Prosthetists' perceptions and use of outcome measures in clinical practice: Long-term effects of focused continuing education

Use of standardized outcome measures for people with lower-limb amputation: A survey of prosthetic practitioners in Canada

BACKGROUND

Outcome measures (OMs) are useful tools; however, clinicians may find implementing them into clinical practice challenging.

OBJECTIVES

To characterize Canadian prosthetists' use of OMs for people with lower-limb amputation, including motivations for use, comfort selecting OMs, resources available for administration, and barriers to implementation.

METHODS

A cross-sectional study was conducted between March and July 2021. Orthotics Prosthetics Canada sent Canadian prosthetists an invitation to take the online survey.

RESULTS

Forty-nine Certified Prosthetists completed the survey. Only 16% of participants reported that they were expected to use OMs. Participants reported being more comfortable administering performance-based OMs than self-report surveys. More than two-thirds of participants agreed that OMs "can be administered with knowledge they have" and are "within their scope of practice." However, less than 25% agreed that OMs are "administered in a standardized way in the profession," and less than 40% indicated they are "easy to make part of my routine." Participants reported they generally have time and space to do OMs, but there was no agreed-on reason to use them.

CONCLUSIONS

Use of OMs among Canadian prosthetists seems to be low relative to prosthetists in the United States. Education, financial incentives, or changes to professional expectations are likely needed to increase routine OM use. Efforts to improve the standardization of OM administration and ease the incorporation of OMs into routine practice may also increase use. Canadian prosthetists may elevate their standards of clinical practice and better understand the impact of prosthetic treatments on their patients by more routinely using OMs.

Exploring the patient experience and perspectives of taking part in outcome measurement during lower limb prosthetic rehabilitation: a qualitative study

PURPOSE

Outcome measurement provides clinicians, services and funders with useful information. However, little is known about the experience of participating in outcome measurement during lower limb prosthetic rehabilitation from the patient's perspective.

MATERIALS AND METHODS

Thirty-two participants who underwent lower limb amputation within 5 years, and had experience of taking part in outcome measurement during prosthetic rehabilitation, were recruited from UK limb fitting centers and social media. Data were collected using focus groups and interviews and analysed using reflexive thematic analysis.

RESULTS

Four themes were identified. (1) How does participating in outcome measurement make me feel? (2) Do the outcome measures used in routine clinical care capture an accurate picture of my recovery? (3) Who is outcome measurement for? and (4) are prosthetic services measuring what is meaningful? These themes suggest outcome measurement is not a neutral activity for patients following lower limb amputation.

CONCLUSIONS

Harnessing the positive impacts of measuring outcomes could be used for motivation, to support adjustment and recovery, to improve communication and to support shared decision-making. This could make outcome measurement more meaningful and patient-centered. However, there may be potential for patients to respond negatively to outcome measures and clinicians should consider their impact on psychosocial factors.

Validating a fear-of-falling-related activity avoidance scale in lower limb prosthesis users

BACKGROUND

Limited available data suggest that fear of falling (FoF) may be common among lower limb prosthesis users (LLPUs) and associated with negative rehabilitation outcomes. The impact of FoF on outcomes may be exacerbated when fear leads to self-imposed declines in activity. There is a need to identify the validity of fear-of-falling-related activity avoidance scales in LLPUs.

OBJECTIVE

To evaluate the convergent, discriminant, and known-group construct validity of the modified Survey of Activities and FoF in the Elderly (mSAFE) for LLPUs. Secondarily, we sought to determine if the mSAFE scale could be reduced without losing information regarding construct validity.

DESIGN

Online survey.

SETTING

Not applicable.

PARTICIPANTS

Fifty-nine persons with unilateral or bilateral amputation at the transtibial or transfemoral level, with ≥6 months experience using a definitive prosthesis for activities other than transfers.

INTERVENTION

Participants completed an online survey that consisted of the mSAFE and questions to assess FoF (yes/no), fear-of-falling-related activity avoidance (yes/no), as well as previously validated scales capturing related and unrelated constructs. T-tests were used to compare mSAFE score between yes/no respondents for known-group construct validity. Correlations between mSAFE and previously validated surveys assessed convergent and discriminant validity. Analyses were repeated on a reduced number of mSAFE items following a redundancy analysis.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

Significant correlation coefficients of |0.440-0.825| were found for convergent validity with evidence of known-group construct validity (p < .021 for all comparisons). There was evidence for discriminant validity, with non-significant associations for two-of-three correlations. Results from validity analyses for a shortened 6-item mSAFE were similar to that for the full scale.

CONCLUSION

This study provided initial evidence regarding validity of the mSAFE as a measure to assess fear-of-falling-related activity avoidance in LLPUs. A 6-item scale may be appropriate if the full scale would be taxing or time-consuming.

Efficacy of rehabilitation after provision of ICRC lower limb prostheses in low-income and middle-income countries: A quantitative assessment from Myanmar

BACKGROUND

Low-income and middle-income countries (LMICs) have poorly resourced health services. Lack of access to assistive devices, such as prosthetics, may limit the functional outcomes of persons with amputation and affect quality of life (QoL).

OBJECTIVE

The objective of this study was to assess the functional level and QoL of prosthetic users in LMICs when prescribed a prosthesis made from International Committee for Red Cross (ICRC) components.

STUDY DESIGN

The study design included a quantitative descriptive methodology assessing functional outcomes and QoL after prosthetic provision.

METHODS

Participants were identified from the prosthetic service in Mandalay, Myanmar. Included participants were those with unilateral, traumatic, lower limb amputations, with ICRC devices delivered at least 6 months earlier. Participants attended the prosthetic service and were assessed using the Amputee Mobility Predictor with Prosthesis tool and the World Health Organization Quality of Life Brief and Disability modules.

RESULTS

Thirty-five participants completed the study; of them, 63% were persons with transtibial level amputation and 37% were with transfemoral level amputation. Approximately 83% achieved a score of more than 37 using the Amputee Mobility Predictor with Prosthesis. There is a strong positive correlation between QoL and physical health (r = 0.55; p < 0.001), social relationships (r = 0.66; p < 0.001), and inclusion (r = 0.53; p < 0.001). Participants had a better QoL and overall health when they had better psychological health.

CONCLUSION

The patient-based results presented within this study could be considered as a contribution to the evidence base and importance of provision of prosthetic services in LMICs. It was observed that participants with an amputation were able to achieve a high level of physical function with the ICRC prostheses while also reporting a high QoL.

Cross-Cultural Adaptation and Validation of The Nepali Version of The Prosthetic Limb Users Survey of Mobility Short-Form (Plus-M™/Nepali-12Sf) In Lower Limb Prosthesis Users

BACKGROUND

Objective mobility measurement of Nepali prosthesis users is lacking.

OBJECTIVE

The objective of this study was to cross-culturally adapt, translate and evaluate construct validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M™/Nepali-12 Short Form (SF)) instrument in lower limb prosthesis users residing in Nepal.

METHODOLOGY

Two forward translations, review and reconciliation, back translation, expert review, developer review to create the PLUS-M™/Nepali-12SF. Psychometric testing for internal consistency, test-retest reliability and construct validity against the Two-Minute Walk Test (2MWT) and Amputee Mobility Predictor with Prosthesis (AMPPRO) were performed on sixty-six lower limb prosthesis users.

FINDINGS

The majority of populations were with transtibial amputation 45 (68%), with transfemoral amputation 15 (23%), with knee disarticulation 5 (7.5%) and with syme's amputation 1 (1.5%). The most common cause of amputation among the population was trauma and the least was tumor. Chronbach's alpha for the PLUS-M™/Nepali-12SF was 0.90, mean T-Score was 52.90, test-retest intraclass correlation coefficient (ICC) was 0.94 (95% confidence interval 0.90-0.96). Construct validity with the 2MWT was good (r = 0.62, p< 0.001) and moderately positive with the AMPPRO (r = 0.57, p< 0.001).

CONCLUSION

Our research evidenced that the PLUS-M™/Nepali-12SF had excellent reproducibility. The significance of this work is that it may allow for the measurement of mobility in austere locations of Nepal.

Psychometric properties of outcome measures for lower-limb absence: A protocol for a systematic review

BACKGROUND

Outcome measures are an important part of clinical practice to assist with the care of individuals with lower-limb absence (LLA). They aid with the devising and evaluation of rehabilitation plans, and guide decisions regarding the provision and funding of prosthetic services worldwide. To date, no outcome measure has been identified as a gold standard for use in individuals with LLA. Furthermore, the large number of outcome measures available has created uncertainty regarding outcome measures that are most appropriate for individuals with LLA.

OBJECTIVE

To critically appraise the existing literature related to the psychometric properties of outcome measures for use in individuals with LLA and provide evidence as to which outcome measures may be most appropriate for this clinical population.

STUDY DESIGN

This is a systematic review protocol.

METHODS

CINAHL, Embase, MEDLINE (PubMed), and PsycINFO databases will be searched using a combination of Medical Subject Headings terms and keywords. Search terms that define the population (people with LLA or amputation), intervention (outcome measures), and outcome (psychometric properties) will be used to identify studies. The reference lists of included studies will be hand-search to identify other pertinent articles, with a further search conducted through Google Scholar to ensure that all studies not yet indexed through MEDLINE are captured. Full-text peer-reviewed journal studies published in English will be included, with no date limit set. Included studies will be appraised using the 2018 and 2020 COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklists. Data extraction and study appraisal will be completed by two authors, with a third author serving as an adjudicator. Quantitative synthesis will be used to summarize characteristics of the included studies, with kappa statistics used to determine agreement between authors for study inclusion and the application of COSMIN. Qualitative synthesis will be conducted to report on both quality of the included studies and psychometric properties of the included outcome measures.

CONCLUSION

This protocol was designed to identify, appraise, and summarize patient-reported and performance-based outcome measures that have been psychometrically tested in people with LLA. Results from this review will be used to guide a consensus process on outcome measure use for people with LLA.Systematic review registration: PROSPERO registry number: CRD42020217820.

Use of Physical Activity Measures in Rehabilitation Interventions Following Lower Extremity Amputation

Purpose of Review

This systematic review aims to evaluate physical performance outcome tools that are used most frequently to assess rehabilitation interventions. The scope of this paper focused on outcomes used with established lower limb amputees when assessing interventions such as exercise programs or changes in prescription published in the last 5 years.

Recent Findings

The most recorded outcome measures used across all the papers were timed walk tests and the Activity Balance Confidence Scale. Many outcomes did not produce statistically significant results with established amputee cohorts. Understanding the minimal important clinical difference is key.

Summary

The use of outcome measures is essential. Training and education are likely to increase the use of outcome measures. Quality of life measures are important in conjunction with physical outcomes. Simple timed walk tests are commonly used. These are in general easy to administer requiring a small space, limited equipment, and a short time frame.

Attitudes and behaviors toward using outcome measures in clinical practice: Findings of a blended education program

BACKGROUND

Outcome measures (OMs) are important in healthcare, but there are barriers to their use. A blended education program was designed to teach orthotic and prosthetic professionals a standard practice of collecting and using OMs in their facility. This study used a single group pretest and post-test mixed methods survey to evaluate the effects of a blended education program for orthotic and prosthetic professionals to incorporate OMs into routine clinical practice.

METHODS

Fifteen learners (seven practitioners, four technicians, and four administrative staff) completed online education and in-person training. Learners' attitudes toward knowledge of confidence administering and rate of adoption of OMs into clinical practice were assessed before the start of the program, immediately upon completion, and four months after completion. Performance indicators were accessed through electronic medical records (EMRs).

RESULTS

Participants' attitudes toward OMs were overwhelmingly positive and remained positive (P = .64). Practitioners' posteducation knowledge scores on the standardized use of OMs increased significantly (P = .046) as did their confidence administering OMs (F = 8.47, P = .007). Practitioners' reported using OMs significantly more 4 months after the program (F = 19.7, P < .001), and they doubled the number of times OMs were collected each month resulting in a 3000% increase and a 500 data points recorded in the electronic medical record at the end of the 4 months.

CONCLUSIONS

This education program had a significant and positive lasting impact on practitioners' knowledge of confidence and use of OMs demonstrating an overall change in everyday clinical practice and clinic operations.

Use of Standardized Outcome Measures for People With Lower Limb Amputation: A Survey of Prosthetic Practitioners in the United States

OBJECTIVE

To assess the clinical resources available for the assessment of health outcomes in people with lower limb amputation and to understand barriers and facilitators associated with use of standardized outcome measures in clinical practice.

DESIGN

Cross-sectional survey.

SETTING

General community (online).

PARTICIPANTS

A volunteer sample of prosthetic practitioners was recruited through national professional organizations. Eligible participants were practitioners certified by a professional prosthetics organization and currently practicing as a prosthetist, prosthetist-orthotist, or prosthetic assistant.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

A custom-designed online survey on clinical use of patient-reported and performance-based standardized outcome measures to assess patients with lower limb amputation.

RESULTS

A total of 375 participants completed the survey. Most participants (79%) reported that they are encouraged or required to administer standardized outcome measures in their clinic or facility. Most participants reported that use of patient-reported and performance-based outcome measures are within their scope of practice (88%) and that they have the knowledge required for outcomes measurement (84%). Few participants agreed that outcomes measurement is standardized across the profession (30%). Most participants had access to small spaces and equipment for outcomes measurement, such as short hallways (65%-94%), stairs (69%), and tablets with wireless internet connection (83%). Most participants reported that they would be willing to spend between 5 (36% of participants) and 10 (43% of participants) minutes on self-reported surveys, and between 10 (41% of participants) and 20 (28% of participants) minutes on performance-based tests.

CONCLUSIONS

Outcomes measurement is encouraged or expected in contemporary prosthetic practice. Strategies to improve standardization and efficiency of administration are needed to facilitate routine use of outcome measures in clinical care.

From outcome measurement to improving health outcomes after lower limb amputation-A narrative review exploring outcome measurement from a clinical practice perspective

Outcome measurement is essential to understand the impact of clinical interventions and the performance of services. Despite national and professional body encouragement, and successful examples of system level outcome measurement within some health care settings, many barriers still exist preventing outcome measurement from becoming embedded in clinical practice. This paper presents a narrative review which aims to describe the state of the outcome measurement evidence base in prosthetic rehabilitation, as applied in clinical practice, with a view to identifying areas for future work aimed at making outcome measurement in prosthetic rehabilitation a meaningful reality. A literature search of four databases was undertaken, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principals appropriate to narrative reviews, and using the search terms outcome, measur*, tool, scale, instrument, prosthe*, amput* and limb loss. A total of 1116 papers were identified. Following screening 35 papers, focusing on four main themes, were included in the review. Themes were: 1) What outcome domains should be measured? 2) How can these outcome domains be measured? 3) What are the barriers to outcome measurement? and 4) What can be learnt from examples of ROM in prosthetic rehabilitation? Findings suggest that successful outcome measurement is multifaceted. Understanding and embedding value at every step appears to be key to success. Addressing the questions of 'what' outcome domains to measure and 'how' to measure them, may help establish consensus. Routine outcome measurement practice at the clinical level should ensure data collection is valuable to clinical practice, makes use of information technology solutions and has organisational engagement.

Clinical Resources for Assessing Mobility of People with Lower-Limb Amputation: Interviews with Rehabilitation Clinicians

Introduction

Mobility tests are increasingly used in prosthetic rehabilitation to evaluate patient outcomes. Knowledge of the space, equipment, and time resources available to clinicians who work in different settings can guide recommendations for which tests are most clinically-feasible and promote coordination of mobility testing among members of the rehabilitation team. The primary aim of this study was to characterize the different resources available to clinicians for measuring mobility of people with lower limb amputation. A secondary aim was to identify performance tasks that clinicians use to evaluate prosthetic mobility.

Materials and methods

Semi-structured interviews were conducted with prosthetists, physical therapists, and physiatrists who treat people with lower limb amputation. Researchers used convenience and snowball sampling to identify participants. Interviews included questions about the resources available for conducting mobility tests, as well as questions about which tasks clinicians deemed valuable to assessing mobility of patients with lower limb amputation. Interviews were audio-recorded and transcribed. Summary and frequency statistics were calculated for quantitative data; explanatory comments were summarized.

Results

Interviews were conducted with 25 clinicians (8 prosthetists, 9 physical therapists, and 8 physiatrists). Participants had access to multiple spaces and basic measurement equipment. The maximum time participants were willing to spend on performance tests varied. Physiatrists reported less time available (median=10 minutes, range 5-30 minutes) than prosthetists and physical therapists (median=30 minutes, range 5-60 minutes for both professions). Mobility tasks commonly used to evaluate patients with lower limb amputation included sit-to-stand, standing balance, walking, and varying speed. Participant comments suggested that mobility tests need to be quick, simple, and add value; existing mobility tests are beneficial but challenging to incorporate into practice; mobility tests should reflect real-world activities; and technological advancements could improve mobility testing.

Conclusions

Clinicians generally had small-to-medium spaces, basic measurement equipment, and sufficient training to administer mobility tests in their clinics. A limiting factor was time, which can be addressed through selection of efficient measures and collaboration within the rehabilitation team.

Limb Prostheses: Industry 1.0 to 4.0: Perspectives on Technological Advances in Prosthetic Care

Technological advances from Industry 1.0 to 4.0, have exercised an increasing influence on prosthetic technology and practices. This paper explores the historical development of the sector within the greater context of industrial revolution. Over the course of the first and up the midpoint of the second industrial revolutions, Industry 1.0 and 2.0, the production and provision of prosthetic devices was an ad hoc process performed by a range of craftspeople. Historical events and technological innovation in the mid-part of Industry 2.0 created an inflection point resulting in the emergence of prosthetists who concentrated solely on hand crafting and fitting artificial limbs as a professional specialty. The third industrial revolution, Industry 3.0, began transforming prosthetic devices themselves. Static or body powered devices began to incorporate digital technology and myoelectric control options and hand carved wood sockets transitioned to laminated designs. Industry 4.0 continued digital advancements and augmenting them with data bases which to which machine learning (M/L) could be applied. This made it possible to use modeling software to better design various elements of prosthetic componentry in conjunction with new materials, additive manufacturing processes and mass customization capabilities. Digitization also began supporting clinical practices, allowing the development of clinical evaluation tools which were becoming a necessity as those paying for devices began requiring objective evidence that the prosthetic technology being paid for was clinically and functionally appropriate and cost effective. Two additional disruptive dynamics emerged. The first was the use of social media tools, allowing amputees to connect directly with engineers and tech developers and become participants in the prosthetic design process. The second was innovation in medical treatments, from diabetes treatments having the potential to reduce the number of lower limb amputations to Osseointegration techniques, which allow for the direct attachment of a prosthesis to a bone anchored implant. Both have the potential to impact prosthetic clinical and business models. Questions remains as to how current prosthetic clinical practitioners will respond and adapt as Industry 4.0 as it continues to shape the sector.

Understanding the Relationship Between Patient-Reported Function and Actual Function in the Upper Limb Prosthesis User Population: A Preliminary Study

Objective

To understand how perceived function relates to actual function at a specific stage in the rehabilitation process for the population using upper limb prostheses.

Design

Quantitative clinical descriptive study.

Setting

Clinical offices.

Participants

A sample of 61 participants (N=61; mean age, 43.0±12.8y; 51 male/10 female) with upper limb amputation who use a prosthetic device and were in the definitive stage of a prosthesis fitting process.

Interventions

Not applicable.

Main Outcome Measures

A patient-reported outcome measure, the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH), and 2 performance-based outcome measures, Box and Blocks Test (BBT) and Capacity Assessment of Prosthesis Performance for the Upper Limb (CAPPFUL), were used as variables in multiple linear regression models.

Results

The multiple linear regression models, which controlled for prosthesis type and amputation level, did not show evidence that changes in the independent variable (DASH) are significantly associated with changes in the dependent variables (log(BBT) (B=−0.007; 95% confidence interval [CI], −0.015 to 0.001; P=.0937) and CAPPFUL (B=−0.083, 95% CI, −0.374 to 0.208; P=.5623)). In both models, individuals with elbow, transhumeral (above elbow), and shoulder disarticulation showed a significant negative association with the dependent variable (CAPPFUL or logBBT). In the CAPPFUL model, there was a significant negative association with individuals using a hybrid prosthesis (B=−20.252; 95% CI, −36.562 to −3.942; P=.0170). In the logBBT model, there was a significant positive association with individuals using body-powered prostheses (B=0.430; 95% CI, 0.089-0.771; P=.0157).

Conclusions

Although additional data and analyses are needed to more completely assess the association between self-reported measures and performance-based measures of functional abilities, these preliminary results indicate that patient-reported outcomes alone may not provide a complete assessment of an upper limb prosthesis users’ functional ability and should be accompanied by population-specific performance-based measures.

Reflections and future directions for psychological science in Prosthetics and Orthotics International

In the inaugural edition of Prosthetics and Orthotics International in 1977, Dr Sidney Fishman identified the Psychological Sciences as one of six indispensable areas of skill and knowledge in professional prosthetic-orthotic practice. Since then, there have been substantial changes and developments in the complexity and capabilities of assistive technologies, greater emphasis on understanding the relationships between people and enabling technologies, growing recognition of the importance of the contexts and environments that support their use, and changes in both health care services and the professional development of prosthetists and orthotists. The aim of this narrative review is to reflect on the role of Prosthetics and Orthotics International in shaping the evolving understanding of psychology in prosthetics and orthotics. There remains considerable potential and opportunity for the development and application of psychology in addressing the challenges of disability globally. However, a broad interpretation and application of the principles of rehabilitation psychology are needed if we are to meaningfully incorporate psychological science into the knowledge that informs prosthetic and orthotic practice.

Selecting, Administering, and Interpreting Outcome Measures among Adults with Lower-Limb Loss: An Update for Clinicians

Purpose of review

To summarize outcome measurement research among adults with lower-limb loss (LLL) for clinicians.

Recent findings

Houghton Scale, Prosthetic Evaluation Questionnaire-mobility subscale (PEQ-m), Prosthetic Limb Users Survey of Mobility (PLUS-M™), Activities-Specific Balance Confidence Scale (ABC), Amputee Mobility Predictor (AMP), Comprehensive High-Level Activity Mobility Predictor, Four Square Step Test (FSST), Narrowing Beam Walking Test (NBWT), L Test, 10 Meter Walk Test (10MWT), and 6 Minute Walk Test (6MWT) are appropriate for evaluating individual patient changes post-LLL. Post-LLL, Socket Comfort Score, Patient-Specific Functional Scale, Patient-Reported Outcomes Measurement Information System 29-Item Profile, Timed Up and Go, and 2 Minute Walk Test may be more appropriate for evaluating groups. Minimal detectable change is available for 15/20 reviewed measures. Many measures differ between mobility levels.

Summary

Quick, reliable measures for evaluating patient functional change include ABC, PEQ-m, PLUS-M™, FSST, and L Test; when resources allow, NBWT, 10MWT, 6WMT and AMP may be considered.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

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.

Orthotists' and physical therapists' perspectives on quality of care indicators for persons with custom ankle-foot orthoses

Purpose: To describe the priorities of orthotists and physical therapists about quality measurement themes, and the feasibility and utility of collecting data from persons using custom AFOs that could inform quality measure development.Materials and Methods: Online survey assessed respondents' perspectives and experiences. An Advisory Committee representing professional, organizational, and accreditor groups distributed survey invitations.Results: 461 orthotists and 153 physical therapists completed part or all of the survey; 60% rated 9 quality themes and 20 quality of care topics as extremely important, and 12 standard instruments as feasible and good to use for quality measurement. Patients were the preferred source of information for ease of scheduling, device weight, ease of donning and doffing, adherence to device use, beneficial effects, activity level and independence, and quality of life. Clinicians were the preferred source for material quality, device modifiability, and joint range of motion. Facility records were the preferred source for timeliness of device delivery and clinician follow-up. Respondents reported that gait speed and walking endurance were best obtained by patient performance.Conclusions: Results provide insight on the topics orthotists and physical therapists regard as priorities for defining healthcare quality for persons using custom ankle-foot orthoses and instruments for data collection.

A study to assess whether fixed-width beam walking provides sufficient challenge to assess balance ability across lower limb prosthesis users

OBJECTIVE

To evaluate the feasibility of fixed-width beam walking for assessing balance in lower limb prosthesis users.

DESIGN

Cross-sectional.

SETTING

Laboratory.

SUBJECTS

Lower limb prosthesis users.

METHODS

Participants attempted 10 walking trials on three fixed-width beams (18.6, 8.60, and 4.01 wide; 5.5 m long; 3.8 cm high).

MAIN MEASURES

Beam-walking performance was quantified using the distance walked to balance failure. Heuristic rules applied to each participant's beam-walking distance to classify each beam as "too easy," "too hard," or "appropriately challenging" and determine whether any single beam provided an appropriate challenge to all participants. The number of trials needed to achieve stable beam-walking performance was quantified for appropriately challenging beams by identifying the last inflection point in the slope of each participant's trial-by-trial cumulative performance record.

RESULTS

In all, 30 unilateral lower limb prosthesis users participated in the study. Each of the fixed-width beams was either too easy or too hard for at least 33% of the sample. Thus, no single beam was appropriately challenging for all participants. Beam-walking performance was stable by trial 8 for all participants and by trial 6 for 90% of participants. There was no significant difference in the number of trials needed to achieve stable performance among beams ( P = 0.74).

CONCLUSION

Results suggest that a clinical beam-walking test would require multiple beams to evaluate balance across a range of lower limb prosthesis users, emphasizing the need for adaptive or progressively challenging balance tests. While the administrative burden of a multiple-beam balance test may limit clinical feasibility, alternatives to ease this administrative burden are proposed.

Construct Validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M) in Adults With Lower Limb Amputation

OBJECTIVE

To assess construct validity of the Prosthetic Limb Users Survey of Mobility (PLUS-M), a self-report mobility measure for people with lower limb amputation (LLA).

DESIGN

Cross-sectional study.

SETTING

Private prosthetic clinics (n=37).

PARTICIPANTS

Current lower limb prosthesis users (N=199; mean age ± SD, 55.4±14.3y; 71.4% men) were assessed before receiving a replacement prosthesis, prosthetic socket, and/or prosthetic knee.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Convergent construct validity was examined using correlations between participants' PLUS-M T-scores and measures of physical function, mobility, and balance, including the Amputee Mobility Predictor (AMP), timed Up and Go (TUG), Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Prosthesis Evaluation Questionnaire-Mobility Subscale (PEQ-MS), and Activities-specific Balance Confidence (ABC) Scale. Known-groups construct validity was evaluated by comparing differences in PLUS-M T-scores among participants grouped by Medicare Functional Classification Level (MFCL).

RESULTS

PLUS-M T-scores demonstrated a moderate positive relationship with AMP scores (ρ=.54, P<.001) and a moderate negative relationship with TUG times (ρ=-.56, P<.001). The PLUS-M also showed a strong positive relationship with PEQ-MS scores (ρ=.78, P<.001), ABC Scale scores (ρ=.81, P<.001), and PROMIS-PF T-scores (ρ=.81, P<.001). Significant differences (P<.05) in PLUS-M T-scores were found among groups of people classified by different MFCLs.

CONCLUSIONS

Study results support the validity of the PLUS-M as a self-report measure of prosthetic mobility. Correlations between PLUS-M and measures of physical function, mobility, and balance indicate convergent construct validity. Similarly, significant differences in PLUS-M T-scores across MFCL groups provide evidence of known-groups construct validity. In summary, evidence indicates that PLUS-M has good construct validity among people with LLA.

Psychometric evaluation of self-report outcome measures for prosthetic applications

Documentation of clinical outcomes is increasingly expected in delivery of prosthetic services and devices. However, many outcome measures suitable for use in clinical care and research have not been psychometrically tested with prosthesis users. The aim of this study was to determine test-retest reliability, mode-of-administration (MoA) equivalence, standard error of measurement (SEM), and minimal detectable change (MDC) of standardized, self-report instruments that assess constructs of importance to people with lower limb loss. Prosthesis users (n = 201) were randomly assigned to groups based on MoA (i.e., paper, electronic, or mixed-mode). Participants completed two surveys 2 to 3 d apart. Instruments included the Prosthetic Limb Users Survey of Mobility, Prosthesis Evaluation Questionnaire-Mobility Subscale, Activities-Specific Balance Confidence Scale, Quality of Life in Neurological Conditions-Applied Cognition/General Concerns, Patient-Reported Outcomes Measurement Information System Profile, and Socket Comfort Score. Intraclass correlation coefficients indicated all instruments are appropriate for group-level comparisons and select instruments are suitable for individual-level applications. Several instruments showed evidence of possible floor and ceiling effects. All were equivalent across MoAs. SEM and MDC were quantified to facilitate interpretation of outcomes and change scores. These results can enhance clinicians' and researchers' ability to select, apply, and interpret scores from instruments administered to prosthesis users.