Evaluation of disabilities and activities of daily living of war-related bilateral lower extremity amputees

A systematic review of the prevalence of postamputation and chronic neuropathic pain associated with combat injury in military personnel

ABSTRACT

Combat trauma can lead to widespread tissue damage and limb loss. This may result in chronic neuropathic and post amputation pain, including phantom limb pain (PLP) and residual limb pain (RLP). The military population is distinct with respect to demographic, injury, and social characteristics compared with other amputation and trauma cohorts. We undertook a systematic review of studies of military personnel, with a history of combat injury, that reported a prevalence of any type of postamputation pain or chronic neuropathic pain, identified from Embase and MEDLINE databases.Using the inverse variance method with a random-effects model, we undertook a meta-analysis to determine an overall prevalence and performed exploratory analyses to identify the effect of the type of pain, conflict, and time since injury on prevalence. Pain definitions and types of pain measurement tools used in studies were recorded. Thirty-one studies (14,738 participants) were included. The pooled prevalence of PLP, RLP, and chronic neuropathic pain were 57% (95% CI: 46-68), 61% (95% CI: 50-71), and 26% (95% CI: 10-54), respectively. Between-study heterogeneity was high (I 2 : 94%-98%). Characterisation of duration, frequency, and impact of pain was limited. Factors reported by included studies as being associated with PLP included the presence of RLP and psychological comorbidity. The prevalence of postamputation pain and chronic neuropathic pain after combat trauma is high. We highlight inconsistency of case definitions and terminology for pain and the need for consensus in future research of traumatic injury.

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.

Mapping lines of non-extension in persons with lower limb amputation to aid comfort-driven prosthetic socket design

OBJECTIVE

This study aimed to develop a new technique to map the strain field for persons with lower-limb amputations to use for the design of comfortable prostheses.

METHODS

Using a DSLR camera with stenciled 2D markers, we demonstrated a technique to measure skin strain around the residual limb of persons with lower limb amputations. We used open-source software programs to reconstruct a series of cloud points derived from the pictures of the marked residual limb into 3D models, then calculated the minimum, maximum, and non-extension lines from directional strain fields.

RESULTS

A DSLR camera was successful in capturing 2D markers. The maximum mean principal strain was 68% ± 14%, observed around the patella. The minimum compressive mean principal strain of -31% ± 4% was observed posteriorly in the popliteal region of the knee. Although lines of non-extension (LoNE) appear separate in different participants, they are anatomically located in regions that could be generalized for the design of prostheses.

CONCLUSIONS

Marker locations extracted from the video of different poses can be compared to calculate strains from which the position of LoNE can be generated. The use of LoNE could be valuable in reducing discomfort at the socket interface and informing future socket design.

Design to Assist Better Youthhood for Adolescents with Lower-Limb Disability through Virtual Reality Sports

Background: Youths with lower limb dysfunction display low levels of sports participation, which limits their growth and self-development, both physically and mentally. Recently, VR technology has proven its profound value in the psychological evaluation and treatment, rehabilitation, and immersive training of people in need. We have proposed, designed, and developed a VR rock-climbing game for youths with lower-limb dysfunction that allows them to engage in enjoyable and purposeful in-game tasks that simultaneously bring about intensive real-world exercise. Methods: Pilot studies were conducted on college students whose lower limbs were fixed to chairs. Heart rate monitoring, a flow questionnaire, interviews, and observation were conducted for each participant to evaluate the impact of the VR rock-climbing game. The collected data were trimmed on the basis of Cronbach’s alpha and corrected item−total correlation (CITC) to guarantee the data’s reliability. Results: The average value of each flow experience dimension was greater than 4 (0.76 < SD < 0.91). According to the flow-based analysis and the whole-process feeling distribution (WPFD), the evaluated study brought about the participants’ happiness and a sense of mastery and achievement. Conclusions: By bringing about a deep and enjoyable immersion in VR, it remarkably promotes the participants’ intention to participate in exercises.

The relationship between self-reported physical functioning, mental health, and quality of life in Service members after combat-related lower extremity amputation

PURPOSE

Service members with amputations experience numerous challenges, yet few studies have examined patient-reported outcomes, including physical functional status, mental-health screening status, and quality of life (QOL) or the relationship between these outcomes.

MATERIALS AND METHODS

Service members with combat-related lower extremity amputations (N = 82) and participants in the Wounded Warrior Recovery Project were included. Patient-reported outcomes of physical functional status, posttraumatic stress disorder (PTSD), depression screening status, and QOL were compared, while accounting for amputation level. Linear regression assessed relationships between physical functional status and QOL, as well as mental-health screening status.

RESULTS

Higher physical functioning scores were associated with better QOL, and lower physical functioning scores were associated with screening positive for PTSD or depression. When stratified by mental-health screening, a significant relationship was observed between mean physical functioning scores and amputation level with a negative PTSD or depression screen only. Additionally, those with bilateral amputation reported lower physical functioning.

CONCLUSIONS

Physical functioning was associated with patient-reported outcomes, including QOL and mental-health screening. Screening positive for PTSD or depression was associated with worsened self-reported physical function and may outweigh the impact of amputation severity on physical functioning. Successful rehabilitation requires the integration of physical and mental health domains in order to achieve optimal functioning.Implications for rehabilitationThe current study shows that physical functioning in participants with combat-related amputation is related to the amputation level, quality of life, and mental-health symptom screening.Good mental health is crucial to optimal functioning, as presence of adverse mental-health symptoms may exacerbate physical functional limitations among those with combat-related amputations.Assessing variables related to adverse mental-health symptoms and ultimate physical functioning outcomes is critical for clinicians to optimize rehabilitative strategies and outcomes.

Cardiometabolic risk parameters of individuals with lower extremity amputation: What is the effect of adherence to DASH diet and Mediterranean diet?

Objectives

The aim of our study was to investigate the relationship between nutrition (adherence to Mediterranean Diet [MD] and Dietary Approaches to Stop Hypertension [DASH] diets) and cardiovascular disease risk factors in patients with traumatic lower limb amputation (LLA).

Patients and methods

A total of 35 male patients (mean age 36.9±9.3 years; range, 21 to 54 years) with unilateral traumatic LLA between April 2019 and November 2019 were included. Data including age, education status, clinical data, level of amputation, time of amputation, comorbidities, physical activities, medications including nutritional supplements were collected. Blood pressure and anthropometric measurements including weight, height, waist, hip, and upper median arm circumferences were measured. Three-day food records were evaluated to determine daily nutrient intake of each patient. The patients were divided into groups according to their diet scores.

Results

The DASH scores showed a moderate, negative correlation with the body mass index (BMI), hip circumference, waist circumference, waist-to-hip ratio, waist-to-height ratio, serum total cholesterol (TC), triglyceride (TG), and low-density lipoprotein cholesterol (LDL-C). The MD scores showed a moderate, negative correlation with the BMI, waist circumference, hip circumference, waist-to-height ratio, serum TC, TG, and LDL-C.

Conclusion

Patients with traumatic LLA should be monitored closely for accompanying conditions such as cardiovascular diseases, and it is necessary to encourage them for healthy nutrition habits.

Understanding Low Back Pain in Traumatic Lower Limb Amputees: A Systematic Review

Objective

This systematic review aims to evaluate current literature for the prevalence, causes, and effect of low back pain (LBP) in traumatic lower limb amputees, specifically its association with the kinematics and kinetics of the lumbar spine and lower extremities.

Data Sources

Databases (EMBASE, MEDLINE, Scopus, CINAHL, PsycINFO) were searched systematically for eligible studies from inception to January 2018.

Study Selection

The inclusion terms were synonyms of low back pain, lower limb amputation, and trauma, whereas studies involving nontraumatic amputee populations, single cases, or reviews were excluded. 1822 studies were initially identified, of which 44 progressed to full-text reading, and 11 studies were included in the review.

Data Extraction

Two independent reviewers reviewed the included studies, which were evaluated using a quality assessment tool and the Grades of Recommendation, Assessment, Development and Evaluation system for risk of bias, prior to analyzing results and conclusions.

Data Synthesis

There was an LBP prevalence of 52%-64% in traumatic amputees, compared to 48%-77% in the general amputee population (predominantly vascular, tumor, trauma), attributed to a mixture of biomechanical, psychosocial, and personal factors. These factors determined the presence, frequency, and severity of the pain in the amputees, significantly affecting their quality of life. However, little evidence was available on causality.

Conclusion

The high prevalence of LBP in traumatic amputees highlights the necessity to advance research into the underlying mechanics behind LBP, specifically the spinal kinematics and kinetics. This may facilitate improvements in rehabilitation, with the potential to improve quality of life in traumatic amputees.

Daily step count of British military males with bilateral lower limb amputations: A comparison of in-patient rehabilitation with the consecutive leave period between admissions

BACKGROUND:

Reduced function and health in individuals with lower limb amputation is well documented. Step count measurement could facilitate rehabilitation and help monitor functional health outcomes.

OBJECTIVES:

To determine whether mean daily step count changed between in-patient rehabilitation and consecutive leave periods.

STUDY DESIGN:

Observational study.

METHODS:

Nine individuals with bilateral traumatic amputations attending rehabilitation at the Defence Medical Rehabilitation Centre during a 4-month period were invited to participate in the study (two bilateral transfemoral, two bilateral transfemoral/knee disarticulation, two transfemoral/transtibial, one bilateral transfemoral plus transradial, one bilateral transfemoral plus transhumeral and one transfemoral/transtibial/transradial). Prostheses worn by each participant were fitted with an activity monitor (LAM2^TM; PAL Technologies Ltd, Glasgow). Mean daily step count was analysed for each participant following 2 weeks in-patient rehabilitation and consecutive 2 weeks away from rehabilitation.

RESULTS:

Nine participants completed the study (time since injury: 19 ± 7 months, age: 26 ± 6 years). Mean daily step count significantly decreased from 2258 ± 192 during in-patient rehabilitation to 1387 ± 363 at home ( p < 0.01).

CONCLUSION:

The step count decreased when away from rehabilitation, confirming the hypothesis that the mean daily step count would change between in-patient rehabilitation and consecutive leave period.

CLINICAL RELEVANCE

These data provide an indication of the step count achievable by young, military male personnel with bilateral lower limb amputations and highlights differences between intensive in-patient rehabilitation and consecutive leave periods. It is suggested that further investigation and support of clinical monitoring could facilitate rehabilitation tailored to the individual.

Bicycling participation in people with a lower limb amputation: a scoping review

BACKGROUND

To review literature on bicycling participation, as well as facilitators and barriers for bicycling in people with a lower limb amputation (LLA).

METHODS

Peer-reviewed, primary, full text, studies about bicycling in people with a LLA from midfoot level to hemipelvectomy were searched in Pubmed, Embase, Cinahl, Cochrane library, and Sportdiscus. No language or publication date restrictions were applied. Included full-text studies were assessed for methodological quality using the Effective Public Health Practice Project tool. Data were extracted, synthesized and reported following Preferred Reporting Items for Systematic Review.

RESULTS

In total, 3144 papers were identified and 14 studies were included. The methodological quality of 13 studies was weak and 1 was moderate. Bicycling participation ranged from 4 to 48%. A shorter time span after LLA and a distal amputation were associated with a higher bicycling participation rate particularly for transportation. In people with a transtibial amputation, a correct prosthetic foot or crank length can reduce pedalling asymmetry during high-intensity bicycling. People with limitations in knee range of motion or skin abrasion can use a hinged crank arm or a low profile prosthetic socket respectively.

CONCLUSION

People with a LLA bicycled for transportation, recreation, sport and physical activity. Adaptation of prosthetic socket, pylon and foot as well as bicycle crank can affect pedalling work and force, range of motion, and aerodynamic drag. Because the suggestions from this review were drawn from evidences mostly associated to competition, prosthetists should carefully adapt the existing knowledge to clients who are recreational bicyclists.

Health concerns of veterans with high-level lower extremity amputations

BACKGROUND

The aim of the study was to identify health concerns of veterans with high-level lower extremity amputations.

METHODS

Through a cross-sectional study, general practitioners, an orthopedic specialist, psychologists, psychiatrists, physiotherapist and prosthetists examined 100 veterans using a short-form health-related quality of life questionnaire (SF-36) that assessed their ability to perform activities of daily living (ADL), instrumental activities of daily living (IADL) and life satisfaction (SWLS) after hip disarticulation or hemi-pelvectomy amputations. The assessment tool was designed to gather statistically useful information about their health needs.

RESULTS

The means of the Physical Component Summary (PCS), Mental Component Summary (MCS), SWLS, ADL and IADL were 48.58 ± 29.6, 33.33 ± 22.0, 19.30 ± 7.7, 48.10 ± 10.5 and 5.08 ± 1.8, respectively. Somatization, depression, and anxiety were the most prevalent disorders; among the veterans who were visited by psychiatrists, 11.6% had a history of hospitalization in a psychiatry section, and 53.2% had a psychiatric visit. Regardless of their injury in battle, 34% of veterans were hospitalized. Hearing problems were common, and about four-fifths of the participants suffered from at least one orthopedic condition. Neuroma (49%) was the most common stump-related complication during orthopedic evaluations, though the prevalence of phantom pain was 81% during the pain assessment. A total of 87% of the participants had a history of wearing a prosthesis, but only 29% wore a prosthesis at the time of the present study. The Canadian-type of prosthesis was uncomfortable and not useful (27%) and excessively heavy (10%) according to the amputees.

CONCLUSIONS

Understanding veterans' characteristics and special needs are important to make sure that enough facilities and services are afforded to them. These findings emphasize the importance of paying close attention to different dimensions of health in veterans and can help health providers identify health needs and make regular assessments.

Patients with unilateral transfemoral amputation treated with a percutaneous osseointegrated prosthesis: a cost-effectiveness analysis

Aims

The aim of this study was to compare the cost-effectiveness of treatment with an osseointegrated percutaneous (OI-) prosthesis and a socket-suspended (S-) prosthesis for patients with a transfemoral amputation.

Patients and Methods

A Markov model was developed to estimate the medical costs and changes in quality-adjusted life-years (QALYs) attributable to treatment of unilateral transfemoral amputation over a projected period of 20 years from a healthcare perspective. Data were collected alongside a prospective clinical study of 51 patients followed for two years.

Results

OI-prostheses had an incremental cost per QALY gained of €83 374 compared with S-prostheses. The clinical improvement seen with OI-prostheses was reflected in QALYs gained. Results were most sensitive to the utility value for both treatment arms. The impact of an annual decline in utility values of 1%, 2%, and 3%, for patients with S-prostheses resulted in a cost per QALY gained of €37 020, €24 662, and €18 952, respectively, over 20 years.

Conclusion

From a healthcare perspective, treatment with an OI-prosthesis results in improved quality of life at a relatively high cost compared with that for S-prosthesis. When patients treated with S-prostheses had a decline in quality of life over time, the cost per QALY gained by OI-prosthesis treatment was considerably reduced. Cite this article: Bone Joint J 2018;100-B:527-34.

Bone-anchored prostheses in patients with traumatic bilateral transfemoral amputations: rehabilitation description and outcome in 12 cases treated with the OPRA implant system

PURPOSE

To describe the rehabilitation experience and outcome of treatment with bone-anchored prostheses in individuals with bilateral transfemoral amputations (TFAs) treated in Sweden over a period of 25 years.

METHOD

Hospital records were reviewed for all patients with traumatic bilateral TFAs treated until 2015. The use of prostheses, walking aids and wheelchairs was noted.

RESULTS

The cohort comprised 12 patients (nine men and three women with a mean age 35 years at treatment) and the median follow-up time was seven years (1-20). At baseline, 9/12 used prostheses and 3/12 did not. The main means of locomotion was in a wheelchair without wearing prostheses (n = 8/12) or in a wheelchair in combination with prosthetic walking supported by walking aids (n = 4/12). All prosthetic users had problems with sitting comfort. At follow-up, 11/12 patients used prostheses, while one did not. The means of locomotion was prosthetic walking in 3/12 cases, a combination of a wheelchair and prosthetic walking in 4/12, a wheelchair while wearing prostheses but not walking in 4/12 and a wheelchair without wearing prostheses in 1/12. Three patients walked unsupported by walking aids. Seven patients had no problem with prosthetic sitting comfort (n = 3 had small problems).

CONCLUSIONS

Bone-anchored prostheses in patients with bilateral TFAs resulted in more prosthesis use during everyday locomotion, due hypothetically to improved comfort while wearing prostheses. The results further underline the importance of other assistive devices such as wheelchairs and walking aids used in combination with prostheses in this group of patients facing severe functional limitations. Implications for Rehabilitation This study provides an insight into the details of the rehabilitation and outcome in patients with traumatic bilateral transfemoral amputations treated with bone-anchored prostheses in Sweden. The treatment can lead to a large amount of prosthetic use, but most patients will also use a range of assistive devices including full-length prostheses, stubbies, walking aids and wheelchairs after treatment. The importance of sitting in comfort while wearing prostheses should not be underestimated in patients with bilateral transfemoral amputations.

Prevalence of metabolic syndrome and health-related quality of life in war-related bilateral lower limb amputees

BACKGROUND

Lower limb amputation is correlated with considerable impairments in health-related quality of life (HRQOL) in veterans. The aim of this study is to determine the prevalence of metabolic syndrome (MetS) in veterans with bilateral lower limb amputation and to identify its association with HRQOL.

METHODS

This cross-sectional study was conducted on 235 Iranian male veterans with bilateral lower limb amputation. Demographics, anthropometrics, and biochemical measurements were assessed and MetS was defined by National Cholesterol Education Program Adult Treatment Panel III definition. HRQOL was assessed using the 36-item Short Form Health Survey (SF-36) questionnaire which measures eight health-related domains. The scores were compared between two groups of bilateral lower limb Amputees who have diagnosed with and without MetS.

RESULTS

The response rate was 40.7% and the mean age of the amputees was 52.05 years. 62.1% of participants were suffering from MetS (95% CI: 55.9%-68.4%). Patients with MetS were observed to have higher weight, waist and hip circumferences, FBS, TG, LDL and liver enzymes concentrations (P < 0.05). Although scores on all 8 subscales of SF-36 were low, no significant difference was observed in HRQOL scores between amputees with and without MetS. Moreover, the risk of MetS was not significantly different across subjects in the highest compared to the lowest quartile category of HRQOL scores.

CONCLUSIONS

Prevalence of MetS in veterans with bilateral lower limb amputation was higher and their HRQOL was lower compared to general population. Some strategies are needed to reduce the risk of cardiovascular diseases among this susceptible population.

Quality of life of caregiver spouses of veterans with bilateral lower extremity amputations

Background:

Providing care for patients with chronic disability affects caregivers’ social lives and relationships and can lead to poor health and lower quality of life.

Objectives:

In this study, our goal was to assess the quality of life in spouses of war veterans with bilateral lower limb amputations to find factors affecting caregivers’ quality of life.

Patients and Methods:

In a cross-sectional study, spouses of 244 veterans with war-related bilateral lower limb amputations for at least one year were invited to participate in this study; 189 couples accepted to participate. Information about age, gender, education level, duration of time since amputation, duration of care provided by the spouses and SF-36 questionnaire for both veterans and their spouses were collected.

Results:

The average age of spouses was 47 years and duration of care provided by spouses was 25 years. We found lower scores for general health domains in amputees’ spouses compared to the general population. Factors correlated with both Physical Component Summary (PCS) and Mental Component Summary (MCS) included the duration of care, duration of marriage, spouses’ education level and the veterans’ PCS and MCS scores. Veterans’ age, spouses’ age and the number of children only correlated with PCS. Veterans’ education level only correlated with MCS. In multivariable analysis, only spouses’ education level correlated with MCS and the veterans’ PCS only correlated with that of spouses.

Conclusions:

The quality of life of amputees and their spouses were closely correlated; therefore, any improvement in one is likely to improve the other. In addition, lower education level should be considered as a risk factor for poorer quality of life in amputees’ spouses.