A systematic literature review of physiotherapy and rehabilitation approaches to lower-limb amputation

Relationship of stump length with muscle strength, proprioception, and balance in patients with traumatic unilateral transfemoral amputation

BACKGROUND

Many factors affect the rehabilitation of lower limb amputation. One of these factors is the length of the stump.

OBJECTIVE

The aim of this study was to assess the relationship of stump length with muscle strength, proprioception, and balance in patients with traumatic unilateral transfemoral amputation.

STUDY DESIGN

Sixteen patients with traumatic unilateral transfemoral amputation were included in this cross-sectional study.

METHODS

Stump length was determined by measuring the distance from the trochanter major to the tip of the stump. Hip extensor and flexor muscle strength on the amputated side was determined using the computer-assisted isokinetic system. The proprioceptive sensation of the lower extremities was measured at hip flexion with computer-assisted isokinetic system. Balance of the patients was determined using the Berg Balance Scale.

RESULTS

There was a statistically significant negative correlation between the stump length and proprioception measurements (r = -0.508, p = 0.044). There was also a statistically significant correlation between Berg Balance Scale and the flexion total work value at 60° angular velocity (r = 0.541, p = 0.03). There was no significant correlation between stump length and other muscle strength, proprioception, and balance parameters.

CONCLUSIONS

A relationship was found between stump length and proprioception, and balance and hip flexor muscle strength in patients with traumatic unilateral transfemoral amputation. In elective lower limb amputations, the level of amputation should be determined at the most functional level with the longest possible stump.

Effectiveness of telerehabilitation-based structured exercise program in individuals with unilateral transtibial amputation: a randomized controlled study

PURPOSE

The study aimed to compare the effects of home exercise alone and telerehabilitation combined with home exercise in individuals with transtibial amputation.

MATERIALS AND METHODS

The telerehabilitation group (n = 24) received telerehabilitation combined with home exercise, while the control group (n = 24) received home exercise alone. Outcomes included the timed up-and-go (TUG) test and the 30-second chair-stand test (30CST), the Activities-specific Balance Confidence (ABC) Scale, the Trinity Amputation and Prosthesis Experience Scales (TAPES), the Amputee Body Image Scale (ABIS), and the Nottingham Health Profile (NHP). The analysis used a 2 × 2 mixed repeated measures ANOVA.

RESULTS

The group-by-time interactions were significant for TUG (p = 0.002, F[1;41] = 10.74) and 30CST (p = 0.001, F[1;41] = 11.48). The mean difference (6th week-baseline) was -0.49 for TUG and 0.95 for 30CST in the telerehabilitation group and -0.14 for TUG and 0.13 for 30CST in the control group. There were statistically meaningful group-by-time interactions on the ABC (p = 0.0004, F[1;41] = 14.47), the TAPES-activity restriction (p = 0.0001, F[1;41] = 28.96), TAPES-prosthesis satisfaction (p = 0.004, F[1;41] = 9.19), and the NHP (p = 0.0002, F[1;41] = 16.07) favoring the telerehabilitation group.

CONCLUSIONS

Telerehabilitation combined with home exercise can offer greater benefits in improving gait, muscle strength, balance confidence, activity restriction, prosthesis satisfaction, and quality of life compared to home exercise alone for individuals with transtibial amputation.Implications for rehabilitationExercise helps individuals with lower limb amputation overcome their physical limitations and enables them to use their prostheses effectively.Physiotherapy and rehabilitation after amputation are not at the desired level, and individuals with lower limb amputation encounter various difficulties in accessing physiotherapy.Telerehabilitation has great potential to facilitate access to physiotherapy for individuals with amputation and reduce resource utilization.In a relatively small sample of amputees, this study shows that telerehabilitation-based exercise improves physical health and quality of life.

Utilization and Perception of Peer-Support After Lower Limb Loss in the United States: Potential Benefits on Mobility Outcomes

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.

Outcomes of Patients with Lower Limb Loss after Using a Training Prosthesis: A Retrospective Case Series Study

The aim of this retrospective case series study was to investigate outcomes in patients with lower limb loss based on whether or not they used a training prosthesis (TP) during rehabilitation. The medical records of 171 consecutive patients admitted to rehabilitation hospitalization between January 2014 and December 2018 following a major amputation of the lower limb were reviewed. Patients were categorized into two groups: patients who underwent rehabilitation with a TP and patients who did not use a TP. Outcomes (i.e., discharge destination, length of stay, number of sockets required, and number of the size adaptation of each socket, as well as functional level) were compared between groups. Of the 171 patients, 126 underwent rehabilitation with a TP, and 45 patients underwent rehabilitation without any TP. In conclusion, we found that patients who used a TP had a significantly shorter hospital length of stay when compared to those who did not. This length of stay for patients with TP was not influenced by age but was lowered by a higher body mass index (BMI), tibial instead of femoral amputation, and the male gender. No association was found between the use of TP and discharge destination, functional level, number of socket modifications, and number of sockets required.

Physiotherapy Rehabilitation for Above-Knee Amputation Secondary to Infected External Fixation: A Case Report

This case study examines the total physiotherapy care of a 50-year-old male patient, who had a right-sided displaced distal tibia and fibula fracture, a talus fracture due to a road traffic accident, and an above-knee amputation due to a serious infection. Enhancing muscle strength, reducing pain from phantom limbs, avoiding problems, maintaining range of motion, increasing endurance, and promoting functional independence in the postoperative period were the main goals of the patient's rehabilitation. The recovery plan included an intensive four-week program of physiotherapy care. The regimen included a variety of interventions, such as pain management, edema control, wound healing techniques, range of motion (ROM) exercises, muscle strengthening activities, mobility and transfer exercises, cardiovascular endurance training, psychosocial support, education on prosthetic use, and independence in daily living activities. ROM measures, manual muscle testing, and functional independence measure scores were used to evaluate the patient's improvement. The patient's physical health and level of functional independence both exhibited significant improvements, according to the statistics. Following treatment, the patient's ROM, muscle strength, and overall functional independence all improved. The study highlights the positive impacts of physical therapy interventions on the patient's quality of life, mobility, and self-sufficiency following the amputation and subsequent recovery. These findings support the patient's transition to a more self-sufficient and active lifestyle by providing valuable insights into the efficient use of physiotherapy and the comprehensive post-amputation treatment plan.

Lower limb prosthetic prescription

Lower limb amputations are the most common level of amputation. Mobilization of patients with lower limb amputations is an important rehabilitation goal. It is critical to prescribe the most appropriate prosthesis for the patient to achieve the rehabilitation goal in lower extremity amputations. Appropriate prosthesis prescription in lower extremity amputations is based on the selection of the correct prosthetic parts. The choice of prosthesis should be based on the patient's activity level and potential. The prosthesis decision should be made by a team, particularly with the participation of the patient.

Effects of simulated hypo-gravity on lower limb kinematic and electromyographic variables during anti-gravitational treadmill walking

Introduction: This study investigated kinematic and EMG changes in gait across simulated gravitational unloading levels between 100% and 20% of normal body weight. This study sought to identify if each level of unloading elicited consistent changes-particular to that percentage of normal body weight-or if the changes seen with unloading could be influenced by the previous level(s) of unloading. Methods: 15 healthy adult participants (26.3 ± 2.5 years; 53% female) walked in an Alter-G anti-gravity treadmill unloading system (mean speed: 1.49 ± 0.37 mph) for 1 min each at 100%, 80%, 60%, 40% and 20% of normal body weight, before loading back to 100% in reverse order. Lower-body kinematic data were captured by inertial measurement units, and EMG data were collected from the rectus femoris, biceps femoris, medial gastrocnemius, and anterior tibialis. Data were compared across like levels of load using repeated measures ANOVA and statistical parametric mapping. Difference waveforms for adjacent levels were created to examine the rate of change between different unloading levels. Results: This study found hip, knee, and ankle kinematics as well as activity in the rectus femoris, and medial gastrocnemius were significantly different at the same level of unloading, having arrived from a higher, or lower level of unloading. There were no significant changes in the kinematic difference waveforms, however the waveform representing the change in EMG between 100% and 80% load was significantly different from all other levels. Discussion: This study found that body weight unloading from 100% to 20% elicited distinct responses in the medial gastrocnemius, as well as partly in the rectus femoris. Hip, knee, and ankle kinematics were also affected differentially by loading and unloading, especially at 40% of normal body weight. These findings suggest the previous level of gravitational load is an important factor to consider in determining kinematic and EMG responses to the current level during loading and unloading below standard g. Similarly, the rate of change in kinematics from 100% to 20% appears to be linear, while the rate of change in EMG was non-linear. This is of particular interest, as it suggests that kinematic and EMG measures decouple with unloading and may react to unloading uniquely.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

ADVERSE EVENTS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Virtual Reality-Based Rehabilitation to Restore Motor Function in People With Amputation: A Systematic Literature Review

ABSTRACT

Virtual reality is an emerging technology with accumulating research and clinical evidence in the field of physical rehabilitation. This study aimed to systematically identify and examine the effects of virtual reality on motor function outcomes in patients with amputation to inform clinical decision making on amputation rehabilitation and inform further research endeavors. Five databases were searched, including PubMed, CINAHL, PsycINFO, Embase, and Scopus. After screening for 1052 records, 10 clinical studies were included in this review: four randomized controlled trials, three pre-post single-arm studies, and three case studies; all studies had fair to good methodological quality. Seven studies were for lower extremity amputation, and three were for upper extremity amputation. Results reveal the positive effects of virtual reality on improving motor function in prosthesis training, including balance, gait, and upper extremity outcomes. Participants also report enjoyment during virtual reality intervention as measured by subjective experience. However, it is unclear whether virtual reality can induce better therapeutic outcomes than conventional rehabilitation, given the limited number of controlled studies and conflicting results reported in the included studies. More properly designed randomized controlled trials with adequately powered sample sizes are warranted to elucidate the benefits of virtual reality-based rehabilitation in the amputation population.

A Systematic Review of Cognitive Functioning and its Relationship to Outcomes Following Amputation Secondary to Vascular Etiology

Amputation is a major life event, impacting on all aspects of daily living, and has the goal of achieving maximal patient mobility and independence. The level of cognitive function of those patients who are assigned a prosthesis is an important consideration in the rehabilitation process. Therefore we set out to understand the relationship between cognitive functioning and functional and/or health outcomes following amputation secondary to a vascular condition. This systematic review searched five databases: PsycINFO, Cumulative index to nursing and allied health literature (CINAHL), Scopus, MEDLINE, and Web of Science for peer-reviewed English language articles that met the inclusion criteria. Two authors independently assessed suitability for inclusion, determined biases (Cochrane risk of bias assessment) and extracted data. Results are presented as associations determined on the balance of probabilities. A total of 14 studies were included, with a total of 6891 participants across six domains. Evidence of an association between cognitive function and prosthetic use, mobility and activities of daily living (ADLs) were found. Evidence revealed 83.3% association for cognition and mobility, 66.7% for cognition and ADL, and 62.5% for cognition and prosthetic use. The evidence was indeterminate for an association between cognitive function and living/discharge destination. There was insufficient weight of evidence to determine an association between cognitive function and general health or social participation. The associations found between cognitive function and prosthetic use, mobility and ADL highlight the need for cognitive assessment to form part of the postoperative pathway for vascular amputees.

Gait Alteration in Individual with Limb Loss: The Role of Inertial Sensors

Amputation has a big impact on the functioning of patients, with negative effects on locomotion and dexterity. In this context, inertial measurement units represent a useful tool in clinical practice for motion analysis, and in the development of personalized aids to improve a patient's function. To date, there is still a gap of knowledge in the scientific literature on the application of inertial sensors in amputee patients. Thus, the aim of this narrative review was to collect the current knowledge on this topic and stimulate the publication of further research. Pubmed, Embase, Scopus, and Cochrane Library publications were screened until November 2022 to identify eligible studies. Out of 444 results, we selected 26 articles focused on movement analysis, risk of falls, energy expenditure, and the development of sensor-integrated prostheses. The results showed that the use of inertial sensors has the potential to improve the quality of life of patients with prostheses, increasing patient safety through the detection of gait alteration; enhancing the socio-occupational reintegration through the development of highly technologic and personalized prosthesis; and by monitoring the patients during daily life to plan a tailored rehabilitation program.

Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey

INTRODUCTION

Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations.

METHODS

With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark.

RESULTS

Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall.

CONCLUSIONS

This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.

Physiotherapists’ Perspectives on Type 2 Diabetes Management and as a Primary Condition for Referral to Physiotherapy Services: A Qualitative Descriptive Study

Purpose:

We explored the current and potential role of physiotherapists in the management of people with type 2 diabetes (T2D) and T2D as a primary condition for physiotherapy referral.

Method:

We conducted a qualitative descriptive study. Participants were physiotherapists practicing in community and outpatient settings across Canada. One-on-one telephone interviews were completed to explore provision of physiotherapy care for people with T2D, including current practices and readiness of physiotherapists to provide direct care. We employed thematic analysis for generation of themes from interviews.

Results:

We interviewed 21 participants from eight provinces and territories. Three themes were generated from the data: current approach to T2D management; challenges for physiotherapy integration; and merits of physiotherapy and needed evolution. Participants described that physiotherapists are not part of the healthcare team for T2D management. There is a gap in medical management of T2D that physiotherapy would fill, that is, education and prescription for exercise participation.

Conclusions:

Our findings support a gap in the management of T2D in Canadian healthcare, particularly in reference to physiotherapy. Further, our findings support the need for greater inclusion of physiotherapists for lifestyle counseling with an emphasis on physical activity and exercise for patients at risk of and with T2D to maximize health and improve/maintain function. Studies focusing on accessibility and funding of physiotherapy services are needed to validate these findings.

Physiotherapy Rehabilitation in an Above-Knee Amputee Following Compartment Syndrome in Post-tibial Plateau Fracture: A Case Report

Proximal tibia fractures are generally open fractures resulting in life-threatening complications. There is an increase in the prevalence of compartment syndrome post-tibial fractures. Though fasciotomy and wound debridement is the choice of treatment in such conditions, amputation becomes a necessity when there is widespread muscle and tissue damage. Specifically, compartment syndrome involving the lower limb is distressing as its symptoms can be misleading at times resulting in delayed diagnosis and hence life-threatening complications. A 48-year-old male met with a road accident and presented to the hospital with complaints of pain and an open wound over the anterior aspect of the right lower leg 14 days ago. He was managed by Ilizarov external fixator. Later he developed compartment syndrome as a complication of tibial plateau fracture, for which decompressive fasciotomy was performed. But due to irreversible tissue loss and gangrene, he had to undergo above-knee amputation followed by physiotherapy rehabilitation. We mainly focused on postoperative/pre-prosthetic rehabilitation. During postoperative rehabilitation, we concentrated on reducing phantom limb pain, preventing complications, and improving strength and endurance. Current literature claims that mirror therapy is effective in reducing phantom limb pain in post amputees, but there are only a few case reports emphasizing mirror therapy in particularly lower limb amputees. Therefore, we emphasized using mirror therapy for phantom limb pain in this case of lower limb amputation. It resulted in positive outcomes. Our broader aim was to strengthen the upper limbs and the intact lower limb so that the patient's overall functional independence can be enhanced. Further prosthetic rehabilitation was planned in which we focused on gait and balance training. Physiotherapy rehabilitation improved the patient's quality of life and independence.

An exploration of specialist clinicians' experiences and beliefs about inpatient amputee rehabilitation as a pathway option for adult primary amputees

PURPOSE

To explore specialist amputee physiotherapists' experiences and subsequent views about specialist inpatient rehabilitation (IPR) as a National Health Service (NHS) pathway option for adult primary amputees and their perceptions and beliefs about the effects of inpatient amputee rehabilitation.

MATERIALS AND METHODS

A qualitative study using a phenomenological approach. Semi-structured interviews were completed with seven physiotherapists experienced in working in both specialist amputee inpatient and outpatient rehabilitation settings. Interviews were audio-recorded and fully transcribed. Data were analysed using thematic analyses; inductive coding was completed; emerging themes are shown and a conceptual framework was developed. To promote rigour, this study was peer reviewed and coding was done by two people.

RESULTS

Clinicians believed inpatient amputee rehabilitation to be the preferred model of rehabilitation for the majority of adult primary amputees. A central theme of healthcare inequality within primary amputee rehabilitation provision emerged with four sub-themes: IPR, outpatient rehabilitation, barriers, the ideal world. Geographical variation was described in: type of rehabilitation provided, timescales of prosthetic rehabilitation provision, fitting a prosthesis with wounds, and the availability of community rehabilitation services.

CONCLUSIONS

Healthcare inequality is a central concern identified by clinicians who work within amputee rehabilitation in the UK. Clinicians interviewed believe NHS specialist amputee inpatient rehabilitation should be a more accessible pathway.Implications for rehabilitationClinicians believe healthcare inequality exists within primary amputee rehabilitation provision in the UK National Health Service (NHS).Geographical variation in type of care provision, fitting a prosthesis with wounds, timescales in prosthetic rehabilitation provision and community rehabilitation services were described.Clinicians believe inpatient amputee rehabilitation to be the preferred model of care for the majority of adult primary amputees and should be a more accessible pathway within the NHS.Inpatient rehabilitation facilities may be a way of compensating for amputee rehabilitation inequalities.

Rehabilitation of a Patient after a Transtibial Amputation: A Case Report

Amputation is the surgical removal of a body part or limb caused by excessive tightness, pathological conditions, or a surgical procedure on an extremity. Transtibial amputation involves removing the feet, ankle, distal part of the tibia, and fibula with the surrounding structures like connective tissues and other structures surrounding the distal part of the bone. This type of surgery has a high rate of contraindications but has adequate indications; it maintains a therapeutic technique with a high clinical price and, in general, lifesaving value. The primary objectives of rehabilitation are to improve normal and affected extremity power, patient mobility, aerobic capacity, coordination and balance, and independence in performing activities of daily living. In this case, the patient was a 50-year-old man who complained of pain in his left lower limb and had an ulcer on his left foot. Initially, it was small in size when noticed by the patient but gradually progressed to a large wound of 7x6cm over the medial side, with foul-smelling discharge, associated with blackish discoloration. Walking aggravated foot pain, which was relieved by standing still, medications, and rest. On investigation, the patient was diagnosed with gangrene in the left lower limb and referred for rehabilitation to the physiotherapy department after surgery. This case study provides information on the recovery of a patient with the help of prosthetic devices.

Impact of Kinesiotherapy and Hydrokinetic Therapy on the Rehabilitation of Balance, Gait and Functional Capacity in Patients with Lower Limb Amputation: A Pilot Study

The purpose of this pilot study was to identify impact differences in the rehabilitation of balance, gait and functional capacity in patients with lower limb amputation performing hydrokinetic therapy and kinesiotherapy programs during the pre-prosthetic and prosthetic phases. The study included 16 male patients aged 40–60 years with amputated lower limbs for 6 to 12 months, which involved transfemoral amputation (TFA), transtibial amputation (TTA), traumatic and vascular amputation, who were divided into the following two groups: the hydrokinetic therapy (HKT) group and the kinesiotherapy (KT) group, named after the content of the rehabilitation programs that were implemented for 2 weeks in the pre-prosthetic and prosthetic periods. The initial and final evaluation of the participants included the following tests: the Berg Scale and the four square test for the evaluation of the balance; the PodoSmart device for gait assessment; through the walking test over 6 min, we evaluated the functional capacity. The results were processed in SPSS 24. Analysis of the results on balance rehabilitation through the Berg Scale highlighted that the progress related to the mean of the total score was 7.62 points, p = 0.00 for the HKT group and 7.50 points, p = 0.00 for the KT group, while in the four square step test, the mean of progress was 6.125 s, p = 0.00 for the HKT group and 6 s, p = 0.000 for the KT group. The PodoSmart gait analysis revealed that the HKT group showed a progress mean of 4.875%, p = 0.00, for the foot symmetry parameter, which was 1.875% less than the score achieved by the KT group whose symmetry progress mean was 6.75%, p = 0.00, while the average progress mean for the cadence parameter was 2.75 steps/min higher for the KT group than the HKT group. The comparative analysis of the impact of these two programs on the patients’ functional capacity indicated that the score recorded by the KT group was a progress mean of 15.12 m, p = 0.00 better than the HKT group for the travelled distance parameter; the implementation of the hydrokinetic therapy program led to better exercise adaptation for the HKT group compared to the KT group at an average HR (HRavg) with 0.50 BPM, p = 0.00. After analyzing the results, it has been found that hydrokinetic therapy programs have a greater impact on balance rehabilitation and exercise adaptation, while kinesiotherapy programs have a greater impact on gait rehabilitation and functional capacity optimization for the travelled distance parameter.

Characterizing the Gait of People With Different Types of Amputation and Prosthetic Components Through Multimodal Measurements: A Methodological Perspective

Prosthetic gait implies the use of compensatory motor strategies, including alterations in gait biomechanics and adaptations in the neural control mechanisms adopted by the central nervous system. Despite the constant technological advancements in prostheses design that led to a reduction in compensatory movements and an increased acceptance by the users, a deep comprehension of the numerous factors that influence prosthetic gait is still needed. The quantitative prosthetic gait analysis is an essential step in the development of new and ergonomic devices and to optimize the rehabilitation therapies. Nevertheless, the assessment of prosthetic gait is still carried out by a heterogeneous variety of methodologies, and this limits the comparison of results from different studies, complicating the definition of shared and well-accepted guidelines among clinicians, therapists, physicians, and engineers. This perspective article starts from the results of a project funded by the Italian Worker's Compensation Authority (INAIL) that led to the generation of an extended dataset of measurements involving kinematic, kinetic, and electrophysiological recordings in subjects with different types of amputation and prosthetic components. By encompassing different studies published along the project activities, we discuss the specific information that can be extracted by different kinds of measurements, and we here provide a methodological perspective related to multimodal prosthetic gait assessment, highlighting how, for designing improved prostheses and more effective therapies for patients, it is of critical importance to analyze movement neural control and its mechanical actuation as a whole, without limiting the focus to one specific aspect.

The Effectiveness of Exercise Interventions to Improve Gait and Balance in Individuals with Lower Limb Amputations: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the effectiveness of exercise interventions to improve gait and balance in individuals with lower limb amputations.

METHODS

A systematic search was conducted on the PubMed, Scopus, Web of Science, SPORTDiscuss, and CINAHL databases until January 2022. Only randomized control trials that evaluated adults (>18 years old) with lower limb amputations and compared any exercise intervention with a traditional prosthetic training were included in the study. Two independent researchers screened articles for inclusion, extracted data, and evaluated the methodological quality of the trials. Findings were summarized and meta-analysis was conducted.

RESULTS

Fifteen randomized clinical trials with 594 participants were included in the study and 12 in quantitative synthesis. Meta-analysis indicates that exercise interventions significantly improved walking distance measured with the 2-Minute Walking Test compared to traditional training (mean difference-MD: 8.38, 95% CI: 2.54-14.23; P < 0.01). Gait speed performance also significantly improved after exercise interventions compared to traditional training (MD: 0.10, 95% CI, 0.03-0.16, P <0.01). Meta-analysis of exercise interventions compared to traditional training on the Locomotor Capabilities Index, Timed Up and Go, and Activities-specific Balance Confidence did not show a statistically significant difference (P > 0.05). However, the qualitative analysis demonstrated significant improvement in balance performance after different exercise interventions and traditional training. The studies demonstrated overall good methodological quality.

CONCLUSION

Specific exercise interventions are more effective than traditional prosthetic training to improve walking speed and walking distance among people with lower limb amputation. Findings on balance outcomes are inconsistent and deserve further exploration.

Walking Practice Combined with Virtual Reality Contributes to Early Acquisition of Symmetry Prosthetic Walking: An Experimental Study Using Simulated Prosthesis

Virtual reality (VR)-based rehabilitation has been used in lower limb amputees; however, the extent to which VR is effective in reacquiring symmetrical gait in lower limb amputees is unclear. The purpose of this study was to confirm whether a VR intervention is effective in obtaining a simulated prosthetic gait. The participants were 24 healthy males who had never worn a simulated prosthesis. They were divided into three groups: VR, tablet, and control groups. The intervention consisted of 5 min of in situ stepping on parallel bars and watching a video of a simulated prosthetic leg walker on a head-mounted display or a tablet. Measurements included Gait Up parameters during a 10-m walk and immersion scores. After the intervention, there was a significant interaction between walking speed and leg swing speed in the VR group. The rate of improvement in walking speed and immersion scores was significantly higher in the VR group than in the other two groups, and there was a significant positive correlation between the rate of improvement and immersion scores. Compared to the tablet and control groups, the VR group showed the highest rate of immersion and improvement in walking speed.

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

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

The Value of Health Economics and Outcomes Research in Prosthetics and Orthotics

The demand has increased for evidence regarding the effectiveness and value of prosthetic and orthotic rehabilitation interventions. Clinicians and managers are under pressure to provide treatment recommendations and demonstrate effectiveness through outcomes. It is often assumed that rehabilitation interventions, including the provision of custom-made and custom-fit orthotic and prosthetic devices, are beneficial to patients. Assessing the value of orthotic and prosthetic services has become more critical to continue to ensure equitable access to needed services. Health economics and outcomes research methods serve as tools to gauge the value of prosthetic and orthotic rehabilitation interventions. The purpose of this article is to provide an overview of the current need of health economics and outcomes research in orthotics and prosthetics, to introduce common economic methods that assist to generate real-world evidence, and to discusses the potential value of economic methods for clinicians and clinical practice.

Robot-mediated overground gait training for transfemoral amputees with a powered bilateral hip orthosis: a pilot study

Background

Transfemoral amputation is a serious intervention that alters the locomotion pattern, leading to secondary disorders and reduced quality of life. The outcomes of current gait rehabilitation for TFAs seem to be highly dependent on factors such as the duration and intensity of the treatment and the age or etiology of the patient. Although the use of robotic assistance for prosthetic gait rehabilitation has been limited, robotic technologies have demonstrated positive rehabilitative effects for other mobility disorders and may thus offer a promising solution for the restoration of healthy gait in TFAs. This study therefore explored the feasibility of using a bilateral powered hip orthosis (APO) to train the gait of community-ambulating TFAs and the effects on their walking abilities.

Methods

Seven participants (46–71 years old with different mobility levels) were included in the study and assigned to one of two groups (namely Symmetry and Speed groups) according to their prosthesis type, mobility level, and prior experience with the exoskeleton. Each participant engaged in a maximum of 12 sessions, divided into one Enrollment session, one Tuning session, two Assessment sessions (conducted before and after the training program), and eight Training sessions, each consisting of 20 minutes of robotically assisted overground walking combined with additional tasks. The two groups were assisted by different torque-phase profiles, aiming at improving symmetry for the Symmetry group and at maximizing the net power transferred by the APO for the Speed group. During the Assessment sessions, participants performed two 6-min walking tests (6mWTs), one with (Exo) and one without (NoExo) the exoskeleton, at either maximal (Symmetry group) or self-selected (Speed group) speed. Spatio-temporal gait parameters were recorded by commercial measurement equipment as well as by the APO sensors, and metabolic efficiency was estimated via the Cost of Transport (CoT). Additionally, kinetic and kinematic data were recorded before and after treatment in the NoExo condition.

Results

The one-month training protocol was found to be a feasible strategy to train TFAs, as all participants smoothly completed the clinical protocol with no relevant mechanical failures of the APO. The walking performance of participants improved after the training. During the 6mWT in NoExo, participants in the Symmetry and Speed groups respectively walked 17.4% and 11.7% farther and increased walking speed by 13.7% and 17.9%, with improved temporal and spatial symmetry for the former group and decreased energetic expenditure for the latter. Gait analysis showed that ankle power, step width, and hip kinematics were modified towards healthy reference levels in both groups. In the Exo condition metabolic efficiency was reduced by 3% for the Symmetry group and more than 20% for the Speed group.

Conclusions

This study presents the first pilot study to apply a wearable robotic orthosis (APO) to assist TFAs in an overground gait rehabilitation program. The proposed APO-assisted training program was demonstrated as a feasible strategy to train TFAs in a rehabilitation setting. Subjects improved their walking abilities, although further studies are required to evaluate the effectiveness of the APO compared to other gait interventions. Future protocols will include a lighter version of the APO along with optimized assistive strategies.

Potential and Limitations of Feedback-Supported Gait Retraining in Users of Lower Limb Prostheses

The outcomes of prosthetic rehabilitation after lower limb loss are, in large part, affected by the effectiveness of the provided gait retraining. The noted prevalence of adverse long-term effects, such as further joint and muscle degeneration, suggests that traditional rehabilitation programs have limitations. Recent advances in technology and in the understanding of motor learning promise the potential for better gait retraining interventions. This article reviews current literature on systems and methodologies of improving gait parameters in those with lower limb prostheses via exercise programs and various biofeedback systems. A total of 13 articles were included in the qualitative analysis. Findings indicate that many of the investigated systems are able to effectively analyze and change gait in the target population, but there remain considerable gaps in the knowledge. It has been noted that feedback modalities and dosage must be customized based on patient characteristics and rehabilitation goals, yet there is currently not enough published evidence to inform such customization.

Estimating the costs and benefits of stroke rehabilitation in South Africa

OBJECTIVE

This paper explores the economic value of rehabilitation to South Africa, using a costed example of cerebrovascular accident (CVA) (stroke) rehabilitation.

DESIGN

We report an economic modelling approach using a worked cost-effectiveness to validate the argument for the cost-saving benefits of stroke rehabilitation.

SETTING

South African health care, employing analysis of available secondary data from South African research and government reports.

PARTICIPANTS

In line with international trends in stroke epidemiology, we focused on people who were employed prior to having their stroke, with return-to-work as the desired rehabilitation outcome.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

We used information on stroke rehabilitation and secondary data derived from grey and published literature, to determine if early stroke rehabilitation represents value for money from the government perspective. For our worked example, we used return-to-work rates, intervention costs, and the cost of rehabilitation services to estimate cost-savings as a result of an individualized workplace intervention.

RESULTS

The cost of delivering the individualized intervention was estimated at R5633/patient. Combining survivor rates, return-to-work rate, and costs of the programme, a work intervention programme could result in a net saving of R133.1 million over 5 years (or about R26.6 per year (discount 3%).

CONCLUSION

The value of rehabilitation should not be considered in terms of cost-effectiveness alone, but also as an investment for the country. A staged, prioritized approach should be considered in future South African national health budget.

Modular motor control of the sound limb in gait of people with trans-femoral amputation

Background

The above-knee amputation of a lower limb is a severe impairment that affects significantly the ability to walk; considering this, a complex adaptation strategy at the neuromuscular level is needed in order to be able to move safely with a prosthetic knee. In literature, it has been demonstrated that muscle activity during walking can be described via the activation of a small set of muscle synergies. The analysis of the composition and the time activation profiles of such synergies have been found to be a valid tool for the description of the motor control schemes in pathological subjects.

Methods

In this study, we used muscle synergy analysis techniques to characterize the differences in the modular motor control schemes between a population of 14 people with trans-femoral amputation and 12 healthy subjects walking at two different (slow and normal self-selected) speeds. Muscle synergies were extracted from a 12 lower-limb muscles sEMG recording via non-negative matrix factorization. Equivalence of the synergy vectors was quantified by a cross-validation procedure, while differences in terms of time activation coefficients were evaluated through the analysis of the activity in the different gait sub-phases.

Results

Four synergies were able to reconstruct the muscle activity in all subjects. The spatial component of the synergy vectors did not change in all the analysed populations, while differences were present in the activity during the sound limb’s stance phase. Main features of people with trans-femoral amputation’s muscle synergy recruitment are a prolonged activation of the module composed of calf muscles and an additional activity of the hamstrings’ module before and after the prosthetic heel strike.

Conclusions

Synergy-based results highlight how, although the complexity and the spatial organization of motor control schemes are the same found in healthy subjects, substantial differences are present in the synergies’ recruitment of people with trans femoral amputation. In particular, the most critical task during the gait cycle is the weight transfer from the sound limb to the prosthetic one. Future studies will integrate these results with the dynamics of movement, aiming to a complete neuro-mechanical characterization of people with trans-femoral amputation’s walking strategies that can be used to improve the rehabilitation therapies.