Nonamputated Limb Research Articles

Differences in the coordination of agonist and antagonist muscle groups in below-knee amputee and able-bodied children during dynamic exercise

A lack of co-contraction may predispose to knee instability or laxity, resulting in additional shear stress on the internal structures of the knee, especially in below-knee amputee (BKA) subjects. The purposes of this study were: (1) to provide information on how BKA children regulate agonist and antagonist muscle coordination, and (2) to quantify the level of knee co-contraction in able-bodied (AB) and BKA children during the stepping-in-place (SIP) task. Fourteen children (7 BKA vs. 7 AB), paired for age, weight and height, participated in this study. One-way ANOVA with Newman–Keuls post hoc tests ( p < 0.05) were used to compare peak power, the co-contraction index, and the resultant agonist and antagonist moments during different phases of SIP. Statistical analysis revealed that BKA children perform the task with similar kinematics than AB children while they generated less co-contraction in both their non-amputated limb and amputated limb, notably because the two groups of children used different agonist and antagonist muscles during the same periods of the SIP. This lack of co-contraction may reduce knee stability and may stress the internal structures of the knee in both the NAL and AL, and may lead to the development of premature knee osteoarthritis.

Isometric hip muscle strength in posttraumatic below-knee amputees

Traumas and war injuries, next to chronic occlusive artery disease and diabetes mellitus-derived complications, are the most frequent cause of the lower limbs amputation. They affect mostly younger population that need a higher level of activities as compared with the elderly. Medical rehabilitation is very significant for the muscle performance improvement in this population providing their social reintegration. The aim of this study was to investigate the effect of below-knee amputation on the hip isometric muscle strength and effect of rehabilitation on improvement of hip muscle strength in below-knee amputees, secondary to war wounding. Forty below-knee amputees (after war wounding), average age 35.6 +/- 10.6 years, that were included in primary rehabilitation program with prosthetics, were examined. Objective parameters were used to evaluate therapeutical effects. Isometric muscle strength of hip flexors, extensors, abductors and adductors was measured by dynamometer and expressed in Newton (N) at admission, control and discharge for each patient. Average length of the treatment was 51 +/- 34.1 days. For isometric hip flexors (t = -1.99346, p < 0.05), extensors (t = -4.629073, p < 0.001), abductors (t = -4.9408, p < 0.001) and adductors (t = -2.00228, p < 0.05), muscle strength was significantly less on the amputated than on nonamputated side. The highest differences in muscle strength between amputated and nonamputated limbs were noted for hip abductors (26.6%) and extensors (23.3%). There was significant improvement of mean values of strength for all examined hip muscles after rehabilitation and prosthetics for both legs in comparison to beginning of the therapy. The hip abductor on the amputated side was for 19.4% weaker after rehabilitation in comparison to the non-amputated limb. Decreases of isometric muscle strength in all examined hip muscles were observed, more in the amputated limb. Rehabilitation with prosthetics is a successful method for improving isometric hip muscle strength on the both, amputated and non-amputated limbs in war wounded below-knee amputees.

Phantom Pain, Residual Limb Pain, and Back Pain in Amputees: Results of a National Survey

Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Objectives To describe the prevalence of amputation-related pain; to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain; and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee. Design Cross-sectional survey. Setting A sample of persons who contacted the Amputee Coalition of America from 1998 to 2000 were interviewed by telephone. Participants A stratified sample by etiology of 914 persons with limb loss. Interventions Not applicable. Main Outcome Measures Prevalence, intensity, and bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee. Results Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7–10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome. Identifiable risk factors for intensity and bothersomeness of amputation-related pain varied greatly by pain site. However, across all pain types, depressive symptoms were found to be a significant predictor of level of pain intensity and bothersomeness. Conclusions Chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.

Functional outcome of patients with proximal upper limb deficiency–acquired and congenital

To investigate the functional outcome of patients with proximal upper limb deficiency--acquired and congenital (elbow disarticulation, transhumeral, shoulder disarticulation and forequarter level). Cohort observational study. All proximal upper limb amputees and patients with congenital upper limb absence currently registered with the Sheffield Mobility and Specialised Rehabilitation Centre. A self-administered postal questionnaire and medical records were used to collect data. The questionnaire obtained information about demographic details, dominancy of the amputated arm and independence and participation in activities of daily living (ADL), domestic and recreational activities. The prevalence of pain in the phantom limb and stump, and information regarding the remaining arm was also obtained. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the psychological state of the subjects. Trauma was the commonest cause of proximal upper limb loss (71.25%). Transhumeral amputation was the predominant level (78.75%). Although 73.2% returned to work following amputation, 66.6% had to change job. Overall rejection rate of prosthesis was 33.75%. Twenty-five per cent of patients found the prosthesis beneficial for driving and a small proportion used the prosthesis for employment and recreational activities, but the vast majority used the prosthesis primarily for cosmesis. Pain in the phantom limb was reported in 60% of our patients but there was no significant correlation between this and depression. Symptoms of overuse injury in the nonamputated limb were higher than expected in the normal population. As many as 33.75% of patients with proximal upper limb deficiency rejected their prostheses and many who continue to wear them do not find them useful in ADL and employment, etc. It is vital that rehabilitation programmes should focus on both prosthetic and nonprosthetic training to achieve maximal independence.

Selective thigh muscle atrophy in trans-tibial amputees: an ultrasonographic study.

In trans-tibial amputees, PTB (patellar tendon bearing) prostheses provide almost physiological mobility of the knee joint in the sagittal plane. Nevertheless, there are characteristic adaptations of the knee joint muscles. Myosonography is a suitable method for depicting muscle atrophy and hypertrophy due to muscle dysfunction. The present study was intended to assess anatomical alterations of thigh muscles in trans-tibial amputees wearing a PTB prothesis. Thicknesses and cross-sectional areas of the quadriceps femoris, sartorius, gracilis, semitendinosus and biceps femoris muscles were determined ultrasonographically on both limbs in 17 amputees with a PTB prothesis. The gait was analysed using an optoelectronical system, force plates and surface electromyography of the vastus lateralis and biceps femoris muscles. Quadriceps femoris and sartorius muscles of the amputated extremity exhibited significant atrophy compared with the contralateral limb (reduction of muscle thickness ranged between 11.7% and 30.4%), whereas the gracilis and hamstring muscles were not significantly affected. Even the quadriceps femoris muscle of the non-amputated limb showed a slight atrophy compared with a reference group. Increased echointensities were found predominantly in the quadriceps muscle on the amputated leg. During gait, electromyographical activity within the amputated limb was reduced in the vastus lateralis and increased in the biceps femoris muscle. Even long-term adaptation to PTB prostheses results in characteristic deviation from normal gait. Atrophy occurs in the ventral thigh muscles, predominantly on the amputated leg, whereas the dorsal thigh muscles are hardly affected, probably due to compensatory hyperactivity.

Predisposing Factors Related to Prosthetic Use by People with a Transtibial and Transfemoral Amputation

A survey was conducted to evaluate prosthetic use and factors predisposing to prosthetic use among 396 adults with unilateral amputations. A response rate of 76% was obtained. Eighty-five percent of the respondents were prosthetic wearers; 53% actively used their prosthesis for the majority of their indoor activities; and 64% did so for the majority of their outdoor activities. Adaptation to the amputation and prosthesis and level of amputation were significantly correlated with prosthetic wear and active use indoors and outdoors. Presence of arthritic problems in the nonamputated limb were negatively related to prosthetic wear, but for activities outdoors, muscle cramps and sores were the limiting factors. Long delays in limb fitting, prolonged training, cardiac and respiratory problems, and constant stump pain were significantly related to disuse. Linear and logistic regression analyses further identified the combined factors that could be predictive of prosthetic use.

Muscle metabolism changes with training in the nonamputated limb after vascular amputation: Interest of phosphorus 31 NMR spectroscopy

Objective: To determine by 31P nuclear magnetic resonance (NMR) spectroscopy the efficacy of training in improving aerobic metabolism of calf muscle in nonamputated limb after recent vascular amputation; to assess the possible associated microcirculatory changes; and to evaluate the need for noninvasive monitoring techniques during training in the nonamputated limb after recent vascular amputation. Design: Prospective study, before and after training. Subjects served as their own controls and were compared with a control group. Setting: Rehabilitation center of a university hospital. Patients: Ten unilateral vascular amputated patients were included with ankle systolic index between 0.5 and 0.8 in the nonamputated limb, and 10 control subjects without cardiovascular disease or risk factors of atherosclerosis with ankle systolic index of >.95. Intervention: Walking with prosthesis at self-selected velocity over increasing walking distance, arm training at a workload of 60% of a maximal arm test, and analytical exercises of the nonamputated leg (dynamic contractions against low resistance). Subjects received training as inpatients, 5 days a week. Main Outcome Measures: Before and after training, ankle systolic index, forefoot transcutaneous oxygen tension (TcPo 2) and veno-arteriolar reflex, and digital plethysmography of the second toe with reactive hyperemia test were studied. Changes in calf muscle pH, phosphocreatine (PCr), and inorganic phosphate (Pi) were measured by 31P NMR spectroscopy at rest and during a plantar flexion-type incremental protocol. Results: There was no significant difference in ankle systolic index (.63 ± .10 vs .64 ± .07) or in TcPo 2 (42 ± 11 vs 44 ± 10mmHg), and there was reappearance of veno-arteriolar reflex in 3 cases, of a plethysmographic signal in 2 cases, and of the positivity of the reactive hyperemia test in 3 cases. No differences were found with 31P NMR spectroscopy at rest before and after training. At the same workload (1 watt) the difference of the ratio (PCr/(PCr + Pi)) of rest to effort (PCr depletion) was significantly increased in the amputated patients (.423 ± .159 vs .145 ± .058; p < .01). This difference of ratio was lower after training (.360 ± .158 vs .423 ± .159; p < .05). The pH was less acid between the two periods. Conclusion: Vascular monitoring with systolic index and TcPo 2 is necessary to follow and to prevent serious ischemia of the nonamputated limb. Claudication is often not detected because of early exhaustion during walking. Training after recent vascular amputation improves the skeletal muscle oxydative capacity.

Osteoarthritis and elderly amputee gait.

The hypothesis that an increased load on the nonamputated leg of long-term prosthetic users leads to an increased risk of developing osteoarthritis was investigated using physical examinations and gait analysis. Based on the clinical results from an elderly group of experienced trans-tibial amputees and a similar control group of nonamputees, the amputee group experienced a significantly greater incidence of osteoarthritis (p < 0.05) in the knee of their nonamputated leg. The amputee group had consistently larger knee joint reaction forces, joint impulses, net joint moments, and net joint powers. Significantly higher results (p < 0.05) were found for amputee vertical impulse and net joint power during the double support phase of gait. These results support the hypothesis that elderly, trans-tibial amputees have a higher risk of developing osteoarthritis and experience larger forces at the knee of their nonamputated limb than people without lower extremity amputations.