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Yao AWR, Shapiro DR. An Examination of the Sport Commitment Model for Athletes With Physical Disabilities. Percept Mot Skills 2024; 131:971-988. [PMID: 38591440 DOI: 10.1177/00315125241244471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Sport commitment describes a psychological attachment to a sport that influences one's desire or resolve to continue involvement in it. Studying antecedents believed to influence long term commitment to sport among athletes with a disability will help ensure that participants gain those psychosocial and health outcomes from sport participation that benefit quality of life. Our purposes in this study were: (i) to examine the Sport Commitment Model (SCM) in terms of the magnitude of the contribution of antecedent factors (i.e., enjoyment, personal investment, involvement opportunities, social constraints, involvement alternatives) to sport commitment of athletes with disabilities; and (ii) to examine the model structure (i.e., original SCM, mediation, and direct/indirect model) that best reflects an understanding of the sport commitment antecedents for these athletes. A total of 157 adult athletes (M age = 34.87, SD = 11.78) with physical disabilities from both team and individual sports across the United States, Europe, and Asia completed the Sport Commitment Questionnaire. Data analyses indicated that sport involvement opportunities, followed by personal investment, were the strongest predictors of these athletes' sport commitments (R2 = .66). Based on the principle of parsimony, the original structural equation model (χ2 (215) = 384.95; RMSEA = .07; CFI = .95; SRMR = .06) was deemed better for understanding the mechanism of sport commitment than the mediation or direct/indirect models. We address implications of applying the SCM to athletes with disabilities, and we offer suggestions for future research.
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Affiliation(s)
- Andy Wei-Ru Yao
- Department of Kinesiology, San Francisco State University, San Francisco, CA, USA
| | - Deborah R Shapiro
- Department of Kinesiology and Health, Georgia State University, Atlanta, GA, USA
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Rosenblatt NJ, Major MJ, Manesh B, Schneider K, Miller SA. Validating a fear-of-falling-related activity avoidance scale in lower limb prosthesis users. PM R 2024; 16:462-473. [PMID: 37632836 PMCID: PMC10895070 DOI: 10.1002/pmrj.13063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 07/05/2023] [Accepted: 08/04/2023] [Indexed: 08/28/2023]
Abstract
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.
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Affiliation(s)
- Noah J Rosenblatt
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Matthew J Major
- Department of Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
- Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Bobak Manesh
- Center for Lower Extremity Ambulatory Research (CLEAR) at the Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Kristin Schneider
- Psychology Department, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
| | - Steven A Miller
- Psychology Department, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois, USA
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Berger AL, Nielsen AØ, Stie SB, Kristensen MT. Fatigue, fear of being mobilized and residual limb pain limit independent basic mobility and physiotherapy for patients early after major dysvascular lower extremity amputation: A prospective cohort study. Geriatr Gerontol Int 2024; 24:470-476. [PMID: 38597140 DOI: 10.1111/ggi.14874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/07/2024] [Accepted: 03/29/2024] [Indexed: 04/11/2024]
Abstract
AIM Early mobilization of patients with a major lower extremity amputation (LEA) is often a challenge because of lack of compliance. Therefore, we investigated factors limiting independent mobility and physiotherapy on the first day with physiotherapy (PTDay1) and the following 2 days after LEA. METHODS A total of 60 consecutive patients, mean age 73.7 years (SD 12.1 years), undergoing LEA were included over a period of 7 months. The Basic Amputee Mobility Score was used to assess basic mobility. Predefined limitations for not achieving independent mobility or not completing physiotherapy were residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea/vomiting, acute cognitive dysfunction or "other" factors reported on PTDay1 and the following 2 days after LEA. RESULTS Fatigue and fear of being mobilized were the most frequent limitations for not achieving independent mobility on PTDay1 and the following 2 days after LEA. Patients (n = 55) who were not independent in the Basic Amputee Mobility Score activity transferring from bed to chair on PTDay1 were limited by fatigue (44%) and fear of being mobilized (33%). A total of 21 patients did not complete planned physiotherapy on PTDay1, and were limited by fatigue (38%), residual limb pain (24%) and "other" factors (24%). CONCLUSION Fatigue and fear of being mobilized were the most frequent factors that limited independent mobility early after LEA. Fatigue, residual limb pain and "other" factors limited completion of physiotherapy. Geriatr Gerontol Int 2024; 24: 470-476.
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Affiliation(s)
- Anja Løve Berger
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Annie Østergaard Nielsen
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Sanne Busk Stie
- Physical Medicine and Rehabilitation Research-Copenhagen (PMR-C), Department of Physical and Occupational Therapy, Copenhagen University Hospital, Amager and Hvidovre, Hvidovre, Denmark
| | - Morten Tange Kristensen
- Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Asher M, Strike S, Diss C. Training program intervention to encourage physical activity for health in people with transtibial amputation: A feasibility study. Prosthet Orthot Int 2024; 48:122-127. [PMID: 37708344 DOI: 10.1097/pxr.0000000000000280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 07/20/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND People with transtibial amputation (PTTA) would benefit from increased physical activity levels (PAL) but generic programs developed to support increased PAL do not address the barriers which PTTA experience. OBJECTIVE To evaluate the effect of a 12-week training program, developed for PTTA, on their PAL. METHODS Ten PTTA participated in a 12-week training program, which involved one instructor-led supervised group session per week. The program incorporated balance, flexibility, cardiovascular endurance, strength, and agility, as well as educational elements. Personalized starting level and progression intensity were based on the instructor's assessment in the first training session. The effect of the intervention on PAL (self-report questionnaire and accelerometer), fitness, walking symmetry, and adverse effects was determined by analysis of variance before and after the intervention. RESULTS There was a significant increase in self-reported time in moderate-intensity activity and accelerometer-measured step count and time in movement after the program compared with baseline ( p = 0.02). The distance walked in the Six-Minute Walk Test (6MWT) ( p < 0.001), time to perform agility test ( p = 0.01), and lower-limb strength power ( p = 0.01) and endurance ( p = 0.01) were significantly greater after the program, and no adverse effects were identified. CONCLUSIONS This study demonstrated an intervention designed specifically for PTTA that can increase PAL.
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Affiliation(s)
- Miranda Asher
- Life Sciences Department, University of Roehampton, London, United Kingdom
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ElAbd R, Dow T, Jabori S, Alhalabi B, Lin SJ, Dowlatshahi S. Pain and Functional Outcomes following Targeted Muscle Reinnervation: A Systematic Review. Plast Reconstr Surg 2024; 153:494-508. [PMID: 37104493 DOI: 10.1097/prs.0000000000010598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
BACKGROUND It is estimated that by 2050, a total of 3.6 million patients will be living with an amputation in the United States. The objective of this systematic review is to evaluate the effect of targeted muscle reinnervation (TMR) on pain and physical functioning in amputees. METHODS A literature search was performed on PubMed, Embase, and MEDLINE up to November 28, 2021. Clinical studies assessing the outcomes of TMR (pain, prosthesis control, life quality, limb function, and disability) were included. RESULTS Thirty-nine articles were included. The total number of patients who underwent TMR was 449, and 716 were controls. Mean follow-up was 25 months. A total of 309 (66%) lower-limb and 159 (34%) upper-limb amputations took place in the TMR group, the most common being below-knee amputations (39%). The control group included a total of 557 (84%) lower-limb and 108 (16%) upper-limb amputations; the greatest proportion being below-knee amputations in this group as well (54%). Trauma was the most common indication for amputation. Phantom limb pain scores were lower by 10.2 points for intensity ( P = 0.01), 4.67 points for behavior ( P = 0.01), and 8.9 points for interference ( P = 0.09). Similarly, residual limb pain measures were lower for cases for intensity, behavior, and interference, but they failed to reach significance. Neuroma symptoms occurred less frequently, and functional and prosthesis control outcomes improved following TMR. CONCLUSION The literature evidence suggests that TMR is a promising therapy for improving pain, prosthesis use, and functional outcomes after limb amputation.
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Affiliation(s)
- Rawan ElAbd
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
- Division of Plastic and Reconstructive Surgery, Jaber AlAhmad AlSabah Hospital
| | - Todd Dow
- Division of Plastic and Reconstructive Surgery, Dalhousie University
| | - Sinan Jabori
- Division of Plastic and Reconstructive Surgery, University of Miami
| | - Becher Alhalabi
- From the Division of Plastic and Reconstructive Surgery, McGill University Health Centre
| | | | - Sammy Dowlatshahi
- Division of Plastic and Reconstructive Surgery
- Division of Hand Surgery, Department of Orthopedics, Beth Israel Deaconess Medical Center, Harvard Medical School
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6
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MacKay C, Hitzig SL, Mayo AL, Devlin M, Dilkas S, Marinho-Buzelli A, Lee L. Perceptions of physical activity among individuals with limb loss: A qualitative study. Prosthet Orthot Int 2024:00006479-990000000-00206. [PMID: 38170927 DOI: 10.1097/pxr.0000000000000313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 11/17/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Individuals with lower-limb amputations (LLA) often have deficits in balance and community walking ability. As a result, people with LLA are often sedentary. The aim of this study was to explore perceptions of physical activity from the perspective of people with LLA. METHODS A qualitative descriptive study situated within an interpretive research paradigm was conducted. Semistructured interviews were held by telephone or in person with adults living with major LLAs recruited from rehabilitation hospitals and advertisements on social media. Individuals were included if they were age 18 years and older with a major LLA. Purposive sampling was used to ensure variation by sex, cause, and level of amputation. RESULTS Thirty-three people with LLA participated (22 men/11 women; median age 63 years). The majority of individuals had a unilateral, transtibial amputation (∼50% dysvascular LLA). Three main themes were developed to characterize participants' perceptions of physical activity: (1) physical activity is perceived as important but can be challenging after amputation; (2) physical activity has physical and mental health benefits; and (3) physical activity is a means to maintain independence and engagement in community and social life. CONCLUSIONS Obtaining the perspectives of individuals with LLA about physical activity helps us understand how they think about it, what motivates them, and how we can optimize physical activity levels. Future research is needed to evaluate the effectiveness of interventions to enhance physical activity in this population.
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Affiliation(s)
- Crystal MacKay
- West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Physical Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Sander L Hitzig
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Occupational Science and Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Amanda L Mayo
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Steven Dilkas
- West Park Healthcare Centre, Toronto, Ontario, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Leanna Lee
- West Park Healthcare Centre, Toronto, Ontario, Canada
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Olsen SH, Aparicio EM, Jaeger PT, Howard DE. Exploring motivations to be active among amputees: a phenomenological approach to leisure time physical activity. Int J Qual Stud Health Well-being 2023; 18:2143053. [DOI: 10.1080/17482631.2022.2143053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Sara H. Olsen
- Department of Behavioral and Community Health, University of Maryland at College Park, College Park, Maryland, USA
| | - Elizabeth M. Aparicio
- Department of Behavioral and Community Health, University of Maryland at College Park, College Park, Maryland, USA
| | - Paul T. Jaeger
- College of Information Studies, University of Maryland at College Park, College Park, Maryland, USA
| | - Donna E. Howard
- Department of Behavioral and Community Health, University of Maryland at College Park, College Park, Maryland, USA
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Sidiropoulos A, Nelson L, Pruziner A, Glasberg JJ, Maikos J. Evaluation of Weight Shift and X-Factor During Golf Swing of Veterans With Lower Limb Loss. Am J Phys Med Rehabil 2023; 102:85-91. [PMID: 34864764 PMCID: PMC9163200 DOI: 10.1097/phm.0000000000001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the weight shift and X-Factor values of golfers with lower limb loss. DESIGN Veterans with above or below knee limb loss participated in a 3-day adaptive golf event hosted by the Department of Veterans Affairs. Professional golf instructors educated participants on proper golf swing mechanics, after which kinematic analysis of trunk rotation and kinetic analysis of weight transfer between the legs during the golf swing were evaluated using three-dimensional motion capture and force platforms. RESULTS Golfers with a trail leg amputation, regardless of level of limb loss, demonstrated superior weight shift, whereas golfers with lead limb amputation showed greater X-Factor values (all P < 0.05). Golfers with below knee limb loss demonstrated better weight shift strategies compared to those with above knee limb loss, regardless of which leg was amputated (i.e., lead or trail limb, all P < 0.05). CONCLUSIONS Sports rehabilitation programs should focus on increased weight bearing on the prosthetic limb to achieve appropriate weight shift and increased flexibility to increase X-Factor values. Participation in such programs can offer both physical and psychosocial benefits and may be a valid tool to increase the overall quality of life of veterans with lower limb loss.
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Affiliation(s)
- A.N. Sidiropoulos
- Department of Veterans Affairs, New York Harbor Healthcare
System, New York, USA
| | - L.M. Nelson
- Department of Veterans Affairs, National Veterans Sports
Programs and Special Events, Washington DC, USA
| | - A.L. Pruziner
- Department of Veterans Affairs, National Veterans Sports
Programs and Special Events, Washington DC, USA
| | - J. J. Glasberg
- Department of Veterans Affairs, New York Harbor Healthcare
System, New York, USA
| | - J.T. Maikos
- Department of Veterans Affairs, New York Harbor Healthcare
System, New York, USA
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Sidiropoulos AN, Glasberg JJ, Moore TE, Nelson LM, Maikos JT. Acute influence of an adaptive sporting event on quality of life in veterans with disabilities. PLoS One 2022; 17:e0277909. [PMID: 36441761 PMCID: PMC9704555 DOI: 10.1371/journal.pone.0277909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022] Open
Abstract
Veterans with disabilities can experience poor quality of life following military service due to the associated negative physical and psychological ramifications. However, participation in physical activities has shown to induce both physical and mental benefits and improve the quality of life of this population. Adaptive sports, an innovative approach to address the unique physical and psychosocial needs of veterans with disabilities, are becoming more widely used as a rehabilitation tool to improve the quality of life for these veterans. This study aimed to determine the acute influence of participation in a single-day, veteran-based, adaptive kayaking and sailing event on the perceived overall health, quality of life, and quality of social life of veterans with varying disabilities. It was hypothesized that all three categories and the sum score of quality of life would reflect a positive acute response after participation in the community-based physical activity event. Veterans responded to three quality of life-related questions using a 5-point Likert scale before and directly after participating in the event. Findings indicated that an adaptive sporting event can have an acute positive influence on the quality of life of veteran participants, with improvements observed in all three categories of perceived quality of life. Therefore, it is advantageous for the whole-health rehabilitation of veterans with disabilities for the Department of Veterans Affairs to continue to provide opportunities for veterans to participate in non-traditional, community-based activities.
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Affiliation(s)
- Alexis N. Sidiropoulos
- Department of Veterans Affairs, New York Harbor Healthcare System, New York, New York, United States of America
- * E-mail:
| | - Jonathan J. Glasberg
- Department of Veterans Affairs, New York Harbor Healthcare System, New York, New York, United States of America
| | - Timothy E. Moore
- Statistical Consulting Services, Center for Open Research Resources and Equipment, University of Connecticut, Storrs, CT, United States of America
| | - Leif M. Nelson
- Department of Veterans Affairs, National Veterans Sports Programs and Special Events, Washington, DC, United States of America
| | - Jason T. Maikos
- Department of Veterans Affairs, New York Harbor Healthcare System, New York, New York, United States of America
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Kowal M, Winiarski S, Gieysztor E, Kołcz A, Dumas I, Paprocka-Borowicz M. Symmetry Function: The Differences between Active and Non-Active Above-the-Knee Amputees. SENSORS (BASEL, SWITZERLAND) 2022; 22:5933. [PMID: 36015694 PMCID: PMC9413346 DOI: 10.3390/s22165933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/03/2022] [Accepted: 08/05/2022] [Indexed: 06/15/2023]
Abstract
The number of patients with unilateral above-knee amputation (AKA) due to non-vascular causes has remained stable over the years, at 0.92 per 1000 people per year. Post-AKA individuals are at risk of experiencing a higher incidence of chronic pain. Post rehabilitation, it is estimated that between 16−62% of patients with musculoskeletal disabilities fail to meet the minimum criteria for physical activity in comparison to a healthy population. The current study included 14 participants (11 men and 3 women) with a mean age of 46.1 ± 14.2 years, body height of 1.76 ± 0.09 m, and weight of 79.6 ± 18.3 kg, who were all post-unilateral above-the-knee amputees. Patients in the study were divided into two groups: active (AC) and non-active (NAC). This study was conducted in a certified Laboratory of Biomechanical Analysis using the BTS Smart-E system (BTS Bioengineering). In order to investigate the symmetry function (SF) of gait, the only measurements included were the time series assessment of gait variables defining pelvic and lower limb joint motion and ground reaction forces (GRF). Both groups had an asymmetrical gait pattern with a different magnitude and relative position in the gait cycle, which was revealed by SF. The differences in terms of median, minimum, and maximum were statistically significant (p < 0.05), with SF ranging from −25 to 24% for the AC group and from 43 to 77% (59% on average) for the NAC group. The AC’s pattern was more symmetrical compared to the NAC’s pattern, especially in the case of pelvic and hip joint motion.
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Affiliation(s)
- Mateusz Kowal
- Department of Physiotherapy, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Sławomir Winiarski
- Department of Biomechanics, University School of Physical Education in Wroclaw, 51-612 Wroclaw, Poland
| | - Ewa Gieysztor
- Department of Physiotherapy, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Anna Kołcz
- Department of Physiotherapy, Wroclaw Medical University, 50-367 Wroclaw, Poland
- Ergonomics and Biomedical Monitoring Laboratory, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Ilias Dumas
- Department of Physiotherapy, Wroclaw Medical University, 50-367 Wroclaw, Poland
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Seth M, Pohlig RT, Hicks GE, Sions JM. Clinical mobility metrics estimate and characterize physical activity following lower-limb amputation. BMC Sports Sci Med Rehabil 2022; 14:124. [PMID: 35799260 PMCID: PMC9264684 DOI: 10.1186/s13102-022-00518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/01/2022] [Indexed: 12/04/2022]
Abstract
Background Regular physical activity following a lower-limb amputation is essential for maintaining health and a high quality of life. Most adults with a lower-limb amputation, however, participate in insufficient daily physical activity, and thus, are predisposed to poor health outcomes. Estimating physical activity after lower-limb amputation via common mobility metrics may aid in clinical decisions regarding treatment prioritization and prosthesis prescription. The objectives of this study were (a) to examine associations between daily physical activity and patient-reported and performance-based mobility metrics among adults with lower-limb amputation, and (b) to determine whether patient-reported and performance-based mobility metrics can distinguish between physical activity status [i.e., sedentary (< 5000 steps/day) or non-sedentary (≥ 5000 steps/day)] of adults with lower-limb amputation. Methods A cross-sectional study involving 35 adults with a unilateral transtibial (N = 23; 63.0 ± 10.4 years) or transfemoral amputation (N = 12; 58.8 ± 9.5 years) was conducted. Participants completed patient-reported (Prosthesis Evaluation Questionnaire-Mobility Subscale) and performance-based mobility metrics (L-Test, 10-m Walk Test, 6-min Walk Test). Physical activity, i.e., average steps/day, was measured with an accelerometer. Results Patient-reported and performance-based mobility metrics were associated with daily physical activity (p < 0.050). Prosthesis Evaluation Questionnaire-Mobility Subscale scores, L-Test time, 10-m Walk Test speed and 6-min Walk Test distance independently explained 11.3%, 31.8%, 37.6% and 30.7% of the total variance in physical activity. Receiver operating characteristic curves revealed patient-reported and performance-based mobility metrics significantly distinguish between physical activity status, i.e., sedentary (< 5000 steps/day) versus non-sedentary (≥ 5000 steps/day). Preliminary cut-points for mobility metrics to classify physical activity status were determined. Conclusions Following a lower-limb amputation, patient-reported and performance-based mobility metrics may estimate daily physical activity, thereby aiding clinical decisions regarding treatment prioritization as well as prosthesis selection.
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Affiliation(s)
- Mayank Seth
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, 540 South College Avenue, Suite 210JJ, Newark, DE, 19713, USA
| | | | - Gregory Evan Hicks
- Delaware Spine Studies, Department of Physical Therapy, University of Delaware, Newark, DE, USA
| | - Jaclyn Megan Sions
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, 540 South College Avenue, Suite 210JJ, Newark, DE, 19713, USA. .,Delaware Spine Studies, Department of Physical Therapy, University of Delaware, Newark, DE, USA.
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12
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Lee DJ, Miller CA, Gambale A, Nisani M, Marra M, Leung ER, Chillianis D, Rodgers M. Survey of physical activity in persons with limb loss during the COVID-19 pandemic in the United States. Prosthet Orthot Int 2022; 46:220-226. [PMID: 35121718 DOI: 10.1097/pxr.0000000000000093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Physical activity has been shown to be fundamental in the prevention of numerous diseases and disorders. Achieving and maintaining physical activity levels can be particularly challenging in those with impairments, such as those experiencing a lower limb amputation. To slow the spread of the virus, COVID-19 lockdown mandates imposed by the US state governments may have inadvertent consequences on physical activity levels of those dependent on specific forms of exercise. Understanding how physical activity levels may have affected persons with limb loss can inform intervention strategies for this vulnerable population. OBJECTIVES Examine the effects of the COVID-19 pandemic on physical activity levels in persons with limb loss. STUDY DESIGN Mixed-method design. METHODS A 20-item logic web-based survey and semistructured interviews were administered to individuals who were 18 years or older, spoke English, and had a history of lower limb loss. Quantitative data were analyzed using SPSS v25, whereas qualitative data were analyzed using constant comparison to formulate themes. RESULTS There were a significant effect on the amount of physical activity minutes performed per day, a negative effect on the ability to exercise and participate in societal engagements, and a series of barriers to performing physical activity because of the pandemic. CONCLUSION Physical activity was reduced significantly in persons with limb loss during the COVID-19 pandemic. A combination of health concerns, fitness center closures, and social distancing mandates were the primary drivers behind the decrease in activity.
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Affiliation(s)
| | - Carol A Miller
- Philadelphia College of Osteopathic Medicine, Suwanee, GA
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Seth M, Pohlig RT, Beisheim-Ryan EH, Stauffer SJ, Horne JR, Hicks GE, Sions JM. Residual and sound limb hip strength distinguish between sedentary and nonsedentary adults with transtibial amputation. Int J Rehabil Res 2022; 45:137-145. [PMID: 35131977 PMCID: PMC9086098 DOI: 10.1097/mrr.0000000000000520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Following a transtibial amputation (TTA), physical activity has known benefits for health and quality of life. Adults post-TTA, however, demonstrate reduced physical activity, predisposing them to adverse health outcomes. Identifying adults at the risk of sedentarism post-TTA via commonly used, objective clinical measures may enhance clinical decisions, including prosthesis prescription. The study's purpose was to determine whether residual and sound limb hip strength distinguishes between sedentary and nonsedentary adults post-TTA. A secondary analysis of a cross-sectional dataset (n = 44) was conducted. Participant residual and sound limb hip flexion, extension, abduction and adduction strength were assessed via handheld dynamometry. Physical activity was monitored for 7 days and participants were classified as sedentary (<5000 steps/day; n = 13) or nonsedentary (≥5000 steps/day; n = 31). Receiver operating curves revealed that residual and sound limb hip extension, abduction and adduction strength distinguished between sedentary and nonsedentary adults post-TTA (P < 0.050). Preliminary cut-points for hip strength measures to classify adults at the risk of sedentarism were determined. A hip strength composite score (0-6) estimates a 2.2× increased odds of being sedentary with each additional hip strength deficit. Post-TTA, residual and sound limb hip strength can help identify adults at risk of sedentarism to aid clinical decision making, including prosthesis prescription.
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Affiliation(s)
- Mayank Seth
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
| | - Ryan T Pohlig
- Biostatistics Core, University of Delaware, Newark, DE, USA
| | - Emma H Beisheim-Ryan
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
| | - Samantha J Stauffer
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
- Independence Prosthetics-Orthotics, Inc., Newark, DE, USA
| | - John R Horne
- Independence Prosthetics-Orthotics, Inc., Newark, DE, USA
| | - Gregory E Hicks
- Delaware Spine Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
| | - Jaclyn Megan Sions
- Delaware Limb Loss Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
- Delaware Spine Studies, Department of Physical Therapy, University of Delaware, Newark DE, USA
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Lee LS, Hitzig SL, Mayo A, Devlin M, Dilkas S, MacKay C. Factors influencing physical activity among individuals with lower limb amputations: a qualitative study. Disabil Rehabil 2022; 45:1461-1470. [PMID: 35452590 DOI: 10.1080/09638288.2022.2065539] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE The purpose of this study was to explore the barriers and facilitators to physical activity from multiple stakeholder perspectives including individuals with LLA and health professionals. MATERIALS AND METHODS A qualitative descriptive study situated within an interpretive research paradigm was conducted. Semi-structured interviews were held with individuals with LLA recruited from rehabilitation hospitals in a metropolitan city in Canada. Health professionals with experience in amputation care were recruited from across Canada. Data were analysed using codebook thematic analysis. RESULTS Thirty-three individuals with LLA and eighteen health professionals participated. Six themes were generated which represent the perceived barriers and facilitators to physical activity. Themes including Informal and Formal Supports, Availability of and Access to Community Resources, and Fit and Function of the Prosthesis were perceived by many individuals as facilitators, while acting as a barrier for others depending on an individual's circumstances. CONCLUSIONS These findings provide us with a basis of understanding from which we can begin addressing barriers to physical activity for individuals with LLA, in support of developing patient-centred interventions and physical activity programs for this population. IMPLICATIONS FOR REHABILITATIONIrrespective of amputation etiology, individuals who have lower limb amputation experience several barriers to engaging in physical activity.Many system-level barriers to physical activity exist for people with lower limb amputation, which include lack of availability and access to community resources and specialised prostheses conducive to physical activity participation.A participatory approach engaging both patients and rehabilitation professionals can address the patient-provider discordance with respect to a patient's motivation and attitude towards physical activity participation by creating a supportive environment conducive to behaviour change.The development of future, patient-centered interventions, and physical activity programs for individuals with lower limb amputation must consider fear of falling as a prominent barrier to physical activity and devise potential strategies to address this barrier, by setting realistic and actionable goals.
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Affiliation(s)
- Leanna S Lee
- West Park Healthcare Centre, Toronto, Canada.,University Health Network/Toronto Rehabilitation Institute, Toronto, Canada
| | - Sander L Hitzig
- Evaluative Clinical Sciences, St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Canada
| | - Amanda Mayo
- Sunnybrook Health Sciences Centre, Toronto, Canada
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Jamieson A, Murray L, Stankovic L, Stankovic V, Buis A. Human Activity Recognition of Individuals with Lower Limb Amputation in Free-Living Conditions: A Pilot Study. SENSORS 2021; 21:s21248377. [PMID: 34960463 PMCID: PMC8704297 DOI: 10.3390/s21248377] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 12/09/2021] [Accepted: 12/13/2021] [Indexed: 12/21/2022]
Abstract
This pilot study aimed to investigate the implementation of supervised classifiers and a neural network for the recognition of activities carried out by Individuals with Lower Limb Amputation (ILLAs), as well as individuals without gait impairment, in free living conditions. Eight individuals with no gait impairments and four ILLAs wore a thigh-based accelerometer and walked on an improvised route in the vicinity of their homes across a variety of terrains. Various machine learning classifiers were trained and tested for recognition of walking activities. Additional investigations were made regarding the detail of the activity label versus classifier accuracy and whether the classifiers were capable of being trained exclusively on non-impaired individuals’ data and could recognize physical activities carried out by ILLAs. At a basic level of label detail, Support Vector Machines (SVM) and Long-Short Term Memory (LSTM) networks were able to acquire 77–78% mean classification accuracy, which fell with increased label detail. Classifiers trained on individuals without gait impairment could not recognize activities carried out by ILLAs. This investigation presents the groundwork for a HAR system capable of recognizing a variety of walking activities, both for individuals with no gait impairments and ILLAs.
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Affiliation(s)
- Alexander Jamieson
- Wolfson Centre, Department of Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK; (A.J.); (L.M.)
| | - Laura Murray
- Wolfson Centre, Department of Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK; (A.J.); (L.M.)
| | - Lina Stankovic
- Department of Electronic and Electrical Engineering, University of Strathclyde, Glasgow G1 1XW, UK; (L.S.); (V.S.)
| | - Vladimir Stankovic
- Department of Electronic and Electrical Engineering, University of Strathclyde, Glasgow G1 1XW, UK; (L.S.); (V.S.)
| | - Arjan Buis
- Wolfson Centre, Department of Biomedical Engineering, University of Strathclyde, Glasgow G4 0NW, UK; (A.J.); (L.M.)
- Correspondence:
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Rosenblatt NJ, Stachowiak A, Reddin C. Prosthetic Disuse Leads to Lower Balance Confidence in a Long-Term User of a Transtibial Prosthesis. Adv Wound Care (New Rochelle) 2021; 10:529-533. [PMID: 34232743 PMCID: PMC8260888 DOI: 10.1089/wound.2019.1086] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/29/2019] [Indexed: 11/12/2022] Open
Abstract
Residual limb wounds or ulcers are one of the most frequent skin problems reported by lower extremity prosthesis users. Healing often requires prosthesis disuse, which can logically impair physical functioning. However, there are limited data available to support this idea. We report the impact of prosthesis disuse by presenting assessments of balance, gait, physical activity, and balance confidence obtained on a case subject before experiencing a wound and following reintroduction to a well-fit prosthesis after wound-related prosthesis disuse. The case subject was a 76-year-old male who suffered a unilateral, transtibial amputation due to synovial sarcoma 13 years before. After presenting with a history of pain in the area of a chronic skin plaque, he received a punch biopsy, which resulted in 4 weeks of prosthesis disuse followed by 12 weeks of limited use before a final well-fitting socket was received. The following data were collected 24 weeks before the biopsy and 4 weeks after receiving the final well-fitting socket: Berg Balance Scale, L-test of walking, quantitative gait analysis, Activity-specific Balance Confidence Scale, and 1 week of community-based activity. Balance confidence decreased nearly 19%, walking speed decreased by 12%, and steps/day decreased by 19% following ∼4 months of prosthesis disuse/limited use; functional measures were not impacted. Lower balance confidence is not trivial as it can lead to activity avoidance and increased fall risk. Interventions to target balance confidence changes following prosthesis disuses may be important to minimize the impact of disuse on physical and mental well-being.
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Affiliation(s)
- Noah J. Rosenblatt
- Dr. William M. Scholl College of Podiatric Medicine's Center for Lower Extremity Ambulatory Research (CLEAR), Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Aaron Stachowiak
- Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
| | - Christopher Reddin
- Captain James A. Lovell Federal Health Care Center, North Chicago, Illinois
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Physical Activity Among People With Lower Limb Amputation in Brazil. J Phys Act Health 2021; 18:1269-1276. [PMID: 34433702 DOI: 10.1123/jpah.2020-0841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 06/09/2021] [Accepted: 06/10/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Limb loss affects quality of life, well-being, and autonomy. The World Health Organization has launched a global action plan to reduce physical inactivity and presented recommendations of physical activity for people living with disability. Knowledge of the characteristics of people with lower limb amputation regarding physical activity is important. Thus, the aim of this study was to identify the quantity and type of physical activity done by people with lower limb amputation. METHODS The sample (N = 149) included adults aged 53.08 (17.24) years old with lower limb loss. Data collection was performed through the application of a sociodemographic, behavioral, and clinical data sheet and the Brazilian version of the Physical Activity Scale for Individuals with Physical Disabilities. RESULTS The total Physical Activity Scale for Individuals with Physical Disabilities score was between 0 and 65.79 metabolic equivalents of task per hour per day, which suggests low practice of physical activities. The most frequently practiced activities (79.9%) were those that involved stationary behavior. Women carried out more domestic activities, and subjects who used lower limb prosthesis and those with traumatic amputation reported higher practice of physical activity. CONCLUSIONS People living with lower limb amputation, from different regions of Brazil, have low levels of physical activity and mainly carry out activities of stationary behavior.
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Gülhane lower extremity amputee rehabilitation protocol: A nationwide, 123-year experience. Turk J Phys Med Rehabil 2020; 66:373-382. [PMID: 33364556 PMCID: PMC7756831 DOI: 10.5606/tftrd.2020.7637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 11/02/2020] [Indexed: 11/21/2022] Open
Abstract
Amputation, one of the oldest known surgical procedures, causes many physical, mental and sociological problems. With its 123 years of experience, Gülhane has a special knowledge and experience, particularly in amputation. The main purpose of this protocol is to reveal the steps to be followed in individuals with lower extremity amputation. In this way, it is aimed to create a resource which can be used by our colleagues who have difficulties in using an appropriate approach due to the lack of experience.
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The Role of Interprofessional Teams in the Biopsychosocial Management of Limb Loss. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00293-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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20
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Sederberg M, Tarkhan A, Ray LS, Lee ES, Lin C. Physical Activity in Adults With an Amputation as Assessed With a Self-Reported Exercise Vital Sign. PM R 2020; 12:861-869. [PMID: 31990141 DOI: 10.1002/pmrj.12333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 01/17/2020] [Indexed: 11/06/2022]
Abstract
BACKGROUND Physical activity (PA) is important for the prevention and treatment of numerous chronic medical conditions. Individuals with a limb amputation face unique challenges for staying physically active. There are few studies evaluating PA of civilians with amputation in the United States. OBJECTIVE To evaluate self-reported PA in persons with an amputation in the outpatient setting using a standardized exercise vital sign (EVS) and correlate PA with demographic information, amputation characteristics, and disease burden. DESIGN Cross-sectional observational study. SETTING Outpatient rehabilitation clinic at a tertiary care institution. INTERVENTIONS N/A. PARTICIPANTS Two hundred twenty-nine patients with limb amputation. MAIN OUTCOME MEASUREMENTS EVS (self-reported weekly participation in moderate to vigorous intensity exercise), disease burden using a modified Charlson Comorbidity Index (CCI), possession of a prosthetic limb, amputation level, time from amputation, body mass index (BMI), gender, race, and age. RESULTS A total of 28.8% of patients with limb amputation self-reported exercising at or above 150 min/wk as recommended by the United States Department of Health and Human Services (HHS); 31.8% of patients with transfemoral amputations, 27.8% with transtibial amputations, and 36% with upper extremity amputations reported exercising the recommended amount. Those with a prosthesis exercised 0.91 h/wk more than those without a prosthesis (95% CI 0.01, 1.8, P = .047), and female patients exercised 1.09 h/wk less than male patients (95% confidence interval [CI] 1.69-0.49, P < .001). Increasing age (P = .045), CCI (P = .006), and BMI (P = .005) all had a small but significant correlation with lower EVS. There was no statistically significant correlation between EVS and amputation level, race, or time from amputation. CONCLUSIONS Less than one-third of patients with an amputation meet HHS recommendations for aerobic exercise. Male patients, those with a prosthesis, lower CCI, lower BMI, and younger age reported higher PA rates. Assessing EVS can help clinicians to identify patients with amputation that are not sufficiently active and may benefit from PA counseling and prescription.
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Affiliation(s)
- Mark Sederberg
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | | | - Lisa S Ray
- University of Washington Population Health Analytics, Seattle, WA
| | - E Sally Lee
- University of Washington Population Health Analytics, Seattle, WA
| | - Cindy Lin
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.,The Sports Institute at UW Medicine, Seattle, WA
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21
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Poonsiri J, Dekker R, Dijkstra PU, Nutchamlong Y, Dismanopnarong C, Puttipaisan C, Suakonburi S, Pimchan P, Hijmans JM, Geertzen JHB. Cycling of people with a lower limb amputation in Thailand. PLoS One 2019; 14:e0220649. [PMID: 31374098 PMCID: PMC6677311 DOI: 10.1371/journal.pone.0220649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 07/19/2019] [Indexed: 11/18/2022] Open
Abstract
AIM To investigate cycling participation and barriers, and facilitators in adults with a lower limb amputation in Thailand. METHOD Questionnaires were given to 424 adults with uni/bilateral lower limb amputation from midfoot to hip disarticulation level at five public hospitals in Bangkok and prosthetic mobile units in Thailand. Participant characteristics were summarized using descriptive statistics. Variables associated with cycling (p<0.1) were entered in a logistic regression model. RESULTS Participants who cycled (46.7%, N = 197), mostly used their walking prostheses (91.9%, n = 188). Of cyclists, 92.4% had cycled before the amputation. Cyclists started cycling after the amputation by themselves (86.7%) mostly in order to increase/maintain health (67.0%). Most cyclists cycled on quiet roads. The most frequent destination was shops/market (64.1%). More facilitators were reported than barriers. Most reported barriers were related to health problems and negative attitudes toward cycling. Most reported facilitators were related to perceived health benefits and positive attitude toward cycling. The likelihood of cycling after the amputation increased in people who cycled before the amputation, were amputated lower than the knee, used a prosthetic foot with axis/axes, were amputated due to trauma, had income higher than 415 euro/month, and who reported a higher numbers of facilitators. CONCLUSION After a lower limb amputation, nearly half of people cycled. People with a below knee amputation due to trauma with prior cycling experience and higher income tended to cycle after the amputation. People who perceived more facilitators were more likely to cycle. Although cyclists could use a walking prosthesis to cycle, a prosthetic foot with a greater range of motion than the SACH increased the cycling likelihood.
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Affiliation(s)
- Jutamanee Poonsiri
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
- Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rienk Dekker
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Pieter U. Dijkstra
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of Oral and Maxillofacial Surgery, Groningen, The Netherlands
| | - Yasmin Nutchamlong
- Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chanapak Dismanopnarong
- Prosthetic and Orthotic Unit, Orthopaedic Department, Veterans General Hospital, Bangkok, Thailand
| | - Chiraphan Puttipaisan
- Rehabilitation Medicine Department, Prosthetic and Orthotic Unit, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Pensupa Pimchan
- Prosthetic and Orthotic Unit, Orthopaedic Department, Phramongkutklao Hospital, Bangkok, Thailand
| | - Juha M. Hijmans
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Jan H. B. Geertzen
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
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LaVela SL, Etingen B, Miskevics S, Cella D. Use of PROMIS-29® in US Veterans: Diagnostic Concordance and Domain Comparisons with the General Population. J Gen Intern Med 2019; 34:1452-1458. [PMID: 31144276 PMCID: PMC6667584 DOI: 10.1007/s11606-019-05011-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 12/21/2018] [Accepted: 02/26/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND PROMIS® items have not been widely or systematically used within the Veterans Health Administration (VA). OBJECTIVE To examine the concordance of PROMIS-29® scores and medical record diagnosis in US Veterans and to compare Veteran scores relative to US population norms. DESIGN/PARTICIPANTS Cross-sectional multi-site survey of Veterans (n = 3221) provided sociodemographic and PROMIS-29® domain data. Electronic medical records provided health condition (depression, anxiety, sleep disorders, pain disorders) diagnosis data. MAIN MEASURES For each domain, we calculated PROMIS® standardized T scores and used t tests to compare PROMIS® scores for Veterans diagnosed with each targeted health condition vs. those without that documented clinical diagnosis and compare mean Veterans' PROMIS-29® with US adult population norms. KEY RESULTS Veterans with (vs. without) a depression diagnosis reported significantly higher PROMIS® depression scores (60.3 vs. 49.6, p < .0001); those with an anxiety diagnosis (vs. without) reported higher average PROMIS® anxiety scores (62.7 vs. 50.9, p < .0001). Veterans with (vs. without) a pain disorder reported higher pain interference (65.3 vs. 57.7, p < .0001) and pain intensity (6.4 vs. 4.4, p < .0001). Veterans with (vs. without) a sleep disorder reported higher sleep disturbance (55.8 vs. 51.2, p < .0001) and fatigue (57.5 vs. 51.8, p < .0001) PROMIS® scores. Compared with the general population norms, Veterans scored worse across all PROMIS-29® domains. CONCLUSIONS We found that PROMIS-29® domains are selectively sensitive to expected differences between clinically-defined groups, suggesting their appropriateness as indicators of condition symptomology among Veterans. Notably, Veterans scored worse across all PROMIS-29(R) domains compared with population norms. Taken collectively, our findings suggest that PROMIS-29® may be a useful tool for VA providers to assess patient's physical and mental health, and because PROMIS® items are normed to the general population, this offers a way to compare the health of Veterans with the adult population at large and identify disparate areas for intervention.
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Affiliation(s)
- Sherri L LaVela
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines Jr. VA Hospital, Hines, IL, USA.
- Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Bella Etingen
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Scott Miskevics
- Department of Veterans Affairs, Center of Innovation for Complex Chronic Healthcare, Health Services Research & Development, Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - David Cella
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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Batten H, Lamont R, Kuys S, McPhail S, Mandrusiak A. What are the barriers and enablers that people with a lower limb amputation experience when walking in the community? Disabil Rehabil 2019; 42:3481-3487. [DOI: 10.1080/09638288.2019.1597177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Heather Batten
- Department of Physiotherapy, Princess Alexandra Hospital, Woolloongabba, Australia
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Robyn Lamont
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
| | - Suzanne Kuys
- School of Physiotherapy Faculty of Health Sciences, Australian Catholic University, Banyo, Australia
| | - Steven McPhail
- Centre for Functioning and Health Research, Buranda, Australia
- Institute of Health and Biomedical Innovation and School of Public Health & Social Work, Queensland University of Technology, Brisbane, Australia
| | - Allison Mandrusiak
- School of Health & Rehabilitation Sciences, The University of Queensland, Brisbane, Australia
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Correlation Between Functional Ability and Physical Activity in Individuals With Transtibial Amputations: A Cross-Sectional Study. Cardiopulm Phys Ther J 2019. [DOI: 10.1097/cpt.0000000000000091] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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25
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Sherman K, Roberts A, Murray K, Deans S, Jarvis H. Daily step count of British military males with bilateral lower limb amputations: A comparison of in-patient rehabilitation with the consecutive leave period between admissions. Prosthet Orthot Int 2019; 43:188-195. [PMID: 30375269 DOI: 10.1177/0309364618806058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND: Reduced function and health in individuals with lower limb amputation is well documented. Step count measurement could facilitate rehabilitation and help monitor functional health outcomes. OBJECTIVES: To determine whether mean daily step count changed between in-patient rehabilitation and consecutive leave periods. STUDY DESIGN: Observational study. METHODS: Nine individuals with bilateral traumatic amputations attending rehabilitation at the Defence Medical Rehabilitation Centre during a 4-month period were invited to participate in the study (two bilateral transfemoral, two bilateral transfemoral/knee disarticulation, two transfemoral/transtibial, one bilateral transfemoral plus transradial, one bilateral transfemoral plus transhumeral and one transfemoral/transtibial/transradial). Prostheses worn by each participant were fitted with an activity monitor (LAM2TM; PAL Technologies Ltd, Glasgow). Mean daily step count was analysed for each participant following 2 weeks in-patient rehabilitation and consecutive 2 weeks away from rehabilitation. RESULTS: Nine participants completed the study (time since injury: 19 ± 7 months, age: 26 ± 6 years). Mean daily step count significantly decreased from 2258 ± 192 during in-patient rehabilitation to 1387 ± 363 at home ( p < 0.01). CONCLUSION: The step count decreased when away from rehabilitation, confirming the hypothesis that the mean daily step count would change between in-patient rehabilitation and consecutive leave period. CLINICAL RELEVANCE These data provide an indication of the step count achievable by young, military male personnel with bilateral lower limb amputations and highlights differences between intensive in-patient rehabilitation and consecutive leave periods. It is suggested that further investigation and support of clinical monitoring could facilitate rehabilitation tailored to the individual.
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Affiliation(s)
- Kate Sherman
- 1 Defence Medical Rehabilitation Centre Stanford Hall, Loughborough, LE12 5BL, UK
| | - Andrew Roberts
- 1 Defence Medical Rehabilitation Centre Stanford Hall, Loughborough, LE12 5BL, UK
| | | | | | - Hannah Jarvis
- 3 Department of Exercise and Sport Science, Manchester Metropolitan University, Crewe, UK
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Poonsiri J, Dekker R, Dijkstra PU, Hijmans JM, Geertzen JHB. Bicycling participation in people with a lower limb amputation: a scoping review. BMC Musculoskelet Disord 2018; 19:398. [PMID: 30424748 PMCID: PMC6234608 DOI: 10.1186/s12891-018-2313-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 10/22/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND To review literature on bicycling participation, as well as facilitators and barriers for bicycling in people with a lower limb amputation (LLA). METHODS Peer-reviewed, primary, full text, studies about bicycling in people with a LLA from midfoot level to hemipelvectomy were searched in Pubmed, Embase, Cinahl, Cochrane library, and Sportdiscus. No language or publication date restrictions were applied. Included full-text studies were assessed for methodological quality using the Effective Public Health Practice Project tool. Data were extracted, synthesized and reported following Preferred Reporting Items for Systematic Review. RESULTS In total, 3144 papers were identified and 14 studies were included. The methodological quality of 13 studies was weak and 1 was moderate. Bicycling participation ranged from 4 to 48%. A shorter time span after LLA and a distal amputation were associated with a higher bicycling participation rate particularly for transportation. In people with a transtibial amputation, a correct prosthetic foot or crank length can reduce pedalling asymmetry during high-intensity bicycling. People with limitations in knee range of motion or skin abrasion can use a hinged crank arm or a low profile prosthetic socket respectively. CONCLUSION People with a LLA bicycled for transportation, recreation, sport and physical activity. Adaptation of prosthetic socket, pylon and foot as well as bicycle crank can affect pedalling work and force, range of motion, and aerodynamic drag. Because the suggestions from this review were drawn from evidences mostly associated to competition, prosthetists should carefully adapt the existing knowledge to clients who are recreational bicyclists.
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Affiliation(s)
- Jutamanee Poonsiri
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, CB41, PO Box 30001, 9700 RB Groningen, The Netherlands
- Sirindhorn School of Prosthetics and Orthotics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Rienk Dekker
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, CB41, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Pieter U. Dijkstra
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, CB41, PO Box 30001, 9700 RB Groningen, The Netherlands
- Department of Oral and Maxillofacial Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Juha M. Hijmans
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, CB41, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Jan H. B. Geertzen
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, CB41, PO Box 30001, 9700 RB Groningen, The Netherlands
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Littman AJ, Haselkorn JK, Arterburn DE, Boyko EJ. Pilot randomized trial of a telephone-delivered physical activity and weight management intervention for individuals with lower extremity amputation. Disabil Health J 2018; 12:43-50. [PMID: 30115584 DOI: 10.1016/j.dhjo.2018.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 06/27/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Obesity and inactivity are common and burdensome for people with lower extremity amputation (LEA). The extent to which home-based physical activity/weight management programs are effective and safe for people with LEA is unknown. Translating effective interventions for understudied disability groups is needed. OBJECTIVE To test the feasibility, acceptability, and safety of a weight management and physical activity intervention and obtain preliminary efficacy estimates for changes in weight, body composition, and physical functioning. METHODS Eligibility criteria included: LEA ≥1 year prior, 18-69 years of age, overweight or obese and living in the Seattle area. The intervention arm received self-monitoring tools (e.g., pedometer, scale) and written materials, a single exercise counseling home visit by a physical therapist, and up to 11 telephone calls from a health coach over 20 weeks that involved motivational interviewing to set specific, attainable, and measurable goals. The self-directed control group received the same tools and materials but no home visit or coaching calls. RESULTS Nineteen individuals consented to participate, 15 were randomized (mean age = 56, 73% male, 80% transtibial amputation) and 11 completed 20-week follow-up assessments. The intervention was acceptable and safe. Coached participants had greater decreases in waist circumference (mean difference between groups over 20 weeks, baseline values carried forward: -4.3 cm, 95% CI -8.2, -0.4, p = 0.03) and fat mass (-2.1 kg, 95% CI -3.8, -0.4, p = 0.02). CONCLUSIONS The home-based intervention was promising in terms of efficacy, safety and acceptability. Inclusion of multiple trial centers and increased use of technology may facilitate recruitment and retention.
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Affiliation(s)
- Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States; Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States; Department of Epidemiology, University of Washington, Seattle, WA, United States.
| | - Jodie K Haselkorn
- Department of Epidemiology, University of Washington, Seattle, WA, United States; Multiple Sclerosis Center of Excellence West, VA Puget Sound Health Care System, United States; Department of Rehabilitation, University of Washington, Seattle, WA, United States.
| | - David E Arterburn
- Kaiser Permanente Washington Research Institute, Kaiser Permanente Washington, Seattle, WA, United States; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, United States.
| | - Edward J Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, United States; Department of Epidemiology, University of Washington, Seattle, WA, United States; Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, United States.
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Abstract
ABSTRACTThe impact of losing a limb in military service extends well beyond initial recovery and rehabilitation, with long-term consequences and challenges requiring health-care commitments across the lifecourse. This paper presents a systematic review of the current state of knowledge regarding the long-term impact of ageing and limb-loss in military veterans. Key databases were systematically searched including: ASSIA, CINAHL, Cochrane Library, Medline, Web of Science, PsycArticles/PsychInfo, ProQuest Psychology and ProQuest Sociology Journals, and SPORTSDiscus. Empirical studies which focused on the long-term impact of limb-loss and/or health-care requirements in veterans were included. The search process revealed 30 papers relevant for inclusion. These papers focused broadly on four themes: (a) long-term health outcomes, prosthetics use and quality of life; (b) long-term psycho-social adaptation and coping with limb-loss; (c) disability and identity; and (d) estimating the long-term costs of care and prosthetic provision. Findings present a compelling case for ensuring the long-term care needs and costs of rehabilitation for older limbless veterans are met. A dearth of information on the lived experience of limb-loss and the needs of veterans’ families calls for further research to address these important issues.
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Langford J, Dillon MP, Granger CL, Barr C. Physical activity participation amongst individuals with lower limb amputation. Disabil Rehabil 2018; 41:1063-1070. [DOI: 10.1080/09638288.2017.1422031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Jennifer Langford
- Physiotherapy Department, Royal Melbourne Hospital, Parkville, Australia
| | - Michael P. Dillon
- Department of Rehabilitation, Nutrition and Sport, La Trobe University, Bundoora, Australia
| | | | - Chris Barr
- Department of Rehabilitation and Aged Care, Flinders University, Adelaide, Australia
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Pepin M, Akers K, Galen S. Physical activity in individuals with lower extremity amputations: a narrative review. PHYSICAL THERAPY REVIEWS 2017. [DOI: 10.1080/10833196.2017.1412788] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- M.E. Pepin
- Physical Therapy Program, Wayne State University, Detroit, MI, USA
| | - K.G. Akers
- Shiffman Medical Library, Wayne State University, Detroit, MI, USA
| | - S.S. Galen
- Physical Therapy Program, Wayne State University, Detroit, MI, USA
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Littman AJ, Bouldin ED, Haselkorn JK. This is your new normal: A qualitative study of barriers and facilitators to physical activity in Veterans with lower extremity loss. Disabil Health J 2017; 10:600-606. [DOI: 10.1016/j.dhjo.2017.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2016] [Revised: 01/27/2017] [Accepted: 03/09/2017] [Indexed: 11/26/2022]
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Piazza L, Ferreira E, Minsky R, Pires G, Silva R. Assesment of physical activity in amputees: A systematic review of the literature. Sci Sports 2017. [DOI: 10.1016/j.scispo.2017.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Morgan SJ, Friedly JL, Amtmann D, Salem R, Hafner BJ. Cross-Sectional Assessment of Factors Related to Pain Intensity and Pain Interference in Lower Limb Prosthesis Users. Arch Phys Med Rehabil 2017; 98:105-113. [PMID: 27742450 PMCID: PMC5183499 DOI: 10.1016/j.apmr.2016.09.118] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/10/2016] [Accepted: 09/13/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine relationships between pain sites and pain intensity/interference in people with lower limb amputations (LLAs). DESIGN Cross-sectional survey. SETTING Community. PARTICIPANTS Lower limb prosthesis users with unilateral or bilateral amputations (N=1296; mean time since amputation, 14.1y). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity (1 item to assess average pain), PROMIS pain interference (4-item short form to assess the consequences of pain in desired activities), and questions that asked participants to rate the extent to which each of the following were a problem: residual limb pain (RLP), phantom limb pain (PLP), knee pain on the nonamputated side, back pain, and shoulder pain. RESULTS Nearly three quarters (72.1%) of participants reported problematic pain in 1 or more of the listed sites. Problematic PLP, back pain, and RLP were reported by 48.1%, 39.2%, and 35.1% of participants, respectively. Knee pain and shoulder pain were less commonly identified as problems (27.9% and 21.7%, respectively). Participants also reported significantly (P<.0001) higher pain interference (T-score ± SD, 54.7±9.0) than the normative sample based on the U.S. population (T-score ± SD, 50.0±10.0). Participants with LLAs rated their pain intensity on average ± SD at 3.3±2.4 on a 0-to-10 scale. Pain interference (ρ=.564, P<.0001) and intensity (ρ=.603, P<.0001) were positively and significantly correlated with number of pain sites reported. CONCLUSIONS Problematic pain symptoms, especially RLP, PLP, and back pain, affect most prosthetic limb users and have the potential to greatly restrict participation in life activities.
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Affiliation(s)
- Sara J Morgan
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Janna L Friedly
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Dagmar Amtmann
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Rana Salem
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA
| | - Brian J Hafner
- Department of Rehabilitation Medicine, University of Washington, Seattle, WA.
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Littman AJ, McFarland LV, Thompson ML, Bouldin ED, Arterburn DE, Majerczyk BR, Boyko EJ. Weight loss intention, dietary behaviors, and barriers to dietary change in veterans with lower extremity amputations. Disabil Health J 2014; 8:325-35. [PMID: 25612803 DOI: 10.1016/j.dhjo.2014.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/22/2014] [Accepted: 10/16/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Obesity is thought to be highly prevalent in persons with lower extremity amputations (LEAs) and can impair physical and social functioning. OBJECTIVE The aim of this study was to determine the prevalence of weight loss intention, weight loss strategies, dietary patterns, and barriers to making dietary changes, and their associations with body mass index (BMI, kg/m(2)), amputation characteristics, health status, and socioeconomic factors. METHODS We conducted a cross-sectional study (n = 150) using data from a self-administered questionnaire. RESULTS 43% of participants were obese and 48% were trying to lose weight; 83% of those trying to lose weight reported trying to "eat differently", but only 7% were following a comprehensive weight loss program involving dietary changes, physical activity, and behavioral counseling. 21% of participants reported ≥ 6 barriers to changing their eating habits (e.g., habit, too little money, stress/depression). Obesity was associated with younger age, lower physical health scores, hypertension, arthritis, and diabetes. Compared to those not trying to lose weight, a greater proportion of those trying to lose weight had a BMI ≥ 35 kg/m(2), age <55 years, higher physical and mental health scores, and more frequent consumption of vegetables, beans, chicken, and fish. CONCLUSIONS Though over half of overweight and obese individuals with LEA were trying to lose weight, few reported following a comprehensive program to lose weight, which may indicate an unmet need for services for this group. To be effective, these programs will need to address the complex physical and mental health challenges that many of these individuals face.
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Affiliation(s)
- A J Littman
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - L V McFarland
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Medicinal Chemistry, University of Washington, Seattle, WA, USA
| | - M L Thompson
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
| | - E D Bouldin
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Epidemiology, University of Washington, Seattle, WA, USA; Denver-Seattle Center of Innovation for Veteran-Centered & Value Driven Care, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA
| | | | - B R Majerczyk
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA
| | - E J Boyko
- Seattle Epidemiologic Research and Information Center, Department of Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA 98108, USA
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