How do users define success with a lower limb prosthesis? A focus group study

PURPOSE

In this study, we sought to examine how lower limb prosthesis users define success, what constructs they associate with success, and what barriers and facilitators contribute to achieving success.

MATERIALS AND METHODS

Purposively sampled lower limb prosthesis users were recruited to participate in a focus group study. Verbatim transcripts from focus groups were analyzed using inductive thematic analysis. Identified constructs were mapped to existing outcome measures, and a conceptual framework for success with a lower limb prosthesis was proposed.

RESULTS

Thirty-one lower limb prosthesis users participated in one of five focus groups. Five themes were developed: keep moving forward, despite ups and downs; being able to live MY normal life and do the things I want to do with ease; learning what works for me and how to manage my prosthesis; only I can define my success; and what about my mental health? Several constructs that do not align with existing measures were identified, including prosthetic attention, grief/loss after amputation, and trust in prosthesis. Facilitators for success described by participants included peer connection, finding the right prosthetist, and mental health support.

CONCLUSIONS

According to lower limb prosthesis users, success must be patient-driven, individually defined, and continually reassessed.

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

PURPOSE

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Integrating Complementary Therapies in Managing Phantom Limb Pain: A Case Review

OBJECTIVES

This paper describes phantom limb pain (PLP), its impact on patients, and the various treatment options, including pharmacologic and complementary therapies. It investigates the efficacy of incorporating complementary and alternative therapies, both invasive and noninvasive, for amputees who have not achieved satisfactory results with pharmacologic treatments and suffer from adverse drug events. Furthermore, with the predicted increase in limb amputations, it is crucial for nurses, as frontline providers, to understand PLP, be prepared to manage persistent pain and associated psychological and functional issues and educate patients and families about alternative treatment options.

APPROACH

The review includes recent studies on pharmacologic interventions for PLP, case reports, and randomized clinical trials on non-pharmacologic complementary therapies, covering both invasive and noninvasive modalities. Studies from 2013 to 2022 were identified using the PubMed search engine with terms such as "Amputation," "phantom limb pain," "invasive therapies," and "non-invasive therapies."

RESULTS AND CONCLUSION

The pathogenesis of PLP remains unclear, complicating the identification of causes and the selection of targeted therapies for each patient. Uncontrolled PLP can severely impact the quality of life, causing psychological distress and loss of productivity. Traditional pharmacologic therapy often requires supplementation with other options due to PLP's refractory nature. A comprehensive, multimodal treatment plan, including non-pharmacologic therapies, can enhance rehabilitation and reduce complications. Incorporating these therapies can decrease reliance on medications, particularly opioids, and mitigate side effects. Although many potential PLP treatments exist, further clinical studies are needed to determine their effectiveness and establish protocols for optimizing patient outcomes.

A qualitative study of clinicians' and individuals' with lower limb loss perspectives on the development of a novel online self-management program

PURPOSE

To explore the rehabilitation preferences and experiences of clinicians and patients for education after lower limb loss to facilitate the development of an online self-management program.

METHODS

A qualitative descriptive approach was used. Thirty-one clinicians (physiotherapists, occupational therapists, and prosthetists), and 26 patients with lower limb loss (transtibial and transfemoral amputation; mean age (SD) of 63.3 (9.1), years) were recruited. We used semi-structured focus groups and one-on-one interviews, and audio recorded the interviews. Data were analyzed using conventional content analysis.

RESULTS

Three themes were identified: (1) Needing education in rehabilitation described the education in current practice as one-on-one discussion and booklets and highlighted the limitations of education such as its length, static nature, and inaccessible for patients living in remote areas. (2) Getting back to activities prior to amputation emphasized how goal setting and social support could assist patients and facilitate self-management. (3) Augmenting learning highlighted the need for an accessible complementary source for education and potential solutions to overcome the barriers of online delivery.

CONCLUSIONS

Our findings underscore the importance of education in the rehabilitation of patients to help them get back to their activities. An online accessible tool may improve education by providing information and peer support.

Machine Learning Model for Predicting Walking Ability in Lower Limb Amputees

Background/Objectives: The number of individuals with lower limb loss (LLL) is rising. Therefore, identifying the walking potential in individuals with LLL and prescribing adequate prosthetic systems are crucial. Various factors can influence participants' walking ability, to different extents. The aim of the present study was to apply machine learning methods to develop a predictive mode. This model can assist rehabilitation and limb loss care teams in making informed decisions regarding prosthesis prescription and predicting walking ability in individuals with LLL. Methods: The present study was designed as a prospective cross-sectional study encompassing 104 consecutively recruited participants with LLL (average age 62.1 ± 10.9 years, 80 (76.9%) men) at the Medical Rehabilitation Clinic. Demographic, physical, psychological, and social status data of patients were collected at the beginning of the rehabilitation program. At the end of the treatment, K-level estimation of functional ability, a Timed Up and Go Test (TUG), and a Two-Minute Walking Test (TMWT) were performed. Support vector machines (SVM) were used to develop the prediction model. Results: Three decision trees were created, one for each output, as follows: K-level, TUG, and TMWT. For all three outputs, there were eight significant predictors (balance, body mass index, age, Beck depression inventory, amputation level, muscle strength of the residual extremity hip extensors, intact extremity (IE) plantar flexors, and IE hip extensors). For the K-level, the ninth predictor was The Multidimensional Scale of Perceived Social Support (MSPSS). Conclusions: Using the SVM model, we can predict the K-level, TUG, and TMWT with high accuracy. These clinical assessments could be incorporated into routine clinical practice to guide clinicians and inform patients of their potential level of ambulation.

Predicting Functional Outcomes Following Dysvascular Lower Limb Amputation: An Evidence Review of Personalizing Patient Outcomes

Most research on people undergoing lower limb amputations for dysvascular disease summarizes average patient outcome risks and average associations between patient factors and these outcomes. More recently, the importance of predicting patient-specific outcomes based on individual factors (ie, personalized rehabilitation) has become evident. This article reviews the evidence and discusses the importance of the following: (1) predicting outcomes to facilitate amputation-level and prosthesis prescription decisions and (2) how prediction models can be leveraged to develop decision support tools to facilitate provider/patient shared decision-making to ensure decisions considering each individual patient's priorities and preferences. Examples of these tools are discussed and referenced.

Lower limb prosthesis users' perceptions of everyday life-A phenomenographic study

INTRODUCTION

A lack of understanding of personal experiences related to limb amputation and prosthetic use limits the extent to which clinicians involved in rehabilitation can support and advise their clients in a person-centered consultation. The objective of this qualitative study was to explore the personal experience of daily life as a lower limb prosthesis user.

METHODS

Fifteen lower limb prosthesis users participated in individual semistructured interviews. Transcripts were analyzed using a phenomenographic approach.

RESULTS

The extent to which prosthesis users were able to adjust to their impairment and move on with their life was influenced by social interactions with other prosthesis users, access to relevant information about prosthetic solutions that may benefit them, and finding a balance between desired activities and their physical and/or cognitive capacity.

CONCLUSIONS

After a period of existential adjustment, prosthesis users described themselves as living active, fulfilling lives. This was facilitated to a large extent by social interactions with other prosthesis users and access to information they perceived as relevant. Social media plays a particularly important role in establishing connections with other prosthesis users and is perceived as a useful source of information.

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.

Experiences of lower limb prosthesis users in Kenya: a qualitative study to understand motivation to use and satisfaction with prosthetic outcomes

PURPOSE

To explore the personal and system factors that motivate and enhance outcomes for patients accessing a prosthetic service and using a lower-limb prosthesis within a low resource setting.

MATERIALS AND METHODS

This study employed a qualitative approach to explore the motivations and satisfaction of individuals with lower limb loss engaging with a prosthetic service in Mombasa, Kenya. In-depth interviews were conducted over Microsoft Teams with 10 lower limb prosthesis users and thematic analysis was applied.

RESULTS

Five key themes emerged: acceptance, self-determination, hope, clinician relationship and perception. These findings demonstrate the importance of hopeful thinking and a supportive community in overcoming physical and stigmatising challenges. The findings further highlight the value of the service provider relationship beyond just prescribing an assistive device.

CONCLUSION

These results have relevance in developing patient-centred services, assistive devices and personnel training that are responsive, motivating, and cognisant of the service user. This is of particular interest as assistive technology services are newly developed in low resource settings.IMPLICATIONS FOR REHABILITATIONThis research provides an understanding of lower-limb prosthesis users' satisfaction of a device and motivation for engaging with a prosthetic service within a low resource setting.The relationship the rehabilitation professional has with the service user plays a significant role in facilitating motivation during rehabilitation.Rehabilitation professionals should consider how they can foster a network of support amongst service users when planning services in remote, rural locations.Rehabilitation professionals should be aware of how hopeful thinking can be facilitated during rehabilitation to support motivation.When reviewing the success of services, or designing new service models, the service users should be consulted on what they would deem as a successful outcome.

What Is Hidden behind Amputation? Quanti-Qualitative Systematic Review on Psychological Adjustment and Quality of Life in Lower Limb Amputees for Non-Traumatic Reasons

OBJECTIVE

This systematic review aims to investigate Quality of Life (QoL)/Health Related Quality of Life (HRQoL) and psychological adjustment in non-traumatic lower limb amputees (LLA).

METHODS

PubMed, Scopus, and Web of Science databases were used for the literature search. Studies were read and analysed using the (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA statement procedure.

RESULTS

The literature search retrieved 1268 studies, of which 52 were included in the systematic review. Overall, psychological adjustment, especially depression with or without anxiety symptoms, influences the QoL/HRQoL in this clinical population. Other factors influencing QoL/HRQoL include subjective characteristics, physical aspects, the cause and level of the amputation, relational aspects, social support, and the doctor-patient relationship. In addition, the patient's emotional-motivational status, depression and/or anxiety symptoms, and acceptance play a key role in the subsequent rehabilitation process.

CONCLUSIONS

In LLA patients, psychological adjustment is a complex and multifaceted process, and QoL/HRQoL may be influenced by various factors. Shedding light on these issues may provide useful suggestions for promoting clinical and rehabilitative interventions that may be tailored and effective in this clinical population.

Evolving 3D-Printing Strategies for Structural and Cosmetic Components in Upper Limb Prosthesis

The evolution of prosthetic limbs continues to develop, with novel manufacturing techniques being evaluated, including additive manufacturing. Additive manufacturing (AM), or 3D-printing, holds promise for enabling personalized and tailored medical device options. The requirements for personalized medicine, coupled with the limitations of small-batch manufacturing, have made the technique viable for exploration. In this manuscript, an approach is presented for incorporating additive manufacturing for prostheses, both as a final part and in applications as an intermediate manufacturing step. As a result, through the use of these methods a multi-gesture capable electromyographic prosthesis was designed and manufactured, currently being evaluated in clinical trials for pediatric patients. This paper explored the results of this unique method of applying additive manufacturing techniques, and assessed how the blend of different manufacturing techniques improved performance and reduced device weight. Creating unique and aesthetic cosmetic coverings for the device was achieved through using additive manufacturing as an intermediate manufacturing component and, then, applying thermoforming. Cosmesis components saw a 33% reduction in weight from this change in manufacturing. The approach is explored to blend multiple manufacturing techniques to create cosmesis components and structural components for the prosthesis. The techniques serve the design intent to reduce reported challenges with upper limb prosthesis devices and to encourage device retention. Recommendations for manufacturing strategies are discussed, including the limitations.

User-relevant factors influencing the prosthesis use of persons with a transfemoral amputation or knee-disarticulation: A meta-synthesis of qualitative literature and focus group results

OBJECTIVE

Persons with a transfemoral amputation or knee-disarticulation are heavily reliant on an adequate set of components for their prosthesis. To improve the process of adjusting the specific prosthetic properties to the expectations of the prosthesis users, it is of importance to first identify which factors have an influence on prosthesis use. Therefore, we aimed to identify factors that influence prosthesis use in adults with a transfemoral amputation or knee-disarticulation.

METHODS

A qualitative meta-synthesis was conducted by searching five databases (last update January 20th 2022). Studies were considered eligible if they contained qualitative data about adult persons with a transfemoral amputation or knee-disarticulation with experience in using a prosthesis and focused on the users' opinions. All eligible studies were independently screened by two reviewers. The results sections of the included studies were entered in Atlas.ti software (v8) and coded using the framework approach. The quality of the included studies was assessed using the Critical Appraisal Skills Program (CASP) qualitative research checklist. Results of the meta-synthesis were validated with prosthesis users (n = 8) in a focus group.

RESULTS

Out of 5757 articles, 14 studies were included. An overview of seven themes ('prosthesis related'; 'rehabilitation, costs and prosthetist'; 'mental'; 'physical'; 'social'; 'activities and participation' and 'walking') containing 84 factors was created. Ten factors were added during the focus group, resulting in an overview of 94 factors that may influence the prosthesis use of lower-limb prosthesis users. Participants would like more user-involvement from the rehabilitation team. The development of a patient decision aid could help this process in the future.

CONCLUSION

The large number of factors demonstrates that there is a great variety between prosthesis users and the factors that influence their prosthesis use. Therefore, it is important to take individual preferences into account for the selection of a new prosthesis.

A review of user needs to drive the development of lower limb prostheses

Background

The development of bionic legs has seen substantial improvements in the past years but people with lower-limb amputation still suffer from impairments in mobility (e.g., altered balance and gait control) due to significant limitations of the contemporary prostheses. Approaching the problem from a human-centered perspective by focusing on user-specific needs can allow identifying critical improvements that can increase the quality of life. While there are several reviews of user needs regarding upper limb prostheses, a comprehensive summary of such needs for those affected by lower limb loss does not exist.

Methods

We have conducted a systematic review of the literature to extract important needs of the users of lower-limb prostheses. The review included 56 articles in which a need (desire, wish) was reported explicitly by the recruited people with lower limb amputation (N = 8149).

Results

An exhaustive list of user needs was collected and subdivided into functional, psychological, cognitive, ergonomics, and other domain. Where appropriate, we have also briefly discussed the developments in prosthetic devices that are related to or could have an impact on those needs. In summary, the users would like to lead an independent life and reintegrate into society by coming back to work and participating in social and leisure activities. Efficient, versatile, and stable gait, but also support to other activities (e.g., sit to stand), contribute to safety and confidence, while appearance and comfort are important for the body image. However, the relation between specific needs, objective measures of performance, and overall satisfaction and quality of life is still an open question.

Conclusions

Identifying user needs is a critical step for the development of new generation lower limb prostheses that aim to improve the quality of life of their users. However, this is not a simple task, as the needs interact with each other and depend on multiple factors (e.g., mobility level, age, gender), while evolving in time with the use of the device. Hence, novel assessment methods are required that can evaluate the impact of the system from a holistic perspective, capturing objective outcomes but also overall user experience and satisfaction in the relevant environment (daily life).

Social participation in persons with upper limb amputation receiving an esthetic prosthesis

STUDY DESIGN

Qualitative study.

INTRODUCTION

An amputation injury to the hand may lead to not only impaired hand function but also psychosocial consequences.

PURPOSE OF THE STUDY

The purpose of the study was to explore personal experiences of social participation for persons provided with an esthetic prosthesis after acquired upper limb amputation.

METHODS

Thirteen persons with acquired upper limb amputation, who were in need of and had received an esthetic prosthesis, were interviewed. The transcribed text was subjected to content analysis.

RESULTS

The emotional reactions to a visibly different hand were linked to a changed appearance and a feeling of being exposed. Recollecting the accident could result in nightmares and sleeping disorders. A change of personality, due to sadness after the amputation was expressed, as well as social insecurity and impact on relations and life roles. Adapting to social challenges comprised hiding or exposing the hand, using personal internal resources and receiving support from others. The esthetic prosthesis contributed to an intact appearance and could serve as a facilitator for initial or long-term social participation. The time that had passed since the injury made it easier to deal with the consequences or in achieving acceptance.

DISCUSSION

Coping with emotions and social relations after an acquired amputation can be difficult and complex.

CONCLUSIONS

Individual needs must be considered and questions about appearance and how it may affect social participation must be asked. An esthetic prosthesis can normalize the appearance and offer the confidence needed to facilitate social participation in those struggling with appearance-related concerns.

A qualitative study examining prosthesis use in everyday life in individuals with lower limb amputations

BACKGROUND

Lower limb amputation (LLA) is a life-changing event that affects functional mobility and participation in everyday life. Prostheses provide individuals with LLA the opportunity to improve mobility and quality of life; however, existing literature suggests that there is underuse of prostheses.

OBJECTIVES

The purpose of this study is to describe how individuals with major LLA use their prosthesis in everyday life and describe barriers and facilitators that influence prosthesis use.

STUDY DESIGN

A qualitative descriptive methodology was used.

METHODS

Ten community dwelling adults (>18 years) with unilateral major LLAs (transtibial, transfemoral, and knee disarticulation) attending outpatient follow-up at a specialized rehabilitation center were recruited. Participants were purposively sampled for variation in prosthesis use and level of amputation. One-on-one semistructured in-depth interviews were conducted in person or by telephone. The interviews were audio recorded, transcribed verbatim, and analyzed inductively using thematic analysis.

RESULTS

The experiences of individuals with major LLA were organized into three overarching themes: everyday experiences using a prosthesis, extrinsic factors influencing prosthesis use, and intrinsic factors influencing prosthesis use. These themes, and their associated subthemes, highlight how individuals use their prosthesis and the various factors perceived to act as barriers and facilitators to prosthesis use in everyday life.

CONCLUSIONS

These findings provide valuable insight into the everyday experiences of individuals with LLA and can be used to implement strategies to optimize prosthesis use.

Computational Design of Skinned Quad-Robots

We present a computational design system that assists users to model, optimize, and fabricate quad-robots with soft skins. Our system addresses the challenging task of predicting their physical behavior by fully integrating the multibody dynamics of the mechanical skeleton and the elastic behavior of the soft skin. The developed motion control strategy uses an alternating optimization scheme to avoid expensive full space time-optimization, interleaving space-time optimization for the skeleton, and frame-by-frame optimization for the full dynamics. The output are motor torques to drive the robot to achieve a user prescribed motion trajectory. We also provide a collection of convenient engineering tools and empirical manufacturing guidance to support the fabrication of the designed quad-robot. We validate the feasibility of designs generated with our system through physics simulations and with a physically-fabricated prototype.

Psychiatric understanding and treatment of patients with amputations

Amputation changes the lives of patients and their families. Consequently, the patient must adapt to altered body function and image. During this adaptation process, psychological problems, such as depression, anxiety, and posttraumatic stress disorder, can occur. The psychological difficulties of patients with amputation are often accepted as normal responses that are often poorly recognized by patients, family members, and their primary physicians. Psychological problems can interfere with rehabilitation and cause additional psychosocial problems. Therefore, their early detection and treatment are important. A multidisciplinary team approach, including mental health professionals, is ideal for comprehensive and biopsychosocial management. Mental health professionals could help patients set realistic goals and use adaptive coping styles. Psychiatric approaches should consider the physical, cognitive, psychological, social, and spiritual functions and social support systems before and after amputation. The abilities and limitations of physical, cognitive, psychological, and social functions should also be considered. To improve the patient’s adaptation, psychological interventions such as short-term psychotherapy, cognitive behavioral therapy, mindfulness meditation, biofeedback, and group psychotherapy can be helpful.

Improving the Selectivity of an Osseointegrated Neural Interface: Proof of Concept For Housing Sieve Electrode Arrays in the Medullary Canal of Long Bones

Sieve electrodes stand poised to deliver the selectivity required for driving advanced prosthetics but are considered inherently invasive and lack the stability required for a chronic solution. This proof of concept experiment investigates the potential for the housing and engagement of a sieve electrode within the medullary canal as part of an osseointegrated neural interface (ONI) for greater selectivity toward improving prosthetic control. The working hypotheses are that (A) the addition of a sieve interface to a cuff electrode housed within the medullary canal of the femur as part of an ONI would be capable of measuring efferent and afferent compound nerve action potentials (CNAPs) through a greater number of channels; (B) that signaling improves over time; and (C) that stimulation at this interface generates measurable cortical somatosensory evoked potentials through a greater number of channels. The modified ONI was tested in a rabbit (n = 1) amputation model over 12 weeks, comparing the sieve component to the cuff, and subsequently compared to historical data. Efferent CNAPs were successfully recorded from the sieve demonstrating physiological improvements in CNAPs between weeks 3 and 5, and somatosensory cortical responses recorded at 12 weeks postoperatively. This demonstrates that sieve electrodes can be housed and function within the medullary canal, demonstrated by improved nerve engagement and distinct cortical sensory feedback. This data presents the conceptual framework for housing more sophisticated sieve electrodes in bone as part of an ONI for improving selectivity with percutaneous connectivity toward improved prosthetic control.

Fall-related events in people who are lower limb prosthesis users: the lived experience

PURPOSE

To explore lived experiences, and identify common themes as well as vocabulary associated with fall-related events in lower limb prosthesis (LLP) users.

MATERIALS AND METHODS

Five focus groups of LLP users from across the United States were conducted remotely via video or tele-conferencing. Focus group transcripts were coded and analyzed using methods adapted from a grounded theory approach to identify themes.

RESULTS

Focus group participants (n = 25) described experiences associated with fall-related events that resulted in the identification of six themes: (1) memories of fall-related events are shaped by time and context, (2) location and ground conditions influence whether falls occur, (3) some activities come with more risk, (4) fall-related situations are multi-faceted, and often involve the prosthesis, (5) how LLP users land, but not the way they go down, tends to vary, and (6) not all falls affect LLP users, but some near-falls do.

CONCLUSION

Consideration for where LLP users fall, what they are doing when they fall, how they fall, what occurs as a result of a fall, and how well memory of a fall persists may enhance recording and reporting of falls, contribute to development of improved fall risk assessment tools, and inspire the design and function of prosthetic componentry for patient safety.Implications for rehabilitationFalls are a common problem in lower limb prosthesis (LLP) users that can lead to adverse health outcomes.Concerns over near falls, not just falls, may merit greater attention from rehabilitation professionals.Elements of the lived experience that appear unique to LLP users include the role of prosthetic fit, function, and comfort in losing and/or recovering balance; as well as the tendency of LLP users to modify rather than stop or avoid activities associated with falls.

Obstacles to Prosthetic Care—Legal and Ethical Aspects of Access to Upper and Lower Limb Prosthetics in Germany and the Improvement of Prosthetic Care from a Social Perspective

Prosthetic technology for people with missing limbs has made great progress in recent decades. However, acceptance rates and user satisfaction are not only dependent on technical aspects, but also to a great extent on social and psychological factors. We propose that these factors should receive greater attention in order to improve prosthetic care and give recommendations how to incorporate the findings from social science in research and development (R&D) and in care practice. Limited access due to high costs of new prosthetic technology combined with rising costs in health care systems in general is a further issue we address. Our legal and ethical analysis of the reimbursement process in Germany shows that this issue requires further empirical investigation, a stakeholder dialogue and maybe even policy changes. Social science knowledge and participatory methods are of high relevance to answer questions about the benefit of prosthetics for users, based on individual needs and preferences, which should be at the core of debates on ethical resource allocation.

Amputees Unanimous: A 12-step program

BACKGROUND

Alongside physical impairment, psychosocial health issues may arise after amputation, impacting quality of life. Traditional psychosocial care models provide services in a linear fashion, with limited supports upon discharge. A novel program entitled Amputees Unanimous is a 12-step program provided for amputees by amputees.

OBJECTIVE

To shape the final content of Amputees Unanimous by identifying personal beliefs and opinions of healthcare professionals and amputees.

STUDY DESIGN

Qualitative design utilizing a phenomenological approach.

METHOD

Five focus groups were held: four with amputees and one with healthcare providers. A phenomenological approach shaped the inquiry of the lived experience of limb loss in relation to the content of Amputees Unanimous.

RESULTS

Three themes emerged: (1) accepting limb loss, (2) peer inspiration, and (3) regaining prior level of function.

CONCLUSION

Limb loss may alter one's self-image, both physically and psychologically, having a profound effect on how an individual copes throughout his or her lifetime. The content and delivery format of Amputees Unanimous could be tested for effectiveness as a program tailored to facilitate coping after limb loss and to provide encouragement, support, and hope for the future of amputees.

CLINICAL RELEVANCE

A dynamic, amputee-led, mutual help program may provide individuals with limb loss a place for encouragement, support, and optimism for the future.

Implementation of 3D Printing Technology in the Field of Prosthetics: Past, Present, and Future

There is an interesting and long history of prostheses designed for those with upper-limb difference, and yet issues still persist that have not yet been solved. Prosthesis needs for children are particularly complex, due in part to their growth rates. Access to a device can have a significant impact on a child’s psychosocial development. Often, devices supporting both cosmetic form and user function are not accessible to children due to high costs, insurance policies, medical availability, and their perceived durability and complexity of control. These challenges have encouraged a grassroots effort globally to offer a viable solution for the millions of people living with limb difference around the world. The innovative application of 3D printing for customizable and user-specific hardware has led to open-source Do It Yourself “DIY” production of assistive devices, having an incredible impact globally for families with little recourse. This paper examines new research and development of prostheses by the maker community and nonprofit organizations, as well as a novel case study exploring the development of technology and the training methods available. These design efforts are discussed further in the context of the medical regulatory framework in the United States and highlight new associated clinical studies designed to measure the quality of life impact of such devices.

Prosthesis satisfaction in lower limb amputees: A systematic review of associated factors and questionnaires

BACKGROUND

Factors influencing patient satisfaction with a transtibial prosthesis have been studied fragmentarily. The aims of this systematic review were to review the literature regarding factors of influence on patient satisfaction with a transtibial prosthesis, to report satisfaction scores, to present an overview of questionnaires used to assess satisfaction and examine how these questionnaires operationalize satisfaction.

METHODS

A literature search was performed in PubMed, Embase, PsycInfo, CINAHL, Cochrane, and Web of Knowledge databases up to February 2018 to identify relevant studies.

RESULTS

Twelve of 1832 studies met the inclusion criteria. Sample sizes ranged from 14 to 581 participants, mean age ranged from 18 to 70 years, and time since amputation ranged from 3 to 39 years. Seven questionnaires assessed different aspects of satisfaction. Patient satisfaction was influenced by appearance, properties, fit, and use of the prosthesis, as well as aspects of the residual limb. These influencing factors were not relevant for all amputee patients and were related to gender, etiology, liner use, and level of amputation. No single factor was found to significantly influence satisfaction or dissatisfaction. Significant associations were found between satisfaction and gender, etiology, liner use, and level of amputation.

CONCLUSION

Relevance of certain factors for satisfaction was related to specific amputee patient groups. Questionnaires assessing satisfaction use different operationalizations, making comparisons between studies difficult.

Satisfaction with life in individuals with a lower limb amputation: The importance of active coping and acceptance

The aim of this study was to analyze the relationship between sociodemographic/clinical characteristics, coping strategies and satisfaction with life in individuals with lower limb amputation. Sixty-three individuals with a lower limb amputation due to Diabetes and Peripheral Vascular Disease participated in the study and answered measures of coping strategies and satisfaction with life. Findings revealed high dissatisfaction with life. Acceptance and active coping were the most used coping strategies. Satisfaction with life was positively associated with active and planning coping, religion, acceptance and humour. There were differences in coping strategies according to gender, age, marital status, presence of residual limb pain, prosthesis use and mobility level. Results emphasize the differential role of coping strategies, for each individual. Psychosocial interventions need to take into consideration coping strategies during the process of rehabilitation and be specific regarding individuals` sociodemographic and clinical characteristics. This study may help design interventions that answer individuals with lower limb amputations given that coping strategies are a valuable resource in the promotion of satisfaction with life.

Understanding posttraumatic growth of paratriathletes with acquired disability

PURPOSE

To examine the relevance of key components of Organismic Valuing Theory of Growth through Adversity in understanding posttraumatic growth amongst paratriathletes with acquired disability.

METHODS

Semi-structured interviews informed by organismic valuing theory of growth through adversity were conducted with 14 elite paratriathletes (eight male, six female). To increase the likelihood that participants had experienced posttraumatic growth, a short form of the Posttraumatic Growth Inventory was completed prior to interview participation. Interview data were analyzed using directed content analysis.

RESULTS

Although the initial response to disability was largely negative, paratriathlon experiences were reported to be a mechanism through which growth was facilitated. In particular, participants suggested that social, competence, empowerment, and identity development processes were instrumental in facilitating posttraumatic growth.

CONCLUSIONS

Analysis identified themes largely consistent with the main tenets of organismic valuing theory of growth through adversity, supporting its utility in understanding response to a traumatic event and subsequent growth. These findings also suggest that para sport may be an efficacious means for promoting posttraumatic growth, especially for individuals with severe initial reactions to their disability. Lastly, findings suggest that fostering perceptions of competence, autonomy, and social connection may promote posttraumatic growth. Implications for Rehabilitation Acquiring a physical disability may have a detrimental impact on the satisfaction of an individual's fundamental psychological needs. In order to foster posttraumatic growth, the para sport environment should allow for participants to feel competent, autonomous, and to have meaningful interactions with fellow athletes and coaches. Para sport may be particularly beneficial for individuals with previous sporting backgrounds and for those with severe initial reactions to their disability.

The process of becoming a user of an osseointegrated prosthesis following transfemoral amputation: a qualitative study

PURPOSE

To investigate what characterizes the process of becoming a user of an osseointegrated prosthesis following transfemoral amputation.

METHOD

The study is based on the descriptive phenomenological framework Reflective Lifeworld Research. Data were collected through in-depth interviews with seven participants who had undergone transfemoral implant surgery and currently used their osseointegrated prosthesis. Data were analyzed according to the guidelines given in Reflective Lifeworld Research.

RESULTS

The essential meaning of becoming a user of an osseointegrated prosthesis is characterized by determination to achieve rehabilitation results as well as a struggle to get familiar with the new prosthesis. When familiar with the prosthesis, participants begin to experience radical improvements in their everyday life, compared to their life with the socket suspended prosthesis. The essential meaning is elaborated on in four constituents: Determination to achieve rehabilitation results with the short training prosthesis, struggling to get familiar with the osseointegrated prosthesis, experiencing improvements in everyday life and reconnecting with one's prior self-perception.

CONCLUSION

All the participants experienced increased action space and a more positive outlook on life. However, it took determination and stamina to become a user of an osseointegrated prosthesis, and participants faced several challenges throughout this process. Consequently, it remains important to raise awareness of the difficulties faced during this process. Implications for Rehabilitation The findings from this study suggest an increased healthcare support to users of an transfemoral osseointegrated prosthesis in the period of rehabilitation and adjustment, as the results of being able to use the osseointegrated prosthesis may outweigh the obstacles of getting there. Implementation of long-term follow-up and psychosocial support initiatives may improve the adjustment process following osseointegration. Support of patients with an osseointegrated prosthesis may be facilitated through formation of specific rehabilitation groups together with increased use of information technology such as social media and relevant online communities which provide forums for interaction and dialog with people in similar situations.

Being "just normal": a grounded theory of prosthesis use

PURPOSE

Whilst research tells us about the benefits and challenges of using prostheses, little attempt has been made to account for and provide explanations for the differing experiences of prosthesis users. In this study, a core concern shared by prosthesis users and an account of how this concern is managed are explored.

METHOD

Data were collected and analysed according to Grounded Theory procedures, involving interviews with 24 participants, 17 weblogs, 17 autobiographical texts, and posts from 4 online forums.

RESULTS

Prosthesis users are primarily concerned with being "just normal": the condition of being and living in ways that persons variously perceive are "about right"; that are sufficient, fair, and generally how things "ought to be" for them. This concern is acted upon through: (i) "preserving", where persons foresee and manage threats to being "just normal", (ii) "redressing", involving rectifying things judged not to be "just normal", and (iii) "persevering", where persons keep living "just normally" despite accompanying difficulties.

CONCLUSIONS

"Just normal" is a new means for rehabilitation practitioners to better understand a key concern of prosthesis users and the motivations underlying behaviours in their prosthesis use. It is also relevant and transferable to broader fields of assistive technology use and disability. Implications for Rehabilitation The grounded theory of "just normal" invites practitioners to discover a key concern in prosthesis use, enabling a richer understanding of the needs and desires of service users. Being "just normal" is presented as an important motivator underlying a range of diverse actions within prosthesis use. The theory is relevant and transferable to broader areas of assistive technology use and disability.

The meaning and consequences of amputation and mastectomy from the perspective of pain and suffering

BACKGROUND

The concepts 'pain' and 'suffering' are frequently treated as synonymous. However, they are clearly distinct phenomena. Phantom phenomena including pain and sensory disturbances are still recognized as long-lasting problems after limb amputation and after mastectomy. The complex nature of phantom phenomena makes the interpretation of its results ambiguous, regarding the prevalence of pain, sensory disturbances and the accompanying suffering. There is clinical experience that suffering is a great burden for the individual but there is a lack of systematic studies of patients' own evaluations of the suffering caused by their phantom phenomena.

OBJECTIVES

The overall aim of this study was to identify and describe patients' suffering related to, and as a part, of their post-amputation situation.

METHODS

The present study constitutes a part of a prospective, two-year follow up project investigating interviews of 28 men and women in different ages and who have undergone a limb amputation or mastectomy. The reason for amputation or mastectomy varied among the patients and included vascular diseases, cancer (sarcoma and breast-cancer) and trauma. Our ambition was to extract as much variations as possible in different, individualized aspects of the actual pain and suffering producing situation. The participants were, here, invited to open-ended, narrative-oriented interviews one month after the surgery. The interviews were transcribed verbatim and analyzed within qualitative methodology: thematic content analysis.

RESULTS

Twenty-two of 28 interviewees experienced phantom pain and phantom sensations. The two surgical processes amputation and mastectomy meant for a majority of the interviewees a critical event with threatening consequences for everyday life such as loss of function and personal integrity. Nine interviewees felt even stigmatized as a result of their lost body part. Numerous inter-related factors following the amputation/mastectomy, which can inflict severe suffering on the amputee, were uncovered. The context in which the interviewees were informed about the decision to amputate proved to be one such critical and important factor.

CONCLUSION

To understand potential suffering in relation to phantom phenomena, it will never be enough merely to have knowledge of the underlying physiological or neurological mechanisms and/or the intensity of phantom pain and phantom sensations. Rather, it is necessary to find out how the loss of the body part and its everyday consequences are experienced by patients.

IMPLICATIONS

It is important to create time for real dialogue with the patients both during pre-operative preparation and post-operative rehabilitation in order to clarify and verbalize elements that constitute the patients individual suffering. Hopefully this strategy can alleviate future chronic pain problems, severe psycho-social distress and suffering. Such an approach ought to have impact also for perceived suffering after other types of surgery or different invasive treatments.

Characterizing mobility from the prosthetic limb user's perspective: Use of focus groups to guide development of the Prosthetic Limb Users Survey of Mobility

BACKGROUND

Input from target respondents in the development of patient-reported outcome measures is necessary to ensure that the instrument is meaningful.

OBJECTIVES

To solicit perspectives of prosthetic limb users about their mobility experiences and to inform development of the Prosthetic Limb Users Survey of Mobility.

STUDY DESIGN

Qualitative study.

METHODS

Four focus groups of lower limb prosthesis users were held in different regions of the United States. Focus group transcripts were coded, and themes were identified. Feedback from participants was used to develop a framework for measuring mobility with a lower limb prosthesis.

RESULTS

Focus group participants (N = 37) described mobility as a confluence of factors that included characteristics of the individual, activity, and environment. Identified themes were defined as individual characteristics, forms of movement, and environmental situations. Prosthetic mobility was conceptualized as movement activities performed in an environmental or situational context.

CONCLUSION

Respondent feedback used to guide development of Prosthetic Limb Users Survey of Mobility established a foundation for a new person-centered measure of mobility with a prosthetic limb.

CLINICAL RELEVANCE

Perspectives of target respondents are needed to guide development of instruments intended to measure health outcomes. Focus groups of prosthetic limb users were conducted to solicit experiences related to mobility with a lower limb prosthesis. Results were used to inform development of a clinically meaningful, person-centered instrument.

Why people in Benin are reluctant to undergo amputations? A systematic inventory of motives

We made an inventory of the reasons for inhabitants of Benin are reluctant to undergo the amputation of a limb. A robust six-factor structure of motives was found: Change in Appearance, Lack of Information, Fear of Hospitals and Medical Staff, Loss of Others' Consideration and Affection, Denial of Necessity, and Spiritual and Religious Concerns. The first three motives were the most strongly endorsed. To improve people's timely acceptance, it is important to attack the main emotional-motivational barriers by using artificial limbs imitating real ones, by providing complete information on post-operative care and rehabilitation, and by strengthening family support.

The Social Meanings of Prosthesis Use

The present research explores the social meanings surrounding the use of artificial limbs. Semi-structured email and face-to-face interviews were conducted with 35 prosthesis users, along with analysis of the posts made on an email discussion group for prosthesis users. This data was subject to an Interpretative Phenomenological Analysis. It is concluded that prosthesis use plays a social role in the lives of persons with limb loss/absence. The ability to conceal such use enabled participants to ward off social stigmatisation that in turn enabled their social integration and the reduction of emotional problems surrounding such disability.

Relationship between cognition and functional outcomes after dysvascular lower extremity amputation: a prospective study

OBJECTIVE

The aim of this study was to examine associations between a cognitive screen and four neuropsychologic tests administered at both 6 wks and 4 mos after amputation and five functional outcomes measured 12 mos after lower extremity amputation.

DESIGN

This study includes a prospective cohort from four medical centers. Participants were primarily male Veterans experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Of those eligible, 87 (64%) enrolled; 75 (86%) were retained at 12 mos. Measures included demographic/health information, four neuropsychologic measures, the Locomotor Capability Index-5, the Gronigen Activity Restriction Scale, prosthetic use, community participation, and social integration.

RESULTS

Better performance on the Short Portable Mental Status Questionnaire at 4 mos was associated with greater 12-mo mobility and social integration. Better attention and working memory abilities 6 wks after amputation were associated with increased 12-mo prosthetic wear; and at 4 mos after amputation, with greater 12-mo mobility. Better verbal memory at 6 wks was associated with greater 12-mo social integration and community participation as well as increased prosthetic wear.

CONCLUSIONS

These findings highlight the potential value in including a brief, formal cognitive assessment in addition to a general mental status screen. Specific domains of cognitive function are differentially associated with functional outcomes and may inform amputation rehabilitation decisions.

Posttraumatic growth in individuals with amputations

BACKGROUND

Studying positive outcomes post-amputation is an important area of research in order to help individuals recover with the optimal quality of life possible.

OBJECTIVE

To examine posttraumatic growth (PTG) in the understudied population of individuals with amputations. Our main aim was to assess the effect of gender, veteran status, age, and time since amputation on PTG. Our secondary aim was to examine the role support group participation on PTG.

METHODS

Sixty-six adults with amputations completed an online survey consisting of the Posttraumatic Growth Inventory (PTGI) and free response questions about experiences with support groups. T-tests and correlations were the main statistical analyses.

RESULTS

There were no gender differences in PTGI scores. Veterans had significantly lower PTGI scores than civilians, t(64) = 2.63, p < 0.05, Cohen's d = .41. Age was negatively correlated with PTGI score, r = -.27, p < 0.05. Participants who indicated consistent engagement in a support group had significantly higher PTGI scores than participants without support group engagement, t(64) = 3.49, p < 0.01, Cohen's d = .89.

CONCLUSIONS

Veterans may be a specific population to target for PTG. Support groups appear to be a venue associated with higher levels of growth.

Satisfaction with cosmesis and priorities for cosmesis design reported by lower limb amputees in the United Kingdom: instrument development and results

BACKGROUND

Amputee satisfaction with cosmesis and the importance they place on cosmesis design have not been published in the literature.

OBJECTIVES

To investigate the current satisfaction levels of amputees in the United Kingdom with their cosmesis and the importance placed on attributes of cosmesis design to inform future cosmesis redesign.

STUDY DESIGN

Cross-sectional questionnaire study.

METHODS

Questionnaires were administered to lower limb amputees in the United Kingdom. Satisfaction scores and the overall importance ranking of cosmesis features were calculated. Statistically significant relationships between two demographic, satisfaction or importance variables were tested using Fisher's exact tests (one-tailed) at a significance level p = 0.05.

RESULTS

Between 49% and 64% of respondents reported neutral or dissatisfied opinions with the cosmesis features (greater than 50% for five of the nine features). The three most important features identified were shape matching the cosmesis to the sound limb, free prosthetic joint movement underneath the cosmesis and natural fit of clothing over the cosmesis.

CONCLUSIONS

The results indicate that current cosmesis satisfaction levels of amputees in the United Kingdom are below what the medical device industry and clinical community would desire. The most important cosmesis features identified by the sample can be used to direct future cosmesis design research.

CLINICAL RELEVANCE

The findings will enable the medical device industry to improve cosmesis design in the areas that are important to amputees. The findings also counter anecdotal opinions held by clinicians, providing an opportunity for them to evaluate any preconceptions they harbour and how this might influence their clinical work.

Illusory sense of human touch from a warm and soft artificial hand

To touch and be touched are vital to human development, well-being, and relationships. However, to those who have lost their arms and hands due to accident or war, touching becomes a serious concern that often leads to psychosocial issues and social stigma. In this paper, we demonstrate that the touch from a warm and soft rubber hand can be perceived by another person as if the touch were coming from a human hand. We describe a three-step process toward this goal. First, we made participants select artificial skin samples according to their preferred warmth and softness characteristics. At room temperature, the preferred warmth was found to be 28.4 °C at the skin surface of a soft silicone rubber material that has a Shore durometer value of 30 at the OO scale. Second, we developed a process to create a rubber hand replica of a human hand. To compare the skin softness of a human hand and artificial hands, a robotic indenter was employed to produce a softness map by recording the displacement data when constant indentation force of 1 N was applied to 780 data points on the palmar side of the hand. Results showed that an artificial hand with skeletal structure is as soft as a human hand. Lastly, the participants' arms were touched with human and artificial hands, but they were prevented from seeing the hand that touched them. Receiver operating characteristic curve analysis suggests that a warm and soft artificial hand can create an illusion that the touch is from a human hand. These findings open the possibilities for prosthetic and robotic hands that are life-like and are more socially acceptable.

Adjustments to amputation and an artificial limb in lower limb amputees

BACKGROUND

Positive adjustments to amputation and an artificial limb play important roles in the rehabilitation process.

OBJECTIVES

To study the different facets of adjustments to amputation and an artificial limb in lower limb amputees and to assess the possible role of different background and amputation-related factors that could potentially influence these adjustments.

STUDY DESIGN

Cross-sectional.

METHODS

Adult unilateral and non-congenital lower limb amputees (n = 368) met the inclusion/exclusion criteria. Face-to-face interviews were conducted using structured questionnaires including patient's background, amputation and the Trinity Amputation and Prosthesis Experience Scales.

RESULTS

Amputees were on average satisfied with the functioning of the prosthesis, moderately psychosocially adjusted and not restricted in performing functional and social activities, except for athletic activities. Age, employment, daily use of prosthesis and assistive device use were the most important factors associated with adjustments to amputation and prosthesis, followed by gender, co-morbidity and amputation level.

CONCLUSIONS

Evaluation of employment status and measures to curb unemployment through vocational rehabilitation and providing assistance for placement should be intrinsic to the rehabilitation programme. Future studies are envisaged to understand the underlying factors determining the extent of daily use of prosthesis and the reasons for the use of assistive devices by the amputees. Clinical relevance Proper appraisal and measures to alleviate employment and co-morbidity, related issues, routine evaluation of daily use of prosthesis and providing appropriate gait training might facilitate immediate and long-term adjustment.