Factors affecting quality of life in lower limb amputees

Duration, frequency, and factors related to lower extremity prosthesis use: systematic review and meta-analysis

PURPOSE

A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use.

MATERIALS AND METHODS

A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed.

RESULTS

The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) (p < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization.

CONCLUSIONS

The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

Using Electrical Muscle Stimulation to Enhance Electrophysiological Performance of Agonist-Antagonist Myoneural Interface

The agonist-antagonist myoneural interface (AMI), a surgical method to reinnervate physiologically-relevant proprioceptive feedback for control of limb prostheses, has demonstrated the ability to provide natural afferent sensations for limb amputees when actuating their prostheses. Following AMI surgery, one potential challenge is atrophy of the disused muscles, which would weaken the reinnervation efficacy of AMI. It is well known that electrical muscle stimulus (EMS) can reduce muscle atrophy. In this study, we conducted an animal investigation to explore whether the EMS can significantly improve the electrophysiological performance of AMI. AMI surgery was performed in 14 rats, in which the distal tendons of bilateral solei donors were connected and positioned on the surface of the left biceps femoris. Subsequently, the left tibial nerve and the common peroneus nerve were sutured onto the ends of the connected donor solei. Two stimulation electrodes were affixed onto the ends of the donor solei for EMS delivery. The AMI rats were randomly divided into two groups. One group received the EMS treatment (designated as EMS_on) regularly for eight weeks and another received no EMS (designated as EMS_off). Two physiological parameters, nerve conduction velocity (NCV) and motor unit number, were derived from the electrically evoked compound action potential (CAP) signals to assess the electrophysiological performance of AMI. Our experimental results demonstrated that the reinnervated muscles of the EMS_on group generated higher CAP signals in comparison to the EMS_off group. Both NCV and motor unit number were significantly elevated in the EMS_on group. Moreover, the EMS_on group displayed statistically higher CAP signals on the indirectly activated proprioceptive afferents than the EMS_off group. These findings suggested that EMS treatment would be promising in enhancing the electrophysiological performance and facilitating the reinnervation process of AMI.

[Peer counseling for amputations : A somewhat different instrument in trauma surgery]

The abrupt onset of the situation after a traumatic amputation and the preparatory discussions following unsuccessful attempts to preserve limbs with necessary amputation require a high level of empathy, attention and well-founded information individually tailored to the affected individuals. Optimization of the treatment process can only be achieved by considering these aspects.The self-motivation and cooperation of the patient should be encouraged. To achieve this goal, the professions involved are less suitable for counseling due to a lack of personal experience, whereas so-called peers, as knowledgeable and experienced advisors, are more appropriate. This insight can be derived from existing studies. Peer counseling has increasingly been integrated into routine treatment following amputations in trauma surgery, with positive effects. It is considered guideline-compliant therapy not only in rehabilitation. Against the background of long-standing legislation, especially the UN Convention on the Rights of Persons with Disabilities and the demands of those affected by amputation, the following presentation focuses on the instrumentalization and benefits of counseling. The structures of this particular counseling option, including regular training of counselors and established implementation, are currently not necessarily given but are continuously expanding and being adapted to needs. Concrete scientific evidence regarding measurable effects and positive impacts on outcomes is pending and are presented in a current research project.

Quality of life in young people with limb loss: a systematic review

PURPOSE

Life after any amputation can be significantly altered and can have a significant impact on quality of life (QoL). However, most of the evidence base involves older aged amputees, therefore there is a lack of understanding about the impact of amputation on QoL and the factors that predict QoL in younger amputees. The aim of this review is to identify the factors that predict QoL in young amputees.

METHODS

MEDLINE, CINAHL, EMBASE, PsycINFO, Web of Science were searched to identify articles that measured QoL in young amputees. Articles were independently assessed by two assessors. Data was extracted from the selected articles and a narrative synthesis performed.

RESULTS

18 articles were included in this review. QoL outcome measures varied between studies. The quality of evidence was generally low. This review identified, gender, age, cause of amputation, level of amputation, phantom pain, ability to use a prosthesis, physical function, depression, anxiety, body image, type of prosthesis as predictors of QoL.

CONCLUSION

This review identified modifiable and non-modifiable predictors of QoL in young amputees. Future research needs to focus on exploring the modifiable predictors of QoL as these are the aspects that can be improved to enhance QoL.

The relationships between body image, self-esteem and quality of life in adults with trauma-related limb loss sustained in the Syrian war

BACKGROUND

Numerous military soldiers have lost limbs as a result of the Syrian War. While there are variations between trauma-related amputations in military and civilian populations, both scenarios result in life-changing injuries.

OBJECTIVE

To explore the relationship between body image, self-esteem, and quality of life (QOL) domains following trauma-related major amputation. It will be the first study in Syria on the correlation between self-esteem and body image. It will help improve our quality of care to meet patient needs and increase well-being, which in turn will help to address body image, self-esteem, and QOL.

METHOD

A cross-sectional study that recruited 235 soldiers with amputations in two centers and two military hospitals in Latakia and Tartous. Patients were given an 81-item questionnaire that included the Amputee Body-Image Scale (ABIS), the Rosenberg Self-esteem (RSE) scale, the WHOQOL-BREF questionnaire, and unidimensional pain measures. The ANOVA test, a student's t-test, multiple linear regression, internal consistency, and test-retest reliability were utilized for statistical analysis.

RESULTS

There was a strong relationship between body image, self-esteem, and QOL, with the presence of body image concerns significantly associated with lower self-esteem scores and lower QOL scores (p=0.001). Patients with phantom pain sensation had significantly reduced self-esteem (p =0.001), greater body image concerns (p =0.001), and lower scores in all domains of QOL. We found that body image and self-esteem impacted the psychological, social, and environmental domains. After controlling for pain level and number of co-morbid conditions, body image and self-esteem did not predict WHOQOL-BREF scores, with the exception of the environmental domain, where no pain and low self-esteem predicted better environmental domain scores.

CONCLUSION

Patients' body image and self-esteem were greatly impacted by lower-limb amputations. Additionally, phantom pain further impacted self-esteem, body image, and QOL. The image of the body had a profound effect on psychological, social, and environmental domains, and self-esteem was influenced by almost all aspects of QOL.

Racial disparities in prosthesis abandonment and mobility outcomes after lower limb amputation from a dysvascular etiology in a veteran population

BACKGROUND

Non-Hispanic Black (NHB) individuals have higher rates of amputation and increased risk of a transfemoral amputation due to dysvascular disease than non-Hispanic White (NHW) individuals. However, it is unclear if NHB individuals have differences in prosthesis use or functional outcomes following an amputation.

OBJECTIVE

To determine if there are racial disparities in prosthesis abandonment and mobility outcomes in veterans who have undergone their first major unilateral lower extremity amputation (LEA) due to diabetes and/or peripheral artery disease.

DESIGN

National cohort study that identified individuals retrospectively through the Veterans Affairs (VA) Corporate Data Warehouse (CDW) from March 1, 2018, to November 30, 2020, then prospectively collected their self-reported prosthesis abandonment and mobility. Multiple logistic regression was used to control for potential confounders and identify potential effect modifiers.

SETTING

The VA CDW, participant mailings and phone calls.

PARTICIPANTS

Three hundred fifty-seven individuals who underwent an incident transtibial or transfemoral amputation due to diabetes and/or peripheral arterial disease.

INTERVENTIONS

Not applicable.

MAIN OUTCOMES MEASURES

(1) Self-reported prosthesis abandonment. (2) Level of mobility assessed using the Locomotor Capabilities Index.

RESULTS

Rurally located NHB individuals without a major depressive disorder (MDD) had increased odds of abandoning their prosthesis (adjusted odds ratios [aOR] = 5.3; 95% confidence interval [CI]: [1.3-21.1]). This disparity was nearly three times as large for rurally located NHB individuals with MDD diagnosis, compared with other races from rural areas and with MDD (aOR = 15.8; 95% CI, 2.5-97.6). NHB individuals living in an urban area were significantly less likely to achieve advanced mobility, both with MDD (aOR=0.16; 95% CI: [0.04-7.0]) and without MDD (aOR = 0.26; 95% CI: [0.09-0.73]).

CONCLUSIONS

This study demonstrated that health care disparities persist for NHB veterans following a dysvascular LEA, with increased prosthesis abandonment and worse mobility outcomes.

Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial

Background: Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Methods: Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Results: Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG (P = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS (P < 0.05). However, the EG showed a superior significance in BDI and MHS scores (P < 0.05). There was no significance between groups in PHS score. Conclusion: Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.

Prosthetic device and service satisfaction, quality of life, and functional performance in lower limb prosthesis clients

OBJECTIVE

The aim of this study was to characterize the relationship between prosthetic device and service satisfaction, health-related quality of life (HRQOL), and functional movement in a diverse population of lower limb prosthesis users.

METHODS

An online survey was conducted on individuals with lower limb amputation between September and October 2021. Sample validated questionnaires assessing demographic and clinical features, satisfaction, functional outcomes, and quality of life were analyzed using path analysis.

RESULTS

Participants were 1736 individuals with lower limb amputation. Overall, 44% of participants reported dissatisfaction with prosthetic device, whereas 37% were dissatisfied with prosthetic service. Low functional mobility was reported by 58% of participants and 61% reported low HRQOL. Lower extremity functional status (β = 0.55), HRQOL (β = 0.08), Activities-specific Balance Scale (β = 0.22), and modified fall efficacy scale (β = -0.07) are significantly associated with prosthetic device satisfaction ( P < 0.0005, R 2 = 0.47). Satisfaction with provider service was significantly associated with lower extremity functional status (β = 0.44) and balance confidence (β = 0.18) ( P < 0.0005, R 2 = 0.34).

CONCLUSION AND CLINICAL RELEVANCE

Civilians, veterans, and service members reported low functional mobility, low quality of life, and moderate levels of dissatisfaction with their lower extremity prosthetic device and provider service. Improvements in mobility, balance, quality of life, and fall efficacy may enhance device satisfaction. Functional mobility and balance improvements may increase ratings of provider service. This study provides feedback that may improve clinical decisions on lower limb prosthesis patient care.

Quality of Life, Physical Activity Participation, and Perceptions of Physical Rehabilitation Among Community-Reintegrated Veterans With Lower Limb Amputation in Sri Lanka: Convergent Parallel Mixed Methods Study

BACKGROUND

Lower limb amputation (LLA) impacts physical activity (PA) participation and quality of life (QoL). To minimize the effects of these challenges, LLA survivors need to have opportunities to engage in appropriately tailored rehabilitation throughout their lives. However, in Sri Lanka, where a 3-decade civil war resulted in trauma-related LLA among young male soldiers, access to rehabilitation was limited to the immediate postinjury period. Developing rehabilitation interventions for these veterans requires an understanding of their current health status and rehabilitation perceptions.

OBJECTIVE

This study was conducted to evaluate the QoL and PA participation of veterans with LLA and explore perceptions of factors influencing their PA participation and expectations for a future community-based physical rehabilitation (CBPR) intervention.

METHODS

This mixed methods study combined a comparative cross-sectional quantitative survey with qualitative semistructured interviews in 5 districts of Sri Lanka. QoL and PA participation were assessed among community-reintegrated veterans with LLA (n=85) and compared with a matched able-bodied cohort (control; n=85) using Mann-Whitney U and Chi-square tests. PA was assessed in terms of metabolic equivalent of task (MET) minutes per week and was computed for walking, moderate-intensity, and vigorous-intensity activities. PA was classified as sufficiently active, low, or sedentary. The design of interview questions was guided by the Theoretical Domains Framework and followed a phenomenological approach. Interviews were conducted with 25 veterans and were analyzed thematically, and the perceptions regarding PA participation and CBPR were codified using the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Based on the quantitative survey findings, scores for both physical (P<.001) and psychological (P<.001) well-being and participation in walking (P=.004) and vigorous-intensity activities (P<.001) were significantly lower among veterans than among controls. A "sedentary" classification was made for 43% (34/79) of veterans and 12% (10/82) of controls. Veterans mostly engaged in moderate-intensity PA inside the house (49/79, 62%) and in the yard (30/79, 38%). Qualitative interviews revealed that barriers to PA exist at individual (eg, comorbidity burden), primary care (eg, absence of community rehabilitation services), and policy levels (eg, limited resources) and facilitators exist primarily at societal (eg, inclusive community) and individual levels (eg, preinjury activity baseline and positive attitudes toward exercise). Expectations regarding CBPR included individualized rehabilitation parameters; functional exercises; and involvement of peers, amputee societies, and community health care providers. The nonresponse rate for interviews was 7% (2/27).

CONCLUSIONS

The findings of reduced PA participation, poor QoL, and physical and psychological impairments among relatively young veterans reveal the long-term impacts of living with LLA in the absence of long-term rehabilitation. Policy-level changes need to be implemented along with behavior-change strategies to promote PA participation and minimize physical inactivity-induced health issues. Veterans' perceptions regarding future CBPR programs were positive and centered on holistic, individualized, and peer-led activities.

Assessment of self-esteem and quality of life in patients with transtibial amputations using an exoskeletal prosthesis

BACKGROUND

Lower limb amputation can have profound physical, psychological, and social effects on individuals. Assistive aids like prosthetic lower limbs can help an individual regain mobility and thereby affect their self-esteem and quality of life.

OBJECTIVE

To assess self-esteem and quality of life in patients with transtibial amputations who are using a transtibial prosthesis and explore the association between sociodemographic and amputation-related factors with self-esteem and prosthesis-related quality of life measures.

DESIGN

A cross-sectional study.

SETTING

An orthotics and prosthetics center (Bhagwan Mahaveer Viklang Sahayata Samiti) in Jaipur, Rajasthan.

PARTICIPANTS

Patients with transtibial amputations using exoskeletal prostheses between July and September 2022, in Jaipur, Rajasthan.

MAIN OUTCOME MEASURES

The study used Rosenberg self-esteem questionnaire and Prosthesis Evaluation Questionnaire (PEQ) for self-esteem and quality of life assessment, respectively. Descriptive analysis was used to present the demographic details, and nonparametric tests examined the relationship between PEQ dimensions and sociodemographic variables.

RESULTS

The study included 138 participants, primarily <40 years old (45.7%) and mostly engaged in high-activity occupations. Self-esteem mean score (SD) was 19.9 (3.9), with 89.1% exhibiting normal self-esteem. Prosthesis-related quality of life, showed high satisfaction across various domains, including ambulation, appearance, frustration, perceived response, residual limb health, social burden, sounds, utility, and well-being. No significant associations were found between sociodemographic factors, amputation-related variables, and self-esteem. However, PEQ scales showed associations with gender, age, occupation, type of amputation, and years of prosthesis use.

CONCLUSION

These results highlight the potential advantages of exoskeletal prostheses in improving the standard of living for people with transtibial amputations. Further research is essential to develop targeted interventions for improving their overall quality of life.

The biomechanical influence of transtibial Bone-Anchored limbs during walking

Individuals with unilateral transtibial amputation (TTA) using socket prostheses demonstrate asymmetric joint biomechanics during walking, which increases the risk of secondary comorbidities (e.g., low back pain (LBP), osteoarthritis (OA)). Bone-anchored limbs are an alternative to socket prostheses, yet it remains unknown how they influence multi-joint loading. Our objective was to determine the influence of bone-anchored limb use on multi-joint biomechanics during walking. Motion capture data (kinematics, ground reaction forces) were collected during overground walking from ten participants with unilateral TTA prior to (using socket prostheses) and 12-months after bone-anchored limb implantation. Within this year, each participant completed a rehabilitation protocol that guided progression of loading based on patient pain response and optimized biomechanics. Musculoskeletal models were developed at each testing timepoint (baseline or 12-months after implantation) and used to calculate joint kinematics, internal joint moments, and joint reaction forces (JRFs). Analyses were performed during three stance periods on each limb. The between-limb normalized symmetry index (NSI) was calculated for joint moments and JRF impulses. Discrete (range of motion (ROM), impulse NSI) dependent variables were compared before and after implantation using paired t-tests with Bonferroni-Holm corrections while continuous (ensemble averages of kinematics, moments, JRFs) were compared using statistical parametric mapping (p < 0.05). When using a bone-anchored limb, frontal plane pelvic (residual: pre = 9.6 ± 3.3°, post = 6.3 ± 2.5°, p = 0.004; intact: pre = 10.2 ± 3.9°, post = 7.9 ± 2.6°, p = 0.006) and lumbar (residual: pre = 15.9 ± 7.0°, post = 10.6 ± 2.5°, p = 0.024, intact: pre = 17.1 ± 7.0°, post = 11.4 ± 2.8°, p = 0.014) ROM was reduced compared to socket prosthesis use. The intact limb hip extension moment impulse increased (pre = -11.0 ± 3.6 Nm*s/kg, post = -16.5 ± 4.4 Nm*s/kg, p = 0.005) and sagittal plane hip moment impulse symmetry improved (flexion: pre = 23.1 ± 16.0 %, post = -3.9 ± 19.5 %, p = 0.004, extension: pre = 29.2 ± 20.3 %, post = 8.7 ± 22.9 %, p = 0.049). Residual limb knee extension moment impulse decreased compared to baseline (pre = 15.7 ± 10.8 Nm*s/kg, post = 7.8 ± 3.9 Nm*s/kg, p = 0.030). These results indicate that bone-anchored limb implantation alters multi-joint biomechanics, which may impact LBP or OA risk factors in the TTA population longitudinally.

Rehabilitation experiences following major lower limb amputation due to complications of vascular disease: a UK qualitative study

PURPOSE

Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease.

METHODS

Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data.

FINDINGS

Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants' imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations.

CONCLUSIONS

Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.

Daily steps and stepping cadence increase one-year following prosthesis osseointegration in people with lower-limb amputation

PURPOSE

People with lower-limb loss participate in less physical activity than able-bodied individuals, which increases the mortality risk and incidence of metabolic syndromes. This study evaluated the effect of lower-limb prosthesis osseointegration on physical activity, including daily steps and stepping cadence.

METHODS

Free-living walking activity was assessed from 14 patients scheduled to undergo prosthesis osseointegration at two time points (within 2 weeks prior to osseointegration surgery and 12-months following). Daily step count, stepping time, number of walking bouts, average step cadence per bout, maximum step cadence per bout, and time spent in bands of step cadence were compared before and after osseointegration.

RESULTS

Twelve months after prosthesis osseointegration, participants increased daily steps, daily stepping time, average step cadence, and maximum cadence per walking bout compared to pre-osseointegration.

CONCLUSIONS

Participants engaged in more daily steps, higher stepping cadence, and longer bouts at higher cadence one year following osseointegration compared to when using a socket prosthesis. As a novel intervention that is becoming more common, it is important to understand walking activity outcomes as these are critical for long-term health.

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.

Comparing quality of life in lower extremity tumor patients undergoing limb salvage surgery and amputation: a meta-analysis

Purpose

Limb salvage surgery and amputation are two commonly performed procedures for lower extremity tumors. When comparing these procedures in tumor patients, it is important to consider their impact on quality of life (QOL) and functional mobility. These patients often experience physical, emotional, and psychological challenges, making these factors crucial in determining the most suitable treatment approach.

Method

The outcomes of lower extremity tumors patients for QOL were collected from PubMed, MEDLINE, EMBASE, Cochrane, and Google Scholar until 28 February 2023. The physical function, mental health, role function, social function, emotional function, Toronto Extremity Salvage Score, and Musculoskeletal Tumor Society Score outcomes were analyzed to determine the differences between the two procedures.

Results

Five articles were included according to the selection criteria with a total of 245 patients. The standard mean difference (SMD) values of each parameter were slightly higher in limb salvage surgery patients but not higher enough to produce statistically significant results; the SMD values for physical function and mental health were 0.72 and 0.04, respectively. This study did not report any heterogeneity or publication bias.

Conclusions

QOL is a large and enhanced term, which carries its importance and is challenging to compare between any procedures. The minimal rise in SMD of different QOL parameters highlighted only a slight advantage of limb salvage surgery over amputation. Therefore, further research is required to explore the impact of this crucial topic.

Functional Mobility in Individuals With Lower Limb Amputation: An Observational Study

INTRODUCTION

Amputation leads to a permanent disability and brings a dramatic change in the life and function of the individual, more so in individuals with lower limb amputation. A lower limb amputation reduces mobility and can make persons dependent on assistive devices like crutches or a wheelchair. Restoring mobility and optimal physical functioning of an individual with lower limb amputation is the most important rehabilitation goal. There are very few studies that have quantified mobility deficits with valid outcome measures, especially in the Indian population. Our study aims to quantify the mobility deficit in individuals with lower limb amputation and add to the scant literature available on mobility values in the Indian population.

METHODS

This was a cross-sectional study. Individuals with lower limb amputation who attended an orthotic and prosthetic clinic in Vadodara city were recruited for the study. Those individuals who were above 18 years of age and had undergone either unilateral or bilateral amputation, at least six weeks prior to assessment, were included in the study. Those individuals who had total impairment of vision and hearing, cognitive impairment, upper limb amputation, and ankle and foot amputation were excluded from the study. Functional mobility was assessed with the prosthesis worn, using the Timed "Up and Go" (TUG) test.

RESULTS

There was a total of 54 individuals with lower limb amputation, 47 males and seven females. The mean age was 47.38±18.83 years. Transtibial (66.67%) was the most common amputation followed by transfemoral (27.8%). The mean TUG score for the total population was 20.19 ± 11.95 sec, for unilateral transfemoral amputation 20.26 ± 12.06 sec, and for unilateral transtibial amputation 20.01 ± 12.31 sec. There was a statistically significant direct relation of the TUG score with age (p=0.02), level of amputation (p<0.01), and length of time prosthesis was used (in years) (p=0.02) and a statistically significant inverse relation of TUG score with the cause of amputation (traumatic, p=0.02, non-traumatic, p=0.03), assistive devices used for mobility (p<0.01), and number of hours the prosthesis was worn in a day (p<0.01). There was a significant negative correlation between the duration of amputation and TUG score (r=-0.282, p<0.05) Conclusion: The functional mobility was reduced in individuals with lower limb amputation. There was a statistically significant direct relation of functional mobility with age, cause of amputation, level of amputation, and length of time of prosthesis used, and a statistically significant inverse relation with the number of hours of use of prosthesis in a day and assistive devices used. Individuals who were old, had a non-traumatic amputation, a higher level of amputation, those wearing a prosthesis for a short duration since amputation, who wore the prosthesis for a shorter duration during the day, and who used assistive devices for ambulation in addition to a prosthesis had longer TUG times. As the duration of amputation increased, the time taken for TUG decreased.

Development of a prosthetic fit and alignment assessment (ProFit) in persons with post-traumatic transtibial amputation

BACKGROUND

There are no standards for reliably measuring the quality of prosthetic fit and alignment which is important for evaluation and improvement of clinical care for patients with transtibial amputation.

OBJECTIVES

The purpose of this study was to develop an instrument to quantitatively assess prosthetic fit and alignment in patients with transtibial amputation.

STUDY DESIGN

Prospective cohort study.

METHODS

The fit and alignment assessment (ProFit) included 39 items for assessments of skin quality, stance and gait, and radiographic characteristics that could be feasibly captured in clinic using photographs, video, and radiographs. Data were collected on adults aged 18-60 years treated with transtibial amputation and followed up for 18 months at 1 of 27 US hospitals. One hundred thirteen assessments were conducted by 6 prosthetists using an online platform. Items demonstrating reliability and face validity were included in the ProFit score for subsequent validation testing. Validation measures included 18-month patient-reported function (Short Musculoskeletal Function Assessment ), tests of physical performance, patient-reported pain (Brief Pain Inventory ), satisfaction with prosthesis (Orthotics Prosthetics Users Survey), prosthesis use, and walking activity.

RESULTS

The ProFit score included 10 of 39 items that demonstrated high inter-rater reliability and face validity. A higher ProFit score correlated with worse function on all domains of the Short Musculoskeletal Function Assessment except arm and hand and with worse performance on the 4-Square Step Test, Shuttle Run, and Illinois Agility Test. ProFit scores did not correlate with the Brief Pain Inventory, Orthotics Prosthetics Users Survey, prosthesis use, or walking activity.

CONCLUSIONS

The ProFit score can be used by researchers and clinicians to measure the quality of socket fit and prosthetic alignment. Future prospective validation is necessary to verify the promising results observed in ProFit development and establish clinical utility.

The Moment Criterion of Anthropomorphicity of Prosthetic Feet as a Potential Predictor of Their Functionality for Transtibial Amputees

The purpose of this paper is to discuss a new quantitative mechanical parameter of prosthetic feet called the Index of Anthropomorphicity (IA), which has the potential to be adopted as an objective predictor of their functionality. The objectives are to present the research findings supporting the introduction of IA and unify previous results into a coherent theory. The IA is founded on the moment criterion of the anthropomorphicity of prosthetic feet. The term "anthropomorphicity" is defined for this application. Studies with a small number of human subjects and prostheses have shown that the value of the parameter is positively correlated with patient comfort and with the restoration of certain normal gait characteristics. Confirmatory studies with controlled human trials and mechanical tests with a wider selection of prosthesis types can give prosthesis manufacturers a new criterion to follow in the design process, and prosthetists may use the IA for selecting more suitable prostheses for a patient's comfort and health.

Targeted muscle reinnervation and regenerative peripheral nerve interfaces for pain prophylaxis and treatment: A systematic review

OBJECTIVE

Nerve pain frequently develops following amputations and peripheral nerve injuries. Two innovative surgical techniques, targeted muscle reinnervation (TMR) and regenerative peripheral nerve interfaces (RPNI), are rapidly gaining popularity as alternatives to traditional nerve management, but their effectiveness is unclear.

LITERATURE SURVEY

A review of literature pertaining to TMR and RPNI pain results was conducted. PubMed and MEDLINE electronic databases were queried.

METHODOLOGY

Studies were included if pain outcomes were assessed after TMR or RPNI in the upper or lower extremity, both for prophylaxis performed at the time of amputation and for treatment of postamputation pain. Data were extracted for evaluation.

SYNTHESIS

Seventeen studies were included, with 14 evaluating TMR (366 patients) and three evaluating RPNI (75 patients). Of these, one study was a randomized controlled trial. Nine studies had a mean follow-up time of at least 1 year (range 4-27.6 months). For pain treatment, TMR and RPNI improved neuroma pain in 75%-100% of patients and phantom limb pain in 45%-80% of patients, averaging a 2.4-6.2-point reduction in pain scores on the numeric rating scale postoperatively. When TMR or RPNI was performed prophylactically, many patients reported no neuroma pain (48%-100%) or phantom limb pain (45%-87%) at time of follow-up. Six TMR studies reported Patient-Reported Outcomes Measurement Information System (PROMIS) scores assessing pain intensity, behavior, and interference, which consistently showed a benefit for all measures. Complication rates ranged from 13% to 31%, most frequently delayed wound healing.

CONCLUSIONS

Both TMR and RPNI may be beneficial for preventing and treating pain originating from peripheral nerve dysfunction compared to traditional techniques. Randomized trials with longer term follow-up are needed to directly compare the effectiveness of TMR and RPNI with traditional nerve management techniques.

Lower limb amputation rehabilitation status in India: A review

Rehabilitation of lower limb amputation in developing countries is quite challenging. Though there are basic to highly advanced prostheses available in India, the set-up is still facing difficulties in developing countries. Prosthetic management is difficult due to lack of availability of prostheses and reduced affordability among low income populations. In this review we highlighted the lower limb amputation and prosthetic rehabilitation status in India. Currently, India is advancing well in the rehabilitation field, but further studies are required to provide more evidence and recommendation.

Functioning among persons with lower limb amputation with or without prostheses in Rwanda

Background

Limb loss limits functioning and restricts participation in various environments. Persons with lower limb amputations (PLLA) experience challenges ranging from self-care and independence to psychological disorders that negatively impact their functioning.

Objectives

To assess the functioning and the level of disability of PLLA with or without prostheses in Rwanda.

Method

A descriptive, cross-sectional study was conducted among PLLAs aged 18 years and above in 10 districts of Rwanda. A total of 247 participants were purposively selected to fill the questionnaires. Descriptive and inferential statistics using t-test and binary logistic regression were performed to analyse data using Statistical Package for Social Sciences (SPSS) (version 21.0).

Results

Out of 247 PLLA, 99 (40.1%) had prostheses and remaining 148 (59.9%) did not. Majority of PLLA without prostheses reported having more difficulties in mobility (s.d. 3.98), participation (s.d. 5.18) and life activities (s.d. 3.87). The majority of PLLA reported mild and moderate functioning in the domains of cognitive (odds ratio [OR] 8.842, 5.384 with 95% confidence interval [CI]) mobility (OR 16.154, 2.485 with 95% CI) and participation (OR 13.299, 15.282 with 95% CI).

Conclusion

Persons without prostheses demonstrated reduced level of functioning and high levels of disability compared to those with prostheses in all domains. However, the mobility, self-activities and the participation domains were the mainly affected.

Contribution

The study helps to understand the needs of the PLLA and emphasises that not only having prostheses can improve functioning but also emphasises the psychosocial aspects to reduce disability.

Investigation of the correlation between knee joint position sense and physical functional performance in individuals with transtibial amputation

INTRODUCTION

In individuals with transtibial amputation, the distal part of the lower extremity is lost. Therefore, the knee joint is of greater importance to be able to provide physical performance. The aim of this study was to evaluate the correlation between knee joint position sense and physical functional performance in individuals with transtibial amputation.

METHODS

The study included 21 subjects with transtibial amputation. A digital inclinometer was used to evaluate the joint position sense of the amputated side knee joint. The timed up and go test, the 4-square step test, and 10-m walk test were used to evaluate physical functional performance. Linear regression analysis was used to investigate the associations between independent variables and functional performance tests.

RESULTS

The mean age of the participants was 52.52 ± 15.68 years. The mean of the error in knee joint position sense was 5.33 degree (standard deviation = 3.08 degree). The error in knee joint position sense of the amputated limb predicted 45% of the variance in the 4-square step test and 22% of the variance in the 10-m walk test ( P < 0.05).

CONCLUSIONS

The knee joint position sense on the amputated side was found to be associated with physical functional performance in individuals with transtibial amputation. Residual limb knee joint position sense should be considered when prescribing prostheses and planning rehabilitation programs.

Life of an amputee: predictors of quality of life after lower limb amputation

Lower limb amputations (LLA) have a significant impact on global morbidity. Approximately 2 million people are living with lower limb amputation in the United States and this figure is expected to rise. LLA lead to physical disabilities and can cause restriction in functionalities in the everyday life of amputees. Patients lose their independence, which can be very debilitating and eventually causes physical, behavioral, and psychical changes. These changes after amputations should be properly addressed and must be incorporated into rehabilitation to improve and regain better adjustment to life among amputees. This article focuses on determining various factors and their effect on quality of life after lower limb amputations.

Predictors of health-related quality of life in patients undergoing extracorporeal membrane oxygenation for acute severe respiratory failure

Background

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of life support used in severe respiratory failure. While the short-term complications of VV-ECMO are well described, impacts on health-related quality of life (HRQOL) are less well characterised. This study aims to assess the HRQOL of patients who underwent VV-ECMO for acute severe respiratory failure and explore predictors of poor HRQOL.

Methods

We performed a retrospective, observational study of a large cohort of adults who underwent VV-ECMO for acute severe respiratory failure in a single tertiary centre (June 2013-March 2019). Patients surviving critical care discharge were invited to a six-month clinic, where they completed an EQ-5D-5L questionnaire assessing HRQOL. Multivariate analysis was performed to assess prognostic factors for HRQOL.

Results

Among the 245 consecutive patients included in this study (median age 45 years), 187 (76.3%) survived until ECMO decannulation and 172 (70.2%) until hospital discharge. Of those, 98 (57.3%) attended a follow-up clinic at a mean (±SD) of 204 (±45) days post-discharge. Patients reported problems with pain/discomfort (56%), usual daily activities (53%), anxiety/depression (49%), mobility (46%), and personal care (21%). Multivariate analysis identified limb ischaemia (-0.266, 95% C.I. [-0.116; -0.415], p = 0.0005), renal replacement therapy (-0.149, [-0.046; -0.252], p = 0.0044), and having received more than four platelet units (-0.157, [-0.031; -0.283], p = 0.0146) as predictors of poor HRQOL.

Conclusion

We report that survivors of VV-ECMO have reduced HRQOL in multiple domains at 6 months, with pain reported most frequently. Patients who had limb ischaemia, renal replacement therapy or were transfused more than four units of platelets are particularly at risk of poor HRQOL and may benefit from added support measures.

Thoughts and experiences regarding leg amputation among patients with diabetic foot ulcers: A phenomenological study

Despite lower-limb amputation being common among patients with diabetic foot ulcers, few studies have qualitatively investigated the patients' perspectives. Therefore, this study aimed to explore the thoughts and experiences of patients with diabetic foot ulcers regarding lower-limb amputation in Hong Kong. A phenomenological study using individual, semi-structured interviews was conducted with 18 participants with foot ulcers recruited in Hong Kong between July and September 2022. The interviews were audio-recorded, transcribed verbatim, and analysed using an interpretative phenomenological approach and a constant comparison strategy. The results highlighted four substantial themes: (a) coping or being alone and taciturn, (b) altered appearance impacting one's sense of maintaining social relations, (c) thoughts about self-efficacy and encountering a new normal, and (d) the possibility of a reduced gap in physical consequences between the old and new self. This study provided different perspectives of patients with a history of diabetic foot ulcers, even in cases where lower-limb amputation has not yet been performed. The results demonstrate that lower-limb amputation is considered a forbidden topic. This makes it culturally difficult for Chinese patients to discuss the matter with healthcare authorities and family members. Healthcare workers should be aware of how they communicate regarding lower-limb amputation.

Development of a Bioimpedance and sEMG Fusion Sensor for Gait Phase Detection: Validation with a Transtibial Amputee

Accurate gait phase detection is crucial for safe and efficient robotic prosthesis control in lower limb amputees. Several sensing modalities, including mechanical and biological signals, have been proposed to improve the accuracy of gait phase detection. In this paper, we propose a bioimpedance and sEMG fusion sensor for high-accuracy gait phase detection. We fabricated a wearable band-type sensor for multichannel bioimpedance and sEMG measurement, and we conducted gait experiments with a transtibial amputee to obtain biosignal data. Finally, we trained a deep-learning-based gait phase detection algorithm and evaluated its detection performance. Our results showed that using both bioimpedance and sEMG yielded the highest accuracy of 95.1%. Using only sEMG yielded a higher accuracy (90.9%) than that using only bioimpedance (85.1%). Therefore, we conclude that using both signals simultaneously is beneficial for improving the accuracy of gait phase detection. In addition, the proposed sensor can be applied to several applications by improving the accuracy of motion intention detection.

Have Surgery and Implant Modifications Been Associated With Reduction in Soft Tissue Complications in Transfemoral Bone-anchored Prostheses?

BACKGROUND

The most frequently occurring adverse events in individuals with a transfemoral amputation treated with a bone-anchored prosthesis are soft tissue infections and stoma-related complications. These soft tissue complications are believed to be influenced by surgical technique and implant design, but little is known about the effect of changes to treatment on these events.

QUESTIONS/PURPOSES

(1) What is the result of surgical technique and implant modifications on the incidence of soft tissue infections and stoma-related complications in transfemoral bone-anchored prosthesis users, depending on whether they had a conventional stoma and a cobalt-chrome-molybdenum (CoCrMo) osseointegration implant (treatment period 2009 to 2013) or a shallower stoma and titanium osseointegration implant (2015 to 2018)? (2) What is the incidence of serious complications, such as bone or implant infection, aseptic loosening, intramedullary stem breakage, and periprosthetic fracture?

METHODS

Between 2009 and 2013, we performed osseointegration implant surgery using a conventional surgical technique and a CoCrMo implant in 42 individuals who had a lower extremity amputation experiencing socket-related problems that resulted in limited prosthesis use. We considered all individuals treated with two-stage surgery with a standard press-fit transfemoral osseointegration implant as potentially eligible for inclusion. Based on this, 100% (42) were eligible, and 5% (two of 42) were excluded because they did not provide informed consent, leaving 95% (40 of 42) for analysis. Between 2015 and 2018, we treated 79 individuals with similar indications with osseointegration implant surgery, now also treating individuals with dysvascular amputations. We used an adapted surgical technique resulting in a shallower stoma combined with a titanium implant. Using the same eligibility criteria as for the first group, 51% (40 of 79) were eligible; 49% (39 of 79) were excluded because they were treated with transtibial amputation, a patient-specific implant, or single-stage surgery and 1% (one of 79) were lost before the 2-year follow-up interval, leaving 49% (39 of 79) for analysis. The period of 2013 to 2015 was a transitional period and was excluded from analysis in this study to keep groups reasonably comparable and to compare a historical approach with the present approach. Hence, we presented a comparative study of two study groups (defined by surgical technique and implant design) with standardized 2-year follow-up. The risk factors for adverse events were similar between groups, although individuals treated with the shallow stoma surgical technique and titanium implant potentially possessed an increased risk because of the inclusion of individuals with dysvascular amputation and the discontinuation of prolonged postoperative antibiotic prophylaxis. Outcomes studied were soft tissue infections and stoma-related complications (hypergranulation or keloid formation as well as stoma redundant tissue) and bone or implant infection, aseptic loosening, implant stem breakage, periprosthetic fracture, and death.

RESULTS

Patients treated with the shallow stoma surgical technique and titanium implant experienced fewer soft tissue infections (13 versus 76 events, absolute risk 0.17 [95% CI 0.09 to 0.30] versus 0.93 [95% CI 0.60 to 1.45]; p < 0.01), which were treated with less invasive measures, and fewer stoma redundant tissue events (0 versus five events, absolute risk 0 versus 0.06 [95% CI 0.03 to 0.14]) than patients treated with the conventional stoma surgical technique and CoCrMo implant. This was contrasted by an increased incidence of surgical site infections occurring between surgical stages 1 and 2, when no stoma was yet created, after the implementation of treatment changes (conventional surgery and CoCrMo implant versus shallow stoma surgery and titanium implant: one versus 11 events, absolute risk 0.01 [95% CI 0.00 to 0.08] versus 0.14 [95% CI 0.08 to 0.25]; p = 0.02). Patients treated with the shallow stoma surgical technique and titanium implant did not experience serious complications, although bone infections occurred (six events in 8% [three of 40] of patients) in the conventional surgery and CoCrMo implant group, all of which were successfully treated with implant retention.

CONCLUSION

Adaptations to surgical technique and newer implant designs, as well as learning curve and experience, have resulted in a reduced incidence and severity of soft tissue infections and stoma redundant tissue, contrasted by an increase in surgical site infections before stoma creation. Serious complications such as deep implant infection were infrequent in this 2-year follow-up period. We believe the benefits of these treatment modifications outweigh the disadvantages and currently advise surgeons to create a shallower stoma with a stable soft tissue envelope, combined with a titanium implant.

LEVEL OF EVIDENCE

Level III, therapeutic study.

GGEM: Gender, Geography, and EMployment differences based on mobility levels among lower limb prosthesis users living in the United States

BACKGROUND

For individuals with a disability, an increase in functional mobility may improve their quality of life and well-being. Greater understanding is needed on how factors such as gender, geography, and employment may play a role in mobility levels among individuals with lower limb amputation.

OBJECTIVES

To assess the relationship between gender, geography, and employment status on mobility among lower limb prosthesis users.

METHODS

A cross-sectional analysis of 7,524 patient mobility outcomes completed across the United States was performed. The regression model included the independent variables, such as age, gender, region, employment status, and amputation level. Mobility was entered as the dependent variable.

RESULTS

Individuals who were employed had 3.6 times the odds of reaching increased mobility (Prosthetic Limb Users' Survey of Mobility ≥ 50) than those unemployed (odds ratio 3.56, 95% confidence interval 3.10-4.09). Gender and geography were significantly associated with mobility as well.

CONCLUSIONS

Being employed is associated with greater odds of reaching increased mobility. Addressing factors such as returning to employment may aid in improving mobility levels among prosthesis users.

A Workflow for Studying the Stump-Socket Interface in Persons with Transtibial Amputation through 3D Thermographic Mapping

The design and fitting of prosthetic sockets can significantly affect the acceptance of an artificial limb by persons with lower limb amputations. Clinical fitting is typically an iterative process, which requires patients' feedback and professional assessment. When feedback is unreliable due to the patient's physical or psychological conditions, quantitative measures can support decision-making. Specifically, monitoring the skin temperature of the residual limb can provide valuable information regarding unwanted mechanical stresses and reduced vascularization, which can lead to inflammation, skin sores and ulcerations. Multiple 2D images to examine a real-life 3D limb can be cumbersome and might only offer a partial assessment of critical areas. To overcome these issues, we developed a workflow for integrating thermographic information on the 3D scan of a residual limb, with intrinsic reconstruction quality measures. Specifically, workflow allows us to calculate a 3D thermal map of the skin of the stump at rest and after walking, and summarize this information with a single 3D differential map. The workflow was tested on a person with transtibial amputation, with a reconstruction accuracy lower than 3 mm, which is adequate for socket adaptation. We expect the workflow to improve socket acceptance and patients' quality of life.

Detangling the Structural Neural Correlates Associated with Resting versus Dynamic Phantom Limb Pain Intensity Using a Voxel-based Morphometry Analysis

The management of phantom limb pain (PLP) is still challenging due to a partial understanding of its neurophysiological mechanisms. Structural neuroimaging features are potential biomarkers. However, only a few studies assessed their correlations with clinical severity and treatment response. This study aims to explore the association between brain gray matter volume (GMV) with phantom limb manifestations severity and PLP improvement after neuromodulatory treatments (transcranial direct current stimulation and mirror therapy). Voxel-based morphometry analyses and functional decoding using a reverse inference term-based meta-analytic approach were used. We included 24 lower limb traumatic amputees with moderate to severe PLP. We found that alterations of cortical GMV were correlated with PLP severity but not with other clinical manifestations. Less PLP severity was associated with larger brain clusters GMV in the non-affected prefrontal, insula (non-affected mid-anterior region), and bilateral thalamus. However, only the insula cluster survived adjustments. Moreover, the reverse inference meta-analytic approach revealed that the found insula cluster is highly functionally connected to the contralateral insula and premotor cortices, and the decoded psychological processes related to this cluster were "rating," "sustained attention," "impulsivity, " and "suffering." Moreover, we found that responders to neuromodulatory treatment have higher GMV in somatosensory areas (total volume of S1 and S2) in the affected hemisphere at baseline, compared to non-responders, even after adjustments.

Peptide grafting on intraosseous transcutaneous amputation prostheses to promote sealing with skin cells: Potential to limit infections

The long-term success of intraosseous transcutaneous amputation prostheses (ITAPs) mainly relies on dermal attachment of skin cells to the implant. Otherwise, bacteria can easily penetrate through the interface between the implant and the skin. Therefore, infection at this implant/skin interface remains a significant complication in orthopedic surgeries in which these prostheses are required. Two main strategies were investigated to prevent these potential infection problems which consist in either establishing a strong sealing at the skin/implant interface or on eradicating infections by killing bacteria. In this work, two adhesion peptides, either KRGDS or KYIGSR and one antimicrobial peptide, Magainin 2 (Mag 2), were covalently grafted via phosphonate anchor arms to the surface of the Ti6Al4V ELI (extra low interstitials) material, commonly used to manufacture ITAPs. X-ray photoelectron spectroscopy, contact angle, and confocal microscopy analyses enabled to validate the covalent and stable grafting of these three peptides. Dermal fibroblasts cultures on bare Ti6Al4V ELI surfaces and functionalized ones displayed a good cell adhesion and proliferation on all samples. However, cell spreading and viability appeared to be improved on grafted surfaces, especially for those conjugated with KRGDS and Mag 2. Moreover, the dermal sheet attachment, was significantly higher on surfaces functionalized with Mag 2 as compared to the other surfaces. Therefore, the surface functionalization with the antimicrobial peptide Mag 2 seems to be the best approach for the targeted application, as it could play a dual role, inducing a strong skin adhesion while limiting infections on Ti6Al4V ELI materials.

Validity and reliability of Turkish transcultural adaptation of the Prosthetic Limb Users Survey of Mobility

BACKGROUND

Amputee-specific, self-assessment mobility scales are essential to evaluate mobility in lower-limb amputees.

OBJECTIVES

To evaluate the validity and reliability of a Turkish translation and adaptation of the Prosthetic Limb Users Survey of Mobility.

STUDY DESIGN

This is a validation study.

METHODS

Turkish translation of the Prosthetic Limb Users Survey of Mobility (PLUS-M-T) from its original was performed following the rules of intercultural adaptation and translation methods. The PLUS-M-T and its 12-item short form were applied to '100 induviduals with limb loss twice in 3-day intervals. The structural validity analysis was determined by calculating the correlation with the Amputee Mobility Scale, which is a valid, reliable scale for assessing the functional level in amputees. The Cronbach alpha coefficient was calculated to analyze the internal consistency. The interclass correlation coefficient (ICC) and Spearman correlation coefficient (r) were calculated, and the test-retest reliability was determined.

RESULTS

A positive, high correlation was found between the first application and its repetition of both PLUS-M-T (ICC = 0.85, r = 0.94, P < 0.001) and 12-item short form (ICC = 0.92, r = 0.93, P < 0.001). The internal consistency was high for both PLUS-M-T (Cronbach alpha = 0.94) and 12-item short form (Cronbach alpha = 0.91). A positive, high correlation was found between the scores obtained from the Amputee Mobility Scale and PLUS-M-T (r = 0.84, P < 0.001) and 12 question short form (r = 0.77, P < 0.001).

CONCLUSION

Turkish translation of the PLUS-M questionnaire is a valid and reliable scale for assessing the mobility of individuals who have undergone lower-extremity amputation using a prosthesis.

Lower extremity amputations (LEAs) in a tertiary hospital in Togo: a retrospective analysis of clinical, biological, radiological, and therapeutic aspects

BACKGROUND

We analysed the clinical, biological, radiological profiles, and therapeutic patterns of the patients who underwent a surgical lower extremity amputation (LEA) in Togo from 2010 to 2020.

METHODS

Retrospective analysis of clinical files of adult patients who underwent an LEA at a single centre (Sylvanus Olympio Teaching Hospital) from 1st January 2010 to 31st December 2020. Data were analysed by CDC Epi Info Version 7 and Microsoft Office Excel 2013 software.

RESULTS

We included 245 cases. The mean age was 59.62 years (15.22 SD) (range: 15-90 years). The sex ratio was 1.99. The medical history of diabetes mellitus (DM) was found in 143/222 (64.41%) files. The amputation level found in 241/245 (98.37%) files was the leg in 133/241 (55.19%) patients, the knee in 14/241 (5.81%), the thigh in 83/241 (34.44%), and the foot in 11/241 (4.56%). The 143 patients with DM who underwent LEA had infectious and vascular diseases. Patients with previous LEAs were more likely to have the same limb affected than the contralateral one. The odds of trauma as an indication for LEA were twice as high in patients younger than 65 years compared to the older (OR = 2.095, 95% CI = 1.050-4.183). The mortality rate after LEA was 17/238 (7.14%). There was no significant difference between age, sex, presence or absence of DM, and early postoperative complications (P = 0.77; 0.96; 0.97). The mean duration of hospitalization marked in 241/245 (98.37%) files was 36.30 (1-278) days (36.20 SD). Patients with LEAs due to trauma had a significantly longer hospital admission than those with non-traumatic indications, F (3,237) = 5.505, P = 0.001.

CONCLUSIONS

Compared to previous decades, from 2010 to 2020, the average incidence of LEAs for all causes at Sylvanus Olympio Teaching Hospital (Lomé, Togo) decreased while the percentage of patients with DM who underwent LEAs increased. This setting imposes a multidisciplinary approach and information campaigns to prevent DM, cardiovascular diseases, and  relative complications.

Effects of Resistance Training in Individuals with Lower Limb Amputation: A Systematic Review

Individuals with lower-limb amputations may have a significant strength deficit. This deficit may be related to the stump length and can lead to changes in gait, reduced energy efficiency, walking resistance, altered joint load, and increased risk of osteoarthritis and chronic low back pain. This systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) guidelines to examine the effects of resistance training in lower limb amputees. Interventions with resistance training and other training methods were sufficient to achieve muscle strength gain in muscles of the lower limbs, improved balance, and improvements in gait pattern and speed when walking. However, it was impossible to determine from the results whether resistance training was mainly responsible for these benefits or even whether the positive effects presented would be observed with only this training method. When combined with other exercises, interventions with resistance training made possible gains for this population. Accordingly, it is noteworthy that the main finding of this systematic review is that the effects may be different according to the level of amputation, with mainly transtibial and transfemoral amputations studied.

Health utility in community-dwelling adults with dysvascular lower limb loss

PURPOSE

Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA.

METHODS

Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests.

RESULTS

A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain.

CONCLUSION

Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Prosthesis use among individuals with lower limb amputation in Bangladesh

OBJECTIVE

This study aimed to assess factors related to prostheses use among individuals with lower limb amputation in Bangladesh.

METHODS

Data related to prosthesis use, functional capabilities (as measured with the Locomotor Capabilities Index [LCI]), and user satisfaction were collected using telephone interviews between January 2014 and October 2016. Descriptive and regression analyses were performed.

RESULTS

This study involved 183 participants (89.6% male); the mean (SD) age was 49.5 (10.7) years. Most of the participants (95.6%) used prostheses daily, and the mean (SD) duration of use was 7.0 (4.1) hours per day. The mean (SD) basic LCI score, advanced LCI score, and total LCI score were 25.1 (4.9), 20.8 (8.3), and 45.9 (12.2), respectively. Among them, 36.7% were dissatisfied with the weight of the prosthesis. Having a below knee amputation (odds ratio 2.6 and confidence interval 1.3, 5.3) and absence of comorbidities (odds ratio 2.1; confidence interval 1.0, 4.4) were associated significantly with an increased use of prosthesis.

CONCLUSION

Factors such as weight of the prosthesis, amputation level, and presence of comorbidities are important considerations while planning for prosthetic rehabilitation and optimize utilization of the prosthetic devices.

Understanding decision-making in prosthetic rehabilitation by prosthetists and people with lower limb amputation: a qualitative study

PURPOSE

Little has been published about the process of decision-making between prosthetists and people with lower limb amputation (LLA). The purpose of this study is to identify decisions and factors influencing decision-making in prosthetic rehabilitation from the perspectives of prosthetists and prosthesis users, to identify barriers and opportunities for shared decision-making (SDM).

METHODS

Qualitative semi-structured individual interviews were conducted with 13 prosthetists and 14 prosthesis users from three clinics in three states of the Rocky Mountain and Southwest regions of the United States. Transcripts were analyzed using thematic analysis.

RESULTS

Four main themes were identified: perceived decision points, importance of relationship, balancing competing priorities, and experience. Contrasts between perceptions of prosthetists and prosthesis users were related to prosthesis design decisions, and the purpose of communication (e.g., goals for a prosthesis vs. goals informing prosthesis design). Both prosthetists and prosthesis users described balancing priorities that contribute to prosthetic rehabilitation decisions, and the role of experience for informing realistic expectations and preferences necessary for participating in decision-making.

CONCLUSION

Opportunities for improving SDM between prosthetists and prosthesis users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.IMPLICATIONS FOR REHABILITATIONMany people with lower limb amputation experience poor physical function and psychosocial outcomes, which may be further compounded by under informed prosthesis-user expectations for function with a prosthesis.Shared decision-making offers an opportunity for improving realistic prosthesis-user expectations, reducing healthcare costs, and improving prosthesis-user satisfaction and adherence to care plans.Opportunities for improving shared decision-making between prosthetists and prosthesis-users include (1) clarifying key rehabilitation decisions, (2) identifying the purpose of initial communications, (3) support for balancing priorities, and (4) utilizing experience to achieve informed preferences.

Therapeutic benefits of lower limb prostheses: a systematic review

BACKGROUND

Enhancing the quality of life of people with a lower limb amputation is critical in prosthetic development and rehabilitation. Yet, no overview is available concerning the impact of passive, quasi-passive and active ankle-foot prostheses on quality of life.

OBJECTIVE

To systematically review the therapeutic benefits of performing daily activities with passive, quasi-passive and active ankle-foot prostheses in people with a lower limb amputation.

METHODS

We searched the Pubmed, Web of Science, Scopus and Pedro databases, and backward citations until November 3, 2021. Only English-written randomised controlled trials, cross-sectional, cross-over and cohort studies were included when the population comprised individuals with a unilateral transfemoral or transtibial amputation, wearing passive, quasi-passive or active ankle-foot prostheses. The intervention and outcome measures had to include any aspect of quality of life assessed while performing daily activities. We synthesised the participants' characteristics, type of prosthesis, intervention, outcome and main results, and conducted risk of bias assessment using the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021290189.

RESULTS

We identified 4281 records and included 34 studies in total. Results indicate that quasi-passive and active prostheses are favoured over passive prostheses based on biomechanical, physiological, performance and subjective measures in the short-term. All studies had a moderate or high risk of bias.

CONCLUSION

Compared to passive ankle-foot prostheses, quasi-passive and active prostheses significantly enhance the quality of life. Future research should investigate the long-term therapeutic benefits of prosthetics devices.

Neutralization of excessive CCL28 improves wound healing in diabetic mice

Introduction: Chronic, non-healing skin wounds such as diabetic foot ulcers (DFUs) are common in patients with type 2 diabetes mellitus (T2DM) and often result in limb amputation and even death. However, mechanisms by which T2DM and inflammation negatively impact skin wound healing remains poorly understood. Here we investigate a mechanism by which an excessive level of chemokine CCL28, through its receptor CCR10, impairs wound healing in patients and mice with T2DM. Methods & Results: Firstly, a higher level of CCL28 was observed in skin and plasma in both patients with T2DM, and in obesity-induced type 2 diabetic db/db mice. Compared with WT mice, adipose tissue from db/db mice released 50% more CCL28, as well as 2- to 3-fold more IL-1β, IL-6, and TNF-α, and less VEGF, as determined by ELISA measurements. Secondly, overexpression of CCL28 with adenovirus (Adv-CCL28) caused elevation of proinflammatory cytokines as well as CCR10 expression and also reduced eNOS expression in the dorsal skin of WT mice as compared with control Adv. Thirdly, topical application of neutralizing anti-CCL28 Ab dose-dependently accelerated wound closure and eNOS expression, and decreased IL-6 level, with an optimal dose of 1 μg/wound. In addition, mRNA levels of eNOS and anti-inflammatory cytokine IL-4 were increased as shown by real-time RT-PCR. The interaction between eNOS and CCR10 was significantly reduced in diabetic mouse wounds following application of the optimal dose of anti-CCL28 Ab, and eNOS expression increased. Finally, enhanced VEGF production and increased subdermal vessel density as indicated by CD31 immunostaining were also observed with anti-CCL28 Ab. Discussion: Taken together, topical application of neutralizing anti-CCL28 Ab improved dorsal skin wound healing by reducing CCR10 activation and inflammation in part by preventing eNOS downregulation, increasing VEGF production, and restoring angiogenesis. These results indicate anti-CCL28 Ab has significant potential as a therapeutic strategy for treatment of chronic non-healing diabetic skin wounds such as DFUs.

Effect of mirror therapy in the treatment of phantom limb pain in amputees: A systematic review of randomized placebo-controlled trials does not find any evidence of efficacy

BACKGROUND AND OBJECTIVE

Phantom limb pain (PLP) concerns >50% of amputees and has a negative impact on their rehabilitation, mental health and quality of life. Mirror therapy (MT) is a promising strategy, but its effectiveness remains controversial. We performed a systematic review to: (i) evaluate the effectiveness of MT versus placebo in reducing PLP, and (ii) determine MT effect on disability and quality of life.

DATABASES AND DATA TREATMENT

We selected randomized-controlled trials in five databases (Medline, Cochrane Library, CINAHL, PEDro and Embase) that included patients with unilateral lower or upper limb amputation and PLP and that compared the effects on PLP of MT versus a placebo technique. The primary outcome was PLP intensity changes and the secondary outcomes were PLP duration, frequency, patients' disability and quality of life.

RESULTS

Among the five studies included, only one reported a significant difference between the MT group and control group, with a positive MT effect at week 4. Only one study assessed MT effect on disability and found a significant improvement in the MT group at week 10 and month 6.

CONCLUSIONS

Our systematic review did not allow concluding that MT reduces PLP and disability in amputees. This lack of strong evidence is probably due to (i) the low methodological quality of the included studies, and (ii) the lack of statistical power. Future trials should include a higher number of patients, increase the number and frequency of MT sessions, have a long-term follow-up and improve the methodological quality.

SIGNIFICANCE

Recent meta-analyses concluded that MT is effective for reducing phantom limb pain. Conversely, the present systematic review that included only studies with the best level of evidence did not find any evidence about its effectiveness for this condition. We identified many ways to improve future randomized-controlled trials on this topic: increasing the number of participants, reducing the intra-group heterogeneity, using a suitable placebo and intensifying the MT sessions and frequency.

Neuromuscular adaptations after osseointegration of a bone-anchored prosthesis in a unilateral transfemoral amputee - a case study

PURPOSE

Many individuals with a lower limb amputation experience problems with the fitting of the socket of their prosthesis, leading to dissatisfaction or device rejection. Osseointegration (OI)- the implantation of a shaft directly interfacing with the remaining bone- is an alternative for these patients. In this observational study, we investigated how bone anchoring influences neuromuscular parameters during balance control in a patient with a unilateral transfemoral amputation.

MATERIAL AND METHODS

Center of pressure (CoP) and electromyography (EMG) signals from muscles controlling the hip and the ankle of the intact leg were recorded during quiet standing six months before and one and a half years after this patient underwent an OI surgery. Results were compared to a control group of nine able-bodied individuals.

RESULTS

Muscle co-activation and EMG intensity decreased after bone anchoring, approaching the levels of able-bodied individuals. Muscle co-activation controlling the ankle decreased in the high-frequency range, and the EMG intensity spectrum decreased in the lower-frequency range for all muscles when vision was allowed. With eyes closed, the ankle extensor muscle showed an increased EMG intensity in the high-frequency range post-surgery. CoP length increased in the mediolateral direction of the amputated leg.

CONCLUSIONS

These findings point to shifts in the patient's neuromuscular profile towards the one of able-bodied individuals.

The status and use of prosthetic devices by persons with lower limb amputation in Rwanda

Background

Amputation is one of the leading causes of disabilities because of reduced mobility. Without assistive devices specifically prostheses, the quality of life of persons with lower limb amputation (PLLA) further deteriorates. Therefore, prostheses are fundamental to improving their quality of life.

Objectives

This study aimed to establish the number of PLLA with or without prosthesis and to determine their socio-economic profile in Rwanda.

Method

A descriptive, cross-sectional study was conducted in all sectors of Rwanda. As a result of coronavirus disease 2019 movement restrictions, data collection was carried out through telephone calls with participants to complete the questionnaires. Descriptive, inferential statistics and chi-square test were performed to analyse data using Statistical Package for Social Science (SPSS) 21.0.

Results

Of the 3026 participants identified countrywide, 68.8% were males and 60.3% of them did not have any prosthesis (p = 0.003). The majority (62.4%) of those who had prosthetic devices needed repair of their prostheses while 14.8% of participants reported that their prosthetic devices were completely broken and/or damaged (p = 0.604). Among the participants, 63.7% had no source of income and 66.7% had dependents (p ≤ 0.001).

Conclusion

The majority of the PLLA in Rwanda did not have prosthetic devices and even those with prostheses did not fully function and thus required repair. Therefore, it adversely affects their livelihood.

Contribution

The government should collaborate with stakeholders working with persons with disabilities and implement mechanisms and/or strategies to make prosthetic devices accessible and affordable.

Health-related quality of life in patients with lower limb amputation - an assessment of the measurement properties of EQ-5D-3L and EQ-5D-5L using data from the Swedish Amputation and Prosthetics Registry

PURPOSE

To assess the measurement properties of EQ-5D-3L and EQ-5D-5L in patients with a major lower limb amputation (LLA).

METHODS

This was a retrospective register-based study using data from the Swedish Amputation and Prosthetics Registry (SwedeAmp). Patients with a six-months follow-up (including either EQ-5D-3L or EQ-5D-5L) after a major unilateral LLA were included. The measurement properties of EQ-5D-3L and EQ-5D-5L were compared in terms of feasibility, response patterns, informativity, and convergent and known-group validity.

RESULTS

The sample included 700 patients with below-knee amputation (76%), above-knee amputation (18%), or knee disarticulation (7%). Responses to EQ-5D-3L and -5L were similar regarding feasibility (98% completion rate) and the proportion reporting no problems (7% and 6%). Compared to EQ-5D-3L, EQ-5D-5L showed higher absolute and relative informativity in all dimensions, with the largest improvement in the mobility dimension. In the analyses of convergent validity, the EQ-5D-5L generally showed stronger correlations with disease-specific measures. Only EQ-5D-5L was able to discriminate between subgroups with different amputation levels.

CONCLUSION

The findings support the use of EQ-5D-5L over EQ-5D-3L in patients with an LLA, mainly due to improved informativity and improved convergent and known-group validity.Implications for rehabilitationThe measurement properties of two EQ-5D versions, EQ-5D-3L and EQ-5D-5L, has so far not been evaluated in patients with a lower limb amputation (LLA)The results support the use of EQ-5D-5L over the use of EQ-5D-3L, mainly due to improved informativity and stronger correlations with disease-specific patient-reported outcome measuresThe five-level version of EQ-5D is recommended for future applications of EQ-5D in clinical outcome studies, health economic evaluations, and in the routine follow-up of patients with a major LLAIn the early rehabilitation process six months after an LLA, the majority of patients reported problems with mobility, pain/discomfort, and usual activities.

Influential factors for access to and participation in rehabilitation for people with lower limb amputation in East, South, and Southeast Asian developing countries: a scoping review

PURPOSE

To explore factors impacting access to and participation in rehabilitation for people with lower limb amputation (LLA) in East, South, and Southeast Asian developing countries.

MATERIALS AND METHODS

A scoping review was undertaken following the PRISMA-ScR guidelines. Five electronic databases (PsycINFO (Ovid), Medline (Ovid), CINAHL (EBSCO), AMED, and Proquest Social Sciences) were searched for articles from January 1980 till March 2020. Two authors independently assessed articles for inclusion. Included articles were classified according to the Health Care Delivery System Approach (HCDSA) framework levels.

RESULTS

Twenty-four studies from 14 countries were identified. At patient level, age, gender, limited rehabilitation awareness, and economic status; at the rehabilitation level, gaps in referrals, family support, and professional skills; at the environmental level, services availability, and location; and, at government level, service costs, income loss, and lack of supporting policies were identified as important influencing factors.

CONCLUSIONS

Rehabilitation access and participation factors were identified at multiple levels of the HCDSA. Contextually appropriate and accessible services considering individual characteristics and socio-economic status of individuals with LLA are needed, with timely referral to rehabilitation by trained professionals. Improving rehabilitation services for people with LLA in Asian developing countries requires supportive environments, accessible transport, social and financial security, and increased awareness, underpinned by appropriate policy.Implications for rehabilitationProvision of timely referral to rehabilitation by primary/acute health care settings with involvement of family/peer supports.Improved government support systems to facilitate individual access to and participation in rehabilitation with consideration of contextual socio-demographic and economic factors.Prioritisation of adequately resourced and well-designed rehabilitation centres by health care organisations in accessible locations.Implementation by local government of strategies to support development and implementation of well resourced, accessible, equitable, and contextually responsive rehabilitation services.

Facilitators and Barriers That Transfemoral Amputees Experience in Their Everyday Life: A Norwegian Qualitative Study

Background

Living with a lower limb amputation influences multiple facets of life due to altered function. Individuals achieve a varied level of function post amputation, depending on several variables like age, level of function prior to amputation, and available personal and environmental resources. Releasing the potential to live life to the fullest despite a disability is important to the individual.

Objectives

The primary objective of this study is to identify barriers and facilitators for function which lower limb amputees experience in their lives several years after amputation, from the amputee's perspective. This knowledge can contribute to further development of the clinical pathway for lower limb amputees in a Norwegian rehabilitation hospital.

Methods

The study has a descriptive and exploratory qualitative design with a phenomenological hermeneutical approach. Semistructured, individual interviews were conducted for data collection. Thematic analysis inspired by Braun and Clarke was used for data analysis. The sample consisted of eight transfemoral amputees (70 ± 6.9 (58-77 years)) living in the southern part of Norway. Average time since amputation was 11 years.

Results

The results have been categorised into two main themes with subthemes: (1) facilitators: personal resources, a well-fitted prosthesis, rehabilitation, social network, balance in activity/rest, and accessibility and (2) barriers: walking distance, poorly fitted prosthesis, pain, comorbidities, climate/terrain/falling, reduced local competence on amputation, and pandemic.

Conclusion

Lower limb amputees experience barriers in their everyday life, but they also develop strategies to cope with their disability. Clinical implications can include increased nutritional guidance, structural psychological mapping and follow-up, structured follow-ups over a significant period of time, and extended use of digital consultation.

Gait asymmetry is associated with performance-based physical function among adults with lower-limb amputation

BACKGROUND

Adults with lower-limb amputation walk with an asymmetrical gait and exhibit poor functional outcomes, which may negatively impact quality-of-life.

OBJECTIVE

To evaluate associations between gait asymmetry and performance-based physical function among adults with lower-limb amputation.

METHODS

A cross-sectional study involving 38 adults with a unilateral transtibial (N = 24; 62.5 ± 10.5 years) or transfemoral amputation (N = 14; 59.9 ± 9.5 years) was conducted. Following gait analysis (capturing step length and stance time asymmetry at self-selected (SSWS) and fast walking speeds (FWS)), participants completed performance-based measures (i.e. Timed Up and Go (TUG), the 10-Meter Walk Test (10mwt), and the 6-Minute Walk Test (6MWT)).

RESULTS

Step length and stance time asymmetry (at SSWS and FWS) were significantly correlated with each performance-based measure (p < .001 to p = .035). Overall, models with gait measures obtained at SSWS explained 40.1%, 46.8% and 40.1% of the variance in TUG-time (p = .022), 10mwt-speed (p = .003) and 6MWT-distance (p = .010), respectively. Models with gait measures obtained at FWS explained 70.0%, 59.8% and 51.8% of the variance in TUG-time (p < .001), 10mwt-speed (p < .001), and 6MWT-distance (p < .001), respectively.

CONCLUSIONS

Increases in step length or stance time asymmetry are associated with increased TUG-time, slower 10mwt-speed, and reduced 6MWT-distance. Findings suggest gait asymmetry may be a factor in poor functional outcomes following lower-limb amputation.

High-Level Mobility of Trans-Tibial Prosthesis Users Wearing Commercial and sPace Energy-Storing Prosthetic Feet

Outcomes of users provided with a commercial ESR Vari-Flex foot (Össur, Reykjavik, Iceland) and a locally designed sPace foot were investigated. Step activity with users' own prosthetic foot compared to the sPace foot was explored.

METHODS

Eleven individuals with unilateral trans-tibial amputation participated and were provided with an sPace and Vari-Flex foot. Ten- and twenty-meter walk tests (10/20MWT) at comfortable and fast walking speeds (CWS/FWS), the two-minute walk test (2-MWT) and Comprehensive High-Level Activity Mobility Predictor (CHAMP) were administered. A subgroup was provided a pedometer to record their steps over a 7-day period in their own foot and later the sPace.

RESULTS

The sPace foot performed well in a battery of high-level mobility outcome measures. On CHAMP, participants scored 16.94 ± 5.41 and 16.72 ± 6.09 with the sPace and Vari-Flex feet, respectively. Subgroup testing of step activity showed 4490 ± 3444 steps in users' own feet and 3115 ± 1967 in the sPace foot, p = 0.176.

CONCLUSIONS

Participants using the sPace foot were capable of performing walking, high-level mobility and activity outcome measures.

Cost-effectiveness analysis of prosthesis provision for patients with transfemoral amputation in Tanzania

BACKGROUND

Limb loss leads to significant disability. Prostheses may mitigate this disability but are not readily accessible in low- and middle-income countries (LMICs). Cost-effectiveness data related to prosthesis provision in resource-constrained environments such as Tanzania is greatly limited.

OBJECTIVES

This study aimed to compare the cost-effectiveness of a prosthesis intervention compared with that of no prosthesis for persons with transfemoral amputations in an LMIC.

STUDY DESIGN

This is a prospective cohort study.

METHODS

Thirty-eight patients were prospectively followed up. Clinical improvement with prosthesis provision was measured using EuroQuol-5D, represented as quality-adjusted life years gained. Direct and indirect costs were measured. The primary outcome was incremental cost per quality-adjusted life year, measured at 1 year and projected over a lifetime using a Markov model. Reference case was set as a single prosthesis provided without replacement from a payer perspective. Additional scenarios included the societal perspective and replacement of the prosthesis. Uncertainty was measured with one-way probabilistic sensitivity analysis.

RESULTS

From the payer perspective, the incremental cost-effectiveness ratio (ICER) was $242 for those without prosthetic replacement over a lifetime, and the ICER was $390 for those with prosthetic replacement over a lifeime. From the societal perspective, prosthesis provision was both less expensive and more effective. One-way sensitivity analysis demonstrated the ICER remained below the willingness to pay threshold up to prosthesis costs of $763.

CONCLUSIONS

These findings suggest prosthesis provision in an LMIC may be cost-effective, but further studies with long-term follow up are needed to validate the results.

Disability, economic and work-role status of individuals with unilateral lower-limb amputation and their families in Bangladesh, post-amputation, and pre-rehabilitation: A cross-sectional study

BACKGROUND: Amputation has significant negative impacts on physical, psychological, social and economic wellbeing of individuals and families. This is potentially compounded by significant delays to rehabilitation in Bangladesh. OBJECTIVE: To quantify disability, occupation and socioeconomic status of people with unilateral lower-limb amputation (LLA) and their families in Bangladesh, post-amputation and pre-rehabilitation. METHODS: Between November 2017 and February 2018, people with unilateral LLA attending two locations of Center for the Rehabilitation of the Paralyzed, Bangladesh, for prosthetic rehabilitation were surveyed pre-rehabilitation, using the World Health Organization Disability Assessment Schedule (WHODAS-2.0) with additional socio-economic questions. Data were analysed descriptively, using cross-tabulation with Chi-square and Fisher’s exact tests. RESULTS: Seventy-six individuals participated. The majority had traumatic (64.5%), transtibial amputation (61.8%), were young adults (37.92±12.35 years), in paid work prior to LLA (80%), married (63.2%), male (81.6%), from rural areas (78.9%), with primary/no education (72.4%). After LLA mobility (WHODAS score 74.61±13.19) was their most negatively affected domain. Most (60.5%) did not return to any occupation. Acute healthcare costs negatively impacted most families (89.5%), over 80% becoming impoverished. Nearly 70% of previous income-earners became economically dependent changing traditional family roles. CONCLUSIONS: Following LLA, most participants experienced significant mobility impairment and became economically dependent. The impact of LLA extends beyond the individual, to families who often face challenges to traditional primary earner gendered roles. Improved access to timely and affordable rehabilitation is required to reduce the significant personal and societal costs of disability after LLA.

Amputation-specific and generic correlates of participation among Veterans with lower limb amputation

Participation in valued interpersonal and community activities is a key component of rehabilitation for Veterans with amputation. The purpose of this study was to identify specific factors that promote or inhibit participation to inform development of interventions that may facilitate participation in desired life activities. A convenience sample of 408 Veterans with at least one lower limb amputation and who had received outpatient care from the Regional Amputation Center (RAC) completed a mailed survey. Participation was measured using the Community Participation Indicators (CPI) Importance, Control, and Frequency scales and the Patient Reported Outcome Measurement Information System (PROMIS) Ability to Participate in Social Roles and Satisfaction with Social Participation scales. Multiple imputation procedures were used to address missing data. Correlates of participation were examined through multiple linear regression. A total of 235 participants completed the survey, a response rate of 58%. Levels of participation, measured with the PROMIS instruments, were 43.2 (SD = 8.1) for Ability and 46.4 (SD = 8.6) for Satisfaction. Regression analyses found robust amputation-specific correlates for participation, including body image and balance confidence. Generic (non-amputation specific) correlates for participation included depression and pain interference. Development of treatment approaches and devices that can address body image, balance confidence, pain, and mental health concerns such as depression have the potential to enhance the participation and rehabilitation of Veterans with lower limb amputation.