Prosthetics, orthotics, and assistive devices. 1. General concepts

Objective assessment of functional ambulation in adults with hemiplegia using ankle foot orthotics after stroke

OBJECTIVE

To objectively evaluate the effect of ankle foot orthotics (AFOs) on functional ambulation in individuals with hemiplegia secondary to stroke using quantifiable outcome measures.

DESIGN

With-without repeated measures design.

SETTING

Rehabilitation research center.

PARTICIPANTS

Eighteen adults with stroke-related hemiplegia 6 months using a prescribed AFO.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASUREMENTS

The distance (m) and velocity (m/s) during the 6-Minute Walk Test (6MWT) and total time (s) and velocity (m/s) during the 25-ft walk (25ftW). Secondary analysis evaluated the 6MWT and 25ftW grouped by the time component of the Ambulatory Index (AI).

RESULTS

Distance walked during the 6MWT was significantly greater with AFO (228.54 +/- 103.93) than without AFO (197.49 +/- 104.13), P = .002. Time to complete the 25ftW was significantly greater without AFO (21.22 +/- 20.57) than with AFO (15.49 +/- 14.65), P = .010. There was a significant difference in average velocity between the 25ftW and 6MWT during the with AFO condition, P = .010. Secondary analysis grouped by the AI time showed that as level of function decreases, brace effect on functional ambulation increases (Group 3: 25ftW with AFO, P = .040).

CONCLUSIONS

AFO usage in hemiplegic stroke patients improves functional ambulation, particularly in individuals with a slower gait velocity. The 25ftW, with and without AFO, may be useful to the patient and clinician when determining the importance of brace utilization. Speed modulation was improved when the AFO was added to the paretic limb, and AI grouping indicated that the AFO was more beneficial in people with a slower gait velocity (>20 seconds for the 25ftW). A more definitive study is needed to more completely address this issue. As an exploratory study, the feasibility of different walking assessments was determined so that future studies can validate which objective measures can be used and easily implemented in clinical settings.

Experience in prosthetic supply of patients with lower limb amputations in Croatia

This study analyses some demographic characteristics of the amputees in Croatia, reason and level of amputation, care the amputees receive, the first prosthetic supply and functional level after rehabilitation. Anonymised data on all amputees in the Clinical Institute for Rehabilitation and Orthopaedic Aids in Zagreb (a national centre) were collected during the year 2000. Follow-up was undertaken for one year. As a result, the authors analysed 221 patients, classified into 3 groups according to the level of amputations: trans-tibial, except foot (TT), trans-femoral (TF) and bilateral amputations (bilateral). Among the population there were: 76% men and 24% women with average age of about 62 years (the average age of women was 8 years more than men). The most common diseases that resulted in amputation were: diabetes mellitus (DM) 48.9%; obstructive vascular diseases (OD): occlusive peripheral arterial disease, Buerger's disease and atherosclerosis 27.1%; trauma 11.3%; both OD and DM 7.2%; osteomyelitis (OM) 3.2% and tumours (TM) 2.3%. Average period from the amputation to admission for prosthetic supply was over 190 days but the average period from admission to discharge from the Institute was about 40 days. Prosthetic supply was accompanied by certain complications: flexion contractures of neighbouring joints, knee 37.9% and hip 35.2%; local complications of soft tissues: necrosis, wound dehiscence, soft tissue surplus, ischaemic tissue damage (the most frequent in TT amputation 35.9%) and phantom pain (55.7% of patients). Hours of daily use of the prosthesis at discharge was about 5 hours. Greater independence in fitting and removing the prosthesis was observed in patients with TT amputation (86.4%). In conclusion, it can be said that the time between the amputation and the beginning of the prosthetic supply, mobility at the time of admission, frequency of general and local complications and number of days in prosthetic supply, are very important for the result of rehabilitation.

Controlling an artificial arm with foot movements

A history of prosthesis control techniques is outlined. An alternative approach to hand and arm prosthesis control is proposed, and a working-prototype model is described. Commercial artificial limbs have function limited by a small number of user-interface control channels, and they are awkward to operate because joints are turned on and off in a serial fashion and not in parallel. Because of natural anatomic and physiologic similarities between the upper and lower extremities, the foot and leg is an ideal control interface. A stocking laced with multiple sensors can provide input on multiple joint positions, and this information used to control homologous movements in a prosthetic upper extremity. One significant advantage of this form of control is simultaneous activation of multiple joints.

Functional outcome of quadruple amputees with end-stage renal disease

A rare but catastrophic complication in end-stage renal disease (ESRD) patients with peripheral vascular disease is amputation of all four limbs secondary to gangrene. We present three patients with ESRD who underwent quadruple amputation. The purpose of this case study is to investigate the functional benefit of inpatient rehabilitation for such amputees. Our large, tertiary acute care hospital admitted 1,469 patients with ESRD during a continuous 63-month period. There were 72 amputation procedures: 57 involving lower limbs, and 15 involving upper limbs. Three patients had all four limbs amputated; these three were subsequently admitted to our acute inpatient rehabilitation center. Their median Functional Independence Measurement (FIM) score on admission was 52 and on discharge was 75. Their median length of stay was 24.5 days, which may be attributed to early postoperative therapy and de-emphasis on prosthetic replacement. At discharge, all three patients were able to perform sliding board transfers and self-propel wheelchairs modified with quad knobs and brake extenders. Each continued hemodialysis three times per week. Two patients were independent with feeding using adaptive equipment, and one required verbal cues. Two patients were able to write using dorsal wrist splints and pencil holders. One patient was able to use a speaker phone and lift lightweight objects with a left below-the-elbow hook-type prosthesis. Our review of these three cases demonstrates that inpatient rehabilitation can improve functional scores in quadruple amputee patients with ESRD. A large multicenter study is warranted to obtain adequate sample size to demonstrate statistical significance.