Evaluation of amputees

During 1978 the Queen Alia Fund registered all disabled persons in the East Bank of Jordan. This paper is intended to investigate the actual condition of a sample selected from those persons registered as amputees. The registration showed a total of 696 amputees and a sample of 100 patients was randomly selected from this group. This study explored the disability, its nature and location, physical and vocational rehabilitation received, and the functional capability of the amputee. The two most important causes which lead to the amputation were mine explosions and road accidents. 32 persons received physical rehabilitation and prosthesis was recommended for 56 persons. Only 9 patients received vocational rehabilitation. Final analysis of the data showed steady increase in the past two decades with a doubling of the number from the 1960s to the 1970s. Road accidents played a major role in this increase. It is interesting to note that males and educated persons tend to use their prosthesis more than females and illiterate persons. In conclusion vocational rehabilitation remains an important element missing from the management of amputees. More emphasis and effort should be directed toward this element in order to complete the picture of an effective rehabilitation of this group of disabled persons.     

Muscles of the below-knee amputees]

OBJECTIVE: The objective of this article is to review anatomical, histological and physiological muscle changes following below-knee amputation. MATERIALS AND METHODS: We searched the PubMed and Reedoc databases for studies evaluating modifications of the below-knee stump and changes over time in its anatomy, volume and histology. We also looked at postamputation modifications in gait and balance. RESULTS: Below-knee amputees show muscular atrophy on both the amputated side and nonamputated side, with fewer and smaller muscle fibres (particularly slow-twitch fibres). This amyotrophy varies in magnitude and distribution and can reach about 25% for the quadriceps (predominantly on the medial side), but is nonsignificant for the hamstrings. This amyotrophy results from the anatomical consequences of the surgical act. The loss of one or more of a muscle's insertions or reimplantation into a nonphysiological site prompts greater atrophy. Changes in muscle activation patterns also lead to atrophy. The hamstrings replace the triceps as the main muscles for propulsion and the remaining stump muscles contract so as to ensure a good fit with the prosthesis. The below-knee amputee must adapt to a new muscular state: gait symmetry is altered, energy expenditure for walking is higher and training is needed in order to achieve optimal balance control.     

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.     

Evaluation of prosthetic usage in upper limb amputees

Purpose: Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method: The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type - phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results: Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis - 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion: No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.     

Evaluation of prosthetic usage in upper limb amputees

Purpose:?Upper limb amputations cause severe functional disability and lower the patient's self body image, with severe psychological implications. Many parameters are involved in the successful rehabilitation of upper limb amputations. The aim of this study was to investigate whether there are any parameters that might predict the successful prosthetic rehabilitation of upper limb amputees.

Method:?The records of 45 patients who had undergone an upper limb amputation were traced. The patients were evaluated according to four parameters: (1) Modified upper extremities amputees' questionnaire; (2) Pain level according to Visual Analog Scale (VAS), range from 1 (lowest) up to 10 (highest); (3) Pain type – phantom or pain in the stump; (4) Functional assessment of prosthetic usage.

Results:?Thirty (71.43%) of the patients reported difficulties with prosthesis usage. Twenty-three patients (54.76%) were satisfied with their prosthesis – 19 had cosmetic prosthesis and four had body-powered prosthesis.

Conclusion:?No significant affect of the amputation level except for trans-wrist amputation with 100% prosthesis use. No significant difference was found between prosthesis type and the correlation to stump problems.

The above-elbow amputees, with dominant hand amputation, who used functional prosthesis (body-powered), achieved the best functional outcome and result.     

Classification and mechanisms of body perceptions in the amputees]

OBJECTIVE: Amputees can experience several types of physical illusions and phantom limb phenomenon. The objective was to establish a synthetic classification of theses perceptions. METHOD: Prospective study in 75 amputees (group 1: amputation (n = 60), group 2: congenital defect). The subjects were asked first to report their perceptions spontaneously and then to detail the perception, if exist, of the missing limb: form recognition, posture, movement, reminiscence of a lost limb. RESULTS: Different types of perception were described besides the perception of the real state : normal, deformed or commemorative phantom limb and illusion of a normal body. DISCUSSION: Whatever the model (i.e.: neuro-matrix) which support the construction of the scheme and the body image, the representations related to identified perceptions, use various innate, autobiographic and identity frames of references as well as instantaneous peripheral information, treated by reorganized cerebral structures. Each type of perception is related to a particular representation pattern. CONCLUSION: This approach, in accordance with the literature, offers a better understanding of the differences between amelic and amputated subjects and of their perception of any prosthetic equipment.     

The functional and professional future of lower limb amputees with prosthesis]

OBJECTIVE: The objective of our study is to evaluate the functional and professional becoming of lower limb amputated population with prosthesis. MATERIAL AND METHODS: Our study is retro-prospective. It interested lower limbs amputated patients who have beneficed during the period between 1982-1998 with prosthesis and have consulted in 1999. Data of our study were gathered by an hetero questionnaire. In order to evaluate the functional results of our patients, we have adopted the score established by the National association of doctors specialized in apparatus in France (ANMA). However, this score was little modified (in fact, we have eliminated the item "use of personalized vehicle for handicapped [VHP]", because no one of our patients possess it). The results were judged favourable: score 6-7; unfavourable: mean score between 3-5 and bad between 0-2. RESULTS: During the year of our survey, we have questioned 85 lower limb amputated patients with prosthesis: 67 were male and 18 were female. The mean age of our patients is 48 years (6 to 86 years). Our population was divided into: 31 traumatic amputated, 28 arteritics and 26 amputated of other etiologies (tumoral, infectious, congenital...). In 76 cases, the amputation is unilateral. It's located upper the knee in 51 cases. The evaluation of functional autonomy of our patients according to score adopted showed those results: 54.11% were favourable and 45.88% were unfavourable. In professional side, only 35 among our 60 active patients before amputation, have been able to resume, 12 have needed a professional rehabilitation. Among the 25 who hadn't taken up again their work, 15 have early retirement and ten are in unemployment. CONCLUSION: The amputation of lower limb constitute a major handicap which involves a functional and professional incapacity. We can reduce the risk of this incapacity by a good and appropriate rehabilitation.     

Rehabilitation of hemiplegic amputees

The authors report on results of rehabilitation of their 49 hemiplegic amputee cases. Most of the patients had vascular disease. A majority of them had also other conditions with negative effects on rehabilitation. 29 patients achieved walking, 14 used a wheelchair, three remained bedridden and another three died during the hospitalization. The influence of different factors on mobility has been studied. Below-knee amputation had significant effect on mobility, and the time interval between amputation and hemiplegia was also of importance. Other correlations need further studies and more experience.     

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.     

Physical fitness of lower limb amputees

OBJECTIVE: To investigate the cardiorespiratory endurance of the physical fitness of amputees and able-bodied subjects of the same ages and to demonstrate deterioration of the physical fitness of the amputees. DESIGN: The test subjects were 31 amputees. Eighteen able-bodied persons served as controls. The incremental exercise test was performed to evaluate physical fitness. Sixteen of 31 amputees underwent endurance training by using a cycle ergometer driven by the intact leg, and their physical fitness was evaluated after completion of the endurance training program. RESULTS: The Vo2max, anaerobic threshold, and maximum workload for the amputees were significantly lower than those of the able-bodied group. The equivalent values for the endurance training group before exercise treatment were 18.0, 12.1, and 63.9, respectively. After exercise treatment, these values significantly increased, and there was no significant difference from the able-bodied subjects. CONCLUSIONS: This study showed that the physical fitness of amputees was clearly lower than that of the able-bodied subjects and that the amputees were able to recover from a poorly conditioned status after endurance training.     

Functional capabilities of lower extremity amputees

One hundred thirty-four lower extremity amputees were evaluated from six months to 12 years postamputation by means of retrospective questionnaires. Patient population was similar to that of the "Amputee Census" in terms of sex, amputation level and cause of amputation. Information was gathered on activities generally considered essential for daily living, vocation and recreation, living arrangements and adjustments therein, as well as feedback on the patients' beliefs concerning what rehabilitation personnel should be doing to improve amputees' lifestyle. The relationship of functional outcome to age, amputation level, and cause of amputation was also evaluated. Results showed that most amputees did not resume a completely normal lifestyle and many modifications were made. The most popular recreational activities were fishing and swimming. Activities that amputees found most difficult were running and walking long distances. Patients requested better communication between professional staff and themselves. Below-knee amputees were significantly more independent than above-knee and bilateral amputees, but the differences between above-knee and bilateral amputees were statistically insignificant. Tumor patients did better than the other three etiologic groups. As age increased, functional independence decreased.     

Study of bone mass with dual energy x-ray absorptiometry in a population of 99 lower limb amputees]

OBJECTIVES: Osteopenia in lower extremity amputation is described with an increased risk of fracture and it seems to be interesting to study bone mass in a population of 99 amputees of limb. MATERIAL AND METHOD: We studied the bone mass with Dual Energy Xray Absorptiometry in patients with limb amputation, above and under knee and who have been treated in the rehabilitation department of Mulhouse's hospital and more specifically the percentage of the difference of the mesure between amputed and non amputed side and the influence on this mesure of several factors like sexe; age; diabetes mellitus; delay of amputation; aetiology and use of prosthesis. RESULTS: For all the population, we find lower values of BMD (Bone mineral density) for femoral neck -10.4% +/- 12.2 (P < 0,001) and trochanter -14.9% +/- 14.5 (P < 0,001) between amputated and non amputated side, and also comparing with normal population -19.9% +/- 18.8 (P < 0,001) for femoral neck and -8.8% +/- 22 (P < 0,001) for trochanter.There is no influence of sexe, age, and time since amputation on BMD. The study of sub-groupes shows that the loss of bone mass is depending on traumatic amputation, the level of amputation (above knee) and when prothetis doesn't fit. Arteritis or diabetis are not pejoratif factors. CONCLUSION: This work confirms the mechanical factors as an important parameter of bone loss in the limb amputation.