Unilateral Lower Limb Amputation Research Articles

Reflexology treatment for patients with lower limb amputations and phantom limb pain—An exploratory pilot study

The objectives of the study were to evaluate the possibility of reflexology being used as a non-invasive form of phantom limb pain relief and of empowering patients to maintain any positive results with self-treatment. Prosthetic Services Centre, Herbert Street, Wolverhampton, West Midlands, England. A same-subject, experimental pilot study, recording the intensity of phantom limb pain in weekly pain diaries over a 30-week period, which was divided into five phases: phase 1 gave a baseline of pain, whilst phase 3 was a resting phase. Phases 2, 4 and 5 provided the reflexology interventions. Ten participants with unilateral lower limb amputations and phantom limb pain were selected from the database at the Prosthetic Centre. REFLEXOLOGY INTERVENTIONS: In phase 2, six weekly reflexology treatments were given, which consisted of: full foot reflexology to the remaining foot and full hand reflexology to the hand of the amputated side of the body. In phase 4, six weekly hand reflexology teaching sessions were carried out; patients copied on their own hands what the therapist did on hers. A hand reflexology booklet gave the sequence of the treatment and was used as a reference. In phase 5, the patients self-treated for 6 weeks at home, using the reference material. Over the 30-week period, there was an improvement in the perception of the presence and the intensity of the phantom limb pain, with a corresponding improvement in the duration of the pain and the affect on the person's lifestyle. The improvement was maintained when the clients self-treated. FOLLOW-UP QUESTIONNAIRE: A follow-up questionnaire was carried out in 2007--12 months after the project had ended--to elicit whether the patients had suffered from phantom pain over the previous 12 months, whether they still had relief from phantom limb pain and whether they still self-treated. The project indicated that reflexology treatment, teaching and self-treatment were effective in eradicating or reducing the intensity and duration of phantom limb pain, in this group of clients. The follow-up questionnaire revealed that there was a maintained improvement in the intensity of phantom limb pain the patients experienced and that the majority still self-treated.

Uphill and downhill walking in unilateral lower limb amputees

Objective To study adjustment strategies in unilateral amputees in uphill and downhill walking. Design Observational cohort study. Subjects Seven transfemoral, 12 transtibial unilateral amputees and 10 able-bodied subjects. Methods In a motion analysis laboratory the subjects walked over a level surface and an uphill and downhill slope. Gait velocity and lower limb joint angles were measured. Results In uphill walking hip and knee flexion at initial contact and hip flexion in swing were increased in the prosthetic limb of transtibial amputees. In downhill walking transtibial amputees showed more knee flexion on the prosthetic side in late stance and swing. Transfemoral amputees were not able to increase prosthetic knee flexion in uphill and downhill walking. An important adjustment strategy in both amputee groups was a smaller hip extension in late stance in uphill and downhill walking, probably related with a shorter step length. In addition, amputees increased knee flexion in early stance in the non-affected limb in uphill walking to compensate for the shorter prosthetic limb length. In downhill walking fewer adjustments were necessary, since the shorter prosthetic limb already resulted in lowering of the body. Conclusion Uphill and downhill walking can be trained in rehabilitation, which may improve safety and confidence of amputees. Prosthetic design should focus on better control of prosthetic knee flexion abilities without reducing stability.

Balance control on a moving platform in unilateral lower limb amputees

Objective To study balance control on a moving platform in lower limb amputees. Design Observational cohort study. Participants Unilateral transfemoral and transtibial amputees and able-bodied control subjects. Interventions Balance control on a platform that moved in the anteroposterior direction was tested with eyes open, blindfolded and while performing a dual task. Main outcome measures Weight bearing symmetry, anteroposterior ground reaction force and centre of pressure shift. Results Compared to able-bodied subjects, in amputees the anteroposterior ground reaction force was larger in the prosthetic and non-affected limb, and the centre of pressure displacement was increased in the non-affected limb and decreased in the prosthetic limb. In amputees body weight was loaded more on the non-affected limb. Blindfolding or adding a dual task did not influence the outcome measures importantly. Conclusion The results of this study indicate that experienced unilateral amputees with a high activity level compensate for the loss of ankle strategy by increasing movements and loading in the non-affected limb. The ability to cope with balance perturbations is limited in the prosthetic limb. To enable amputees to manage all possible balance disturbances in real life in a safe manner, we recommend to improve muscle strength and control in the non-affected limb and to train complex balance tasks in challenging environments during rehabilitation.

Short-term effect of physiotherapy rehabilitation on functional performance of lower limb amputees

The objective of the trial was to evaluate the effectiveness of a short and intensive physiotherapy programme versus usual care, mainly consisting of walking. Fifty-eight male unilateral lower limb amputees were randomised over intensive care (N = 29) and usual care (N = 29); this study was carried out in a clinical environment, within the premises of the International Committee of the Red Cross, in Southern Myanmar. The amputees in the experimental group received a three-day programme built around 7 specific exercises, lasting approximately one hour altogether. Effects were assessed on: 2-minute walk test, physiological cost index (PCI), amount of weight bearing on both legs, 5 questions of the Functional Measure for Amputees questionnaire and the timed up and go test. Trans-tibial amputees were tested the first day they were fitted and then 2 days later; trans-femoral amputees were tested when walking out of the parallel bars and 4 days later. The experimental group showed significant improvement in the 2-minute walk test (p = 0.02), in the PCI (p = 0.02) and in the maximal weight bearing test on the amputated leg (p = 0.04). Despite limited means, research remains feasible in a developing country; this study has demonstrated that physiotherapy is effective in improving functional performance of lower limb amputees and therefore has its place in every rehabilitation centre.

Activity Levels Among Lower-Limb Amputees: Self-Report Versus Step Activity Monitor

Stepien JM, Cavenett S, Taylor L, Crotty M. Activity levels among lower-limb amputees: self-report versus step activity monitor. Objective To determine the accuracy of self-reported activity by community-dwelling, lower-limb amputees. Design Descriptive study. Setting A regional prosthetics outpatient service. Participants Seventy-seven unilateral lower-limb amputees at least 6 months after prosthetic rehabilitation. Interventions Not applicable. Main Outcome Measures Measured activity counts (in steps/min) and self-reported activity (rest, low, medium, high) in 15-minute intervals over 1 week were recorded for each participant. Results Participants averaged 3063±1893 steps per day. Strong agreement (γ≥0.7) between self-reported and measured activity was found for only 34% of participants between the hours of 9:00 am to 9:00 pm. The measured and self-reported proportion of time spent in various states of activity also showed poor agreement (rest, r=.41; low level activity, r=.39; medium level, r=.26; high level, r=.40). There was no bias toward either over- or under-reporting. Conclusions The majority of participants were unable to accurately self-report their activity levels (sleep excluded) as compared with measured activity levels. This may have important implications for prescribing appropriate prosthetics and for clinicians who provide patients with advice on promoting health.

Energy cost of walking measurements in subjects with lower limb amputations: A comparison study between floor and treadmill test

Measuring the energy cost of walking (ECW) is a valid way of assessing the walking efficiency of subjects who were prosthetic users following lower limb amputation. The aim of this study was to determine whether, in these subjects, treadmill and floor ECW measurements are comparable. We tested 24 subjects who had undergone unilateral lower limb amputations for vascular diseases as they walked at a self-selected comfortable speed on the floor and on a treadmill. The tests were conducted at the end of rehabilitative treatment to fit prosthesis. Eight subjects underwent transtibial and 16 transfemoral amputation. The measurements were taken with a portable gas analyzer. The self-selected comfortable speed on the treadmill was significantly lower than that on the floor, where the patients adopted the aid they normally used for walking; oxygen consumption was the same in the two tests. Therefore, for both transtibial and transfemoral patients, ECW was greater during walking on the treadmill. Steady-state heart rate did not differ in the two tests. The data show that the ECW values of the amputated subjects obtained on the treadmill at the end of rehabilitation did not correspond with those they obtained on the floor. The floor test is the one that may better reflect walking with prostheses and aids in everyday life, in subjects with dysvascular lower limb amputation, using the prosthesis for a short time.

Mental Health Outcome Of Unilateral Lower Limb Amputee Soldiers In Two Districts Of Sri Lanka

Thousands of armed forces personnel in Sri Lanka have undergone lower limb amputations due to war injuries. The aims were to describe the mental health outcome of unilateral lower limb amputee male soldiers of the Sri Lanka Army in comparison with nonamputee males and to identify factors affecting the mental health outcome. Selected amputee soldiers (n = 461) and controls (n = 461) were evaluated for psychological distress using self-administered versions of GHQ-30 and BSI. Alcohol and drug consumption patterns were compared. Probable addiction to alcohol and drugs were assessed using the CAGE questionnaire. A majority were below-knee amputees (413, 89.6%). Among amputee soldiers 36% were found to be psychologically distressed according to GHQ-30 while 13.4% were found to be psychologically distressed using BSI. Psychological distress was greater among amputee soldiers compared to controls (p < 0.001). Alcohol consumption and substance abuse were more common among amputees (p < 0.05), as was probable addiction to alcohol (p < 0.001). Being less than 30 years of age (OR =1.6, 95% CI (1.12-2.26)) was a factor influencing presence of psychological distress, characterized by psychological symptoms. Employment in the army adversely influenced psychological distress, characterized by psychological symptoms (OR = 2.35, 95% CI (2.0-3.64)) and by somatic symptoms (OR = 1.8, 95% CI (1.23-3.14)). The study concluded that amputees have a comparatively poor mental health outcome, which could be improved by modifying some associated factors.

Pain, functional status, social function and conditions of habitation in elderly unilaterally lower limb amputees

Few authors are involved in home rehabilitation of amputees or their reintegration into the community. It has been remarked that there is a discontinuity between the phases of the amputee rehabilitation in Serbia. The aim of the study was to establish pain characteristics and functional status of amputees two months after the amputation and to determine their social function and the conditions of their habitation. This prospective observation study involved 38 elderly amputees with unilateral lower limb amputations. The patients were tested at the hospital on discharge and at their homes two months after the amputation. Pain intensity and functional status were measured by a visual analogue scale (VAS) and by Functional Independence Measure (FIM). The patients' social function was assessed using the Social Dysfunction Rating Scale (SDRS) and conditions of their habitation by the self-created Scale of Conditions of Habitation (SCH). In statistic analysis we used the Student t test, chi2 test and Analysis of variance (ANOVA). The majority of patients (63%) underwent below knee amputation caused by diabetes (89%). A significant number of patients (84%, chi2 = 17.78; p < 0.01) was not visited by a physiotherapist nor an occupational therapist during two months at home. In this period, the majority of the amputees (68%) had phantom pain or residual limb pain (21%). Two months after amputation the pain intensity was significantly lower (VAS = 4.07 +/- 2.19; 2.34 +/- 1.41; p < 0.001), and the functional status significantly better than on discharge (FIM = 75.13 +/- 16.52; 87.87 +/- 16.48; p < 0.001). The amputees had the average level of social dysfunction (SDRS = 62.00 +/- 11.68) and conditions of habitation (SCH = 7.81 +/- 1.97). A total 38 elderly amputees with unilateral lower limb amputations achieved significant functional improvement and reduction of pain, in spite of their social dysfunction, the absence of socio-medical support and inadequacy of the conditions of habitation.

A Descriptive Study of Traumatic Lower Limb Amputees from the Hospital del Trabajador

The purpose of the study was to describe the demographics, the causes of amputations, the amputation levels, the clinical outcomes, the durability of prostheses in unilateral lower limb amputee among workers entitled to non-state related work insurance, the ACHS, Chile, between 1974 and 2001. It was a retrospective descriptive study based on selected clinical files. One hundred files, with the minimal data required, were selected with a diagnosis of traumatic lower limb amputation, the levels ranging from Boyd's foot amputation to hip disarticulation, as defined by the Occupational Accidents Act from 1974 to December 2001. The mean age was 35.5 years, 96% were males, with an average follow-up of 7.7 years. In 50% of the cases the education level did not exceed elementary school. Ninety-eight percent were blue collar workers. The traumatic injury resulting in amputation took place during work in 89% of the cases the main causes being crushing injury (50%), traffic accident (19%), run over by car (14%) and burns (6%). The most common amputation levels were trans-femoral (40%) and trans-tibial (47%). Amputations were performed within the first 24 h in 49% of the cases. The hospitalization stay reached 8 weeks in 56.7%. Early complications were dehiscence (9.4%), superficial infection, (14.6%) and deep infection (26%). Late complications detected were soft tissue lesions (34.1%), exostosis (3.6%), painful neuroma (12.5%) and phantom limb pain (12.5%). Prostheses durability was on average 3 years. The average period to resume work was 1 year for 60% of the cases.

Functional Outcomes of Unilateral Lower Limb Amputee Soldiers in Two Districts of Sri Lanka

The purpose of this study was to describe functional outcomes of unilateral lower limb amputee soldiers, in comparison to nonamputee male subjects, and to identify factors affecting functional outcomes. Selected lower limb amputee soldiers of the Sri Lanka Army (n = 461) and matched nonamputee male subjects (n = 461) were evaluated with the prevalidated self-administered version of Short-Form Health Survey-36. A majority were below-knee amputees (n = 413; 89.6%), and the mean age was 30.2 +/- 4.6 years. Short-Form Health Survey-36 health profile scores of amputees were significantly lower than those of nonamputees (p < 0.001). The differences in profiles were largest in scales sensitive to physical health. Higher levels of amputation and problems with the stump and sound leg were significantly associated with poor physical and mental health scores. Amputee soldiers' assessment of changes in health over the past year was significantly worse than that of nonamputees (p < 0.001). The study concluded that amputees have comparatively poor functional outcomes, which could be improved by modifying some associated factors.

The mechanics of landing when stepping down in unilateral lower-limb amputees

The ability to successfully negotiate stairs and steps is an important factor for functional independence. While work has been undertaken to understand the biomechanics of gait in lower-limb amputees, little is known about how amputees negotiate stairs and steps. This study aimed to determine the mechanics of landing in unilateral lower-limb amputees when stepping down to a new level. A secondary aim was to assess the effects of using a shank-mounted shock-absorbing device (Tele-Torsion Pylon) on the mechanics of landing. Ten unilateral amputees (five transfemoral and five transtibial) and eight able-bodied controls performed single steps down to a new level (73 and 219 mm). Trials were repeated in amputees with the Tele-Torsion Pylon active and inactive. The mechanics of landing were evaluated by analysing peak limb longitudinal force, maximal limb shortening, lower extremity stiffness, and knee joint angular displacement during the initial contact period, and limb and ankle angle at the instant of ground-contact. Data were collected using a Vicon 3D motion analysis system and two force platforms. Amputees landed on a straightened and near vertical limb. This limb position was maintained in transfemoral amputees, whereas in transtibial amputees knee flexion occurred. As a result lower extremity stiffness was significantly greater in transfemoral amputees compared to transtibial amputees and able-bodied controls (P<0.001). The Tele-Torsion Pylon had little effect on the mechanics of landing in transtibial amputees, but brought about a reduction in lower extremity stiffness in transfemoral amputees (P<0.05). Amputees used a stepping strategy that ensured the direction of the ground reaction force vector was kept anterior of the knee joint centre. Using a Tele-Torsion Pylon may improve the mechanics of landing during downward stepping in transfemoral amputees.

The gait initiation process in unilateral lower-limb amputees when stepping up and stepping down to a new level

Background. Unilateral lower-limb amputees lead with their intact limb when stepping up and with their prosthesis when stepping down; the gait initiation process for the different stepping directions has not previously been investigated. Methods. Ten unilateral amputees (5 transfemoral and 5 transtibial) and 8 able-bodied controls performed single steps up and single steps down to a new level (73 and 219 mm). Duration, a-p and m-l centre of mass and centre of pressure peak displacements and centre of mass peak velocity of the anticipatory postural adjustment and step execution phase were evaluated for each stepping direction by analysing data collected using a Vicon 3D motion analysis system. Findings. There were significant differences (in the phase duration, peak a-p and m-l centre of pressure displacement and peak a-p and m-l centre of mass velocity at heel-off and at foot-contact) between both amputee sub-groups and controls ( P < 0.05), but not between amputee sub-groups. These group differences were mainly a result of amputees adopting a different gait initiation strategy for each stepping direction. Interpretation. Findings indicate the gait initiation process utilised by lower-limb amputees was dependent on the direction of stepping and more particularly by which limb the amputee led with; this suggests that the balance and postural control of gait initiation is not governed by a fixed motor program, and thus that becoming an amputee will require time and training to develop alternative neuromuscular control and coordination strategies. These findings should be considered when developing training/rehabilitation programs.

Prosthetic Outcome of Unilateral Lower Limb Amputee Soldiers in Two Districts of Sri Lanka

In Brief The purpose of this study was to evaluate the prosthetic outcome of unilateral lower limb amputee soldiers and to identify factors affecting prosthesis use. Selected unilateral above-knee (AK) and below-knee (BK) amputee soldiers of the Sri Lanka Army (n = 461) who had completed prosthetic training were evaluated using an interviewer-administered questionnaire. The theoretical model, PRECEDE (predisposing, reinforcing, and enabling factors in educational diagnosis and evaluation), was used as the framework to identify factors affecting prosthetic use. A majority was BK amputees (413, 89.6%). Mean age of amputees at the time of the study was 30.2 (± 4.6) years. All 48 (100%) AK amputees and 410 (99.3%) of 413 BK amputees were wearing prostheses at least 1 day per week. BK amputees showed higher mean hours of wearing per day (11.0 ± 3.9) compared with AK amputees (8.2 ± 4.2; P <.001). Of the prosthesis wearers, 196 (42%) performed all indoor mobilizations and 292 (62.8%) performed all outdoor mobilizations wearing a prosthesis. Wheelchair use for indoor and outdoor mobilizations was minimal (<5%). A majority did not use any technical aid for walking indoors (308, 66.4%) or outdoors (270, 58.2%). Higher level of amputation, presence of problems in the residual limb, and problems with the unaffected leg were factors that significantly reduced prosthesis use indoors and outdoors. The inability to wear a prosthesis alone was a factor associated with less use indoors, and nonparticipation in sports/social work was a factor significantly associated with less prosthesis use outdoors. It was concluded that prosthesis use was satisfactory but could be improved. The purpose of this study was to evaluate the prosthetic outcome of unilateral lower limb amputee soldiers and to identify factors affecting prosthesis use. Theoretical model PRECEDE (predisposing, reinforcing, and enabling factors in educational diagnosis and evaluation) was used to identify factors affecting prosthetic use in above-knee and below-knee amputee soldiers who had completed prosthetic training. The authors found that prosthesis use was satisfactory but could be improved.

The Trinity amputation and prosthesis experience scales and quality of life in people with lower-limb amputation

Gallagher P, MacLachlan M. The Trinity Amputation and Prosthesis Experience Scales and quality of life in people with lower-limb amputation. Arch Phys Med Rehabil 2004;85:730–6. Objectives To undertake preliminary research into quality of life (QOL) for a group of people with a lower-limb amputation and to investigate what aspects of the “prosthetic experience” are most strongly associated with QOL using the Trinity Amputation and Prosthesis Experience Scales (TAPES). Design Cross-sectional survey. Setting Prosthetic limb fitting center. Participants Sixty-three people older than 18 years with unilateral lower-limb amputation. Interventions Not applicable. Main outcome measures The TAPES and the World Health Organization Quality of Life Questionnaire—Brief Version. Results There were no significant differences in any of the QOL domain scores (physical health, psychological, social relationships, environmental) arising from age, gender, level of amputation, or cause of amputation. However, there were significant differences depending on the length of time living with the prosthesis and the degree of prosthetic use. Stepwise regression identified different significant predictors for each domain of QOL. Conclusions These findings support the claim that the TAPES can be used to evaluate QOL for this patient group. Further research is warranted to learn how sensitive the scale and its items are to change in clinical status.

Reliability, validity, and responsiveness of the locomotor capabilities index in adults with lower-limb amputation undergoing prosthetic training

Franchignoni F, Orlandini D, Ferriero G, Moscato TA. Reliability, validity, and responsiveness of the Locomotor Capabilities Index in adults with lower-limb amputation undergoing prosthetic training. Arch Phys Med Rehabil 2004;85:743-8. Objective To assess the reliability, validity, and responsiveness of both the standard and revised Locomotor Capabilities Index (LCI) in people with lower-limb amputation who undergo prosthetic training. Design Reliability and validity study. Setting Two freestanding rehabilitation centers. Participants Fifty inpatients with a recent unilateral lower-limb amputation. Interventions Not applicable. Main outcome measures The standard LCI and a new version with a 5-level ordinal scale (LCI-5) were tested for internal consistency, test-retest reliability, ceiling effect, and effect size. The construct validity of both versions was analyzed by correlation with the Rivermead Mobility Index, a timed walking test, and the FIM instrument. Results The Cronbach α of both LCI versions was .95. The item-to-total correlations (Spearman ρ) ranged from .50 to .87 ( P<.0001 for all). The percent agreement and κ values for the item scores ranged, respectively, from 78.4% to 100% and .58 to 1.00 in the LCI, and from 75.7% to 97.3% and .54 to .96 in the LCI-5. The intraclass correlation coefficient (model 2,1) for the total scores was .98 for both versions; the Bland-Altman plot revealed no systematic trend for either version. Both the LCI and LCI-5 correlated with all criterion measures (ρ range, .61–.76), with the LCI-5 showing a larger effect size during the rehabilitation period and a lower ceiling effect. Patients with transtibial amputation were more independent in performing activities than were those with transfemoral amputation; their locomotor capability negatively correlated with age. Conclusions Both the LCI and LCI-5 captured the global locomotor ability of people with lower-limb amputation during prosthetic training. The new LCI-5 presents similar and sometimes better psychometric properties than the standard LCI.

Health practices of veterans with unilateral lower-limb loss: Identifying correlates

Persons with a nontraumatic lower-limb amputation are at high risk of losing their contralateral limb in the years postamputation. In this study, veterans with a unilateral lower-limb amputation participated in a survey about health beliefs and health practices known to affect risk of amputation (foot care and smoking). Most participants reported good foot-care practices (93% checked the top of their foot, 73% checked the bottom of their foot, 75% checked between their toes, and 72% washed their foot daily); however, a small percentage engaged in important foot-care practices less than once a week (2% checked the top of their foot, 7% checked the bottom of their foot, and 7% checked between their toes less than once a week). In addition, nearly a third still smoked. The belief in one's ability to engage in good foot care and the belief that good foot care reduces the risk of future foot problems were significantly correlated with foot-care practices. In addition, psychological well-being (life satisfaction) was significantly related to foot care and smoking status. Longitudinal research is needed to identify determinants of health behaviors to better direct intervention efforts.

Mobility outcome following unilateral lower limb amputation.

This study investigated mobility outcome following unilateral trans-tibial or trans-femoral amputation. It was an observational study at the sub-regional amputee rehabilitation centre in Sheffield, UK. All unilateral trans-tibial or transfemoral amputees referred during the study period were included. The Harold Wood Stanmore mobility grade was recorded approximately one year following initial assessment at the centre. Of the 357 amputees referred, complete outcome data was available for 281 (78.7%). The mean age was 68 years (range 16-95), 70.1% were male, and the aetiology of the amputation was vascular or diabetic in 87.5% of cases. Trans-tibial amputations accounted for 50.5% and trans-femoral 49.5%. Almost all trans-tibial and trans-femoral amputees aged 50 and under achieved functional household and community mobility. Approximately 50% of the trans-tibial amputees aged over 50 years gained independent community mobility and around 60% household mobility. There was a significant worsening of community mobility rates with increasing age but for household mobility the differences did not reach statistical significance. Fewer than 25% of trans-femoral amputees aged over 50 achieved community mobility and around 50% achieved household mobility. There was a statistically significant deterioration in both community and household mobility levels with increasing age. This study concludes that mobility rates one year after prosthetic provision for unilateral trans-tibial and trans-femoral amputees worsen with increasing age at amputation and a higher level of amputation.

Physical, Mental, and Social Predictors of Functional Outcome in Unilateral Lower-Limb Amputees

Schoppen T, Boonstra A, Groothoff JW, de Vries J, Göeken LN, Eisma WH. Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees. Objective: To study the value of physical, mental, and social characteristics as predictors of functional outcome of elderly amputees. Design: Prospective, inception cohort study; comparisons with reference populations. Setting: Main hospitals, rehabilitation centers, nursing homes, patients’ own residence settings in 1 of the 3 northern provinces in the Netherlands. Participants: Forty-six patients older than 60 years, with unilateral transtibial or transfemoral amputation or knee disarticulation because of vascular disease. Interventions: Measurement of physical, mental, and social predictors 2 and 6 weeks postamputation. Main Outcome Measures: The Sickness Impact Profile (SIP-68), Groningen Activity Restriction Scale (GARS), Timed up and go (TUG) test, and prosthetic use. Results: A total of 15% of amputees died within the first year after amputation. Seventy percent lived independently at home 1 year postamputation. The functional level of the patients was low, as shown by high scores on the SIP-68 (mean, 23.6), GARS (mean, 41.2), and TUG test (mean, 23.9s). Functionally effective prosthetic use, as measured with the classification of Narang and Pohjolainen, was reached by 49%. For the SIP-68 scores, age, comorbidity, 1-leg balance, and the 15-word test predicted functional outcome in 69% of amputees. For the GARS score, age, 1-leg balance, and the 15-word test predicted functional outcome in 64%. For the TUG test, age and 1-leg balance predicted functional outcome in 42% of amputees. After correction for age, the only significant predictor for prosthetic use was 1-leg balance. Conclusions: Elderly patients with a leg amputation had a low functional level 1-year postamputation. An important part of functional outcome could be predicted 2 weeks after amputation by age at amputation, 1-leg balance on the unaffected limb, and cognitive impairment. Severe comorbidity probably also played a role. The results may be used in the general policy concerning leg amputees.

Return to work after lower limb amputation.

This study investigated the proportion of patients who returned to work following amputation and the factors that influenced a positive or negative outcome. One hundred patients of working age who had sustained unilateral lower limb amputation at least 1 year previously and who were established prosthesis users participated in the study. A specially designed questionnaire similar to a guided interview was administered by the rehabilitation physician at the patients' routine follow-ups. The questionnaire yielded a unique score dependent on whether return to work (or a different or preferred occupation) had been achieved with good or reduced productivity. All patients were eligible for mobility benefit, including schemes to purchase suitably adapted vehicles if necessary. However, no vocational rehabilitation was available. Sixty-six per cent of patients returned to employment and this was related to mobility, time since amputation and Handicap Scale scores. Age, socket comfort, level and cause of amputation, type of previous work or the presence of other medical problems did not differ between those who did and did not return to work. The Employment Questionnaire showed good correspondence with the London Handicap Scale, indicating some concurrent validity, although future development might include consideration of psychological factors, which could explain more of the reasons for continued unemployment.

Is the Rivermead Mobility Index a suitable outcome measure in lower limb amputees?--A psychometric validation study.

To examine the internal consistency, validity, responsiveness and test scalability of the Rivermead Mobility Index. Methodological research (consecutive sampling, prospective longitudinal study). 140 unilateral lower limb amputees (79 above-knee and 61 below-knee). The Rivermead Mobility Index was administered to all patients at the beginning (T0) and at the end (T2) of the prosthetic training. In 70 of the patients, the Functional Independence Measure and a timed walking test were also carried out. The Cronbach's alpha of the Rivermead Mobility Index was 0.85 and the item-to-total correlation coefficients rpb ranged from 0.33 to 0.74 (p < 0.0001), for the items considered, at T0; 4 correlations were not calculated due to the extremely low variability of some item responses (mode > or = 98%). The correlation (rs) of Rivermead Mobility Index score with the motor subscale of the Functional Independence Measure was 0.83 at T0 and 0.69 at T2 (p < 0.0001, for both) and that with timed walking test 0.70 (p < 0.0001) at T2. The effect size was 1.35. The scalability coefficients were below the limits of acceptability. When applied in lower limb amputees, the Rivermead Mobility Index is an ordinal measure with adequate levels of a series of psychometric properties, which seems more useful for epidemiological studies than for clinical decision-making in single patients. Further steps should be considered to improve its item selection, response format and scaling properties.