Unilateral Lower Limb Amputation Research Articles

Importance of Bilateral Hip Assessments in Unilateral Lower-Limb Amputees: A Retrospective Review Involving Older Veterans

Background/Objectives: This study aimed to evaluate bone mineral density (BMD) discordance and its implications in veterans with unilateral lower-limb amputation, emphasizing the need for comprehensive hip assessments. Methods: Data were collected from 84 male veterans, and BMD was measured using dual-energy X-ray absorptiometry (DXA) at the lumbar spine, intact hip, and amputated hip. Results: The T-scores for the lumbar spine, intact hip, and amputated hip were −0.27 ± 1.69, −0.25 ± 1.20, and −1.07 ± 1.33, respectively. Osteoporosis and osteopenia were present in 19% and 34.6% of patients, respectively. Osteopenia and osteoporosis were most prevalent in the hips on the amputated side (32.1% and 13.1%, respectively), followed by the lumbar spines (22.6% and 8.3%) and the hips on the intact side (17.9% and 2.4%). BMD discordance between the lumbar spine and hip was found in 47.6% of participants, while discordance between both hips was observed in 39.3%. Transfemoral amputees had significantly lower BMD at the amputated hip compared to transtibial amputees (−2.38 ± 1.72 vs. −0.87 ± 1.16, p < 0.001). Conclusions: Veterans with unilateral lower-limb amputation exhibit a high prevalence of osteoporosis and significant BMD discordance, particularly between both hips. These findings underscore the necessity for bilateral hip assessments to ensure the accurate diagnosis and effective management of osteoporosis in this population.

P34 Evaluating the adaptation of the amputee skin owing to prosthesis use: a study using in vivo Raman spectroscopy

Abstract Introduction and aims Lower limb prosthesis has proven to be an extremely successful intervention for amputees. However, to achieve adequate function, the device places significant friction and load on the skin, which leads to substantial skin breakdown. Current rehabilitation practices require skin to be ‘trained’ to perform a load-bearing role. Despite this, there are very high injury statistics for skin on the residual limb in the literature, we hypothesize that rehabilitation practices to adapt amputee skin are limited. Methods To interrogate this, we used in vivo Raman spectroscopy to evaluate the lower limbs of 13 unilateral lower limb amputees. This enabled us to assess how key constituents of the stratum corneum (SC) such as natural moisturizing factor (NMF), water and lipid content vary with depth. We also analysed sebum content to quantify cytokines present and performed mechanical characterization of the lower limb to investigate stiffness and friction. Results We found that the Raman spectra of the amputated limb show reduced NMF, lipid content and water content at the top of the SC when compared with the intact limb (P < 0.05). In addition, we found that amputee skin contains higher levels of inflammatory cytokines compared with control skin. We also recorded that skin on the residuum is four times softer than the intact limb, while friction is much higher at 0.5 on the residuum skin, compared with 0.3 on the intact limb. Conclusions Here, we show the adaptations of amputee skin in response to rehabilitation to be minimal. Contrary to the dogma that rehabilitation trains skin to bear load, we found that skin barrier function in amputee skin is impaired, as indicated by altered water and lipid profile in addition to higher baseline inflammation.

A disparity in prosthetic access for Ecuadorians with lower-limb amputation.

Individuals with disabilities in low- and middle-income countries face barriers to rehabilitation services, including prosthetic care. Many countries, such as Ecuador, have adapted policies toward achieving universal health care coverage. For optimal functional outcomes, understanding the physical potential of prosthetic users is critical for appropriate prosthetic services. To determine the association between the functional level of Ecuadorians with lower-limb amputations and the functional level of their prosthetic componentry. Retrospective study. A data set containing functional level (K-Level) of Ecuadorians with lower-limb amputations and the K-Level of their prosthesis was analyzed. A diverse cohort of 164 participants with unilateral lower-limb amputation was recruited. Most participants were male (76.8%) with transfemoral amputations (56.1%) due to traumatic causes (51.2%). There was a small, positive, and statistically significant correlation between participants' functional levels and prosthetic componentry. Participants's functional levels were typically superior (median = 3) to their prostheses' functional abilities (median = 1), and 37.2% of participants did not have a prosthesis at the time of assessment. These data indicated that participants whose physical ability exceeded basic ambulation lacked access to prostheses to match their functional abilities. The detailed disparity between physical potential and prosthetic access derived from the study's analysis supports investment into high functioning prosthetic componentry and further investigation into where gaps in care exist.

Effect of Adding Virtual Reality Training to Traditional Exercise Program on Pain, Mental Status and Psychological Status in Unilateral Traumatic Lower Limb Amputees: A Randomized Controlled Trial.

Background: Lower limb amputation is an emotionally devastating condition that causes a complete change in the quality of life, may lead to phantom limb pain in most of the cases, and puts the individual in a high risk of developing psychological disorders. The objective of this study is to evaluate the consequence of adding virtual reality (VR) to a traditional exercise program on pain, mental status, and psychological status in traumatic unilateral lower limb amputees (LLAs). Methods: Thirty-two traumatic LLAs were randomly assigned into two equal groups in this randomized control trial. Participants did accomplish a postfitting exercise program at least 6 months before enrolment; the control group (CG) underwent a traditional rehabilitation program, and experimental group (EG) had the same program, in addition to VR training. Data were collected before and after 6 weeks of intervention using visual analog scale (VAS) for pain, Beck's depression inventory (BDI) for depression, and 12-item short form survey for mental health summary (MHS) and physical health summary (PHS). Results: Thirty-two amputees (29 males and 3 females) were included with mean age in CGs and EG (27.6 ± 4) and (27.6 ± 7.6) years, respectively. Postintervention, the VAS score was significantly reduced only in EG (P = 0.003). Both groups showed significant improvement in BDI, MHS, and PHS (P < 0.05). However, the EG showed a superior significance in BDI and MHS scores (P < 0.05). There was no significance between groups in PHS score. Conclusion: Adding VR to conventional training is beneficial in decreasing pain and in improving depression and MHS of traumatic unilateral LLAs.

Estimating Control Torque for Postural Balance Among Unilateral Lower Limb Amputees During Different Visual Environments

Estimating Control Torque for Postural Balance Among Unilateral Lower Limb Amputees During Different Visual Environments

Distinct patterns of metabolic motor cortex activity for phantom and residual limb pain in people with amputations: A functional near-infrared spectroscopy study

BackgroundPhantom pain limb (PLP) has gained more attention due to the large number of people with amputations around the world and growing knowledge of the pain process, although its mechanisms are not completely understood. ObjectivesThe aim of this study was to understand, in patients with amputations, the association between PLP and residual limb pain (RLP), and the brain metabolic response in cortical motor circuits, using functional near-infrared spectroscopy (fNIRS). MethodsSixty participants were recruited from the rehabilitation program in São Paulo, Brazil. Included patients were aged over 18 years, with traumatic unilateral lower-limb amputation, with PLP for at least 3 months after full recovery from amputation surgery. PLP and RLP levels were measured using visual analogue scales. fNIRS was performed during motor execution and motor mirror tasks for 20 s. In order to highlight possible variables related to variation in pain measures, univariate linear regression analyses were performed for both experimental conditions, resulting in four fNIRS variables (two hemispheres x two experimental conditions). Later, in order to test the topographic specificity of the models, eight multivariate regression analyses were performed (two pain scales x two experimental conditions x two hemispheres), including the primary motor cortex (PMC) related channel as an independent variable as well as five other channels related to the premotor area, supplementary area, and somatosensory cortex. All models were controlled for age, sex, ethnicity, and education. ResultsWe found that: i) there is an asymmetric metabolic activation during motor execution and mirror task between hemispheres (with a predominance that is ipsilateral to the amputated limb), ii) increased metabolic response in the PMC ipsilateral to the amputation is associated with increased PLP (during both experimental tasks), while increased metabolic response in the contralateral PMC is associated with increased RLP (during the mirror motor task only); ii) increased metabolic activity of the ipsilateral premotor region is associated with increased PLP during the motor mirror task; iii) RLP was only associated with higher metabolic activity in the contralateral PMC and lower metabolic activity in the ipsilateral inferior frontal region during motor mirror task, but PLP was associated with higher metabolic activity during both tasks. ConclusionThese results suggest there is both task and region specificity for the association between the brain metabolic response and the two different types of post-amputation pain. The metabolic predominance that is ipsilateral to the amputated limb during both tasks was associated with higher levels of PLP, suggesting a cortical motor network activity imbalance due to potential interhemispheric compensatory mechanisms. The present work contributes to the understanding of the underlying topographical patterns in the motor-related circuits associated with pain after amputations.

Primary Motor Area Activity in Phantom Limb Imagery of Traumatic Unilateral Lower Limb Amputees With Phantom Limb Pain

Introduction: Estimates of the worldwide increase in amputees raises the awareness to solve long-standing problems. Understanding the functional brain modifications after a lower limb amputation (LLA) is one of the first steps towards proposing new rehabilitation approaches. Functional modifications in the central nervous system due the amputation could be involved in prosthesis use failures and Phantom Limb Pain (PLP), increasing costs and overwhelming the health services. Objective: This study analyses orphan primary motor area (M1-Orphan) hemodynamic and metabolic behaviour, which previously controlled the limb that was amputated, in comparison with the M1-Preserved, responsible for the intact limb (IL) during phantom limb imagery moving during Mirror Therapy (MT), compared to Isolated Intact Limb Movement Task (I-ILMT). Methodology: A case-control study with unilateral traumatic LLA with moderate PLP who measured [oxy-Hb] and [deoxy-Hb] in the M1 area by Functional Near InfraredSpectroscopy (fNIRS) during the real (I-ILMT) and MT task. Results: Sixty-five patients, with 67.69% of men, young (40.32 ± 12.91), 65.63% amputated due motorcycle accidents, 4.71 ± 7.38 years ago, predominantly above the knee (57.14%). The M1 activation in the orphan cortex did not differ from the activation in the intact cortex during MT ( P &gt; .05). Conclusion: The perception of the Phantom limb moving or intact limb moving is metabolically equivalent in M1, even in the absence of a limb. In other words, the amputation does not alter the brain metabolism in control of phantom movement.

Pain, Balance-Confidence, Functional Mobility, and Reach Are Associated With Risk of Recurrent Falls Among Adults With Lower-Limb Amputation

ObjectiveThe study evaluated whether pain intensity and extent, balance-confidence, functional mobility, and balance (eg, functional reach) are potential risk factors for recurrent falls among adults with a lower-limb amputation. DesignCross-sectional study. SettingResearch laboratory. ParticipantsEighty-three adults with unilateral lower-limb amputation that occurred >1 year prior (26 transfemoral- and 57 transtibial-level amputation; 44.6% women; 51.8% traumatic cause of amputation; N=83). InterventionNot applicable. Main Outcome MeasuresParticipants reported on the number of falls in the past year, as well as pain intensity in the low back, residual, and sound limbs. Balance-confidence (per the Activities-Specific Balance-Confidence Scale [ABC]), functional mobility (per the Prosthetic Limb Users Survey of Mobility ([PLUS-M]), and balance (per the Functional Reach and modified Four Square Step Tests) were obtained. ResultsAfter considering non-modifiable covariates, greater extent of pain, less balance-confidence, worse self-reported mobility, and reduced prosthetic-side reach were factors associated with recurrent fall risk. Adults reporting pain in the low back and both lower-limbs had 6.5 times the odds of reporting recurrent falls as compared with peers without pain. A 1-point increase in ABC score or PLUS-M T score, or 1-cm increase in prosthetic-side reaching distance, was associated with a 7.3%, 9.4%, and 7.1% decrease in odds of reporting recurrent falls in the past year, respectively. ConclusionsOf the 83 adults, 36% reported recurrent falls in the past year. Presence of pain in the low back and both lower-limbs, less balance-confidence, worse PLUS-M score, and less prosthetic-side reaching distance were identified as modifiable factors associated with an increased odd of recurrent falls.

The global burden of traumatic amputation in 204 countries and territories.

Traumatic amputation leads to disability and imposes a heavy health burden. This study aims to explore the current status and temporal trends of the global burden of traumatic amputation according to sex, age, amputation site, cause, and reginal level of social development. The data were extracted from the Global Burden of Diseases (GBD) Study 2019. Prevalence, incidence, years lived with disability (YLDs) and corresponding age-standardized rate were compared. Estimated annual percentage change (EAPC) was applied to reflect trends in age-standardized rates over a specific period. Spearman rank test and curve fitting methods were used to analyze the relationship between disease burden and Socio-Demographic Index (SDI). Globally, the incidence and prevalence number of traumatic amputation increased from 11.37 million and 370.25 million in 1990, to 13.23 million and 552.45 million in 2019, with a raise of 16.4 and 49.2%, respectively. But the age-standardized incidence rate (ASIR) (EAPC = -0.56; 95%CI, -0.72 to -0.41) and age-standardize prevalence rate (ASPR) (EAPC = -0.63; 95%CI, -0.74 to -0.52) declined during this period. The YLDs count also increased by 39.2% globally (from 5.28 million to 7.35 million), while the age-standardize YLDs rate (ASYR) decreased by an average of 1.00% per year (95% CI, -1.10 to -0.90) from 1990 to 2019. The incidence, prevalence, and YLDs rate of traumatic amputation continue to increase with age. Traumatic amputations were most common in the fingers, while unilateral lower limb amputation caused the greatest burden of disability. ASIR and SDI were positively correlated (ρ = 0.442, p < 0.001), while ASYR and SDI were not significantly correlated (ρ = -0.030, p = 0.669), and EAPC in ASYR and SDI were negatively correlated (ρ = -0.275, p < 0.001). Exposure to mechanical forces and falls were the leading causes of traumatic amputation. Despite the declining trends in ASIR, ASPR, and ASYR, the incidence, prevalence, and YLDs counts of traumatic amputation have increased significantly worldwide, especially in the older adults population. With the population aging, targeted health policies are needed to address the increasing global burden of traumatic amputations in the future.

Neuromechanical Model-Based Corrective Torque Estimation During Weight Shifting in Lower Limb Amputees

As a consequence of limb loss, unilateral lower limb amputees (LLAs) exert additional flexion torque in the intact limb during postural balance, leading to other secondary complications. A prosthetic device with torque delivery is required to avoid such complications. However, estimating desired torque is an acknowledged challenge in this domain. Motivated by the above, this paper focuses on estimating the corrective torque required from an assistive device to balance the individual while performing weight-shifting exercises. Further, a healthy individual’s inverted pendulum (IP) model is explored to model LLA’s dynamics during weight-shifting. The model and the control strategy are validated using forward and backward body lean angles recorded from healthy and LLA individuals. Finally, a robust Proportional Integral Derivative controller is designed to estimate the corrective torque for maintaining the postural balance during weight-shifting. Along with the IP dynamics, a suitable control law based on Coefficient Diagram Method achieves the experimentally recorded body lean angle. The proposed control scheme is validated through simulation studies to evaluate the tracking performance in two different biomechanically relevant IP postural models. The findings assist in determining the external torque required to maintain the postural balance during gait initiation and compensatory measures for pathologically reduced torque. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">Note to Practitioners</i> —Gait initiation is a transition between vertical posture and gait. Since vertical stance is inherently unstable, a postural adjustment occurs before gait initiates, propelling the center of mass forward and towards the first stance leg. The absence of flexor torque in the amputated limb causes a loss of postural stability during weight shifting activities. In the case of powered exoskeletons and prosthetic devices, a prior estimation of corrective torque through a computational approach helps to select a suitable actuator that provides an appropriate joint torque while maintaining the postural balance. As a result, an efficient computational model of gait initiation that accounts for neuromuscular system components before designing assistive devices is necessary. The controllers further provide corrective action to the assistive device to obtain robust and optimal coordination between the prosthetic element and gait. Therefore, this study demonstrates the significance of neuromuscular controller and assists in determining how much corrective torque from an external device is required to maintain postural stability and adaptability during weight shifting exercises. The effectiveness of the neural controller is also tested for real-time data to compensate for the effect of external disturbance and noise, thereby achieving a proper and controlled degree of movement in amputee users. These findings could provide one of the fundamental aspects of gait initiation model paradigms of compensatory measures for pathologically diminished torque and contribute to developing low-cost prosthetic solutions for the benefit of the rehabilitation society in developing countries.

A pilot study comparing prosthetic to sound limb gait mechanics during a turning task in people with transtibial amputation

BackgroundObservational gait analysis is frequently used by clinicians to subjectively assess straight walking but is not often used to examine turning. Interlimb comparisons of phase- specific turning biomechanics in people with unilateral lower limb amputation has not previously been documented. MethodsA retrospective examination of gait kinematics and kinetics from five participants with unilateral transtibial amputation was performed. Data were collected during 90° step and spin turns capturing three distinct turning steps. Gait metrics of interest included: total turn time, stance time, peak knee flexion angle during Pre-Swing and Initial Swing gait phases, peak hip flexion and extension, ground reaction impulse, and whole body angular momentum. Statistical comparisons were made based on turn type between sound and prosthetic limbs. FindingsDuring the three turn steps (approach, apex, depart), participants spent significantly more time (P < 0.01) on their sound limb compared to their prosthetic limb regardless of turn type. Additionally, the prosthetic limb hip and knee exhibited more flexion (P < 0.05) during the apex step of turns, and whole body angular momentum was higher when the sound limb was used during the apex step of a turn (P < 0.05). InterpretationThis descriptive study offers the first phase-specific quantification of turning biomechanics in people with lower limb amputation. Results indicate that people with unilateral transtibial amputation spend more time on and experience higher impulses through their sound compared to their prosthetic limb during 90° turns, and that the prosthetic limb is performing differently than the sound limb, potentially increasing risks of injury or falls.

Experiences of persons with lower limb amputation after prosthetic rehabilitation in Ghana: A qualitative inquiry.

Lower limb amputations (LLAs) have long been associated with physical, social, and psychological consequences. Individuals with LLAs have challenges with mobility and often become isolated from their social networks. Disability rehabilitation technologies such as prosthetic devices are used to improve the mobility capabilities of lower limb amputees. To improve clinical outcomes, feedback from the prosthetic users is a key element to consider. The study sort to explore the experiences of lower-limb prosthetic users after prosthetic rehabilitation in a prosthetic and orthotic rehabilitation center in the Eastern Region of Ghana. This study adopted an exploratory descriptive qualitative study design. A purposive sampling technique and semistructured interview guide was used to interview 17 participants by the first author. The social model of disability underpinned the study. Lower-limb prosthetic users (≥18 years) with unilateral LLA attending outpatient follow-up at a prosthetic and orthotic rehabilitation center were recruited. The interviews were audio recoded, transcribed verbatim, and analyzed using the procedure for thematic content analysis by Braun and Clarke (2013). Participants reported injuries and tingling in their residual limb. Internal stigma resulting from negative comments and labeling from the public were reported. Prosthetic users experienced empathy and being treated as weaklings by their family/peers. Participants avoided relationships because of recurrent rejection, embarrassment, fear of sexual abuse, and exploitation. As a coping method, some participants chose to isolate themselves to avoid humiliation and public disgrace. Other coping mechanisms included watching television, listening to music, conversing with others, ignoring criticism, and having faith in God. Participants' narrative in this study gave insight into the varied lived experiences on the individual level, family/peer level, and the coping mechanisms used. Challenges relating to discomfort from the prosthesis, internal stigma, relationship avoidance, and altered sexual life should be given much attention and used in implementing initiatives to improve clinical outcomes.

Principal components analysis of postural sway in persons with unilateral lower limb amputation: A wearable sensor approach

Standing sway assessments can detect sensory imbalances which compromise postural control. Persons with lower limb amputation (LLA) often demonstrate impaired postural control, increasing fall risk. Here, principal features of postural sway were identified in persons with unilateral LLA using a single, commercially available wearable sensor. Sixty-one persons with LLA (n = 44 transtibial; n = 17 transfemoral) stood on a firm surface with eyes open/closed while wearing a single accelerometer mounted over the sacrum. Common parameters quantified spatiotemporal and spectral features of sway in anterior-posterior (AP) and mediolateral (ML) directions. Principal component (PC) dimensionality reduction was applied and loadings inspected to identify a reduced, non-redundant set among 14 original variables capturing 90 % variance. Six PCs described ≥ 90 % variance, with the first 3 explaining 75 %. With eyes open and closed, PC1 was loaded by variables characterizing trajectory planar size: area, jerk (i.e., sway smoothness), AP/ML RMS path distance, and AP/ML path range. With eyes open, PC2 was loaded by variables characterizing direction and spectral features: ellipse rotation, AP centroidal frequency, and ML jerk. With eyes closed, PC2 spectral loadings increased: ML centroidal frequency, ML frequency dispersion, and AP centroidal frequency. With eyes open, PC3 was loaded by ellipse rotation, jerk, ML velocity, ML centroidal frequency. With eyes closed, PC3 was loaded by ellipse rotation, ML centroidal frequency, ML frequency dispersion, and AP path velocity, characterizing off-axis error/corrections. RMS of path distance, ellipse rotation, centroidal frequency, frequency dispersion, path velocity, and jerk are a concise parameter set, derived from an accelerometer, to capture principal sway features in persons with LLA during standing balance with visual perturbations.

The development and reliability testing of the Functional Lower-Limb Amputee Gait Assessment.

The study purpose was three-fold: (a) to describe the development of the Functional Lower-Limb Amputee Gait Assessment, (b) to determine its reliability with two groups of raters, physical therapists, and certified prosthetists, and (c) to determine the agreement on its results between the two groups. A reliability study. Institution for higher education. Five physical therapists and five certified prosthetists. Not applicable. The gait of people with unilateral lower limb amputation was evaluated using the Functional Lower-Limb Amputee Gait Assessment. Kappa statistic was used to analyze reliability. The intra-rater reliability of nine gait deviations in the physical therapists' group and eight in the certified prosthetists' group was between moderate and almost perfect agreement (kappa = .41-1). In the physical therapists' group, the inter-rater reliability of four gait deviations was moderate (kappa = .41-.6). In the certified prosthetists' group, the inter-rater reliability of six gait deviations was moderate to substantial (kappa = .41-.8). Three gait deviations achieved moderate agreement in both groups of clinicians (kappa = .41-.6). Most gait deviations included in the Functional Lower-Limb Amputee Gait Assessment appear stable over time when used by the same clinician. Six gait deviations in the certified prosthetists' group and four in the physical therapists' group may be used by multiple clinicians, and three gait deviations may be used across both professions to assist in communication and collaboration on the best course of treatment for a patient with a unilateral lower limb amputation.

Thermographic Evaluation, Residual Limb Skin Sensitivity, and Adaptation to the Prosthesis of Individuals with Lower-Limb Amputation with Prosthesis Provided by the Universal Health System

ABSTRACT Introduction Prosthesis fixation is considered the central point for functionality, which promotes social reintegration of the individual with amputation. The deficits in the making of the prosthetic socket may trigger excessive friction on the residual limb and socket discomfort, possibly leading to a poor adaptation and consequent reduction of activity. Thermography is an evaluation and diagnostic method that may aid in the verification of the functionality of the prosthesis. The objective of the study was to analyze the superficial thermal distribution characteristics, the skin sensitivity of the residual limb, and the adaptation to the prosthesis of individuals with lower-limb amputation with prostheses provided by the Universal Health System. Materials and Methods Sixteen individuals of both genders with unilateral lower-limb amputation with ages between 18 and 64 years were recruited. The data collection protocol was composed of completing the physiotherapeutic evaluation form, assessment of residual limb skin sensitivity, application of the Prosthesis Evaluation Questionnaire (PEQ), treadmill walk for 10 minutes, thermographic evaluation immediately after the removal of the prosthesis, and lastly postacclimatization thermographic assessment. Results Before the acclimatization, the region of the L3 dermatome of those who had altered sensitivity, the maximum (31.43°C), mean (28.97°C), and minimum (28.27°C) temperatures were significantly lower compared with those who had normal sensitivity (32.81°C, 29.68°C, and 28.91°C, respectively) (P &lt; 0.05). Regarding the period after the acclimatization, there was no significant difference in the comparison performed between temperature and sensitivity. The individuals with transtibial amputation obtained results above the overall median for the PEQ items, whereas the individuals with transfemoral amputation obtained results above the overall median for the “total score.” There is a strong negative relationship between the mean temperature of the residual limb extremity with item “utility” in the preacclimatization moment and a strong negative relationship between the mean and minimum temperatures at the residual limb extremity with the “residual limb health” item at the moment after the acclimatization. There is no association between the PEQ items and residual limb sensitivity. Conclusions One may conclude that high temperatures at the postacclimatization moment indicate areas of friction that trigger a poor adaptation of the residual limb with the prosthetic socket, in which case the development of new strategies for improving the quality of the prostheses supplied is suggested. Clinical Relevance Thermography helps in evaluating the residual limb and adapting the prosthesis, as it is a noninvasive clinical assessment tool. Thermography aids health professionals for management of the patient with amputation in the preprosthesis and postprosthesis phases.

The lower limb-loss rehabilitation continuum (LLRC) – a framework for program design and implementation

Purpose: The multistep journey to prosthetic device-enabled functioning following amputation requires a structured approach for optimal care delivery, but such program structures and outcomes are inadequately characterized. The study is responsive by describing an implementation framework for lower limb loss rehabilitation and evaluating its utility. Materials and methods: The lower limb loss rehabilitation continuum framework (LLRC) was developed using literature-based continuum of care and amputation phase concepts as well as input from limb loss rehabilitation stakeholders. LLRC structure includes five sequential steps (Postsurgical Stabilization (PS), Preprosthetic Rehabilitation (PPR), Limb Healing and Maturation (LHM), Prosthetic Fitting (PF), Prosthetic Rehabilitation (PR)) between six touchpoints of patient-healthcare interaction (Surgery, Preprosthetic Rehabilitation Admission and Discharge, Functioning Evaluation and Prescription, Prosthetic Rehabilitation Admission and Discharge). The utility of this framework was evaluated through LLRC program implementation in a semiurban US setting and program functioning and process outcomes assessment from an IRB-approved, retrospective observational study about patients with unilateral lower-limb amputations completing this program. Results: Program functional (FIM gain; efficiency) scores were greater for PPR(32.6(8);3.1) compared with PR(24.3(8.5);3.8). Program completion duration was 149.7(63.4) days. LHM(75.8(58.5) days) and PF(51.4(24.3) days) were the longest steps. PR duration was significantly longer(p = 0.033) for the transfemoral level. Conclusion: The LLRC framework is useful for the design and implementation of structured limb loss rehabilitation programs. IMPLICATIONS FOR REHABILITATION The lower limb-loss rehabilitation continuum (LLRC) is a novel implementation framework with a five-step structure from limb loss to completion of prosthetic rehabilitation between six touchpoints of patient-healthcare interaction, with standardized terminology and baseline and outcome metrics. The utility of the program was demonstrated by successful program development in a suburban health setting and actionable process outcomes and superior functioning outcomes compared with literature. The LLRC can be adapted by health systems, institutions, and care providers for program development. Programs can expect high FIM gains and efficiency for Preprosthetic rehabilitation and Prosthetic rehabilitation steps. With an LLRC completion time of 5 months, long Limb healing and maturation and Prosthetic fitting steps present areas of opportunity for improvement.

The frequency and risk factors associated with the development of knee and hip osteoarthritis of the intact limb after unilateral lower limb amputation at PIPOS Bannu.

Objective: To determine the frequency and risk factors associated with the development of osteoarthritis of the knee and hip joints of the intact limbs after unilateral amputation of the lower extremities with PIPOS Bannu. Study Design: Cross Sectional. Setting: Pakistan Institute for Prosthetics and Orthotics (PIPOS). Period: June 2019 to November 2019. Material &amp; Methods: The presence of osteoarthritis (OA) was determined by a standardized questionnaire, primarily based on laboratory tests/physical examination. Participants were evaluated by experts who diagnosed symptomatic hip and knee OA using a structured questionnaire and standardized joint tests based on American College of Rheumatology (ACR) clinical standards. Individuals who tested positive were tested by a rheumatologist, who checked for the presence of clinical ACR criteria to confirm the diagnosis. Results: A total of 150 patients were included in the study. Data is analyzed by SPSS 21. The average age of the patients was 38.12 ± 14.82 years. Of the total of 150 patients, 131 (87.3%) were male and 19 (12.7%) were female. According to the degree of amputation, 79.3% (n = 119) patients were traumatic and 20.7% (n = 31) were non-traumatic limbs. The incidence of knee osteoarthritis is 9.3% (9.3% for men and 0.0% for women) and 4.0% for hip osteoarthritis (2.7% for men and 1.3% for women), both in hip and knee osteoarthritis. 2.7% (2.0% for men and 0.7% for women). Conclusion: According to this study, traumatic and non-traumatic lower limb amputees are more likely to develop knee and hip osteoarthritis in the intact lower limb. Demographics and patient characteristics are major risk factors for osteoarthritis.

Functional outcomes and associated factors of individuals with unilateral traumatic lower limb amputation in Sri Lanka: An observational study.

Rehabilitation is important after an amputation surgery. This study was conducted to find the level of functional outcomes of individuals with unilateral traumatic lower limb amputation and the impact of sociodemographic, amputation, and rehabilitation characteristics on functional outcomes. An observational cross-sectional study was conducted with 48 participants (aged 20-60 years) who visited the Center for Handicapped from across the country. Functional outcomes were measured using the Locomotor Capabilities Index, Amputee Mobility Predictor with Prosthesis, 6-minute walk distance, and spirometry test and sociodemographic, amputation, and rehabilitation characteristics using a self-constructed questionnaire. Amputee Mobility Predictor with Prosthesis K levels showed 65% had the ability to ambulate in the community and could master environmental barriers. Locomotor Capabilities Index scores showed 96% could independently perform basic daily activities with or without using assistive devices and 83% could perform advanced daily activities. None of the individuals had achieved their predicted 6-minute walk distance, but 52% had "good and above" level of maximum oxygen consumption; restrictive respiratory pattern was indicated among 31%. Amputee Mobility Predictor with Prosthesis and Locomotor Capabilities Index scores were significantly ( p < 0.005) affected by mobility hours/day, amputation level, prosthesis usage, and satisfaction. Six-minute walk distance was significantly ( p < 0.005) related to income, time since amputation, duration of rehabilitation, mobility hours/day, sex, job engagement, previous job, amputation level, K levels, and satisfaction with prosthesis. Rehabilitation in Sri Lanka mainly focuses on basic walking training, not on long-term survival, distance walking, and cardiorespiratory endurance, which can lead to future comorbidities. Raising awareness in the society about rehabilitation services and more effective rehabilitation programs are recommended.

Quality of Life in People With Unilateral Lower Limb Amputation at a Tertiary Rehabilitation Centre in Northern India: A Cross-Sectional Study.

Background and purpose The patients after amputation undergo a sudden transformation in their quality of life. In India, amputation done at the appropriate time is a rare phenomenon because usually, the patients present themselves at the later stages. The surgeons, however, while performing amputation surgeries, primarily consider saving the life of a patient under adverse conditions when patients report to them very late that the surgeries are carried out urgently. Assessing the quality of life (QOL) and the various sociodemographic factors affecting the QOL paves the way for future rehabilitation programs. Aims and objectives To evaluate the quality of life of subjects with unilateral lower limb amputation among the North Indian population. Materials and methods This cross-sectional study was conducted in the tertiary rehabilitation center. A total of 106 Subjects were recruited. Informed consent was taken. WHOQOL-BREF contains 26 items covering four important aspects of QOL. The WHOQOL-BREF self-administered free questionnaire was used as a data collection tool, and the Hindi version downloaded from the WHO website was also used for those who can't understand English. Results The range of the physical domain, psychological domain, social domain, and environmental domain were 0 and 100. The mean score of different QOL transformed domain scores (on a scale of 100) were 47.91±20.12, 57.37±20.46, 59.36±25.32 and 51.50±21.96, respectively. Trauma was the leading cause of amputation, followed by diabetes mellitus, cancer, peripheral vascular disease, and other causes. Transtibial amputees were more in number compared to transfemoral. The percentage of male and female amputees was 78.30%, and 21.70%, respectively. Conclusion The physical domain was the most affected domain, followed by the psychological, social, and environmental domains. A delay in the prosthesis fitment aggravates the physical burden of amputees. Early prosthesis & psychological counseling will improve the QOL significantly.

Development of an item bank for measuring prosthetic mobility in people with lower limb amputation: The Prosthetic Limb Users Survey of Mobility (PLUS-M).

Achieving mobility with a prosthesis is a common post-amputation rehabilitation goal and primary outcome in prosthetic research studies. Patient-reported outcome measures (PROMs) available to measure prosthetic mobility have practical and psychometric limitations that inhibit their use in clinical care and research. To develop a brief, clinically meaningful, and psychometrically robust PROM to measure prosthetic mobility. A cross-sectional study was conducted to administer previously developed candidate items to a national sample of lower limb prosthesis users. Items were calibrated to an item response theory model and two fixed-length short forms were created. Instruments were assessed for readability, effective range of measurement, agreement with the full item bank, ceiling and floor effects, convergent validity, and known groups validity. Participants were recruited using flyers posted in hospitals and prosthetics clinics across the United States, magazine advertisements, notices posted to consumer websites, and direct mailings. Adult prosthesis users (N=1091) with unilateral lower limb amputation due to traumatic or dysvascular causes. Not applicable. Candidate items (N=105) were administered along with the Patient Reported Outcome Measurement Information System Brief Profile, Prosthesis Evaluation Questionnaire - Mobility Subscale, and Activities-Specific Balance Confidence Scale, and questions created to characterize respondents. A bank of 44 calibrated self-report items, termed the Prosthetic Limb Users Survey of Mobility (PLUS-M), was produced. Clinical and statistical criteria were used to select items for 7- and 12-item short forms. PLUS-M instruments had an 8th grade reading level, measured with precision across a wide range of respondents, exhibited little-to-no ceiling or floor effects, correlated expectedly with scores from existing PROMs, and differentiated between groups of respondents expected to have different levels of mobility. ThePLUS-M appearstobe well suited to measuring prosthetic mobility in people with lower limb amputation. PLUS-M instruments are recommended for use in clinical and research settings.