Changing dynamics in lower-extremity amputation in China

OBJECTIVE: To evaluate the current pattern of lower-extremity amputation (LEA) in a Chinese population and to identify independent risk factors for failure to ambulate in the community after LEA. DESIGN: Retrospective study. SETTING: Tertiary hospital. PARTICIPANTS: Consecutive Chinese adults (N=189) who underwent LEA from 1995 to 1997. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Pattern of LEA in comparison with previous data and risk factors for failure to ambulate in the community after LEA. RESULTS: The mean age at amputation was 74.1 years. Vascular occlusive disease and infection accounted for most of the reasons for the LEA. The pattern of LEA had changed significantly. The proportion of patients who were able to ambulate in the community decreased from 66.1% before the LEA to 29.9% 12 months after LEA. Logistic regression analysis showed that major amputation level, presence of diabetes mellitus, hypertension, inability to ambulate in the community before LEA, and failed use of prosthesis were significant independent risk factors for failure to ambulate in the community after LEA. CONCLUSIONS: A more aggressive rehabilitation approach, together with efforts targeted at various levels is required to achieve better functional ambulation level and to improve reintegration into the community after LEA.     

Return to driving after lower-extremity amputation

OBJECTIVES: To study driving behaviors after major lower-extremity amputations and to determine which factors influence return to driving after amputation. DESIGN: A cross-sectional study. SETTING: Data were collected from patients attending an outpatient amputee and prosthetics clinic between February 2001 and September 2001. PARTICIPANTS: A convenience sample (N=123). Inclusion criteria were: age greater than 18 years, unilateral or bilateral major lower-extremity amputation, minimum 1 year since prosthetic fitting, and active automobile driver within 6 months prior to amputation. Subjects had an average age of 63.4+/-12.1 years and were on average 6.8+/-8.3 years since amputation. Common causes for amputation were peripheral vascular disease (73.2%), trauma (13.8%), and tumor (12.2%). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Driving habits after lower-extremity amputation. RESULTS: Overall, 80.5% of participants were able to return to driving an average of 3.8 months after amputation, although the majority reported a decreased driving frequency. Female sex (odds ratio [OR]=.08; 95% confidence interval [CI], .02-.34), age of 60 years or greater (OR=.16; 95% CI, .03-.74), right-sided amputation (OR=.13; 95% CI, .03-.52), and preamputation driving frequency of less than every day (OR=.18; 95% CI, .05-.69) were all significantly related to a reduced likelihood of return to driving postamputation. Items that did not have a statistically significant association with return to driving included level of amputation, reason for amputation, preamputation automobile transmission, and accessibility to public transit. Subjects with left-sided amputation had significantly fewer concerns about driving, while those with a right amputation frequently required vehicle modifications (40.6%) or switch to a left-foot driving style for braking (81.3%) and accelerating (65.6%). Common barriers to return to driving included preference not to drive, fear and/or lack of confidence, and related medical conditions. CONCLUSIONS: The majority of subjects with major lower-extremity amputation were able to return to driving after major lower-extremity amputation. Major automobile modifications are commonly performed by right-sided amputees. Several predictors of return to driving and barriers preventing return to driving were identified.     

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.     

Venous thromboembolism after spinal cord injury: incidence, time course, and associated risk factors in 16,240 adults and children

OBJECTIVE: To analyze the incidence of venous thromboembolism (VTE) after spinal cord injury (SCI). DESIGN: Retrospective cohort analysis of all SCI cases (16,240) in California from 1991 through 2001. SETTING: All public hospitals in California. PARTICIPANTS: Subjects (cases) coded as having complete or incomplete SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Diagnosis of VTE or death within 91 days of the day of hospital admission. RESULTS: For all cases, the 91-day cumulative incidence of VTE was 5.4%. In a multivariate model, significant predictors of VTE included male sex (odds ratio [OR]=1.4; 95% confidence interval [CI], 1.2-1.7), African-American race (OR=1.6; 95% CI, 1.3-1.9), complete paraplegia versus tetraplegia (OR=1.8; 95% CI, 1.4-2.3), and presence of 3 or more comorbid conditions versus none (OR=1.6; 95% CI, 1.3-2.1). Age less than 14 years was predictive of not developing VTE (OR=0.2; 95% CI, 0.1-0.7). The incidence of VTE did not change significantly over the 11-year time period (P=.07), and VTE was not a significant predictor of death in the first 91 days after hospitalization. CONCLUSIONS: The incidence of VTE in SCI patients in California did not change between 1991 and 2001. We identified specific risk factors for VTE. Further studies are needed to determine if prompt initiation of medical prophylaxis in high risk subjects reduces the incidence of symptomatic VTE.     

Clinical identification of multiple fall risk early after unilateral transtibial amputation

OBJECTIVE: To examine if previously reported clinical tests of stepping and functional mobility could discriminate between multiple-falling and nonmultiple-falling people with unilateral transtibial amputations. DESIGN: Nonrandomized prospective cohort. SETTING: Rehabilitation hospital and general community. PARTICIPANTS: Forty-seven subjects initially recruited and tested at discharge. Forty subjects were retested at 6 months postdischarge and grouped as either multiple fallers (n=13) or nonmultiple fallers (n=27). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Four Square Step Test (FSST), Timed Up & Go (TUG) test, 180 degrees turn test, and the Locomotor Capabilities Index (LCI) advanced score. RESULTS: Significant differences (P<.01) were found between the 2 groups for all of the main outcome measures. The test scores associated with an increased risk of having multiple falls were as follows: TUG test of 19 seconds or more (sensitivity, 85%; specificity, 74%), turn time of 3.7 seconds or more (sensitivity, 85%; specificity, 78%), turn steps 6 steps or more (sensitivity, 100%; specificity, 74%), FSST of 24 seconds or more (sensitivity, 92%; specificity, 93%), and LCI advanced score of 15 or less (sensitivity, 43%; specificity, 91%). CONCLUSIONS: In this study, multiple-falling people with transtibial amputations displayed impaired mobility on the outcome measures reported. These measures offer valuable clinical tests of different and functionally relevant activities and provide good identification of multiple-falls risk.     

康复护理小组对骨肉瘤截肢患者生活质量的影响

目的探讨由患者、家长和护士组成的康复护理小组对骨肉瘤截肢患者生活质量的影响。方法将38例骨肉瘤截肢患者分为两组,2008年2月—2009年1月18例患者为对照组,2009年2月—2009年12月20例患者为干预组。对照组接受常规的护理指导,干预组接受康复护理小组的护理干预,采用欧洲癌症治疗研究组织针对肿瘤患者制定的生活质量核心问卷（EORTC-C30）中文版（QLQ-C30）分别对患者5个功能领域、3个症状领域、1个整体健康状况和6个单一条目的生活质量进行比较。结果干预组在角色功能、社会功能、认知功能、情感功能、整体健康、疲倦、疼痛、失眠和食欲丧失方面比对照组明显改善。结论康复护理小组的综合指导与护理能明显调适骨肉瘤截肢患者的心理状态,改善患者的各项功能,对提高患者的生活质量有积极的促进作用。     

Sex disparities in level of amputation

Lefebvre KM, Chevan J. Sex disparities in level of amputation.

Objective

To determine whether there is a sex-related disparity in the management of lower-extremity ischemia by evaluating the relationship between sex and level of nontraumatic amputation.

Design

This is a retrospective secondary analysis of community hospital data from the Healthcare Cost and Utilization Project, Nationwide Inpatient Sample for 2007. Level of amputation was determined from International Classification of Diseases–9th Revision–Clinical Modifications procedure and coded as either transfemoral or transtibial. The main predictor was sex; covariates including age, race, income, insurance status, and presence of vascular disease were incorporated as control variables in regression analysis.

Setting

Nonfederal, short-term U.S. community hospitals.

Participants

Persons discharged from hospitals with a nontraumatic transtibial or transfemoral amputation (N=11,114).

Interventions

Not applicable.

Main Outcome Measures

Level of limb loss.

Results

A significant association was found between female sex and transfemoral amputation in both the bivariable (χ²=187.0; P<.000) and multivariable analysis (odds ratio [OR]=1.4; 95% confidence interval [CI]=1.3–1.5). Other covariates significant for influencing level of amputation during multivariable analysis include age, with highest age greater than 78 years at highest risk (OR=3.0; 95% CI, 2.6–3.5); 0–25% quartile of income or annual income less than $36,000 (OR=1.3; 95% CI, 1.1–1.5); Medicare insurance (OR=1.4; 95% CI, 1.1–1.6); Medicaid insurance (OR=1.3; 95% CI, 1.3–1.6); and cerebrovascular disease (OR=2.0; 95% CI, 1.7–2.4).

Conclusions

Female sex is significantly associated with transfemoral amputation compared with male sex. Transfemoral amputation has significant consequences, and further evaluation of preventative care and screening for women with vascular disease should be considered.     

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.

     

Bilateral changes in somatosensory sensibility after unilateral below-knee amputation

OBJECTIVE: To evaluate possible alteration in proprioceptive and cutaneous sensibility in the nonamputated leg of unilateral transtibial amputees. DESIGN: Cross-sectional study with between-subjects (amputees vs controls) and within-subjects (nonamputated vs amputated leg) comparisons. SETTING: Canadian rehabilitation hospital research laboratory. PARTICIPANTS: Two groups of amputees (34 due to traumatic causes, 14 due to vascular causes), recruited more than 1 year after their prosthetic training; and 2 groups (n=34, n=14) of age-matched control subjects. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Threshold of movement detection and touch-pressure perception at the knee and foot levels. RESULTS: In the traumatic group, the sensory thresholds of the nonamputated leg were significantly higher than the control values in the 2 modalities tested. The movement detection was reduced at the knee and ankle levels, whereas a decrease in touch-pressure sensibility was observed only at the plantar site. As expected, a large proportion of the vascular amputees presented with severe sensory deficits in the nonamputated leg, particularly a loss in touch-pressure perception at the foot. The thresholds of movement detection were similar and correlated at both knees in the 2 groups of amputees. For the touch-pressure thresholds, no significant relationship was found between sides at the knee level. CONCLUSIONS: Sensory changes observed in the nonamputated leg suggest that central sensory adaptations occur after amputation. For movement detection, they were marked by a matching of perception on both sides of the body. Functional significance of these changes remains to be determined.     

Relationship between models of care and key rehabilitation milestones following unilateral transtibial amputation: a national cross-sectional study

ObjectivesTo identify different models of care (MOC) post transtibial amputation (TTA) and relate these to achievement of rehabilitation milestones.DesignRetrospective analysis of rehabilitation milestone data and a survey of MOC in 10 vascular centres.SettingNHS Scotland vascular centres.ParticipantsAll unilateral TTA between January 2011 and December 2014 (n = 643).Main outcome measuresTime (in days) to achieve the following rehabilitation milestones: compression therapy, early walking aid, casting for a prosthetic limb, prosthetic delivery, inpatient discharge and final discharge from rehabilitation. MOC were scored according to seven key aspects of service provision.ResultsThe mean age of the cohort was 67 [standard deviation (SD) 13] years, 76% were male and 63% had peripheral arterial disease and diabetes. The median number of days to achieve rehabilitation milestones varied between centres {compression therapy six [interquartile range (IQR) 0–12], early walking aid 14 (IQR 10–27), prosthetic casting 39 (IQR 27–71), prosthetic delivery 53 (IQR 36–87), inpatient discharge 53 (IQR 29–85) and final discharge from rehabilitation 141 (IQR 92–209)}. Only two centres included all seven key aspects of service provision within their MOC. Vascular centres that achieved the optimal MOC achieved the rehabilitation milestones more quickly than other vascular centres.ConclusionsA positive association was found between optimal MOC and early achievement of rehabilitation milestones post TTA. Key aspects of service provision associated with a quicker time to achieve rehabilitation milestones included: use of a postoperative rigid dressing, specialist physiotherapy input in the early postoperative period, daily inpatient gym sessions and inpatient prosthetic provision. To the authors’ knowledge, this is the first study to document MOC following TTA and to relate these to the achievement of rehabilitation milestones.     

Memory and executive function predict mobility rehabilitation outcome after lower-limb amputation

Purpose.?Post-amputation rehabilitation is physically and cognitively demanding. Understanding which specific cognitive domains mediate outcome is critical to the development of interventions.

Method.?A cohort undergoing post-amputation rehabilitation was assessed before limb fitting and followed up at 6 months (n = 34). The average age was 60.69 years (SD = 13.98). 82.4% of the sample was male. 79.4% had amputations because of peripheral arterial disease. Memory, visuospatial function, executive function, praxis, emotion and language were assessed at Time 1 (first prosthetic clinic attendance). Time 1 data were also gathered on aetiology, level of amputation, comorbidities, pain and demographics. Six month outcomes were the locomotor capability index (LCI), the special interest group in amputee medicine (SIGAM) mobility grades and self reported hours of use.

Results.?The LCI at 6 months was significantly predicted in regression analyses by a measure of visual memory (figure recall) (adjusted R² = 24.8%, df = 32, zβ = 0.52, p = 0.002. Hours of use were predicted by the verbal fluency test total (adjusted R² = 17.1%, df = 26, zβ = 0.45, p = 0.017). SIGAM mobility grades were predicted by a combination of immediate verbal memory (story recall), age, level of amputation and presence of pain (adjusted R² = 58.2, df = 30, zβ = 0.52, p = 0.000).

Conclusions.?Neuropsychological and clinical variables predict a large amount of 6 month outcome variance. Cognitive difficulties may be considered mediators of poor outcome.     

Article 3: Comparing amputation patterns in veterans affairs medical centers from 1997 to 2000

Objectives: To examine patterns of amputation (all levels) among veterans who were identified as at-risk and to examine factors that predict greater risks for a major (below-knee, above-knee) amputation. Design: Database approach, secondary data analysis. Setting: Veterans Affairs medical centers (VAMCs). Participants: 451,824 were selected if they had diagnoses of diabetes mellitus or peripheral vascular disease, and were at-risk for lower-extremity amputation. These patients were followed for 4 years (1997-2000) to determine the occurrence of amputation. Interventions: Not applicable. Main Outcome Measures: Differences in frequency and level of amputation were assessed among 132 VAMCs with different Preservation of Amputation Care and Treatment (PACT) rankings. Regression techniques were used to identify factors associated with increased risk. Results: Over the 4-year period, 10,258 patients had at least 1 amputation (2.3%). Highly ranked VAMCs had greater amputation rates and performed more above-knee amputations than less well ranked VAMCs. Factors that increase risk for a major amputation include race, skin ulcers, gangrene, and prior amputation. Conclusion: High-PACT VAMCs are often located in an urban setting, affiliated with academic medical programs, and have higher volume of patients. Higher amputation rate at high-PACT facilities may reflect a movement toward centers of excellence for prevention of and treatment for lower-extremity amputations.     

Psychometric properties of the Activities-specific Balance Confidence Scale among individuals with a lower-limb amputation

OBJECTIVE: To evaluate the internal consistency, test-retest reliability, and construct validity of the Activities-specific Balance Confidence (ABC) Scale among people who have a lower-limb amputation. DESIGN: Retest design. SETTING: A university-affiliated outpatient amputee clinic in Ontario. PARTICIPANTS: Two samples of individuals who have unilateral transtibial and transfemoral amputation. Sample 1 (n=54) was a consecutive and sample 2 (n=329) a convenience sample of all members of the clinic population. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Repeated application of the ABC Scale, a 16-item questionnaire that assesses confidence in performing various mobility-related tasks. Correlation to test hypothesized relationships between the ABC Scale and the 2-minute walk (2MWT) and the timed up-and-go (TUG) tests; and assessment of the ability of the ABC Scale to discriminate among groups based on amputation cause, amputation level, mobility device use, automatic stepping ability, wearing time, stair climbing ability, and walking distance. RESULTS: Test-retest reliability (intraclass correlation coefficient) of the ABC Scale was .91 (95% confidence interval [CI], .84-.95) with individual item test-retest coefficients ranging from .53 to .87. Internal consistency, measured by Cronbach alpha, was .95. Hypothesized associations with the 2MWT and TUG test were observed with correlations of .72 (95% CI, .56-.84) and -.70 (95% CI, -.82 to -.53), respectively. The ABC Scale discriminated between all groups except those based on amputation level. CONCLUSIONS: Balance confidence, as measured by the ABC Scale, is a construct that provides unique information potentially useful to clinicians who provide amputee rehabilitation. The ABC Scale is reliable, with strong support for validity. Study of the scale's responsiveness is recommended.     

The Trinity Amputation and Prosthesis Experience Scales and quality of life in people with lower-limb amputation

OBJECTIVES: To undertake preliminary research into quality of life (QOL) for a group of people with a lower-limb amputation and to investigate what aspects of the "prosthetic experience" are most strongly associated with QOL using the Trinity Amputation and Prosthesis Experience Scales (TAPES). DESIGN: Cross-sectional survey. SETTING: Prosthetic limb fitting center. PARTICIPANTS: Sixty-three people older than 18 years with unilateral lower-limb amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The TAPES and the World Health Organization Quality of Life Questionnaire-Brief Version. RESULTS: There were no significant differences in any of the QOL domain scores (physical health, psychological, social relationships, environmental) arising from age, gender, level of amputation, or cause of amputation. However, there were significant differences depending on the length of time living with the prosthesis and the degree of prosthetic use. Stepwise regression identified different significant predictors for each domain of QOL. CONCLUSIONS: These findings support the claim that the TAPES can be used to evaluate QOL for this patient group. Further research is warranted to learn how sensitive the scale and its items are to change in clinical status.     

Daily physical activity and heart rate response in people with a unilateral transtibial amputation for vascular disease

OBJECTIVE: To study the activity level and heart rate response, objectively measured during normal daily life, of persons with a unilateral transtibial amputation for vascular disease. DESIGN: Case comparison. SETTING: General community, daily life in the Netherlands. PARTICIPANTS: Nine subjects with a unilateral transtibial amputation for vascular disease (convenience sample) and 9 control subjects without known impairments (matched for sex, age, social situation, employment). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Duration of dynamic activities, body motility (the intensity of body movement, measured with accelerometry), and heart rate (on 2 consecutive days). RESULTS: Persons with an amputation were less active than the comparison subjects (4.3% vs 11.4% of a 48-h period, P=.007). Body motility during walking was lower in the amputee group (.111 g vs.147 g, P=.003). No differences between groups were found in normalized heart rate during walking. In the amputee group, a strong relationship was found between body motility during walking and the percentage of the day that the subject walked (r=.88, P=.002). No relationship was found between the percentage of the day that persons with an amputation were active and data from disability questionnaires. CONCLUSION: Persons with a unilateral transtibial amputation for vascular disease were considerably less active than persons without known impairments. Heart rate response during walking of the amputee group did not differ from the response in the comparison group.     

针灸联合康复治疗汶川地震伤员截肢后幻肢痛疗效观察

目的探讨针灸联合康复对幻肢痛的治疗效果。方法将44例存在幻肢痛的5.12汶川地震伤员分为治疗组和对照组各22例,治疗组采用针灸联合康复方法综合治疗,对照组单纯采用康复方法治疗。以简明McGill疼痛问卷表（SF-MPQ）评分作为评价指标,观察两组治疗效果。结果治疗组总有效率为100%,对照组总有效率为81.9%,两组比较差异有显著性意义（P〈0.05）;两组治疗前后组内SF-MPQ评分比较,差异均有显著性意义（P〈0.01）;治疗后组间SF-MPQ评分比较,差异有显著性意义（P〈0.01）。结论针灸和康复治疗联合运用对幻肢痛有很好的疗效,远期疗效稳定。     

Daily physical activity and heart rate response in people with a unilateral traumatic transtibial amputation

Bussmann JB, Schrauwen HJ, Stam HJ. Daily physical activity and heart rate response in people with a unilateral traumatic transtibial amputation.

Objectives

To test the hypothesis that people with a unilateral traumatic transtibial amputation are less active than people without an amputation, and to explore whether both groups have a similar heart rate response while walking.

Design

A case-comparison study.

Setting

General community.

Participants

Nine subjects with a unilateral traumatic transtibial amputation and 9 matched subjects without known impairments.

Interventions

Not applicable.

Main Outcome Measures

Percentage of dynamic activities in 48 hours (expressing activity level). Additionally, we examined heart rate and percentage heart rate reserve during walking (expressing heart rate response) and body motility during walking (expressing walking speed). These parameters were objectively measured at participants’ homes on 2 consecutive days.

Results

Subjects with an amputation showed a lower percentage of dynamic activities (6.0% vs 11.7% in a 48-h period, P=.02). No significant differences were found between the 2 groups in heart rate (91.1bpm vs 89.5bpm, P=.86) and percentage heart rate reserve during walking (28.2% vs 27.5%, P=1.0). Body motility during walking was lower in the amputation group (.14g vs .18g, P<.01).

Conclusions

Our results support our hypothesis that persons with a unilateral traumatic transtibial amputation are considerably less active than persons without known impairments. The results indicate that heart rate response during walking is similar in both groups, and is probably regulated by adapting one’s walking speed.     

Houghton Scale of prosthetic use in people with lower-extremity amputations: Reliability, validity, and responsiveness to change

OBJECTIVE: To evaluate the responsiveness to change and the floor and ceiling effects of the Houghton Scale. DESIGN: One-week and 3-month test-retest to evaluate reliability, validity, and responsiveness to change. SETTING: Amputee rehabilitation program. PARTICIPANTS: Persons (N=125) with unilateral or bilateral lower-extremity amputation who were wearing a prostheses: 1 group (n=49) for the reliability component and another group (n=76) for the responsiveness and validity component. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Responsiveness to change, ceiling and floor effects, and reliability and convergent validity. RESULTS: Evaluation of responsiveness to change (n=76) showed that the total score increased from a mean +/- standard deviation of 6.14+/-2.40 at discharge to 7.70+/-2.62 (P<.001) at follow-up 3 months later. Floor and ceiling effects were not detected for the overall score but were noted for the individual subscales. The internal consistency was moderate at discharge (Cronbach alpha=.71) and follow-up (Cronbach alpha=.70). The Houghton Scale correlated significantly, although moderately, with the physical composite score of the Medical Outcomes Study 36-Item Short-Form Health Survey (r=.393, P<.01) and the 2-minute walk test at admission (r=.620, P<.01) and discharge (r=.653, P<.01). The reliability (intraclass correlation coefficient=.96) of the Houghton Scale was high (n=49). CONCLUSIONS: The Houghton Scale is appropriately responsive to change in prosthetic use in individuals with lower-limb amputation after rehabilitation.     

Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review

Prinsen EC, Nederhand MJ, Rietman JS. Adaptation strategies of the lower extremities of patients with a transtibial or transfemoral amputation during level walking: a systematic review.

Objective

To describe adaptation strategies in terms of joint power or work in the amputated and intact leg of patients with a transtibial (TT) or transfemoral (TF) amputation.

Data Sources

MEDLINE, CINAHL, Physiotherapy Evidence Database, Embase, and the Cochrane Register of Controlled Trials were searched. Studies were collected up to November 1, 2010. Reference lists were additionally scrutinized.

Study Selection

Studies were included when they presented joint power or work and compared (1) the amputated and intact legs, (2) the amputated leg and a referent leg, or (3) the intact leg and a referent leg. Eligibility was independently assessed by 2 reviewers. A total of 13 articles were identified.

Data Extraction

Data extraction was performed using standardized forms of the Cochrane Collaboration. Methodologic quality was independently assessed using the Downs and Black instrument by 2 reviewers. The possibility of data pooling was examined. Significant differences found in studies that could not be pooled are also presented.

Data Synthesis

Significant results (P<.05). For work TT, for the concentric work total stance phase knee, the amputated was less than the intact/referent side, and the referent was less than the intact side. For the eccentric knee extensor (K1) phase, the amputated was less than the intact side, and the intact was greater than the referent side. For the concentric knee extensor (K2) phase, the amputated/referent was less than the intact side. For the concentric work total stance phase hip, the amputated/intact was greater than the referent side. For the concentric hip extensor (H1) phase, the amputated/intact was greater than the referent side. For power TT, for the peak power generation stance phase knee, the amputated was less than the referent side. For peak power generation swing phase knee, the amputated was less than the referent side. For the eccentric knee flexor (K4) phase, the amputated was less than the intact side. For the eccentric hip flexor (H2) phase, the amputated was greater than the intact side. For work TF, for the concentric plantar flexor (A2) phase, the referent was less than the intact side. For the H1 phase, the referent was less than the intact side. For the H2 phase, the amputated was greater than the intact/referent side, and the referent was greater than the intact side. For power TF, for the K2 phase, the referent was less than the intact side. Sensitivity analysis did not alter the conclusions.

Conclusions

Adaptations were seen in the amputated and intact legs. TT and TF use remarkably similar adaptation strategies at the level of the hip to compensate for the loss of plantar flexion power and facilitate forward progression. At the knee level, adaptations differed between TT and TF.