Domains that Determine Quality of Life in Vascular Amputees

Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial

Background: Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Methods: Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Results: Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG (P = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS (P < 0.05). However, the EG showed a superior significance in BDI and MHS scores (P < 0.05). There was no significance between groups in PHS score. Conclusion: Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.

Prosthetic fitting and mortality after major lower extremity amputation

BACKGROUND

Studies suggest that ambulation after major lower extremity amputation (LEA) is low and mortality after LEA is high. Successful prosthetic fitting after LEA has a significant quality of life benefit; however, it is unclear if there are benefits in post-LEA mortality. Our objective was to examine a contemporary cohort of patients who underwent LEA and determine if there is an association between fitting for a prosthetic and mortality.

METHODS

We reviewed all patients who underwent LEA between 2015 and 2022 at two academic health care systems in a large metropolitan city. The exposure of interest was prosthetic fitting after LEA. The primary outcomes were mortality within 1 and 3 years of follow-up. Ambulation after LEA was defined as being ambulatory with or without an assistive device. Patients with prior LEA were excluded. Extended Cox models with time-dependent exposure were used to evaluate the association between prosthetic fitting and mortality at 1 and 3 years of follow-up.

RESULTS

Among 702 patients who underwent LEA, the mean (SD) age was 64.3 (12.6) years and 329 (46.6%) were fitted for prosthetic. The study population was mostly male (n = 488, 69.5%), predominantly non-Hispanic Black (n = 410, 58.4%), and nearly one-fifth were non-ambulatory before LEA (n = 139 [19.8%]). Of note, 14.3% of all subjects who were nonambulatory at some point after LEA, and 28.5% of patients not ambulatory preoperatively were eventually ambulatory after LEA. The rate of death among those fitted for a prosthetic was 12.0/100 person-years at 1 year and 5.8/100 person-years at 3 years of follow-up; among those not fitted for a prosthetic, the rate of death was 55.7/100 person-years and 50.7/100 person-years at 1 and 3 years of follow-up, respectively. After adjusting for several sociodemographic data points, comorbidities, pre- or post- coronavirus disease 2019 pandemic timeframe, and procedural factors, prosthetic fitting is associated with decreased likelihood of mortality within 1 year of follow-up (adjusted hazard ratio, 0.24; 95% confidence interval, 0.14-0.40) as well as within 3 years (adjusted hazard ratio, 0.40; 95% confidence interval, 0.29-0.55).

CONCLUSIONS

Prosthetic fitting is associated with improved survival, and preoperative functional status does not always predict postoperative functional status. Characterizing patient, surgical, and rehabilitation factors associated with receipt of prosthetic after LEA may improve long-term survival in these patients. Process measures employed by the Department of Veterans Affairs, such as prosthetic department evaluation of all amputees, may represent a best practice.

Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia

INTRODUCTION

We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation.

METHODS

In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback.

RESULTS

The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs.

CONCLUSIONS

Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

The Effect of Prosthetic Limb Sophistication and Amputation Level on Self-reported Mobility and Satisfaction With Mobility

OBJECTIVE

To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level.

DESIGN

Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes.

SETTING

The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls.

PARTICIPANTS

347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020.

INTERVENTIONS

Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system.

MAIN OUTCOME MEASURE

Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0-10-point Likert scale.

RESULTS

Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI), .98-3.3; P=.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1-96.8; P=.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted β coefficient (aβ)=.77, 95% CI, .11-1.4; P=.02). A statistically significant association was only observed in those who underwent a TT amputation (aβ=.79, 95% CI, .09-1.5; P=.03).

CONCLUSIONS

Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Experiences of middle-aged individuals with lower extremity amputation caused by diabetic foot ulcer after disability in China: A qualitative study

AIM

To understand the experiences of individuals who undergo LEA due to DFU after disability.

DESIGN

A descriptive research design in qualitative research.

METHODS

Semi-structured interviews were used in this qualitative descriptive study. Eleven middle-aged patients (45-59 years) who underwent LEA due to DFU were purposively selected and interviewed. Qualitative data were thematically analysed.

RESULTS

Three themes and 10 subthemes were identified. The themes were (1) role function confusion, (2) self-concept stress and (3) unreasonable objective support. Subthemes included (1) weakened career role, (2) family role reversal, (3) social role restriction, (4) over-focusing on appearance, (5) immersion in patient experience, (6) living with faith, (7) polarization of independent consciousness, (8) low perceived benefits of peer support, (9) existence of treatment disruption and (10) poor participation in medical decision-making.

Cardiorespiratory fitness in persons with lower limb amputation

The aim of this study is to gain insight in the cardiorespiratory fitness of persons with lower limb amputation (LLA) during rehabilitation, and in potential factors influencing their cardiorespiratory fitness. We performed a retrospective cohort study using data from cardiopulmonary exercise tests. Included participants were adults with LLA. Main outcome was cardiorespiratory fitness expressed as O 2 peak (ml/min/kg) and was directly determined using breath-by-breath gas analysis. O 2 peak was compared to reference values for able-bodied controls. Multivariate regression analysis was performed to investigate potential factors related to O 2 peak in persons with LLA. Potential factors were age, BMI adjusted, gender, level of amputation, aetiology of amputation, unilateral/bilateral, type of ergometry and use of beta blockers. Data of 74 participants with LLA are presented; 84% male (n = 62), mean age 58.9 (SD 11.6), mean BMI 26.7 (SD 5.6), 44 participants have a LLA above the knee, 30 below the knee. Overall O 2 peak was lower in persons with LLA compared to reference values for able-bodied controls, with mean O 2 peak for the total LLA group of 14.6 ± 4.1 ml/kg/min. In the multivariate regression analysis, only age was a significant predictor for lower O 2 peak (regression coefficient: -0.15, 95% CI [0.23-0.069], r 2  = 0.166). These results indicate that the cardiorespiratory fitness in persons with LLA is low, while they actually need more energy to walk and perform other daily activities. Cardiorespiratory fitness is not closely associated with the analysed demographic or clinical factors and will have to be determined on an individual basis for use in daily practice.

The effect of depression on prosthesis prescription in men and women who have undergone a lower limb amputation

PURPOSE

To determine gender disparities and potential factors that modify prosthesis prescription practices in veteran patients who have undergone their first major unilateral amputation due to diabetes or peripheral arterial disease.

MATERIALS AND METHODS

A retrospective cohort study using the VA Corporate Data Warehouse to compare prosthesis prescription rates and time to prescription between men and women veterans. The primary exposure was gender. The primary outcome was a qualifying prosthesis prescription within 12 months of the incident amputation. The secondary outcome was time to prosthesis prescription. Multiple logistic and linear regression was used to control for potential confounders and identify potential effect modification.

RESULTS

2,862 individuals met study criteria, with 1690 (60%) prescribed a qualifying prosthesis. Men were more likely to receive a prosthesis prescription than women (59% versus 45%, respectively; p = 0.03). This difference was observed primarily among those with a diagnosis of major depressive disorder. In this subgroup, the odds of men receiving a prosthesis over women was over 3 times (adjusted odds ratio = 3.3; 95% Confidence Interval, 1.5, 7.4). Men had a mean shorter time to prescription compared to women (112 ± 72 versus 136 ± 79 days, respectively, p = 0.08).

Depression in women negatively impacts their prosthesis prescription rates and time to prescription compared to men. This disparity may have significant impacts on future function and quality of life.Implications for RehabilitationThis study found that men more commonly received a prosthesis prescription and received it earlier than women.This disparity was most extreme among women who had been diagnosed with major depressive disorder.Providers should identify at risk patients early and consider targeted interventions to address depression during the preoperative and immediate postoperative phases.Future research should continue to work to identify gender-specific needs that exacerbate disparity.

Making decisions about amputation for chronic limb threatening ischaemia

INTRODUCTION

Chronic limb threatening ischaemia causes pain, loss of function and complex wounds, necessitating urgent interventions. While growing options for minimally invasive revascularisation make operating on frail and older persons safer, the challenge is knowing when to stop this option and offer amputation. Decisions about amputation are difficult for the person, or for the family who act as substitute decision-makers. Timely treatment decisions are important to optimise clinical outcomes but do not always align with outcomes that are acceptable to patients.

AIM

To provide a philosophically-based understanding of patient/family experiences of making decisions for chronic limb threatening ischaemia.

METHODS

Longitudinal qualitative study using Heideggerian phenomenology. Patient and family participants were recruited from three sites. Semi-structured interviews occurred at two time points: soon after advice to consider major amputation, and for those who experienced amputation, six-months post-operatively. The COnsolidated criteria for REporting Qualitative studies (COREQ) checklist guided this report.

FINDINGS

Variable timelines, disease progression, and interventions were encountered prior to confronting the possibility of amputation. Decision-making was interpreted as an initial irresoluteness (neglecting or renouncing decisions). For most, this was eventually followed by a resoluteness where participants either turned away or towards amputation, according to one's preferred mode of suffering, and thus owning the decision to turn. Those who opted for amputation often experienced better-than-anticipated outcomes.

CONCLUSION

Patients and families had difficulty making decisions about amputation. Clinicians may have been complicit in the neglecting and renouncing of decisions and have an important role in sharing decision-making through their authentic discourse.

IMPLICATIONS

Chronic limb threatening ischaemia requires complex discussions to support decisions and shared decision-making requires clinician presence and engagement in discourse. Patients and family members benefit from more time to experience and process the phenomenon as they move towards owning their decision about amputation.

The Moment Criterion of Anthropomorphicity of Prosthetic Feet as a Potential Predictor of Their Functionality for Transtibial Amputees

The purpose of this paper is to discuss a new quantitative mechanical parameter of prosthetic feet called the Index of Anthropomorphicity (IA), which has the potential to be adopted as an objective predictor of their functionality. The objectives are to present the research findings supporting the introduction of IA and unify previous results into a coherent theory. The IA is founded on the moment criterion of the anthropomorphicity of prosthetic feet. The term "anthropomorphicity" is defined for this application. Studies with a small number of human subjects and prostheses have shown that the value of the parameter is positively correlated with patient comfort and with the restoration of certain normal gait characteristics. Confirmatory studies with controlled human trials and mechanical tests with a wider selection of prosthesis types can give prosthesis manufacturers a new criterion to follow in the design process, and prosthetists may use the IA for selecting more suitable prostheses for a patient's comfort and health.

Predictors of Ambulatory Status at 1 Year Following Major Lower Extremity Amputation

Nearly 60,000 major lower extremity amputations (AKA/BKA) are performed annually in the United States. We created a simple risk score for predicting ambulation at 1 year following AKA/BKA. We queried the Vascular Quality Initiative amputation database for patients who underwent above-knee (AKA) or below-knee (BKA) amputation (2013-2018). The primary endpoint was ambulation at 1 year either independently or with assistance. The cohort was divided into 80% derivation and 20% validation. Using the derivation set, a multivariable model identified preoperatively available independent predictors of 1 year ambulation and an integer-based risk-score was created. Scores were calculated to assign patients to risk groups-low, medium, or high chance of being ambulatory at 1 year. Internal validation was performed by applying the risk score to the validation set. Of 8725 AKA/BKA, 2055 met inclusion criteria-excluded: 2644 nonambulatory prior to amputation, 3753 missing 1-year follow-up ambulatory status. The majority-n = 1366, 66% were BKAs. The indications were CLTI; 47%, ischemic tissue loss; 9%, ischemic rest pain; 35%, infection/neuropathic; 9%, acute limb ischemia. Ambulation at 1 year was higher for BKA than AKA: 67%, versus 50%, p < .0001. In the final prediction model, contralateral BKA/AKA was the strongest predictor of nonambulation. The score provided reasonable discrimination (C-statistic = 0.65) and was well calibrated (Hosmer-Lemeshow p = .24). Sixty-two percent of patients who were ambulatory preoperatively remained ambulatory at 1 year. An integer-based risk score can stratify patients according to chance of ambulation at 1 year after major amputation and may be useful for preoperative patient counseling and selection.

AMPREDICT PROsthetics-Predicting Prosthesis Mobility to Aid in Prosthetic Prescription and Rehabilitation Planning

OBJECTIVE

To develop and validate a patient-specific multivariable prediction model that uses variables readily available in the electronic medical record to predict 12-month mobility at the time of initial post-amputation prosthetic prescription. The prediction model is designed for patients who have undergone their initial transtibial (TT) or transfemoral (TF) amputation because of complications of diabetes and/or peripheral artery disease.

DESIGN

Multi-methodology cohort study that identified patients retrospectively through a large Veteran's Affairs (VA) dataset then prospectively collected their patient-reported mobility.

SETTING

The VA Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls.

PARTICIPANTS

Three-hundred fifty-seven veterans who underwent an incident dysvascular TT or TF amputation and received a qualifying lower limb prosthesis between March 1, 2018, and November 30, 2020 (N=357).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The Amputee Single Item Mobility Measure (AMPSIMM) was divided into a 4-category outcome to predict wheelchair mobility (0-2), and household (3), basic community (4), or advanced community ambulation (5-6).

RESULTS

Multinomial logistic lasso regression, a machine learning methodology designed to select variables that most contribute to prediction while controlling for overfitting, led to a final model including 23 predictors of the 4-category AMPSIMM outcome that effectively discriminates household ambulation from basic community ambulation and from advanced community ambulation-levels of key clinical importance when estimating future prosthetic demands. The overall model performance was modest as it did not discriminate wheelchair from household mobility as effectively.

CONCLUSIONS

The AMPREDICT PROsthetics model can assist providers in estimating individual patients' future mobility at the time of prosthetic prescription, thereby aiding in the formulation of appropriate mobility goals, as well as facilitating the prescription of a prosthetic device that is most appropriate for anticipated functional goals.

The Development and Pilot Study of a Multiple Criteria Decision Analysis (MCDA) to Compare Patient and Provider Priorities around Amputation-Level Outcomes

Background. Patients with chronic limb-threatening ischemia who are facing a lower-limb amputation often require a transmetatarsal amputation (TMA) or a transtibial amputation (TTA). A TMA preserves more of the patient's limb and may provide better mobility but has a lower probability of primary wound healing relative to a TTA and may result in additional amputation surgeries. Understanding the differences in how patients and providers prioritize key outcomes may enhance the amputation decisional process. Purpose. To develop and pilot test a multiple criteria decision analysis (MCDA) tool to elicit patient values around amputation-level selection and compare those with provider perceptions of patient values. Methods. We conducted literature reviews to identify and measure the performance of criteria important to patients. Because the quantitative literature was sparse, we developed a Sheffield elicitation framework exercise to elicit criteria performance from subject matter experts. We piloted our MCDA among patients and providers to understand tool acceptability and preliminarily assess differences in patient and provider priorities. Results. Five criteria of importance were identified: ability to walk, healing after amputation surgery, rehabilitation intensity, limb length, and prosthetic/orthotic device ease. Patients and providers successfully completed the MCDA and identified challenges in doing so. We propose potential solutions to these challenges. The results of the pilot test suggest differences in patient and provider outcome priorities. Limitations. The pilot test study enrolled a small sample of providers and patients. Conclusions. We successfully implemented the pilot study to patients and providers, received helpful feedback, and identified solutions to improve the tool. Implications. Once modified, our MCDA tool will be suitable for wider rollout.

Highlights

Patients and providers have successfully completed our MCDA, and patients feel the MCDA may be useful in clinical practice.We encountered several methodologic challenges and identified approaches to ease participant burden.When data are sparse, using the Sheffield elicitation framework is helpful in creating a performance matrix, although patients relied largely on their amputation experiences to complete the exercise. Blinding the alternatives may help patients better understand the process.

Physical therapists demonstrate clinical behaviors consistent with established clinical practice guidelines in managing individuals following amputation

BACKGROUND AND PURPOSE

Investigating physical therapy in amputation management offers insights into clinical practice. This study explores the self-reported clinical practice of physical therapists in amputation management and compares it to established clinical practice guidelines to determine whether physical therapists are delivering care that is considered recommended clinical practice.

METHOD

An online survey of Australian physical therapists with limited or extensive experience in managing individuals following amputation.

RESULTS

A total of 110 responses were received. The majority of Australian physical therapists (83%) reported their skills were adequate however, reported a lack of professional development opportunities. Physical therapists reported coordinating care with other health and medical professionals across all phases of care. They report providing comprehensive care in the following areas: residual limb management, pain management, falls prevention, education, counselling, psychological and peer support, and discharge planning. The majority of physical therapists were not aware if a comprehensive care plan was in place following a transition of care from a previous health service.

DISCUSSION

Overall, physical therapists displayed clinical practice meeting the guidelines across most areas of amputation management. Future research into alternate data collection of clinical practice, and the development of physical therapy-specific clinical practice guidelines is needed.

Voices of Women Veterans with Lower Limb Prostheses: a Qualitative Study

BACKGROUND

Women Veterans with amputation are a group with unique needs whose numbers have grown over the last 5 years, accounting for nearly 3% of all Veterans with amputation in 2019. Although identified as a national priority by the Veterans Health Administration, the needs of this population have remained largely underrepresented in amputation research.

OBJECTIVE

To describe the experiences of women Veterans with lower extremity amputation (LEA) related to prosthetic care provision and devices.

DESIGN

National qualitative study using semi-structured individual interviews.

PARTICIPANTS

Thirty women Veterans with LEA who had been prescribed a prosthesis at least 12 months prior.

APPROACH

Inductive content analysis.

KEY RESULTS

Four key themes emerged: (1) a sense of "feeling invisible" and lacking a connection with other women Veterans with amputation; (2) the desire for prosthetic devices that meet their biological and social needs; (3) the need for individualized assessment and a prosthetic limb prescription process that is tailored to women Veterans; the current process was often perceived as biased and either dismissive of women's concerns or failing to adequately solicit them; and (4) the desire for prosthetists who listen to and understand women's needs.

CONCLUSIONS

Women Veterans with LEA articulated themes reminiscent of those previously reported by male Veterans with LEA, such as the importance of prostheses and the central role of the provider-patient relationship. However, they also articulated unique needs that could translate into specific strategies to improve prosthetic care, such as integrating formal opportunities for social support and peer interaction for women Veterans with LEA, advocating for administrative changes and research efforts to expand available prosthetic component options, and ensuring that clinical interactions are gender-sensitive and free of bias.

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.

A concern for falling impacts quality of life for people with a lower limb amputation

The purpose of this web-based survey study was to comprehensively evaluate subdomains of concern for falling and its association with quality of life (QoL) among people with lower-limb amputations (PLLA). Forty-eight adults (mean 61.8 ± 11.6 years) with a major (i.e. transtibial or transfemoral) amputation participated. Individuals were currently using a prosthesis for ambulation, completed a prosthetic rehabilitation program, had functional use of English and had access to an internet-connected device (e.g. laptop). Five standardized scales assessed a concern for falling: Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE), Activities-specific Balance Confidence (ABC) Scale, Prosthetic Limb Users Survey - Mobility (PLUS-M), Consequences of Falling Scale and Perceived Ability to Manage Falls Scale. QoL was evaluated using the WHO QoL-100 questionnaire. Spearman correlation analysis evaluated the relationship between the five concerns for falling scales. Five independent linear regression modeling evaluated the association of each concern for falling measure on QoL. Strong statistically significant correlations were found between mSAFFE and PLUS-M (rs = -0.87; P < 0.05). Three scales were significantly associated with QoL: mSAFFE [-1.16 (95% CI, -2.04 to -0.29)], ABC [0.36 (95% CI, 0.11-0.61)] and PLUS-M [0.50 (95% CI, 0.05-0.95)]. This is the first study to evaluate multiple concerns for falling subdomains among PLLA. Concern for falling should be addressed in prosthetic rehabilitation to improve community re-integration and QoL.

Peer support for traumatic injury survivors: a scoping review

PURPOSE

Peers are uniquely able to draw on their lived experiences to support trauma survivors' recovery. By understanding the functions and outcomes of peer support and the factors that impact implementation, evidence can be mobilized to enhance its application and uptake into standard practice. As such, we aimed to review the literature on peer support for trauma survivors to: examine the role of peer support in recovery; describe the nature and extent of peer support; Examine the influence of peer support on health and well-being; and identify the barriers and facilitators to developing and implementing peer support.

METHODS

Scoping review methodology as outlined by Arksey and O'Malley.

RESULTS

Ninety-three articles were reviewed. Peer support was highlighted as an important component of care for trauma survivors and provided hope and guidance for the future post-injury. Most peer support programs were offered in the community and provided one-on-one support from peer mentors using various modalities. Interventions were successful when they involved knowledgeable peer mentors and maintained participant engagement. Prior negative experiences and stigma/privacy concerns deterred trauma survivors from participating.

CONCLUSIONS

Peer support fulfills several functions throughout trauma survivors' recovery that may not otherwise be met within existing health care systems. Implications for rehabilitationBy understanding the functions and outcomes and the factors that impact implementation of peer support, evidence can be mobilized to enhance its application and uptake into standard practice.Peers provide trauma survivors with socioemotional support as well as assistance in daily management and life navigation post-injury.Peer support provided hope and guidance for the future after injury and improved self-efficacy amongst trauma survivors.Peer support programs are most likely to be successful when they involve knowledgeable peer mentors, are flexibly delivered, align with organizations' values and priorities, and have adequate resources and funding to support their implementation.

A systematic review of patient-reported outcome measures patients with chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) causes significant morbidity with profound negative effects on health-related quality of life. As the prevalence of peripheral artery disease and diabetes continue to rise in our aging population, the public health impact of CLTI has escalated. Patient-reported outcome measures (PROMs) have become common and important measures for clinical evaluation in both clinical care and research. PROMs are important for the measurement of clinical effectiveness and cost effectiveness and for shared decision-making on treatment options. However, the PROMs used to describe the experience of patients with CLTI are heterogeneous, incomplete, and lack specific applicability to the underlying disease processes and diverse populations. For example, certain PROMs exist for patients with extremity wounds, and other PROMs exist for patients with pain, and still others exist for patients with vascular disease. Despite this multiplicity of tools, no single PROM encompasses all of the components necessary to describe the experiences of patients with CLTI. This significant unmet need is evident from both published reports and contemporary large-scale clinical trials in the field. In this systematic review, we review the current use of PROMs for patients with CLTI in clinical practice and in research trials and highlight the gaps that need to be addressed to develop a unifying PROM instrument for CLTI.

Association Between Balance Self-efficacy and Walking Ability in Those With New Lower Limb Amputations

BACKGROUND

A relationship between walking ability and self-efficacy has been demonstrated in various rehabilitation patient populations. In experienced prosthetic ambulators, walking ability is related to self-efficacy of balance, however, this relationship has not been quantified for those with newly acquired lower limb amputations (LLA).

OBJECTIVES

To investigate the association between walking performance (objective) and self-reported walking abilities (subjective) on balance self-efficacy in those with LLA.

METHODOLOGY

Cross-sectional study of 27 people (17 men; mean age=63.57±9.33) at discharge from inpatient prosthetic rehabilitation for first major unilateral LLA. Individuals completed 6m straight path walking and the L-Test under single- and dual-task conditions. The Prosthesis Evaluation Questionnaire (PEQ) was administered, and the Ambulation subscale provided subjective measures of walking ability. A single PEQ question on satisfaction with walking (16B) was also used as a proxy for subjective walking ability. The Activities-specific Balance Confidence Scale measured balance self-efficacy. Multivariable linear regression was used to evaluate the strength of association between walking ability (objective and subjective) and balance self-efficacy (dependent variable).

FINDINGS

Walking velocity on the 6m straight path under single-task (p=0.011) and dual-task conditions (p=0.039), the single-task L-Test (p=0.035) and self-reported satisfaction with walking (p=0.019) were associated with self-efficacy of balance.

CONCLUSIONS

Objective measures of walking ability that were independently associated with balance self-efficacy included straight path walking velocity under single and dual-task conditions and the single-task L-Test. Satisfaction with walking was also associated with balance self-efficacy. This highlights the interplay between physical and psychological factors during rehabilitation. More research in the area of self-efficacy and walking ability is needed to establish self-efficacy as a target during prosthetic rehabilitation for those with LLA.

Quality of Life of Patients With Major Amputations in the Tertiary Care Center of Western Rajasthan: A Prospective Observational Study in 2019-2020

Introduction Amputation of a limb is a loss of physical integrity that has disastrous consequences for a person's mental, physical, and social well-being. Aim We aim to analyze the quality of life (QoL) after major amputations and long-term outcomes. Method and materials A prospective, observational study has been conducted in a health care institute in western Rajasthan from January 2019 to July 2020. This study included 64 patients who had major upper or lower limb amputations. We analyzed the sociodemographic factors of the patients, the type of procedure, postoperative hospital stay, complications, and follow-up status with both the SF-12 and the World Health Organization Quality of Life (WHOQOL)-BREF questionnaires. Mean, median, range, standard deviation, percentages, univariable, and multivariable logistic regression were analyzed with SPSS version 23.0 software (IBM Corp., Armonk, NY). Results The mean age of the study patients was 53.6 years (SD 2.6) and they were mostly male (71.9%). Atherosclerotic peripheral vascular disease (PVD) was the most common indication (37.5%) of amputation, and below-the-knee amputation (46.88%) was the most commonly performed procedure. There was a significant increment in both PCS (p-value= 0.001), MCS scores (p-value=0.0001) of SF-12 and physical (p-value=0.0001) and psychological domains (p-value=0.001) of the WHOQOL-BREF questionnaire in the postoperative period. A total of 83.9% of patients have used prostheses, and 15.6% had mortality. Conclusions Major amputations can significantly affect the quality of life of patients, and all efforts should be made to avoid factors that adversely affect their quality of life.

Effects of phantom exercises on pain, mobility, and quality of life among lower limb amputees; a randomized controlled trial

Background

The objective of the current study is to evaluate the effects of phantom exercises on phantom limb pain, mobility status, and quality of life in lower limb amputees treated with mirror therapy and routine physiotherapy.

Methods

It is a randomized controlled trial in which 24 unilateral lower limb amputees (above and below the knee) were randomly assigned to two equal groups i.e., control group (mirror therapy and conventional physical therapy) and experimental group in which, phantom exercises were given, additionally. Physical therapy included conventional therapeutic exercises while phantom exercises include imagining the movement of the phantom limb and attempting to execute these movements Data were collected at baseline, after 2 and 4 weeks of intervention using VAS (pain), AMP (mobility) and RAND SF-36 Version 1.0 (QOL) questionnaires. All statistical analyses were done with IBM SPSS 25.0 with 95% CI.

Results

Twenty-four amputees (17 males and 7 females) participated in this trial. The Mean age of the participants in experimental and control groups was 45.3 ± 11.1 years and 40.5 ± 12.5 years respectively. After the intervention, the pain (VAS score) was significantly lower in the experimental group (p = 0.003). Similarly, the experimental group demonstrated a significantly better score in the “bodily pain” domain of SF-36 (p = 0.012). Both groups significantly (p < 0.05) improved in other domains of SF-36 and ambulatory potential with no significant (p > 0.05) between-group differences.

Conclusions

The Addition of phantom exercises resulted in significantly better pain management in lower limb amputees treated with mirror therapy and routine physiotherapy.

Trial registration

This study is registered in the U.S National Library of Medicine. The clinical trials registration number for this study is NCT04285138 (ClinicalTrials.gov Identifier) (Date: 26/02/2020).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02441-z.

Validade de construto do teste de caminhada de 2 minutos para pacientes com amputação de membro inferior protetizados

RESUMO Aliados da avaliação funcional, os testes de caminhada têm sido considerados confiáveis e válidos para várias populações, quantificando a capacidade funcional do indivíduo e respondendo a mudanças durante o processo de reabilitação. O objetivo deste artigo foi analisar a validade de construto do teste de caminhada de 2 minutos para pacientes com amputação de membro inferior protetizados, submetidos à reabilitação. Foi aplicado o teste de caminhada de 2 minutos em 51 pacientes maiores de 18 anos com diagnóstico clínico de amputação de membro inferior em qualquer nível e que tivessem sido submetidos à reabilitação há pelo menos seis meses no momento da avaliação, que foi correlacionada com os questionários Medida Funcional para Amputados (MFA) e os aspectos do Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), a fim de obter o coeficiente de correlação de Pearson com o nível de significância de p<0,05. Entre os participantes do estudo, 64,7% eram do sexo masculino, com média de idade de 53,4 anos; 59,92% tinham amputação de nível transtibial e a principal causa foi trauma, com 54,9%. O escore médio para os questionários foi de 63,58 pontos para a capacidade física do SF-36, e 37,14 pontos para a segunda questão do MFA. A correlação da distância percorrida no teste de caminhada de 2 minutos mostrou moderada correlação com a capacidade física do SF-36 e com a segunda questão do MFA. Os achados mostram moderada correlação entre o teste de caminhada de 2 minutos e as ferramentas subjetivas de avaliação de função utilizadas, mostrando que é um instrumento válido como medida objetiva para a população estudada.

The Development and Usability of the AMPREDICT Decision Support Tool: A Mixed Methods Study

OBJECTIVE

Amputation level decision making in patients with chronic limb threatening ischaemia is challenging. Currently, evidence relies on published average population risks rather than individual patient risks. The result is significant variation in the distribution of amputation levels across health systems, geographical regions, and time. Clinical decision support has been shown to enhance decision making, especially complex decision making. The goal of this study was to translate the previously validated AMPREDICT prediction models by developing and testing the usability of the AMPREDICT Decision Support Tool (DST), a novel, web based, clinical DST that calculates individual one year post-operative risk of death, re-amputation, and probability of achieving independent mobility by amputation level.

METHODS

A mixed methods approach was used. Previously validated prediction models were translated into a web based DST with additional content and format developed by an expert panel. Tool usability was assessed using the Post-Study System Usability Questionnaire (PSSUQ; a 16 item scale with scores ranging from 1 to 7, where lower scores indicate greater usability) by 10 clinician end users from diverse specialties, sex, geography, and clinical experience. Think aloud, semi-structured, qualitative interviews evaluated the AMPREDICT DST's look and feel, user friendliness, readability, functionality, and potential implementation challenges.

RESULTS

The PSSUQ overall and subscale scores were favourable, with a mean overall total score of 1.57 (standard deviation [SD] 0.69) and a range from 1.00 to 3.21. The potential clinical utility of the DST included (1) assistance in counselling patients on amputation level decisions, (2) setting outcome expectations, and (3) use as a tool in the academic environment to facilitate understanding of factors that contribute to various outcome risks.

CONCLUSION

After extensive iterative development and testing, the AMPREDICT DST was found to demonstrate strong usability characteristics and clinical relevance. Further evaluation will benefit from integration into an electronic health record with assessment of its impact on physician and patient shared amputation level decision making.

Transtibial Osseointegration for Patients with Peripheral Vascular Disease: A Case Series of 6 Patients with Minimum 3-Year Follow-up

The management of peripheral vascular disease (PVD) can require amputation. Osseointegration surgery is an emerging rehabilitation strategy for amputees. In this study, we report on 6 patients who had PVD requiring transtibial amputation (PVD-TTA) and either simultaneous or subsequent osseointegration (PVD-TTOI).

Methods

Six patients (aged 36 to 84 years) with transtibial amputation and preexisting PVD underwent osseointegration between 2014 and 2016 and were followed for 3 to 5 years. Pre- and postoperative clinical and functional outcomes (pain, prosthesis wear time, mobility, walking ability, and quality of life) and adverse events (infection, fracture, implant failure, revision surgery, additional amputation, and death) were prospectively recorded.

Results

All patients' mobility improved following osseointegration. Three patients initially had required the use of a wheelchair, precluding baseline walking tests; the other 3 were classified as K level 1 or 2, with mean baseline Timed Up and Go (TUG) test = 14.0 ± 2.2 s and 6-Minute Walk Test (6MWT) = 262 ± 75 m. At the time of the latest follow-up, all patients were K level 2 or 3; mean TUG = 12.7 ± 7.2 s and 6MWT = 353 ± 148 m. Four patients wore their prosthesis ≥16 hours daily. Three patients had superficial soft-tissue infections. One other patient experienced recurrent infections 2.8 years after osseointegration requiring debridements and transfemoral amputation; the patient died 2 days following surgery from myocardial infarction caused by coronary atherosclerosis.

Conclusions

All 6 patients who underwent PVD-TTOI in this case series survived through 2 years. Patients who initially had used a wheelchair achieved and maintained independent, unaided ambulation until PVD-related impairments in the contralateral leg occurred in 1 patient. Patients previously using a traditional socket prosthesis reported improvement in mobility and quality of life. One patient's death underscores the importance of careful patient selection. However, marked improvement in the other 5 patients suggests cautious optimism that PVD-TTA is not an absolute osseointegration contraindication. Conscientious further investigation seems appropriate.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anxiety and Depression Scores in Patients Subjected to Arterial Revascularization for Critical Limb Ischemia

OBJECTIVES

This study aims to examine the changes in anxiety and depression scores in 138 patients with critical limb ischemia (rest pain or gangrene) who had no previous psychiatric history, at 30 days and 6 months after surgical revascularization.

METHODS

Patients were submitted to a questionnaire-based evaluation using the Beck Anxiety and Depression Inventories before surgery (no more than three days before surgery) ("Pre-Op"), 30 days after surgical revascularization ("Early PO") and at least 6 months after surgical revascularization ("Late PO"). The cut-off scores for depression were (1) < 10, no depression or minimal depression; (2) 10‒18, mild to moderate depression; (3) 19‒29, moderate to severe depression; and (4) 30‒63, severe depression. The cut-off scores for anxiety were (1) < 8, no anxiety or minimal anxiety; (2) 8‒15, mild anxiety; (3) 16‒25, moderate anxiety; and (4) 26‒63, severe anxiety.

RESULTS

No perioperative mortality was observed 30 days after surgical revascularization. Thirty-nine (28.2%) patients underwent major (above-ankle) amputation within 30 days. Mean anxiety and depression scores, respectively, declined from 12.48 ± 9.74 (mean ± SD) and 16.92 ± 12.48 preoperatively to 4.89 ± 7.04 and 6.52 ± 9.36 postoperatively (P<0.001, both). Anxiety and depression scores were not significantly affected by preoperative comorbidities (systemic arterial hypertension, diabetes mellitus, previous stroke, and smoking), affected arterial territory (aortoiliac, femoropopliteal, or infrapopliteal), or surgical technique (open surgery vs endovascular therapy). Only patients undergoing amputation within 30 days showed no improvement in depressive symptoms.

CONCLUSIONS

Patients with critical limb ischemia have a high incidence of anxiety and depressive symptoms, which improve considerably after successful surgical revascularization. Major amputation was associated with a lack of improvement in depression scores. A formal psychiatric evaluation may be beneficial in patients who show no improvement in depressive symptoms.

Configuration of vascular services: a multiple methods research programme

Background

Vascular services is changing rapidly, having emerged as a new specialty with its own training and specialised techniques. This has resulted in the need for reconfiguration of services to provide adequate specialist provision and accessible and equitable services.

Objectives

To identify the effects of service configuration on practice, resource use and outcomes. To model potential changes in configuration. To identify and/or develop electronic data collection tools for collecting patient-reported outcome measures and other clinical information. To evaluate patient preferences for aspects of services other than health-related quality of life.

Design

This was a multiple methods study comprising multiple systematic literature reviews; the development of a new outcome measure for users of vascular services (the electronic Personal Assessment Questionnaire – Vascular) based on the reviews, qualitative studies and psychometric evaluation; a trade-off exercise to measure process utilities; Hospital Episode Statistics analysis; and the development of individual disease models and a metamodel of service configuration.

Setting

Specialist vascular inpatient services in England.

Data sources

Modelling and Hospital Episode Statistics analysis for all vascular inpatients in England from 2006 to 2018. Qualitative studies and electronic Personal Assessment Questionnaire – Vascular evaluation with vascular patients from the Sheffield area. The trade-off studies were based on a societal sample from across England.

Interventions

The data analysis, preference studies and modelling explored the effect of different potential arrangements for service provision on the resource use, workload and outcomes for all interventions in the three main areas of inpatient vascular treatment: peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. The electronic Personal Assessment Questionnaire – Vascular was evaluated as a potential tool for clinical data collection and outcome monitoring.

Main outcome measures

Systematic reviews assessed quality and psychometric properties of published outcome measures for vascular disease and the relationship between volume and outcome in vascular services. The electronic Personal Assessment Questionnaire – Vascular development considered face and construct validity, test–retest reliability and responsiveness. Models were validated using case studies from previous reconfigurations and comparisons with Hospital Episode Statistics data. Preference studies resulted in estimates of process utilities for aneurysm treatment and for travelling distances to access services.

Results

Systematic reviews provided evidence of an association between increasing volume of activity and improved outcomes for peripheral arterial disease, abdominal aortic aneurysm and carotid artery disease. Reviews of existing patient-reported outcome measures did not identify suitable condition-specific tools for incorporation in the electronic Personal Assessment Questionnaire – Vascular. Reviews of qualitative evidence, primary qualitative studies and a Delphi exercise identified the issues to be incorporated into the electronic Personal Assessment Questionnaire – Vascular, resulting in a questionnaire with one generic and three disease-specific domains. After initial item reduction, the final version has 55 items in eight scales and has acceptable psychometric properties. The preference studies showed strong preference for endovascular abdominal aortic aneurysm treatment (willingness to trade up to 0.135 quality-adjusted life-years) and for local services (up to 0.631 quality-adjusted life-years). A simulation model with a web-based interface was developed, incorporating disease-specific models for abdominal aortic aneurysm, peripheral arterial disease and carotid artery disease. This predicts the effects of specified reconfigurations on workload, resource use, outcomes and cost-effectiveness. Initial exploration suggested that further reconfiguration of services in England to accomplish high-volume centres would result in improved outcomes, within the bounds of cost-effectiveness usually considered acceptable in the NHS.

Limitations

The major source of evidence to populate the models was Hospital Episode Statistics data, which have limitations owing to the complexity of the data, deficiencies in the coding systems and variations in coding practice. The studies were not able to address all of the potential barriers to change where vascular services are not compliant with current NHS recommendations.

Conclusions

There is evidence of potential for improvement in the clinical effectiveness and cost-effectiveness of vascular services through further centralisation of sites where major vascular procedures are undertaken. Preferences for local services are strong, and this may be addressed through more integrated services, with a range of services being provided more locally. The use of a web-based tool for the collection of clinical data and patient-reported outcome measures is feasible and can provide outcome data for clinical use and service evaluation.

Future work

Further evaluation of the economic models in real-world situations where local vascular service reconfiguration is under consideration and of the barriers to change where vascular services do not meet NHS recommendations for service configuration is needed. Further work on the electronic Personal Assessment Questionnaire – Vascular is required to assess its acceptability and usefulness in clinical practice and to develop appropriate report formats for clinical use and service evaluation. Further studies to assess the implications of including non-health-related preferences for care processes, and location of services, in calculations of cost-effectiveness are required.

Study registration

This study is registered as PROSPERO CRD42016042570, CRD42016042573, CRD42016042574, CRD42016042576, CRD42016042575, CRD42014014850, CRD42015023877 and CRD42015024820.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 9, No. 5. See the NIHR Journals Library website for further project information.

Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association

Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.

Influence of Pain on the Quality of Life and Disease Acceptance in Patients with Complicated Diabetic Foot Syndrome

OBJECTIVE

The aim of the study was to evaluate the relationship between pain and quality of life and illness acceptance, anxiety and depression in a group of patients with complicated diabetic foot syndrome, following lower limb amputation.

PATIENTS AND METHODS

The studies were carried out in three stages: 7 days, 6 months and 12 months after surgery in a group of 100 patients after amputation of the lower limb due to complications resulting from type 2 diabetes. The study was performed using standardised instruments: WHOQOL-BREF, the Acceptance of Illness Scale (AIS), the Hospital Anxiety and Depression Scale (HADS), and the Visual Analog Scale (VAS) for pain intensity assessment.

RESULTS

Pain occurred in the examined patients throughout the study. The greatest intensity of pain was observed in the postoperative period and significantly weakened over time. Pain intensity was significantly associated with worse overall QoL perceived (-0.255, p=0.011/-0.283, p=0.005) and QoL scores in the physical and psychological domains at the first and second stage of the study (physical domains -0.257, p=0.011/-0.219, p=0.03 and psychological -0.22, p=0.029/-0.24/0.018). The intensity of pain negatively correlates with the acceptance of the disease in all three stages of the study, the greater the severity of pain, the lower the acceptance of illness (-0.298, p=0.003/-0.326, p=0.001/-0.26, p=0.009). The occurrence of anxiety and depression is highly dependent on the severity of pain, especially at the first and second stage of the study (anxiety 0.203, p=0.045/0.257, p=0.01, depression 0.299, p=0.003/0.253, p=0.012). The stronger the pain, the greater the severity of mood disorders.

CONCLUSION

Pain and its severity are associated with QoL in the patients with complicated diabetic foot syndrome following lower limb amputation. Disease acceptance was lower in patients experiencing more severe pain at all stages of the study. There is an association of pain with the occurrence of anxiety and depression in amputees, especially 6 months after surgery.

Fall-related events in people who are lower limb prosthesis users: the lived experience

PURPOSE

To explore lived experiences, and identify common themes as well as vocabulary associated with fall-related events in lower limb prosthesis (LLP) users.

MATERIALS AND METHODS

Five focus groups of LLP users from across the United States were conducted remotely via video or tele-conferencing. Focus group transcripts were coded and analyzed using methods adapted from a grounded theory approach to identify themes.

RESULTS

Focus group participants (n = 25) described experiences associated with fall-related events that resulted in the identification of six themes: (1) memories of fall-related events are shaped by time and context, (2) location and ground conditions influence whether falls occur, (3) some activities come with more risk, (4) fall-related situations are multi-faceted, and often involve the prosthesis, (5) how LLP users land, but not the way they go down, tends to vary, and (6) not all falls affect LLP users, but some near-falls do.

CONCLUSION

Consideration for where LLP users fall, what they are doing when they fall, how they fall, what occurs as a result of a fall, and how well memory of a fall persists may enhance recording and reporting of falls, contribute to development of improved fall risk assessment tools, and inspire the design and function of prosthetic componentry for patient safety.Implications for rehabilitationFalls are a common problem in lower limb prosthesis (LLP) users that can lead to adverse health outcomes.Concerns over near falls, not just falls, may merit greater attention from rehabilitation professionals.Elements of the lived experience that appear unique to LLP users include the role of prosthetic fit, function, and comfort in losing and/or recovering balance; as well as the tendency of LLP users to modify rather than stop or avoid activities associated with falls.

Perceptions of patients with wounds due to chronic limb-threatening ischemia

Patients with chronic limb-threatening ischemia (CLTI) face numerous barriers to caring for lower extremity wounds. We explored the perceptions of CLTI patients to their wound/management and sought to determine attitudes towards their vascular provider as well as willingness for management through telemedicine. Patients admitted to hospital for treatment of Rutherford Grade 5 and 6 CLTI were asked complete a wound evaluation survey and took part in a semi-structured interview. Semi-structured interviews were recorded, transcribed, and analyzed using an inductive coding strategy. Codes were grouped for thematic analysis and aggregated into assertions. Eleven patients with a mean age of 60 years (35-79 years) were interviewed. All patients had peripheral artery disease (PAD) and eight patients had diabetes as well. Three overarching themes were identified. First, patients appear to have limited coping mechanisms and are overwhelmed by the care of their wounds. Second, in this cohort of patients, many had become passive observers of their care as demonstrated by a limited understanding of their disease processes and detachment from wound management. The third theme was how strong the desire to do everything to prevent limb loss was, but patients acknowledged this is hard to translate into real life with limited resources. Patients with CLTI have concerns that vascular providers must recognize and address to build strong patient-provider relationships and increase activation for management of their wounds and other medical conditions. Patients who have access to technology and with guidance may be able to understand getting care through remote medicine.

Change in Domains that Influence Quality of Life after Major Lower Limb Amputation in Patients with Peripheral Arterial Disease

BACKGROUND

Recent guidelines raise the concept of the importance of health-related quality of life (QoL). Change in QoL after amputation in ischemic patients is not well described. We aim to evaluate the change in quality of life after major limb amputation in patients with peripheral arterial disease.

METHODS

We retrospectively identified all patients submitted to above-knee amputation (AKA) and below-knee amputation in our vascular surgery department in a 2-year period. Trauma excluded. A vascular amputee adapted QoL questionnaire was administered comparing the last 2 weeks to the 2 weeks before amputation. It included subjective and objective questions adapted from WHOQoL-BREEF and SF-36 divided into specific domains of QoL (physical health, role physical, pain, social, and psychological health) that were compared to 2 global items (overall QoL and general health). Independent samples tests and linear correlations were calculated.

RESULTS

A total of 106 patients were included, 30-day mortality rate 16.3% and 1-year 39.1%. Patients had an increase in mean total score after amputation of 14.35 out of 100 points, with an improvement of 52.1 points in pain and 11 points in social and psychological health out of 100 (P<0.001). Physical health and role physical scores decreased after amputation. Overall QoL was correlated with total score (P<0.001). Mean QoL total score after amputation was 79.0% ± 12.6. In general, amputees scored higher in the domains social and psychological health. Older people, women, AKA and bilateral amputees had lower physical health scores (P<0.05), prosthesis was correlated with improvement in physical health after amputation (P = 0.026). Elderly and married people had big improvement in overall QoL after amputation (P = 0.008 and P = 0.056, respectively).

CONCLUSIONS

QoL does not seem to diminish in advanced ischemic patients after amputation. Older people value more a decrease in pain and family support over physical health. Therefore, patient oriented treatments should be preferred. Future research should be made to validate a disease-specific questionnaire for this population.

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.

Two-year Outcome of Quality of Life and Health Status for the Elderly with Chronic Limb-threatening Ischemia

Purpose

In elderly patients with chronic limb-threatening ischemia (CLTI), there is little scientific understanding of the long-term changes of quality of life (QoL) and health status (HS) after treatment. The primary goal of this study was to provide long-term QoL and HS results for elderly CLTI patients after therapy. Treatments consisted of endovascular revascularization, surgical revascularization, or conservative treatment. Furthermore, the aim of this study was to identify the distinctive trajectories of QoL and HS.

Patients and Methods

CLTI patients aged ≥70 years were included in a prospective observational cohort study with a two-year follow-up. The WHOQOL-BREF was used to asses QoL. The 12-Item Short Form Health Survey was used to measure HS. The QoL and HS scores were compared to the scores in the general elderly Dutch population. Latent class trajectory analysis was used.

Results

A total of 195 patients were included in this study. After two years, in all treatment groups patients showed significantly higher physical QoL score compared to baseline and there was no significant difference with the corresponding values in the elderly Dutch population. In the latent class trajectory analysis, there were no overlapping risk factors for poorer QoL or HS.

Conclusion

This study shows that QoL levels in surviving elderly CLTI patients in the long-term do not differ from the corresponding values for elderly in the general population. There were no disparities in sociodemographic, clinical and treatment characteristics associated with poorer QoL and HS. This study was carried out to encourage further analysis of the influence of biopsychosocial characteristics on QoL and HS in elderly CLTI patients.

The most important activities of daily functioning: the opinion of persons with lower limb amputation and healthcare professionals differ considerably

The aim of this study is to determine the 15 most important daily activities according to persons with lower limb amputation (LLA) and healthcare professionals. Persons with LLA (n = 125) and healthcare professionals (n = 44) filled in a questionnaire. Participants had to select 10 items out of a list of 40 items on the domains activity and/or participation. Selection criterion was what they considered to be most important to perform independently and order the selected 10 items from most to least important. Mean rank scores of the 15 highest scored items according to participants with LLA were compared with the mean rank scores given by professionals, using the Mann-Whitney U test with a Hochberg adjustment for multiple testing. Participants with LLA rated five activities as significantly more important compared to professionals: 'driving a car', 'bicycling', 'ascending/descending stairs', 'heavy exercise', and 'preparing meals'. Healthcare professionals rated four activities as significantly more important compared to persons with LLA: 'going to the toilet', 'getting in and out bed', 'walking around outdoors', and 'walking around indoors'. A significant difference in rating importance was present in 9 out of 15 activities between persons with LLA and healthcare professionals. This result makes it all the more clear how complex shared decision making can be and how important it is for healthcare professionals to communicate with the person with LLA.

The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia

Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.

The effect of participation in a mobility clinic on self-reported mobility and quality of life in people with lower limb amputation: A pilot study

BACKGROUND

Many people with lower limb amputation experience mobility impairment and reduced quality of life. Mobility clinics are designed to improve mobility and quality of life for people with lower limb amputation, but their effectiveness is unknown.

OBJECTIVES

To compare changes in mobility prior to, and 12 weeks following participation in mobility clinic for people with lower limb amputation, and to explain whether changes in mobility explained changes in quality of life. To determine whether the PLUS-M™ was sensitive to the effects of participation in the mobility clinic, and to estimate the sample size required for a definitive study.

STUDY DESIGN

Longitudinal observational.

METHODS

Electronic versions of the PLUS-M and SF-36v2^® were completed by people living in the community with lower limb amputation prior to, and 12 weeks following participation in a mobility clinic.

RESULTS

There was a significant increase in mobility from baseline to 12 weeks post participation in the clinic (p = 0.012). Changes in mobility explained a significant proportion of variance in the SF-36v2 mental component summary (p = 0.024) but not the physical component summary (p = 0.804).

CONCLUSION

For people with lower limb amputation, mobility increased after participation in the clinic and this explained improvements in SF-36v2 mental component summary. The PLUS-M was sensitive enough to detect a change in mobility over time.

CLINICAL RELEVANCE

This preliminary data indicated that participation in a mobility clinic improved mobility and the mental components of quality of life for people living with lower limb amputation. The PLUS-M™ seems sensitive to changes in mobility as a result of participation in a mobility clinic.

Sex-Related Differences in the Outcomes of Endovascular Interventions for Chronic Limb-Threatening Ischemia: Results from the LIBERTY 360 Study

INTRODUCTION

Previous studies have suggested that women with chroniclimb-threatening ischemia (CLTI) may have worse outcomes than men. The aim of this study was to determine whether there are sex-related differences in outcomes of patients with CLTI undergoing endovascular treatment with current endovascular technologies.

PATIENTS AND METHODS

Data were derived from the LIBERTY 360 study (NCT01855412). Hazard ratios and the respective 95% confidence intervals were synthesized to examine the association between sex and all-cause mortality, target vessel revascularization (TVR), major amputation, major adverse event (MAE) and major amputation/death up to 3 years of follow-up.

RESULTS

A total of 689 patients with CLTI (female: N=252 vs male: N=437) treated with any FDA approved or cleared device were included. The mean lesion length was 126.9±117.3mm and 127.4±113.3mm for the female and male patients, respectively. Although a slightly higher incidence of in-hospital mortality was observed in the female group (1.2% vs 0.0%, p=0.049), there was no difference in female vs male survival rates during follow-up. However, the risk of major amputation at 18 months was higher for the male group (male vs female: HR: 2.36; 95% CI: 1.09-5.12; p=0.030). No difference between the two groups was detected in terms of TVR or MAE during follow-up.

DISCUSSION

Data regarding sex-related disparity in outcomes after endovascular therapy of patients with CLTI are conflicting. Gender-related characteristics rather than biological sex characteristics might be the cause of these conflicting findings. Further studies are needed to evaluate the role of sex in revascularization outcomes among this high-risk population.

Mobility Analysis of AmpuTees (MAAT 6): Mobility, Satisfaction, and Quality of Life among Long-Term Dysvascular/Diabetic Prosthesis Users-Results of a Cross-Sectional Analysis

Objective

The aim of this study was to establish the mobility, satisfaction, and quality of life (QoL) among prosthesis users with dysvascular/diabetic amputation at both acute and long-term phases of prosthetic rehabilitation.

Methods

This is a multisite, cross-sectional outcomes analysis. A total of 341 individuals met the inclusion/exclusion criteria. Individuals were grouped into acute phases (0–3 months [n = 24], 4–6 months [n = 72]) and chronic phases (24–36 months [n = 91], 37–48 months [n = 53], 49–60 months [n = 47], and 60–84 months [n = 54]) after amputation. Mobility was measured with the Prosthetic Limb Users Survey of Mobility (PLUS-M), whereas QoL and satisfaction (Sat) were reported using 10-point scales adapted from the Prosthesis Evaluation Questionnaire–Well-Being (PEQ-WB). Composite PEQ-WB scores were also compared.

Results

The average mobility, QoL, and Sat among prosthesis users was, respectively, 44.8 ± 10.6, 7.6 ± 2.2, and 7.6 ± 2.2. There were no observed differences in mobility (F_5,330 = 1.52, P = 0.18), QoL (F_5,333 = 0.78, P = 0.57), or PEQ-WB (F_5,335 = 1.618, P = 0.155) between any groups. For Sat, there was a group difference (F_5,334 = 2.44, P = 0.03) as individuals appear to experience an initial increase in Sat with receipt of a prosthesis (0–3 months) compared with 25 to 36 months (P = 0.005), 49 to 60 months (P = 0.008), and 61 to 84 months (P = 0.009).

Conclusions

Those individuals with amputation secondary to dysvascular disease and diabetes who continue to participate in prosthetic rehabilitation appear to experience levels of mobility, Sat, and QoL 7 years after amputation comparable to that reported in the first 6 months postamputation. There may be a modest increase in Sat with receipt of an initial prosthesis, potentially due to an increased optimism for one's situation. Notably, the mobility levels observed in the dysvascular population through a range of long-term postamputation periods remain within a single standard deviation of the population mean for individuals with a lower-limb amputation using a prosthesis for mobility.

Quality of life of patients with lower limb amputation with prostheses

Abstract Quality of life is often acknowledged as an important outcome of rehabilitation programs for people with amputation. Despite the importance of the subject, the number of studies focusing on the multiplicity of factors influencing this matter is still limited. These assessments are increasingly needed to demonstrate changes related to intervention over time. In order to evaluate the quality of life of patients with lower limb amputation and wearing prostheses, a study was conducted with 49 patients followed in a rehabilitation hospital in the Midwest region of Brazil. A generic instrument (Medical Outcomes Study 36-Item Short-Form Health Survey) for quality of life assessment and Trinity Amputation and Prosthesis Experience Scale-Revised that is specific for people with amputation were used in addition to a functional assessment measure. The results showed that the time since amputation, male gender and below-knee amputations were predictors of a better perception of quality of life and better adjustment to amputation.

Percutaneous Vascular Interventions Versus Bypass Surgeries in Patients With Critical Limb Ischemia: A Comprehensive Meta-analysis

OBJECTIVE

The aim of our study was to compare percutaneous vascular interventions (PVI) versus bypass surgeries (BSX) in patients with critical limb ischemia (CLI).

BACKGROUND

Previous relevant reviews with limited numbers of included studies did not strictly confine the inclusion criteria to CLI, also involving patients with severe claudication, which may introduce bias in the decision-making of CLI revascularization. Current treatment strategies for CLI still remain controversial.

METHODS

We performed a meta-analysis of all available randomized controlled trials and observational clinical studies comparing PVI with BSX in CLI patients. Primary endpoints included overall survival, amputation-free survival, 30-day mortality, and major adverse cardiovascular and cerebrovascular events.

RESULTS

We identified 45 cohorts and 1 RCT in over 20,903 patients. In overall population, PVI reduced the risks of 30-day mortality [odds ratio (OR) 0.69, 95% confidence interval (CI) 0.51-0.95), major adverse cardiovascular and cerebrovascular events (OR 0.42, 95% CI 0.29-0.61), and surgical site infection (OR 0.31, 95% CI 0.19-0.51), but increased the risks of long-term all-cause mortality [hazard ratio (HR) 1.16, 95% CI 1.05-1.27) and primary patency failure (HR 1.31, 95% CI 1.08-1.58). When compared with autogenous BSX, PVI was also associated with additional increased risks of long-term death or amputation (HR 1.41, 95% CI 1.02-1.94) and secondary patency failure (HR 1.51, 95% CI 1.17-1.95). In patients with infrapopliteal lesions, we found PVI had inferior primary patency (HR 1.39, 95% CI 1.10-1.75) compared with BSX.

CONCLUSION

For patients in good physical condition with long life-expectancy, BSX may represent a better choice compared with PVI, particularly when autogenous bypass is available. While enhanced perioperative care for cardiovascular events and surgical site should be considered in patients underwent BSX to achieve comparable short-term outcomes provided by PVI.

Is amputation in the elderly patient with critical limb ischemia acceptable in the long term?

Purpose

Despite high amputation rates, data on patient-reported outcomes is scarce in the elderly population with critical limb ischemia. The aim of this study was to provide mortality rates and long-term changes of the following patient-reported outcomes in elderly critical limb ischemia amputees: quality of life (QoL), health status (HS), and symptoms of depression.

Patients and methods

In this prospective observational cohort study, amputated critical limb ischemia patients ≥70 years were included. The follow-up period was two years. Within the follow-up period patients completed the following questionnaires: the World Health Organization Quality Of Life -abbreviated version of the WHOQOL 100 (WHOQOL-BREF), the 12-Item Short Form Health Survey, and the Center for Epidemiological Studies Depression Scale.

Results

A total of 49 elderly patients with critical limb ischemia had undergone major limb amputation within two years after inclusion. In these patients, the one-year mortality rate was 39% and the two-year mortality rate was 55%. The physical QoL was the only domain of the WHOQOL-BREF that improved significantly across time after amputation (p≤0.001). In the long-term, there was no difference in the ability to enjoy life (p=0.380) or the satisfaction in performing daily living activities (p=0.231) compared to the scores of the general elderly population. After amputation, the physical HS domain (p≤0.001) and the mental HS domain (p=0.002) improved. In the first year, amputees experienced less symptoms of depression (p=0.004).

Conclusion

Elderly critical limb ischemia amputees are a fragile population with high mortality rates. Their QoL and HS increased after major limb amputation as compared to the baseline situation and they experienced less symptoms of depression. Moreover, our results show that, in the long-term, major limb amputation in the elderly patients with critical limb ischemia shows an acceptable QoL, which, in some aspects, is comparable to the QoL of their peers. These results can improve the shared-decision making process that does not delay the timing of major limb amputation.

Predicting reamputation risk in patients undergoing lower extremity amputation due to the complications of peripheral artery disease and/or diabetes

Background

Patients undergoing amputation of the lower extremity for the complications of peripheral artery disease and/or diabetes are at risk of treatment failure and the need for reamputation at a higher level. The aim of this study was to develop a patient-specific reamputation risk prediction model.

Methods

Patients with incident unilateral transmetatarsal, transtibial or transfemoral amputation between 2004 and 2014 secondary to diabetes and/or peripheral artery disease, and who survived 12 months after amputation, were identified using Veterans Health Administration databases. Procedure codes and natural language processing were used to define subsequent ipsilateral reamputation at the same or higher level. Stepdown logistic regression was used to develop the prediction model. It was then evaluated for calibration and discrimination by evaluating the goodness of fit, area under the receiver operating characteristic curve (AUC) and discrimination slope.

Results

Some 5260 patients were identified, of whom 1283 (24·4 per cent) underwent ipsilateral reamputation in the 12 months after initial amputation. Crude reamputation risks were 40·3, 25·9 and 9·7 per cent in the transmetatarsal, transtibial and transfemoral groups respectively. The final prediction model included 11 predictors (amputation level, sex, smoking, alcohol, rest pain, use of outpatient anticoagulants, diabetes, chronic obstructive pulmonary disease, white blood cell count, kidney failure and previous revascularization), along with four interaction terms. Evaluation of the prediction characteristics indicated good model calibration with goodness-of-fit testing, good discrimination (AUC 0·72) and a discrimination slope of 11·2 per cent.

Conclusion

A prediction model was developed to calculate individual risk of primary healing failure and the need for reamputation surgery at each amputation level. This model may assist clinical decision-making regarding amputation-level selection.

Hip extension power and abduction power asymmetry as independent predictors of walking speed in individuals with unilateral lower-limb amputation

BACKGROUND

Preferred walking speed (PWS) is an indicator of walking ability, prosthetic walking potential, and function following a lower-limb amputation (LLA). There is a link between lower-limb muscle performance and PWS in individuals with LLA. However, the ability of select hip muscle performance parameters to determine PWS in these individuals still needs to be thoroughly investigated.

RESEARCH QUESTION

Which hip muscle and joint torque parameters best determine PWS in persons with LLA?

METHODS

Seventeen patients with LLA (6 transfemoral, 4 knee disarticulation, and 7 transtibial; 16 men, 1 woman; mean age ± standard deviation, 56 ± 15yr) participated in this cross-sectional study. Maximal joint torque and power were evaluated unilaterally, for both amputated and intact limbs, in isometric and isokinetic conditions during hip flexion/extension (60°/s and 180°/s) and abduction/adduction (30°/s and 90°/s). PWS was measured at habitual walking speed over a 10-m distance. Pearson's correlation coefficient was used to verify the degree of association between each torque parameter and PWS and multiple regression analysis was performed to identify the best predictors of PWS. The level of significance was p < 0.05.

RESULTS

Correlations between hip muscle performance parameters and PWS were found in most cases (r = 0.51-0.82; p ≤ 0.036-0.0005). The multiple regression model revealed that the best independent predictors of PWS were hip extension power at 180°/s on the amputated side (r² = 0.672; p < 0.0005) and the asymmetry of hip abduction power at 30°/s (r² = -0.147; p < 0.008), accounting together for 82% of the variance in PWS.

SIGNIFICANCE

Lesser hip extension power on the amputated side and greater hip abduction power asymmetry between limbs are detrimental to PWS in persons with LLA. These muscle groups and performance parameters should be considered during gait rehabilitation to assist individuals with LLA in achieving functional waking speed.

Relationship between body image and physical functioning following rehabilitation for lower-limb amputation

The aim of the present study was to evaluate change in body image and the association between body image at discharge and mobility 4 months after rehabilitation. A prospective cohort comprising adults older than or equal to 50 years of age undergoing rehabilitation for first major lower-limb amputation at an inpatient prosthetic rehabilitation program were assessed at discharge and 4 months after rehabilitation. Paired t-tests compared total Amputee Body Image Scale (ABIS), gait velocity, and L-test scores between discharge (T1) and 4 months (T2). Multivariable linear regression assessed relationship between ABIS scores and mobility. Nineteen participants completed assessments (mean±SD age=60.86±6.85 years; 63.20% male patients). Body image changed from T1 (43.58±7.83) to T2 (48.26±12.21), but was not statistically significant (P=0.063). Mobility significantly improved at T2. ABIS scores at T1 were not associated with mobility at T2. Mobility improved after discharge but was not related to body image at T1. Additional research on the impact of body image perception on patient outcomes after rehabilitation is needed.

Mortality prediction following non-traumatic amputation of the lower extremity

BACKGROUND

Patients who undergo lower extremity amputation secondary to the complications of diabetes or peripheral artery disease have poor long-term survival. Providing patients and surgeons with individual-patient, rather than population, survival estimates provides them with important information to make individualized treatment decisions.

METHODS

Patients with peripheral artery disease and/or diabetes undergoing their first unilateral transmetatarsal, transtibial or transfemoral amputation were identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Stepdown logistic regression was used to develop a 1-year mortality risk prediction model from a list of 33 candidate predictors using data from three of five Department of Veterans Affairs national geographical regions. External geographical validation was performed using data from the remaining two regions. Calibration and discrimination were assessed in the development and validation samples.

RESULTS

The development sample included 5028 patients and the validation sample 2140. The final mortality prediction model (AMPREDICT-Mortality) included amputation level, age, BMI, race, functional status, congestive heart failure, dialysis, blood urea nitrogen level, and white blood cell and platelet counts. The model fit in the validation sample was good. The area under the receiver operating characteristic (ROC) curve for the validation sample was 0·76 and Cox calibration regression indicated excellent calibration (slope 0·96, 95 per cent c.i. 0·85 to 1·06; intercept 0·02, 95 per cent c.i. -0·12 to 0·17). Given the external validation characteristics, the development and validation samples were combined, giving a total sample of 7168.

CONCLUSION

The AMPREDICT-Mortality prediction model is a validated parsimonious model that can be used to inform the 1-year mortality risk following non-traumatic lower extremity amputation of patients with peripheral artery disease or diabetes.