis confirmed that the prosthesis use (P < .001) and TT amputation level (P = .042) are predictors of a positive outcome (Walking Handicap Scale 4-6).These findings highlight the importance of the use of prosthesis in people with LLA for the restoration of a good capacity of participation (CA), especially in subjects with TT amputation level. The identification of predictive factors may help tailor-made rehabilitation approaches addressing an earlier reintegration to social life.

Running-specific prostheses reduce lower-limb muscle activity compared to daily-use prostheses in people with unilateral transtibial amputations

People with unilateral transtibial amputation (TTA) have biomechanical differences between the amputated and intact legs and compared to people without TTA during running. Additional biomechanical differences emerge between running with running-specific (RSPs) and daily-use prostheses (DUPs), but the associated underlying muscle activity is unclear. We collected surface electromyography from the biceps femoris long head, rectus femoris, vastus lateralis, and gastrocnemius as well as body kinematics and ground reaction forces in six people with and six people without TTA. We compared stance phase muscle activity and peak activation timing in people with and without TTA and between people using RSPs compared to DUPs during running at 3.5 m/s. Peak amputated leg hamstring activity occurred 34% (RSP) and 31% (DUP) earlier in stance phase compared to the intact leg. Peak amputated leg rectus femoris activity of people wearing DUPs occurred 8% and 9% later in stance phase than the intact leg of people wearing DUPs and amputated leg of people wearing RSPs, respectively. People with TTA had 45% (DUP) and 61% (RSP) smaller peak amputated leg knee extension moments compared to people without TTA, consistent with observations of quadriceps muscle activity. Using RSPs decreased overall muscle activity compared to DUPs.

Falls in unilateral lower limb amputees living in the community. A Portuguese study

INTRODUCTION

Lower limb amputees present a high risk of falling. This study aims to characterise fall history in unilateral lower limb amputees that are autonomous in the community, identifying differences between transfemoral and transtibial amputees and assessing fear of falling between fallers and non-fallers.

MATERIAL AND METHODS

Descriptive, cross-sectional study of consecutive community-dwelling unilateral lower limb adult amputees of any aetiology, attending outpatient consultation in a Portuguese Physical and Rehabilitation Medicine central and university hospital department.

INCLUSION CRITERIA

a prior 12 week individualised rehabilitation program for prosthesis training; regular prosthesis use for more than one year with autonomous gait; and a Functional Independence Measure® score equal to or greater than 100. Injury severity was classified according to the National Database of Nursing Quality Indicators® injury falls measure. In order to assess walking performance over short distances and fear of falling we used the 10-meter walk test and the Falls Efficacy Scale, respectively.

RESULTS

In a sample of 52 lower limb amputees, mainly men (80.8%) and of traumatic aetiology (63.5%), with a mean age of 57.21 ± 11.55 years, 36.5% reported at least one fall in the previous 12 months, all classified as minor injuries. Transfemoral amputees (n = 23) presented a higher number of falls (2.22 ± 3.23, p = 0.025) and lower gait velocity (0.77 ± 0.26 m per second, p < 0.001). Regarding fear of falling, we found no significant differences between fallers and non-fallers.

DISCUSSION

The prevalence of falls was low and of minor severity. Transfemoral amputees fell more often and were slower. There were no reported differences in fear of falling between groups.

CONCLUSION

This paper contributes information about Portuguese lower limb amputees, whose studies are scarce and are rarely dedicated to falling.

Effects of tactile vibration feedback system on balance function and walking ability of a unilateral transtibial amputee with a prosthesis: A case report

RATIONALE

There is still a lack of case reports about tactile vibration feedback devices for the treatment of transtibial amputees so far. This case report aims to introduce a tactile vibration feedback device designed to improve the balance and walking function of the transtibial amputee.

PATIENT CONCERNS

The amputee was a 20-year-old man with right transtibial amputation in a car accident four years ago.

DIAGNOSE

The clinical diagnosis of him was "Right transtibial amputation," and the rehabilitation diagnosis was "Motor dysfunction (Balance function abnormality and Gait abnormality)."

INTERVENTIONS

The patient was reminded to adjust their posture in time via the tactile vibration feedback device.

OUTCOMES

The balance and walking function of the volunteer transtibial amputee was improved.

CONCLUSION

The tactile vibration feedback device has the potential to improve the balance and walking function of the transtibial amputee after installation. Potential fields that can be recommended for future research include intelligent prosthetics, feedback training, motor function, prosthetic acceptance, compliance, social communication, and the quality of life.

Characteristics and prosthesis usage of amputees attending Medical Rehabilitation services in Malaysia

INTRODUCTION

Increasing numbers of limb amputation are performed globally and in Malaysia due to the rise of complications because of Diabetes Mellitus (DM). Limb amputation influences many aspects of an individual's life, and prosthesis restoration is one of the primary rehabilitation goals to help amputees resume daily activities. As limited information is available in Malaysia, this study aims to determine the socio-demographic, clinical characteristics and prosthesis usage among the amputees.

METHODS

A cross-sectional study using self-developed survey form was conducted at 13 Medical Rehabilitation Clinics in Malaysia among 541 upper and lower limb amputees of any duration and cause.

RESULTS

The study population had a mean age of 54 years. Majority were males, Malays, married and had completed secondary school. About 70% of amputations were performed due to DM complications and at transtibial level. Fifty-eight percent of unilateral lower limb amputees were using prosthesis with a mean (standard deviation) of 6.48 (±4.55) hours per day. Time since amputation was the true factor associated with prosthesis usage. Longer hours of prosthesis use per day was positively correlated with longer interval after prosthesis restoration (r=0.467).

CONCLUSION

Higher aetiology of DM and lower prosthesis usage among amputees may be because of high prevalence of DM in Malaysia. The prosthesis usage and hours of use per day were low compared to the international reports, which may be influenced by sampling location and time since amputation. Nevertheless, this is a novel multicentre study on the characteristics and prosthesis usage of amputees. Hopefully, this research will assist to support, facilitate and promote prosthesis rehabilitation in Malaysia.