Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial

Quality of life in young people with limb loss: a systematic review

PURPOSE

Life after any amputation can be significantly altered and can have a significant impact on quality of life (QoL). However, most of the evidence base involves older aged amputees, therefore there is a lack of understanding about the impact of amputation on QoL and the factors that predict QoL in younger amputees. The aim of this review is to identify the factors that predict QoL in young amputees.

METHODS

MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science were searched to identify articles that measured QoL in young amputees. Articles were independently assessed by two assessors. Data was extracted from the selected articles and a narrative synthesis performed.

RESULTS

18 articles were included in this review. QoL outcome measures varied between studies. The quality of evidence was generally low. This review identified, gender, age, cause of amputation, level of amputation, phantom pain, ability to use a prosthesis, physical function, depression, anxiety, body image, type of prosthesis as predictors of QoL.

CONCLUSION

This review identified modifiable and non-modifiable predictors of QoL in young amputees. Future research needs to focus on exploring the modifiable predictors of QoL as these are the aspects that can be improved to enhance QoL.

Non-surgical interventions for preventing contralateral tissue loss and amputation in dysvascular patients with a primary major lower limb amputation

RATIONALE

Major lower limb amputation (LLA, above the ankle) is performed for people with intractable pain, life-threatening infections, or non-functional limbs. Of 7500 LLAs carried out in England between 2015 and 2018, the majority of these were performed in dysvascular patients. Dysvascularity is the absence of adequate blood supply to maintain a limb's usual function (ischaemia, usually caused by peripheral arterial disease or diabetes mellitus), ultimately leading to pain and tissue injury (ulcers, gangrene, sometimes referred to as tissue loss). Among those who undergo dysvascular LLA, 5.7% and 11.5% will likely undergo contralateral LLA at one and five years respectively, which is associated with greater disability and lower likelihood of returning to work, increasing the psychological burden to the patient and socioeconomic cost to the patient and health service. While extensive research has been carried out in the management of peripheral arterial disease and the care of diabetic feet, there are no guidelines for practice on prevention of contralateral amputation.

OBJECTIVES

To assess the effects of non-surgical interventions versus placebo, no intervention, or other non-surgical interventions on contralateral limb (CLL) tissue loss and amputation in dysvascular patients with a primary major LLA.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL and PEDro databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers until 20 March 2023. We also checked the references of identified studies and contacted study authors and manufacturers of relevant products.

ELIGIBILITY CRITERIA

We aimed to include all randomised controlled trials (RCTs) and quasi-RCTs (e.g. randomised by birthdate) comparing the effectiveness of a non-surgical intervention with placebo, no intervention, or other non-surgical intervention, in adults with a primary major LLA due to dysvascularity. Interventions could be physical, pharmacological, educational, behavioural, or organisational, and delivered by a healthcare professional or carer.

OUTCOMES

Our critical and important outcomes of interest were as follows. Critical outcomes • Incidence of new localised tissue injury or ulceration (tissue loss) of the CLL, regardless of stage or classification at given time points. • Time to the development of any localised tissue injury or ulceration (tissue loss) of the CLL, regardless of stage or classification. • Incidence of new minor amputation (through the ankle, foot, or toe(s)) of the CLL at given time points. • Time to new minor amputation (through the ankle, foot, or toe(s)) of the CLL. • Incidence of new major amputation (whole limb or partial limb, above the ankle) of the CLL at given time points. • Time to new major amputation (whole limb or partial limb, above the ankle) of the CLL. Important outcomes • Survival (time to death from all causes) at 12 months. • Patient-reported outcome measures of health-related quality of life (HRQoL) using validated scales such as the 12-item Short Form Health Survey (SF-12) and EQ-5D. • Adverse events (e.g. infections in the CLL). • Hospital readmission.

RISK OF BIAS

We used Cochrane's RoB 1 tool to assess risk of bias in the included study.

SYNTHESIS METHODS

We were only able to perform a narrative review due to lack of data. We reported risk ratios (RR) with 95% CIs for dichotomous outcomes. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES

We found one eligible study, which compared electrostimulation of the gastrocnemius muscle and standard rehabilitation against standard rehabilitation in 50 dysvascular amputees.

SYNTHESIS OF RESULTS

There was no new incidence of tissue loss reported. The following outcomes were not reported: time to new tissue loss; time to and incidence of minor amputation; HRQoL outcomes; adverse events; and hospital readmissions. Electrostimulation was associated with a three-fold reduction in the incidence of new major amputation of the CLL (RR 0.33, 95% CI 0.04 to 2.99), although time to new major amputation was not reported. There was no difference between groups in 12-month survival (RR 1.0, 95% CI 0.85 to 1.18). We judged the overall certainty of the evidence (GRADE) as very low across all outcomes, with unclear risk of selection and detection bias and high risk of performance bias.

AUTHORS' CONCLUSIONS

Despite the care of the CLL being identified as a key research priority by two separate consensus papers, there is insufficient high-quality evidence to address this priority to date. We found only a single RCT suitable for inclusion, and this study was subject to risk of bias. Contralateral limb outcomes should be recorded in future research on dysvascular amputees. Until better evidence and clearer recommendations are available, this topic is likely to remain a research priority.

FUNDING

This Cochrane review had no dedicated funding.

REGISTRATION

Protocol available via DOI 10.1002/14651858.CD013857.

Demystifying the Digital Divide: Disparities in Telerehabilitation Readiness Among Older Adults in the United States

OBJECTIVE

To estimate readiness of older rehabilitation users in the United States to participate in video-based telerehabilitation and assess disparities in readiness among racial and ethnic minoritized populations, socioeconomically disadvantaged populations, and rural-dwelling older adults.

DESIGN

Retrospective cohort study using nationally representative survey data from the National Health and Aging Trends Study from 2015 and 2020. Survey-weighted regression models, accounting for complex survey design, were used to generate estimates of readiness and evaluate disparities across racial and ethnic, socioeconomic, and geographic subgroups. Odds ratios (OR) and 95% confidence intervals (CIs) were estimated for each comparison.

SETTING

Home or community rehabilitation environments.

PARTICIPANTS

A cohort of 5274 home or community-based rehabilitation users aged 70 years or older (N=5274), representing a weighted 33,576,313 older adults in the United States.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Video-based telerehabilitation readiness was defined consistent with prior work; unreadiness was defined as lacking ownership of internet-enabled devices, limited proficiency of use, or living with severe cognitive, visual, or hearing impairment. Telerehabilitation readiness was categorized as "Ready" or "Unready".

RESULTS

Approximately 2 in 3 older rehabilitation users were categorized as ready to participate in video-based rehabilitation. Significantly lower rates of readiness were observed among those living in rural areas (OR=0.75, 95% CI: 0.60-0.94), financially strained individuals (OR=0.37, 95% CI: 0.26-0.53), and among individuals identifying as Black or Hispanic (as compared with non-Hispanic White older adults: Non-Hispanic Black [OR=0.23, 95% CI: 0.18-0.30]; Hispanic [OR=0.17, 95% CI: 0.11, 0.27]).

CONCLUSIONS

Our findings highlight significant disparities in the readiness to uptake video-based telerehabilitation. Policy and practice interventions to address telerehabilitation readiness should focus not only on improving broadband access but also on technology ownership and training to ensure equitable adoption in populations with lower baseline readiness.

Do Exercise Programs Improve Fitness, Mobility, and Functional Capacity in Adults With Lower Limb Amputation? A Systematic Review on the Type and Minimal Dose Needed

OBJECTIVE

To answer the following questions: (1) Do physical activity (PA) and exercise improve fitness, mobility, and functional capacity among adults with lower limb amputation (LLA) and (2) What is the type and minimum dose of PA (frequency, intensity and duration) needed?

DESIGN

Systematic review.

SETTING

Outpatient intervention, outside of the prosthetic rehabilitation phase.

PARTICIPANTS

Adults with lower limb amputation living in the community.

INTERVENTION

Any physical activity or exercise intervention.

OUTCOMES AND MEASURES

Any fitness, mobility, or functional capacity indicators and measurements.

RESULTS

Twenty-three studies were included, totaling 408 adults with LLA. Studies evaluated the effect of structured PA sessions on fitness, mobility, and functional capacity. The highest evidence is for mixed exercise programs, that is, programs combining aerobic exercise with strengthening or balance exercise. There is moderate confidence that 1-3 sessions of 20-60 minutes of exercise per week improves balance, walking speed, walking endurance, and transfer ability in adults with LLA above the ankle. As for flexibility, cardiorespiratory health, lower-limb muscles strength, and functional capacity, there was low confidence that exercise improves these fitness components because of the lack of studies.

CONCLUSION

Exercise 1-3 times per week may improve balance, walking speed, walking endurance, and transfer ability in adults with LLA, especially when combining aerobic exercises with lower limb strengthening or balance exercises. There is a need for most robust studies focusing on the effect of PA on cardiorespiratory health, muscles strength, flexibility, and functional status.

The effect of exercise interventions on gait outcomes in subacute and chronic rehabilitation from lower-limb amputation: A systematic review and meta-analysis

Successful walking is a substantial contributor to quality of life in people with lower-limb amputation (PLLA), yet gait difficulties are common. Evidence-based exercise guidelines are necessary for PLLA with different clinical characteristics and at different phases of recovery. To systematically review the literature evaluating effects of exercise interventions on gait outcomes in PLLA at subacute and chronic stages of recovery. Databases MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, and the Cochrane Library were searched (inception to May 10, 2022). Inclusion criteria: randomized controlled trials assessing gait outcomes following exercise intervention; subjects were PLLA ≥18 years of age and used a prosthesis for walking. Meta-analysis using random effects with inverse variance to generate standardized mean differences (SMDs) was completed for primary gait outcomes. Subgroup analysis was conducted for the recovery phase (i.e., subacute and chronic) and level of amputation (e.g., transfemoral and transtibial). Of 16 included articles, 4 studies examined the subacute phase of recovery, whereas 12 examined the chronic phase. Subacute interventions were 30 minutes, 1-7 times/week, for 2-12 weeks. Chronic interventions were 15-60-minutes, 2-3 times/week, for 4-16 weeks. Low-moderate level evidence was shown for a small improvement in the subacute phase (SMD = 0.42, 95% confidence interval [0.06-0.79], I 2 = 46.0%) and a moderate improvement in the chronic phase (SMD = 0.67, 95% confidence interval [0.40-0.94], I 2 = 0.0%) in favor of exercise intervention groups. Multicomponent exercise programs consisting of gait, balance, and strength training are effective at improving gait outcomes in PLLA at subacute and chronic phases of recovery. The optimal duration and frequency of exercise is unclear because of variation between interventions, highlighting an area for future work.

A qualitative study of clinicians' and individuals' with lower limb loss perspectives on the development of a novel online self-management program

PURPOSE

To explore the rehabilitation preferences and experiences of clinicians and patients for education after lower limb loss to facilitate the development of an online self-management program.

METHODS

A qualitative descriptive approach was used. Thirty-one clinicians (physiotherapists, occupational therapists, and prosthetists), and 26 patients with lower limb loss (transtibial and transfemoral amputation; mean age (SD) of 63.3 (9.1), years) were recruited. We used semi-structured focus groups and one-on-one interviews, and audio recorded the interviews. Data were analyzed using conventional content analysis.

RESULTS

Three themes were identified: (1) Needing education in rehabilitation described the education in current practice as one-on-one discussion and booklets and highlighted the limitations of education such as its length, static nature, and inaccessible for patients living in remote areas. (2) Getting back to activities prior to amputation emphasized how goal setting and social support could assist patients and facilitate self-management. (3) Augmenting learning highlighted the need for an accessible complementary source for education and potential solutions to overcome the barriers of online delivery.

CONCLUSIONS

Our findings underscore the importance of education in the rehabilitation of patients to help them get back to their activities. An online accessible tool may improve education by providing information and peer support.

Effectiveness of telerehabilitation-based structured exercise program in individuals with unilateral transtibial amputation: a randomized controlled study

PURPOSE

The study aimed to compare the effects of home exercise alone and telerehabilitation combined with home exercise in individuals with transtibial amputation.

MATERIALS AND METHODS

The telerehabilitation group (n = 24) received telerehabilitation combined with home exercise, while the control group (n = 24) received home exercise alone. Outcomes included the timed up-and-go (TUG) test and the 30-second chair-stand test (30CST), the Activities-specific Balance Confidence (ABC) Scale, the Trinity Amputation and Prosthesis Experience Scales (TAPES), the Amputee Body Image Scale (ABIS), and the Nottingham Health Profile (NHP). The analysis used a 2 × 2 mixed repeated measures ANOVA.

RESULTS

The group-by-time interactions were significant for TUG (p = 0.002, F[1;41] = 10.74) and 30CST (p = 0.001, F[1;41] = 11.48). The mean difference (6th week-baseline) was -0.49 for TUG and 0.95 for 30CST in the telerehabilitation group and -0.14 for TUG and 0.13 for 30CST in the control group. There were statistically meaningful group-by-time interactions on the ABC (p = 0.0004, F[1;41] = 14.47), the TAPES-activity restriction (p = 0.0001, F[1;41] = 28.96), TAPES-prosthesis satisfaction (p = 0.004, F[1;41] = 9.19), and the NHP (p = 0.0002, F[1;41] = 16.07) favoring the telerehabilitation group.

CONCLUSIONS

Telerehabilitation combined with home exercise can offer greater benefits in improving gait, muscle strength, balance confidence, activity restriction, prosthesis satisfaction, and quality of life compared to home exercise alone for individuals with transtibial amputation.Implications for rehabilitationExercise helps individuals with lower limb amputation overcome their physical limitations and enables them to use their prostheses effectively.Physiotherapy and rehabilitation after amputation are not at the desired level, and individuals with lower limb amputation encounter various difficulties in accessing physiotherapy.Telerehabilitation has great potential to facilitate access to physiotherapy for individuals with amputation and reduce resource utilization.In a relatively small sample of amputees, this study shows that telerehabilitation-based exercise improves physical health and quality of life.

Development of a co-created online self-management program for people with lower limb loss: self-management for amputee rehabilitation using technology (SMART)

PURPOSE

To develop an online self-management program for individuals with recent lower limb loss, called Self-Management for Amputee Rehabilitation using Technology (SMART).

MATERIALS AND METHODS

We used the Intervention Mapping Framework as a blueprint and involved stakeholders throughout the process. A six-step study was conducted including (1) needs assessment using interviews, (2) translating needs to content, (3) applying the content into a prototype using theory-based methods, (4) a usability assessment using think-aloud cognitive testing, (5) planning for future adoption and implementation, and (6) assessing feasibility using mixed-methods to generate a plan to assess the effectiveness on health-outcomes in a randomized controlled trial.

RESULTS

Following interviews with healthcare professionals (n = 31) and people with lower limb loss (n = 26), we determined the content of a prototype version. We then tested usability (n = 9) and feasibility (n = 12) by recruiting individuals with lower limb loss from different pools. We modified SMART to be assessed in a randomized controlled trial. SMART is a six-week online program with weekly contact of a peer mentor with lower limb loss who supported patients with goal-setting and action-planning.

CONCLUSIONS

Intervention mapping facilitated the systematic development of SMART. SMART may improve health outcomes, but this would need to be confirmed in future studies.Implications for rehabilitationLearning new coping strategies and habits are essential after lower limb loss.Given the limitations and inaccessibility of educational and rehabilitation programs, online self-management education can assist patients in their recovery.Self-Management for Amputee Rehabilitation using Technology (SMART) has the potential to augment the self-management behaviors in individuals with lower limb loss through an improvement in access to educational content, skill-based videos, and support of a peer.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Older Veterans' Experiences of a Multicomponent Telehealth Program: Qualitative Program Evaluation Study

BACKGROUND

There are 8.8 million American veterans aged >65 years. Older veterans often have multiple health conditions that increase their risk of social isolation and loneliness, disability, adverse health events (eg, hospitalization and death), mental illness, and heavy health care use. This population also exhibits low levels of physical function and daily physical activity, which are factors that can negatively influence health. Importantly, these are modifiable risk factors that are amenable to physical therapy intervention. We used a working model based on the dynamic biopsychosocial framework and social cognitive theory to conceptualize the multifactorial needs of older veterans with multiple health conditions and develop a novel, 4-component telehealth program to address their complex needs.

OBJECTIVE

This study aims to describe veterans' experiences of a multicomponent telehealth program and identify opportunities for quality and process improvement. We conducted qualitative interviews with telehealth program participants to collect their feedback on this novel program; explore their experience of program components; and document perceived outcomes and the impact on their daily life, relationships, and quality of life.

METHODS

As part of a multimethod program evaluation, semistructured interviews were conducted with key informants who completed ≥8 weeks of the 12-week multicomponent telehealth program for veterans aged ≥50 years with at least 3 medical comorbidities. Interviews were audio recorded and transcribed. Data were analyzed by a team of 2 coders using a directed content analysis approach and Dedoose software was used to assist with data analysis.

RESULTS

Of the 21 individuals enrolled in the program, 15 (71%) met the inclusion criteria for interviews. All 15 individuals completed 1-hour interviews. A total of 6 main conceptual domains were identified: technology, social networks, therapeutic relationship, patient attributes, access, and feasibility. Themes associated with each domain detail participant experiences of the telehealth program. Key informants also provided feedback related to different components of the program, leading to adaptations for the biobehavioral intervention, group sessions (transition from individual to group sessions and group session dynamics), and technology supports.

CONCLUSIONS

Findings from this program evaluation identified quality and process improvements, which were made before rigorously testing the intervention in a larger population through a randomized controlled trial. The findings may inform adaptations of similar programs in different contexts. Further research is needed to develop a deeper understanding of how program components influence social health and longer-term behavior change.

Effectiveness and Equity in Community-Based Rehabilitation on Pain, Physical Function, and Quality of Life After Unilateral Lower Limb Amputation: A Systematic Review

OBJECTIVES

To synthesize evidence for (1) the effectiveness of exercise-based rehabilitation interventions in the community and/or at home after transfemoral and transtibial amputation on pain, physical function, and quality of life and (2) the extent of inequities (unfair, avoidable differences in health) in access to identified interventions.

DATA SOURCES

Embase, MEDLINE, PEDro, Cinahl, Global Health, PsycINFO, OpenGrey, and ClinicalTrials.gov were systematically searched from inception to August 12, 2021, for published, unpublished, and registered ongoing randomized controlled trials.

STUDY SELECTION

Three review authors completed screening and quality appraisal in Covidence using the Cochrane Risk of Bias Tool. Included were randomized controlled trials of exercise-based rehabilitation interventions based in the community or at home for adults with transfemoral or transtibial amputation that assessed effectiveness on pain, physical function, or quality of life.

DATA EXTRACTION

Effectiveness data were extracted to templates defined a priori and the PROGRESS-Plus framework was used for equity factors.

DATA SYNTHESIS

Eight completed trials of low to moderate quality, 2 trial protocols, and 3 registered ongoing trials (351 participants across trials) were identified. Interventions included cognitive behavioral therapy, education, and video games, combined with exercise. There was heterogeneity in the mode of exercise as well as outcome measures employed. Intervention effects on pain, physical function, and quality of life were inconsistent. Intervention intensity, time of delivery, and degree of supervision influenced reported effectiveness. Overall, 423 potential participants were inequitably excluded from identified trials (65%), limiting the generalizability of interventions to the underlying population.

CONCLUSIONS

Interventions that were tailored, supervised, of higher intensity, and not in the immediate postacute phase showed greater promise for improving specific physical function outcomes. Future trials should explore these effects further and employ more inclusive eligibility to optimize any future implementation.

Interventions for motor rehabilitation in people with transtibial amputation due to peripheral arterial disease or diabetes

BACKGROUND

Amputation is described as the removal of an external part of the body by trauma, medical illness or surgery. Amputations caused by vascular diseases (dysvascular amputations) are increasingly frequent, commonly due to peripheral arterial disease (PAD), associated with an ageing population, and increased incidence of diabetes and atherosclerotic disease. Interventions for motor rehabilitation might work as a precursor to enhance the rehabilitation process and prosthetic use. Effective rehabilitation can improve mobility, allow people to take up activities again with minimum functional loss and may enhance the quality of life (QoL). Strength training is a commonly used technique for motor rehabilitation following transtibial (below-knee) amputation, aiming to increase muscular strength. Other interventions such as motor imaging (MI), virtual environments (VEs) and proprioceptive neuromuscular facilitation (PNF) may improve the rehabilitation process and, if these interventions can be performed at home, the overall expense of the rehabilitation process may decrease. Due to the increased prevalence, economic impact and long-term rehabilitation process in people with dysvascular amputations, a review investigating the effectiveness of motor rehabilitation interventions in people with dysvascular transtibial amputations is warranted.

OBJECTIVES

To evaluate the benefits and harms of interventions for motor rehabilitation in people with transtibial (below-knee) amputations resulting from peripheral arterial disease or diabetes (dysvascular causes).

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 9 January 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCT) in people with transtibial amputations resulting from PAD or diabetes (dysvascular causes) comparing interventions for motor rehabilitation such as strength training (including gait training), MI, VEs and PNF against each other.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. prosthesis use, and 2.

ADVERSE EVENTS

Our secondary outcomes were 3. mortality, 4. QoL, 5. mobility assessment and 6. phantom limb pain. We use GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We included two RCTs with a combined total of 30 participants. One study evaluated MI combined with physical practice of walking versus physical practice of walking alone. One study compared two different gait training protocols. The two studies recruited people who already used prosthesis; therefore, we could not assess prosthesis use. The studies did not report mortality, QoL or phantom limb pain. There was a lack of blinding of participants and imprecision as a result of the small number of participants, which downgraded the certainty of the evidence. We identified no studies that compared VE or PNF with usual care or with each other. MI combined with physical practice of walking versus physical practice of walking (one RCT, eight participants) showed very low-certainty evidence of no difference in mobility assessment assessed using walking speed, step length, asymmetry of step length, asymmetry of the mean amount of support on the prosthetic side and on the non-amputee side and Timed Up-and-Go test. The study did not assess adverse events. One study compared two different gait training protocols (one RCT, 22 participants). The study used change scores to evaluate if the different gait training strategies led to a difference in improvement between baseline (day three) and post-intervention (day 10). There were no clear differences using velocity, Berg Balance Scale (BBS) or Amputee Mobility Predictor with PROsthesis (AMPPRO) in training approaches in functional outcome (very low-certainty evidence). There was very low-certainty evidence of little or no difference in adverse events comparing the two different gait training protocols.

AUTHORS' CONCLUSIONS

Overall, there is a paucity of research in the field of motor rehabilitation in dysvascular amputation. We identified very low-certainty evidence that gait training protocols showed little or no difference between the groups in mobility assessments and adverse events. MI combined with physical practice of walking versus physical practice of walking alone showed no clear difference in mobility assessment (very low-certainty evidence). The included studies did not report mortality, QoL, and phantom limb pain, and evaluated participants already using prosthesis, precluding the evaluation of prosthesis use. Due to the very low-certainty evidence available based on only two small trials, it remains unclear whether these interventions have an effect on the prosthesis use, adverse events, mobility assessment, mortality, QoL and phantom limb pain. Further well-designed studies that address interventions for motor rehabilitation in dysvascular transtibial amputation may be important to clarify this uncertainty.

Effectiveness of the perioperative encounter in promoting regular exercise and physical activity: a systematic review and meta-analysis

Background

Low levels of physical activity (PA) are associated with poorer health outcomes. The perioperative encounter (extending from initial contact in primary care to beyond discharge from hospital) is potentially a good time to intervene, but data regarding the effectiveness of interventions are scarce. To address this, we systematically reviewed existing literature to evaluate the effectiveness of interventions applied perioperatively to facilitate PA in the medium to long-term (at least six months after the intervention).

Methods

In this systematic review and meta-analysis, we searched Central Register of Controlled Trials (CENTRAL, Cochrane Library), MEDLINE, CINAHL, Embase, PsycInfo, and SPORTDiscus from database inception to October 22nd 2020, with an updated search done on August 4th 2022. We searched clinical trials registers, and conducted forward- and backward-citation searches. We included randomised controlled trials and quasi-randomised trials comparing PA interventions with usual care, or another PA intervention, in adults who were scheduled for, or had recently undergone, surgery. We included trials which reported our primary outcomes: amount of PA or whether participants were engaged in PA at least six months after the intervention. A random effects meta-analysis was used to pool data across studies as risk ratios (RR), or standardised mean differences (SMDs), which we interpreted using Cohen. We used the Cochrane risk of bias tool and used GRADE to assess the certainty of the evidence. This study is registered with PROSPERO, CRD42019139008.

Findings

We found 57 trials including 8548 adults and compared 71 interventions facilitating PA. Most interventions were started postoperatively and included multiple components. Compared with usual care, interventions may slightly increase the number of minutes of PA per day or week (SMD 0.17, 95% CI 0.09-0.26; 14 studies, 2172 participants; I2 = 0%), and people's engagement in PA at the study's end (RR 1.19, 95% CI 0.96-1.47; 9 studies, 882 participants; I2 = 25%); this was moderate-certainty evidence. Some studies compared two different types of interventions but it was often not feasible to combine data in analysis. The effect estimates generally indicated little difference between intervention designs and we judged all the evidence for these comparisons to be very low certainty. Thirty-six studies (63%) had low risk of selection bias for sequence generation, 27 studies (47%) had low risk of bias for allocation concealment, and 56 studies (98%) had a high risk of performance bias. For detection bias for PA outcomes, we judged 30 studies (53%) that used subjective measurement tools to have a high risk of detection bias.

Interpretation

Interventions delivered in the perioperative setting, aimed at enhancing PA in the medium to long-term, may have overall benefit. However, because of imprecision in some of the findings, we could not rule out the possibility of no change in PA.

Funding

National Institute for Health Research Health Services and Delivery Research programme (NIHR127879).

Amputation and prosthetics of the lower extremity: The 2020 Dutch evidence-based multidisciplinary guideline

BACKGROUND

Lower-limb amputations are rare but debilitating events in the lives of affected persons. Treatment of persons with amputation inherently involves many different health care professions at different stages leading to and after an amputation. There are prevailing clinical questions within the work field related to different facets of care including peri/postoperative aspects, prosthetic components, rehabilitation treatment, and health care processes.

OBJECTIVES

To provide an up-to-date multidisciplinary evidence-based guideline for health care professionals involved in the treatment of persons with lower-limb amputation in the Netherlands.

METHODS

Identification of key questions in a focus group, systematic review of the evidence (up to March 2019, using Embase and MEDLINE databases), and weighing considerations, culminating in clinical recommendations.

RESULTS

Twelve key questions were formulated. Recommendations of two key questions were upheld in line with the previous 2012 guideline. Ten systematic literature searches were performed, leading to the inclusion of 59 studies.

CONCLUSION

A summary of evidence-based conclusions, considerations, and recommendations of the 2020 guideline is presented.

Effectiveness of (Active) Lifestyle Interventions in People With a Lower Limb Amputation: A Systematic Review

Objective

To explore the effectiveness of (active) lifestyle interventions for the health of people with a lower limb amputation in order to offer effective interventions during rehabilitation that may improve physical and psychosocial functioning of people with lower limb amputation.

Data Sources

PubMed, CINAHL and Embase were searched from inception to February 2021.

Study Selection

Inclusion criteria were (1) (quasi-)randomized controlled trial; (2) minimum of 10 participants with a lower limb amputation; (3) lifestyle intervention focusing on physical activity, smoking habits, alcohol use, nutrition, and/or stress management; (4) focus on health outcomes; (5) participants older than 18 years; (6) studies in Dutch, German, or English; and (7) primary research. Title, abstract, and full-text screening and quality assessment were performed by 2 independent assessors.

Data Extraction

Of 2460 studies identified, 13 studies were included in this review. Two studies were of moderate methodological quality, 2 studies were of medium quality, and 9 studies were of poor quality.

Data Synthesis

Lifestyle interventions in the included studies focused on physical activity and stress management. These interventions seemed effective for improving physical fitness, walking capacity, changes in body mass, quality of life, and intensity of physical activity.

Conclusion

Lifestyle interventions focusing on physical activity and stress management seem effective for improving physical and psychosocial functioning of people with a lower limb amputation. However, the findings should be interpreted with caution given the limited methodological quality of the included studies. Future research should evaluate the effectiveness of interventions on nutrition, smoking habits, and alcohol use and the effectiveness of combined interventions in people with a lower limb amputation.

Telehealth interventions for mobility after lower limb loss: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Mobility is a crucial component for healthy aging after lower limb loss (LLL). Telehealth technologies, for example, smart devices, are novel approaches for health programs delivery regardless of geographical boundaries.

OBJECTIVES

To assess the effect of telehealth interventions on mobility, quality of life, and antecedents of health behavior compared with a control condition (usual care or simpler telehealth interventions with fewer number of behavior change techniques [BCTs]) for community-dwelling adults (>50 years) with an LLL and the effect of mode of delivery and BCTs used in telehealth interventions on health outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

We systematically searched MEDLINE, PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane, PsycINFO, and SPORTDiscus on January 28, 2021, to identify relevant randomized controlled trials. Two authors independently screened records and assessed risk of bias. We conducted a narrative synthesis of evidence and, when appropriate, used the standardized mean difference (SMD) and mean difference for meta-analyses and the Grading Recommendations Assessment, Development, and Evaluation approach for practice recommendations.

RESULTS

We identified six randomized controlled trials. Telephone was the most common delivery mode (n = 3), and "instructions for performing behaviors" was the most common BCT (n = 5). Very low certainty evidence showed no changes in mobility (six studies: SMD = 0.33 [95% confidence interval [CI] = -0.08, 0.75]), quality of life (two studies: mean difference = -0.08 [95% CI = -0.30, 0.15]), and antecedents of behavior (five studies: SMD = 0.04 [95% CI = -0.28, 0.36]).

CONCLUSIONS

Our review highlights a knowledge gap for the effect of telehealth interventions for people with LLL. Although no promising effect was shown for telehealth interventions, very low certainty evidence precludes making a definitive clinical recommendation.

Reported Outcome Measures in Studies of Real-World Ambulation in People with a Lower Limb Amputation: A Scoping Review

BACKGROUND

The rapidly increasing use of wearable technology to monitor free-living ambulatory behavior demands to address to what extent the chosen outcome measures are representative for real-world situations. This scoping review aims to provide an overview of the purpose of use of wearable activity monitors in people with a Lower Limb Amputation (LLA) in the real world, to identify the reported outcome measures, and to evaluate to what extent the reported outcome measures capture essential information from real-world ambulation of people with LLA.

METHODS

The literature search included a search in three databases (MEDLINE, CINAHL, and EMBASE) for articles published between January 1999 and January 2022, and a hand-search.

RESULTS AND CONCLUSIONS

98 articles met the inclusion criteria. According to the included studies' main objective, the articles were classified into observational (n = 46), interventional (n = 34), algorithm/method development (n = 12), and validity/feasibility studies (n = 6). Reported outcome measures were grouped into eight categories: step count (reported in 73% of the articles), intensity of activity/fitness (31%), type of activity/body posture (27%), commercial scores (15%), prosthetic use and fit (11%), gait quality (7%), GPS (5%), and accuracy (4%). We argue that researchers should be more careful with choosing reliable outcome measures, in particular, regarding the frequently used category step count. However, the contemporary technology is limited in providing a comprehensive picture of real-world ambulation. The novel knowledge from this review should encourage researchers and developers to engage in debating and defining the framework of ecological validity in rehabilitation sciences, and how this framework can be utilized in the development of wearable technologies and future studies of real-world ambulation in people with LLA.

The Effectiveness of Exercise Interventions to Improve Gait and Balance in Individuals with Lower Limb Amputations: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effectiveness of exercise interventions to improve gait and balance in individuals with lower limb amputations.

METHODS

A systematic search was conducted on the PubMed, Scopus, Web of Science, SPORTDiscuss, and CINAHL databases until January 2022. Only randomized control trials that evaluated adults (>18 years old) with lower limb amputations and compared any exercise intervention with a traditional prosthetic training were included in the study. Two independent researchers screened articles for inclusion, extracted data, and evaluated the methodological quality of the trials. Findings were summarized and meta-analysis was conducted.

RESULTS

Fifteen randomized clinical trials with 594 participants were included in the study and 12 in quantitative synthesis. Meta-analysis indicates that exercise interventions significantly improved walking distance measured with the 2-Minute Walking Test compared to traditional training (mean difference-MD: 8.38, 95% CI: 2.54-14.23; P < 0.01). Gait speed performance also significantly improved after exercise interventions compared to traditional training (MD: 0.10, 95% CI, 0.03-0.16, P <0.01). Meta-analysis of exercise interventions compared to traditional training on the Locomotor Capabilities Index, Timed Up and Go, and Activities-specific Balance Confidence did not show a statistically significant difference (P > 0.05). However, the qualitative analysis demonstrated significant improvement in balance performance after different exercise interventions and traditional training. The studies demonstrated overall good methodological quality.

CONCLUSION

Specific exercise interventions are more effective than traditional prosthetic training to improve walking speed and walking distance among people with lower limb amputation. Findings on balance outcomes are inconsistent and deserve further exploration.

Telephone-Delivered Physiotherapy Interventions Improve Physical Function for Adults With a Chronic Condition: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the efficacy of telephone-delivered physiotherapy interventions to improve lower extremity physical function and walking in adults aged ≥45 years with a chronic condition.

DATA SOURCES

A literature search was conducted using health databases (MEDLINE, PsychINFO, EMBASE, The Allied and Complementary Medicine Database, Web of Science, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature) up to April 26, 2020. Reference lists of relevant studies were explored to identify additional studies.

STUDY SELECTION

The original search resulted in 3465 studies. Five other studies were included from hand searches. After duplicates were removed, 2820 studies remained. Title and abstract screening was completed independently by 2 authors and resulted in the exclusion of 2596 studies. The full-texts of the remaining 224 articles were assessed and 204 studies were excluded. Twenty articles were examined.

DATA EXTRACTION

Data were extracted independently by 2 authors, including study, population, and intervention details; assessment timings; outcome characteristics; appropriateness of statistical methods; adverse events; and reasons for loss to follow-up. Study quality was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS

Twenty studies were included in the systematic review. One study was not meta-analyzed owing to insufficient data. Telephone-delivered physiotherapy had a small to moderate effect on distance walked compared with control groups with no exercise intervention (standardized mean difference [SMD], 0.28; 95% confidence interval [CI], 0.00-0.56; I², 45%) and no effect when compared with control groups with an exercise intervention not delivered by telephone (SMD, 0.08; 95% CI, -0.19 to 0.36; I², 0%).

CONCLUSION

Telephone-delivered physiotherapy may be an effective method to improve walking. Further research is required to validate these findings.

A Scoping Review of Physical Activity in People With Lower-Limb Loss: 10,000 Steps Per Day?

OBJECTIVE

After amputation, people with lower-limb loss (PLL) face challenges to regain their previous physical activity level. Assessing the scope of evidence regarding physical activity in PLL can identify sources of evidence and gaps within the literature that can influence amputation-related research, outcome assessment choices, and wellness activities. The purpose of this scoping review was to map the evidence regarding steps per day as a physical activity measure for PLL. Specific aims were to (1) identify research designs, (2) catalog population subgroups, (3) document steps per day measurement methods, and (4) provide descriptive data for steps per day in PLL.

METHODS

The MEDLINE, CINAHL, Embase, Web of Science, and AMED databases; and the Journal of Prosthetics and Orthotics archive were searched without language or time limits. Exclusion criteria included no PLL subjects, not peer-reviewed, and no direct step count measure. Inclusion criteria allowed any sample size, nonprosthetic use, and self-reported step count. As a scoping review, only descriptive statistics were compiled, and no methodologic quality assessment was performed.

RESULTS

Twenty-one articles using crossover (8), cohort (4), cross-section (8), and case-study (1) designs were included that reported accelerometer (19) or pedometer (2) data. Studies often mixed amputation etiologies (15/21) and most (13/21) excluded transfemoral amputations. Studies primarily examined people with transtibial amputations (81.2%) and people at independent community walking levels (Medicare functional classifications: K3 = 49.2%, K4 = 36.3%). All 21 studies had fewer than 100 participants, and overall included 515 subjects (343, 66.6% male), mean (SD) age 53.2 (22.1) years. Mean (SD) number of pooled steps per day for PLL was 5087 (2998): 5929 (3047) for transtibial amputations and 3553 (2030) for transfemoral amputations.

CONCLUSIONS

Most PLL have low activity levels compared with the 10,000 steps per day generally recommended or 6000 common in people with diabetes. Research with larger samples, defined subgroups, and data along the recovery continuum would enhance knowledge of physical activity level in PLL.

IMPACT

This scoping review has identified gaps in the research related to steps per day as a measure of physical activity in people with lower-limb loss to guide future research.

LAY SUMMARY

People with lower-limb loss take fewer steps per day than suggested for general health. Increasing steps per day may be a useful goal for this population, and this study is a first step in improving knowledge of physical activity levels in people with lower-limb loss.

Psychosocial Factors Influence Physical Activity after Dysvascular Amputation: A Convergent Mixed-Methods Study

BACKGROUND

Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear.

OBJECTIVE

To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives.

DESIGN

Convergent mixed-methods.

SETTING

General community.

PARTICIPANTS

Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews.

RESULTS

Higher steps/d was moderately correlated with better TUG time (r = -.58, P < .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P > .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases.

CONCLUSIONS

Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA.

COVID-19: A catalyst for change in virtual health care utilization for persons with limb loss

The dramatic uptake of virtual care, or telehealth, utilization because of COVID‐19 restrictions for persons with limb loss has led to a much greater understanding of this health care delivery method for this complex patient population. However, much is still unknown. Therefore, the authors provide a comprehensive literature review of existing evidence for virtual care delivery across the phases of amputation rehabilitation, as well as anecdotal evidence, to provide a platform for further discussion and development of research and innovative opportunities. Evidence reveals that virtual care serves as a complement to in‐person health care for individuals with limb loss because it allows for increased accessibility to these services. The authors conclude that continued use of telehealth beyond the COVID‐19 restrictions to optimize outcomes across the continuum of care for persons with limb loss is warranted.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation

OBJECTIVE

The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables.

METHODS

Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space.

RESULTS

Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space.

CONCLUSION

The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA.

IMPACT

The CD-RISC may be an appropriate tool to measure resilience following LLA.

Falls After Dysvascular Transtibial Amputation: A Secondary Analysis of Falling Characteristics and Reduced Physical Performance

INTRODUCTION

Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited.

OBJECTIVE

To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories.

DESIGN

Secondary data analysis from two randomized controlled trials.

SETTING

Outpatient setting.

PARTICIPANTS

People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis.

INTERVENTION

None.

OUTCOME

Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated.

RESULTS

Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities.

CONCLUSION

Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring.

Patient Reported Outcome Measures for Major Lower Limb Amputation Caused by Peripheral Artery Disease or Diabetes: A Systematic Review

OBJECTIVE

Most major lower limb amputations are related to peripheral artery disease (PAD) or diabetes. Just 40% of patients who undergo major lower limb amputation will use a prosthesis yet measures of surgical success commonly focus on prosthesis use. Patient reported outcome measures (PROMs) are valuable to comprehensively evaluate health related quality of life (HRQL) after surgery. This systematic review aimed to identify and describe PROMs available to assess HRQL in patients after amputation for PAD or diabetes.

METHODS

A search was conducted based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) for systematic reviews of PROMs. Ovid MEDLINE, Ovid EMBASE, PsycINFO, CINAHL, and Cochrane CENTRAL were also searched from inception until August 2019. Included were articles describing the development, measurement properties, or evaluation of HRQL via a PROM in adult patients after amputation for PAD or diabetes. Studies of amputation exclusively for trauma or malignancy were excluded. Data were collected on study characteristics, PROM characteristics (generic/disease specific), and properties of amputation specific PROMs.

RESULTS

Of 3 317 abstracts screened, 111 full text articles were assessed for eligibility and 64 included. Fifty-six studies evaluated HRQL, with 23 (46%) of these using an amputation specific PROM to do so. Eleven different amputation specific PROMs were identified, 10 (91%) of which were developed only for prosthesis users. One measure was suitable for use in all patients after amputation. This "Amputee single item mobility measure" includes a single item evaluating mobility. Nine studies reported some psychometric testing of an amputation specific PROM.

CONCLUSION

A well tested, multidimensional PROM applicable to wheelchair and prosthetic users after amputation is lacking and urgently needed for studies in this field. Future work to develop an appropriate measure is required.

Patterns of Sitting, Standing, and Stepping After Lower Limb Amputation

OBJECTIVE

The objectives of this study were to describe sitting, standing, and stepping patterns for people with lower limb amputation (LLA) and to compare sitting, standing, and stepping between people with dysvascular LLA and people with traumatic LLA.

METHODS

Participants with dysvascular or traumatic LLA were included if their most recent LLA was at least 1 year earlier, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Sitting, standing, and stepping were measured using accelerometry. Daily sitting, standing, and stepping times were expressed as percentages of waking time. Time spent in bouts of specified durations of sitting (<30, 30-60, 60-90, and >90 minutes), standing (0-1, 1-5, and >5 minutes), and stepping (0-1, 1-5, and >5 minutes) was also calculated.

RESULTS

Participants (N = 32; mean age = 62.6 [SD = 7.8] years; 84% men; 53% with dysvascular LLA) spent most of the day sitting (median = 77% [quartile 1 {Q1}-quartile 3 {Q3} = 67%-84%]), followed by standing (median = 16% [Q1-Q3 = 12%-27%]) and stepping (median = 6% [Q1-Q3 = 4%-9%]). One-quarter (median = 25% [Q1-Q3 = 16%-38%]) of sitting was accumulated in bouts of >90 minutes, and most standing and stepping was accrued in bouts of <1 minute (standing: median = 42% [Q1-Q3 = 34%-54%]; stepping: median = 98% [Q1-Q3 = 95%-99%]). Between-etiology differences included proportion of time sitting (traumatic: median = 70% [Q1-Q3 = 59%-78%]; dysvascular: median = 79% [Q1-Q3 = 73%-86%]) and standing (traumatic: median = 23% [Q1-Q3 = 16%-32%]; dysvascular: median = 15% [Q1-Q3 = 11%-20%]).

CONCLUSION

Participants had high daily volumes of long durations of sitting. Further, these individuals accumulated most physical activity in bouts of <1 minute.

IMPACT

High levels of sedentary behavior and physical inactivity patterns may place people with LLA at greater mortality risk relative to the general population. Interventions to minimize sedentary behaviors and increase physical activity are potential strategies for improving poor outcomes of physical therapy after LLA.

Evaluation of Pragmatic Telehealth Physical Therapy Implementation During the COVID-19 Pandemic

OBJECTIVE

The objective was to evaluate implementation of telehealth physical therapy in response to COVID-19 and identify implementation strategies to maintain and scale up telehealth physical therapy within a large urban academic medical center.

METHODS

The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework was used to evaluate telehealth physical therapy implementation. Patient-level data were extracted from electronic medical records between March 16, 2020, and May 16, 2020 (implementation phase). Reach was defined as the proportion of physical therapy sessions completed via telehealth. Effectiveness was assessed using a patient-reported satisfaction survey with a 5-point Likert scale. Adoption was defined as the proportion of physical therapists who used telehealth. Implementation was assessed through qualitative analysis of patient and clinician perspectives to identify emergent themes, retrospectively classify strategies used during the implementation phase, and prospectively identify evidence-based strategies to increase telehealth maintenance and scale-up. Maintenance of telehealth was defined as the proportion of patients who indicated they would attend another telehealth session.

RESULTS

There were 4548 physical therapy sessions provided by 40 therapists from March 22, 2020, to May 16, 2020, of which 3883 (85%) were telehealth. Ninety-four percent of patients were satisfied. All physical therapists (100%) used telehealth technology at least once. Retrospectively classified and prospectively identified evidence-based strategies were organized into 5 qualitative themes that supported implementation: organizational factors (policies, preexisting partnerships), engaging external stakeholders (satisfaction survey), champions (clinician leaders), clinician education (dynamic, ongoing training), and process (promote adaptability, small tests of change). Ninety-two percent of patients reported they would attend another telehealth session.

CONCLUSION

Findings from this study suggest that implementation of telehealth physical therapy during the COVID-19 pandemic was feasible and acceptable in this setting.

IMPACT

These results can be used to guide future health policy, quality improvement, and implementation science initiatives to expand the use and study of telehealth for physical therapy.

Biobehavioral Intervention Targeting Physical Activity Behavior Change for Older Veterans after Nontraumatic Amputation: A Randomized Controlled Trial

BACKGROUND

Lower-limb amputation (LLA) due to non-traumatic vascular etiology is linked to extremely low physical activity and high disability.

OBJECTIVE

To test the feasibility of a biobehavioral intervention designed to promote physical activity.

DESIGN

A randomized, single-blind feasibility trial with a crossover design.

SETTING

Veterans Administration Medical Center.

PARTICIPANTS

Military veterans (age: 65.7 [7.8] years; mean [standard deviation]) with nontraumatic lower-limb amputation (LLA), randomized to two groups: GROUP1 (n = 16) and GROUP2 (n = 15). Both groups had similar baseline amputation characteristics (level of amputation and time since amputation).

INTERVENTIONS

Twelve weekly, 30-minute telehealth sessions of physical activity behavior-change intervention, with GROUP1 participating in weeks 1-12 and GROUP2 in weeks 13-24. GROUP1 noncontact phase in weeks 13-24 and GROUP2 attention control telehealth phase in weeks 1-12.

MAIN OUTCOME MEASURES

Feasibility (participant retention, dose goal attainment, intervention acceptability [Intrinsic Motivation Inventory [IMI] Interest and Enjoyment scale], safety) and signal of efficacy (free-living physical activity [accelerometer-based average daily step count], Late Life Function and Disability Index - Disability Scale [LLFDI-DS]).

RESULTS

Participant retention rate was high (90%), with three participants lost to follow-up during the intervention period. Dose goal attainment was low, with only 10% of participants achieving an a priori walking dose goal. Intervention was rated as acceptable, with mean IMI Interest and Enjoyment score (5.8) statistically higher than the null value of 5.0 (P = .002). There were no between-group differences in adverse event rates (falls: P = .19, lower extremity wounds: P = .60). There was no signal of efficacy for change in average daily step count (d = -0.15) or LLFDI-DS (d = -0.22 and 0.17 for frequency and limitations scales, respectively).

CONCLUSIONS

Telehealth delivered biobehavioral intervention resulted in acceptable participant retention, low dose goal attainment, high participant acceptability, and low safety risk, while having no signal of efficacy (physical activity, disability) for people with nontraumatic LLA.

Effects of exercise on the physical fitness and functionality of people with amputations: Systematic review and meta-analysis

STUDY DESIGN

systematic review and meta-analysis.

BACKGROUND

Despite existing scientific evidence alluding to the positive effects of physical exercise on people with amputations, there is a lack of consistency between the results of past studies.

OBJECTIVE

To identify if people with amputations taking part in an exercise training programme can benefit from improvements in their health status as measured by changes in their physiological fitness and functionality levels.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) were performed after searching within several databases up to October 2019.

RESULTS

Ten RCTs with satisfactory methodological quality were found. Five RCTs were pooled in the meta-analysis. Exercise programmes with a combination of activities were most commonly delivered. Exercise had positive effects on aerobic and muscular fitness parameters. Findings from the meta-analysis indicated that exercise improved distance walked but did not have a significant impact on functional mobility or self-reported functional capacity.

CONCLUSION

Combined exercise of muscular endurance and functional physical exercise appear to have greater positive effects on cardiorespiratory fitness, muscular fitness and functionality levels in adult prosthesis users with unilateral lower limb amputation. Future studies should include different profiles of patients with amputations that are poorly represented in the current scientific literature.

Technology for monitoring everyday prosthesis use: a systematic review

BACKGROUND

Understanding how prostheses are used in everyday life is central to the design, provision and evaluation of prosthetic devices and associated services. This paper reviews the scientific literature on methodologies and technologies that have been used to assess the daily use of both upper- and lower-limb prostheses. It discusses the types of studies that have been undertaken, the technologies used to monitor physical activity, the benefits of monitoring daily living and the barriers to long-term monitoring, with particular focus on low-resource settings.

METHODS

A systematic literature search was conducted in PubMed, Web of Science, Scopus, CINAHL and EMBASE of studies that monitored the activity of prosthesis users during daily-living.

RESULTS

Sixty lower-limb studies and 9 upper-limb studies were identified for inclusion in the review. The first studies in the lower-limb field date from the 1990s and the number has increased steadily since the early 2000s. In contrast, the studies in the upper-limb field have only begun to emerge over the past few years. The early lower-limb studies focused on the development or validation of actimeters, algorithms and/or scores for activity classification. However, most of the recent lower-limb studies used activity monitoring to compare prosthetic components. The lower-limb studies mainly used step-counts as their only measure of activity, focusing on the amount of activity, not the type and quality of movements. In comparison, the small number of upper-limb studies were fairly evenly spread between development of algorithms, comparison of everyday activity to clinical scores, and comparison of different prosthesis user populations. Most upper-limb papers reported the degree of symmetry in activity levels between the arm with the prosthesis and the intact arm.

CONCLUSIONS

Activity monitoring technology used in conjunction with clinical scores and user feedback, offers significant insights into how prostheses are used and whether they meet the user's requirements. However, the cost, limited battery-life and lack of availability in many countries mean that using sensors to understand the daily use of prostheses and the types of activity being performed has not yet become a feasible standard clinical practice. This review provides recommendations for the research and clinical communities to advance this area for the benefit of prosthesis users.

The Use of Physical Activity Outcomes in Rehabilitation Interventions for Lower Limb Amputees: a Systematic Review

BACKGROUND

Interventions which have focused on improving the physical activity of individuals with lower limb amputation can be mostly categorized into behavioural-based and prosthetic-based interventions. The aim of this review was to assess the quality of these interventions, and to identify the key gaps in research in this field.

METHODOLOGY

The databases of Scopus, Pubmed, Embase, Medline and Web of Science were searched between September and December of 2019 for articles relating to physical activity, amputees and interventions. Articles were assessed quantitively based on internal validity, external validity and intervention intensity.

FINDINGS

Sixteen articles (5 behavioural, 11 prosthetic) were assessed. Both approaches had comparable methodological quality and mixed efficacy for producing a significant change in physical activity outcomes. Almost all interventions used a simplistic measurement of activity as their outcome.

CONCLUSIONS

There is an insufficient amount of studies to assess the overall efficacy of behavioural interventions in regard to how they impact on physical activity behaviour. However, the increase of quality of the methodology in the more recent studies could indicate that future interventions will retain similar levels of quality. Prosthetic interventions have shown no major improvement in efficacy compared to similar reviews and may need to utilise more advanced prosthetic components to attain significant changes in physical activity. Activity outcomes should expand into more complex activity measurements to properly understand the physical activity profile of people with lower limb amputation.

Physical Function and Pre-Amputation Characteristics Explain Daily Step Count after Dysvascular Amputation

BACKGROUND

People with dysvascular lower limb amputation (LLA) achieve one-third of the recommended steps per day and experience severe disability. Although physical function improves with rehabilitation after dysvascular LLA, physical activity remains largely unchanged, and factors contributing to limited daily step count are unknown.

OBJECTIVES

To identify factors that contribute to daily step count after dysvascular LLA.

DESIGN

Cross-sectional, secondary data analysis.

SETTING

Outpatient rehabilitation facilities.

PARTICIPANTS

Fifty-eight patients with dysvascular major LLA (age: 64 ± 9 years, body mass index: 30 ± 8 kg/m² , male: 95%, transtibial LLA: 95%).

METHODS

Data were collected by a blinded assessor after dysvascular LLA. Candidate explanatory variables included (1) demographics, (2) LLA characteristics, (3) comorbidities and health behaviors, and (4) physical function. Variables with univariate associations with log steps/day (transformed due to non-normality) were included in a multiple linear regression model using backward elimination to identify factors that explained significant variability in log steps/day.

PRIMARY OUTCOME MEASURE

The primary outcome, daily step count, was measured with accelerometer-based activity monitors worn by participants for 10 days.

RESULTS

Participants took an average (± SD) of 1450 ± 1309 steps/day. After backward elimination, the final model included four variables explaining 62% of the overall daily step count (P < .0001): 2-minute walk distance (32%), assistive device use (11%), cardiovascular disease (10%), and pre-amputation walking time (11%).

CONCLUSIONS

Average daily step count of 1450 steps/day reflects the lowest category of sedentary behavior. Physical function, cardiovascular disease, and pre-amputation walking time explain 62% of daily step count after dysvascular LLA. Although physical rehabilitation commonly focuses on improving physical function, interventions to increase daily step count after dysvascular LLA should also consider chronic disease and health behaviors that predate LLA.

LEVEL OF EVIDENCE

III.

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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