Dysvascular Transtibial Amputation Research Articles

Is Maximum Available Hip Extension Range of Motion of the Residual Limb Reached During Passive Prone Lying in the Acute Stage After Dysvascular Transtibial Amputation?

ABSTRACT Introduction Individuals after a transtibial amputation (TTA) are at risk to develop a hip flexion contracture, which may adversely affect future ambulation with a prosthesis. Although patients have traditionally been advised to lie prone to maintain or improve hip extension, compensatory pelvic tilting may occur in prone lying (PL). We sought to compare hip extension range of motion (ROM) in PL to the modified Thomas test (MTT) position, because research implies that, in the MTT, patients are better able to control for compensatory pelvic tilting. We hypothesized that individuals after a TTA would have a greater peak hip extension angle in the MTT position compared with the PL position. Methods Ten individuals after a dysvascular TTA, mean age of 60 ± 8.42 years, participated in this study. The same physical therapist marked the femur and pelvis for goniometric measurement of peak hip extension angle by 12 raters blinded to each other's measurements. The markers remained unchanged as six raters measured all participants in PL and six different raters measured all participants in the MTT position. Results and Discussion The intraclass correlation (ICC) indicated high interrater reliability between the raters for the PL and MTT positions (ICC = 0.985 for PL and 0.976 for MTT). The average peak hip extension angle in PL was −14.0° ± 13.3°, standard error of mean = 4.3°; and in the MTT position was −8.6° ± 15.3°, standard error of mean = 4.8° (the negative mean connotes that, on average, participants did not have hip extension to neutral for either condition). We found a mean of 5.4° ± 6.6° more hip extension ROM for the MTT position compared with PL (P = 0.028). Conclusions Our findings show that, on average, patients after a TTA have significantly greater peak hip extension angle in the MTT position compared with the PL position. Thus, passive PL may not be as effective of a stretching position for preventing a hip flexion contracture after a TTA, because PL does not always extend the patient's hip to its maximum available ROM, due to the reduced ability to control the pelvis from tilting anteriorly. Clinical Relevance Adequate hip flexor length is positively correlated with gait parameters, which include increased velocity and step length in people using a prosthesis after transtibial amputation. This study implies that the MTT position may be a better method for improving and maintaining hip flexor length over the traditional strategy of passive PL.

Movement asymmetry during low and high demand mobility tasks after dysvascular transtibial amputation

BackgroundMovement asymmetries between lower limbs are commonly exhibited by adults after transtibial amputation. However, the degree of movement asymmetry between low- and high-demand functional tasks remains unknown. MethodsKinematic and kinetic data were collected during overground walking (low-demand) and step ascent (high-demand) tasks for two groups: 1) persons with transtibial amputation and 2) healthy matched peers. Analysis of covariance was used to compare sagittal-plane peak knee moment and joint angle (primary) and hip and ankle moments and joint angles, vertical ground reaction force and impulse (secondary). FindingsWithin transtibial amputation group comparisons showed significantly greater between-limb asymmetry in peak knee moment (p < .01), vertical impulse (p < .01), peak vertical ground reaction force (p = .05), peak ankle angle (p < .01) and peak ankle moment (p < .01) with the step ascent task compared to overground walking. The transtibial amputation group had greater between-limb asymmetry during step ascent in peak knee moment (p < .01), vertical impulse (p < .01), peak vertical ground reaction force (p = .04) and peak ankle angle (p < .01) than healthy matched peers. During overground walking, the transtibial amputation group had greater between-limb asymmetry in peak vertical impulse (p = .05) and peak ankle moment (p < .01) than healthy matched peers. InterpretationMovement asymmetry is increased during step ascent compared to overground walking for adults with transtibial amputation. While the restoration of overground walking is the focus of post-amputation rehabilitation and prosthetic design, higher demand tasks should also be considered to maximize mobility for adults with transtibial amputation.

Falls After Dysvascular Transtibial Amputation: A Secondary Analysis of Falling Characteristics and Reduced Physical Performance.

Over half of all people with lower limb amputation (LLA) experience at least one fall annually. Furthermore, the majority of LLAs result from dysvascular health complications, contributing to balance deficits. However, fall-related research specific to dysvascular LLA remains limited. To characterize falls among adults with dysvascular LLA, using an existing Fall-Type Classification Framework and to describe the functional characteristics of participants across the framework categories. Secondary data analysis from two randomized controlled trials. Outpatient setting. People (n = 69) 6 months to 5 years from dysvascular lower extremity amputation, who were ≥50 years of age and independently ambulatory using a prosthesis. None. Descriptions of self-reported falls were collected on a weekly basis for 12 weeks, and analyzed using an existing Fall-Type Classification Framework. Fall frequencies, estimated count, and estimated proportions were compared across all framework categories, with 95% confidence intervals. Functional measures (Timed Up and Go, Two Minute Walk, Five Meter Walk, and average step count) were collected, and averages for each participant who experienced a fall were calculated. Thirty participants (43.5%) reported 42 falls within 12 weeks. A variety of fall types were described. Incidence of falls was highest for intrinsic destabilization sources, from incorrect weight shift patterns during transfer activities. Patients with dysvascular LLAs experience a variety of fall types. The high frequency of intrinsically sourced, incorrect weight-shift falls during transfer activities emphasizes the need to focus rehabilitation efforts on improving postural control in patients with dysvascular LLAs during activities such as reaching, turning, and transferring.

Behavior-Change Intervention Targeting Physical Function, Walking, and Disability After Dysvascular Amputation: A Randomized Controlled Pilot Trial

ObjectiveTo determine preliminary efficacy of a home-based behavior-change intervention designed to promote exercise, walking activity, and disease self-management. DesignA single-blind, randomized controlled pilot trial. SettingOne Veterans Administration and 2 regional medical centers. ParticipantsA total of 38 participants randomized to behavior-change intervention (n=19) or attention control (CTL; n=19) group. InterventionsWeekly 30-minute telephone sessions for 12 weeks with intervention group sessions focused on health behavior change and CTL group sessions focused on health status monitoring. Main Outcome MeasuresPhysical function, walking activity (steps/d averaged over 10d), and disability were measured at baseline, 12 weeks (intervention end), and 24 weeks after baseline with the Timed Up and Go (TUG) test as the primary outcome measure. ResultsThe TUG test was not changed from baseline in either group and was not different between groups after 12 or 24 weeks. Several exploratory outcomes were assessed, including daily step count, which increased 1135 steps per day in the intervention group compared to 144 steps per day in the CTL group after 12 weeks (P=.03). Only the intervention group had within-group increase in steps per day from baseline to 12 (P<.001) and 24 (P=.03) weeks and spent significantly less time in sedentary activity (4.8% decrease) than the CTL group (0.2% decrease) at 24 weeks (P=.04). There were no other between-group differences in physical function or disability change over time. ConclusionThe behavior-change intervention demonstrates promise for increasing walking activity for people with dysvascular transtibial amputation (TTA). The efficacy of implementing such intervention in the scope of conventional TTA rehabilitation should be further studied.

Relationships Among Perceived Functional Capacity, Self-Efficacy, and Disability After Dysvascular Amputation

BackgroundProsthesis rehabilitation after dysvascular transtibial amputation (TTA) is focused on optimizing functional capacity with limited emphasis on promoting health self-efficacy. Self-efficacy interventions decrease disability for people living with chronic disease, but the influence of self-efficacy on disability is unknown for people with dysvascular TTA. ObjectivesTo identify if self-efficacy mediates the relationship between self-reported functional capacity and disability after dysvascular TTA. DesignCross-sectional, secondary data analysis. SettingOutpatient rehabilitation facilities. ParticipantsThirty-eight men (63.6 ± 9.1 years old) with dysvascular TTA. MethodsParticipants had been living with an amputation for less than 6 months and using walking as their primary form of locomotion using a prosthesis. The independent variable, functional capacity, was measured using the Prosthesis Evaluation Questionnaire–Mobility Scale (PEQ-MS). The proposed mediator, self-efficacy, was measured with the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD). Main Outcome MeasureDisability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire. ResultsThe relationship between self-reported functional capacity and disability is partially mediated by self-efficacy. Relationships between WHODAS 2.0 and PEQ-MS (r = –0.61), WHODAS 2.0 and SEMCD (r = –0.51), and PEQ-MS and SEMCD (r = 0.44) were significant (P < .01). Controlling for SEMCD (P = .04), the relationship between PEQ-MS and WHODAS 2.0 remained significant (P < .01). Statistically significant mediation was determined by a bootstrap method for the product of coefficients (95% confidence interval: –2.23, –7.39). ConclusionsThis study provides initial evidence that the relationship between self-reported functional capacity and disability is partially mediated by self-efficacy after dysvascular TTA. The longitudinal effect of self-efficacy should be further examined to identify causal pathways of disability after dysvascular amputation. Furthermore, additional factors contributing to the relationship between self-reported functional capacity and disability need to be identified. Level of EvidenceIII

Biomechanical compensations of the trunk and lower extremities during stepping tasks after unilateral transtibial amputation

BackgroundLower extremity movement compensations following transtibial amputation are well-documented and are likely influenced by trunk posture and movement. However, the biomechanical compensations of the trunk and lower extremities, especially during high-demand tasks such as step ascent and descent, remain unclear. MethodsKinematic and kinetic data were collected during step ascent and descent tasks for three groups of individuals: diabetic/transtibial amputation, diabetic, and healthy. An ANCOVA was used to compare peak trunk, hip and knee joint angles and moments in the sagittal and frontal planes between groups. Paired t-tests were used to compare peak joint angles and moments between amputated and intact limbs of the diabetic/transtibial amputation group. FindingsDuring step ascent and descent, the transtibial amputation group exhibited greater trunk forward flexion and lateral flexion compared to the other two groups (P<0.016), which resulted in greater low back moments and asymmetric loading patterns in the lower extremity joints. The diabetic group exhibited similar knee joint loading patterns compared to the amputation group (P<0.016), during step descent. InterpretationThis study highlights the biomechanical compensations of the trunk and lower extremities in individuals with dysvascular transtibial amputation, by identifying low back, hip, and knee joint moment patterns unique to transtibial amputation during stepping tasks. In addition, the results suggest that some movement compensations may be confounded by the presence of diabetes and precede limb amputation. The increased and asymmetrical loading patterns identified may predispose individuals with transtibial amputation to the development of secondary pain conditions, such as low back pain or osteoarthritis.

Identification of trunk and pelvis movement compensations in patients with transtibial amputation using angular momentum separation

Patients with unilateral dysvascular transtibial amputation (TTA) have a higher risk of developing low back pain than their healthy counterparts, which may be related to movement compensations used in the absence of ankle function. Assessing components of segmental angular momentum provides a unique framework to identify and interpret these movement compensations alongside traditional observational analyses. Angular momentum separation indicates two components of total angular momentum: (1) transfer momentum and (2) rotational momentum. The objective of this investigation was to assess movement compensations in patients with dysvascular TTA, patients with diabetes mellitus (DM), and healthy controls (HC) by examining patterns of generating and arresting trunk and pelvis segmental angular momenta during gait. We hypothesized that all groups would demonstrate similar patterns of generating/arresting total momentum and transfer momentum in the trunk and pelvis in reference to the groups (patients with DM and HC). We also hypothesized that patients with amputation would demonstrate different (larger) patterns of generating/arresting rotational angular momentum in the trunk. Patients with amputation demonstrated differences in trunk and pelvis transfer angular momentum in the sagittal and transverse planes in comparison to the reference groups, which indicates postural compensations adopted during walking. However, patients with amputation demonstrated larger patterns of generating and arresting of trunk and pelvis rotational angular momentum in comparison to the reference groups. These segmental rotational angular momentum patterns correspond with high eccentric muscle demands needed to arrest the angular momentum, and may lead to consequential long-term effects such as low back pain.

Postural Control in Response to Altered Sensory Conditions in Persons With Dysvascular and Traumatic Transtibial Amputation

ObjectiveTo compare the postural control of persons with a dysvascular transtibial amputation and traumatic transtibial amputation with able-bodied adults with and without a dysvascular condition in altered sensory testing conditions. DesignCross-sectional study. SettingUniversity balance clinic. ParticipantsThe study participants (N=35) included: participants with a dysvascular transtibial amputation (n=9), participants with a traumatic transtibial amputation (n=9), age-matched able-bodied adults without a dysvascular condition (n=9), and able-bodied adults with a dysvascular condition (n=8). InterventionsSix Sensory Organization Test (SOT) conditions, which included standing with eyes open (condition 1) and closed (condition 2) on a static force platform with visual surround; standing with eyes open on a static force platform with movable visual surround (condition 3); standing with eyes open (condition 4) and closed (condition 5) on a movable force platform with static visual surround; and standing with eyes open on a movable force platform with movable visual surround (condition 6). Main Outcome MeasuresBilateral anteroposterior (AP) and mediolateral (ML) center of pressure variables, namely root mean square distance (RMSD) and mean velocity (mVel), for each of the 6 SOT conditions. ResultsThe dysvascular transtibial amputation group demonstrated a higher AP RMSD (P≤.04) on the sound side than did the able-bodied adults without a dysvascular condition and the able-bodied adults with a dysvascular condition in SOT conditions 1 and 2, respectively. Both the dysvascular transtibial amputation group and the traumatic transtibial amputation group demonstrated a higher AP RMSD (P≤.002) than the able-bodied adults without a dysvascular condition in SOT conditions 3 and 4. The dysvascular transtibial amputation group showed higher AP mVel (P≤.002) on the sound side for SOT conditions 2 and 3, whereas both amputation groups showed higher AP mVel for SOT conditions 1 and 4 than the able-bodied adults with and without a dysvascular condition. ConclusionsPostural control of the dysvascular transtibial amputation group was not different than the traumatic transtibial amputation group in challenging sensory conditions. However, when compared with the groups of able-bodied adults with and without a dysvascular condition, postural strategies distinct with amputation etiology were observed.

Effects of Early Mobilization on Unhealed Dysvascular Transtibial Amputation Stumps: A Clinical Trial

Effects of Early Mobilization on Unhealed Dysvascular Transtibial Amputation Stumps: A Clinical Trial

Effects of Early Mobilization on Unhealed Dysvascular Transtibial Amputation Stumps: A Clinical Trial

VanRoss ER, Johnson S, Abbott CA. Effects of early mobilization on unhealed dysvascular transtibial amputation stumps: a clinical trial. Objective To observe the effects of early mobilization on unhealed transtibial (TT) amputation stump wounds of dysvascular etiology. An “unhealed” stump was defined as having a wound greater than 1cm × 1cm at least 3 weeks after surgery. Design An observational cohort study. Setting This center receives about 250 new lower-limb amputees a year from over 50 surgeons working in 16 hospitals. Over 35% are unhealed. Participants Sixty-six consecutive new TT amputees (age 62.8±10.8y) of dysvascular etiology (diabetes 50%) with unhealed stumps were recruited. Sixty-one percent were current or past smokers. The mean ± SD stump wound size was 7.7±2.7cm × 3.2±2.0cm. Interventions The wound size was measured, and stump transcutaneous oxygen (TcpO 2) and transcutaneous carbon dioxide (TcpCO 2) were measured. Wounds were debrided and dressed by using a standard protocol. Mobilization using a Pneumatic Post-Amputation Mobility (PPAM) Aid for approximately 3 weeks was followed by provision of a TT prosthesis. A standard physiotherapy walking training program was performed. Main Outcome Measures Stump wound healing, time to achieve healing, and resting transcutaneous oxygen pressure pre- and posttherapy. Results Of the 66 amputees, 4 did not start. Sixty-two started; 6 withdrew, and 56 completed the trial. Complete wound healing was achieved in 74% (46/62) over a mean of 141 (87–270) days. The mean ± SD stump TcpO 2 at baseline was 41.3±19.8mmHg and increased significantly to 50.6±21.9mmHg ( P<.02) after 97 (34–185) days of mobilization. Nine of 46 required revision plastic surgery. Five subjects, whose wounds were healing, became unwell, dropped out, and later deceased. Five subjects, all current smokers, did not heal and underwent higher amputation. Conclusions Patients with large unhealed TT stump wounds can simultaneously undergo walking training by using a prosthesis and can achieve wound healing. Seventy-four percent of subjects achieved full wound healing. The small minority of patients who did not heal were current smokers whose TcpO 2 levels did not improve throughout the trial. Rising levels of stump TcpO 2were associated with wound healing.

Health related quality of life in patients with dysvascular transtibial amputation.

Sixty adults with transtibial amputations completed a validated outcomes instrument assessing their prosthesis related quality of life. All had their amputations because of peripheral vascular disease or nonsalvageable diabetic foot infection. Of the patients, 46 were male and 14 were female. Forty-four had diabetes. All of the subjects used a prosthesis for a minimum of 6 months. The Prosthetic Evaluation Questionnaire measured prosthesis function (usefulness, residual limb health, and appearance), mobility (ambulation and transfers), psychosocial response (perceived responses, frustration, and social burden), well-being, and satisfaction. Scoring was accomplished using a linear analog scale, with poor responses rated as 0 and excellent responses rated as 100. Mobility scores were the lowest (ambulation, 55.3; transfer, 64.6). Functional scores were slightly better (usefulness, 65.7; residual limb health, 79.7; and appearance, 73.3). Psychosocial response scored best (perceived responses, 86.6; frustration, 69.1; and social burden, 66.4). The overall well-being scale graded at 67.0, and overall satisfaction scored at 65.2. Although experts in rehabilitation would expect function and mobility scores to be highest and psychosocial scores to be lowest, this population actually perceived the reverse to be true. These data provide realistic expectations for patients faced with transtibial amputation and a benchmark to measure newer treatment modalities or technical innovations.