The experience of amputation and prosthesis use for adults: a metasynthesis

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.

The experiences and needs of people with dysvascular lower extremity amputations: a qualitative systematic review and meta-synthesis

PURPOSE

The aim of this review is to synthesise the experiences and needs of people who had undergone dysvascular lower extremity amputations. Given the increasing global prevalence of vascular diseases like diabetes mellitus and peripheral arterial disease, the risk of requiring an amputation remains high.

MATERIALS AND METHODS

This systematic review follows the PRISMA and ENTREQ reporting guidelines. Seven databases were searched for qualitative studies from January 2011 to October 2023. In total 6435 studies were obtained, where 1146 were duplicates and 5271 studies failed to meet the eligibility criteria. The remaining 18 studies were synthesised using Sandelowski and Barroso's approach and appraised using the CASP checklist.

RESULTS

Four themes emerged from the meta-synthesis: (1) making the decision to amputate, (2) difficulties in the physical adaptation to limb loss, (3) psychosocial consequences of living with an amputation, and (4) regaining control and building hope.

CONCLUSIONS

Having dysvascular lower extremity amputations is a complicated experience as not only was the pre-amputation pain relieved, but a new set of physical, emotional and social challenges would surface after the amputation. These synthesised findings serve as a platform to explore the factors behind the various experiences faced by these people and how healthcare professionals can help them in their adjustment.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of a customized aesthetic prosthetic leg cover on social interaction cues and attitudes in the general UK population: Two experimental studies

OBJECTIVES

To explore the impact of an aesthetic prosthetic leg cover on attitudes toward individuals with lower-limb amputation and associated social interaction cues among the general UK population.

STUDY DESIGN

Two novel experimental methodologies.

METHODS

In study 1, participants (n = 188) viewed 1 of 3 images of an individual: (1) wearing a traditional stem prosthetic, (2) wearing an aesthetic leg cover, or (3) as a nonamputee. They then completed an attitude scale and rated the personality of the individual using the 10-item Big Five Inventory. Study 2 (n = 31) used eye tracking and facial expression software to explore gaze and facial arousal when viewing 1 of 9 manipulated videos of the same individual talking about 3 different scenarios.

RESULTS

In study 1, the aesthetic leg cover led to significantly higher ratings of agreeableness than stem and nonamputee images and significantly higher ratings of extraversion than the nonamputee image. Attitudes toward an individual with a prosthesis did not significantly differ depending on which image they viewed and were generally positive. In study 2, all participants focused mainly on the individual's face regardless of scenario topic or leg condition, although participants focused more around the leg cover in more active contexts.

CONCLUSIONS

Customized aesthetic leg covers may help individuals living with amputation to be perceived more positively in social situations. These experimental methodologies could be extended to explore the differential impact of context, functionality, and activity of specific types of customized aesthetic prosthetics and could help inform shared decision-making processes in clinical settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-operative Phase

OBJECTIVE

To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation.

DESIGN

Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques.

SETTING

Regional hospital's ambulatory rehabilitation clinic.

PARTICIPANTS

Patients with major lower limb amputation (N=329).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP.

RESULTS

In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79.

CONCLUSION

The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.

Lived experience of using assistive technology for sandy beach based leisure for Australian people with mobility limitations

PURPOSE

This study explores experiences of using beach assistive technology (AT), such as beach wheelchairs, powered wheelchairs, prosthetics and crutches, to participate in sandy beach-based leisure for people with mobility limitations.

METHODS

Online semi-structured interviews were conducted with 14 people, with mobility limitations and experience of using Beach AT. A phenomenological interpretative hermeneutic approach guided reflexive thematic analysis of verbatim transcripts.

FINDINGS

Three overarching themes were identified as: The meaning of using Beach AT, Practicalities of using Beach AT and Responses to using Beach AT. Each overarching theme was underpinned by subthemes. Meaning included: AT connects me, AT impacts my identity and AT attracts attention. Practicalities included: using AT requires other people, AT impacts spontaneity, AT limitations and AT use differs in water. Responses to using Beach AT included: I didn't think it was possible, adaptions to AT limitations and not everyone wants to own Beach AT.

CONCLUSION

This study illustrates the use of Beach AT as a facilitator for beach leisure, enabling connections to social groups and contributing to one's identity as a beachgoer. Access to Beach AT is meaningful and may be made possible through personal Beach AT ownership or access to loaned AT. The unique nature of sand, water, and salt environments requires users to identify how they plan to use the devices, with realistic expectations that the Beach AT may not enable full independence. The study acknowledges the challenges related to size, storage, and propulsion, but emphasizes that these can be overcome through ingenuity.

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.

'A whole different ball game': the qualitative experience of older adults with a transtibial amputation and the use of a self-aligning prosthetic ankle-foot on the STEPFORWARD trial

BACKGROUND

Older patients with lower limb amputation, categorised as having "limited community mobility", are under-researched. Understanding their experience with a new prosthetic ankle-foot is important when designing clinical trials. The aim of this qualitative study was to explore the adjustments they made after amputation and the acceptability of a self-aligning ankle-foot (SA-AF) to older adults.

METHODS

Fourteen participants, who took part in the STEPFORWARD randomised controlled feasibility trial (ISRCTN15043643), were purposively recruited; nine were intervention participants and five were standard care participants. They were asked to reflect on their life prior to and consider the adjustments they made following their amputation. Participants in the intervention group were also asked about their views of the new SA-AF compared to their standard non-SA-AF. A thematic analysis was undertaken.

RESULTS

Three broad themes were identified: The impact of the amputation; Role of clinical support; and Experiences of the SA-AF. The findings tell a narrative of the long-term impact that amputation has on these individuals' lives. Participants randomised to receive the SA-AF were very positive about it, reporting less pain, greater mobility and being able to do more.

CONCLUSION

Participants who used the SA-AF found it an acceptable intervention. These findings suggest that a full-scale RCT is warranted.

Considering the psychological experience of amputation and rehabilitation for military veterans: a systematic review and metasynthesis of qualitative research

PURPOSE

Research highlights the differences and unique experiences of military veterans experiencing amputation compared to civilians. This review aimed to synthesise qualitative research exploring the experience of amputation and rehabilitation among existing or previous members of the military.

METHODS

A systematic search of six databases (PsycINFO, AMED, MEDLINE, CINAHL, Web of Science and Scopus) was undertaken in March 2022. The results of 17 papers reporting 12 studies published between 2009 and 2022 were synthesised using a meta-ethnographic approach to generate new interpretations reflecting the experiences of members of the military who have experienced limb loss.

RESULTS

Three themes were developed from the data: (1) Making the physical and psychological transition to life after amputation; (2) The role of the military culture in rehabilitation; and (3) The impact of relationships and the gaze of others during rehabilitation and beyond.

CONCLUSIONS

Military veterans with limb loss experience difficulties in navigating civilian healthcare systems and gaining appropriate support away from the military. Rehabilitation professionals, with psychological training or mentoring, involved in the care of military veterans following amputation could offer psychological support during the transition to civilian life and targeted therapies to veterans experiencing high levels of pain, and facilitate peer support programmes.

'Am I fixed, am I better now?': undergoing MR-guided focused ultrasound for essential tremor: an interpretative phenomenological analysis

Introduction

Essential tremor (ET) is characterised by postural and intentional tremor typically affecting the upper limbs, which can negatively impact functionality and quality of life. Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is a novel and promising non-invasive treatment for ET which offers instantaneous results.

Methods

Using interpretative phenomenological analysis we explored the experience of undergoing MRgFUS in six ET patients as well as their experiences pre- and post-procedure.

Results

One-time, retrospective semi-structured interviews were conducted and six themes emerged: Life pre-treatment: "It's everyday tasks that get you down" and "Most people who understand, they are okay. Some people aren't"; MRgFUS: Treatment day: "Going into the unknown" and "There's no way I was going to press that button"; and Life post-treatment: "One is good. Two is better" and "Am I fixed, am I better now?."

Discussion

The findings point to a significant period of adjustment associated with living with ET and the effects of undergoing ET MRgFUS treatment. As ET progressed, participants struggled to cope with increasing symptoms and had to develop coping strategies to manage life with ET. The procedure itself was perceived as strange and extraordinary and despite some immediate adverse effects participants were determined to go through with it. Post procedure, all participants reported tremor suppression which was life changing. While some participants still felt burdened by ET, others expressed it took them a while to psychologically adjust to what essentially was their new body. This study has highlighted the need for patients to be supported at all stages of their ET journey.

Development of an evidence-based diagnostic algorithm for infection in patients with transcutaneous osseointegration following amputation

Introduction: Transcutaneous osseointegration following amputation (TOFA) confers better mobility and quality of life for most patients versus socket prosthesis rehabilitation. Peri-TOFA infection remains the most frequent complication and lacks an evidence-based diagnostic algorithm. This study's objective was to investigate preoperative factors associated with positive intraoperative cultures among patients suspected of having peri-TOFA infection in order to create an evidence-based diagnostic algorithm. Methods: We conducted a retrospective study of 83 surgeries (70 patients) performed to manage suspected lower-extremity peri-TOFA infection at a specialty orthopedic practice and tertiary referral hospital in a major urban center. The diagnosis of infection was defined as positive intraoperative cultures. Preoperative patient history (fevers, subjective pain, increased drainage), physician examination findings (local cellulitis, purulent discharge, implant looseness), and laboratory data (white blood cell count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and external swab culture) were evaluated for association with subsequent positive intraoperative cultures using regression and area under receiver-operator curve (AUC) modeling. Results: Peri-implant limb pain (highly correlated with infection), ESR > 30 (highly correlated against infection), positive preoperative swab (moderately correlated with infection), gross implant motion (moderately correlated against infection), and erythema or cellulitis of the transcutaneous region (mildly correlated with infection) were variables included in the best AUC model, which achieved an 85 % positive predictive value. Other clinical findings and laboratory values (notably CRP and WBC) were non-predictive of infection. Conclusions: This seminal investigation to develop a preoperative diagnostic algorithm for peri-TOFA infection suggests that the clinical examination remains paramount. Further evaluation of a wider spectrum of clinical, laboratory, and imaging data, consistently and routinely collected with prospective data techniques in larger cohorts of patients, is necessary to create a robust predictive algorithm.

A BIONIC HAND VS. A REPLANTED HAND

Objective

Evaluation of the hand function affected when replacing a malfunctioning hand by a bionic hand.

Design

Case report.

Subjects

One individual that wished for a better quality of life after unsatisfying hand function following a replantation.

Methods

A quantitative and qualitative evaluation of body functions as well as activity performance and participation before and after a planned amputation and prosthetic fitting is presented.

Results

Improvements were seen in the patient-reported outcome measures (PROMs) that were used regarding activity (Disability of the Arm, Shoulder and Hand [DASH] and Canadian Occupational Performance Measure [COPM]), pain (Neuropathic Pain Symptom Inventory [NPSI], Brief Pain Inventory [BPI], Visual Analogue Scale [VAS]), cold intolerance (CISS) and health related quality of life (SF-36), as well as in the standardised grip function test, Southampton Hand Assessment Procedure (SHAP). No referred sensations were seen but the discriminative touch on the forearm was improved. In the qualitative interview, a relief of pain, a lack of cold intolerance, improved appearance, better grip function and overall emotional wellbeing were expressed.

Conclusions

The planned amputation and subsequent fitting and usage of a hand prosthesis were satisfying for the individual with positive effects on activity and participation.

Clinical relevance

When the hand function after a hand replantation does not reach satisfactory levels, a planned amputation and a prosthetic hand can be the right solution.

Depression and Anxiety Symptoms Among Lebanese Lower Limb Traumatic Amputees: Association with Education, Employment, Adjustment to Amputation and Prosthesis Satisfaction

ObjectiveTo examine and compare the association between the presence of depression and anxiety symptoms and different sociodemographic and clinical factors including the adjustment to amputation and prosthesis satisfaction among Lebanese individuals with lower limb amputation (LLA). Method: This cross-sectional study was conducted between December 2022 and May 2023 among 72 participants with LLA. Participants completed a questionnaire that included sociodemographic and clinical variables, the revised Trinity Amputation and Prosthesis Experience Scale (TAPES-R), and the Hopkins Symptom Checklist (HSCL-25). Result: Using the HSCL depression and anxiety cut-off, 25% of participants were categorized as having depression symptoms, with unemployment being significantly associated (p-value < .05) with depression. Similarly, 25% were classified as having anxiety symptoms, with both lower education and unemployment (p-value < .05) significantly linked to anxiety. TAPES-R subscales scores exhibited significant differences between non-depressed and depressed, as well as non-anxious and anxious participants (p-value < .05). Correlation analysis demonstrated significant relationship between HSCL scales and TAPES-R subscales; lower scores in adjustment to amputation and prosthesis satisfaction were moderately associated with increased rates of depression (r ranging between -0.331 and -0.500, p-values < .005) and increased rates of anxiety symptoms (r ranging between -0.362 and -0.441, p-values < .002). In addition, higher scores in activity limitation were moderately correlated to increased rates of depression and anxiety (r = 0.438 for anxiety and 0.490 for depression; p < .001). Conclusion: Mental health symptoms are associated with educational level, employment status, and adjustment to amputation and prosthesis satisfaction in Lebanese individuals with LLA. These findings should be considered to achieve optimal prosthetic rehabilitation.

Exploring the psychosocial needs of persons with lower extremity amputation and feasibility of internet cognitive behavioural therapy: a qualitative study

PURPOSE

Following major lower extremity amputation (LEA), patients experience significant emotional distress and are at risk for anxiety and depression. There is a lack of mental health supports for this population, and internet-based cognitive behavioural therapy (iCBT) may be a useful resource to meet this need. The purpose of this study was to use a qualitative approach to explore the mental health needs of LEA patients and to gauge their attitudes of the use of iCBT to help them cope with their amputation.

METHODS

Semi-structured qualitative interviews were conducted with inpatients and outpatients with LEA recruited from a major urban rehabilitation hospital. Data were analysed using inductive codebook thematic analysis (TA).

RESULTS

Ten interviews were completed with individuals with LEA. The main themes identified were: (1) Fixating on the past; (2) Worry about the future; (3) Unmet mental health needs; (4) Barriers to Mental Health Support; (5) Importance of peer support; and (6) Tailoring iCBT.

CONCLUSIONS

Our findings highlight that patients with LEA are open to learning more about iCBT to meet their mental health needs. Key iCBT implementation considerations include taking into account issues of stigma associated with mental health, timing of delivery, levels of digital literacy, online security, and interactive content.IMPLICATIONS FOR REHABILITATIONFollowing lower extremity amputation (LEA), people experience significant emotional distress and are at risk for the development of anxiety and/or depression.Patients with LEA are receptive to an online mental health resource (i.e., internet-based cognitive behavioural therapy [iCBT]) but it needs to be tailored to meet the various mental health needs and digital literacy of the LEA population.The use of an implementation science approach can help identify factors related to the development and potential uptake of an iCBT for patients with LEA.

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.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychosocial patient perspectives following major lower-limb amputation due to vascular aetiology: a protocol for a systematic meta-aggregation study

INTRODUCTION

Persistent psychosocial problems in people with lower-limb amputation due to vascular aetiology indicate a great need for long-lasting holistic rehabilitation. An in-depth understanding of the psychosocial problems is essential for the guidance of health professionals in meeting and normalising patients' experiences and emotions. Furthermore, identifying the psychological problems may help develop effective rehabilitation and counselling programmes. This meta-aggregation study aims to explore the psychosocial perspectives of individuals who have undergone a major lower-limb amputation due to vascular aetiology during the post-discharge rehabilitation phase.

METHODS AND ANALYSIS

A systematic meta-aggregation study will be performed to identify full-text, peer-reviewed journal articles reporting on patients' psychosocial perspectives on major lower-limb amputation due to vascular aetiology from post-discharge to several years afterward. The databases Embase, CINAHL Ultimate, APA PsycInfo, PubMed and Scopus will be searched with no limitations regarding the publication year. Studies that satisfy the eligibility criteria will be critically appraised using an acknowledged checklist and synthesised using the Joanna Briggs Institute three-phase approach for the synthesis of meta-aggregation studies. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation- Confidence in Evidence from Reviews of Qualitative research) tool will be used to determine the level of confidence in the qualitative evidence, and the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) reporting guidelines will be followed throughout the review process.

ETHICS AND DISSEMINATION

Ethical approval is not required for the study, as the review is built on pre-existing available data in the literature. Findings from the review will be disseminated through publication in a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42022377114.

Comparing Patient and Provider Priorities Around Amputation Level Outcomes Using Multiple Criteria Decision Analysis

BACKGROUND

Patients with chronic limb threatening ischemia may require a transmetatarsal amputation (TMA) or a transtibial amputation. When making an amputation-level decision, these patients face a tradeoff-a TMA preserves more limb and may provide better mobility but has a lower probability of primary wound healing and may therefore result in additional same or higher level amputation surgeries with an associated negative impact on function. Understanding differences in how patients and providers prioritize these tradeoffs and other outcomes may enhance shared decision-making.

OBJECTIVES

Compare patient priorities with provider perceptions of patient priorities using Multiple Criteria Decision Analysis (MCDA).

METHODS

The MCDA Analytic Hierarchy Process was chosen due to its low cognitive burden and ease of implementation. We included 5 criteria (outcomes): ability to walk, healing after amputation surgery, rehabilitation program intensity, limb length, and ease of use of prosthetic/orthotic device. A national sample of dysvascular lower-limb amputees and providers were recruited from the Veterans Health Administration with the MCDA administered online to providers and telephonically to patients.

RESULTS

Twenty-six dysvascular amputees and 38 providers participated. Fifty percent of patients had undergone a TMA; 50%, a transtibial amputation. When compared to providers, patients placed higher value on TMA (72% vs. 63%). Patient versus provider priorities were ability to walk (47% vs. 42%), healing (18% vs. 28%), ease of prosthesis use (17% vs. 13%), limb length (11% vs. 13%), and then rehabilitation intensity (7% vs. 6%).

LIMITATIONS

Our sample may not generalize to other populations.

CONCLUSIONS

Provider perceptions aligned with patient values on amputation level but varied around the importance of each outcome.

IMPLICATIONS

These findings illuminate some differences between patients' values and provider perceptions of patient values, suggesting a role for shared decision-making. Embedding this MCDA framework into a future decision aid may facilitate these discussions.

Chronic limb-threatening ischaemia and confronting amputation: A Heideggerian derived understanding of Being-with and discourse

AIMS AND OBJECTIVES

To explore the notion of Being-with and authentic discourse for people making decisions about major amputation.

BACKGROUND

Chronic limb-threatening ischaemia is a devastating disease with a high burden of pain and complex wounds. Patients may deteriorate suddenly after multiple revascularisation procedures and, amputation is offered when further reperfusion is considered futile. Delayed decisions about amputation have negative consequences for patients, families and health systems, yet little attention is given to training clinicians for the sophisticated communication required. Clinicians need to engage in authentic discourse about amputation to create shared meaning and facilitate decision-making.

DESIGN

Qualitative study using hermeneutic Heideggerian phenomenology.

METHODS

Twelve patients offered major amputation, and 13 family participants from three vascular units in Australia engaged in 42 semi-structured interviews, representing 19 cases of chronic limb-threatening ischaemia. Hermeneutic phenomenology using the Heideggerian tenet of Being-with as an analytic framework, a philosophically based understanding of Being-with and Discourse related to treatment discussions and decisions was derived. The research was reported in accordance with the COREQ checklist.

FINDINGS

Effective discourse between the person and family was hampered by changed circumstances of Being-with, characterised by guilt, and a retreat from discourse through deficient discourse and filtering information. Clinician Being-with was hampered by discourse that was deficient, poorly delivered, discordant and disconnected through a lack of empathetic listening. There were also examples of enhanced clinician Being-with that made room for more constructive discourse and more timely decisions about amputation.

CONCLUSIONS

Heidegger's construct of Being-with provides a useful framework to reveal the role of authentic discourse in improving patient and family experience and decisions about treatment.

NO PATIENT OR PUBLIC CONTRIBUTION

This study did not engage consumers other than as patient and carer participants.

RELEVANCE TO CLINICAL PRACTICE

Decisions about amputation are often difficult for patients or family members who may be substitute decision-makers. A better understanding of the experience may assist clinicians in their interactions with patients and families.

The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS

Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.

What is the cost, impact, and willingness to pay for an Amputee Peer Support Program?

BACKGROUND

The provision of peer support from those who have already made positive adjustments to amputation is recommended for people incurring a major limb amputation; however, few receive this service.

OBJECTIVE

From a program perspective, determine the cost, impact, and willingness to pay for an Amputee Peer Support Program.

STUDY DESIGN

Cost analysis.

METHODS

Cost of the Amputee Peer Support Program included a cost analysis of program data over a 5-year time horizon (2013-2018) reported in Australian Dollars 2018/2019. Impact and willingness to pay for an Amputee Peer Support Program was determined through surveys of the 3 participant groups: referring health professionals, program volunteers, and program participants.

RESULTS

Over 5 years, there were 793 program participants, serviced by 256 program volunteers, for a cost of $631,497. The cost per program participant was $796. Thirty-eight health professionals, 86 program volunteers, and 12 program participants reported on impact and willingness to pay. The Program was reported to have a positive impact on all participant groups. The themes of access to resources and information and the provision of social and emotional well-being were identified across all 3 groups as being important. All 3 groups reported a higher willingness to pay for the health service (range $113-$450), National Disability Insurance Scheme ($156-$432), and private health insurance ($153-$347), and a lower willingness to pay for the program participant ($23-$49).

CONCLUSION

Amputee peer support had a positive impact on those receiving and providing the service. Amputee peer support is likely to be a powerful yet inexpensive addition to routine care.

Understanding amputation care in England and Scotland: a qualitative exploration of patient stories posted on an online patient feedback site

PURPOSE

Undergoing an amputation is a life-altering experience that can involve a protracted and intensive period of care from a range of healthcare professionals. Amputation care within the NHS has historically been criticised. Here we seek to understand how patients are experiencing care by exploring their stories and identifying features of both high- and low-quality care.

MATERIALS AND METHODS

We analysed patient stories posted on the patient feedback site Care Opinion during the period 2018-2020 to examine how amputee patients (and their families) experience NHS care. Using thematic analysis, we identified four key themes.

RESULTS

We found that patients' stories of undergoing an amputation as posted on Care Opinion give overwhelmingly positive feedback on their experiences. Patients report feeling well-supported by empathetic staff, and that the outcomes, in terms of quality of life and restoration of mobility, are beneficial. Time was a common feature within the posts we examined and negative experiences of care often related to untimeliness in a variety of ways.

CONCLUSIONS

Care Opinion provides a useful and accessible resource for understanding how patients experience amputation care; analysis of stories posted there provides preliminary ideas of the features of "good care" from a patient-centred perspective.IMPLICATIONS FOR REHABILITATIONPatients undergoing amputations view professionalism of staff as important for good care.Timeliness is important to patients in seeing care in positive terms, ensuring patients are supported in their care during and after amputation in a timely manner is therefore important for achieving good rehabilitation care.Rehabilitation and related services supporting patients who have undergone amputations could usefully patient feedback sites as a means for further understanding the experiences of their patients and for improving services where necessary.

User experiences of digital prostheses in daily functioning in people with an amputation of thumb or finger

STUDY DESIGN": Qualitative research design using interpretative phenomenological analysis (IPA) to interpret users' experiences with digital prostheses.

BACKGROUND

Digital prostheses are rarely used, and little is known about the experiences of traumatic finger amputees with digital prostheses. When advising patients regarding digital prostheses, it is crucial for professionals to understand users experiences of wearing a digital prosthesis and the meaning attached to wearing a digital prosthesis.

PURPOSE OF STUDY

The aim of this study was to explore and understand users experiences of wearing a digital prostheses in daily functioning.

METHODS

Individual semi-structured interviews were conducted, recorded, and transcribed. The written interview texts were analysed following Interpretative phenomenological analysis guidelines.

RESULTS

Four participants were interviewed. They experienced the prostheses as valuable additions to their daily functioning. Three different themes relating to wearing and using digital prostheses emerged from in-depth analysis of the data: How the prosthesis supporting them regaining a 'grip' on life, reduced overload on unaffected side and restored body image.

CONCLUSIONS

This study provides a deeper understanding of the experiences of people with digital amputations who use prostheses. Most importantly, that a prosthesis is of crucial importance for participants to be able to act independently and autonomously as well as to participate in family, work and social environments. This insight will help practitioners when considering, with clients the most appropriate digital prosthesis to meet their goals.

Emulating the Effective Ankle Stiffness of Commercial Prosthetic Feet Using a Robotic Prosthetic Foot Emulator

Prosthetic foot selection for individuals with lower limb amputation relies primarily on clinician judgment. The prosthesis user rarely has an opportunity to provide experiential input into the decision by trying different feet. A prosthetic foot emulator (PFE) is a robotic prosthetic foot that could facilitate prosthesis users' ability to trial feet with different mechanical characteristics. Here, we introduce a procedure by which a robotic PFE is configured to emulate the sagittal plane effective ankle stiffness of a range of commercial prosthetic forefeet. Mechanical testing was used to collect data on five types of commercial prosthetic feet across a range of foot sizes and intended user body weights. Emulated forefoot profiles were parameterized using Bezier curve fitting on ankle torque-angle data. Mechanical testing was repeated with the PFE, across a subset of emulated foot conditions, to assess the accuracy of the emulation. Linear mixed-effects regression and Bland-Altman Limits of Agreement analyses were used to compare emulated and commercial ankle torque-angle data. Effective ankle stiffness of the emulated feet was significantly associated with the corresponding commercial prosthetic feet (p<.001). On average, the emulated forefeet reproduced the effective ankle stiffness of corresponding commercial feet within 1%. Furthermore, differences were independent of prosthetic foot type, foot size, or user body weight. These findings suggest a PFE could be an effective tool for emulating commercial prosthetic feet, enabling prosthesis users to quickly trial different feet and provide experiential input as part of a prosthetic foot prescription.

The lived experience of people with upper limb absence living in Uganda: A qualitative study

Background

The impact of upper limb absence on people's lived experiences is understudied, particularly in African countries, with implications for policy and service design.

Objectives

The objective of this study was to explore the lived experiences of people with upper limb absence (PWULA) living in Uganda.

Method

Informed by preliminary work, we designed a qualitative study employing semi-structured interviews to understand the experience of living with upper limb absence in Uganda. Seventeen adults with upper limb absence were individually interviewed and their interviews were analysed utilising thematic analysis.

Results

Seven themes illustrating the impact on the individual's life after amputation were identified and categorised into (1) living and adapting to life, (2) productivity and participation and (3) living within the wider environment. This study presents three main findings: (1) PWULA need psychological and occupational support services which are not available in Uganda, (2) PWULA want to work, but face multiple barriers to employment and has limited support, combined with the complex parenting and caring responsibilities, (3) the local Ugandan culture and social structures affect the everyday life of PWULA, both in positive and negative ways.

Conclusion

This study provides information on the lived experiences of PWULA in Uganda which are lacking in the literature. People with upper limb absence face ableism and hardship underpinned by a lack of formal support structures and policies, which may in turn exacerbate the impact of upper limb absence on multiple facets of life.

Subjective Response Measurement to Prosthesis or Device Use: Validation of the Prosthetic-Bionic Paradigm Questionnaire (PBP-Q)

Many subjects with somatic pathologies or traumas in their recent anamnesis tend to experience symptoms and changes to their daily life parameters after technically successful treatment. Hence, this study aims to validate an investigation tool inspired by the prosthetic-bionic paradigm-namely, the PBP-Q-which allows for the evaluation of variation in questions relating to identity, psychosociality, and psychopathology in relation to the use of a prosthesis or device. We gathered 118 participants (68 females and 50 males) aged between 27 and 94 years (Mean = 58.42 ± 15.17). We performed both exploratory (EFA) and confirmatory (CFA) factor analyses on this sample. Moreover, we calculated the internal consistency for the PBP-Q scales and the total score for the questionnaire's final 26-item and 5-factor versions. The five scales are psychological well-being; interpersonal relationships; professional relationships; autonomy and safety; addictions, compulsions, and obsessions. The internal consistency is good for both the total score and the subscales. In conclusion, overall, the PBP-Q has satisfactory psychometric properties, especially considering the measure's complexity. It provides a quick and effective way to evaluate the changes that might arise after the use of a prosthesis or device and, subsequently, has implications for clinical practice.

Understanding the experience of veterans who require lower limb amputation in the veterans health administration

Purpose

There is limited qualitative research on the experience of patients undergoing lower limb amputation due to chronic limb threatening ischemia (CLTI) and their participation in amputation-level decisions. This study was performed to understand patient lived experiences related to amputation and patient involvement in shared decision making.

Materials and methods

Phenomenological interviews were conducted with Veterans 6–12 months post transtibial or transmetatarsal amputation due to CLTI. Interviews were read and summarized by two analysts who discussed the contents of each interview and relationships between interviews to identify emergent, cross-cutting elements of patient experience.

Results

Twelve patients were interviewed between March and August 2019. Three cross cutting elements of patient lived experience and participation in shared decision making were identified: 1) Lacking a sense of decision making; 2) Actively working towards recovery as response to a perceived loss of independence; and 3) Experiencing amputation as a Veteran.

Conclusions

Patients did not report a high level of involvement in shared decision making about their amputation or amputation level. Understanding patient experiences and priorities is crucial to supporting shared decision making for Veterans with amputation due to CLTI.

Sensory Feedback for Upper-Limb Prostheses: Opportunities and Barriers

The addition of sensory feedback to upper-limb prostheses has been shown to improve control, increase embodiment, and reduce phantom limb pain. However, most commercial prostheses do not incorporate sensory feedback due to several factors. This paper focuses on the major challenges of a lack of deep understanding of user needs, the unavailability of tailored, realistic outcome measures and the segregation between research on control and sensory feedback. The use of methods such as the Person-Based Approach and co-creation can improve the design and testing process. Stronger collaboration between researchers can integrate different prostheses research areas to accelerate the translation process.

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.

Development and validation of a sensitive MEDLINE search strategy to identify literature relevant to limb prostheses

BACKGROUND

Researchers and clinicians may find it challenging to identify relevant articles about limb prostheses in online databases. Searches may be improved by using standardized strategies, also known as filters or hedges.

OBJECTIVES

To develop and validate a highly sensitive MEDLINE (EBSCOHost) search strategy for limb prostheses.

STUDY DESIGN

Search strategy development/validation.

METHODS

A gold standard (GS) list of peer-reviewed articles on the topic of limb prostheses was created using a relative recall method. This involved identifying and including relevant systematic reviews/meta-analyses and then adding articles that were included in the analysis section of these reviews. Possible terms for the search strategy were identified through brainstorming and exploration of medical subject headings in MEDLINE (MeSH) and standards from the International Organization for Standardization (ISO). Concepts were grouped using relevant Boolean operators (e.g. AND and OR) and database record search fields (i.e. MeSH terms, title, and abstract). Part of the GS was used to refine the search strategy and reduce the number of records retrieved in total. The remaining GS set was used to validate and calculate sensitivity of the search strategy. Performance of the search strategy was compared against searches using only relevant MeSH terms.

RESULTS

After screening, the final GS totaled 853 records. The developed search strategy was highly sensitive (99.80%) and performed with higher relative recall than searches with relevant MeSH terms.

CONCLUSIONS

This study provides a highly sensitive search strategy that can be used by clinicians and researchers when searching for relevant literature on limb prostheses in MEDLINE (EBSCOHost).

Psychological Consequences in Patients With Amputation of a Limb. An Interpretative-Phenomenological Analysis

The study aimed to identify the psychological changes that result from the amputation of a limb and the ways in which patients coordinate their daily lives. The study uses an interpretative phenomenological analysis (IPA) aimed at understanding individual experiences in seven patients who have suffered limb amputation. The method used consisted of individual, semi-structured interviews, conducted approximately 4 months after surgery, to patients at home or in hospital, at the time of their regular checkup. The interviews were audio recorded, transcribed and, following the qualitative analysis performed, six common themes were identified: emotional impact, negative affects, tendency toward isolation, role constraints and limitations, phantom limb, and emotional balancing. A specific theme for patients who have suffered amputations is phantom limb pain, which has received special attention from researchers. The last topic relates to the tendency toward emotional balancing and psychological calibration to return to normal life.

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.

Mobility with a lower limb prosthesis: experiences of users with high levels of functional ability

PURPOSE

The Prosthetic Limb Users Survey of Mobility (PLUS-M) is a self-report item bank designed to measure the abilities with which people with lower limb amputation perform physical activities. Although PLUS-M includes items that span a range of mobility, additional items are needed to accurately measure mobility of highly active prosthesis users, such as athletes and service members with lower limb amputation. The aim of this study was to understand mobility in highly active lower limb prosthesis users to inform the development of new items for the PLUS-M item bank.

METHODS

Focus groups were conducted with active, lower limb prosthesis users from across the USA. In-person and online focus groups were conducted by a trained facilitator using a semi-structured guide. Focus group transcripts were reviewed and coded by two researchers. Thematic analysis was used to identify important experiences across participants.

RESULTS

Twenty-nine participants took part in four focus groups. Three resultant themes were identified: mobility after amputation, mobility characteristics, and healthcare providers and systems.

CONCLUSIONS

Identified themes inform clinician and researcher understanding of mobility in highly active lower limb prosthesis users. The results of this study will be used to inform development of high-activity items for the PLUS-M item bank.Implications for rehabilitationParticipants described engagement in high-level activities as a learning process that included elements such as equipment challenges and modifications, pain and injury, and the need to trust the prosthetic limb.Participants with lower limb amputation who use prostheses identified mobility characteristics, such as postural changes, terrain, and obstacles, that influenced their ability to perform high-level activities.High-level mobility characteristics identified in these focus groups can be integrated into a revised version of the Prosthetic Limb Users Survey of Mobility to assess mobility in active adults and athletes with amputation.Rehabilitation professionals play an important role in facilitating access to specialized prosthetic components and training that can help patients achieve their mobility goals and potential.

Sensory Feedback in Hand Prostheses: A Prospective Study of Everyday Use

Introduction

Sensory feedback in hand prostheses is lacking but wished for. Many amputees experience a phantom hand map on their residual forearm. When the phantom hand map is touched, it is experienced as touch on the amputated hand. A non-invasive sensory feedback system, applicable to existing hand prostheses, can transfer somatotopical sensory information via phantom hand map. The aim was to evaluate how forearm amputees experienced a non-invasive sensory feedback system used in daily life over a 4-week period.

Methods

This longitudinal cohort study included seven forearm amputees. A non-invasive sensory feedback system was used over 4 weeks. For analysis, a mixed method was used, including quantitative tests (ACMC, proprioceptive pointing task, questionnaire) and interviews. A directed content analysis with predefined categories sensory feedback from the prosthesis, agency, body ownership, performance in activity, and suggestions for improvements was applied.

Results

The results from interviews showed that sensory feedback was experienced as a feeling of touch which contributed to an experience of completeness. However, the results from the questionnaire showed that the sense of agency and performance remained unchanged or deteriorated. The ability to feel and manipulate small objects was difficult and a stronger feedback was wished for. Phantom pain was alleviated in four out of five patients.

Conclusion

This is the first time a non-invasive sensory feedback system for hand prostheses was implemented in the home environment. The qualitative and quantitative results diverged. The sensory feedback was experienced as a feeling of touch which contributed to a feeling of completeness, linked to body ownership. The qualitative result was not verified in the quantitative measurements.

Clinical Trial Registration

Name: Evaluation of a Non-invasive Sensory Feedback System in Hand Prostheses. Date of registration: March 15, 2019. Date the first participant was enrolled: April 1, 2015. ClinicalTrials.gov Identifier: NCT03876405 ORCID ID: https://orcid.org/0000-0002-4140-7478.

User-relevant factors determining prosthesis choice in persons with major unilateral upper limb defects: A meta-synthesis of qualitative literature and focus group results

OBJECTIVE

Considering the high rejection rates of upper limb prostheses, it is important to determine which prosthesis fits best the needs of each user. The introduction of the multi-grip prostheses hands (MHP), which have functional advantages but are also more expensive, has made prosthesis selection even harder. Therefore, we aimed to identify user opinions on factors determining prosthesis choice of persons with major unilateral upper limb defects in order to facilitate a more optimal fit between user and prosthesis.

METHODS

A qualitative meta-synthesis using a 'best-fit framework' approach was performed by searching five databases (PROSPERO registration number: CRD42019126973). Studies were considered eligible if they contained qualitative content about adults with major unilateral upper limb defects experienced in using commercially available upper limb prostheses and focused on upper limb prosthesis users' opinions. Results of the meta-synthesis were validated with end-users (n = 11) in a focus group.

RESULTS

Out of 6247 articles, 19 studies were included. An overview of six main themes ('physical', 'activities and participation', 'mental', 'social', 'rehabilitation, cost and prosthetist services' and 'prosthesis related factors') containing 86 subthemes that could affect prosthesis choice was created. Of these subthemes, 19 were added by the focus group. Important subthemes were 'work/school', 'functionality' and 'reactions from public'. Opinions of MHP-users were scarce. MHPs were experienced as more dexterous and life-like but also as less robust and difficult to control.

CONCLUSION

The huge number of factors that could determine upper limb prosthesis choice explains that preferences vary greatly. The created overview can be of great value to identify preferences and facilitate user-involvement in the selection process. Ultimately, this may contribute to a more successful match between user and prosthesis, resulting in a decrease of abandonment and increase of cost-effectiveness.

A systematic review in prosthetics and orthotics education research

BACKGROUND

Formal prosthetic/orthotic education has evolved greatly since its inception in the 1950s. The International Society for Prosthetics and Orthotics has established guidelines and recognition for prosthetic/orthotic programs worldwide. However, the current state-of-the-science in prosthetic/orthotic education is largely unknown.

OBJECTIVES

To evaluate and synthesize available prosthetic/orthotic education research.

STUDY DESIGN

Systematic review.

METHODS

Three bibliographic databases were searched and quality of included articles assessed using criteria from the National Institutes for Health Quality Assessment Tool for Observational Cohort, Cross-Sectional Studies, and the Critical Appraisal Skills Programme Qualitative Research Checklist, and Delphi quality criteria.

RESULTS

This review included 25 articles from 23 studies. Included studies explored description, development, implementation, and/or assessment of the teaching/learning methods, curriculum, program, or country/region level. Studies were conducted in 18 countries and published in 14 journals. Methodological quality was rated high in 6 articles, moderate in 6, and low in 13. Content synthesis was not attempted due to the heterogeneous literature.

CONCLUSION

This systematic review suggests that prosthetic/orthotic education research is only being conducted at a limited level. There is a strong need for high quality, collaborative education research to be conducted and published in peer-reviewed journals to improve prosthetic/orthotic education and build a global conversation.

CLINICAL RELEVANCE

Research in prosthetic/orthotic education is limited. The current body of literature is not sufficient to inform and guide future education of prosthetic/orthotic students. Opportunities to improve prosthetic/orthotic education research include academic collaborations, a dedicated education special issue or journal, and disciplinary support for prosthetic/orthotic education research.

Duplex Ultrasound May Predict the Best Level of Lower Limb Amputation in Patients with Chronic Limb-Threatening Ischemia: A Retrospective Observational Cohort Study

BACKGROUND

Despite improved revascularization options, many patients with chronic limb-threatening ischemia (CLI) require lower limb amputation. Duplex ultrasound (DUS) is recommended as first-choice imaging technique in CLI. However, the prognostic utility of DUS for planning lower limb amputations has never been described before. This study aims to evaluate if DUS and findings from physical examination could be used to help predict the best level of lower limb amputation in patients with CLI.

METHODS

A retrospective cohort of 124 patients with CLI and a lower limb amputation was analyzed. Outcome measurements were reoperation, revision, and conversion rates, which were related to findings from physical examination and DUS examinations.

RESULTS

Thirty-nine reoperations were performed, of which 17 stump revisions and 22 conversions were from below- to above-knee amputation. There was a discrepancy in findings of physical examination and DUS of 25% and 64% of femoral and popliteal pulsations respectively. Conversion rates increased with a more proximal occlusion on DUS. All patients with a vascular occlusion in the aortoiliac trajectory or deep femoral artery required a higher amputation level.

CONCLUSIONS

Physical examination seems to be unreliable, and therefore should not be used to assess the optimal level of lower extremity amputation. Performing a primary above-knee amputation in patients with vascular occlusion in the aortoiliac trajectory or deep femoral artery could significantly reduce reoperation rates.

Cross-cultural adaptation and measurement properties of the French version of the Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R)

BACKGROUND

The Trinity Amputation and Prosthesis Experience Scales-Revised (TAPES-R) is a self-administered questionnaire to measure multidimensional adjustment to a prosthetic limb. Our aim was to assess the validity and reliability of the French version of the TAPES-R (TAPES-R-F).

MATERIALS AND METHODS

The cross-cultural adaptation was performed according to the recommendations. Factor analysis and Rasch analysis were also performed to allow comparison with the original English version. Construct validity was assessed by measuring the correlations between TAPES-R-F subscores and quality of life, pain, body image satisfaction, anxiety and depression. Internal consistency was measured with Cronbach's α. The standard error of measurement, smallest detectable change, Bland and Altman limits of agreement, and intraclass correlation were the measures of agreement and reliability.

RESULTS

No major difficulties were encountered throughout the trans-cultural adaptation process. The final version of the TAPES-R-F was well accepted and understood by the patients. According to the factor analysis, the satisfaction scale should be treated as a one-dimensional construct when used by French-speaking people and should not be separated into two separate subscales, functional and aesthetic, as is the case in the original English version. Our study confirmed that there is a strong relationship between biopsychosocial factors and adjustment to amputation. Cronbach's α > 0.8 for all the subscales. Reliability was good to excellent for all the subscales (ICCs between 0.61 and 0.89). The smallest detectable changes were 0.7, 0.8, 1.3, 0.4, and 1.8 (general adjustment, social adjustment, adjustment to limitation, activity restriction, and global satisfaction with the prosthesis).

CONCLUSIONS

The TAPES-R-F is a valid and reliable instrument to assess multidimensional adjustment of French-speaking lower limb amputees. This questionnaire can be used for both clinical assessment and research purposes.

Factors influencing participation in physical activity after dysvascular amputation: a qualitative meta-synthesis

Purpose: Identifying factors associated with physical activity after dysvascular lower limb amputation (LLA) could provide targets for improving rehabilitation outcomes. The purpose of this meta-synthesis was to identify modifiable factors that may influence physical activity after LLA, a condition characterized by amputation in the setting of older age, diabetes mellitus (DM), and/or peripheral artery disease (PAD).Methods: A systematic search of the literature identified qualitative studies exploring the perceptions of physical activity in people with lower limb amputation, older age, DM, or PAD. Qualitative rigor was assessed using the McMaster University's Guidelines for Qualitative Review. Meta-synthesis was undertaken to analyze the findings of included studies.Results: Fourteen studies of variable methodological quality were included for analysis. Three overarching factors that may influence physical activity after LLA emerged: 1) educational experiences and motivation, 2) support and self-efficacy, and 3) special concerns after lower limb amputation (e.g., prosthesis, equipment, and environment).Conclusions: Physical activity after LLA is influenced by relationships among health understanding, motivation, support, and self-efficacy in the presence of disability. Themes from this meta-synthesis can be used to develop and test behavior-based interventions to improve physical activity after LLA.Implications for rehabilitationPhysical activity participation after dysvascular lower limb amputation is complicated by the presence of chronic conditions, severe disability, and unaddressed psychosocial factors.Addressing a patient's self-efficacy, social support, motivation, and understanding during physically focused rehabilitation may improve participation in physical activity after dysvascular lower limb amputation.Rehabilitation professionals can address self-efficacy, motivation, and understanding by using collaborative, empathetic communication strategies known to enhance a patient's sense of support.

Psychosocial and physical adjustments and prosthesis satisfaction in amputees: a systematic review of observational studies

Background: Adjustment to amputation is a complex process because it encompasses physical and psychosocial aspects as well as satisfaction with the artificial limb.Purpose: To review the scientific production on psychosocial and physical adjustments to amputation and prosthesis use as well as prosthetic satisfaction in people with lower limb amputation in the last 10 years.Methods: This review was conducted on the MEDLINE via Pubmed, Web of Science and Scopus databases. Original and observational studies published in the last 10 years were included, with topics related to adjustment to amputation and prosthesis use as well as prosthetic satisfaction in people with lower limb amputations.Results: A total of 1042 articles were identified in the initial search, but after analysing the criteria 16 articles were used for analysis in their entirety. Regarding psychosocial adjustments, higher rates of depression, anxiety and body image disorders were observed among people with amputations. Phantom and residual limb pain, gender, employment status and daily hours of prosthesis use may influence psychosocial adjustment. Physical adjustment may be influenced by the level of amputation, educational background, age, daily prosthesis use, ambulatory assistive devices and presence of comorbidities. The areas of greatest prosthetic dissatisfaction were colour and weight.Conclusion: Considering that most of the studies related to the satisfaction and adjustment of the prosthesis are cross-sectional studies, longitudinal studies should be conducted, since monitoring individuals over the years and verifying how these variables change over time may contribute to obtaining more data on the factors that influence prosthetic fitting and satisfaction.Implications for rehabilitationAdjustment to amputation and prosthesis use involves both physical and psychosocial issues, it is important that besides physical rehabilitation, psychological interventions and education and communication activities between the patient and the health professionals are carried out.The adaptation to the prosthesis and the recovery of walking capacity are important goals in the rehabilitation process and the knowledge of the physical and psychosocial factors associated with amputation and the use of the prosthesis can help the health team to provide better care to these subjects.Well-adjusted, comfortable and easy-to-use prostheses are of great importance as they enable the patient to perform their daily activities and maintain their independence.It is important to encourage the participation of the individual in both rehabilitation and choice of prosthesis.

Prosthesis use is associated with reduced physical self-disgust in limb amputees

Self-disgust is an emotion schema negatively affecting people's body image and is triggered by bodily imperfections and deviations from the "normal" body envelope. In this study, we explore the idea that "normalising" the body in those with limb amputations via the prosthesis would be linked to reduced self-directed disgust. An international clinical community sample (N = 83) with mostly lower limb amputations completed measures about their demographics, prosthesis, adjustment, body image disturbance, psychological distress, and self-directed disgust in a survey design. Consistent with the "normalising" hypothesis, correlation and bootstrapped regression models revealed, first, that frequency of prosthesis use was significantly and negatively associated with physical self-disgust. Second, prosthesis use significantly mediated the exogenous effect of time since amputation on physical self-disgust. These results emphasise the psychological value of the prosthesis beyond its functional use, and stress its importance in normalising the body envelope in those with limb amputations, which may in turn promote psychological well-being.

Cross-cultural adaptation and validation of the ABIS questionnaire for French speaking amputees

Background: The Amputee Body Image Scale (ABIS) and its shortened version (ABIS-R) are self-administered questionnaires to measure body image perception of amputee. Our aim was to assess the validity and reliability of the French ABIS (ABIS-F and ABIS-R-F).Methods: Ninety-nine patients were included. The cross-cultural adaptation was performed according to the recommendations. Construct validity was assessed by measuring the correlation between ABIS-F or ABIS-R-F scores and quality of life, pain, anxiety, and depression. Internal consistency was measured with Cronbach's α. The standard error of measurement, smallest detectable change, Bland and Altman limits of agreement, and intraclass correlation were the measures of agreement and reliability.Results: A highest body image disturbance was associated with lowest quality of life, higher pain, and higher anxiety, and depression. Cronbach's α was 0.91/0.89 (ABIS-F/ABIS-R-F). The standard error of measurement was 5.35/2.28 (ABIS-F/ABIS-R-F). The smallest detectable change was 14.82/6.31 (ABIS-F/ABIS-R-F). The mean difference in ABIS-F score was -3.90 with limits of agreement from -18.71 to 10.92. For ABIS-R-F, the mean difference was -2.12 with limits of agreement from -8.43 to 4.19. Intraclass correlation was 0.87/0.82 (ABIS-F/ABIS-R-F).Conclusions: The French versions ABIS-F and ABIS-R-F share similar psychometric properties, both are as reliable, but ABIS-R-F has a better response structure and is more feasible.Implications for rehabilitationThe quality of life of amputees is impacted by their satisfaction with body imageThe Amputee Body Image Scale questionnaire measures this perception and is available for French-speaking amputeesThe Standard Errors of Measurement proposed could be useful for clinical and research purposesBoth ABIS and ABIS-R showed satisfactory construct validity, internal consistency, and reliabilityThe shortened version has a better response structure and is more readily feasible.

A qualitative metasynthesis of the meaning of speech-generating devices for people with complex communication needs

The aim of this metasynthesis review of published qualitative research was to investigate the lived experience and meaning ascribed to speech-generating devices (SGDs) by people with complex communication needs and their familiar communication partners. Bibliographic databases were searched up to June 2016, and selected articles were assessed for their relevance to the research aim. The metasynthesis included 21 original articles and resulted in the identification of six main themes, each of which was comprised of two or more sub-themes that related to the experience of using SGD: It's an Inefficient Voice, It's Not a Natural Voice, Making the Most of This Voice, It's My Voice, It's More Than a Voice, and Having a Voice: Being Heard. The findings depict how use of an SGD is a complex process of understanding the limitations of the device, acknowledging expectations of society, using strategies to optimize communication, being aware of what an SGD represents, and using the SGD to enable social participation and a sense of empowerment.