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Hargraves IG, Boehmer KR, Amer H, Kennedy CC, Griffin JM, Finnie DM, Montori VM, Smither FC, Mardini S, Moran S, Jowsey-Gregoire S. The role of the purposeful shared decision making model in vascularized composite allotransplantation. FRONTIERS IN TRANSPLANTATION 2024; 3:1421154. [PMID: 38993756 PMCID: PMC11235292 DOI: 10.3389/frtra.2024.1421154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
For some patients who have lost the lower part of an arm, hand transplant offers the possibility of receiving a new limb with varying degrees of sensation and function. This procedure, Vascularized Composite Allotransplantation (VCA), is demanding for patients and their care community and comes with significant risks. As a high-stakes decision, patients interested in VCA are subject to extensive clinical evaluation and eligibility decision making. Patients and their care community must also decide if hand transplant (versus other approaches including rehabilitative therapies with or without prosthesis) is right for them. This decision making is often confusing and practically and emotionally fraught. It is complicated in four ways: by the numerous beneficial and harmful potential effects of hand transplant or other options, the number of people affected by VCA and the diverse or conflicting positions that they may hold, the practical demands and limitations of the patient's life situation, and the existential significance of limb loss and transplant for the patient's being. Patients need support in working through these treatment determining issues. Evaluation does not provide this support. Shared decision making (SDM) is a method of care that helps patients think, talk, and feel their way through to the right course of action for them. However, traditional models of SDM that focus on weighing possible beneficial and harmful effects of treatments are ill-equipped to tackle the heterogeneous issues of VCA. A recent model, Purposeful SDM extends the range of troubling issues that SDM can help support beyond opposing effects, to include conflicting positions, life situations, and existential being. In this paper we explore the pertinence of these issues in VCA, methods of SDM that each require of clinicians, the benefits of supporting patients with the breadth of issues in their unique problematic situations, implications for outcomes and practice, and extend the theory of the Purposeful SDM model itself based on the issues present in hand transplant decision making.
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Affiliation(s)
- Ian G. Hargraves
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
| | - Kasey R. Boehmer
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | - Cassie C. Kennedy
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States
| | - Joan M. Griffin
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, United States
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Dawn M. Finnie
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN, United States
| | - Victor M. Montori
- Knowledge and Encounter Research (KER) Unit, Mayo Clinic, Rochester, MN, United States
| | - Fantley Clay Smither
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, United States
| | - Samir Mardini
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, United States
| | - Steven Moran
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Mayo Clinic, Rochester, MN, United States
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Lee SP, Maluotoga M, Thind R, Lindsay L, Bhatta T, Miller CA. Utilization and Perception of Peer-Support After Lower Limb Loss in the United States: Potential Benefits on Mobility Outcomes. Arch Phys Med Rehabil 2024; 105:939-946.e3. [PMID: 38242299 PMCID: PMC11069449 DOI: 10.1016/j.apmr.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 10/30/2023] [Accepted: 12/14/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes. DESIGN Quantitative and qualitative descriptive study with a cross-sectional design. SETTING National survey (distributed to 169 peer-support groups in 44 states in the US). PARTICIPANTS The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82). MAIN OUTCOME MEASURES A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M). RESULTS Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055). CONCLUSION Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility.
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Affiliation(s)
- Szu-Ping Lee
- Department of Physical Therapy, University of Nevada, Las Vegas, NV.
| | - Moriah Maluotoga
- Department of Physical Therapy, University of Nevada, Las Vegas, NV
| | - Roopkiran Thind
- Department of Physical Therapy, University of Nevada, Las Vegas, NV
| | | | - Tirth Bhatta
- Department of Sociology, University of Nevada, Las Vegas, NV
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Lee SP, Chien LC, Shih HT, Ho S, Clemens S. Returning to work after dysvascular lower limb amputation-A novel multivariate approach to examine relative contributions of biopsychosocial predictors. Prosthet Orthot Int 2024:00006479-990000000-00214. [PMID: 38180145 PMCID: PMC11224136 DOI: 10.1097/pxr.0000000000000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/17/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Returning to work is a key outcome of rehabilitation and social re-integration after lower limb amputation. It is important to understand what biopsychosocial factors contribute to returning to work after dysvascular amputation. OBJECTIVE Examining relative contributions of functional and contextual predictors of returning to work in participants with lower limb amputation due to diabetes and other dysvascular diseases. STUDY DESIGN Cross-sectional. METHODS Return-to-work outcome, biopsychosocial characteristics including physical functioning, self-efficacy & perceived ability, and socioeconomical support data were collected from a purposive sample (n = 57) in a multi-state collaborative research network. Grouped Weighted Quantile Sum model analysis was conducted to evaluate relative contributions of biopsychosocial predictors. RESULTS Less than 30% of the participants returned to work after their amputation. Physical functioning (odds ratio = 10.19; 95% CI 2.46-72.74) was the most important predictor group. Working before amputation, prosthetic mobility, and access to rehabilitation care were also identified as key factors associated with returning to work. CONCLUSIONS Fewer than 1 in 3 participants with dysvascular amputation returned to work, despite an average age of only 54 years at the time of amputation. Physical functioning was shown to be the most important predictor, while socioeconomic factors such as a lack of access to care also contribute to not returning to work after dysvascular amputation.
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Affiliation(s)
- Szu-Ping Lee
- Department of Physical Therapy, University of Nevada, Las Vegas; Las Vegas, Nevada, USA
| | - Lung-Chang Chien
- Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas; Las Vegas, Nevada, USA
| | - Hui-Ting Shih
- Interdisciplinary Health Science Program, University of Nevada, Las Vegas; Las Vegas, Nevada, USA
| | - Sabrina Ho
- Kirk Kerkorian School of Medicine, University of Nevada, Las Vegas; Las Vegas, Nevada, USA
| | - Sheila Clemens
- Department of Physical Therapy, Florida International University; Miami, Florida, USA
- Department of Physical Therapy, University of Kentucky; Lexington, Kentucky, USA
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Lauwers P, Hendriks JMH, Wouters K, Vanoverloop J, Avalosse H, Dirinck E, Nobels F. Impact of diabetes on medical costs in the pre- and postoperative year of lower extremity amputations in Belgium. Diabetes Res Clin Pract 2024; 207:111072. [PMID: 38142745 DOI: 10.1016/j.diabres.2023.111072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 12/10/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
AIMS To compare the medical costs of individuals undergoing lower extremity amputation (LEA) in Belgium with those of amputation-free individuals. METHODS Belgian citizens undergoing LEAs in 2014 were identified. The median costs per capita in euros for the 12 months preceding and following minor and major LEAs were compared with those of matched amputation-free individuals. RESULTS A total of 3324 Belgian citizens underwent LEAs (2295 minor, 1029 major), 2130 of them had diabetes. The comparison group included 31,716 individuals. Amputation was associated with high medical costs (individuals with diabetes: major LEA €49,735, minor LEA €24,243, no LEA €2,877 in the year preceding amputation; €45,740, €21,445 and €2,284, respectively, in the post-amputation year). Significantly higher costs were observed in the individuals with (versus without) diabetes in all groups. This difference diminished with higher amputation levels. Individuals undergoing multiple LEAs generated higher costs (individuals with diabetes: €39,313-€89,563 when LEAs preceded index amputation; €46,629-€92,877 when LEAs followed index amputation). Individuals dying in the year after a major LEA generated remarkably lower costs. CONCLUSIONS LEA-related medical costs were high. Diabetes significantly impacted costs, but differences in costs diminished with higher amputation levels. Individuals with multiple amputations generated the highest costs.
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Affiliation(s)
- Patrick Lauwers
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Drie Eikenstraat 655, B-2650 Edegem, Belgium; University of Antwerp, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Universiteitsplein 1, B-2610 Wilrijk, Belgium.
| | - Jeroen M H Hendriks
- Antwerp University Hospital, Department of Thoracic and Vascular Surgery, Drie Eikenstraat 655, B-2650 Edegem, Belgium; University of Antwerp, Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Kristien Wouters
- Antwerp University Hospital, Clinical Trial Centre (CTC), CRC Antwerp, Drie Eikenstraat 655, B-2650 Edegem, Belgium
| | - Johan Vanoverloop
- Intermutualistisch Agentschap/Agence Intermutualiste (IMA/AIM), Bolwerklaan 21 B 7, B-1210 Brussels, Belgium
| | - Hervé Avalosse
- Intermutualistisch Agentschap/Agence Intermutualiste (IMA/AIM), Bolwerklaan 21 B 7, B-1210 Brussels, Belgium; Landsbond der Christelijke Mutualiteiten/Alliance Nationale des Mutualités Chrétiennes, Haachtsesteenweg 579 B 40, B-1031 Brussels, Belgium
| | - Eveline Dirinck
- Antwerp University Hospital, Department of Endocrinology, Diabetology and Metabolism, Drie Eikenstraat 655, B-2650 Edegem, Belgium; University of Antwerp, Laboratory of Experimental Medicine and Paediatrics (LEMP), Universiteitsplein 1, B-2610 Wilrijk, Belgium
| | - Frank Nobels
- Onze Lieve Vrouw Ziekenhuis Aalst, Department of Endocrinology, Moorselbaan 164, B-9300 Aalst, Belgium
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Janes LE, McAndrew C, Levin LS. Replantation versus transplantation: Where do we stand? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03737-1. [PMID: 37815630 DOI: 10.1007/s00590-023-03737-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/13/2023] [Indexed: 10/11/2023]
Abstract
PURPOSE Despite advances in extremity trauma care and reconstructive microsurgery, management of the traumatic amputations remains a challenge. The majority of patients will forever experience some level of disability even with replantation or advanced prosthetics. The goal of this article is to familiarize hand and reconstructive surgeons with the current state of upper extremity transplantation, so they better can educate their amputee patients regarding this as an option following limb loss. METHODS Current literature, in addition to the international registry on hand and composite tissue transplantation, was reviewed to assemble a summary of outcomes in upper extremity replantation and transplantation. RESULTS Sensory and functional outcomes of replantation and transplantation are comparable. Reported complications of immunosuppression are similar to those of other solid organ transplants. The financial cost of hand transplantation is high, but comparable to the lifetime cost of prosthesis use. CONCLUSION While the risk of immunosuppression is a serious consideration for patients pursuing hand transplantation, in the well-selected and informed patient, hand transplantation can dramatically improve patient reported to outcomes and quality of life.
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Affiliation(s)
- Lindsay E Janes
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA
| | - Christine McAndrew
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA
| | - L Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, Philadelphia, PA, 191904, USA.
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Gordon EJ, Gacki-Smith J, Kuramitsu BR, Downey M, Vanterpool KB, Nordstrom MJ, Riggleman T, Cooney CM, Jensen S, Dumanian G, Tintle S, Levan M, Brandacher G. Ethical and Psychosocial Factors in the Decision-Making and Informed Consent Process for Upper Extremity Vascularized Composite Allotransplantation: A Mixed-Methods Study. Transplant Direct 2023; 9:e1515. [PMID: 37492079 PMCID: PMC10365204 DOI: 10.1097/txd.0000000000001515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/27/2023] [Indexed: 07/27/2023] Open
Abstract
Although upper extremity (UE) vascularized composite allotransplantation (VCA) aims to improve quality of life, relatively few have been performed worldwide to support evidence-based treatment and informed decision-making. Methods We qualitatively examined factors contributing to anticipated and actual decision-making about UE VCA and perceptions of the elements of informed consent among people with UE amputations, and UE VCA candidates, participants, and recipients through in-depth interviews. Thematic analysis was used to analyze qualitative data. Results Fifty individuals participated; most were male (78%) and had a mean age of 45 y and a unilateral amputation (84%). One-third (35%) were "a lot" or "completely" willing to pursue UE VCA. UE VCA decision-making themes included the utility of UE VCA, psychosocial impact of UE VCA and amputation on individuals' lives, altruism, and anticipated burden of UE VCA on lifestyle. Most respondents who underwent UE VCA evaluation (n = 8/10) perceived having no reasonable treatment alternatives. Generally, respondents (n = 50) recognized the potential for familial, societal, cultural, medical, and self-driven pressures to pursue UE VCA among individuals with amputations. Some (n = 9/50, 18%) reported personally feeling "a little," "somewhat," "a lot," or "completely" pressured to pursue UE VCA. Respondents recommended that individuals be informed about the option of UE VCA near the amputation date. Conclusions Our study identified psychosocial and other factors affecting decision-making about UE VCA, which should be addressed to enhance informed consent. Study participants' perceptions and preferences about UE VCA suggest re-examination of assumptions guiding the UE VCA clinical evaluation process.
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Affiliation(s)
- Elisa J. Gordon
- Department of Surgery, and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN
| | - Jessica Gacki-Smith
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Brianna R. Kuramitsu
- Center for Health Services and Outcomes Research, Northwestern University, Chicago, IL
| | - Max Downey
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Karen B. Vanterpool
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Michelle J. Nordstrom
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Tiffany Riggleman
- Center for Rehabilitation Sciences Research, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Carisa M. Cooney
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
| | - Sally Jensen
- Department of Medical Social Sciences and Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Gregory Dumanian
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Scott Tintle
- Department of Orthopaedic Surgery, Uniformed Services University of the Health Sciences, Walter Reed National Military Medical Center, Bethesda, MD
| | - Macey Levan
- Department of Surgery, NYU Grossman School of Medicine, NYU Langone Health, New York, NY
- Department of Population Health, NYU Grossman School of Medicine, New York, NY
| | - Gerald Brandacher
- Department of Plastic and Reconstructive Surgery, School of Medicine, Johns Hopkins University, Baltimore, MD
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Chauhan AS, Varre MS, Izuora K, Trabia MB, Dufek JS. Prediction of Diabetes Mellitus Progression Using Supervised Machine Learning. SENSORS (BASEL, SWITZERLAND) 2023; 23:4658. [PMID: 37430572 DOI: 10.3390/s23104658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 05/08/2023] [Accepted: 05/09/2023] [Indexed: 07/12/2023]
Abstract
Diabetic peripheral neuropathy (DN) is a serious complication of diabetes mellitus (DM) that can lead to foot ulceration and eventual amputation if not treated properly. Therefore, detecting DN early is important. This study presents an approach for diagnosing various stages of the progression of DM in lower extremities using machine learning to classify individuals with prediabetes (PD; n = 19), diabetes without (D; n = 62), and diabetes with peripheral neuropathy (DN; n = 29) based on dynamic pressure distribution collected using pressure-measuring insoles. Dynamic plantar pressure measurements were recorded bilaterally (60 Hz) for several steps during the support phase of walking while participants walked at self-selected speeds over a straight path. Pressure data were grouped and divided into three plantar regions: rearfoot, midfoot, and forefoot. For each region, peak plantar pressure, peak pressure gradient, and pressure-time integral were calculated. A variety of supervised machine learning algorithms were used to assess the performance of models trained using different combinations of pressure and non-pressure features to predict diagnoses. The effects of choosing various subsets of these features on the model's accuracy were also considered. The best performing models produced accuracies between 94-100%, showing the proposed approach can be used to augment current diagnostic methods.
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Affiliation(s)
- Apoorva S Chauhan
- Department of Mechanical Engineering, University of Nevada, Las Vegas, NV 89154, USA
| | - Mathew S Varre
- Department of Mechanical Engineering, University of Washington, Seattle, WA 98195, USA
| | - Kenneth Izuora
- Department of Internal Medicine, University of Nevada, Las Vegas, NV 89154, USA
| | - Mohamed B Trabia
- Department of Mechanical Engineering, University of Nevada, Las Vegas, NV 89154, USA
| | - Janet S Dufek
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, NV 89154, USA
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Lee SP, Bonczyk A, Dimapilis MK, Partridge S, Ruiz S, Chien LC, Sawers A. Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss. PLoS One 2022; 17:e0262977. [PMID: 35797362 PMCID: PMC9262185 DOI: 10.1371/journal.pone.0262977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/18/2022] [Indexed: 11/19/2022] Open
Abstract
Objective Adopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting. Methods Twenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4–21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users’ age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received. Results We recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively). Conclusions Our results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users’ body movements and not externally on the movement effects. Impact statement While more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.
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Affiliation(s)
- Szu-Ping Lee
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, United States of America
- * E-mail:
| | - Alexander Bonczyk
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, United States of America
| | - Maria Katrina Dimapilis
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, United States of America
| | - Sarah Partridge
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, United States of America
| | - Samantha Ruiz
- Department of Physical Therapy, University of Nevada, Las Vegas, Nevada, United States of America
| | - Lung-Chang Chien
- Department of Epidemiology and Biostatistics, University of Nevada, Las Vegas, Nevada, United States of America
| | - Andrew Sawers
- Department of Kinesiology and Nutrition, University of Illinois at Chicago, Chicago, Illinois, United States of America
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Latour D. Advances in Upper Extremity Prosthetic Technology: Rehabilitation and the Interprofessional Team. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2022; 10:71-76. [PMID: 35342660 PMCID: PMC8933658 DOI: 10.1007/s40141-022-00342-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2022] [Indexed: 11/27/2022]
Abstract
Purpose of Review The aim of this paper is to explore current trends and advancements that lead to improved practitioner knowledge and patient care resulting in better outcomes. It is common for the physiatrist to lead the team of interprofessional practitioners in the care of individuals with upper limb absence. The focus of the care is to understand and access prosthetic options, but there are often other health factors and relevant issues to consider. Recent Findings Some of the latest updates offer solutions to pain management, prosthetic control, access to relevant evidence, and outcomes-related data. An interesting finding was the influence of telehealth service delivery on multiple issues faced by this population. These issues include lack of information, pain management, monitoring skin breakdown and peripheral vascular disease, prosthetic training, and access to peers and specialized practitioners. Summary The diverse technology advancements in surgical techniques, materials, outcome measures, and data management, as well as telehealth, work together to assist the collaborative interprofessional team to provide contemporary and comprehensive care to this unique population.
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Affiliation(s)
- Debra Latour
- Single-Handed Solutions, LLC, Springfield, MA USA
- Department of Occupational Therapy, College of Pharmacy and Health Sciences, Western New England University, 1215 Wilbraham Road, Springfield, MA USA
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The Burden of Patients With Lower Limb Amputations in a Community Safety-net Hospital. J Am Acad Orthop Surg 2022; 30:e59-e66. [PMID: 34288892 DOI: 10.5435/jaaos-d-21-00293] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/20/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The functional disability after amputation is tremendous and imposes a high economic burden on patients and health systems. The current literature on the costs of amputation has been limited to the index hospitalization or a short time window around the amputation procedure, which covers a small percentage of the total costs. METHODS We conducted a retrospective cohort study of patients who underwent lower extremity amputations at a single urban public level 1 trauma hospital. Resource utilization and healthcare costs 1 year before and 1 year after the index amputation were examined. Hospitalization costs were estimated using cost center-based cost-to-charge ratios for the 2-year follow-up. RESULTS The sample comprised 90 patients (73 men and 17 women) with a mean age of 55.9 years (SD, 9.9). Most amputations were secondary to diabetes (74%) and vascular disease in the absence of diabetes (22%). During the 2-year window around the index amputation, patients had an average of 2.7 admissions (SD, 2.3), mean index length of stay of 14.6 days (SD, 22.3), and a mean cumulative length of stay of 31.3 days (SD, 43.4). The patients had a mean of 2.3 (SD, 3.2) additional procedures performed on their amputated limb. Twenty-one patients (23%) required additional proximal amputations, with an average change of 2.2 (SD, 1.6) levels. The mean cost, per patient, of the index hospitalization was $51,481. Over the 2-year period, the mean cost of hospitalizations was $114,292 per patient with a total cost, summed over the cohort, of $10,286,250. Approximately 64% of the total cost went uncompensated. DISCUSSION Over a 2-year window, amputees endured multiple procedures, readmissions, and reamputations, leading to high healthcare costs. Further research into resource-conscious interventions and programs is needed to control the burdens faced by amputees and the health systems that care for them.
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Tirrell AR, Kim KG, Rashid W, Attinger CE, Fan KL, Evans KK. Patient-reported Outcome Measures following Traumatic Lower Extremity Amputation: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3920. [PMID: 35028257 PMCID: PMC8751770 DOI: 10.1097/gox.0000000000003920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Outcomes after traumatic major lower extremity amputation (MLEA) have focused on surgical complications, despite the life-altering impact on patients. With advances in the surgical management of MLEA, a heightened need for consistent reporting of patient-centered outcomes (PCO) remains. This meta-analysis assesses articles for the prevalence and methods of PCO reporting among traumatic MLEA studies. METHODS An electronic database search was completed using Ovid MEDLINE for studies published between 2000 and 2020. Studies were included that reported any outcome of traumatic MLEA. Weighted means of outcomes were calculated when data were available. The prevalence of PCO was assessed in the categories of physical function, quality of life (QOL), psychosocial, and pain. Trends in PCO reporting were analyzed using Pearson's chi-squared test and analysis of variance when appropriate. RESULTS In total, 7001 studies were screened, yielding 156 articles for inclusion. PCO were evaluated in 94 (60.3%) studies; 83 (53.2%) reported physical function and mobility outcomes, 33 (21.2%) reported QOL and satisfaction measures, 38 (24.4%) reported psychosocial data, and 43 (27.6%) reported pain outcomes. There was no change in prevalence of PCO reporting when comparing 5-year intervals between 2000 and 2020 (P = 0.557). CONCLUSIONS Optimization of function and QOL following traumatic MLEA has become a cornerstone of surgical success; however, only 60% of studies report PCO, with no trend over the last two decades suggesting improvement. As healthcare progresses toward patient-centered care, this inconsistent means of reporting PCO calls for improved inclusion and standardization of instruments to assess function, QOL, and other patient-focused measures.
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Affiliation(s)
| | - Kevin G. Kim
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Waleed Rashid
- George Washington University School of Medicine, Washington, D.C
| | - Christopher E. Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Kenneth L. Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
| | - Karen K. Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, D.C
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12
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Abstract
Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.
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Armstrong DG, Tettelbach WH, Chang TJ, De Jong JL, Glat PM, Hsu JH, Kelso MR, Niezgoda JA, Tucker TL, Labovitz JM. Observed impact of skin substitutes in lower extremity diabetic ulcers: lessons from the Medicare Database (2015-2018). J Wound Care 2021; 30:S5-S16. [PMID: 34256590 DOI: 10.12968/jowc.2021.30.sup7.s5] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To evaluate large propensity-matched cohorts to assess outcomes in patients receiving advanced treatment (AT) with skin substitutes for lower extremity diabetic ulcers (LEDUs) versus no AT (NAT) for the management of LEDUs. METHOD The Medicare Limited Dataset (1 October 2015 through 2 October 2018) were used to retrospectively analyse people receiving care for a LEDU treated with AT or NAT (propensity-matched Group 1). Analysis included major and minor amputations, emergency department (ED) visits and hospital readmissions. In addition, AT following parameters for use (FPFU) was compared with AT not FPFU (propensity-matched Group 2). A paired t-test was used for comparisons of the two groups. For comparisons of three groups, the Kruskal-Wallis test was used. A Bonferroni correction was performed when multiple comparisons were calculated. RESULTS There were 9,738,760 patients with a diagnosis of diabetes, of whom 909,813 had a LEDU. In propensity-matched Group 1 (12,676 episodes per cohort), AT patients had statistically fewer minor amputations (p=0.0367), major amputations (p<0.0001), ED visits (p<0.0001), and readmissions (p<0.0001) compared with NAT patients. In propensity-matched Group 2 (1131 episodes per cohort), AT FPFU patients had fewer minor amputations (p=0.002) than those in the AT not FPFU group. CONCLUSION AT for the management of LEDUs was associated with significant reductions in major and minor amputation, ED use, and hospital readmission compared with LEDUs managed with NAT. Clinics should implement AT in accordance with the highlighted parameters for use to improve outcomes and reduce costs.
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Affiliation(s)
- David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), US
- Keck School of Medicine, University of Southern California, Department of Surgery, US
| | - William H Tettelbach
- MIMEDX Group, Inc., US
- College of Podiatric Medicine, Western University of Health Sciences, US
- Duke University School of Medicine, Department of Anesthesiology, US
- Association for the Advancement of Wound Care, US
- Western Peaks Specialty Hospital, US
- Encompass Health and Rehabilitation Hospital of Utah, US
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14
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Miller MJ, Mealer ML, Cook PF, Kittelson AJ, Christiansen CL. Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation. Phys Ther 2021; 101:6075036. [PMID: 33421074 PMCID: PMC8023555 DOI: 10.1093/ptj/pzab002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/12/2020] [Accepted: 12/26/2020] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The purpose of this study was to (1) determine the psychometric properties of the 25- and 10-item Connor-Davidson Resilience Scales (CD-RISC25, CD-RISC10) for people with lower-limb amputation (LLA) in middle age or later, and (2) describe relationships of the CD-RISC with biopsychosocial, sociodemographic, and health variables. METHODS Participants were included if their most recent LLA was 1 or more years prior, if they were independently walking with a prosthesis, and if they were between 45 and 88 years of age (N = 122; mean = 62.5 years of age [SD = 8]; 59.5 [mean = 58] months since LLA; 88.5% male; 82.0% with dysvascular etiology; 68.0% with unilateral transtibial LLA). Psychometric analyses included assessment of skewness, floor and ceiling effects, internal consistency, and agreement between versions. Correlation analyses were used to determine associations between the CD-RISC with disability, perceived functional capacity, falls efficacy, life-space, anxiety, depression, self-efficacy, social support, sociodemographic, and health variables. Additionally, quartiles of participants were identified using CD-RISC25 and CD-RISC10 scores and compared using ANOVA and post-hoc comparisons for disability, perceived functional capacity, falls efficacy, and life-space. RESULTS Skewness, floor, and ceiling effects of both CD-RISC versions were acceptable. Both versions of the CD-RISC were internally consistent (CD-RISC25: α = .92; CD-RISC10: α = .89). The CD-RISC25 and CD-RISC10 were highly correlated with disability, perceived functional capacity, falls efficacy, anxiety, depression, and self-efficacy (r = 0.52-0.67). CD-RISC25 and CD-RISC10 quartile differences, especially the lowest quartile, were identified for disability, perceived functional capacity, falls efficacy, and life-space. CONCLUSION The CD-RISC25 and CD-RISC10 have acceptable psychometric properties for use with people who have LLA. CD-RISC scores are associated with clinically relevant biopsychosocial measures targeted by physical therapist intervention following LLA. IMPACT The CD-RISC may be an appropriate tool to measure resilience following LLA.
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Affiliation(s)
| | - Meredith L Mealer
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,Mental Illness Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Paul F Cook
- College of Nursing, University of Colorado, Aurora, Colorado, USA
| | - Andrew J Kittelson
- School of Physical Therapy, University of Montana, Missoula, Montana, USA
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado, USA,VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, Colorado, USA
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15
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Gülhane lower extremity amputee rehabilitation protocol: A nationwide, 123-year experience. Turk J Phys Med Rehabil 2020; 66:373-382. [PMID: 33364556 PMCID: PMC7756831 DOI: 10.5606/tftrd.2020.7637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/02/2020] [Indexed: 11/21/2022] Open
Abstract
Amputation, one of the oldest known surgical procedures, causes many physical, mental and sociological problems. With its 123 years of experience, Gülhane has a special knowledge and experience, particularly in amputation. The main purpose of this protocol is to reveal the steps to be followed in individuals with lower extremity amputation. In this way, it is aimed to create a resource which can be used by our colleagues who have difficulties in using an appropriate approach due to the lack of experience.
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16
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Miller MJ, Blankenship JM, Kline PW, Melanson EL, Christiansen CL. Patterns of Sitting, Standing, and Stepping After Lower Limb Amputation. Phys Ther 2020; 101:6039323. [PMID: 33336706 PMCID: PMC7921296 DOI: 10.1093/ptj/pzaa212] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 07/10/2020] [Accepted: 10/29/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE The objectives of this study were to describe sitting, standing, and stepping patterns for people with lower limb amputation (LLA) and to compare sitting, standing, and stepping between people with dysvascular LLA and people with traumatic LLA. METHODS Participants with dysvascular or traumatic LLA were included if their most recent LLA was at least 1 year earlier, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. Sitting, standing, and stepping were measured using accelerometry. Daily sitting, standing, and stepping times were expressed as percentages of waking time. Time spent in bouts of specified durations of sitting (<30, 30-60, 60-90, and >90 minutes), standing (0-1, 1-5, and >5 minutes), and stepping (0-1, 1-5, and >5 minutes) was also calculated. RESULTS Participants (N = 32; mean age = 62.6 [SD = 7.8] years; 84% men; 53% with dysvascular LLA) spent most of the day sitting (median = 77% [quartile 1 {Q1}-quartile 3 {Q3} = 67%-84%]), followed by standing (median = 16% [Q1-Q3 = 12%-27%]) and stepping (median = 6% [Q1-Q3 = 4%-9%]). One-quarter (median = 25% [Q1-Q3 = 16%-38%]) of sitting was accumulated in bouts of >90 minutes, and most standing and stepping was accrued in bouts of <1 minute (standing: median = 42% [Q1-Q3 = 34%-54%]; stepping: median = 98% [Q1-Q3 = 95%-99%]). Between-etiology differences included proportion of time sitting (traumatic: median = 70% [Q1-Q3 = 59%-78%]; dysvascular: median = 79% [Q1-Q3 = 73%-86%]) and standing (traumatic: median = 23% [Q1-Q3 = 16%-32%]; dysvascular: median = 15% [Q1-Q3 = 11%-20%]). CONCLUSION Participants had high daily volumes of long durations of sitting. Further, these individuals accumulated most physical activity in bouts of <1 minute. IMPACT High levels of sedentary behavior and physical inactivity patterns may place people with LLA at greater mortality risk relative to the general population. Interventions to minimize sedentary behaviors and increase physical activity are potential strategies for improving poor outcomes of physical therapy after LLA.
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Affiliation(s)
| | - Jennifer M Blankenship
- Division of Endocrinology, Metabolism, and Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Paul W Kline
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA,VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, Colorado, USA
| | - Edward L Melanson
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, Colorado, USA,Division of Geriatric Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Cory L Christiansen
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA,VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, Colorado, USA
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17
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McCloskey C, Kenia J, Shofer F, Marschalek J, Dillingham TR. Improved Self-Reported Comfort, Stability, and Limb Temperature Regulation with an Immediate Fit, Adjustable Transtibial Prosthesis. Arch Rehabil Res Clin Transl 2020; 2. [PMID: 33381750 PMCID: PMC7771885 DOI: 10.1016/j.arrct.2020.100090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective The purpose of this investigation was to assess participants’ self-reported satisfaction with an adjustable, immediate fit transtibial prosthetic system as compared to their conventionally fabricated prosthetic device. Design A prospective study involving a 2-week single-group pre-post intervention design. Setting Physical medicine and rehabilitation clinic of a university hospital. Participants Adults (N=27) with transtibial limb loss. Intervention Participants were fit with the iFIT prosthetic system and instructed to wear it for a 2-week evaluation period. Main Outcome Measure A modified Prosthetic Evaluation Questionnaire (PEQ) scale was completed on the participant’s conventional prosthetic during the initial visit and the iFIT system after 2 weeks. Results Twenty-seven persons with lower limb loss were enrolled. Three were lost to follow-up leaving 24 participants with completed data. Three participants had recent amputations with no conventional device for comparison. The modified PEQ scores were significantly higher for the iFIT prosthetic in comparison to their conventional device (29.18±4.63 vs 23.82±6.38, P<.01). Participants were also found to perceive significantly better temperature control with the iFIT prosthetic system (4.19±0.68 vs 2.97±1.02, P<.001). Participants did not report any skin breakdown, prosthetic issues, or falls. Conclusion This immediate fit, adjustable transtibial prosthesis demonstrated significantly better patient satisfaction and temperature perception compared to conventional devices. These results are consistent with previous findings and further support the efficacy of an immediate fit adjustable transtibial prosthetic system. Longer-term studies in the United States and internationally are underway to assess the durability and efficacy of this new prosthesis in different populations and settings.
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Affiliation(s)
- Chloe McCloskey
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Jessica Kenia
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Frances Shofer
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | - Timothy R. Dillingham
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Corresponding author Timothy R. Dillingham, MD, MS, Department of Physical Medicine and Rehabilitation, University of Pennsylvania Perelman School of Medicine, Penn Medicine Rittenhouse, 1800 Lombard St, Philadelphia, PA 19146.
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18
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Lee SP, Chien LC, Chin T, Fox H, Gutierrez J. Financial difficulty in community-dwelling persons with lower limb loss is associated with reduced self-perceived health and wellbeing. Prosthet Orthot Int 2020; 44:290-297. [PMID: 32484076 PMCID: PMC8247678 DOI: 10.1177/0309364620921756] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Socioeconomic status has been shown to be an important factor in the disparate prevalence and selected treatment of limb loss, but how personal financial difficulty affects patients' health outcomes is currently unclear. OBJECTIVE Examining how presence and experience of personal financial difficulty affects perceived health and wellbeing in individuals with lower limb loss. STUDY DESIGN Cross-sectional study. METHODS A total of 90 participants (68 males, mean age 58.7 ± 16.7 years) were recruited from local physical therapy and prosthetic and orthotic clinics, rehabilitation hospitals, and a regional amputee patient support group. All participants were community-dwelling, non-military adults with amputation involving at least one major lower limb joint. Participants were interviewed, and each completed a survey that included basic demographic/medical information, self-reported health and wellbeing (Short-Form Health Survey, SF-36v2), and a question to determine their financial situation after limb loss. Multiple regression analyses were used to examine the effect of financial difficulty on the eight subscales of SF-36v2 while accounting for age, gender, and amputation level. RESULTS Experiencing financial difficulty significantly and negatively affected Role-Physical and Role-Emotional subscale scores (p < 0.01 and p = 0.02, respectively). Individuals with financial difficulty scored approximately 60% lower in these two specific subscales. CONCLUSION Experiencing financial difficulty is a significant predictor for diminished work or daily activity participation due to physical and emotional stresses. Clinicians and health policy makers need to understand how socioeconomic factors may prevent individuals with lower limb loss from achieving higher levels of functional recovery and community re-integration after amputation. CLINICAL RELEVANCE Our findings showed that presence or experience of financial difficulty was significantly associated with diminished community re-integration in community-dwelling, non-military adults with lower limb loss. It affects both physical and emotional aspects of wellbeing. Clinicians should be aware how socioeconomic factors may affect social re-integration after amputation.
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Affiliation(s)
- Szu-Ping Lee
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Lung-Chang Chien
- Epidemiology and Biostatistics, Department of Environmental and Occupational Health, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Tyler Chin
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Heather Fox
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA
| | - Juan Gutierrez
- Department of Physical Therapy, University of Nevada, Las Vegas, Las Vegas, NV, USA
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19
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Miller MJ, Cook PF, Magnusson DM, Morris MA, Blatchford PJ, Schenkman ML, Christiansen CL. Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation. PM R 2020; 13:453-460. [PMID: 32926546 DOI: 10.1002/pmrj.12464] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/09/2020] [Accepted: 08/04/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Interventions targeting psychosocial factors may improve rehabilitation outcomes for prosthesis users after lower-limb amputation (LLA), but there is a need to identify targeted factors for minimizing disability. OBJECTIVE To identify psychosocial factors related to disability for prosthesis users after LLA in middle age or later. DESIGN Cross-sectional study. SETTING General community. PARTICIPANTS Participants with LLA (N = 122) were included in this cross-sectional study if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and they were between 45 and 88 years old. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Disability, the primary outcome, was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS). Candidate psychosocial variables included self-efficacy, social support, and motivation, measured using the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD), Multidimensional Scale of Perceived Social Support questionnaire (MSPSS), and modified contemplation ladder (mCL), respectively. The hypothesis was that greater self-efficacy, social support, and motivation would be associated with lower disability when controlling for covariates. RESULTS The covariate model, including etiology, age, sex, U.S. military veteran status, LLA characteristics, time since LLA, medical complexity, and perceived functional capacity, explained 66.1% of disability variability (WHODAS 2.0). Backward elimination of candidate psychosocial variables stopped after removal of motivation (P = .10), with self-efficacy (P < .001) and social support (P = .002) variables remaining in the final model. The final model fit was statistically improved (P < .001) and explained an additional 6.1% of disability variability when compared to the covariate model. CONCLUSIONS Greater self-efficacy and social support are related to lower disability after LLA. Findings suggest there may be a role for interventions targeting increased physical function, self-efficacy, and social support for ambulatory prosthesis users after LLA in middle age or later, especially when complicated by multiple chronic conditions.
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Affiliation(s)
- Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA.,Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Paul F Cook
- College of Nursing, University of Colorado, Aurora, CO, USA
| | - Dawn M Magnusson
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Megan A Morris
- Adult and Child Consortium of Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Patrick J Blatchford
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, CO, USA.,Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Margaret L Schenkman
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA.,VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, CO, USA
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20
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Targeted Muscle Reinnervation Combined with a Vascularized Pedicled Regenerative Peripheral Nerve Interface. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2689. [PMID: 32537346 PMCID: PMC7253250 DOI: 10.1097/gox.0000000000002689] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/15/2020] [Indexed: 11/25/2022]
Abstract
Symptomatic neuromas and pain caused by nerve transection injuries can adversely impact a patient’s recovery, while also contributing to increased dependence on opioid and other pharmacotherapy. These sources of pain are magnified following amputation surgeries, inhibiting optimal prosthetic wear and function. Targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI) represent modern advances in addressing amputated peripheral nerves. These techniques offer solutions by essentially providing neuromuscular targets for transected peripheral nerves “to grow into and reinnervate.” Recent described benefits of these techniques include reports on pain reduction or ablation (eg, phantom limb pain, residual limb pain, and/or neuroma pain).1–6 We describe a technical adaptation combining TMR with a “pedicled vascularized RPNI (vRPNI).” The TMR with the vRPNI surgical technique described offers the advantage of having a distal target nerve and a target muscle possessing deinnervated motor end plates which may potentially enhance nerve regeneration and muscle reinnervation, while also decreasing amputated nerve-related pain.
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21
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Madhanagopal S, Burns M, Pei D, Mukundhan R, Meyerson H, Vinjamuri R. Introductory Chapter: Past, Present, and Future of Prostheses and Rehabilitation. PROSTHESIS 2020. [DOI: 10.5772/intechopen.89987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Marston WA, Lantis JC, Wu SC, Nouvong A, Lee TD, McCoy ND, Slade HB, Tseng SC. An open-label trial of cryopreserved human umbilical cord in the treatment of complex diabetic foot ulcers complicated by osteomyelitis. Wound Repair Regen 2019; 27:680-686. [PMID: 31376297 PMCID: PMC6900178 DOI: 10.1111/wrr.12754] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/17/2019] [Accepted: 07/25/2019] [Indexed: 02/06/2023]
Abstract
Clinical trials of potential new therapies for diabetic foot ulcers rarely enroll patients whose wounds extend to muscle, fascia, or bone with clinical and radiographic evidence of underlying osteomyelitis. An open‐label, multicenter trial of cryopreserved human umbilical cord (TTAX01) was undertaken in 32 subjects presenting with such complex wounds with a mean duration of 6.1 ± 9.0 (range: 0.2–47.1) months and wound area at screening of 3.8 ± 2.9 (range: 1.0–9.6) cm2. Aggressive surgical debridement at baseline resulted in 17 minor amputations and an increase in mean wound area to 7.4 ± 5.8 (range: 1.1–28.6) cm2. All subjects were placed on systemic antibiotics for at least 6 weeks in conjunction with baseline application of TTAX01. Repeat applications were made at no less than 4‐week intervals over the 16‐week trial. Initial closure occurred in 18 of 32 (56%) wounds, with 16 (50%) of these having confirmed closure in 16 weeks with a median of one‐product application. Cases with biopsy confirmed osteomyelitis (n = 20) showed initial closure in 12 (60%) wounds and confirmed closure in 10 (50%) wounds. Four of the five ulcers presenting as recurrences experienced confirmed closure. Mean overall time to healing was 12.8 ± 4.3 weeks. Mean wound area reduction from baseline was 91% for all wounds. Of the 16 wounds without confirmed closure during the 16‐week treatment period, five (31.3%) achieved 99–100% wound area reduction by their final visit. The product was well tolerated. Two minor amputations occurred during the study period due to recurrent or persistent osteomyelitis; however, there were no major amputations.
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Affiliation(s)
- William A Marston
- Division of Vascular Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - John C Lantis
- Department of Surgery, Mt Sinai West and St Luke's Hospitals, New York, New York
| | - Stephanie C Wu
- Department of Podiatric Surgery & Applied Biomechanics, Rosalind Franklin University, North Chicago, Illinois
| | | | - Tommy D Lee
- Research & Development, TissueTech, Inc., Miami, Florida
| | | | - Herbert B Slade
- Research & Development, TissueTech, Inc., Miami, Florida.,Department of Pediatrics, University of North Texas Health Sciences Center, Fort Worth, Texas
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23
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Comparing Human Amniotic Allograft and Standard Wound Care When Using Total Contact Casting in the Treatment of Patients with Diabetic Foot Ulcers. Adv Skin Wound Care 2019; 32:272-277. [DOI: 10.1097/01.asw.0000557831.78645.85] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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24
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Christiansen CL, Miller MJ, Murray AM, Stephenson RO, Stevens-Lapsley JE, Hiatt WR, Schenkman ML. Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial. Arch Phys Med Rehabil 2018; 99:2160-2167. [PMID: 29746823 PMCID: PMC6215727 DOI: 10.1016/j.apmr.2018.04.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine preliminary efficacy of a home-based behavior-change intervention designed to promote exercise, walking activity, and disease self-management. DESIGN A single-blind, randomized controlled pilot trial. SETTING One Veterans Administration and 2 regional medical centers. PARTICIPANTS A total of 38 participants randomized to behavior-change intervention (n=19) or attention control (CTL; n=19) group. INTERVENTIONS Weekly 30-minute telephone sessions for 12 weeks with intervention group sessions focused on health behavior change and CTL group sessions focused on health status monitoring. MAIN OUTCOME MEASURES Physical function, walking activity (steps/d averaged over 10d), and disability were measured at baseline, 12 weeks (intervention end), and 24 weeks after baseline with the Timed Up and Go (TUG) test as the primary outcome measure. RESULTS The TUG test was not changed from baseline in either group and was not different between groups after 12 or 24 weeks. Several exploratory outcomes were assessed, including daily step count, which increased 1135 steps per day in the intervention group compared to 144 steps per day in the CTL group after 12 weeks (P=.03). Only the intervention group had within-group increase in steps per day from baseline to 12 (P<.001) and 24 (P=.03) weeks and spent significantly less time in sedentary activity (4.8% decrease) than the CTL group (0.2% decrease) at 24 weeks (P=.04). There were no other between-group differences in physical function or disability change over time. CONCLUSION The behavior-change intervention demonstrates promise for increasing walking activity for people with dysvascular transtibial amputation (TTA). The efficacy of implementing such intervention in the scope of conventional TTA rehabilitation should be further studied.
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Affiliation(s)
- Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, Colorado; Department of Geriatrics, Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado.
| | - Matthew J Miller
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, Colorado; Department of Geriatrics, Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Amanda M Murray
- School of Exercise and Rehabilitation Sciences, Doctor of Physical Therapy Program, School of Exercise & Rehabilitation Sciences, University of Toledo, Toledo, Ohio
| | - Ryan O Stephenson
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, Colorado; Department of Physical Medicine and Rehabilitation, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - Jennifer E Stevens-Lapsley
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, Colorado; Department of Geriatrics, Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, Colorado
| | - William R Hiatt
- Department of Medicine, Division of Cardiology, University of Colorado School of Medicine and CPC Clinical Research, Aurora, Colorado, the United States of America
| | - Margaret L Schenkman
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, Colorado
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25
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Raphael A. A single-centre, retrospective study of cryopreserved umbilical cord/amniotic membrane tissue for the treatment of diabetic foot ulcers. J Wound Care 2018; 25:S10-S17. [PMID: 29027852 DOI: 10.12968/jowc.2016.25.sup7.s10] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Histopathological studies have shown a prolonged inflammatory phase in wounds of patients with diabetes, delaying formation of mature granulation tissue and reducing wound tensile strength, making these wounds difficult for physicians to heal. Cryopreserved human umbilical cord (cUC) tissues possess unique anti-inflammatory and anti-scarring properties and have been found to help improve closure of these chronic wounds. METHOD A retrospective chart review was performed to assess the efficacy of cUC as an advanced treatment modality to help promote the closure of chronic DFUs. Overall healing rate, duration to wound closure, and number of cUC applications used to achieve closure were used to assess cUC treatment efficacy. RESULTS A total of 32 wounds in 29 patients treated at a single health-care centre were included in the study population The average initial wound area for all wounds was 10.6 ± 2.15cm2. Of the 32 wounds 28 achieved complete epithelialisation for an overall healing rate of 87.5%. Average time to wound closure was 13.8 ± 1.95 weeks with a median of 9 weeks and an average of 1.68 ± 0.18 cUC applications. CONCLUSION The results suggest cUC allograft may be effective in improving the healing of DFUs ulcers as well as potentially reducing the medical costs associated with chronic DFUs due to the low number of applications needed to achieve complete wound closure. Prospective, randomised controlled trials are suggested to better understand the efficacy of cUC in chronic wound healing. DECLARATION OF INTEREST Dr Raphael is a paid speaker for Amniox Medical, Inc.
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Affiliation(s)
- A Raphael
- Village Podiatry Centers, Smyrna, GA, US
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Lee DJ, Wininger M, Mahler D, Parisi M. Taxonomy of clinical encounters during the first 90 days post-delivery of an initial lower limb prosthesis. Prosthet Orthot Int 2018; 42:490-497. [PMID: 29775130 DOI: 10.1177/0309364618774053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND The incidence and etiology of prosthetic services utilization is poorly understood during the first 90 days post-delivery of the initial lower limb prosthesis. This period is of critical importance, as prevailing policy dictates limits on the reimbursement for certain services provided during this time period. The first step in understanding the financial ramifications of such policy is to examine the taxonomy behind clinical encounters during this tenuous time period. OBJECTIVES Quantify and categorize clinical encounters by incidence and etiology. STUDY DESIGN Retrospective chart review. METHODS A central database containing data on prosthetic services was examined. Incidence and etiology were extracted through independent review of each patient chart. RESULTS A total of 537 unique patients were identified, with 109 meeting the inclusion criteria. Chi-square testing showed that comfort ( p < 0.05), cosmesis ( p < 0.01), and mechanical failure ( p < 0.001) yielded statistical significance in scheduled versus unscheduled visits. Stepwise regression analysis demonstrated that both sex and K-level were important predictors of unscheduled visits. CONCLUSION Taxonomization of clinical encounters experienced during the first 90 days provides a framework for future studies to be conducted. The data provided can serve as a basis for informing reimbursement policy, workforce planning, and advocacy. Clinical relevance Comfort is the most frequent reason for a clinical encounter during the first 90 days after delivering a lower limb prosthesis. The data on the taxonomy behind the clinical encounters can be used to guide workforce planning and advocate for just reimbursement policy that better reflect patient's needs.
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Affiliation(s)
| | - Michael Wininger
- 1 University of Hartford, West Hartford, CT, USA
- 3 Cooperative Studies Program, Department of Veterans Affairs, West Haven, CT, USA
- 4 Yale University, New Haven, CT, USA
| | - David Mahler
- 2 New England Orthotic & Prosthetic Systems, Branford, CT, USA
| | - Mark Parisi
- 2 New England Orthotic & Prosthetic Systems, Branford, CT, USA
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Collins A, Timmons S. Mobility outcomes for those with primary lower limb amputation attending a regional outpatient prosthetic rehabilitation service. ACTA ACUST UNITED AC 2018. [DOI: 10.3233/ppr-170105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aoife Collins
- Prosthetic, Orthotic and Limb Absence Rehabilitation (POLAR) Unit, Mercy University Hospital, Cork, Ireland
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Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 12, 2011. Phantom limb pain (PLP) is pain that arises in the missing limb after amputation and can be severe, intractable, and disabling. Various medications have been studied in the treatment of phantom pain. There is currently uncertainty in the optimal pharmacologic management of PLP. OBJECTIVES This review aimed to summarise the evidence of effectiveness of pharmacologic interventions in treating PLP. SEARCH METHODS For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL, the Cochrane Library), MEDLINE, and Embase for relevant studies. We ran the searches for the original review in September 2011 and subsequent searches for this update up to April 2016. We sought additional studies from clinical trials databases and reference lists of retrieved papers. SELECTION CRITERIA We included randomised and quasi-randomised trials studying the effectiveness of pharmacologic interventions compared with placebo, another active treatment, or no treatment, in established PLP. We considered the following outcomes: change in pain intensity, function, sleep, depression or mood, quality of life, adverse events, treatment satisfaction, and withdrawals from the study. DATA COLLECTION AND ANALYSIS We independently assessed issues of study quality and extracted efficacy and adverse event data. Due to the wide variability in the studies, we did not perform a meta-analysis for all the interventions and outcomes, but attempted to pool the results of some studies where possible. We prepared a qualitative description and narrative summary of results. We assessed clinical heterogeneity by making qualitative comparisons of the populations, interventions, outcomes/outcome measures, and methods. MAIN RESULTS We added only one new study with 14 participants to this updated review. We included a 14 studies (10 with low risk of bias and 4 with unclear risk of bias overall) with a total of 269 participants. We added another drug class, botulinum neurotoxins (BoNTs), in particular botulinum toxin A (BoNT/A), to the group of medications reviewed previously. Our primary outcome was change in pain intensity. Most studies did not report our secondary outcomes of sleep, depression or mood, quality of life, treatment satisfaction, or withdrawals from the study.BoNT/A did not improve phantom limb pain intensity during the six months of follow-up compared with lidocaine/methylprednisolone.Compared with placebo, morphine (oral and intravenous) was effective in decreasing pain intensity in the short term with reported adverse events being constipation, sedation, tiredness, dizziness, sweating, voiding difficulty, vertigo, itching, and respiratory problems.The N-methyl D-aspartate (NMDA) receptor antagonists ketamine (versus placebo; versus calcitonin) and dextromethorphan (versus placebo), but not memantine, had analgesic effects. The adverse events of ketamine were more serious than placebo and calcitonin and included loss of consciousness, sedation, hallucinations, hearing and position impairment, and insobriety.The results for gabapentin in terms of pain relief were conflicting, but combining the results favoured treatment group (gabapentin) over control group (placebo) (mean difference -1.16, 95% confidence interval -1.94 to -0.38; 2 studies). However, gabapentin did not improve function, depression score, or sleep quality. Adverse events experienced were somnolence, dizziness, headache, and nausea.Compared with an active control benztropine mesylate, amitriptyline was not effective in PLP, with dry mouth and dizziness as the most frequent adverse events based on one study.The findings for calcitonin (versus placebo; versus ketamine) and local anaesthetics (versus placebo) were variable. Adverse events of calcitonin were headache, vertigo, drowsiness, nausea, vomiting, and hot and cold flushes. Most of the studies were limited by their small sample sizes. AUTHORS' CONCLUSIONS Since the last version of this review, we identified another study that added another form of medical therapy, BoNTs, specifically BoNT/A, to the list of pharmacologic interventions being reviewed for clinical efficacy in phantom limb pain. However, the results of this study did not substantially change the main conclusions. The short- and long-term effectiveness of BoNT/A, opioids, NMDA receptor antagonists, anticonvulsants, antidepressants, calcitonins, and local anaesthetics for clinically relevant outcomes including pain, function, mood, sleep, quality of life, treatment satisfaction, and adverse events remain unclear. Based on a small study, BoNT/A (versus lidocaine/methylprednisolone) does not decrease phantom limb pain. Morphine, gabapentin, and ketamine demonstrate favourable short-term analgesic efficacy compared with placebo. Memantine and amitriptyline may not be effective for PLP. However, results must be interpreted with caution, as they were based mostly on a small number of studies with limited sample sizes that varied considerably and also lacked long-term efficacy and safety outcomes. The direction of efficacy of calcitonin, local anaesthetics, and dextromethorphan needs further clarification. Overall, the efficacy evidence for the reviewed medications is thus far inconclusive. Larger and more rigorous randomised controlled trials are needed for us to reach more definitive conclusions about which medications would be useful for clinical practice.
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Affiliation(s)
- Maria Jenelyn M Alviar
- University of Melbourne-Royal Melbourne Hospital, Grattan St, Melbourne, Victoria, Australia, 3010
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Caputo WJ, Vaquero C, Monterosa A, Monterosa P, Johnson E, Beggs D, Fahoury GJ. A retrospective study of cryopreserved umbilical cord as an adjunctive therapy to promote the healing of chronic, complex foot ulcers with underlying osteomyelitis. Wound Repair Regen 2016; 24:885-893. [PMID: 27312890 DOI: 10.1111/wrr.12456] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 06/13/2016] [Indexed: 01/29/2023]
Abstract
Complex lower extremity ulcers with exposed bone, tendon, muscle, and/or joint capsule as well as multiple comorbidities including diabetes, ischemia, and underlying osteomyelitis are difficult to heal and associated with high morbidity and mortality and high rates of amputation. A retrospective review was performed to assess healing of 31 patients presenting with 33 complex foot ulcers with a confirmed histopathological diagnosis of osteomyelitis treated by the same surgeon at a single wound care center by the following treatment regimen: sharp debridement, resection of infected bone when necessary, open cortex, antibiotics, and application of cryopreserved umbilical cord (cUC). The average ulcer size was 15.6 ± 17.7 cm2 (0.4-73.95 cm2 ). Overall, 26 out of the 33 wounds achieved complete closure (78.8%). Five patients were lost to follow-up and one patient expired during the course of treatment, not believed to be treatment related. Of the remaining 27 wounds in patients not lost to follow-up, 26 achieved complete healing with an average time to healing of 16 weeks and an average of 1.24 applications of cUC. The results suggest that cUC used as an adjunctive tissue therapy in conjunction with surgical debridement, resection of infected bone, open cortex, and antibiotic treatment may be an effective overall treatment strategy to promote wound healing of complex foot ulcers associated with osteomyelitis. The preliminary results are encouraging and warrant further randomized control studies to determine whether cUC might help address such an unmet medical need.
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Affiliation(s)
- Wayne J Caputo
- Department of Podiatry, Clara Maass Medical Center, Belleville, New Jersey. .,The Wound Center, Clara Maass Medical Center, Belleville, New Jersey.
| | - Carina Vaquero
- The Wound Center, Clara Maass Medical Center, Belleville, New Jersey
| | - Alexis Monterosa
- The Wound Center, Clara Maass Medical Center, Belleville, New Jersey
| | | | - Edward Johnson
- Infectious Diseases Department, Clara Maass Medical Center, Belleville, New Jersey
| | - Donald Beggs
- Infectious Diseases Department, Clara Maass Medical Center, Belleville, New Jersey
| | - George J Fahoury
- Department of Podiatry, Clara Maass Medical Center, Belleville, New Jersey
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Imam B, Miller WC, Finlayson H, Eng JJ, Jarus T. A randomized controlled trial to evaluate the feasibility of the Wii Fit for improving walking in older adults with lower limb amputation. Clin Rehabil 2016; 31:82-92. [DOI: 10.1177/0269215515623601] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To assess the feasibility of Wii.n.Walk for improving walking capacity in older adults with lower limb amputation. Design: A parallel, evaluator-blind randomized controlled feasibility trial. Setting: Community-living. Participants: Individuals who were ⩾50 years old with a unilateral lower limb amputation. Intervention: Wii.n.Walk consisted of Wii Fit training, 3x/week (40 minute sessions), for 4 weeks. Training started in the clinic in groups of 3 and graduated to unsupervised home training. Control group were trained using cognitive games. Main Measures: Feasibility indicators: trial process (recruitment, retention, participants’ perceived benefit from the Wii.n.Walk intervention measured by exit questionnaire), resources (adherence), management (participant processing, blinding), and treatment (adverse event, and Cohen’s d effect size and variance). Primary clinical outcome: walking capacity measured using the 2 Minute Walk Test at baseline, end of treatment, and 3-week retention. Results: Of 28 randomized participants, 24 completed the trial (12/arm). Median (range) age was 62.0 (50-78) years. Mean (SD) score for perceived benefit from the Wii.n.Walk intervention was 38.9/45 (6.8). Adherence was 83.4%. The effect sizes for the 2 Minute Walk Test were 0.5 (end of treatment) and 0.6 (3-week retention) based on intention to treat with imputed data; and 0.9 (end of treatment) and 1.2 (3-week retention) based on per protocol analysis. The required sample size for a future larger RCT was deemed to be 72 (36 per arm). Conclusions: The results suggested the feasibility of the Wii.n.Walk with a medium effect size for improving walking capacity. Future larger randomized controlled trials investigating efficacy are warranted.
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Affiliation(s)
- Bita Imam
- Graduate Program in Rehabilitation Sciences, University of British Columbia, Vancouver, Canada
| | - William C Miller
- Graduate Program in Rehabilitation Sciences, University of British Columbia, Vancouver, Canada
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada
| | - Heather Finlayson
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
| | - Janice J Eng
- Graduate Program in Rehabilitation Sciences, University of British Columbia, Vancouver, Canada
- Department of Physical Therapy, University of British Columbia, Vancouver, Canada
| | - Tal Jarus
- Graduate Program in Rehabilitation Sciences, University of British Columbia, Vancouver, Canada
- Department of Occupational Science and Occupational Therapy, University of British Columbia, Vancouver, Canada
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Ünver B, Şahan TY, Türkyılmaz S, Karagözoğlu A, Ülger Ö. The status of application and physiotherapy-rehabilitation of prosthetics in Turkey. J Phys Ther Sci 2016; 28:1534-7. [PMID: 27313365 PMCID: PMC4905904 DOI: 10.1589/jpts.28.1534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 02/02/2016] [Indexed: 11/30/2022] Open
Abstract
[Purpose] The aim of this study was to determine the frequency of prosthetic applications
and to appraise the importance of amputee rehabilitation in Turkey. [Subjects and Methods]
Questionnaires were administered to owners or employees of 36 institutions and the
obtained data were evaluated. [Results] While 75% of institutions had no physiotherapist,
25% had 1 or 2 physiotherapists; there were 4 or fewer technicians in 86.1%, and the
majority of employees were out of profession in almost all institutions. A total of 83.3%
of institutions reported falls, 75% reported complications, 58.3% of them occasionally
noted the need of repair; 55.6% of institutions made preprosthetic assessments, 63.9% used
gait analysis, and 50% performed prosthetic rehabilitation frequently. [Conclusion] The
results of this study reveal the need for more physiotherapists in these centers, the
utilization of standardized-objective assessment methods, and development of
rehabilitation processes for successful prosthetic applications and amputee rehabilitation
in Turkey.
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Affiliation(s)
- Banu Ünver
- Istanbul Aydın University: Sefaköy-Küçükçekmece, 34295 İstanbul, Turkey
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Mundell BF, Kremers HM, Visscher S, Hoppe KM, Kaufman KR. Predictors of Receiving a Prosthesis for Adults With Above-Knee Amputations in a Well-Defined Population. PM R 2015; 8:730-7. [PMID: 26690021 DOI: 10.1016/j.pmrj.2015.11.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 11/23/2015] [Accepted: 11/27/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Prior studies have identified age as a factor in determining an individual's likelihood of receiving a prosthesis following a lower limb amputation. These studies are limited to specific subsets of the general population and are unable to account for preamputation characteristics within their study populations. Our study seeks to determine the effect of preamputation characteristics on the probability of receiving a prosthesis for the general population in the United States. OBJECTIVE To identify preamputation characteristics that predict of the likelihood of receiving a prosthesis following an above-knee amputation. DESIGN A retrospective, population-based cohort study. SETTING Olmsted County, Minnesota (2010 population: 144,248). PARTICIPANTS Individuals (n = 93) over the age of 18 years who underwent an above-knee amputation, that is, knee disarticulation or transfemoral amputation, while residing in Olmsted County, MN, between 1987 and 2013. METHODS Characteristics affecting the receipt of a prosthesis were analyzed using a logistic regression and a random forest algorithm for classification trees. Preamputation characteristics included age, gender, amputation etiology, year of amputation, mobility, cognitive ability, comorbidities, and time between surgery and the prosthesis decision. MAIN OUTCOME MEASURES The association of preamputation characteristics with the receipt of a prosthesis following an above-knee amputation. RESULTS Twenty-four of the participants received a prosthesis. The odds of receiving a prosthesis were almost 30 times higher in those able to walk independently prior to an amputation relative to those who could not walk independently. A 10-year increase in age was associated with a 53.8% decrease in the likelihood of being fit for a prosthesis (odds ratio = 0.462, P =.030). Time elapsed between surgery and the prosthesis decision was associated with a rise in probability of receiving a prosthesis for the first 3 months in the random forest algorithm. No other observed characteristics were associated with receipt of a prosthesis. CONCLUSIONS The association of preamputation mobility and age with the likelihood of being fit for a prosthesis is well understood. The effect of age, after controlling for confounders, still persists and is associated with the likelihood of being fit for a prosthesis.
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Affiliation(s)
| | - Hilal Maradit Kremers
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN; Department of Health Sciences Research, Mayo Clinic, Rochester, MN(†)
| | - Sue Visscher
- Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN(‡)
| | - Kurtis M Hoppe
- Department of Physical Medicine & Rehabilitation, Mayo Clinic, Rochester, MN(§)
| | - Kenton R Kaufman
- Department of Orthopedic Surgery, Mayo Clinic, 200 First St SW, Rochester 55905, MN(‖)(#).
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Chamlian TR. Use of prostheses in lower limb amputee patients due to peripheral arterial disease. EINSTEIN-SAO PAULO 2014; 12:440-6. [PMID: 25628194 PMCID: PMC4879909 DOI: 10.1590/s1679-45082014ao3132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 10/30/2014] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To evaluate the indication of prosthesis during rehabilitation and the maintenance of their use or abandonment rate after discharge, as well as mortality of lower limb amputees due to peripheral arterial disease. METHODS A retrospective and cross-sectional study carried out with lower limb amputee patients, at transfemoral and transtibial levels, due to vascular conditions. The sample was composed of 310 patients (205 men, 105 women, mean age 61.8 years), transfemoral (142) and transtibial (150) levels, unilateral or bilateral (18). A total of 217 were fitted with prosthesis and 93 did not. Nonparametric statistical tests with equality of two proportions, 95% confidence interval and p value <0,05 were used. RESULTS Out of 195 patients we contacted, 151 were fitted with prosthesis and 44 not. Of those that were fitted with prosthesis, 54 still use it, 80 abandoned and 17 died. In the group without prosthesis, 27 were on wheelchair and 17 died. Mortality is statistically higher among patients who were not fitted with prosthesis and 34 death occur, on average, 3.91 years after amputation. Survival time of patients who were not fitted with prosthesis was smaller than those were fitted. CONCLUSION The use of prosthesis in lower limb amputees, due to vascular conditions, during rehabilitation is high. However, maintenance of prosthesis is not frequent after discharge. Early and high mortality is observed mainly among diabetic patients.
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