Prosthesis use in adult acquired major upper-limb amputees: patterns of wear,prosthetic skills and the actual use of prostheses in activities of daily life

Purpose: To describe patterns of prosthesis wear and perceived prosthetic usefulness in adult acquired upper-limb amputees (ULAs). To describe prosthetic skills in activities of daily life (ADL) and the actual use of prostheses in the performance of ADL tasks. To estimate the influence of prosthetic skills on actual prosthesis use and the influence of background factors on prosthetic skills and actual prosthesis use. Method: Cross-sectional study analysing population-based questionnaire data (n?=?224) and data from interviews and clinical testing in a referred/convenience sample of prosthesis-wearing ULAs (n?=?50). Effects were analysed using linear regression. Results: 80.8% wore prostheses. 90.3% reported their most worn prosthesis as useful. Prosthetic usefulness profiles varied with prosthetic type. Despite demonstrating good prosthetic skills, the amputees reported actual prosthesis use in only about half of the ADL tasks performed in everyday life. In unilateral amputees, increased actual use was associated with sufficient prosthetic training and with the use of myoelectric vs cosmetic prostheses, regardless of amputation level. Prosthetic skills did not affect actual prosthesis use. No background factors showed significant effect on prosthetic skills. Conclusions: Most major ULAs wear prostheses. Individualised prosthetic training and fitting of myoelectric rather than passive prostheses may increase actual prosthesis use in ADL.

Implications for Rehabilitation

• Arm prostheses are important functional aids for adult acquired major upper-limb amputees (ULAs).

• Despite being mainly satisfied with their prostheses, reporting their prostheses as useful and showing good prosthetic skills, prosthesis-wearing major ULAs do not use their prostheses for more than about half of the activities of daily life (ADL) tasks carried out in everyday life.

• In unilateral ULAs, individualised and targeted prosthetic training may increase optimal, active prosthesis use in ADL.

• Fitting the amputee with myoelectric rather than passive prostheses may increase prosthesis use in ADL, regardless of amputation level.

     

Evaluation of rehabilitated bilateral lower limb amputees – an Indian study

Objective: This study assessed activities of daily living (ADL) and ambulation of rehabilitated bilateral lower limb amputees with relation to their level of amputation in an Indian setting. Subjects and Methods: This retrospective study of 25 subjects comprised 12 bilateral Trans-femoral (TF) amputees, 8 bilateral Trans-tibial (TT) amputees and 5 a combination of ipsilateral Trans-femoral and contralateral Trans-tibial amputation. All subjects were contacted by post/telephone, were physically examined and assessed at the Orthopaedic clinic at a mean follow-up of 6.6 years. Physical rehabilitation was evaluated using ADL score and by grading the level of ambulation. Results: ADL scores showed no significant difference according to level of amputation (p > 0.05), but the scores of prosthetic users were significantly higher than non-prosthetic users (p?=?0.002). Only 11/25 amputees became prosthetic ambulators and most (50%, 6/12) were TF amputees. All prosthetically rehabilitated subjects were mobilising with their prostheses at follow-up and graded as unlimited or limited community ambulators. Conclusion: Though it is well documented that the potential for successful rehabilitation is best for bilateral TT amputees, given the subjects’ economic constraints, higher prosthesis rehabilitation among bilateral TF amputees indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

Implications for Rehabilitation

• Rehabilitation of a bilateral lower limb amputee requires a team effort and constitutes a very difficult challenge for the subject.

• Low prosthesis ownership is largely due to subjects’ inability to afford a pair of prostheses in a developing country like India.

• Activities of daily living improve significantly with use of prostheses.

• Though it is well documented that the potential for successful rehabilitation is best for a bilateral TT amputee, higher prosthesis rehabilitation among bilateral TF subjects in this study indicates that successful rehabilitation is possible in most subjects irrespective of the level of amputation.

     

Iodine–Starch test for assessment of hyperhidrosis in amputees,evaluation of different methods of application*

Abstract

Purpose: Hyperhidrosis is a common problem for amputees. The iodine–starch test is frequently used to assess hyperhidrosis, but a method for its application has not been described for amputees.

Methods: We performed an unblinded comparison of the iodine–starch test using various methods to protect the prosthesis in 10 prosthetic limb users with hyperhidrosis.

Results: Plastic wrap produced a diffuse pattern of sweating in 70% of subjects. Forty percent had complaints about this method, and 50% experienced leakage of iodine stain onto prosthetic liners. The prosthetic sheath produced a focal or multifocal reaction in 100% of subjects after 10?min of ambulation. Eighty percent had minor leakage onto the liner, and complaints were noted in 10%. The proportion that experienced diffuse sweating was significantly higher in the plastic wrap condition (p?=?0.016; difference in proportions?=?70%; 95% confidence interval?=?32–100%). The prosthetic sock was tested in four subjects and all had at least mild complaints; three had minor leakage onto the liner. Repeated complaints and lack of stain prevention led to discontinuation with this method.

Conclusions: Of the three methods, the sheath produces a focal or multifocal reaction after 10?min of ambulation and tends to cause less subject complaints. It should be the preferred method to apply the iodine–starch test to amputees.

• Implications for rehabilitation

• Hyperhidrosis is a common problem in amputees which negatively affects quality of life.

• The iodine–starch test is commonly used to guide treatment decisions for hyperhidrosis, but a preferred method for applying it in amputees has not been described.

• This study describes different methods for applying the iodine–starch test.

• A prosthetic sheath covering should be the preferred method for the iodine–starch test in amputees.

     

Case study: survey of patient satisfaction with prosthesis quality and design among below-knee prosthetic leg socket users

The aim of this case study was to explore patient satisfaction with the quality of prosthetic leg sockets intended for persons with lower limb amputations. A qualitative study based on in-depth interviews, preceded by a questionnaire session, was carried out with patients from the Rehabilitation Center and Hospital in Malaysia. Twelve out-patient and in-patient amputees with lower limb amputations, specifically below-knee amputations, were chosen randomly. The analysis of patients’ narratives aimed to identify the functional and esthetic characteristics of currently used prosthetic leg sockets and any problems related to them. The obtained results indicated that out of the 12 participants, 41.7% and 25% were satisfied and somewhat satisfied with their current prosthetic sockets. Durability and comfort were rated by the participants as the most important characteristics of prosthetic sockets, with 83.3%. As regards the esthetic appearance of the socket, 66.7% of the respondents considered that the most important feature was the material from which the socket was fabricated. Thus, we conclude that current satisfaction levels with the quality of prosthetic sockets among amputees in Malaysia are suitable, prosthesis being preferred by many amputees. The results can be used to direct future research on cosmesis and functionality of prosthetic socket design.

• Implications for Rehabilitation

• Case study will help participants to get cost effective prosthetic leg socket.

• Develop prosthetic leg socket comfortable as comparative to existing one.

• Help Malaysian government to make policy to develop local prosthetic leg socket at affordable price.

     

The AirCirc: design and development of a thermal management prototype device for below-knee prosthesis leg socket

Abstract

This study describes a newly developed prosthetic leg socket design for a below-knee amputation. Excessive heat and the resulted perspiration within a prosthetic socket were the most common causes for reporting a reduced quality of life for prosthetic users. The product namely AirCirc means air circulation and it has been designed by approach of medical device design process in providing the amputees to maintain the skin temperature inside the socket. This device has been designed to provide the amputees with comfort and ultimate breathable. In order to design the device, the small hole was made in prosthetic socket surface since it has a function as air circulation. Four types of proposed sockets namely P1, P2, P3 and P4 and one control socket were compared on a single patient to determine the best design of prosthetic socket. The result successfully reveals that by using holes can be maintain the temperature inside prosthetic socket. In addition to the eco-friendly material, the woven kenaf was used as material that provides good strength as compared to glass fibre and offer sustainable and biodegradable product yet provides unique and aesthetic surface as came from woven kenaf itself. The objective of this paper is to provide the airflow prosthetic socket design and optimize the use of natural fibre in prostheses field. Thus, with the use of the environmental friendly material, functionality device and heat removal capability make the device suitable for maintaining a comfortable and healthy environment for prosthesis.

• Implications of Rehabilitation

• Newly developed prosthetic leg socket design for a below-knee amputation

• Device has been designed to provide the amputees with comfort and ultimate breathable

• Woven kenaf was used as material that provides good strength as compared to glass fibre for sustainable and biodegradable product

• Results show that by using holes can be maintain the temperature inside prosthetic socket

     

Kinematic comparison of the wrist movements that are possible with a biomechatronics wrist prosthesis and a body-powered prosthesis: a preliminary study

Purpose: This study examined the kinematic differences between a body-powered prosthesis and a biomechatronics prosthesis as a transradial amputee performed activities that involve flexion/extension and supination/pronation of the wrist.

Method: The subject’s wrist movements were calculated and compared as he completed a wrist range of motion test involving simulated flexion/extension and supination/pronation.

Results: The results revealed that, under the test conditions, the body-powered prosthesis limits an individual’s ability to complete four different tasks of wrist movement especially when it comes to complete the supination/pronation movement. Conversely, while using biomechatronics wrist prosthesis, the user was able to compensate for limited wrist motion through an ability to achieve a greater range of wrist movement.

Conclusions: The biomechatronics wrist prosthesis provides a greater degree of freedom of wrist flexion/extension and supination/pronation movements.

Implications for Rehabilitation

• Body powered prosthesis for transradial amputees involved the wrist movement that focus on flexion/extension and supination/pronation.

• The biomechatronics wrist prosthesis is a combination of controller that controlled the servo motor at the wrist.

• The biomechatronics wrist prosthesis provides a greater degree of freedom of wrist flexion/extension and supination/pronation movements compare to the body powered prosthesis.

     

The potential for non-invasive brain stimulation to improve function after amputation

Purpose: Lower limb amputee rehabilitation has traditionally focussed on restoration of gait and balance through use of prosthetic limbs and mobility aids. Despite these efforts, some amputees continue to experience difficulties with mastering prosthetic mobility. Emerging techniques in rehabilitation, such as non-invasive brain stimulation (NIBS), may be an appropriate tool to enhance prosthetic rehabilitation outcomes by promoting “normal” brain reorganisation and function. The purpose of this review is to highlight the potential of NIBS to improve functional outcomes for lower limb amputees. Methods: To demonstrate the rationale for applying NIBS to amputees, this study will first review literature regarding human motor control of gait, followed by neurophysiological reorganisation of the motor system after amputation and the relationship between brain reorganisation and gait function. We will conclude by reviewing literature demonstrating application of NIBS to lower limb muscle representations and evidence supportive of subsequent functional improvements. Results: Imaging, brain stimulation and behavioural evidence indicate that the cortex contributes to locomotion in humans. Following amputation both hemispheres reorganise with evidence suggesting brain reorganisation is related to functional outcomes in amputees. Previous studies indicate that brain stimulation techniques can be used to selectively promote neuroplasticity of lower limb cortical representations with improvements in function.

Conclusions: We suggest NIBS has the potential to transform lower limb amputee rehabilitation and should be further investigated.

• Implications for Rehabilitation

• Despite extensive rehabilitation some amputees continue to experience difficulty with prosthetic mobility

• Brain reorganisation following amputation has been related to functional outcomes and may be an appropriate target for novel interventions

• Non-invasive brain stimulation is a promising tool which has potential to improve functional outcomes for lower limb amputees

     

The African disability scooter: efficiency testing in paediatric amputees in Malawi

Purpose: The African Disability Scooter (ADS) was developed for lower limb amputees, to improve mobility and provide access to different terrains. The aim of this study was to test the efficiency of the ADS in Africa over different terrains. Method: Eight subjects with a mean age of 12 years participated. Energy expenditure and speed were calculated over different terrains using the ADS, a prosthetic limb, and crutches. Repeated testing was completed on different days to assess learning effect. Results: Speed was significantly faster with the ADS on a level surface compared to crutch walking. This difference was maintained when using the scooter on rough terrain. Oxygen cost was halved with the scooter on level ground compared to crutch walking. There were no significant differences in oxygen consumption or heart rate. There were significant differences in oxygen cost and speed between days using the scooter over level ground, suggesting the presence of a learning effect. Conclusions: This study demonstrates that the ADS is faster and more energy efficient than crutch walking in young individuals with amputations, and should be considered as an alternative to a prosthesis where this is not available. The presence of a learning effect suggests supervision and training is required when the scooter is first issued.

• Implications for Rehabilitation

• The African Disability Scooter:

• is faster than crutch walking in amputees;

• is more energy efficient than walking with crutches;

• supervised use is needed when learning to use the device;

• is a good alternative/adjunct for mobility.

     

Improved design and development of a functional moulded prosthetic foot

Purpose: In the Indian scenario, the Jaipur foot is a low-cost breakthrough that enabled the disabled person to adapt to the Indian environment. The aim of this study is to modify the present foot in terms of ankle support design and method of fabrication, foot moulds profile and the inner core material in order to improve the performance and durability. Method: The optimized design of ankle support and flat foot profile moulds suitable for both left and right foot were developed through CAD/CAM and prosthetic feet were fabricated using ethylene vinyl acetate (EVA) foam as an appropriate alternative core material for microcellular rubber (MCR). The developed prosthetic feet were tested for rigidity by load-deflection analysis in universal testing machine. Result: EVA foot had shown better rigidity than conventional MCR foot, which will help in weight transfer during walking and increase the durability. The CAD modeled ankle support and single block EVA had made the manufacturing process easy and reduced the weight of foot and improved Gait to the person fitted with it due to improved flat foot profile. Conclusion: The new artificial foot had proven to be efficacious technically as well as functionally, which is clearly borne out from the extremely positive feedback given by the amputees.

• Implications of Rehabilitation

• Persons with below knee amputation are usually provided with transtibial prosthesis, which allows for easier ambulation and helps them to get back to their normal life.

• Transtibial prosthesis is an artificial limb that replaces a lower limb that is amputated below the knee.

• In our study, a new prosthetic foot with a modified ankle support and flat foot profile using better inner-core material than the conventional Jaipur foot was developed and the process was also optimized for mass production. The developed prosthetic foot can be fitted with both above and below knee exoskeleton type of prosthesis.

     

Musculoskeletal pain and overuse syndromes in adult acquired major upper-limb amputees

Østlie K, Franklin RJ, Skjeldal OH, Skrondal A, Magnus P. Musculoskeletal pain and overuse syndromes in adult acquired major upper-limb amputees.

Objectives

(1) To compare the prevalence of self-reported musculoskeletal pain in upper-limb amputees (ULAs) in Norway with that of a control group drawn from the Norwegian general population; (2) to describe musculoskeletal pain bothersomeness in ULAs; (3) to estimate the association between prosthesis wear and self-reported musculoskeletal pain in ULAs; and (4) to describe the occurrence of musculoskeletal overuse syndromes in a sample of ULAs.

Design

Cross-sectional study: postal questionnaires and clinical examinations.

Setting

Norwegian ULA population. Clinical examinations performed at 3 clinics.

Participants

Questionnaires: population-based amputee sample (n=224; 57.4% response rate). Random control sample (n=318; 33.1% response rate). Clinical examinations: combined referred sample and convenience sample (n=70; 83.3% of those invited). Survey inclusion criteria: adult, resident in Norway and mastering Norwegian (amputees and controls), acquired major upper-limb amputation (amputees only).

Interventions

Not applicable.

Main Outcome Measures

Self-reported musculoskeletal pain and pain bothersomeness. Self-reported pain in prosthesis wearers and nonwearers. Clinically assessed diagnoses of musculoskeletal overuse syndromes.

Results

Self-reported musculoskeletal pain was more frequent in ULAs than in the control group except for lower back pain. In ULAs, 57.0% reported neck/upper back pain (odds ratio [OR]=2.56; 95% confidence interval [CI], 1.64–3.98), and 58.9% reported shoulder pain (OR=4.00; 95% CI, 2.51–6.36). The percentage difference for arm pain was 24.8% (P<.001). All pain was reported as bothersome. We found no difference in pain prevalence between prosthesis wearers and nonwearers. Musculoskeletal overuse syndromes were found in 6.1% to 24.2% of ULAs, depending on diagnosis and case-definition criteria.

Conclusions

Upper-limb loss increases the risk of self-reported musculoskeletal pain in the neck/upper back, shoulders, and in the remaining arm. Prosthesis wear does not prevent musculoskeletal pain. Further studies should be conducted to investigate the effects of prosthesis wear and possible preventive measures, and to ascertain our preliminary prevalence estimates of overuse syndromes.     

Adaptations from the prosthetic and intact limb during standing on a sway-referenced support surface for transtibial prosthesis users

Abstract

Purpose: To investigate the bilateral postural adaptations as a result of standing on an increasingly unstable sway-referenced support surface with both the intact and prosthetic limb for transtibial prosthesis users (TPUs).

Method: TPUs (n = 14) and matched controls (n = 14) stood quietly in multiple foot placement conditions (intact foot, prosthetic foot and both feet) on a sway-referenced support surface which matched surface rotation to the movement of the centre of pressure (CoP). Force and motion data were collected and used to analyse CoP mean position, displacement integral and force components under intact and prosthetic limbs.

Results: Significant differences were found between prosthesis users and controls in CoP mean position in anteroposterior (1.5 (95% CI, 1.2–1.8) cm) and mediolateral directions (3.1 (95% CI, 0.5–5.7) cm. CoP displacement integrals were significantly different greater for prosthesis user group in the anteroposterior direction. Force components differences were found in all planes (anteroposterior: 0.6 (95% CI, 0.4–0.8 N); mediolateral: 0.1 (95% CI, 0.0–0.2 N & 0.3 (95% CI, 0.2–0.4) N, inferosuperior: 2.2 (95% CI, 1.4–3.0) N).

Conclusions: TPUs have bilateral static and dynamic postural adaptations when standing on a sway-referenced support surface that is different to controls, and between prosthetic and intact sides. Results further support evidence highlighting importance of the intact limb in maintenance of postural control in prosthesis users. Differences indicate clinical treatment should be directed towards improving outcomes on the intact side.

• Implications for rehabilitation

• Prosthesis users have bilateral adaptations when standing on a sway referenced support surface

• These adaptations are different to controls, and between prosthetic and intact sides.

• The intact limb is the major contributor to maintenance of postural control in prosthesis users.

• Clinical treatment should account for this when interventions are designed.

     

Safety and function of a prototype microprocessor-controlled knee prosthesis for low active transfemoral amputees switching from a mechanic knee prosthesis: a pilot study

Purpose: Aim of this pilot study was to assess safety and functioning of a microprocessor-controlled knee prosthesis (MPK) after a short familiarization time and no structured physical therapy.

Materials and methods: Five elderly, low-active transfemoral amputees who were fitted with a standard non-microprocessor controlled knee prosthesis (NMPK) performed a baseline measurement consisting of a 3?D gait analysis, functional tests and questionnaires. The first follow-up consisted of the same test procedure and was performed with the MPK after 4 to 6?weeks of familiarization. After being refitted to their standard NMPK again, the subjects undertook the second follow-up which consisted of solely questionnaires 4?weeks later.

Results: Questionnaires and functional tests showed an increase in the perception of safety. Moreover, gait analysis revealed more physiologic knee and hip extension/flexion patterns when using the MPK.

Conclusion: Our results showed that although the Genium with Cenior-Leg ruleset-MPK (GCL-MPK) might help to improve several safety-related outcomes as well as gait biomechanics the functional potential of the GCL-MPK may have been limited without specific training and a sufficient acclimation period.

• Implications for Rehabilitation

• Elderly transfemoral amputees are often limited in their activity by safety issues as well as insufficient functioning regarding the non microprocessor-controlled knee prostheses (NMPK), thing that could be eliminated with the use of suitable microprocessor-controlled prostheses (MPK).

• The safety and functioning of a prototype MPK (GCL-MPK) specifically designed for the needs of older and low-active transfemoral amputees was assessed in this pilot study.

• The GCL-MPK showed indicators of increased safety and more natural walking patterns in older and low-active transfemoral amputees in comparison to the standard NMPK already after a short acclimatisation time and no structured physical therapy.

• Regarding functional performance it seems as if providing older and low-active transfemoral amputees with the GCL-MPK alone without prescribing structured prosthesis training might be insufficient to achieve improvements over the standard NMPKs.

     

Effects of long-distance walking on socket-limb interface pressure,tactile sensitivity and subjective perceptions of trans-tibial amputees

Purpose: Many trans-tibial amputees could not tolerate long-distance walking. Lack of walking could explain for the increased cardiovascular diseases mortality rate. This study investigated the effects of long-distance walking (LDW) on socket-limb interface pressure, tactile sensitivity of the residual limb, and subjective feedbacks, which potentially identified the difficulties in LDW. Method: Five male unilateral trans-tibial amputees walked on a level treadmill for a total of one hour at comfortable speed. Tactile sensitivity of the residual limb and socket-limb interface pressure during over-ground walking were measured before and after the treadmill walking. Modified Prosthesis Evaluation Questionnaires were also administered. Results: After the treadmill walking, the socket-limb interface pressure and the tactile sensitivity at the popliteal depression area were significantly reduced. This corresponds well with the questionnaire results showing that the level of discomfort and pain of the residual limb did not increase. The questionnaire revealed that there were significant increases in fatigue level at the sound-side plantar flexors, which could lead to impaired dynamic stability. Conclusions: Fatigue of sound-side plantar-flexor was the main difficulty faced by the five subjects when walking long-distances. This finding might imply the importance of refining prosthetic components and rehabilitation protocols in reducing the muscle fatigue.

Implications for Rehabilitation

• After long-distance walking (LDW) of the trans-tibal amputee subjects, there were significant increases in fatigue level at the plantar flexors. These might explain the reduced walking stability as perceived by the subjects.

• LDW did not produce any problems in residual-limb comfort and pain feeling. These were in line with the significant reductions of socket-limb interface pressure and the tactile sensitivity at the popliteal depression after LDW.

• Refinements of prosthetic components and rehabilitation protocols should be attempted to reduce the fatigue of the plantar flexors and facilitate LDW.

     

Cognitive functioning in persons with lower limb amputations: a review

Purpose: To review the literature on cognitive functioning in persons with lower limb amputations. Method: A search of the MEDLINE, PsycINFO and Web of Science databases was carried out. Results: Thirty papers were found that met the inclusion criteria. The studies were characterised by heterogeneity of design, methodological quality, sample characteristics, assessment of cognitive functioning, and outcomes examined. The research published to date suggests that cognitive impairment is more prevalent among persons with lower limb amputations than in the general population, and is linked with a number of important outcomes in this patient group, including mobility, prosthesis use, and maintenance of independence following amputation. Conclusions: These findings highlight the importance of assessing the cognitive abilities of persons with lower limb amputations. An understanding of the cognitive profile of these patients could assist rehabilitation teams in determining their suitability for prosthetic or wheelchair rehabilitation, ascertaining appropriate and realistic goals for rehabilitation, and tailoring rehabilitation programmes to patients’ strengths so that maximal mobility and independence is achieved.

Implications for Rehabilitation

• Cognitive impairment appears to be more prevalent among persons with lower limb amputations than in the general population.

• Cognitive impairment is negatively associated with mobility, prosthesis use, and maintenance of independence following amputation.

• Cognitive screening prior to rehabilitation could assist in determining patients’ suitability for prosthetic or wheelchair use, ascertaining appropriate goals, and tailoring rehabilitation to patients’ strengths so as to optimise their mobility and independence.

     

Metabolic energy expenditure of ambulation in lower extremity amputees: what have we learned and what are the next steps?

Purpose: Amputation results in reduced mobility and contributes to reduced quality of life. The increased metabolic cost of ambulation has been suggested as an important contributor to reduced mobility in this population. Current research on the metabolic energy expenditure of ambulation will be critically reviewed from the perspectives of ecological validity of the research methods and the relative contribution to functional improvement in amputees. Recommendations will be made regarding possible future directions for research and their potential clinical utility. Methods: Narrative review. Results: The methods used to quantify metabolic energy expenditure of amputee ambulation do not emulate typical mobility conditions that amputees experience. Amputee mobility is characterized by short bouts of activity with starting, stopping and changes of direction. This is opposed to the typical metabolic testing protocol that requires at least 5?min of steady state linear walking on a treadmill. These studies, therefore, have limitations in ecological validity and therefore limitations in the extent to which they accurately reflect the effect of amputation level, amputation etiology and prosthetic components on energy consumption during walking. Further, the broader perspective on outcomes after dysvascular amputation and sports participation limitations, raises questions about the relative importance of improving metabolic costs and its potential effect on improving mobility in amputees. Conclusion: The greatest potential clinical impact of future research requires methods with improved ecological validity, and the ability to translate metabolic energy expenditure outcomes into functional terms that are meaningful to both clinicians and patients.

• Implications for Rehabilitation

• The search for objective measurements to define the effects of amputation on outcome and the consequences of prosthetic components on mobility has focused in part on the use of study designs incorporating metabolic measurement.

• However, there are important limitations to the ecological validity of these measures and their relative importance as an outcome measure in dysvascular amputees as well as in sports/leisure participation.

• Novel research approaches are required to quantify the functional impact of increased metabolic energy expenditure and to better understand the psychophysical limitations that result.

     

Cognitive predictors of skilled performance with an advanced upper limb multifunction prosthesis: a preliminary analysis

Purpose The objectives were to 1) identify major cognitive domains involved in learning to use the DEKA Arm; 2) specify cognitive domain-specific skills associated with basic versus advanced users; and 3) examine whether baseline memory and executive function predicted learning. Method Sample included 35 persons with upper limb amputation. Subjects were administered a brief neuropsychological test battery prior to start of DEKA Arm training, as well as physical performance measures at the onset of, and following training. Multiple regression models controlling for age and including neuropsychological tests were developed to predict physical performance scores. Prosthetic performance scores were divided into quartiles and independent samples t-tests compared neuropsychological test scores of advanced scorers and basic scorers. Baseline neuropsychological test scores were used to predict change in scores on physical performance measures across time. Results Cognitive domains of attention and processing speed were statistically significantly related to proficiency of DEKA Arm use and predicted level of proficiency. Conclusions Results support use of neuropsychological tests to predict learning and use of a multifunctional prosthesis. Assessment of cognitive status at the outset of training may help set expectations for the duration and outcomes of treatment.

• Implications for Rehabilitation

• Cognitive domains of attention and processing speed were significantly related to level of proficiencyof an advanced multifunctional prosthesis (the DEKA Arm) after training.

• Results provide initial support for the use of neuropsychological tests to predict advanced learningand use of a multifunctional prosthesis in upper-limb amputees.

• Results suggest that assessment of patients’ cognitive status at the outset of upper limb prosthetictraining may, in the future, help patients, their families and therapists set expectations for theduration and intensity of training and may help set reasonable proficiency goals.

     

How ‘preventable’ are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors

Purpose: Clinicians commonly believe that lower extremity amputations are potentially preventable with coordinated care and motivated patient self-management. We used in-depth interviews with recent amputees to assess how patients viewed their initial amputation risk and causes. Method: We interviewed 22 patients at a rehabilitation hospital 2–6 weeks after an incident amputation. We focused on patients’ representations of amputation cause and methods of coping with prior foot and leg symptoms. Results: Patients reported unexpected onset and rapid progression of ulceration, infection, progressive vascular disease, foot trauma and complications of comorbid illness as precipitating events. Fateful delays of care were common. Many had long histories of painful prior treatments. A fatalistic approach to self-management, difficulties with access and communication with providers and poor understanding of medical conditions were common themes. Few patients seemed aware of the role of smoking as an amputation risk factor. Conclusions: Most patients felt out of control and had a poor understanding of the events leading to their initial amputations. Prevention of subsequent amputations will require rehabilitation programs to address low health literacy and psychosocial obstacles to self-management.

Implications for Rehabilitation

• Among amputees, pre-amputation perceptions of decisional and informational control are known to affect rehabilitation and disability adjustment prospects.

• Our findings on patient perceptions of their experiences with an initial lower extremity amputation are salient to rehabilitation specialists working with amputees to avoid a proximal or contralateral amputation.

     

Expectations of rehabilitation following lower limb amputation: a qualitative study

Abstract

Purpose: To explore the expectations of patients about to undergo prosthetic rehabilitation following a lower limb amputation. Method: Design: Qualitative study using semi structured interviews. Setting: Interviews were conducted at two district general hospitals. Participants: Eight patients who had undergone a major lower limb amputation due to vascular insufficiency were interviewed within two weeks of their amputation. All patients had been referred for prosthetic rehabilitation. Results: Five key themes emerged from the interviews: uncertainty, expectations in relation to the rehabilitation service, personal challenges, the prosthesis and returning to normality. These findings illustrate how participants faced uncertainty both pre- and postoperatively and often looked towards established amputees for the provision of accurate information. Conclusions: As no previous research has specifically explored patients’ expectations following an amputation, this study adds valuable insight into the patient experience. Patient expectations following lower limb amputation appeared to be vague and uninformed which may lead to uncertainty and passivity. It was found that patients did not know what to expect in relation to the rehabilitation process. They expected to return to a normal life following an amputation and this expectation appeared to be an important coping mechanism. Patient information and discussions should form an important part of the rehabilitation process before as well as during prosthetic rehabilitation, to help shape realistic expectations. This will allow patients to take a more active, informed role in the process. Psychoeducation interventions (talking) appears to be as important as “walking” within prosthetic rehabilitation services.

• Implications for Rehabilitation

• Patients’ expectations following lower limb amputation need to be informed by the rehabilitation team and established amputees from an early stage as part of the short- and long-term process of adjustment following amputation.

• Patient expectations of a return to normality appear to be an important part of coping following lower limb amputation, exploration of a new normal, both physically and psychosocially should be addressed as part of the rehabilitation process.

     

Targeted upper-limb Wii-based Movement Therapy also improves lower-limb muscle activation and functional movement in chronic stroke

Purpose: Post-stroke hemiparesis may manifest as asymmetric gait, poor balance, and inefficient movement patterns. We investigated improvements in lower-limb muscle activation and function during Wii-based Movement Therapy (WMT), a rehabilitation program specifically targeting upper-limb motor-function.

Methods: Electromyography (EMG) was recorded bilaterally from tibialis anterior (TA) in 20 stroke patients during a 14-day WMT program. EMG amplitude and burst duration were analyzed during stereotypical movement sequences of WMT activities. Functional movement ability was assessed pre- and post-therapy including 6-min walk test (6MWT), stair-climbing speed, and Wolf Motor Function Test timed-tasks.

Results: TA EMG burst duration during Wii-golf increased by 30% on the more-affected side (p?=?0.04) and decreased by 28% on the less-affected side. Patients who did not step during Wii-tennis had a 16% decrease in more-affected TA burst sum (p?=?0.047) resulting in more symmetrical activation ratio at late-therapy, with the ratio changing from 3.24?±?2.25 to 0.99?±?0.11 (p?=?0.047). Six-minute walk and stair-climbing speed improved (p?=?0.005 and 0.03, respectively), as did upper-limb movement (p?≤?0.001).

Conclusion: This study provides physiological evidence for lower-limb improvements with WMT. Different patterns of muscle activation changes were evident across the WMT activities. Despite the relatively good pre-therapy lower-limb function, muscle activation and symmetry improved significantly with upper-limb WMT.

• Implications for rehabilitation

• WMT is an upper-limb neurorehabilitation program that also improves lower-limb motor-function.

• We report a shift towards more symmetrical muscle activation of tibialis anterior on the more- and less-affected sides that were reflected in increased distance walked during the 6MWT.

• The use of standing during therapy not only improves lower-limb function but also permits larger and more powerful upper-limb movements.

• Targeted upper-limb rehabilitation can also significantly improve mobility and balance, whether dynamic or static, that should reduce the risk of falls post-stroke.