A prospective study of short-term functional outcome after dysvascular major lower limb amputation

Risk factors for readmission of patients with amputation to acute care from inpatient rehabilitation: A retrospective cohort study

INTRODUCTION

Amputation is a major condition that requires inpatient rehabilitation. Some research has been conducted to explore the risk factors for readmission of patients from inpatient rehabilitation facilities to acute care hospitals. However, few studies have included patients with amputation in the study population.

OBJECTIVE

To identify the risk factors for readmission of patients with amputation to acute care hospitals from an inpatient rehabilitation facility.

DESIGN

Retrospective cohort study.

SETTING

An acute rehabilitation hospital associated with a community-based tertiary medical center.

PATIENTS

A retrospective review of 156 independent admissions of 145 patients from June 2019 to July 2022.

MAIN OUTCOME MEASURE

The study outcome measure was readmission to acute care from an acute rehabilitation unit.

RESULTS

Of the 156 independent admissions, the readmission rate was 19% (29/156). The most common cause of transfer was incision-site complications (9/29, 31%), including wound infection and wound dehiscence. Patients with amputation readmitted to acute care are more likely to be receiving dialysis (p < .001), have a longer length of stay in acute care before admission to the rehabilitation facility (p = .039), and have a lower Section GG score on admission (p < .001). Age, sex, ethnicity, amputation level, and history of diabetes mellitus were not associated with acute care hospital readmission. The logistic regression model revealed that patients being on dialysis was the only significant risk factor predictive of readmission to acute care (odds ratio [OR] 4.82, p = .006).

CONCLUSIONS

This study showed that incision-site complications were the most common cause of disruption in inpatient rehabilitation via acute hospital readmission in patients with amputation. Being on dialysis was associated with a higher risk of readmission to acute care hospitals. Based on the results of this study, specific rehabilitation plans might be required for patients with amputation who carry certain risk factors to reduce rehospitalization to the acute care unit.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

ADVERSE EVENTS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

On some paleopathological examples of amputation and the implications for healthcare in 13th-17th century Lithuania

OBJECTIVE

To explore care that was likely provided to an adult male amputee from medieval Lithuania, positioning analysis within what is known of contemporary amputation practices.

MATERIALS

Three sets of skeletal remains with evidence for amputation, dating to between the 13th-17th centuries AD and recovered during different archaeological excavations in Vilnius, Lithuania.

METHODS

Macroscopic inspection of lesions, with additional X-ray analysis of the main subject. The Index of Care was used to investigate possible caregiving.

RESULTS

Two individuals experienced amputation of a single element, and the third experienced bilateral hand amputation. Only one individual displayed healing. Historic sources suggest use of amputation for punitive purposes during this period, and judicial punishment is proposed as the most likely reason for amputation in at least two cases.

CONCLUSIONS

Evidence of long-term healing in one individual suggests receipt of care. This individual likely relied on family and/or community members for survival immediately following amputation, and subsequently for support in managing disability.

SIGNIFICANCE

Successfully combining osteology with history in a framework for analyzing care provision in past Eastern European society, this study underlines the critical importance of context in undertaking bioarchaeology of care analyses. It also adds two examples of perimortem abscissions in this region to the paleopathological record.

LIMITATIONS

Our approach relied on skeletal interpretation. Soft tissue was lost to decomposition and no relevant archaeological evidence was found in association with the remains.

SUGGESTIONS FOR FURTHER RESEARCH

A review of skeletal collections may allow identification of overlooked cases of amputation (and care).

A low-cost easily implementable physiotherapy intervention clinically improves gait implying better adaptation to lower limb prosthesis: a randomized clinical trial

Lower limb amputation highly impacts the lives of individuals. The inability to walk due to difficulties in adapting to wearing prosthesis can potentially result in physical degeneration and comorbidity in this population. In this randomized clinical trial study, we investigated if a low-cost and easily implementable physiotherapy intervention was effective in improving gait performance and adaptation to lower limb prosthesis in individuals with an amputation. A total of 26 individuals participated in the study, 16 with lower limb amputation and 10 without amputation. Participants with amputation were further divided in intervention and control groups. The intervention group underwent a rehabilitation protocol aimed at strengthening muscles and improving prosthesis adaptation. Muscle strengthening targeted the hip segment, prioritizing the abdominal muscles, hip flexors, extensors, adductors and abductors, followed by cicatricial mobilization and weight-bearing on the stump for desensitization. Assessment and measures were performed across the kinetic and kinematic parameters of gait. In the comparison between pre-and post-intervention, a significant increase in gait speed (0.68—2.98, 95% CI, 1.83, effect size ES) and cadence (0.56—2.69, 95% CI, 1.63, ES) was found between groups and time points. Step (0.73—3.11, 95% CI, 1.92, ES) and stride length (0.62—2.84, 95% CI, 1.73) increased between pre- and post-intervention, while in the control group both variables remained smaller. The intervention group decreased stance phase as a percentage of gait cycle between pre- and post-intervention (− 1.33—0.62, 95% CI, − 36, ES), while it increased in the control group. Improvement in a combination of important gait parameters indicates that the intervention protocol promoted the adaptation to prosthesis and the functional independence of individuals with lower limb amputation. It is recommended that the participants continue receiving follow-up assessments and rehabilitation interventions.

Stakeholder Values and Preferences in Lower Limb Amputation for No-Option Chronic Limb Threatening Ischemia

PURPOSE

This study focusses on identifying values and preferences of patients, caregivers and healthcare professionals who have dealt with lower limb amputation for no-option chronic limb threatening ischemia. No-option chronic limb threatening ischemia is defined as limb ischemia for which no treatment options exist and where lower limb amputation is necessary in the short term. The values and preferences identified in this study can help improve decision-making processes.

PATIENTS AND METHODS

This was a qualitative study, using semi-structured interviews to gather data from patients, caregivers and healthcare professionals. Participants were selected from the patient and employee population of an academic medical center in The Netherlands. Nine patients and seven caregivers who dealt with lower limb amputation for no-option chronic limb threatening ischemia six to twelve months prior to the interview and were not cognitively impaired were selected. Nine healthcare professionals dealing with patients with no-option chronic limb threatening ischemia and lower limb amputation were selected.

RESULTS

Lower limb amputation was explicitly discussed late in the disease process, sometimes during an emergency setting. Patients stated goals were never discussed, healthcare professionals stated they were. The most important goal for patients was to live independently after lower limb amputation. Patients and caregivers feel healthcare professionals should be upfront about the possible necessity of lower limb amputation. Reasons to undergo lower limb amputation were absence of treatment options, pain and wanting to enjoy life again. Participants indicated accelerating lower limb amputation was not a viable option.

CONCLUSION

All stakeholders reported overlapping values and preferences regarding main reasons for lower limb amputation, the primary goals after lower limb amputation, and the absence of a desire to accelerate lower limb amputation. The main difference in values and preferences is the preferred timing of discussing lower limb amputation.

Effectiveness of an Evidence-Based Amputee Rehabilitation Program: A Pilot Randomized Controlled Trial

BACKGROUND

Despite the prevalence of lower limb amputation (LLA), only a small percentage of people with LLA actually receive physical therapy post amputation and are rehabilitated to their full potential level of function. There is a need for the development of a rehabilitation program that targets impairments and limitations specific to people with LLA.

OBJECTIVE

The objective of this study was to determine whether the Evidence-Based Amputee Rehabilitation program would improve functional mobility of people with unilateral transtibial amputation (TTA) who have already completed physical therapy and prosthetic training.

DESIGN

This study was a randomized, wait-list control, single-blinded pilot clinical trial.

SETTING

This study researched participants who had received postamputation rehabilitation to varying degrees, either in an inpatient and/or outpatient settings.

PARTICIPANTS

The participants in this study included veterans and nonveterans with unilateral TTA due to dysvascular disease and trauma.

INTERVENTION

This study included a prescription-based rehabilitation program for people with amputations.

MEASUREMENTS

Results were measured with The Amputee Mobility Predictor with (AMPPro) and without a prosthesis (AMPnoPro) and 6-Minute Walk Test (6MWT) at baseline and at the end of the 8-week intervention.

RESULTS

The intervention group improved on the AMPPro scores (36.4 to 41.7), AMPnoro scores (23.2 to 27.1), and 6MWT distance (313.6 to 387.7 m). The effect size for the intervention was very large (1.32). In contrast, the wait-list control group demonstrated no change in AMPPro scores (35.3 to 35.6), AMPnoPro scores (24.7 to 25.0), and 6MWT distance (262.6 m to 268.8 m).

LIMITATIONS

The sample size was small. A total 326 potential candidates were screened with 306 unable to meet inclusion criteria or unwilling to participate.

CONCLUSION

People with unilateral TTA who received Evidence-Based Amputee Rehabilitation program demonstrated significant improvement in functional mobility, with most participants (66.7%) improved at least 1 K-level (58.3%) and greater than the minimal detectable change (66.7%).

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.