Lower Limb Absence Research Articles

The physical experiences of women with lower limb absence during pregnancy and postpartum: symptoms, prosthesis management & mobility

Purpose Little information is available to women with lower limb absence (LLA) and their health care providers regarding the impacts they may experience during the perinatal period. This study explores the physical impacts of pregnancy on women with LLA, including mobility, prosthesis fit and prosthesis use. Methods We conducted semi-structured interviews with 19 women with LLA who had experienced pregnancy in the last 10 years. Interviews were analyzed using thematic analysis. Results Substantial variation exists in the experience of women’s physical symptoms, prosthesis management and mobility. Physical symptoms were similar to any pregnant individual, but the impacts were more substantial. As volume change in the residual limb can impact prosthesis fit, self-management techniques and prosthetist adjustments were used to manage it. Pregnancy impacted the way in which women were mobile and the activities they chose to participate in. A wide variety of creative mobility solutions were utilized to complete activities including prosthesis use, assistive equipment and adaptive movement. Conclusions Women with LLA and their health care providers must be aware of the wide range of experiences women face during pregnancy and treat each pregnancy uniquely. Planning ahead and working with a health care team can mitigate many of these challenges.

Resources, relationships, and resilience: The psychosocial experiences of women with lower limb absence during pregnancy and postpartum

BackgroundThere is limited research on the unique needs of women with lower limb absence (LLA) during pregnancy and postpartum. The lack of information can negatively impact women's physical and emotional experiences. ObjectiveThe purpose of this study is to explore the psychosocial experiences of individuals with LLA through the pregnancy and postpartum periods, and to provide information to women and health care providers (HCPs) on what they can expect. MethodsSemi-structured interviews were conducted with 19 women with LLA who had been pregnant in the previous 10 years. Interviews were analyzed using thematic analysis. ResultsParticipants experienced uncertainty due to a lack of information and limited resources related to pregnancy and LLA. While most women had strong support networks including family, other mothers with LLA and HCPs, some women faced stigma or judgement from HCPs and people in their social networks. Some women had periods where they struggled mentally due to a temporary loss of independence. Despite these challenges, they demonstrated tremendous resilience and noted that their ability to adapt helped them to navigate the difficulties they experienced in the perinatal period (PNP). ConclusionThere is an immediate need to fill the ‘information gap’ about pregnancy and LLA. We recommend the development of support networks, informational guidelines, and further education for HCPs to better support women with LLA through the PNP. Further research is warranted to gain a better understanding of the mental health experiences of women with LLA in the PNP.

Categorization and recommendations for outcome measures for lower limb absence by an expert panel.

Understanding the psychometric strengths and limitations of outcome measures for use with people with lower limb absence (LLA) is important for selecting measures suited to evaluating patient outcomes, answering clinical and research questions, and informing health care policy. The aim of this project was to review the current psychometric evidence on outcome measures in people with LLA to determine which measures should be included in a stakeholder consensus process. An expert panel was assembled, and a 3-stage review process was used to categorize outcome measures identified in a systematic literature review into 3 distinct categories (recommended for measures with better than adequate psychometric properties; recommended with qualification; and unable to recommend). Panelists were asked to individually categorize measures based on results of a systematic review of identified measures' psychometric properties. Each measure's final categorization was based on ≥70% agreement by all panelists. No outcome measure attained the ≥70% consensus threshold needed to achieve a rating of "recommend." Hence, panelists suggested combining "recommend" and "recommend with qualifications" into a single category of "recommend with qualifications." Using this approach, consensus was reached for 59 of 60 measures. Consensus could not be reached on 1 outcome measure (socket comfort score). Thirty-six outcome measures were categorized as "unable to recommend" based on available evidence; however, 23 (12 patient-reported measures and 11 performance-based measures) demonstrated adequate psychometric properties in LLA samples and were thus rated as "recommend with qualification" by the expert panel. The panel of experts were able to recommend 23 measures for inclusion in the subsequent stakeholder review. A key strength of this process was bringing together international researchers with extensive experience in developing and/or using LLA outcome measures who could assist in identifying psychometrically sound measures to include in a subsequent stakeholder consensus process. The above categorizations represent the current state of psychometric evidence on outcome measures for people with LLA and hence may change over time as additional research becomes available. The results will be used to achieve wider consensus from clinicians, health policymakers, health clinic managers, researchers, and end users (i.e., individuals with LLA) on outcome measures for the International Society of Prosthetics and Orthotics lower limb Consensus Outcome Measures for Prosthetic and Amputation ServiceS.

Facilitators and barriers for participation in sports and physical activity for children with lower-limb absence: A systematic review.

Sports and recreational activities offer physical and psychological benefits to children with limb absence. Understanding what facilitators and barriers exist for the participation in sports and physical activity is vital to aid stakeholders to continue enabling facilitators and develop means to tackle existing barriers so that all children with lower-limb absence can participate in sport and physical activity as they wish. The aim of this systematic review was to identify facilitators and barriers that children with lower-limb absence experience when wanting to participate in sports and physical activity. Systematic review. Five databases were used to identify the literature relating to facilitators and barriers to sports and physical activity for children with lower-limb absence. These were Medline, Scopus, Cochrane, SPORTDiscus, and CINAHL. Google scholar was used as a secondary source. The review followed the "Preferred Reporting Item for Systematic Reviews and Meta-Analysis" guidelines. The review identified 10 articles for inclusion that met predefined inclusion criteria. The identified peer-review articles date from 1999 to 2021. The number of published articles steadily increases up to 2010 and then increase rapidly from 2016 to 2021. The results show although there are facilitators for sports participation for children with limb absence, there are many barriers which continue to hinder many children from participating in sports and physical activity. Facilitators that exist include advancements in prosthetic design and technology, increased opportunities, and physical and social benefits. Barriers that were reported include prosthesis failure, stigma, and high costs.

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

Outcome measures are an important part of clinical practice to assist with the care of individuals with lower-limb absence (LLA). They aid with the devising and evaluation of rehabilitation plans, and guide decisions regarding the provision and funding of prosthetic services worldwide. To date, no outcome measure has been identified as a gold standard for use in individuals with LLA. Furthermore, the large number of outcome measures available has created uncertainty regarding outcome measures that are most appropriate for individuals with LLA. To critically appraise the existing literature related to the psychometric properties of outcome measures for use in individuals with LLA and provide evidence as to which outcome measures may be most appropriate for this clinical population. This is a systematic review protocol. CINAHL, Embase, MEDLINE (PubMed), and PsycINFO databases will be searched using a combination of Medical Subject Headings terms and keywords. Search terms that define the population (people with LLA or amputation), intervention (outcome measures), and outcome (psychometric properties) will be used to identify studies. The reference lists of included studies will be hand-search to identify other pertinent articles, with a further search conducted through Google Scholar to ensure that all studies not yet indexed through MEDLINE are captured. Full-text peer-reviewed journal studies published in English will be included, with no date limit set. Included studies will be appraised using the 2018 and 2020 COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklists. Data extraction and study appraisal will be completed by two authors, with a third author serving as an adjudicator. Quantitative synthesis will be used to summarize characteristics of the included studies, with kappa statistics used to determine agreement between authors for study inclusion and the application of COSMIN. Qualitative synthesis will be conducted to report on both quality of the included studies and psychometric properties of the included outcome measures. This protocol was designed to identify, appraise, and summarize patient-reported and performance-based outcome measures that have been psychometrically tested in people with LLA. Results from this review will be used to guide a consensus process on outcome measure use for people with LLA.Systematic review registration: PROSPERO registry number: CRD42020217820.

‘It’s more than just a running leg’: a qualitative study of running-specific prosthesis use by children and youth with lower limb absence

Purpose The purpose of this study was to investigate the use of running-specific prostheses (RSPs) by children with lower limb absence (LLA) along with the benefits and challenges of RSPs. Materials and methods In this descriptive qualitative study, eight children (ages 8–20 years) and their parents participated in semi-structured interviews. The interviews were audio-recorded and transcribed. Coded data were the foundation for central theme development. Results Three main themes were generated. “Run faster, jump higher, do more” (the benefits of RSP use), “Every leg serves its purpose” (comparing functionality between daily use prostheses and RSPs), and “A lot more to think about” (additional considerations with RSP use). Conclusions RSPs have a positive impact in promoting children’s engagement in sports and physical activities. While some children used their RSP primarily for running, others wore it for a broader range of physical activities. Issues with balance and discomfort caused by leg length discrepancies and/or ill-fitting sockets limited daily wear time. Limitations related to current RSP designs and clinical implementation should be addressed to optimize the functional potential of children with unilateral or bilateral LLA. Implications for rehabilitation Running-specific prostheses (RSPs) positively impacted children’s ability to participate in some sports with peers promoting their physical and social well-being. The main issues that children faced were discomfort, difficulty balancing, and inability to use RSPs for certain sports, while parents’ issues focused on supporting prosthesis use and transport, and adjustments of different prostheses to keep up with their child’s growth. Clinicians should be aware of the challenges of RSP use to best support children and their families. Designers should focus on addressing limitations with current RSPs to facilitate the diverse needs of pediatric users.

LEAD and COMPASS: Tools to map the way forward for people with lower limb absence.

LEAD and COMPASS: Tools to map the way forward for people with lower limb absence.

Reliability and Criterion-Related Validity of the activPAL™ Accelerometer When Measuring Physical Activity and Sedentary Behavior in Adults With Lower Limb Absence

Introduction: Accurate measurement of physical behavior in adults with lower limb absence is essential to report true patterns of physical behavior and the effectiveness of interventions. The effect of placing accelerometers on prostheses may also affect the reliability and validity.Purpose: To assess reliability and criterion-related validity of the activPAL for measuring incidental and purposeful stepping, and reclining and stepping time in adults with unilateral lower limb absence.Methods: 15 adults with unilateral lower limb absence completed simulated lifestyle activities in a laboratory setting that were retrospectively scored via video analysis. Objective data were obtained simultaneously from two activPAL monitors placed on the sound and prosthetic side. Data were analyzed using one-way intraclass correlation coefficients (ICC), pairedt-tests and Cohen’sd.Results: Reliability (prosthetic side vs. sound side) was poor for incidental steps (ICC = .05,d = 0.48) but acceptable for all other measures (ICC = .77–.88;d = .00–.18). Mean activPAL measures, although highly related to the criterion, underestimated, on average, stepping and time-related variables. Differences were large for all stepping variables (d = .38–.96).Conclusions: The activPAL is a reliable measurement tool in adults with lower limb absence when used in a laboratory setting. Placement of the monitor on the sound side limb is recommended for testing. The activPAL shows evidence of relative validity, but not absolute validity. Further evaluation is needed to assess whether similar evidence is found in free-living activity and sedentary contexts.

Physical activity guidelines and promotion: An online survey of United Kingdom's prosthetic rehabilitation healthcare professionals.

Background:Healthcare professionals play a key role in supporting physical activity participation for people with lower limb absence.Objectives:The objectives of this study were to survey healthcare professionals’ views of people with lower limb absence in the United Kingdom, explore their awareness and knowledge of physical activity recommendations and investigate their current and desirable practice towards physical activity promotion.Study design:Cross-sectional study.Methods:Potential participants were identified from open-access health-related databases, educational institution databases, and the authors’ professional networks. An online 40-item questionnaire was distributed electronically and by post. Survey items were multiple choice, Likert-type scale or open-ended questions to explore the characteristics of healthcare professionals, awareness/knowledge of physical activity guidelines, current and desired practice and views on physical activity promotion.Results:In total, 106 people responded. Physiotherapists had greater awareness/knowledge of physical activity guidelines compared to prosthetists/orthotists and other respondents. Awareness/knowledge of guidelines decreased as age, experience and time since qualification increased. The most common source of knowledge was self-directed learning.Conclusion:Continuing and improving education on the content of physical activity guidelines may be helpful for healthcare professionals in promoting physical activity to those with lower limb absence.Clinical relevanceThis research aims to inform prosthetic rehabilitation professionals and academics about an under-researched area within physical activity for health. This knowledge could help develop interventions with the aim of improving physical activity promotion and participation, and ultimately the health and well-being of people with limb absence.

Reassessment of Split-Leg Signs in Amyotrophic Lateral Sclerosis: Differential Involvement of the Extensor Digitorum Brevis and Abductor Hallucis Muscles.

Background: The muscle patterns involved in the “split-leg” syndrome of amyotrophic lateral sclerosis (ALS) remains controversial. We sought to evaluate and reassess the pattern of the extensor digitorum brevis (EDB) and the abductor hallucis (AH) muscles' involvement in split-leg syndrome in ALS.Methods: We recruited 60 consecutive patients with ALS and 25 healthy controls (HCs). Compound muscle action potentials (CMAPs) and F-waves were recorded over the EDB and AH muscles in all subjects. For comparison, we classified patients into two categories based on the presence or absence of lower limbs symptoms.Results: The EDB/AH CMAP amplitude ratio was significantly reduced in patients with affected legs (0.33 ± 0.21, P = 0.007), whereas patients with unaffected legs had a ratio similar to that of the HCs. The EDB/AH ratios for the F-wave latencies, mean F-wave amplitude, mean F/M amplitude ratio, and the persistence of the total repeater F-wave shapes (index Freps) of the EDB-AH, were significantly increased in the affected leg group, whereas the EDB/AH ratio for F-wave persistence was significantly reduced. These findings indicated a greater loss of lower motor neurons (LMNs) innervating the EDB and dysfunction of spinal motoneurons innervating the EDB. In the unaffected leg group, the EDB, but not the AH, F-wave latencies, mean and maximal F/M amplitude ratios, and index Freps were significantly altered. Receiver operating characteristic curve analysis suggested that the EDB F-wave latencies, mean F/M amplitude ratios, and index Freqs (area under the curve [AUC] > 0.8) more strongly differentiated patients with ALS from the HCs compared to the EDB/AH CMAP amplitude ratio (AUC = 0.61). Notably, the EDB maximal F-wave latency and index Freqs reliably differentiated patients with unaffected legs (HCs), with AUCs of 0.83 (95% CI 0.76–0.91) and 0.81 (95% CI 0.72–0.89), sensitivities of 76 and 78%, and specificities of 76 and 78%, respectively.Conclusions: These results suggest preferential EDB compared to AH involvement in the split-leg syndrome of ALS. The EDB maximal F-wave latency and index Freqs robustly differentiated patients with ALS from HCs, which might facilitate an earlier identification of ALS.

The effects of prosthetic ankle stiffness on stability of gait in people with transtibial amputation.

The ability to control balance during walking is a critical precondition for minimizing fall risk, but this ability is compromised in persons with lower-limb absence because of reduced sensory feedback mechanisms and inability to actively modulate prosthesis mechanical function. Consequently, these individuals are at increased fall risk compared with nondisabled individuals. A number of gait parameters, including symmetry and temporal variability in step/stride characteristics, have been used as estimates of gait stability and fall risk. This study investigated the effect of prosthetic ankle rotational stiffness on gait parameters related to walking stability of transtibial prosthesis users. Five men walked with an experimental prosthesis that allowed for independent modulation of plantar flexion and dorsiflexion stiffness. Two levels of plantar flexion and dorsiflexion stiffness were tested during level, uphill, and downhill walking. The results demonstrate that low plantar flexion stiffness reduced time to foot-flat, and this was associated with increased perceived stability, while low dorsiflexion stiffness demonstrated trends in temporal-spatial parameters that are associated with improved gait stability (reduced variability and asymmetry). Prosthesis design and prescription for low rotational stiffness may enhance gait safety for transtibial prosthesis users at risk of unsteadiness and falls.

Prenatal sonographic findings in a fetus with splenogonadal fusion limb defect syndrome

Splenogonadal fusion limb defect syndrome (SGFLD) is a very rare abnormality. We report on a case with prenatal sonographic findings of a fetus with postnatally diagnosed SGFLD syndrome. This is also the second case of prenatal ultrasonographic diagnosis of gastrointestinal malrotation associated with SGFLD. A 26-year-old primigravid woman was referred to our clinic because of nonvisualization of both fetal femoral bones at 20 weeks of gestation. A detailed sonographic examination showed complete bilateral absence of lower limbs, micrognathia, single umbilical artery and a right-sided stomach. Autopsy confirmed prenatal sonographic findings and additionally showed that the spleen was abnormally connected to the left gonad by a fibrous band. In conclusion, although all limbs and both sides were equally affected in most of the reported cases, SGFLD syndrome should be considered in cases with terminal limb defects of lower limbs.