Use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study

OBJECTIVE: To document and examine the use, satisfaction, and problems with prosthetic devices among persons who suffered a trauma-related lower limb amputation. DESIGN: Abstracted medical records and follow-up interview data were collected for a retrospective cohort of persons with a lower limb trauma-related amputation who received their acute care at the University of Maryland R. Adams Cowley Shock Trauma Center, Baltimore, MD, between 1984 and 1994. Patients with spinal cord injury, traumatic brain injury, or only toe amputations were excluded. RESULTS: There were 146 patients identified. Of those, 9% died during the acute admission and 3.5% died after discharge. Seventy-eight amputees were available for interview (68% response rate). The majority of those interviewed were male (87%), and two-thirds had undergone amputation before age 40 yr. Nearly 95% had a prosthesis and wore it an average of 80 hr (SD = 33) per week. Despite high use, only 43% reported being satisfied with the comfort of their prosthesis. About one-quarter of all users reported problems with wounds, skin irritation, or pain. Traumatic amputees used an average of four prostheses since injury, about one new prosthesis every 2 yr. Statistical analyses revealed that males reported higher prosthetic use (P < 0.01). Higher Injury Severity Score negatively impacted on prosthetic use (P < 0.01). Phantom pain negatively influenced reported satisfaction with the prosthesis (P < 0.03) CONCLUSIONS: Although almost all persons living with trauma-related amputations use prosthetic devices, the majority are not satisfied with prosthetic comfort. Phantom pain and residual limb skin problems are also common afflictions in this population.     

Reflex sympathetic dystrophy of the stump in below-knee amputees.

OBJECTIVE: To document the occurrence of reflex sympathetic dystrophy of the stump in two patients with below-knee amputation. DESIGN: A retrospective survey emphasising two clinical case reports. SETTING: Department of orthopaedic rehabilitation at a teaching rehabilitation hospital. PATIENTS: Lower limb amputees (n = 164) were accepted for prosthetic rehabilitation. Twenty-one amputees were regarded as rehabilitation failures; in two below-knee amputees intractable pain was the major problem. RESULTS: Clinical manifestations, radiological, and scintigraphic findings in the two amputees with intractable pain met the criteria for diagnosis of reflex sympathetic dystrophy. CONCLUSIONS: Reflex sympathetic dystrophy of the stump should be suspected in below-knee amputees whenever severe pain persists over a period of 3 to 4 months following amputation.     

Psychological adjustment to lower limb amputation amongst prosthesis users

Purpose. Clinical reports indicate that many lower limb amputees experience problems with psychological adjustment. Although depressive responses to amputation have been well investigated, there has been insufficient attention to other aspects of adjustment. This study aimed to determine the prevalence of psychological morbidity in an amputee population and identify variables associated with increased distress. Particular attention was given to cognitive models of emotion which postulate a key role for self-consciousness and appearance-related beliefs.

Method. A cross-sectional survey of 67 adult lower limb prosthesis users who had experienced amputation within the last five years. Outcome measures were the Psychosocial Adjustment Scale of the Trinity Amputation and Prosthesis Experience Scales, the Hospital Anxiety and Depression Scale, the Self Consciousness Scale and the Appearance Schemas Inventory.

Results. Using conservative cut-off scores the prevalence of anxiety and depression was 29.9 and 13.4%, respectively. Appearance-related beliefs were associated with both distress and psychosocial adjustment difficulties. Public but not private self-consciousness was associated with distress and psychosocial adjustment difficulties.

Conclusions. Clinicians need to monitor amputees for distress over a longer time period than the initial post-operative phase. It is particularly important to assess for anxiety. Interventions that target appearance-related beliefs may be of benefit to this population.     

Acquired limb loss in patients with traumatic brain injury

The outcome associated with long-term prosthetic use was evaluated in 12 patients who had a dual disability of severe traumatic brain injury and an extremity amputation. The incidence and nature of complications after limb loss was also reviewed. The 12 patients sustained 15 extremity amputations. Lower extremity amputations were the most common disability. Fifty percent of the patients had at least one postoperative complication after amputation. All patients (100%) had at least one complication documented on rehabilitation admission. No patient was using a prosthesis at the time of rehabilitation admission. At discharge six patients were able to use a prosthesis. Only one patient was considered independent. Patient follow-up averaged 28.6 months. At long-term follow-up six patients were using a prosthesis. Four were considered independent. One-third of the total group was considered able to use the prosthesis independently in the community. Of the lower extremity amputated population, only 40% became ambulatory. This is considerably less than can be expected to become ambulatory if there was no amputation. All three upper extremity amputees did not use a prosthesis. All efforts should be directed at salvaging a limb threatened by amputation after survival of traumatic brain injury. Early transfer to a facility specializing in traumatic brain injury rehabilitation may decrease complications, reduce total hospitalization and improve overall functional ability.     

Cognitive-emotional sensitization contributes to wind-up-like pain in phantom limb pain patients

Peripheral mechanisms are known to play a role in phantom pain following limb amputation, and more recently it has been suggested that central mechanisms may also be of importance. Some patients seem to have a psychological sensitivity that predisposes them to react with pain catastrophizing after amputation of a limb, and this coping style may contribute to increased facilitation, impaired modulation of nociceptive signals, or both. To investigate how pain catastrophizing, independently of anxiety and depression, may contribute to phantom limb pain and to alterations in pain processing twenty-four upper-limb amputees with various levels of phantom limb pain were included in the study. Patients’ level of pain catastrophizing, anxiety and depression was assessed and they went through quantitative sensory testing (QST) of thresholds (mechanical and thermal) and wind-up-like pain (brush and pinprick). Catastrophizing accounted for 35% of the variance in phantom limb pain (p = 0.001) independently of anxiety and depression. Catastrophizing was also positively associated with wind-up-like pain in non-medicated patients (p = 0.015), but not to pain thresholds. These findings suggest that cognitive-emotional sensitization contributes to the altered nociceptive processing seen in phantom limb pain patients. The possible interactions between pain catastrophizing, wind-up-like pain, and peripheral input in generating and maintaining phantom limb pain are discussed.     

围术期认知行为干预对肺癌患者焦虑、抑郁情绪及疼痛、失眠、疲乏症状群的影响研究

目的探讨围术期认知行为干预对肺癌患者焦虑、抑郁情绪及疼痛、失眠、疲乏症状群的影响。方法将57例肺癌患者依对照匹配原则分为干预组(n=28)和对照组(n=29)。于入院后第1天(前测)、术后第3天(中测)、出院前1天(后测)对患者进行焦虑、抑郁、失眠、疼痛、疲乏症状及住院天数的评估,并给予干预组患者认知行为治疗,包括4次40min的面对面合理情绪会谈,以及4次30min的皮温生物反馈仪辅助的放松训练。结果术后第3天、出院前1天的各症状得分,以及住院天数,干预组均低于对照组,差异均具有统计学意义(P0.001)。术后第3天较入院后第1天,干预组焦虑、抑郁减轻,失眠、疼痛、疲乏加重,出院前1天所有症状较术后第3天均减轻,差异有统计学意义(P0.001);而对照组术后第3天较入院后第1天所有症状均加重,出院前1天所有症状较术后第3天缓解,差异有统计学意义(P0.001)。结论对围术期肺癌患者进行焦虑、抑郁情绪及疼痛、失眠、疲乏症状群的评估,并给予认知行为干预,可以有效缓解焦虑、抑郁情绪,失眠、减轻疼痛及疲乏症状,缩短住院时间。认知行为干预有望为肺癌患者症状群管理提供一种经济有效的辅助治疗方法。     

Rehabilitation Outcome in Patients With Lower Limb Amputations Because of Arterial Occlusive Disease: Is it Worth Trying for the Lowest Possible Amputation Level? A Prospective Study

A policy of maximizing the ratio of below-knee to above-knee amputations in patients with severe nonsalvageable limb ischemia is followed. The value of this policy is examined. All the patients that were amputated in our department between 1995 and 1997 were followed up for 2 years after the operation. We correlated the amputation level with 6 different parameters: primary or secondary amputation, perioperative mortality, 2-years mortality, amputation stump healing, artificial limb fitment, and rehabilitation outcome. The results were analyzed statistically. A total of 64 patients were included in the study. The revision rate was 38% in below-knee amputees and 4% in above-knee amputees. The perioperative mortality was 22%. Two years after operation, the limb fitment rate in below-knee amputees was 95% and in above-knee amputees was 64%. The overall artificial limb fitment rate was 50%. A total of 47.6% of the living patients were capable to walk out of their house. Artificial limb fitment and rehabilitation status are greater after a below-knee than an above-knee amputation. Although the morbidity may be higher in below knee procedures, it is worth trying for the lowest level of amputation because of the better rehabilitation results in these patients.     

Predicting health related quality of life 6 months after stroke: the role of anxiety and upper limb dysfunction

Purpose: This study examined the role of anxiety and upper limb dysfunction, amongst other variables, as predictors of health related quality of life (HRQOL) 6 months after stroke. Method: Participants: Stroke survivors (n = 85) who had previously participated in a randomised controlled trial of a physiotherapy intervention. Dependent variable: HRQOL – Nottingham Health Profile (NHP). Predictor variables: Mood – Hospital Depression and Anxiety Scale; Upper Limb Functioning - Action Research Arm Test; Rivermead Motor Assessment; Activities of Daily Living – Modified Barthel Index; Clinical and demographic factors. Results: Anxiety and depression significantly predicted 49% of variance in overall HRQOL (p < 0.05), but only anxiety significantly predicted NHP pain (13% variance, p < 0.001), emotional reactions (41% variance, p < 0.001), sleep (19% variance, p = 0.02) and social isolation (23% variance, p = 0.02). Depression and anxiety together significantly predicted 30% variance in energy level (p < 0.001). UL motor impairment and activities of daily living predicted 36% of variance in NHP physical activity score (p < 0.001). Conclusions: This study indicates that where anxiety is assessed, it appears more important in determining HRQOL than depression. UL impairment and ADL independence predicted perceived physical activity. Management strategies for anxiety and therapy for UL recovery long after stroke onset are likely to benefit perceived HRQOL.

Implications for Rehabilitation

• Anxiety is a major predictor of quality of life six months after stroke.

• Post-stroke anxiety should be routinely assessed in rehabilitation.

• Appropriate management strategies for anxiety should occur during rehabilitation with follow-up into the chronic post-stroke period.

• Upper limb impairment is a stronger predictor of perceptions of physical activity than independence in activities daily living six months after stroke.

• Rehabilitation of the upper limb should continue into the chronic post-stroke period.

     

A foot care program for diabetic unilateral lower-limb amputees

OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees. RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient. RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient. CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.     

Residual limb osteomyelitis: A case series from a national prosthetic centre

Purpose. To examine the impact of residual limb osteomyelitis (RLO) on the rehabilitation of lower limb amputees.

Method. Retrospective review of the casenotes of patients with RLO. Information sought included details of amputation, clinical features of investigations for and management of RLO and its effect on rehabilitation.

Results. There were seven transfemoral and three transtibial amputees. Indications for amputation were vascular disease in nine cases, trauma in one. In each case, delayed wound healing or residual limb pain prompted radiological, hematological and microbiological investigations. Average time between amputation and diagnosis was 187 days. One patient died before treatment commenced. Two transtibial amputees were treated with intravenous antibiotics while rehabilitating using pylons. The remaining seven transfemoral amputees required surgical intervention and intravenous antibiotics. Five achieved independent ambulation following modification to or replacement of the originally cast prosthesis, averaging 408 days between amputation and commencement of rehabilitation. Two patients have not engaged in rehabilitation.

Conclusion. RLO delays rehabilitation and has significant financial implications, incurred by prolonged hospitalisation, radiological investigations and prosthetic modifications. RLO should be considered in any case of delayed wound healing or residual limb pain in amputees, as earlier diagnosis may reduce the time to commencement of rehabilitation and subsequent independent ambulation.     

Venous thromboembolism in a rehabilitation setting after major lower-extremity amputation

OBJECTIVE: To determine the prevalence of venous thromboembolic disease (VTED) and impact on functional outcome in patients with major lower-extremity (LE) amputation admitted to an inpatient rehabilitation unit. DESIGN: Retrospective medical records review. SETTING: Acute inpatient rehabilitation unit in a tertiary, urban academic medical center. PARTICIPANTS: Fifty consecutive patients admitted to an acute inpatient rehabilitation unit after a major LE amputation. Participants were screened at rehabilitation admission for LE deep vein thrombosis using duplex ultrasonography. INTERVENTIONS: Not applicable.Main outcome measures VTED incidence, FIM instrument, total rehabilitation charges, and length of stay (LOS). RESULTS: Six of 50 patients (12%) had evidence of VTED. The VTED cohort had significantly lower admission and discharge FIM scores than the no-VTED cohort (admission FIM score, 57.2 vs 76.0; discharge FIM score, 66.0 vs 90.1, respectively; P< or =.02). Subjects with VTED had a longer rehabilitation LOS (22.8d vs 13.9d, respectively; P=.02) and higher total rehabilitation charges (28,314 US dollars vs 17,724 US dollars, respectively; P<.05). CONCLUSIONS: In this study, VTED prevalence after LE amputation in a rehabilitation setting was 12%. Subjects with VTED had lower admission and discharge functional status, longer LOS, and higher hospital charges. The utility of screening duplex ultrasound examinations at rehabilitation admission remains unclear.     

Fluid collections in amputee stumps: a common phenomenon

OBJECTIVES: To assess the incidence of fluid collections in postoperative amputee stumps and the impact on limb-fitting outcomes in patients with such collections. DESIGN: Cohort study. SETTING: Inpatient rehabilitation ward. PARTICIPANTS: Successive patients with amputation examined with ultrasound over 1 year. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The presence of discrete fluid collections on admission and outcomes of successful limb fitting, length of inpatient stay, and presence of psychologic symptoms. RESULTS: In 105 consecutive admissions, we detected discrete fluid collections in 28 (27%) of stumps with a median volume of 38.5 mL (range, 16-216 mL). All collections diminished and disappeared by discharge with 81% undetectable within 30 days since surgery. A transfemoral amputee was more likely to develop a collection than a transtibial amputee (P<.01). Patients with collections took 9.5 days longer to achieve limb fitting (P=.04) and had a 10-day longer inpatient stay (P=.02). However, the overall success of limb fitting was similar as was the incidence of psychologic distress. CONCLUSIONS: Discrete fluid collections are common in postoperative amputation stumps but regress by discharge. Although limb fitting may be delayed, the ultimate success of limb fitting is not reduced and patients can be reassured.     

Psychological adjustment to lower limb amputation amongst prosthesis users

Purpose. Clinical reports indicate that many lower limb amputees experience problems with psychological adjustment. Although depressive responses to amputation have been well investigated, there has been insufficient attention to other aspects of adjustment. This study aimed to determine the prevalence of psychological morbidity in an amputee population and identify variables associated with increased distress. Particular attention was given to cognitive models of emotion which postulate a key role for self-consciousness and appearance-related beliefs.

Method. A cross-sectional survey of 67 adult lower limb prosthesis users who had experienced amputation within the last five years. Outcome measures were the Psychosocial Adjustment Scale of the Trinity Amputation and Prosthesis Experience Scales, the Hospital Anxiety and Depression Scale, the Self Consciousness Scale and the Appearance Schemas Inventory.

Results. Using conservative cut-off scores the prevalence of anxiety and depression was 29.9 and 13.4%, respectively. Appearance-related beliefs were associated with both distress and psychosocial adjustment difficulties. Public but not private self-consciousness was associated with distress and psychosocial adjustment difficulties.

Conclusions. Clinicians need to monitor amputees for distress over a longer time period than the initial post-operative phase. It is particularly important to assess for anxiety. Interventions that target appearance-related beliefs may be of benefit to this population.     

Evaluation of prosthetic usage in upper limb amputees

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

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

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

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

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

华西医院地震康复中心地震挤压伤截肢伤员的伤情分析

目的：了解地震截肢伤员的伤情特点,为其康复提供依据。方法：2008年6月～2008年12月31日,华西医院康复中心收治33例地震伤截肢患者,观察分析其伤情特点和康复治疗变化。结果：男性15例（45．5％）,女性18例（54．5％）;男性与女性的年龄相比无统计学意义（P〉0．05）;10～19岁青少年45．45％;学生51．52％,在职人员33．33％;重物砸伤占78．79％;膝上截肢占43．90％,上肢截肢21．95％,下肢78．05％;截肢合并症13种,肾功衰最多,占28．57％;手术次数平均2．55次;残端有2例愈合差,有14名培养出细菌;日常生活活动能力Barthel指数入院时50．92±16．76,出院时77．77±14．37。结论：地震截肢伤员伤情重,残端情况差,康复治疗效果明显。     

Geriatric depression, medical diagnosis, and functional recovery during acute rehabilitation

OBJECTIVE: To examine and compare the prevalence and functional impact of depressive symptoms for older adult stroke and nonstroke rehabilitation inpatients. DESIGN: Case-control study examining functional outcome using a 2 (stroke, nonstroke) by 2 (depression, no depression) design. SETTING: Urban hospital rehabilitation unit. PARTICIPANTS: A total of 509 rehabilitation inpatients (age, > or = 60 y) were included and grouped by diagnosis of stroke (n=207) and nonstroke (n=302). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Geriatric Depression Scale and FIM instrument. Analysis of covariance procedures examined the impact of depressive symptoms on discharge functional ability controlling for age, sex, admission functional ability, and hospital length of stay. RESULTS: Prevalence of depressive symptoms was similar for stroke (31.8%) and nonstroke (31.5%) and negatively associated with functional ability at discharge for both groups. Overall, the stroke and nonstroke groups did not differ significantly with respect to functional recovery. CONCLUSIONS: Depression, and its impact on acute rehabilitation, is significantly related to functional recovery but does not differ in its frequency or impact for stroke patients. Because depressive symptoms do not appear to discriminate across diagnostic groups, routine screening for depression is recommended for all rehabilitation inpatients.     

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.

     

个体化护理对单侧下肢截肢患者的影响

目的 探讨个体化护理对单侧下肢截肢患者心理状况、生活自理能力及护理服务满意率的影响。方法 将60例单侧下肢截肢患者随机分为对照组和干预组,对照组实施常规护理,干预组在常规护理基础上加个体化护理干预措施。对两组患者截肢术后第1周、第4周的心理状况、生活自理能力进行评估,并评价护理服务满意率。结果 截肢术后第4周干预组患者的心理状况、生活自理能力及护理服务满意率等均高于对照组 (P＜0.05),差异具有统计学意义。结论 个体化护理干预可提高患者肢体康复功能,提高护理服务满意率。     

中医辨证施护联合康复护理在缺血性脑卒中恢复期患者中的应用效果

目的探讨中医辨证施护联合康复护理在缺血性脑卒中恢复期患者中的应用效果。方法选取2018年10月至2019年8月我院收治的180例缺血性脑卒中恢复期患者,根据入院时间将其分为对照组(85例)和观察组(95例)。对照组予以常规护理干预,观察组予以中医辨证施护联合康复护理。比较两组干预前、后焦虑、抑郁情绪、肢体功能、神经功能、日常生活能力评分及出院后6个月复发率。结果干预后,观察组SAS、SDS、NIHSS评分低于对照组,FMA上肢、下肢及BI评分高于对照组(P<0.05)。观察组出院后6个月复发率低于对照组(P<0.05)。结论中医辨证施护联合康复护理能减轻缺血性脑卒中恢复期患者焦虑、抑郁情绪,降低神经功能损伤程度,促进患者肢体功能恢复,改善日常生活能力,减少预后复发。