The use of the International Classification of Functioning, Disability and Health to classify the factors influencing mobility reported by persons with an amputation: An international study

Development of a Core Outcome Set for users and funders of lower-limb prosthetic interventions (PI-COS): a step to inform the benefits measured in prosthetic health economic evaluations

PURPOSE

Little is known about the outcomes that are most important to prosthesis users and funders. A Prosthetic Interventions Core Outcome Set (PI-COS) will help researchers and practitioners measure outcomes that are the most important to prosthesis users and funders.

MATERIALS AND METHODS

Prosthesis users and funders rated the importance of 121 International Classification of Functioning, Disability, and Health (ICF) second-level categories using a two-round Delphi survey. A Consensus Meeting using the nominal group technique resolved rating differences between groups. The ICF second-level categories were ranked according to importance and a K-Means Cluster Analysis helped establish the PI-COS.

RESULTS

65 users and 8 funders completed the Delphi surveys, followed by a Consensus Meeting. 26 ICF second-level categories were considered important to prosthesis users and funders and a PI-COS of 14 ICF second-level categories drawn predominantly from five ICF chapters was established: Sensory Functions and Pain (b2), Neuromusculoskeletal and Movement-related Functions (b7), General Tasks and Demands (d2), Mobility (d4), and Products and Technology (e1).

CONCLUSIONS

The PI-COS describes the outcomes that are most important to prosthesis users and funders. The PI-COS can help focus on the most important outcome measures in clinical practice and research, including future prosthetic health economic evaluations.

Development of the ECLIPSE model of meaningful outcome domains following lower limb amputation and prosthetic rehabilitation, through systematic review and best fit framework synthesis

BACKGROUND

Little is known about which outcome domains characterise meaningful recovery following prosthetic rehabilitation and should be measured. Our previous qualitative work developed a conceptual model of outcome domains which are meaningful to patients. This qualitative synthesis aims to develop that model by exploring views and experiences of recovery captured in the limb loss literature, and use these to produce a second iteration of the model describing outcome domains of importance following prosthetic rehabilitation from the patient's perspective.

METHODS

Systematic searches were conducted using CINAHL, Psychinfo and Web of Science from 2011 to early 2023. Studies with a qualitative design focusing on views and experiences of lower limb prosthetic users were eligible for inclusion. Quality was assessed using the CASP tool. 'Best Fit' framework synthesis was used to synthesise the evidence and develop the conceptual model.

RESULTS

40 studies were included, describing the experiences of 539 participants. Data supported the pre-existing conceptual model and led to development of four of the five domains. The newly named ECLIPSE model describes meaningful outcome domains as 1) Being able to participate in important activities and roles, 2) Participating in the way I want to, 3) My prosthesis works for me, 4) If I am in pain, I can manage it, and 5) I am able to accept my new normal. Studies came from 15 countries showing good coverage of high-income settings. Few participants from low-and-middle-income countries were included, it is unclear if the ECLIPSE model describes outcome domains of importance in these settings.

CONCLUSIONS

This synthesis provides a rigorous foundation for understanding outcome domains of importance following lower limb prosthetic rehabilitation from the patient's perspective. The ECLIPSE model is an accessible representation of recovery which could direct rehabilitation programmes, as well as inform the evaluation of prosthetic care through the selection of outcome measures.

Effect of pain on activity and participation in individuals with unilateral lower-extremity amputation based on the International Classification of Functioning, Disability, and Health

BACKGROUND

Amputation is a major life-changing event and is regarded as one of the loading causes of permanent disability. However, amputation often causes changes in painful and nonpainful sensory experiences. Pain after amputation has been shown to increase functional limitations caused by limb loss and lower quality of life.

OBJECTIVE

This study aimed to examine the effect of pain on activity and participation in individuals with unilateral below-knee amputations according to the International Classification of Functioning, Disability, and Health.

STUDY DESIGN

Cross-sectional study.

METHODS

In the study, 64 individuals were divided into 2 groups: those who experienced pain and those who did not. Group 1 included 33 below-knee amputees who experienced pain (27 males, mean age 43.9 ± 12.6 years) and Group 2 included 31 below-knee amputees who did not experience pain (25 males, mean age 47.4 ± 12.1 years). The McGill Pain Questionnaire and visual analog scale were used to assess pain, the Prosthetic Limb Users Survey of Mobility was used to assess activity, and the Reintegration to Normal Living Index was used to assess participation.

RESULTS

Demographic characteristics of the 2 groups were statistically insignificant (P > 0.05). The nonpainful group had significantly higher activity and participation scores than the painful group (P < 0.001).

CONCLUSIONS

It was found that phantom pain and stump pain in below-knee amputees limited activity and participation. It was also shown that phantom pain has a more negative effect on the activity level of individuals than stump pain.

Returning to work after dysvascular lower limb amputation-A novel multivariate approach to examine relative contributions of biopsychosocial predictors

BACKGROUND

Returning to work is a key outcome of rehabilitation and social re-integration after lower limb amputation. It is important to understand what biopsychosocial factors contribute to returning to work after dysvascular amputation.

OBJECTIVE

Examining relative contributions of functional and contextual predictors of returning to work in participants with lower limb amputation due to diabetes and other dysvascular diseases.

STUDY DESIGN

Cross-sectional.

METHODS

Return-to-work outcome, biopsychosocial characteristics including physical functioning, self-efficacy & perceived ability, and socioeconomical support data were collected from a purposive sample (n = 57) in a multi-state collaborative research network. Grouped Weighted Quantile Sum model analysis was conducted to evaluate relative contributions of biopsychosocial predictors.

RESULTS

Less than 30% of the participants returned to work after their amputation. Physical functioning (odds ratio = 10.19; 95% CI 2.46-72.74) was the most important predictor group. Working before amputation, prosthetic mobility, and access to rehabilitation care were also identified as key factors associated with returning to work.

CONCLUSIONS

Fewer than 1 in 3 participants with dysvascular amputation returned to work, despite an average age of only 54 years at the time of amputation. Physical functioning was shown to be the most important predictor, while socioeconomic factors such as a lack of access to care also contribute to not returning to work after dysvascular amputation.

Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services

BACKGROUND

Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion.

METHODS

We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article.

RESULTS

Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities.

CONCLUSION

Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

Exploring meaningful outcome domains of recovery following lower limb amputation and prosthetic rehabilitation: the patient's perspective

PURPOSE

There is currently no consensus regarding what outcome domains to measure following lower limb prosthetic rehabilitation. Prosthetic users have a unique insight into important outcome domains, little is currently known about their critical viewpoint.

MATERIALS AND METHODS

A total of 37 participants who underwent lower limb amputation in the last five years were recruited from UK limb fitting centres and social media. Data were collected using focus groups and interviews and analysed using reflexive thematic analysis.

RESULTS

Five themes were identified. 1) The ability to participate in important activities, 2) how participants were able to undertake these activities, i.e., independently, with ease, safely and with minimal equipment. 3) A comfortable, easy-to-use prosthesis, 4) the importance of managing pain and finally, 5) adjusting and accepting their new normal. These five themes, or outcome domains, did not exist in isolation, but appeared to interact with each other, contributing to, or inhibiting the participant's holistic sense of recovery.

CONCLUSIONS

Understanding important outcome domains that define what recovery means to people following amputation can help to inform domain consensus, as well as direct the focus of rehabilitation. Domain consensus would guide the selection of measurement tools that evaluate prosthetic interventions in a meaningful way.IMPLICATIONS FOR REHABILITATIONThere is currently no consensus around which outcome domains should be measured following prosthetic rehabilitation.Outcome domains of importance from a patient's perspective focus on participation in important activities, prosthesis comfort, pain management, and acceptance of their new normal.Identifying these domains can help direct the focus of rehabilitation as well as inform outcome measurement practice.The interrelated nature of these domains suggests the need for a physical and psychosocial multi-domain approach to outcome measurement in prosthetic rehabilitation, with patient priorities at its centre.

Identifying and linking prosthetic outcomes to the ICF framework: a step to inform the benefits measured in prosthetic health economic evaluations

PURPOSE

Prosthetic research seems focused on measuring gait-related outcomes that may not adequately measure real-world benefits of prosthetic interventions. Systematically cataloguing a comprehensive range of outcomes is an important steppingstone towards developing a holistic way to measure the benefits of prosthetic interventions for future health economic evaluations. The purpose of this research was to identify and catalogue the outcomes measured in lower-limb prosthetic research using the International Classification of Functioning, Disability, and Health (ICF) framework and a custom clinical framework, and thereby describe the existing research focus and identify evidence gaps.

MATERIALS AND METHODS

A structured literature search identified systematic reviews of lower-limb prosthetic interventions. Reported outcomes were extracted from included studies and linked to the ICF- and clinical-frameworks.

RESULTS

Of the 1297 extracted outcomes, 1060 were linked to the ICF framework. Most outcomes linked to second- (63.8%) or third-level categories (33.4%), such as Gait Pattern Functions (b770, 49.8%). Most of these outcomes (31.2%) describe temporospatial, kinematic or kinetic gait measures as categorised by the clinical framework.

CONCLUSIONS

Lower-limb prosthetic research is focused on laboratory-based measures of gait. There are evidence gaps describing participation in real-world activities - important outcomes to inform policy and investment decisions that determine the prosthetic interventions available for people with limb-loss.Implications for rehabilitationCataloguing the outcomes used in prosthetic research to the International Classification of Functioning, Disability, and Health (ICF) allows important evidence gaps to be illuminated given the holistic description of function and disability.Establishing a comprehensive list of prosthetic outcomes, described using an internationally recognised framework with unified and consistent language, is an important steppingstone towards developing a core outcome set (COS) for prosthetic interventions and informing the benefits measured in future prosthetic health economic evaluations (HEEs).Being able to measure the benefits of a prosthesis that are most important to prosthesis users and funders has potential to fundamentally change future HEEs that influence funding policies, and ultimately the prostheses made available to people living with limb-loss.

Using theoretical frameworks to examine fall history and associated prosthetic mobility in people with nondysvascular lower limb amputation

BACKGROUND

Over a million people live with lower limb amputation (LLA) in the United States, and many of them will experience a fall in the next year. The aim of this study was to use existing theoretical frameworks in an attempt to organize the complex interactions of reported fall history and prosthetic mobility in community-ambulating people with LLA.

METHODS

Self-reported fall rate and fall circumstances were recorded in a cross-section of people with unilateral LLA due to nondysvascular causes. Self-report and performance-based standardized outcome measures assessed prosthetic mobility and balance confidence. All variables were considered and appropriately placed within a proposed International Classification of Functioning, Disability, and Health framework while using a fall-type classification framework to classify fall circumstances.

RESULTS

Information from 69 participants was analyzed. The reported fall rate was at 46%, with those with transfemoral amputation reporting significantly more falls than those with transtibial amputation ( P = 0.001). Tripping over an object was the most common cause (62.5%), and fallers reported significantly lower perceived prosthetic mobility than nonfallers ( P = 0.001). Despite reporting high levels of balance confidence, results indicate that all groups of fallers and nonfallers are at increased fall risk according to performance-based prosthetic mobility score cutoffs.

CONCLUSIONS

Community-dwelling people with nondysvascular LLA are at increased fall risk. Classifying fall-related variables using theoretical frameworks provides a means to structure more informative fall risk surveys for people with LLA in an attempt to identify those at greater risk for falling and its potential detrimental effects.

Adults with unilateral lower-limb amputation: greater spatial extent of pain is associated with worse adjustment, greater activity restrictions, and less prosthesis satisfaction

OBJECTIVES

This study's primary purpose was to determine if the extent of bodily pain, as evaluated with pain body diagrams, is associated with prosthetic-related activity restrictions, adjustment, and satisfaction among adults with a major unilateral lower-limb amputation. A secondary objective was to evaluate between-days, test-retest reliability for pain body diagrams among adults with lower-limb amputation.

METHODS

Adults with a lower-limb amputation that occurred ≥1 year prior participated in an online, cross-sectional research study. Outcome measures included pain body diagrams and the Trinity Amputation and Prosthesis Experience Scales-Revised, which evaluates post-amputation activity restrictions, psychosocial adjustment, and prosthesis satisfaction. Linear regression modeling was used to evaluate associations between the number of painful body regions and prosthetic outcomes, after considering covariates (alpha ≤ 0.010). A subset of participants recompleted pain body diagrams to evaluate between-days, test-retest reliability.

RESULTS

Data from 74 participants (n = 32 female; n = 42 transtibial-level; n = 27 traumatic etiology) were available. Beyond covariates (i.e., age, sex, amputation level), the total number of painful body regions was significantly associated with all Trinity Amputation and Prosthesis Experience Scales-Revised subscales (p < 0.001-0.006), with the exception of Social Adjustment (p = 0.764). The total number of painful body regions explained 14.5, 11.8, 11.6, and 7.4% of the variance in Functional Satisfaction with the Prosthesis, Adjustment to Limitation, General Adjustment, and Activity Restriction, respectively. In a subset (n = 54), test-retest reliability for total number of painful body regions per body diagrams was good [intraclass correlation coefficient (ICC)3,1 = 0.84].

CONCLUSIONS

A greater number of painful body regions is associated with greater activity restriction, worse adjustment, and lower prosthesis satisfaction, supporting the need to enhance post-amputation pain management and both amputated- and secondary-site pain prevention.

ETHICAL COMMITTEE NUMBER

IRB #1611862.

Disparities in functional recovery after dysvascular lower limb amputation are associated with employment status and self-efficacy

PURPOSE

Employment status is considered a determinant of health, yet returning to work is frequently a challenge after lower limb amputation. No studies have documented if working after lower limb amputation is associated with functional recovery. The study's purpose was to examine the influence of full-time employment on functioning after lower limb amputation.

METHODS

Multisite, cross-sectional study of 49 people with dysvascular lower limb amputation. Outcomes of interest included performance-based measures, the Component Timed-Up-and-Go test, the 2-min walk test, and self-reported measures of prosthetic mobility and activity participation.

RESULTS

Average participant age was 62.1 ± 9.7 years, 39% were female and 45% were persons of color. Results indicated that 80% of participants were not employed full-time. Accounting for age, people lacking full-time employment exhibited significantly poorer outcomes of mobility and activity participation. Per regression analyses, primary contributors to better prosthetic mobility were working full-time (R² ranging from 0.06 to 0.24) and greater self-efficacy (R² ranging from 0.32 to 0.75).

CONCLUSIONS

This study offers novel evidence of associations between employment and performance-based mobility outcomes after dysvascular lower limb amputation. Further research is required to determine cause-effect directionalities. These results provide the foundation for future patient-centered research into how work affects outcomes after lower limb amputation. IMPLICATIONS FOR REHABILITATIONLower limb amputation can pose barriers to employment and activity participation, potentially affecting the quality of life.This study found that the majority of people living with lower limb amputation due to dysvascular causes were not employed full-time and were exhibiting poorer prosthetic outcomes.Healthcare practitioners should consider the modifiable variable of employment when evaluating factors that may affect prosthetic mobility.The modifiable variable of self-efficacy should be assessed by healthcare professionals when evaluating factors that may affect prosthetic mobility.

The most important activities of daily functioning: the opinion of persons with lower limb amputation and healthcare professionals differ considerably

The aim of this study is to determine the 15 most important daily activities according to persons with lower limb amputation (LLA) and healthcare professionals. Persons with LLA (n = 125) and healthcare professionals (n = 44) filled in a questionnaire. Participants had to select 10 items out of a list of 40 items on the domains activity and/or participation. Selection criterion was what they considered to be most important to perform independently and order the selected 10 items from most to least important. Mean rank scores of the 15 highest scored items according to participants with LLA were compared with the mean rank scores given by professionals, using the Mann-Whitney U test with a Hochberg adjustment for multiple testing. Participants with LLA rated five activities as significantly more important compared to professionals: 'driving a car', 'bicycling', 'ascending/descending stairs', 'heavy exercise', and 'preparing meals'. Healthcare professionals rated four activities as significantly more important compared to persons with LLA: 'going to the toilet', 'getting in and out bed', 'walking around outdoors', and 'walking around indoors'. A significant difference in rating importance was present in 9 out of 15 activities between persons with LLA and healthcare professionals. This result makes it all the more clear how complex shared decision making can be and how important it is for healthcare professionals to communicate with the person with LLA.

Assessing mobility for persons with lower limb amputation: the Figure-of-Eight Walk Test with the inclusion of two novel conditions

PURPOSE

To investigate the internal consistency, convergent and known-groups construct validity of the Figure-of-Eight Walk Test with two novel conditions in persons with lower limb amputation, and to examine differences in walking performance between the three conditions within a group of persons with transtibial amputation and transfemoral amputation/knee disarticulation.

MATERIALS AND METHODS

Fifty adults with unilateral amputation participated, 28 of whom had undergone a transtibial amputation and 22 a transfemoral amputation/knee disarticulation. Three Figure-of-Eight Walk Test conditions were investigated: 1) walking at a self-selected walking speed, 2) walking while carrying a tray with two cups of water, and 3) walking on uneven terrain. Internal consistency was evaluated using Cronbach's alpha. Convergent construct validity was examined by analysing the relationship between the Figure-of-Eight Walk Test parameters and performance-based parameters (Amputee Mobility Predictor, Ten-Meter Walk Test, Six-Minute Walk Test) and self-report measures (Prosthetic Limb Users Survey of Mobility, Activities-specific Balance Confidence Scale) using Spearman's rank-order correlations. Known-groups construct validity was assessed by comparing the Figure-of-Eight Walk Test parameters based on anatomical level of amputation. Friedman's test and post hoc analysis were used to examine differences between the walking conditions within each group.

RESULTS

Cronbach's alpha coefficients of the Figure-of-Eight Walk Test parameters for all three conditions ranged from 0.89 to 0.99. The Figure-of-Eight Walk Test time and step parameters demonstrated moderate to good correlation (ρ = -0.50 to -0.77) for performance-based mobility measures. The correlations were stronger during Condition 3 in comparison with the original Figure-of-Eight Walk Test. The correlation was fair to good (ρ = -0.41 to -0.57) for the self-report mobility measures. Comparison between groups showed a difference between transtibial and transfemoral amputation/knee disarticulation participants when it comes to the Figure-of-Eight Walk Test time and smoothness parameters in Condition 2 (p < 0.05). Comparison between walking conditions within each group showed significant differences in the Figure-of-Eight Walk Test parameters in the two novel conditions in comparison with the original Figure-of-Eight Walk Test. The Figure-of-Eight Walk Test and the novel conditions demonstrated excellent internal consistency, good convergent construct validity, and evidence of known-groups construct validity. Future studies should further develop and standardise the smoothness scale to better quantify walking performance and assess the responsiveness and reliability (inter-rater and intra-rater) of the Figure-of-Eight Walk Test (time and steps) and the novel conditions, while studies on known-groups validity should include persons with a wider mobility range.IMPLICATIONS FOR REHABILITATIONFigure-of-Eight Walk Test with the two novel conditions, which include carrying a load and walking on uneven terrain, may help to provide meaningful information about walking ability in daily life.The two novel conditions pose different challenges to persons with lower limb amputation when compared to the original Figure-of-Eight Walk Test and underscore the relevance to assess mobility under challenging walking conditions.The Figure-of-Eight Walk Test and the two novel conditions demonstrated excellent internal consistency, good convergent construct validity, and evidence of known-groups construct validity.

Variables that Influence Basic Prosthetic Mobility in People With Non-Vascular Lower Limb Amputation

BACKGROUND

There exists a dearth of evidence on rehabilitation factors that influence prosthetic mobility in people with lower limb amputation (LLA). Examining variables that contribute to prosthetic mobility can inform rehabilitation interventions, providing guidance in developing more comprehensive care for these individuals.

OBJECTIVE

To determine the influence of modifiable and non-modifiable variables related to LLA and their impact on prosthetic mobility, using the International Classification of Functioning, Disability and Health (ICF) model. Secondarily, to determine if personal factors and self-reported balance and mobility are predictive of Component timed-up-and-go (cTUG) performance.

DESIGN

Cross-sectional study of a convenience sample.

SETTING

National conference.

PARTICIPANTS

People (N=68) with non-vascular causes of unilateral LLA.

METHODS

Assessment of anthropometrics, mobility, bilateral hip extensor strength, hip range of motion, single limb balance, and self report measures. Lasso linear regression and extreme gradient boosting analyses were used to determine influence of variables on prosthetic mobility.

MAIN OUTCOME MEASURE

Timed performance of the cTUG.

RESULTS

The following five variables were found to influence basic prosthetic mobility (P ≤ .05) in people with transtibial amputation: hip extensor strength, hip range of motion, single limb balance, waist circumference, and age. In the transfemoral cohort, number of comorbidities and waist circumference primarily influenced prosthetic mobility. Additionally, 66% of the variance in cTUG total time for the entire sample could be explained by simply regressing on level of amputation, number of comorbidities, age and Activities-specific Balance Confidence scale score, all variables easily collected in a waiting room.

CONCLUSION

Variables that are modifiable with physical therapy intervention including hip extensor strength, hip range of motion, single limb balance, and waist circumference significantly influenced basic prosthetic mobility. These variables can be affected by targeted rehabilitation interventions and lifestyle changes.

LEVEL OF EVIDENCE

II.

Barriers and facilitators to utilisation of rehabilitation services amongst persons with lower-limb amputations in a rural community in South Africa

BACKGROUND:

Persons with disabilities who reside in rural areas experience challenges accessing and utilising health services and rehabilitation. Due to the high prevalence of diabetes mellitus in rural regions, the risk of having a lower-limb amputation is increasing. Comprehensive rehabilitation is vital to mitigate the negative impact that a lower-limb amputation has on a person.

OBJECTIVE:

To explore the barriers and facilitators to accessing rehabilitation experienced by persons with lower-limb amputations in a rural setting.

STUDY DESIGN:

A qualitative descriptive approach was used to collect and analyse data.

METHODS:

Data were collected from 11 conveniently sampled participants from three sub-district hospitals in the rural iLembe district, Kwa-Zulu Natal, South Africa. Data were collected using semi-structured interviews to explore the barriers and facilitators perceived by persons with lower-limb amputations in a rural region.

RESULTS:

The three main barriers identified in this study were environmental factors, financial constraints and impairments. These barriers negatively impacted the participant's utilisation of rehabilitation. The two main facilitators identified were environmental facilitators and personal factors which aided participant's utilisation of rehabilitation.

CONCLUSION:

Access to rehabilitation was mainly hindered by the challenges utilising transport to the hospital, while self-motivation to improve was the strongest facilitator to utilising rehabilitation.

CLINICAL RELEVANCE

Rehabilitation is essential in preparation for prosthetic fitting. If a person cannot access rehabilitation services, they will remain dependent on caregivers. Highlighting the challenges to utilisation of rehabilitation in rural areas can assist to reduce these barriers and improve the functional status of persons with lower-limb amputations.

Mobility in persons with lower extremity amputations and influencing factors: Using the International Classification of Functioning, Disability and Health to quantify expert views

BACKGROUND:

International Classification of Function, Health and Disability provides a common framework and universal language for rehabilitation professionals across the globe.

OBJECTIVES:

To identify problems in functioning and mobility relevant to persons with lower-limb amputation from an expert's point of view and quantify these problems using the International Classification of Function, Health and Disability.

STUDY DESIGN:

Qualitative study using electronic and paper surveys.

METHODS:

Electronic or paper survey was done across six countries targeting clinicians involved in pre- and post-amputation care. Meaningful concepts were extracted from the responses and linked to suitable second-level and where applicable third-level International Classification of Function, Health and Disability categories. Categorical frequency analysis was completed for the combined data and for each location.

RESULTS:

A total of 183 experts from 6 different countries responded to the survey. A total of 2171 concepts were identified, 82% of which could be linked to a second-level International Classification of Function, Health and Disability category. The categorical frequency analysis revealed that the categories of walking, design and construction of buildings for public and private use and sensation of pain were the most frequently occurring concepts and was similar across the six countries.

CONCLUSION:

The International Classification of Function, Health and Disability can be utilised as a common framework for communication among clinicians involved in rehabilitation of persons with lower-limb amputation across the globe. The most important factors that were identified by experts in amputee rehabilitation working in different international locations were similar.

CLINICAL RELEVANCE

The challenges faced by the clinicians involved in care of persons with lower extremity amputation vary across different parts of the world. The overarching goal for the clinician irrespective of the location is to improve mobility and quality of life of their clients. The International Classification of Function, Health and Disability provides a common language between the various stakeholders in amputee rehabilitation across the globe.

Development of a core outcome set for studies involving patients undergoing major lower limb amputation for peripheral arterial disease: study protocol for a systematic review and identification of a core outcome set using a Delphi survey

BACKGROUND

The development of a standardised reporting set is important to ensure that research is directed towards the most important outcomes and that data is comparable. To ensure validity, the set must be agreed by a consensus of stakeholders including patients, healthcare professionals and lay representatives. There is currently no agreed core outcome set for patients undergoing major lower limb amputation for peripheral arterial disease (PAD) for either short- or medium-term research outcomes. By developing these sets we aim to rationalise future trial outcomes, facilitate meta-analysis and improve the quality and applicability of amputation research.

METHODS/DESIGN

We will undertake a comprehensive systematic review of studies of patients undergoing major lower limb amputation for PAD. Data regarding all primary and secondary outcomes reported in relevant studies will be extracted and summarised as outcome domains. We will then undertake focus groups with key stakeholders (patients, carers, health and social care workers) to collect qualitative data to identify the main short- and medium-term research outcomes for patients undergoing major lower limb amputation. Results of the systematic review and focus groups will be combined to create a comprehensive list of potential key outcomes. Stakeholders (patients, researchers and health and social care workers) will then be polled to determine which of the outcomes are considered to be important in a general context using a three-phase Delphi process. After preliminary analysis, results will be presented at a face-to-face meeting of key stakeholders for discussion and voting on the final set of core outcomes. This project is being run in parallel with a feasibility trial assessing perineural catheters in patients undergoing lower limb amputation (the PLACEMENT trial). Full ethical approval has been granted for the study (Wales REC 3 reference number 16/WA/0353).

DISCUSSION

Core outcome sets will be developed for short- and medium-term outcomes of research involving patients undergoing major lower limb amputation for PAD. This will help with the design of future trials and facilitate meta-analyses of trial data.

TRIAL REGISTRATION

PROSPERO: CRD42017059329 . Registered on 30 March 2017.

COMET

975 . Registered on 5 April 2017.