Relationships Among Perceived Functional Capacity, Self-Efficacy, and Disability After Dysvascular Amputation

Dynamic gait stability and stability symmetry for people with transfemoral amputation: A case-series of 19 individuals with bone-anchored limbs

For some individuals with severe socket-related problems, prosthesis osseointegration directly connects a prosthesis to the residual limb creating a bone-anchored limb (BAL). We compared dynamic gait stability and between-limb stability symmetry, as measured by the Margin of Stability (MoS) and the Normalized Symmetry Index (NSI), for people with unilateral transfemoral amputation before and one-year after BAL implantation. The MoS provides a mechanical construct to assess dynamic gait stability and infer center of mass and limb control by relating the center of mass and velocity to the base of support. Before and one-year after BAL implantation, 19 participants walked overground at self-selected speeds. We quantified dynamic gait stability anteriorly and laterally at foot strike and at the minimum lateral MoS value. After implantation, we observed decreased lateral MoS at foot strike for the amputated (MoS mean(SD) %height; pre: 6.6(2.3), post: 5.9(1.3), d = 0.45) and intact limb (pre: 6.2(1.2), post: 5.8(1.0), d = 0.38) and increased between-limb MoS symmetry at foot strike (NSI mean(SD) %; anterior-pre: 10.3(7.3), post: 8.4(3.6), d = 0.23; lateral-pre: 18.8(12.4), post: 12.4(4.9), d = 0.47) and at minimum lateral stability (pre: 28.1(18.1), post: 19.2(6.8), d = 0.50). Center of mass control using a BAL resulted in dynamic gait stability more similar between limbs and may have reduced the adoption of functional asymmetries. We suggest that improved between-limb MoS symmetry after BAL implantation is likely due to subtle changes in individual limb MoS values at self-selected walking speeds resulting in an overall positive impact on fall risk through improved center of mass and prosthetic limb control.

Four weeks of inpatient comprehensive prosthetic rehabilitation achieves contrasting results in different groups of prosthetic users

BACKGROUND

This study explored how inpatient exercise rehabilitation affected prosthetic mobility, function, and ambulation in persons with lower limb loss.

METHODS

In this explorative prospective nonrandomized intervention study, experienced (EXP-INT, n = 20) and new prosthetic users (NEW-INT, n = 18) completed a 4-week rehabilitation intervention. A control group of experienced prosthetic users (n = 19) received no intervention. Tests were performed at baseline (pretest) and after 4 weeks (posttest). A step-monitoring device recorded ambulatory activity.

RESULTS

For the primary outcome measure, Prosthetic Limb Users Survey of Mobility, the between-group analysis revealed significant differences (χ2 = 10.91, df = 2, p < 0.01). Within-group Prosthetic Limb Users Survey of Mobility T-scores improved by 8.1% for the EXP-INT (p < 0.01) and 15.1% for NEW-INT (p < 0.01). Significant between-group differences were observed for the Amputee Mobility Predictor, L-test, 2-minute walk test, and 10-meter walk test. Within-group analysis demonstrated nonsignificant changes for the EXP-INT except for Prosthetic Limb Users Survey of Mobility, while the NEW-INT improved by 24.1% (p < 0.001), 34.0% (p < 0.01), 46.5% (p < 0.05), and 31.0% (p < 0.01), respectively. The number of steps during the last 7 d of rehabilitation showed significant differences between the groups (χ2 = 13.99, df = 2, p < 0.001). The NEW-INT improved by 138% (p < 0.05) compared with the first 7 d of rehabilitation, while the EXP-INT had nonsignificant changes.

CONCLUSIONS

A 4-week rehabilitation intervention substantially increased prosthetic mobility, function, and ambulation activity for new prosthetic users but less so for experienced users. The results of the NEW-INT at discharge signify a considerable functional improvement.

Role of self-efficacy on functional limitations among persons with spinal cord injury

OBJECTIVES

Spinal cord injury (SCI) results in mild to severe functional limitations, decreasing a person's ability to perform activities of daily living. This study aims to identify the influence of SCI characteristics and self-efficacy on functional limitations, controlling for sociodemographic factors.

METHODS

Participants for this cross-sectional descriptive study included 272 persons with SCI. The participants completed questionnaires on sociodemographic information, secondary physical conditions, self-efficacy, and functional limitations, using an online Qualtrics Survey. Multiple hierarchical regression analysis was performed to test the hypothesis.

RESULTS

Participants reported higher functional limitations on dressing the lower body and managing their bowels compared to other activities of daily living. The sociodemographics, injury characteristics, and self-efficacy collectively accounted for 66% variance in functional limitations. A higher level of secondary physical conditions and tetraplegia injury contributed to higher functional limitations. As hypothesized, greater self-efficacy significantly contributed to low functional limitations above and beyond sociodemographic and SCI-related variables.

DISCUSSION

Functional limitations following SCI are a pervasive challange in persons with SCI. Early recognition and management of secondary conditions and implementation of psychological interventions to strengthen self-efficacy in performing activities and managing secondary complications could potentially enhance functional independence and, ultimately, quality of life in this population.

Walking asymmetry and its relation to patient-reported and performance-based outcome measures in individuals with unilateral lower limb loss

Gait asymmetry persists for most people after lower limb amputation and is associated with slower walking speeds. However, the relationship between gait asymmetry and patient-reported function remains unclear because they are not commonly assessed together. The purpose of this study was to determine relationships between gait asymmetries in people with lower limb loss and (1) patient-reported outcomes and (2) performance-based prosthetic functional measures. This cross-sectional analysis included nine people with unilateral limb loss aged 48.2 ± 13.1 years of mixed amputation etiology. Patient-reported outcomes included the Prosthetic Evaluation Questionnaire mobility subscale and Activities-specific Balance Confidence scale. Performance outcomes included the Berg Balance Scale and the 30-second sit-to-stand test. Walking performance measures included the 2-Minute Walk Test, during which APDM Opal sensors recorded spatiotemporal gait parameters, and daily step-counts from StepWatch4 activity monitors. The study found that the most asymmetric gait symmetry ratios (prosthetic-limb divided by intact-limb) could be attributed to prosthetic foot dorsiflexion-plantarflexion and rotation motion limitations: prosthetic-limb trailing double support (0.789 ± 0.052), toe-off (0.760 ± 0.068) and toe-out angle (0.653 ± 0.256). Single limb stance, and stance and swing phase durations were most strongly associated with balance and walking performance measures. Notably, no symmetry ratio was significantly associated with patient-reported prosthetic function (unadjusted Pearson correlation coefficients r < 0.50, P > 0.05). More gait symmetry was associated with better balance and walking performance but had no significant relationship with patient-reported function. Although achieving gait symmetry after lower limb loss is a common walking goal, symmetry was unrelated to the perception of functional mobility for people with lower limb loss.

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users

OBJECTIVE

To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function.

DESIGN

Cross-sectional, observational study SETTING: General community.

PARTICIPANTS

Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire.

RESULTS

Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [β]=-0.15, P=.02), even after adjusting for depressive symptoms (β=-0.31, P<.001), prosthesis satisfaction (β=0.34, P<.001), number of chronic conditions (β=-0.19, P=.006), and assistive device use (βcane=0.01, P=.93; βother=-0.20, P=.003). Together, these variables explained 59% of perceived physical function variability.

CONCLUSIONS

Cognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

Error-Manipulation Gait Training for Veterans With Nontraumatic Lower Limb Amputation: A Randomized Controlled Trial Protocol

OBJECTIVE

he purpose of this study will be to determine the efficacy of error-manipulation gait training (error-augmentation or error-correction) to improve step length symmetry and secondary health outcomes in veterans with unilateral nontraumatic transtibial amputation (TTA).

METHODS

This will be a 3-arm, parallel, assessor-blinded, randomized controlled trial, with baseline, postintervention, and 3-month follow-up assessments in a VA Geriatric Research Education and Clinical Center. Participants are 54 US military veterans ranging in age from 50 to 85 years with a unilateral transtibial nontraumatic amputation. Participants will be randomized into 1 of 3 groups: error-augmentation training (EAT), error-correction training (ECT), or supervised walking (CTL). Each group will complete 8 split-belt treadmill walking training sessions of 25 minutes each over 4 weeks. The EAT group will walk with belts moving at asymmetrical speeds. The ECT group will walk to the cadence of a metronome and the split belts moving at symmetrical speeds. The CTL group will walk with symmetrical belt speeds and without feedback. Step length symmetry is the primary outcome and will be assessed using an asymmetry index during overground walking. Secondary outcomes include lower extremity joint work during treadmill walking, 6-Minute Walk Test performance, daily step count, participant-perceived disability, and residual-limb integumentary health. Outcomes will be assessed at preintervention, 1-week postintervention (primary endpoint), and 13 weeks postintervention.

IMPACT

This study protocol focuses on an understudied area of rehabilitation for patients with nontraumatic unilateral TTA who have high levels of spatiotemporal gait asymmetry and mobility impairment. The results of this study will inform future implementation of clinical gait training interventions to improve spatiotemporal gait symmetry and long-term health and disability outcomes in patients with nontraumatic unilateral TTA.

"This New Chapter of Life": Content Analysis of Facebook Posts After Traumatic Brachial Plexus Injury

Background: After traumatic brachial plexus injuries (BPI), the sudden loss of physical function is often accompanied by psychological distress. Given the complex nature and relative infrequency of the injury, BPI patients will often use online resources for information about their injury as well as emotional support. Questions/Purpose: Recognizing the influence of social media, we sought to search a popular social media platform to identify challenges faced by BPI patients and strategies used to overcome these challenges. Methods: We searched "traumatic brachial plexus injury" on Facebook and selected the 2 most popular BPI support groups. We collected posts regarding traumatic BPI from November 1, 2018 through November 1, 2019. We performed inductive and deductive thematic analysis of the posts to identify recurring topics, knowledge gaps, and peer interaction dynamics. Results: We analyzed 7694 posts from the 2 Facebook support groups. The following themes emerged: (1) BPI patients express discontent regarding the inability to use their arm and the slow or stagnant pace of recovery; (2) BPI patients are frustrated over their inability to retain their preinjury livelihood; and (3) BPI patients emphasize that acceptance and moving on are key components of adjustment to their condition. Some patients described the role of limb amputation in achieving these goals. Conclusions: Our analysis demonstrates the areas in which BPI patients are in need of emotional support. Adjustment to BPI might be facilitated through multidisciplinary care that addresses emotional aspects of recovery and emphasizes self-management skills, in addition to the traditional focus on physical function.

Psychosocial Factors Influence Physical Activity after Dysvascular Amputation: A Convergent Mixed-Methods Study

BACKGROUND

Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear.

OBJECTIVE

To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives.

DESIGN

Convergent mixed-methods.

SETTING

General community.

PARTICIPANTS

Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews.

RESULTS

Higher steps/d was moderately correlated with better TUG time (r = -.58, P < .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P > .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases.

CONCLUSIONS

Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA.

Psychometric Assessment of the Connor-Davidson Resilience Scale for People With Lower-Limb Amputation

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.

Patient Reported Outcome Measures for Major Lower Limb Amputation Caused by Peripheral Artery Disease or Diabetes: A Systematic Review

OBJECTIVE

Most major lower limb amputations are related to peripheral artery disease (PAD) or diabetes. Just 40% of patients who undergo major lower limb amputation will use a prosthesis yet measures of surgical success commonly focus on prosthesis use. Patient reported outcome measures (PROMs) are valuable to comprehensively evaluate health related quality of life (HRQL) after surgery. This systematic review aimed to identify and describe PROMs available to assess HRQL in patients after amputation for PAD or diabetes.

METHODS

A search was conducted based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) for systematic reviews of PROMs. Ovid MEDLINE, Ovid EMBASE, PsycINFO, CINAHL, and Cochrane CENTRAL were also searched from inception until August 2019. Included were articles describing the development, measurement properties, or evaluation of HRQL via a PROM in adult patients after amputation for PAD or diabetes. Studies of amputation exclusively for trauma or malignancy were excluded. Data were collected on study characteristics, PROM characteristics (generic/disease specific), and properties of amputation specific PROMs.

RESULTS

Of 3 317 abstracts screened, 111 full text articles were assessed for eligibility and 64 included. Fifty-six studies evaluated HRQL, with 23 (46%) of these using an amputation specific PROM to do so. Eleven different amputation specific PROMs were identified, 10 (91%) of which were developed only for prosthesis users. One measure was suitable for use in all patients after amputation. This "Amputee single item mobility measure" includes a single item evaluating mobility. Nine studies reported some psychometric testing of an amputation specific PROM.

CONCLUSION

A well tested, multidimensional PROM applicable to wheelchair and prosthetic users after amputation is lacking and urgently needed for studies in this field. Future work to develop an appropriate measure is required.

Self-Efficacy and Social Support are Associated with Disability for Ambulatory Prosthesis Users After Lower-Limb Amputation

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.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Sociodemographic Determinants for the Health-Related Quality of Life of Patients with Vascular Amputations as Determined with the Prosthesis Evaluation Questionnaire

Background: To identify the sociodemographic variables independently related to the different dimensions of the Prosthesis Evaluation Questionnaire (PEQ). Methods: An observational, cross-sectional study was conducted, with a sample of 61 Spanish vascular amputees (Valencia, Spain). Included in this study are the results of the PEQ and explanatory-sociodemographic variables, as well as a descriptive and analytic analysis. Results: Gender differences were observed in “appearance” and “perception of appearance” (significantly higher levels for men). Older patients tended to have worse scores in “utility”, “frustration”, “social burden” and “deambulation”. More favorable scores were obtained for those residing in rural areas in “social burden” and “deambulation”. Educational level had a positive correlation with scores. Conclusion: Gender, age, place of residence, and educational level could be considered determinants of the quality of health related to prosthesis adaptation in vascular amputees. Clinical relevance: Knowing the influential variables in the process of prosthetization will allow better adaptation and an improvement in the quality of life.