Functional assessment scales and lower limb amputation]

INTRODUCTION: This paper is a review of the literature on assessment tools in lower limb amputees.MATERIAL AND METHODS: The authors have research on Medline(R) data base the different tools with keys words "lower limb amputee or amputation, functional evaluation or outcome assessment tools, activity of daily living", and have completed the research with the references of papers.RESULTS: A comprehensive approach of the consequences of an amputation and of the outcome of prosthetic care should include an evaluation of gait, use of the prosthesis in activities of daily life, acceptability and satisfaction with the device.DISCUSSION: Functional assessment tools that are validated are recent, and most of them were developed in English. They take into account the use and the acceptance of the device, but there is no study using them for an important sample population.CONCLUSION: It is now necessary to translate the recent tools into French, and to confirm their validity and sensitivity to change.     

Exercise training for lower limb amputees]

Lower limb amputee have lower exercise capacities, proportionally to the delay necessary to use their well-fitted prosthesis. Exercise training is a valid therapeutic to improve local factors (residual limb), muscle strength and endurance, locomotor performance and to decrease the cardiovascular risk factors. The programs for exercise training used for amputees are derivate from the vascular diseases and adapted (upper limb ergometer, cycloergometer with intact limb, pharmacological stress). Exercise training must be personalised because the population with lower limb amputation is very heterogeneous for deficiency and capacity (orthopaedic, vascular and cardiac) and for their socioprofessional project.     

Mental health and satisfaction with life among upper limb amputees: a Norwegian population-based survey comparing adult acquired major upper limb amputees with a control group

Purpose.?To assess how upper limb amputation affects mental health and life satisfaction.

Method.?Cross-sectional study comparing the mental health and perceived satisfaction with life among adult acquired major upper limb amputees in Norway with a control group drawn from the Norwegian general population. The scales used were the Satisfaction With Life Scale (SWLS) and the Hopkins Symptom Check List 25-item (SCL-25). The groups were compared using multiple linear regression analyses.

Results.?The amputees scored significantly lower on life satisfaction than the control group. A tendency to poorer mental health in the amputee group was observed, but there was no clear evidence of such a difference. The amputation effect on life satisfaction seemed to be mediated mainly by changes in occupational status and by the occurrence of short- or long-term complications related to the amputation.

Conclusions.?Our findings imply that rehabilitation of upper limb amputees should emphasise facilitating return to work as well as the prevention of short- and long-term complications, and that this will be of importance not only for the amputees' physical function, but for the maintenance of acceptable life satisfaction. Further studies on the effect of upper limb amputation on mental health are recommended.     

Evaluating a written emotional disclosure homework intervention for lower-limb amputees

OBJECTIVE: To evaluate the Pennebaker Emotional Disclosure paradigm with lower-limb amputee patients in terms of compliance and efficacy. DESIGN: Repeated measures. SETTING: Home based. PARTICIPANTS: Low compliance, both with the initial mailed request (28%) and the subsequent writing task (48%), resulted in 23 lower-limb amputees who had been fitted with a prosthesis participating. INTERVENTIONS: Patients completed a 15-minute writing task, 6 times, over 2 weeks, with initial baseline and 2-month follow-up assessments. MAIN OUTCOME MEASURES: Cognitive processing, well-being, adjustment to an artificial limb, pain, and prosthetic use. RESULTS: Stronger emotional disclosure was associated with significant reductions in psychologic and physical aspects of amputees' satisfaction with their prosthesis, some of which were mediated by positive changes in affect immediately after the writing tasks. CONCLUSIONS: Our results failed to support previous findings with nonclinical samples; in fact, our results contradicted previous findings. We therefore caution that written emotional disclosure may be contraindicated with lower-limb amputee patients.     

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.     

A cross-sectional study of post-amputation pain in upper and lower limb amputees,experience of a tertiary referral amputee clinic

Purpose.?To determine the pain characteristics and health-related quality of life (HR-QOL) of upper and lower limb amputees.

Method.?Amputees attending the Prince of Wales Prosthetic Clinics in 2006 were administered a questionnaire survey of their pain experiences, Short form McGill pain questionnaire, Short Form 36 (SF 36) and Pain Self-Efficacy Questionnaire (PSEQ).

Results.?Of the 17 who were upper limb amputees (including the two multiple limb amputees), only 1 was pain free and of the 39 who were lower limb amputees 14 were pain free. Upper limb amputees experienced significantly greater proportion, frequency and severity of post-amputation pain than lower limb amputees. The presence of significant pre-operative pain did not correlate with the development of persistent post-amputation pain. In quality of life measures, the amputees experienced a better physical function, role physical and confidence in performance of activities than chronic pain patients attending the pain clinic. Lower limb amputees fared better than upper limb amputees in terms of bodily pain, social function and mental health. However, the amputee groups have a reduced health status in almost all domains compared to the aged matched Australian population norm.

Conclusions.?The study suggests that upper limb amputees are significantly more likely to suffer post-amputation pain which is more frequent, longer lasting and more severe in intensity when compared to lower limb amputees. This is accompanied by reduced HR-QOL especially that related to bodily pain, social function and mental health. The overall health status of amputees are also significantly lower compared to the Australian population norm.     

Somatosensation, circulation and stance balance in elderly dysvascular transtibial amputees

OBJECTIVE: To establish the relationship between poor lower limb somatosensory and circulatory status with standing balance, falls history, age and mobility level in dysvascular transtibial amputees (TTAs). DESIGN: Within-subjects evaluation of somatosensation, circulation and stance balance measures in dysvascular transtibial amputees. SETTING: Physiotherapy department of a tertiary metropolitan hospital in Australia. PARTICIPANTS: Twenty-two community-dwelling unilateral dysvascular transtibial amputee volunteers, aged between 54 and 86 recruited from a metropolitan hospital outpatient amputee clinic. MAIN OUTCOME MEASURES: Lower limb vibration sense, light touch sensation and circulatory status were related to centre of pressure excursion during quiet stance, dynamic balance measures of forward and lateral reach distance, and demographic information such as falls history and mobility level. RESULTS: Overall, poor somatosensory status was associated with poor stance balance. There was an association between poor vibration and circulation and increased centre of pressure excursion in quiet stance and reduced reach distance, whereas poor light touch was linked with even weight-bearing in quiet stance. Poor vibration sense was associated with a history of frequent falls. CONCLUSIONS: Compromised lower limb somatosensation and circulation was linked with poor balance and a history of frequent falls in the elderly dysvascular amputee population.     

The SIGAM mobility grades: a new population-specific measure for lower limb amputees

PURPOSE: To develop a valid measure of lower limb amputee mobility suitable for routine clinical use, including monitoring change. METHODS: The Special Interest Group in Amputee Medicine (SIGAM) described a single-item scale comprising six clinical grades (A-F) of amputee mobility. A self-report questionnaire was developed and algorithm designed to facilitate grade assignment. Reproducibility of the questionnaire and grades were assessed in 62 amputees. Concurrent validity and sensitivity to change were investigated using the timed walking test (TWT). The mobility construct was examined in 200 amputees, using item response theory, by co-calibration with the Rivermead Mobility Index (RMI) on the same patients. RESULTS: Patients included 144 males and 66 females, aged 13-90. Intraclass correlation coefficients and reproducibility kappa values were satisfactory. Observers agreed 100% in using the algorithm. TWT improved as SIGAM grade increased. Examination of psychometric properties revealed the SIGAM item fitted within the RMI mobility matrix. Average measures for the six grades were ordered correctly. There was no local dependency or differential item functioning for clinically relevant patient subgroups. The SIGAM scale showed an effect size of 10.66. CONCLUSIONS: The SIGAM mobility grades represent a novel, valid, clinically useful measure of amputee mobility which is also sensitive to change.     

Job satisfaction and health experience of people with a lower-limb amputation in comparison with healthy colleagues

OBJECTIVES: To describe indicators of job dissatisfaction among amputee employees and to compare job satisfaction and health experience of working amputee employees with that of control subjects. DESIGN: A cross-sectional study, mailed questionnaire. SETTING: Patients were recruited by the orthopedic workshops of the Netherlands. PARTICIPANTS: One hundred forty-four patients who had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean age, 43y), and were living and working in the Netherlands. One hundred forty-four control subjects matched for age, gender, and type of job. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Statistical analysis of responses to a questionnaire regarding patient characteristics and amputation-related factors, amputee patients' opinions about their work and the social atmosphere at work, and their general health (RAND 36-Item Health Survey [RAND-36]). RESULTS: People with an amputation had greater job satisfaction (70%) than did the able-bodied control group (54%). The wish for (better) modifications in the workplace and the presence of comorbidity were significantly related to job dissatisfaction in people with limb loss. Amputee employees were less often hindered by the failures of others and by fluctuations in temperature. People with limb loss showed a worse physical health experience than controls on the RAND-36. CONCLUSIONS: The vocational satisfaction of people with limb loss may be improved by better workplace modifications, depending on the functional capabilities of the person and the functional demands of the job; improvement may also be achieved by vocational rehabilitation programs, especially for those with an amputation in combination with other morbidity. Despite experiencing more health problems, the amputee group expressed greater job satisfaction than the able-bodied group, reflecting a great appreciation of job reintegration by people with a lower-limb amputation.     

Is the Rivermead Mobility Index appropriate to measure mobility in lower limb amputees?

PURPOSE: Measurement of lower limb amputee mobility was investigated using the Rivermead Mobility Index (RMI). METHOD: Reliability and reproducibility were assessed in 62 patients. The timed waking test (TWT) was used to investigate concurrent validity. The RMI construct was examined in 200 established amputees. RESULTS: One hundred and forty-four males and 66 females, aged 13-90 were recruited. Intraclass correlation coefficients and kappa statistics showed good reproducibility. Spearman correlation coefficient between the RMI and TWT -0.58 (p<0.000). Psychometric properties of the RMI were tested using item response theory. Hierachical differences in RMI grades were identified in amputees compared with neurologically impaired patients for which the RMI was developed. The RMI construct was not unidimensional, with redundancy of items and local dependency. At the upper end of the scale there were insufficient items measuring high levels of mobility. Finally, differential item functioning showed items behaving differently for patient subgroups. CONCLUSIONS: Although initial impressions suggest the RMI is a useful measure of lower limb amputee mobility, further analysis shows it is not appropriate for all amputees, with a number of limitations of its psychometric properties. Its use is not recommended in this population.     

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

BACKGROUND: 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. METHODS: 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. FINDINGS: 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). INTERPRETATION: 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.     

Alteration in Phantom Pain and Sensation With Visceral Movement

Some lower limb amputees can present with alteration in phantom pain and sensation with visceral movement (micturition/defaecation). The authors specifically questioned 200 lower limb amputees from 2 amputee rehabilitation centers (150 recent lower limb amputees in the first center and 50 consecutive recent and established lower limb amputees in the second center) for such symptoms. Eight patients from the first center and 5 patients from the second center reported having the phenomenon. In this case series, the authors report the patient-described symptoms, estimate the prevalence, and discuss the likely pathophysiology of the phenomenon.     

Gait analysis in amputees

There are marked differences from normal in both AK and BK gait. Forward velocity of walking is significantly lower in the amputee and is lower in the AK than in the BK subjects. Traumatic AK amputees ambulate with time-distance parameters of velocity, cadence, stride length and gait cycle which are all two standard deviations below normal. The same parameters for the traumatic BK amputee are only one standard deviation below normal. The symmetry of walking seen in the normal subject is not present in the lower extremity amputee. Measurements of single limb support times and motion analysis of the lower extremities as well as of the head, arms and trunk bear this out. This asymmetry of motion increases the excursion of the center of mass during each cycle and thereby increases the energy cost of ambulation. Energy cost of amputee gait often places the dysvascular AK amputee at his limits and strains other amputees severely. Further research is necessary to enable amputees to approach the walking capabilities of normal people.     

Measurement properties of the Frenchay Activities Index among individuals with a lower limb amputation

OBJECTIVE: To assess the reliability and validity of the original and a modified version of the Frenchay Activities Index (FAI) among individuals with a lower limb amputation. DESIGN: Two week test-retest design. SETTING: South Western Ontario Amputee Program, London, Ontario, Canada. SUBJECTS: Consecutive sample of 84 individuals, primarily men (78.6%), mean age 56.5 years with a unilateral transtibial (71.4%) or transfemoral amputation related to traumatic (59.5%) or vascular causes. INTERVENTIONS: All subjects completed a questionnaire containing the FAI and other scales, the 2-minute walk and timed up and go tests during a regularly scheduled clinic visit. Fifty-five subjects completed a second FAI which was mailed to them two weeks later. Twenty-nine others completed the second FAI upon return for testing related to another project. MAIN MEASURES: FAI, Activity-specific Balance Confidence Scale, Prosthetic Evaluation Questionnaire-Mobility Scale, 2-minute walk, timed up and go and walking device aid use. RESULTS: Relative reliability for the FAI (intraclass correlation coefficient (ICC) = 0.79) and FAI-18 (ICC = 0.78) was acceptable, however bias between measurements was detected. Hypothesized relationships (p < 0.001) between both FAI versions and the Activity-specific Balance Confidence Scale, Prosthetic Evaluation Questionnaire-Mobility Scale, 2-minute walk and timed up and go test were observed. Significant group differences were observed for amputation cause, mobility device use, age and years as an amputee. Neither version distinguished between amputee level or gender groups. CONCLUSIONS: The original and modified FAI are valid and reliable tools for unilateral amputees. Reliability is adequate to detect group but not individual level differences. Additional FAI-18 items did not substantially improve the ability to detect between-amputation-group differences.     

Development of an exercise testing protocol for patients with a lower limb amputation: results of a pilot study

Due to a decrease in physical activity, lower limb amputees experience a decline in physical fitness. This causes problems in walking with a prosthesis because energy expenditure in walking with a prosthesis is much higher than in walking with two sound legs. Exercise training may therefore increase the functional walking ability of these patients. To generate a safe and effective aerobic training program, exercise testing of amputees is recommended. The objectives of this study were to develop a maximal exercise testing protocol for lower limb amputees and to compare two different testing methods: combined arm-leg ergometry and arm ergometry. The protocols were tested in five amputee patients. Combined ergometry elicited a higher oxygen uptake and heart rate than arm ergometry. Electrocardiography during combined ergometry was easier to read. Combined ergometry was judged most comfortable by the amputees. The exercise testing protocol was useful in lower limb amputees to determine their maximal aerobic capacity and their main exercise limitation. Future exercise training programs may be based on this testing protocol. Combined arm-leg ergometry is appropriate for unilateral amputees without significant claudication of the remaining leg. Continuous arm ergometry is suitable for unilateral amputees with significant claudication of the remaining limb or bilateral amputees.     

Alignment of lower-limb prostheses

Alignment of a prosthesis is defined as the position of the socket relative to the other prosthetic components of the limb. During dynamic alignment the prosthetist, using subjective judgment and feedback from the patient, aims to achieve the most suitable limb geometry for best function and comfort. Until recently it was generally believed that a patient could only be satisfied with a unique "optimum alignment." The purpose of this systematic study of lower-limb alignment parameters was to gain an understanding of the factors that make a limb configuration or optimum alignment, acceptable to the patient, and to obtain a measure of the variation of this alignment that would be acceptable to the amputee. In this paper, the acceptable range of alignments for 10 below- and 10 above-knee amputees are established. Three prosthetists were involved in the majority of the 183 below-knee and 100 above-knee fittings, although several other prosthetists were also involved. The effects of each different prosthetist on the established range of alignment for each patient are reported to be significant. It is now established that an amputee can tolerate several alignments ranging in some parameters by as much as 148 mm in shifts and 17 degrees in tilts. This paper describes the method of defining and measuring the alignment of lower-limb prostheses. It presents quantitatively established values for bench alignment position and the range of adjustment required for incorporation into the design of new alignment units.     

Adult acquired major upper limb amputation in Norway: prevalence,demographic features and amputation specific features. A population-based survey

Purpose.?To estimate the prevalence of adult acquired major upper limb amputation in Norway. To describe this amputee population regarding demographic features and amputation specific features. To compare our data to data collected internationally.

Method.?Population-based cross-sectional study on adult upper limb amputees with acquired limb loss through or proximal to the radio-carpal joint. Patients were found in the databases of the two companies in Norway that make upper limb prostheses and in the medical records of three of the largest Norwegian hospitals. Data were collected by postal questionnaires.

Results.?We estimated a population prevalence of 11.6 per 100,000 adults (n == 416). Our survey was not 100%% comprehensive and the estimate is conservative. The amputees were predominantly men with traumatic, unilateral, distal amputations at a young age. There were significant gender- and amputation level differences in cause. Most amputees had used prostheses. About four in ten were in paid employment.

Conclusions.?Our findings are mainly consistent with earlier studies from other countries. Implications of our findings related to the planning of future health care for these patients are outlined, including suggestion of regional multidisciplinary rehabilitation emphasising occupational rehabilitation and focus on preventive measures. Potential areas of follow-up are suggested.     

An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report

Smuck M, Christensen S, Lee SS, Sagher O. An unusual cause of S1 radicular pain presenting as early phantom pain in a transfemoral amputee: a case report.Recent epidemiologic studies have shown back pain to be a significant cause of pain in lower-limb amputees, but only a handful of cases have reported sciatica in amputees. The symptoms are usually described as a phantom pain or neuropathic pain in the residual limb that is often refractory to conventional treatments. These symptoms typically occur with back pain and are distinct from the patient’s usual symptoms. Interestingly, back pain is not a universal finding. We present a patient with presumed phantom limb pain subsequently discovered to be caused by an S1 radiculopathy. This patient’s supposed phantom pain persisted despite multiple medication trials. Initial work-up revealed a sciatic neuroma at the stump. Treatments targeting this neuroma were unsuccessful. Further evaluation found that a sacroiliac joint screw placed to stabilize a pelvic fracture had intruded into the S1 neuroforamen. A diagnostic S1 nerve block temporarily relieved the patient’s pain, and the screw was removed. Pain persisted and a spinal cord stimulator was placed resulting in improvement of his pain. Because conventional diagnostic tests are limited, including physical exam and electromyography, a fluoroscopically guided selective spinal nerve block proved to be a useful diagnostic tool in this patient.