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Johansson R, Jensen L, Barnett CT, Rusaw DF. Quantitative methods used to evaluate balance, postural control, and the fear of falling in lower limb prosthesis users: A systematic review. Prosthet Orthot Int 2023; 47:586-598. [PMID: 37318276 DOI: 10.1097/pxr.0000000000000250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 04/23/2023] [Indexed: 06/16/2023]
Abstract
Problems with balance, postural control, and fear of falling are highly prevalent in lower limb prosthesis users, with much research conducted to understand these issues. The variety of tools used to assess these concepts presents a challenge when interpreting research outcomes. This systematic review aimed to provide a synthesis of quantifiable methods used in the evaluation of balance, postural control, and fear of falling in lower limb prosthesis users with an amputation level at or proximal to the ankle joint. A systematic search was conducted in CINAHL, Medline, AMED, Cochrane, AgeLine, Scopus, Web of Science, Proquest, PsycINFO, PsycArticles, and PubPsych databases followed by additional manual searching via reference lists in the reviewed articles databases. Included articles used quantitative measure of balance or postural control as one of the dependent variables, lower limb prosthesis users as a sample group, and were published in a peer-reviewed journal in English. Relevant assessment questions were created by the investigators to rate the assessment methods used in the individual studies. Descriptive and summary statistics are used to synthesize the results. The search yielded (n = 187) articles assessing balance or postural control (n = 5487 persons in total) and (n = 66) articles assessing fear of falling or balance confidence (n = 7325 persons in total). The most used test to measure balance was the Berg Balance Scale and the most used test to measure fear of falling was the Activities-specific Balance Confidence scale. A large number of studies did not present if the chosen methods were valid and reliable for the lower limb prosthesis users. Among study limitations, small sample size was common.
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Affiliation(s)
- Robin Johansson
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
| | - Louise Jensen
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
- Southern Älvsborg Hospital, Borås, Sweden
| | - Cleveland T Barnett
- School of Science and Technology, Nottingham Trent University, Nottingham, United Kingdom
| | - David F Rusaw
- School of Health and Welfare, Jönköping University, Jönköping, Sweden
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Wong CK, Vandervort EE, Moran KM, Adler CM, Chihuri ST, Youdan GA. Walking asymmetry and its relation to patient-reported and performance-based outcome measures in individuals with unilateral lower limb loss. Int Biomech 2022; 9:33-41. [PMID: 36414237 PMCID: PMC9704090 DOI: 10.1080/23335432.2022.2142160] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Gait asymmetry persists for most people after lower limb amputation and is associated with slower walking speeds. However, the relationship between gait asymmetry and patient-reported function remains unclear because they are not commonly assessed together. The purpose of this study was to determine relationships between gait asymmetries in people with lower limb loss and (1) patient-reported outcomes and (2) performance-based prosthetic functional measures. This cross-sectional analysis included nine people with unilateral limb loss aged 48.2 ± 13.1 years of mixed amputation etiology. Patient-reported outcomes included the Prosthetic Evaluation Questionnaire mobility subscale and Activities-specific Balance Confidence scale. Performance outcomes included the Berg Balance Scale and the 30-second sit-to-stand test. Walking performance measures included the 2-Minute Walk Test, during which APDM Opal sensors recorded spatiotemporal gait parameters, and daily step-counts from StepWatch4 activity monitors. The study found that the most asymmetric gait symmetry ratios (prosthetic-limb divided by intact-limb) could be attributed to prosthetic foot dorsiflexion-plantarflexion and rotation motion limitations: prosthetic-limb trailing double support (0.789 ± 0.052), toe-off (0.760 ± 0.068) and toe-out angle (0.653 ± 0.256). Single limb stance, and stance and swing phase durations were most strongly associated with balance and walking performance measures. Notably, no symmetry ratio was significantly associated with patient-reported prosthetic function (unadjusted Pearson correlation coefficients r < 0.50, P > 0.05). More gait symmetry was associated with better balance and walking performance but had no significant relationship with patient-reported function. Although achieving gait symmetry after lower limb loss is a common walking goal, symmetry was unrelated to the perception of functional mobility for people with lower limb loss.
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Affiliation(s)
- Christopher K. Wong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA,CONTACT Christopher K. Wong Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, 617 West 168th St, Georgian-311, New York, NY10032, USA
| | | | - Kayla M. Moran
- Program in Physical Therapy, Columbia University, New York, NY, USA
| | - Carly M. Adler
- Program in Physical Therapy, Columbia University, New York, NY, USA
| | - Stanford T. Chihuri
- School of Public Health, Columbia University Irving Medical Center, New York, NY, USA
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Cimino SR, Vijayakumar A, MacKay C, Mayo AL, Hitzig SL, Guilcher SJT. Sex and gender differences in quality of life and related domains for individuals with adult acquired lower-limb amputation: a scoping review. Disabil Rehabil 2022; 44:6899-6925. [PMID: 34546799 DOI: 10.1080/09638288.2021.1974106] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE To understand what is known about sex and gender differences in quality of life (QoL) and related domains for individuals with an adult acquired lower limb amputation (LLA). METHODS A computer-assisted literature search of four online databases was completed. Articles were included if they incorporated sex or gender as part of their data analysis with a focus on QoL-related domains. Data were analyzed using descriptive numerical analysis and thematic analysis. RESULTS One hundred and eleven articles were included in this review. Women were under-represented across studies, with most of the participants being men. No articles described the inclusion of trans or non-binary persons. Differences by sex or gender were reported by 66 articles. Articles reporting on gender seldom provided descriptions of how gender was defined. Overall, women/females seemed to have worse outcomes in terms of prosthesis-related outcomes, mental health, and return to occupations. CONCLUSION Articles included in this review were not clear with how gender was defined. In order for more targeted interventions that account for sex and gender differences, studies need to be more forthcoming about how they use and define gender. Future research should seek to include gender non-conforming participants to identify additional needs.Implications for rehabilitationSex and gender are important constructs that influence outcomes following lower limb amputation.Rehabilitation professionals should consider sex and gender-specific outcomes when tailoring programs to ensure ethical clinical care.
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Affiliation(s)
- Stephanie R Cimino
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | | | - Crystal MacKay
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,West Park Health Care Centre, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Amanda L Mayo
- St. John's Rehabilitation Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Physical Medicine and Rehabilitation, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sander L Hitzig
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,St. John's Rehabilitation Research Program, Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Canada.,Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sara J T Guilcher
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada
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Youdan GA, Chihuri ST, Wong CK. Preliminary analysis of reliability and validity of the Life Space Questionnaire as a real-world mobility measure for people with lower limb loss: A technical note. Prosthet Orthot Int 2022; 46:491-495. [PMID: 36215058 PMCID: PMC9551355 DOI: 10.1097/pxr.0000000000000148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 03/23/2022] [Indexed: 02/03/2023]
Abstract
People with lower-limb loss (PLL) often have reduced mobility that translates into limited community access. The Life Space Questionnaire (LSQ) measures a person's real-world mobility within their home environment and community but has not been used among PLL. This study assessed preliminary LSQ test-retest reliability and discriminant validity from subjective and objective balance and walking measures in PLL. In addition, LSQ was hypothesized to have an inverse association with overall health status. Nine subjects were analyzed with mean age 48.2 ± 13.1 years and 4.8 ± 3.9 years' time since amputation. Six had transtibial and three had transfemoral amputations due to diabetes (4), vascular disease (3), and trauma (2). The primary outcome was the LSQ, a 9-level scale quantifying the extent to which people accessed their life space including home, yard, and community. Test-retest reliability for the LSQ was moderate (intraclass coefficient = 0.61 with 90% confidence interval: 0.19-0.87). Discriminant validity from balance and walking function was demonstrated by lack of correlation between LSQ score and the Activities-specific Balance Confidence and Berg Balance Scale and the Prosthetic Evaluation Questionnaire mobility subscale and walking speed (r < 0.50, P > .05). LSQ correlated with health status assessed with the Charlson Comorbidity Index (r = -0.84, P = .005). In this sample of PLL, the LSQ demonstrated moderate test-retest reliability as a measure of real-world mobility distinct as a construct from subjective and objective balance or walking measures. People may access their communities using various levels of assistance and methods of transportation. For this sample of PLL, health status was most strongly associated with LSQ score.
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Affiliation(s)
- Gregory A Youdan
- Columbia University, Teacher's College, New York, NY, USA
- Currently with Brown University, Providence, RI, USA
| | | | - Christopher K Wong
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Chihuri ST, Youdan GA, Wong CK. Quantifying the risk of falls and injuries for amputees beyond annual fall rates-A longitudinal cohort analysis based on person-step exposure over time. Prev Med Rep 2022; 24:101626. [PMID: 34976679 PMCID: PMC8683996 DOI: 10.1016/j.pmedr.2021.101626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/24/2021] [Accepted: 10/30/2021] [Indexed: 12/21/2022] Open
Abstract
People with lower-limb loss even with community walking ability have high annual fall and injury rates. True fall and injury risk may be obscured if exposure to risk measured by person-steps over time is not considered. Risk was higher for amputees with limited walking ability per person-step exposure over time. Incorporating person-step exposure over time clarifies fall and injury risk level.
People with lower-limb loss (PLL) have high annual fall and injury rates. People with transtibial amputations have better walking function than those with transfemoral amputations but paradoxically incur more fall-related injuries. Risk exposure, however, has not been previously considered. This study examined whether all-cause fall and injury incidence per person-step exposure over time varied in PLL of different walking abilities. The prospective cohort design, conducted at a major medical center, included five assessments 1-month apart. Walking ability level was categorized by Houghton Scale scores: ≥9 indicating community walking and ≤ 8 indicating limited community-household walking. Accelerometer-measured daily step counts were collected via StepWatch4 monitors. The main outcome measures, self-reported all-cause falls and injuries were assessed using the standard National Health Injury Survey. Generalized estimating equations, using Poisson distributions and log of step count as an offset, determined fall and injury incidence rate ratio [IRR] according to walking ability level. Ten people, aged 33–63 years with amputations of different causes and levels, were assessed monthly over five months. The community walking group (n = 6) had six falls and seven injuries; the limited community walking group (n = 4) had four falls and three injuries. For PLL, limited community walking ability was associated with higher incidence of falls (IRR = 6.10, 95%CI = 1.12–33.33, p = 0.037) and injuries (IRR = 8.56, 95%CI = 1.73–42.40, p = 0.009) when accounting for person-steps. Considering per person-step exposure over time added precision to fall and injury risk assessment that clarified the risks: PLL with limited community walking ability have higher fall and injury risks.
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Affiliation(s)
- Stanford T Chihuri
- Columbia University, Mailman School of Public Health, 722 West 168 Street, New York, NY 10032, USA
| | - Gregory A Youdan
- Teachers College Columbia University, Biobehavioral Sciences, 1152B Thorndike Hall Box 5, New York, NY 10027, USA
| | - Christopher K Wong
- Columbia University Irving Medical Center, Rehabilitation and Regenerative Medicine, 617 West 168 Street Georgian #311, New York, NY 10032, USA
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Anderson CB, Wurdeman SR, Miller MJ, Christiansen CL, Kittelson AJ. Development of a physical mobility prediction model to guide prosthetic rehabilitation. Prosthet Orthot Int 2021; 45:268-275. [PMID: 33840752 PMCID: PMC8422855 DOI: 10.1097/pxr.0000000000000001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 12/06/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Prosthetic rehabilitation decisions depend on estimating a patient's mobility potential. However, no validated prediction models of mobility outcomes exist for people with lower-limb amputation (LLA). OBJECTIVES To develop and test predictions for self-reported mobility after LLA, using the Prosthetic Limb Users Survey of Mobility (PLUS-M). STUDY DESIGN This is a retrospective cohort analysis. METHODS Eight hundred thirty-one patient records (1,860 PLUS-M observations) were used to develop and test a neighbors-based prediction model, using previous patient data to predict the 6-month PLUS-M T-score trajectory for a new patient (based on matching characteristics). The prediction model was developed in a training data set (n = 552 patients) and tested in an out-of-sample data set of 279 patients with later visit dates. Prediction performance was assessed using bias, coverage, and precision. Prediction calibration was also assessed. RESULTS The average prediction bias for the model was 0.01 SDs, average coverage was 0.498 (ideal proportion within the 50% prediction interval = 0.5), and prediction interval was 8.4 PLUS-M T-score points (40% improvement over population-level estimates). Predictions were well calibrated, with the median predicted scores falling within the standard error of the median of observed scores, across all deciles of the data. CONCLUSIONS This neighbors-based prediction approach allows for accurate estimates of PLUS-M T-score trajectories for people with LLA.
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Affiliation(s)
- Chelsey B. Anderson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO
| | - Shane R. Wurdeman
- Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, TX
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE
| | - Matthew J. Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA
| | - Cory L. Christiansen
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO
- Department of Geriatrics, Geriatric Research, Education, and Clinical Center, VA Eastern Colorado Healthcare System, Aurora, CO
| | - Andrew J. Kittelson
- Department of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, MT
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