Rehabilitative outcomes with preparatory suction prostheses following traumatic Gritti-Stokes amputation: A case series.

Gritti-Stokes amputation (GSA) is a knee disarticulation variant, where the femur is transected at the level of the epicondyle and the patella is fixated to the distal end. GSA results in a long residual limb with little postoperative swelling and less potential for muscular atrophy, so stable limb volume may allow the use of seal-in suction for suspension for preparatory prostheses. The purpose of this case series was to report on the efficacy of seal-in suction preparatory prostheses for 2 adults with traumatic GSA. Between October and December of 2021, 2 participants with unilateral traumatic Gritti-Stokes amputation, who had received seal-in suction suspension for their preparatory prostheses, were recruited. Information was extracted from medical charts regarding prosthetic care and mobility at preparatory and definitive prosthesis evaluation, and participants underwent standardized measurement of their residual limb and prosthesis. Duration of preparatory prosthesis use was >6 months; neither participant reported loss of suspension nor significant complications with socket fit. Participant 1 required socket replacement because of residual limb pain secondary to osteophyte formation, and Participant 2 required component replacement because of weight gain. At definitive prosthesis evaluations, both participants were unlimited community ambulators; both successfully returned to work before provision of their definitive prostheses. Results indicate that seal-in suction suspension may be viable for preparatory prostheses among adults with traumatic GSA, but knee center height discrepancies persist. GSA may yield highly functional outcomes for adults with traumatic amputation. Further research is required to substantiate these findings.

Potentially inappropriate medication use among older adults with lower-limb loss.

OBJECTIVE: The aim of this study was to evaluate the prevalence of, and explore factors related to, prescription of potentially inappropriate medications (PIMs) among older adults with lower-limb loss (LLL). METHODS: This was a secondary analysis of a cross-sectional dataset collected through an interdisciplinary limb loss clinic between September 2013 and November 2022. Self-report medication lists were reviewed during in-clinic face-to-face interviews and compared to the American Geriatrics Society Beers Criteria corresponding to the patient's evaluation year. RESULTS: Of 82 participants (72.9 ± 6.6 years-old; 78.0 % male), n = 41 (50.0 %) reported using one or more PIM. PIM prescription was significantly associated with presence of phantom limb pain, history of upper gastrointestinal issues, and a greater number of medications. DISCUSSION: Polypharmacy and PIM use are common among older adults with LLL. Greater attention should be paid to medications post-amputation, especially pain management medications, to minimize potential adverse side-effects.

Risk Factors for Underreporting of Life-Limiting Comorbidity Among Adults With Lower-Limb Loss.

Peripheral neuropathy (PN) and peripheral arterial disease (PAD) are life-limiting comorbidities among adults with lower-limb loss that may not be adequately addressed in current care models. The objective of this study was to evaluate underreporting of PN and PAD among adults with lower-limb loss. We conducted a secondary analysis of a cross-sectional dataset of community-dwelling adults with unilateral lower-limb loss seen in an outpatient Limb Loss Clinic (n = 196; mean age = 56.7 ± 14.4 years; 73.5% male). Individuals participated in standardized clinical examinations including Semmes-Weinstein monofilament testing to assess for PN and pedal pulse palpation to assess for PAD. Bivariate regression was performed to identify key variables for subsequent stepwise logistic regression to discern risk factors. Clinical examination results indicated 16.8% (n = 33) of participants had suspected PN alone, 15.8% (n = 31) had suspected PAD alone, and 23.0% (n = 45) had suspected PN and PAD. More than half of participants with clinical examination findings of PN or PAD failed to self-report the condition (57.7% and 86.8%, respectively). Among adults with lower-limb loss with suspected PN, participants with dysvascular amputations were at lower risk of underreporting (odds ratio [OR] = 0.2, 95% CI: 0.1-0.6). For those with suspected PAD, those who reported more medication prescriptions were at lower risk of underreporting (OR = 0.8, 95% CI: 0.7-1.0). Adults with lower-limb loss underreport PN and PAD per a medical history checklist, which may indicate underdiagnosis or lack of patient awareness. Routine assessment is highly recommended in this population and may be especially critical among individuals with non-dysvascular etiology.

Key Modifiable Factors in Community Participation Among Adults With Lower Limb Amputation.

OBJECTIVE: The aim of the study is to identify factors that may predict community participation among adults with lower limb amputation. DESIGN: This study is a secondary analysis of a cross-sectional data set, including 126 community-dwelling adults, ≥1 yr after unilateral transfemoral- ( n = 44; mean age = 59 ± 14 yrs) or transtibial-level amputation ( n = 82; mean age = 59 ± 14 yrs) seen in an outpatient limb loss clinic. Participation was assessed with the Community Integration Questionnaire. Factors, that is, demographics, comorbidities, prosthesis use per the Houghton Scale, Socket Comfort Score, assistive device use, falls history, and activity level per General Practice Physical Activity Questionnaire were evaluated. Moreover, balance confidence per the Activities-Specific Balance Confidence Scale, mobility per the Locomotor Capabilities Index, fast and self-selected gait speed per 10-meter walk tests, and functional mobility via Timed Up and Go were also included. RESULTS: Community participation was correlated with several factors ( P ≤ 0.050). Stepwise regression of correlated factors found absence of peripheral neuropathy and greater self-reported physical activity, balance confidence, and prosthesis use, as the strongest correlates, collectively explaining 50.1% of the variance in community participation post-lower limb amputation. CONCLUSIONS: Findings identify key modifiable factors for consideration in future prospective research seeking to enhance community reintegration and participation among adults living with a unilateral transfemoral- or transtibial-level amputation.

Post-amputation pain: Comparing pain presentations between adults with and without increased amputated-region sensitivity.

OBJECTIVE: Among adults with persistent post-amputation pain, increased amputated-region pain sensitivity may reflect peripheral sensitization or indicate underlying central sensitization. To determine whether underlying central sensitization may contribute to increased pain sensitivity in this population, this study compared clinical signs and symptoms associated with central sensitization between adults with post-amputation pain who demonstrate or lack increased amputated-region sensitivity (as compared to reference data). DESIGN: Cross-sectional. SUBJECTS: Ninety-nine adults (60 with a unilateral, transtibial amputation and post-amputation pain, 39 pain-free controls with intact limbs). METHODS: Participants underwent pain-pressure threshold testing of amputated-region and secondary (non-amputated region) sites and completed outcome measures assessing central sensitization symptoms (Patient-Reported Outcomes Measurement Information System® pain intensity and interference domains, Central Sensitization Inventory). Among the full sample, the presence and frequency of specific central sensitization symptoms were evaluated. Participants with post-amputation pain were then grouped based on whether normalized, amputated-region pain-pressure thresholds fell below (i.e., sensitive) or above (i.e., non-sensitive) the 25th percentile of sex-specific reference data. Between-group differences in normalized secondary-site sensitivity were evaluated using a multivariate analysis of variance; central sensitization symptom scores were compared using a Kruskal-Wallis test. RESULTS: Noteworthy symptoms associated with central sensitization (e.g., fatigue, sleep disturbance, cognitive difficulty) were reported by 33%-62% of participants. Secondary-site pain sensitivity was greater among individuals with increased amputated-region sensitivity (n = 24) compared to peers without increased amputated-region sensitivity ([n = 36], mean difference > 1.33 standard deviation [SD], p < 0.001). Central sensitization symptom scores, however, were similar between groups (p > 0.187). CONCLUSIONS: Participants with increased amputated-region sensitivity demonstrate generalized, secondary-site pain hypersensitivity, potentially indicating underlying central sensitization. Central sensitization symptom scores, however, were similar between groups, suggesting differences in physiological pain sensitivity may not manifest in subjective post-amputation pain descriptions.

Pain, Balance-Confidence, Functional Mobility, and Reach Are Associated With Risk of Recurrent Falls Among Adults With Lower-Limb Amputation.

Objective: The study evaluated whether pain intensity and extent, balance-confidence, functional mobility, and balance (eg, functional reach) are potential risk factors for recurrent falls among adults with a lower-limb amputation. Design: Cross-sectional study. Setting: Research laboratory. Participants: Eighty-three adults with unilateral lower-limb amputation that occurred >1 year prior (26 transfemoral- and 57 transtibial-level amputation; 44.6% women; 51.8% traumatic cause of amputation; N=83). Intervention: Not applicable. Main Outcome Measures: Participants reported on the number of falls in the past year, as well as pain intensity in the low back, residual, and sound limbs. Balance-confidence (per the Activities-Specific Balance-Confidence Scale [ABC]), functional mobility (per the Prosthetic Limb Users Survey of Mobility ([PLUS-M]), and balance (per the Functional Reach and modified Four Square Step Tests) were obtained. Results: After considering non-modifiable covariates, greater extent of pain, less balance-confidence, worse self-reported mobility, and reduced prosthetic-side reach were factors associated with recurrent fall risk. Adults reporting pain in the low back and both lower-limbs had 6.5 times the odds of reporting recurrent falls as compared with peers without pain. A 1-point increase in ABC score or PLUS-M T score, or 1-cm increase in prosthetic-side reaching distance, was associated with a 7.3%, 9.4%, and 7.1% decrease in odds of reporting recurrent falls in the past year, respectively. Conclusions: Of the 83 adults, 36% reported recurrent falls in the past year. Presence of pain in the low back and both lower-limbs, less balance-confidence, worse PLUS-M score, and less prosthetic-side reaching distance were identified as modifiable factors associated with an increased odd of recurrent falls.

Time Since Lower-Limb Amputation: An Important Consideration in Mobility Outcomes.

OBJECTIVE: The aim of this study was to evaluate associations between time since amputation (TSAmp) and mobility outcomes of adults with lower-limb amputation. DESIGN: A secondary analysis of a cross-sectional dataset, including 109 community-dwelling adults, 1 yr or more after unilateral transfemoral (n = 39; mean age, 54 ± 15 yrs) or transtibial (n = 70; mean age = 58 ± 14 yrs) amputation, was conducted. Participants attended standardized clinical evaluations and completed mobility-related outcome measures: Prosthesis Evaluation Questionnaire-Mobility Subscale, timed up and go, 10-m walk test, and 6-min walk test. RESULTS: After controlling for age, sex, amputation level, and etiology, TSAmp was significantly associated with each mobility outcome. Prosthesis Evaluation Questionnaire-Mobility Subscale and TSAmp were linearly associated, with TSAmp explaining 10.6% of the overall variance. Timed up and go test time and TSAmp were linearly associated, with TSAmp and an interaction term (LevelxTSAmp) explaining 8.4% of the overall variance; 10-m walk test speed and 6-min walk test distance had nonlinear associations with TSAmp, with TSAmp and nonlinear terms (TSAmp2) explaining 12.1% and 13.2% of the overall variance, respectively. CONCLUSIONS: Based on the findings, longer TSAmp may be associated with better Prosthesis Evaluation Questionnaire-Mobility Subscale score and timed up and go test time, whereas longer TSAmp may be associated with better or worse 10-m walk test speed and 6-min walk test distance depending upon time elapsed since lower-limb amputation. Estimations of postamputation mobility among adults with lower-limb amputation should consider TSAmp.

Self-reported socket comfort, mobility, and balance-confidence of individuals with transtibial amputation using pinlock vs suction suspension.

BACKGROUND: Improper suspension between the residual limb and prosthesis can result in pistoning, which may compromise skin integrity and reduce overall user comfort. In addition to objective measures of limb pistoning, user perspective may provide insight into suspension system effectiveness. OBJECTIVES: The primary objective of this analysis was to explore differences in self-reported measures among adults with transtibial amputation (TTA) using pinlock vs suction suspension systems. STUDY DESIGN: This is a secondary analysis of cross-sectional data. METHODS: Participants (n = 48) were included if they (1) were ≥18 years of age, (2) were community-dwelling, (3) had a unilateral TTA of ≥6 months, and (4) were prescribed a prosthesis with either pinlock or suction suspension. Participants completed self-reported measures evaluating socket comfort (Socket Comfort Score [SCS]), prosthesis-enabled mobility (Prosthesis Evaluation Questionnaire-Mobility Section [PEQ-MS]; Locomotor Capabilities Index [LCI]), and balance-confidence (Activities-Specific Balance Confidence Scale [ABC]). RESULTS: Participants using suction suspension reported significantly higher SCS as compared with participants using pinlock suspension (P ≤ .001). No differences were observed between groups for PEQ-MS, LCI, and/or ABC. CONCLUSIONS: Individuals with TTA using suction suspension may report greater socket comfort than peers using pinlock suspension, but prosthesis-enabled mobility and balance-confidence may be similar. Future research is warranted to confirm these preliminary findings using a prospective, crossover study design that controls for all suspected factors that might influence socket comfort.

Vibration Sensitivity Is Associated With Functional Balance After Unilateral Transtibial Amputation.

OBJECTIVES: To evaluate differences in vibration perception thresholds between adults with transtibial amputation and age-matched adults without amputation and to examine associations between vibration perception thresholds and balance performance. We hypothesized that adults with transtibial amputation would demonstrate lower thresholds compared with adults without amputation and that lower thresholds would be associated with better functional balance. DESIGN: Prospective cross-sectional study. SETTING: National conference, clinical practice, and university laboratory. PARTICIPANTS: Adults (N=34) with a nondysvascular, unilateral, transtibial amputation and 43 age-matched controls without amputation. INTERVENTIONS: Participants' vibration perception thresholds were evaluated bilaterally by applying a vibration stimulus to the midpatella and recording their verbal response to conscious perception of stimulus. Functional balance was assessed with the Berg Balance Scale and the Four Square Step Test. MAIN OUTCOME MEASURES: Residual and sound limb (right and left for controls) vibration perception thresholds, Berg Balance Scale, and Four Square Step Test. RESULTS: For participants with transtibial amputation and controls, there were no significant between-group (P=.921) or interlimb (P=.540) differences in vibration perception thresholds. Overall, robust regression models explained 35.1% and 19.3% variance in Berg Balance Scale scores and Four Square Step Test times, respectively. Among adults with transtibial amputation, vibration perception thresholds were negatively associated with Berg Balance Scale scores (P=.009) and positively associated with Four Square Step Test times (P=.048). Among controls, average vibration perception thresholds were not significantly associated with functional balance (P>.050). CONCLUSIONS: Adults with nondysvascular, transtibial-level amputation demonstrated similar vibration detection compared with adults with intact limbs, indicating that vibration detection is preserved in the amputated region postamputation. These findings suggest a unique relationship between vibration perception and functional balance post-transtibial amputation.

Sex-specific Differences in Multisite Pain Presentation among Adults with Lower-Limb Loss.

OBJECTIVES: Multisite pain remains significantly understudied following lower-limb loss (LLL), especially among females. This study aimed to explore sex-specific differences in the presentation of multisite pain post LLL. Hypotheses were multisite pain would be more prevalent among females post LLL as compared with males, and female sex would be significantly associated with multisite pain prevalence. METHODS: In this cross-sectional study, participants answered standardized questions regarding the presence of amputation-specific (ie, phantom-limb, residual-limb) and secondary (ie, contralateral-limb, low-back) pain. Multisite pain was defined as pain in ≥ 2 locations. Sex-specific differences in pain prevalence were evaluated using chi-square tests (P ≤ 0.050). Using logistic regression, the association between sex and multisite pain was examined after controlling for covariates (age, body mass index, time since amputation, amputation etiology and level). RESULTS: The sample included 303 adults (33% females) ≥ 1 year post unilateral LLL. More females than males reported pain in the residual limb (53.0% vs. 38.4%), low back (56.0% vs. 39.9%), contralateral knee (37.0% vs. 24.1%), and contralateral hip (25.0% vs. 12.3%; P < 0.050). More females than males were classified as having multisite pain (72.0% vs. 54.7%; P = 0.004). While patterns of multisite pain were similar (ie, pain affected both amputation-specific and secondary sites) between sexes, being female was independently associated with higher odds of having multisite pain (odds ratio: 2.40, 95% confidence interval: 1.40 to 4.12). DISCUSSION: Female sex appears to be associated with multisite pain ≥ 1 year after LLL. Future work is needed to identify mechanisms underlying sex-specific differences in pain presentation and evaluate the impact of sex on pain-related outcomes post amputation.

Performance-based outcome measures are associated with cadence variability during community ambulation among individuals with a transtibial amputation.

BACKGROUND: In the United States, Medicare Functional Classification Level (K-level) guidelines require demonstration of cadence variability to justify higher-level prosthetic componentry prescription; however, clinical assessment of cadence variability is subjective. Currently, no clinical outcome measures are associated with cadence variability during community ambulation. OBJECTIVES: Evaluate whether physical performance, i.e. 10-meter Walk Test (10mWT)-based walking speeds, L-Test, and Figure-of-8 Walk Test scores, is associated with community-based cadence variability among individuals with a transtibial amputation. STUDY DESIGN: Cross-sectional. METHODS: Forty-nine participants, aged 18-85 years, with a unilateral transtibial amputation were included. Linear regression models were conducted to determine whether physical performance was associated with cadence variability (a unitless calculation from FitBit® OneTM minute-by-minute step counts), while controlling for sex, age, and time since amputation (p ⩽ .013). RESULTS: Beyond covariates, self-selected gait speed explained the greatest amount of variance in cadence variability (19.2%, p < .001). Other outcome measures explained smaller, but significant, amounts of the variance (11.1-17.1%, p = .001-.008). For each 0.1 m/s-increase in self-selected and fast gait speeds, or each 1-s decrease in L-Test and F8WT time, community-based cadence variability increased by 1.76, 1.07, 0.39, and 0.79, respectively (p < .013). CONCLUSIONS: In clinical settings, faster self-selected gait speed best predicted increased cadence variability during community ambulation. CLINICAL RELEVANCE: The 10-meter Walk Test may be prioritized during prosthetic evaluations to provide objective self-selected walking speed data, which informs the assessment of cadence variability potential outside of clinical settings.

Balance-confidence is associated with community participation, perceived physical mobility, and performance-based function among individuals with a unilateral amputation.

OBJECTIVE: To explore relationships between balance-confidence and: 1) community participation; 2) self-perceived mobility; and 3) performance-based physical function among individuals with a lower-limb amputation using a prosthetic. Design: Retrospective, cross-sectional study. Setting: Outpatient, multidisciplinary amputee clinic. Participants: Patients (n = 45) using a prosthesis, aged ≥ 18 years, with a unilateral transfemoral or transtibial amputation of ≥1 year, were included. Methods: Participants completed the following self-report measures: Activities-Specific Balance Confidence Scale (ABC); Community Integration Questionnaire (CIQ); Locomotor Capabilities Index (LCI); and two performance-based measures (i.e. Timed Up and Go and 6 Minute Walk Test). Linear regression modeling was used to explore relationships between balance-confidence (i.e. ABC) and self-report (i.e. CIQ and LCI) and performance-based measures (p ≤ 0.0125). Results: After controlling for potential covariates (i.e. age, sex, and body mass index), balance-confidence explained 47.4% of the variance in CIQ (p = 0.000), 53.0% of the variance in LCI (p = 0.000), 20.3% of the variance in Timed Up and Go (p = 0.001), and 18.2% of the variance in 6 Minute Walk Test (p = 0.001). Conclusion: Lower balance-confidence is associated with less community participation, lower self-perceived mobility, and poorer performance among patients with a unilateral lower-limb amputation.

Differences in Measures of Strength and Dynamic Balance Among Individuals With Lower-Limb Loss Classified as Functional Level K3 Versus K4.

OBJECTIVE: For individuals with lower-limb loss, functional mobility (ie, K-level) classification can be subjective. Performance-based outcome measures improve the objectivity of K-level assignment; therefore, this study aimed to determine differences in functional strength- and dynamic balance-based outcome measures performance between K3- and K4-classified adults with lower-limb loss. DESIGN: Prosthetists used subjective information and prosthetic componentry to determine K-levels before outcome measures testing for adults with a unilateral transtibial (n = 50) or transfemoral amputation (n = 17). Outcome measures (ie, 5-Times Sit-to-Stand Test, Figure-of-8 Walk Test, 360-degree Turn Test, and modified Four-Square Step Test) were administered by a blinded examiner. Univariate analyses of variance were used to evaluate between-subgroup differences. RESULTS: K4-classified participants with a unilateral transfemoral amputation performed better on all outcome measures when compared with K3-classified peers, whereas K4-classified individuals with a transtibial amputation performed better on the modified Four-Square Step Test compared with K3-classified peers (P < 0.050). CONCLUSIONS: K4-classified individuals demonstrated greater lower-limb functional strength and better dynamic balance compared with K3-classified peers. To assist with K-level classification, clinicians should consider selecting outcome measures that objectively differentiate between K-levels (ie, modified Four-Square Step Test for those with a unilateral transtibial or transfemoral amputation; 5-Times Sit-to-Stand Test, Figure-of-8 Walk Test, and 360-degree Turn Test for those with a transfemoral amputation).

Self-Reported Functional Mobility, Balance Confidence, and Prosthetic Use Are Associated With Daily Step Counts Among Individuals With a Unilateral Transtibial Amputation.

BACKGROUND: Adults postamputation are not meeting physical activity recommendations. Physical activity is an important consideration in prosthetic prescription. The objective of this study was to determine if functional mobility, balance confidence, and prosthetic use are associated with physical activity among adults with a lower-limb amputation. METHODS: This study recruited patients aged 18-85 years with unilateral transtibial amputations. The Cumulative Illness Rating Scale was used to determine comorbidity burden. Participants completed the Prosthetic Evaluation Questionnaire-Mobility Section, Activities-specific Balance Confidence Scale, and Houghton Scale of Prosthetic Use and wore a StepWatch monitor for 7 days to obtain daily step counts. Linear regression was used to evaluate relationships between each self-report measure and step counts after controlling for covariates, that is, sex, age, time since initial amputation, and comorbidity burden. RESULTS: Forty-seven participants had ≥5 days of step data and were included in this analysis. The Prosthetic Evaluation Questionnaire-Mobility Section [mean (SD): 35.0 (9.6) points] and Activities-specific Balance Confidence Scale [79.2% (15.9%)] each explained 13% of the variance in step count [5491 (4043) steps], whereas the Houghton Scale of Prosthetic Use [10.3 (1.2) points] explained 10% of the variance. CONCLUSION: Self-reported functional mobility, balance confidence, and prosthetic use predict short-term average daily step counts as determined from research-grade accelerometers.

Differences in Physical Performance Measures Among Patients With Unilateral Lower-Limb Amputations Classified as Functional Level K3 Versus K4.

OBJECTIVE: To determine whether differences in physical function, assessed via self-report questionnaires and physical performance tests, exist between individuals with lower-limb loss using a prosthetic device classified as a K3 versus a K4 functional level. DESIGN: Cross-sectional study. SETTING: A university physical therapy amputee clinic. PARTICIPANTS: Participants (N=55) were included if they (1) were aged ≥18 years with a unilateral transfemoral or transtibial amputation; (2) were classified as K3 or K4 functional level; (3) completed all relevant outcome measures; and (4) were currently using a prosthesis. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Locomotor Capabilities Index (LCI), Prosthetic Evaluation Questionnaire-Mobility Section (PEQ-MS), Timed Up and Go (TUG), 10-Meter Walk Test (10MWT), Amputee Mobility Predictor (AMPPRO), and 6-Minute Walk Test (6MWT). K level was determined by group consensus based on a standardized clinical evaluation. RESULTS: After controlling for covariates, patients classified as K3 had slower TUG times (P=.002) and self-selected and fast gait speeds (P<.001), lower AMPPRO scores (P<.001), and walked shorter distances during the 6MWT (P=.003) when compared with patients classified as K4. No significant between-group differences for the LCI or PEQ-MS were found. CONCLUSIONS: Clinicians involved in prosthetic prescription may consider including the TUG, 10MWT, AMPPRO, and 6MWT during their clinical evaluations to help differentiate between individuals of higher functional mobility. The LCI and PEQ-MS may be less useful in classifying individuals as K3 versus K4 because of a ceiling effect.