Patient rehabilitation following lower limb amputation

Patient rehabilitation following lower limb amputation is essential to provide optimum patient outcomes and to improve the amputee's quality of life. The age of the patient and the stump length or level of amputation emerge as dominant factors affecting the outcome of rehabilitation. A variety of outcome measures are available to assess the patient's rehabilitative potential to maximise functional ability. This article focuses on the factors affecting rehabilitation, outcome measures to assess rehabilitative potential and the nurse's role in providing care for patients following lower limb amputation.     

Non-pharmacological management of phantom limb pain in lower limb amputation: a systematic review

Background: The incidence and severity of phantom limb pain (PLP) does not differ much between the extremities of amputation. However, its impact on functional ability and quality of life in lower limb amputation may be different, as prosthetic weight bearing is a key component in the movement and functional rehabilitation of individuals with a lower limb amputation.

Objective: To evaluate the evidence for effectiveness or efficacy of non-pharmacological interventions in the management of PLP in adults with lower limb amputation.

Methods: A comprehensive literature search conducted on 11 electronic databases, from their inception to 25 March 2016 identified 626 potentially relevant articles. Full-text randomised controlled trials in English which examined any form of non-pharmacologic intervention for managing PLP in lower limb amputees were included. The data with regard to characteristics of the studies, participants, intervention and outcome measures and overall statistical result were extracted. The Cochrane ‘Risk of bias assessment tool’ was used to assess the bias of all included articles.

Results: Four studies met the final criteria to be included in the review. Four treatment techniques had been used in the treatment of 204 patients with lower limb amputation. Two trials showed a positive impact of intervention on PLP compared to control group. Risk of bias varied across studies, and only one included study was assessed as having a low risk of bias.

Conclusion: The review identified lack of evidence to support non-pharmacological interventions in the management of PLP. Adequately powered high-quality trials are needed in this area to inform rehabilitation.     

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.

     

Selection of outcome measures in lower extremity amputation rehabilitation: ICF activities

Purpose. To identify and evaluate the lower extremity amputee (LEA) rehabilitation outcome measurement instruments that quantify those outcomes that have been classified within the ICF category of activities. This was done to assist the clinicians in the selection of the most appropriate instrument based upon four determinants of successful LEA rehabilitation and outcome measurement.

Method. A systematic review of the literature associated with outcome measurement in LEA rehabilitation was conducted. Only articles containing data related to metric properties (reliability, validity or responsiveness) for an instrument were included. Articles were identified by electronic and hand-searching techniques and were subsequently classified first according to the ICF and then by their clinical use.

Results. Seventeen instruments were identified that were classified into one of (A) walk tests, (B) mobility grades and (C) indices (generic and amputee-specific). Evidence about metric properties and clinical utility was summarised in tables which formed the basis for conclusions and recommendations pertaining to LEA rehabilitation.

Conclusions. All instruments examined have the potential for some use within the initial rehabilitation trial following amputation. There is a universal absence of quality evidence demonstrating responsiveness and most instruments would benefit from further investigation to better define their optimal use.     

外骨骼康复机器人改善脑卒中偏瘫患者下肢功能的临床研究

目的：观察应用下肢外骨骼康复机器人康复训练对脑卒中偏瘫患者下肢功能的改善情况。方法：脑卒中偏瘫下肢运动功能障碍患者60例,分为机器人组和对照组各30例。对照组给予脑卒中常规康复治疗,机器人组在常规康复治疗的基础上,应用下肢外骨骼康复机器人进行康复训练。于训练前后通过 Fugl-Meyer运动及平衡功能评分、Holden步行功能分级对患者的下肢康复情况进行评价。结果：训练60d后,2组 Fugl-Meyer运动功能评分、Fugl-Meyer平衡功能评分、Holden步行功能分级均较治疗前明显提高（P＜0．05）,且机器人组提高幅度较对照组更显著（P＜0．05）。结论：应用下肢外骨骼康复机器人可改善脑卒中偏瘫患者的下肢功能,值得在临床上推广应用。     

Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation

Zhou J, Bates BE, Kurichi JE, Kwong PL, Xie D, Stineman MG. Factors influencing receipt of outpatient rehabilitation services among veterans following lower extremity amputation.

Objective

To determine patient-, treatment-, and facility-level characteristics associated with receiving outpatient rehabilitation services after lower extremity amputation within the Veterans Affairs (VA) system.

Design

Observational study.

Setting

All Veterans Affairs Medical Centers (VAMCs).

Participants

Veterans (N=4165) with lower extremity amputation discharged from VAMCs between October 1, 2002, and September 20, 2004.

Interventions

Not applicable.

Main Outcome Measures

Receipt of outpatient rehabilitation services up to 1 year postdischarge. A Cox proportional hazards model was used to determine the adjusted hazard ratio and 95% confidence interval of veterans to receive outpatient services.

Results

Sixty-five percent of veterans with lower extremity amputation received outpatient services. Older veterans, patients admitted for surgical amputation from extended care rather than transferred from another hospital, and those with transfemoral and/or bilateral rather than unilateral transtibial amputations were less likely to receive outpatient services. Those with serious comorbidities and those who had procedures for acute central nervous system disorders, active cardiac pathology, serious nutritional compromise, and severe renal disease during the surgical hospitalization less often initiated outpatient care. Patients who received inpatient consultative rehabilitation compared with inpatient specialized rehabilitation, and who were treated in the Northeast compared with the Southeast less often initiated outpatient care. Finally, those discharged to home or other locations rather than extended care had an initial increased likelihood of receiving outpatient service, but by 180 days postdischarge those discharged to extended care were more likely to initiate outpatient services.

Conclusions

Both clinical characteristics and types of rehabilitation services received appear to influence the receipt of outpatient rehabilitation services. Geographic location also affected the receipt of outpatient rehabilitation, suggesting that care patterns are not standardized across the nation.     

Sexual functioning and sexual well-being in people with a limb amputation: a cross-sectional study in the Netherlands

Purpose: This study aimed to: (a) investigate whether, and if so which, sexual problems are present in people with a limb amputation; (b) analyze how they experience their sexuality; and (c) investigate whether sexuality was discussed with them during their rehabilitation process. Method: In total, 301 participants completed a survey consisting of a questionnaire on participant characteristics, the Hospital Anxiety and Depression Scale (HADS), the Maudsley Marital Questionnaire (MMQ), the Amputee Body Image Scale (ABIS), the Questionnaire about Sexual Counselling, the Questionnaire about Sexuality and the Short Sexual Functioning Scale (SSFS). Results: Overall, 20% of the participants experienced one or more sexual dysfunction(s). Participants who had at least one sexual dysfunction were more likely to be male, had an amputation more recently, and had a more negative body image. Moreover, sexuality was only scantly discussed by rehabilitation professionals. Conclusions: Sexual problems and sexual dysfunctions do occur in people with a limb amputation, but these problems are not discussed during the rehabilitation process. Justice for a person's “whole body” can only be served when sexuality is taken seriously in rehabilitation care in order to avoid cutting sexuality out of an amputee's life.

• Implications for Rehabilitation

• People with a limb amputation may be confronted with sexual problems and/or sexual dysfunctions.

• It is therefore important that sexuality is taken seriously as a part of standard rehabilitation care and that professionals bring up the issue of sexuality during the rehabilitation process.

     

A survey of physiotherapists involved in paediatric lower limb amputee rehabilitation in the British Isles

Objectives

Children require extensive rehabilitation following lower limb amputation and there are few reports describing this rehabilitation process. A survey to assess opinions, practice and caseloads amongst physiotherapists involved with paediatric amputee rehabilitation in the British Isles was therefore undertaken.

Design

A 17-item structured telephone survey was developed to include the main aspects of physiotherapy rehabilitation of children following lower limb amputation. Physiotherapists working in paediatrics and/or amputee rehabilitation in a range of acute, outpatient and community settings were surveyed.

Results

Data were collected between November 2001 and October 2002. Physiotherapists from 70 centres were contacted, and 52 treated paediatric lower limb amputees. A variety of causes of amputation were managed. All physiotherapists commented that they saw very few paediatric patients. No centre had protocols in place for any stage of management. In all geographical areas, rehabilitation was available throughout recovery for all causes of lower limb amputation. Core elements of rehabilitation were similar; however, additional elements differed between centres.

Conclusions

This survey indicates that the small population of children with lower limb amputation has access to rehabilitation throughout their recovery. However, there is variation in the provision of physiotherapy rehabilitation services throughout the British Isles. Redesigning physiotherapy rehabilitation services for paediatric lower limb amputees, and formalisation of cross-speciality links between paediatric and amputee physiotherapists may help to address these issues and better equip these children for future function.     

The experience of men using an upper limb prosthesis following amputation: positive coping and minimizing feeling different

Purpose. Psychosocial factors are likely to play a crucial role in adjustment to upper limb amputation and prosthesis use, and yet have received only minimal exploration within the literature. This study therefore, sought to gain a rich understanding of the experience of living with an upper limb amputation and of using a prosthetic arm and hand.

Methods. The qualitative method of Interpretive Phenomenological Analysis was used. Purposive sampling culminated in a homogenous sample of 11 males with unilateral upper limb amputations, who wore a prosthesis at least weekly. Semi-structured interviews were carried out, transcribed and analysed according to the methodology.

Results. Participants identified a theme of ongoing awareness of difference in appearance and ability. Consequently, participants described themes of psychosocial and functional adjustment to minimize this sense of difference. This was facilitated by the participants' prostheses and their positive coping style. Within this, participants also identified the personal meanings of their prosthesis and highlighted the terms of its use. The minimization of their sense of difference resulted in participants regaining a sense of worth.

Conclusions. The findings offer a greater psychological insight into adjustment from an upper limb amputation and the role of prostheses. These findings have implications for both the clinical rehabilitation of patients who undergo upper limb amputations, as well as for future research into the use and value of prostheses in facilitating the adjustment to this experience.     

Predictors of return to work following traumatic work-related lower extremity amputation

Purpose. To determine factors predictive of return to work (RTW) and days of total disability (TD) in a population of persons working at the time of lower extremity amputation.

Method. Retrospective chart and database review.

Results. Of 88 valid cases, 48% involved toe amputation, 23% transtibial, 14% partial foot, 14% transfemoral, and 2% high level. Fifty-eight percent of all subjects RTW, 19% were deemed ‘fit for work’, and 23% did not RTW. Days TD ranged from 0 to 1664, with a mean of 366 days. Toe amputation level showed a mean of 127 days of TD. Bivariate analysis showed amputation level, total costs to Workers Compensation Board (WCB), and days TD significantly related to RTW, and rehabilitation costs, vocational rehabilitation, work assessment, age, number of surgical procedures, number of days in acute care, and amputation level significantly related to days TD. In the multivariate model, only amputation level and higher gross annual income showed predictive value for RTW. However older age, more surgical procedures, less days in hospital, and higher amputation levels were all predictive of increased days TD.

Conclusion. Toe amputation level had a surprisingly high number of days TD, which may have significant potential economic and disability impact on the workplace. Other factors beyond simply amputation level (such as previous income level) are important considerations for RTW.     

Predictors of return to work following traumatic work-related lower extremity amputation

Purpose. To determine factors predictive of return to work (RTW) and days of total disability (TD) in a population of persons working at the time of lower extremity amputation.

Method. Retrospective chart and database review.

Results. Of 88 valid cases, 48% involved toe amputation, 23% transtibial, 14% partial foot, 14% transfemoral, and 2% high level. Fifty-eight percent of all subjects RTW, 19% were deemed 'fit for work', and 23% did not RTW. Days TD ranged from 0 to 1664, with a mean of 366 days. Toe amputation level showed a mean of 127 days of TD. Bivariate analysis showed amputation level, total costs to Workers Compensation Board (WCB), and days TD significantly related to RTW, and rehabilitation costs, vocational rehabilitation, work assessment, age, number of surgical procedures, number of days in acute care, and amputation level significantly related to days TD. In the multivariate model, only amputation level and higher gross annual income showed predictive value for RTW. However older age, more surgical procedures, less days in hospital, and higher amputation levels were all predictive of increased days TD.

Conclusion. Toe amputation level had a surprisingly high number of days TD, which may have significant potential economic and disability impact on the workplace. Other factors beyond simply amputation level (such as previous income level) are important considerations for RTW.     

下肢康复机器人联合等速肌力训练对脑卒中后下肢运动功能影响的临床对照研究

目的:观察下肢康复机器人联合等速肌力训练对脑卒中后下肢运动功能的影响。方法:将脑卒中患者75例随机分为3组,每组25例。3组病人均进行常规康复,A组增加下肢康复机器人训练,B组增加下肢等速肌力训练,C组增加下肢康复机器人联合等速肌力训练。每周训练6次,共治疗6周。治疗前后进行等速肌力测试(峰力矩值)、下肢Fugl-Meyer运动功能评分(FMA)、Berg平衡量表(BBS)及Holden步行功能分级评定。结果:治疗6周后组内比较,3组患者的峰力矩值、FMA评分、BBS评分及Holden步行功能分级较治疗前提高,差异具有统计学意义(P<0.05)。组间比较,治疗6周后组间比较,C组在角速度60°/s、120°/s及180°/s下的伸膝肌及屈膝肌峰力矩值、BBS评分均高于A组和B组,差异具有统计学意义(P<0.05),但A组与B组比较差异无统计学意义。结论:下肢康复机器人联合等速肌力训练在改善脑卒中患者下肢肌力、平衡功能和步行能力方面较两者单独应用疗效更佳。     

运动想象疗法结合下肢康复机器人训练对脑卒中亚急性期偏瘫患者下肢运动功能的影响

目的:探讨运动想象疗法结合下肢康复机器人训练对脑卒中亚急性期偏瘫患者下肢运动功能的影响。方法:选取亚急性期脑卒中偏瘫患者50例,随机分为对照组和观察组各25例。两组患者均采用常规康复治疗(45min/次,每周6次)和下肢康复机器人的功能训练(20min/次,每周6次),一共6周。观察组在常规康复治疗的基础上,在训练结束后进行运动想象疗法(15min/次,每周6次)。两组患者均在治疗前、治疗6周后采用下肢FuglMeye(rFMA)运动功能量表、Berg平衡量表(BBS)、功能性步行量表(FAC)进行评估。结果:治疗前对照组和观察组在Fugl-Meyer(FMA)运动功能量表、Berg平衡量表(BBS)、功能性步行量表(FAC)的评分无显著差异(P0.05)。治疗6周后,两组患者FMA,BBS,FAC的评分较治疗前均有明显改善(P0.05),且观察组较对照组提高更明显(P0.05)。结论:运动想象疗法结合下肢康复机器人对亚急性期脑卒中患者下肢的运动功能、平衡功能及步行能力有所提高。     

Leisure activities following a lower limb amputation

Purpose. To compare the nature and extent of inter and intralimb coupling during two-handed catching and the effect of manipulating task constraints in children with Developmental Coordination Disorder (DCD) and their typically developing peers (AMC).

Method. Twenty children aged 7 – 10 years, ten with DCD and 10 AMC attempted to catch a ball ten times in condition 1 (C1), ball to the midline; condition 2 (C2), ball to the left shoulder and condition 3 (C3), ball to the right shoulder. Both 3D kinematic data and video data were collected.

Results. Children with DCD caught fewer balls than the AMC children, regardless of age or condition (p ≤ 0.001). Children with DCD demonstrated a higher degree of linkage between limbs in C1 and a lower degree of between limb coupling in C2 and C3 when compared to the AMC (p ≤ 0.05). Differences between the AMC7 – 8 and AMC9 – 10 group were found with respect to interlimb coupling.

Conclusions. The influence of manipulating task constraints and the individual nature of children with DCD must be considered by those involved in rehabilitation. By doing so, children with DCD may search for appropriate motor solutions to many functional movement tasks required for everyday life.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Return to work after lower limb amputation

Purpose. To review the literature on return to work after lower limb amputation.

Method. A comprehensive review of literature on return to work after lower limb amputation was carried out, searching MEDLINE and PubMED.

Results. Most authors found return-to-work rate to be about 66%. Between 22 and 67% of the subjects retained the same occupation, while the remainder had to change occupation. Post-amputation jobs were generally more complex with a requirement for a higher level of general educational development and were physically less demanding. The return to work depends on: general factors, such as age, gender and educational level; factors related to impairments and disabilities due to amputation (amputation level, multiple amputations, comorbidity, reason for amputation, persistent stump problems, the time from the injury to obtaining a permanent prosthesis, wearing comfort of the prosthesis, walking distance and restrictions in mobility); and factors related to work and policies (salary, higher job involvement, good support from the implementing body and the employer and social support network).

Conclusions. Subjects have problems returning to work after lower limb amputation. Many have to change their work and/or work only part-time. Vocational rehabilitation and counselling should become a part of rehabilitation programme for all subjects who are of working age after lower limb amputation. Better cooperation between professionals, such as rehabilitation team members, implementing bodies, company doctors and the employers, is necessary.     

Outcome measures in amputation rehabilitation: ICF body functions

Purpose. To identify and evaluate the lower limb amputation rehabilitation outcome measurement instruments that quantify those outcomes classified within the International classification of functioning, disability and health (ICF) category of body function or structure. This was done to summarise the current evidence base for the most commonly used outcome measurement tools and to provide clinicians with recommendations on how specific tools might be selected for use.

Method. A systematic review of the literature associated with outcome measurement in lower limb amputation rehabilitation was conducted. Only articles containing data related to metric properties (reliability, validity or responsiveness) for an instrument were included. Articles were identified by electronic and hand-searching techniques and were subsequently classified according to the ICF.

Results. Sixteen instruments were identified that were classified into one of Global mental function (12), Sensory and pain (1), Cardiovascular and respiratory (1) and Neuromusculoskeletal and movement (2). Evidence about metric properties and clinical utility was summarised in tables, which formed the basis for conclusions.

Conclusions. Few well-validated body function tools exist in the amputee literature, which may explain their lack of widespread use. For all scales, responsiveness to intervention has not been well established and should be the focus of future studies along with continued establishment of validity and reliability.     

Skin problems in lower limb amputees: a systematic review

Purpose. Skin problems of the stump in lower limb amputees are relative common in daily rehabilitation practice, possibly impeding prosthetic use. This impediment may have great impact in daily life. Our objective was to review literature systematically concerning incidence and prevalence of skin disorders of the stump in lower limb amputees.

Method. A literature search was performed in several medical databases (MEDLINE, CINAHL, EMBASE, RECAL) using database specific search strategies. Reference lists in the identified publications were used as threads for retrieving more publications missed in the searches. Only clinical studies and patient surveys were eligible for further assessment.

Results. 545 publications were initially found. After selection, 28 publications were assessed for research methodology. Only one publication fulfilled the selection criteria. The prevalence of skin problems in a series of 45 lower leg amputees of 65 years and older was 16%.

Conclusions. Prevalence and incidence of skin problems of the stump in lower limb amputees are mainly unknown.     

早期主动性康复对脑梗死偏瘫患者下肢功能恢复的影响

目的:观察早期主动性康复治疗对脑梗死偏瘫患者下肢功能恢复的影响。方法 :在两所二级医院选择符合研究条件的脑卒中患者61例 ,分为康复组37例 ,对照组24例。比较发病4周后两组的下肢功能。结果 :初次评测两组无明显差别(P>0.05) ;末次评测下肢瘫痪程度(用FMA的下肢评分表示)康复组和对照组分别为20.68±8.92和11.42±8.20 ,P值为0.000。步行功能恢复和上下楼梯的功能 ,康复组和对照组间有显著性差异(P<0.05)。结论 :早期主动性的康复治疗可以明显改善脑卒中偏瘫患者下肢功能的恢复。