Physical activity behavior change for older veterans after dysvascular amputation

Emerging Technologies and Open-Source Platforms for Remote Physical Exercise: Innovations and Opportunities for Healthy Population-A Narrative Review

The emergence of tele-exercise as a response to the impact of technology on physical activity has opened up new possibilities for promoting physical health. By integrating innovative technologies and open-source platforms, tele-exercise encourages people to stay active. In our latest analysis, we delved into the scientific literature surrounding the use of tele-exercise technologies in training healthy individuals. After conducting an extensive search on the PubMed database using the keywords "tele-exercise" and "physical activity" (from 2020 to 2023), we identified 44 clinical trials that were applicable to tele-exercise, but less than 10% of them were aimed at healthy individuals, precisely 9.09% (four out of forty-four studies analyzed). Our review highlights the potential of tele-exercise to help maintain physical fitness and psychological well-being, especially when traditional fitness facilities are not an option. We also underscore the importance of interoperability, standardization, and the incorporation of biomechanics, exercise physiology, and neuroscience into the development of tele-exercise platforms. Nevertheless, despite these promising benefits, research has shown that there is still a significant gap in the knowledge concerning the definition and evaluation of training parameters for healthy individuals. As a result, we call for further research to establish evidence-based practices for tele-exercise in the healthy population.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Use of Physical Activity Measures in Rehabilitation Interventions Following Lower Extremity Amputation

Purpose of Review

This systematic review aims to evaluate physical performance outcome tools that are used most frequently to assess rehabilitation interventions. The scope of this paper focused on outcomes used with established lower limb amputees when assessing interventions such as exercise programs or changes in prescription published in the last 5 years.

Recent Findings

The most recorded outcome measures used across all the papers were timed walk tests and the Activity Balance Confidence Scale. Many outcomes did not produce statistically significant results with established amputee cohorts. Understanding the minimal important clinical difference is key.

Summary

The use of outcome measures is essential. Training and education are likely to increase the use of outcome measures. Quality of life measures are important in conjunction with physical outcomes. Simple timed walk tests are commonly used. These are in general easy to administer requiring a small space, limited equipment, and a short time frame.

Telerehabilitation for Amputee Care

Patients with amputation have unique characteristics and needs that must be considered when services are being provided through a virtual platform. The types of amputation rehabilitation services that can be provided virtually are numerous and vary from a full clinical team evaluation to individual therapy services. Whether services are being provided in person or through a virtual platform, rehabilitation of the person with amputation ideally involves a collaborative interdisciplinary team. The potential benefits of providing amputation rehabilitation care through a virtual platform include enhanced access to specialized services, reduced travel burden, and improved continuity of care.

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

INTRODUCTION

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

OBJECTIVE

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

DESIGN

Secondary data analysis from two randomized controlled trials.

SETTING

Outpatient setting.

PARTICIPANTS

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

INTERVENTION

None.

OUTCOME

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

Veterans Administration Medical Center.

PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Transcriptomic analysis of bone and fibrous tissue morphogenesis during digit tip regeneration in the adult mouse

Humans have limited regenerative potential of musculoskeletal tissues following limb or digit loss. The murine digit has been used to study mammalian regeneration, where stem/progenitor cells (the "blastema") completely regenerate the digit tip after distal, but not proximal, amputation. However, the molecular mechanisms responsible for this response remain to be determined. Here, we evaluated the spatiotemporal formation of bone and fibrous tissues after level-dependent amputation of the murine terminal phalanx and quantified the transcriptome of the repair tissue. Distal (regenerative) and proximal (non-regenerative) amputations showed significant differences in temporal gene expression and tissue regrowth over time. Genes that direct skeletal system development and limb morphogenesis are transiently upregulated during blastema formation and differentiation, including distal Hox genes. Overall, our results suggest that digit tip regeneration is controlled by a gene regulatory network that recapitulates aspects of limb development, and that failure to activate this developmental program results in fibrotic wound healing.

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

BACKGROUND

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

METHODOLOGY

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

FINDINGS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

Cross-sectional, secondary data analysis.

SETTING

Outpatient rehabilitation facilities.

PARTICIPANTS

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

METHODS

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

PRIMARY OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

III.

Prosthetic rehabilitation for older dysvascular people following a unilateral transfemoral amputation

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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