Does Terminology Matter? Perspectives From People With Limb Difference, Clinicians, and Researchers.

OBJECTIVE: To elicit the preferred terminology among people with limb difference as well as health care and/or research professionals. DESIGN: Cross-sectional survey. SETTING: Online. PARTICIPANTS: A convenience sample of N=122 individuals (people with limb difference, n=65; health care and/or research professionals, n=57) completed an online survey. People were included if they (1) were aged ≥18 years; (2) self-identified as having limb difference (regardless of etiology) or as a health care or research professional (with experience working with people with limb difference); and (3) lived in the United States for most of the time in their selected role. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Importance of terminology, preference toward person-first or identity-first terms, preferred terms, and individual perspectives on terminology preferences. RESULTS: Most participants identified as White (92.6%). Age significantly differed between groups (people with limb difference, 49.9±15.4y; professionals, 41.0±14.3y; P=.001). Approximately 50% of people with limb difference stated terminology was very or extremely important, compared to 70% of professionals (χ2=16.6, P=.002). While 73.7% of professionals reported a preference for person-first terminology, the sample of people with limb difference were more evenly split, as 42.9% reported a preference for identity-first terminology and 50.8% reported a preference for person-first terminology. The most frequently selected limb and population terms, respectively, were residual limb and individual/person with limb difference; however, many people with limb difference indicated they preferred "amputee" when speaking about a population. CONCLUSIONS: Most of the participants indicated terminology was very or extremely important, and both groups tended to prefer the terms residual limb (limb term) and individual/person with limb difference (population term). However, this study was not intended to recommend terminology, but rather help inform terminology choices that are centered around people with limb difference. Individuality and context should be considered when deciding terminology. Future studies should include more participants from racially/ethnically minoritized groups and people with limb difference who have dysvascular and/or congenital etiologies.

An examination of current stroke rehabilitation practice in Peru: Implications for interprofessional education.

This study aimed to better understand current clinical practice of rehabilitation professionals in Lima, Peru, and to explore the existence of and potential for interprofessional collaboration. A secondary purpose was to assess rehabilitation professionals' agreement with evidence-based stroke rehabilitation statements and confidence performing stroke rehabilitation tasks prior to and following an interprofessional stroke rehabilitation training. Current clinical practice for rehabilitation professionals in Peru differs from high-income counties like the United States, as physical therapists work with dysphagia and feeding, prosthetist orthotists serve a strictly technical role, and nurses have a limited role in rehabilitation. Additionally, while opportunity for future interprofessional collaboration within stroke rehabilitation exists, it appears to be discouraged by current health system policies. Pre- and post-training surveys were conducted with a convenience sample of 107 rehabilitation professionals in Peru. Survey response options included endorsement of professionals for rehabilitation tasks and a Likert scale of agreement and confidence. Training participants largely agreed with evidence-based stroke rehabilitation statements. Differences in opinion remained regarding the prevalence of dysphagia and optimal frequency of therapy post-stroke. Substantially increased agreement post-training was seen in favour of early initiation of stroke rehabilitation and ankle foot orthosis use. Participants were generally confident performing traditional profession-specific interventions and educating patients and families. Substantial increases were seen in respondents' confidence to safely and independently conduct bed to chair transfers and determine physiological stability. Identification of key differences in rehabilitation professionals' clinical practice in Peru is a first step toward strengthening the development of sustainable rehabilitation systems and interprofessional collaboration.

How do users define success with a lower limb prosthesis? A focus group study.

PURPOSE: In this study, we sought to examine how lower limb prosthesis users define success, what constructs they associate with success, and what barriers and facilitators contribute to achieving success. MATERIALS AND METHODS: Purposively sampled lower limb prosthesis users were recruited to participate in a focus group study. Verbatim transcripts from focus groups were analyzed using inductive thematic analysis. Identified constructs were mapped to existing outcome measures, and a conceptual framework for success with a lower limb prosthesis was proposed. RESULTS: Thirty-one lower limb prosthesis users participated in one of five focus groups. Five themes were developed: keep moving forward, despite ups and downs; being able to live MY normal life and do the things I want to do with ease; learning what works for me and how to manage my prosthesis; only I can define my success; and what about my mental health? Several constructs that do not align with existing measures were identified, including prosthetic attention, grief/loss after amputation, and trust in prosthesis. Facilitators for success described by participants included peer connection, finding the right prosthetist, and mental health support. CONCLUSIONS: According to lower limb prosthesis users, success must be patient-driven, individually defined, and continually reassessed.

According to prosthesis users, success with a lower limb prosthesis should be patient-driven, individually defined, and continually reassessed.Lower limb prosthesis users described facilitators for success to include peer connection, finding the right prosthetist, mental health support, and access to appropriate prosthetic technology.Constructs described by lower limb prosthesis users as relating to success that are currently difficult to measure include prosthetic attention, grief/loss after amputation, prosthesis management, ability to blend in, and trust in the prosthesis.

Prevalence of secondary prosthesis use in lower limb prosthesis users.

PURPOSE: Prostheses designed for daily use are often inappropriate for high-level activities and/or are susceptible to water damage and mechanical failure. Secondary prostheses, such as activity-specific or back-up prostheses, are typically required to facilitate uninterrupted participation in desired life pursuits. This study estimated the prevalence of secondary prosthesis use in a large, national sample of lower limb prosthesis users (LLPUs). METHODS: We conducted a secondary analysis of survey data from three cross-sectional studies that assessed mobility in LLPUs. Descriptive statistics were used to determine the percentage of secondary prosthesis users and percentages of LLPUs that used different type(s) of secondary prosthesis(es). Secondary prosthesis users and non-users were compared to identify differences in participant characteristics between groups. RESULTS: Of participants in the analysis (n = 1566), most (65.8%) did not use a secondary prosthesis. The most common secondary prosthesis types were back-up (19.2%) and activity-specific prostheses (13.5%). Secondary prosthesis users differed significantly from non-users with respect to gender, race, and other characteristics. CONCLUSIONS: Results suggest that secondary prosthesis use for most LLPUs is limited and may differ based on users' demographic and clinical characteristics. Future research should determine how LLPUs' health-related quality-of-life outcomes are affected by access to and use of secondary prostheses.Implications for RehabilitationSecondary prostheses, including activity-specific, back-up, and shower prostheses, have the potential to improve function, mobility, and participation for people who use lower limb prostheses.Most lower limb prosthesis users do not use secondary prostheses, and access to these devices may be related to users' demographic and clinical characteristics.Rehabilitation professionals play a key role in facilitating prosthesis users' access to secondary prostheses and should advocate for those who need them.

Applying systems thinking in the prosthetics and orthotics sector: investigating the common challenges in Iran.

PURPOSE: We sought to explore the common challenges across stakeholder groups and also to recognize interactions among them to improve the Iranian prosthetics and orthotics (P&O) sector. MATERIALS AND METHODS: Interviews were performed from January to June 2019. Participants, including 13 prosthetists/orthotists and six P&O faculty members, were selected using purposive and snowball sampling. The collected data were analyzed using the framework analysis method. Additionally, a systems thinking approach was applied to theorize potential leverage points to improve P&O services in Iran. RESULTS: Challenges in leadership and governance included lack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers. Financing challenges included high out-of-pocket payments, inadequate insurance coverage, and insufficient governmental funding. Service delivery challenges included lack of prosthetists and orthotists in hospitals and medical centers, corrupt activities and a weak referral system. Human resource challenges included insufficient practical skills of graduates, misalignment of theoretical and clinical training, and inadequacy of continuing education courses. CONCLUSIONS: This study provides the groundwork to develop and implement national strategies to address modifiable barriers and improve prosthetic and orthotic services.Implications for rehabilitationLack of united stewardship, inappropriate inter-sectoral cooperation, and poor awareness among decision-makers are the governance challenges of prosthetics and orthotics (P&O) and must be managed by the government.Government resources allocated to P&O services should increase, and P&O insurance coverage should improve.P&O services should be incorporated in health benefits packages to lessen the reliance on out-of-pocket payments.Planning should be done toward inclusion of P&O services in universal health coverage.Up-to-date scientific training and high-quality evidence are needed to enhance the practical skills of P&O graduates and consequently improve the quality of P&O services.Effective continuing training courses for P&O graduates are recommended.It is advantageous to provide P&O services in hospitals.

Advances in prosthetic technology: a perspective on ethical considerations for development and clinical translation.

Technological advancements of prostheses in recent years, such as haptic feedback, active power, and machine learning for prosthetic control, have opened new doors for improved functioning, satisfaction, and overall quality of life. However, little attention has been paid to ethical considerations surrounding the development and translation of prosthetic technologies into clinical practice. This article, based on current literature, presents perspectives surrounding ethical considerations from the authors' multidisciplinary views as prosthetists (HG, AM, CLM, MGF), as well as combined research experience working directly with people using prostheses (AM, CLM, MGF), wearable technologies for rehabilitation (MGF, BN), machine learning and artificial intelligence (BN, KKQ), and ethics of advanced technologies (KKQ). The target audience for this article includes developers, manufacturers, and researchers of prosthetic devices and related technology. We present several ethical considerations for current advances in prosthetic technology, as well as topics for future research, that may inform product and policy decisions and positively influence the lives of those who can benefit from advances in prosthetic technology.

Perceptions of prosthetic attention among lower limb prosthesis users: a focus group study.

PURPOSE: Use of a lower limb prosthesis generally requires increased cognitive effort to compensate for missing motor and sensory inputs. This study sought to examine how lower limb prosthesis users perceive paying attention to their prosthesis(es) in daily life. MATERIALS AND METHODS: Focus groups with lower limb prosthesis users were conducted virtually using semi-structured questions. Verbatim transcripts were excerpted, coded, and reconciled. Inductive thematic analysis was undertaken to identify experiences shared by participants. RESULTS: Five themes emerged from five focus groups conducted with thirty individuals: Paying attention to my prosthesis is just what I have to do; I pay attention to how my prosthetic socket fits and feels every day; I pay attention because I don't want to fall; I pay attention because I have to learn to do things in a new way; and If I can trust that my prosthesis will do what I want, I can pay less attention to it. CONCLUSIONS: Prosthetic attention, including both background and foreground attention, is a shared experience among lower limb prosthesis users. The amount and frequency of prosthetic attention fluctuates throughout the day and changes over time. Measuring attention could inform the evaluation and prescription of technology intended to reduce cognitive effort.

Walking or performing mobility tasks with a prosthesis requires increased attention and may limit the cognitive resources available for other important activities.Lower limb prosthesis users report paying attention to their prosthesis(ses) to avoid falling, to maintain the fit of their prosthetic socket, and to learn to complete mobility tasks with a prosthesis.Clinicians should discuss prosthetic attention with new prosthesis users and explain how it is expected to decrease over time.Prosthetic technology may affect prosthetic attention but development of a measure to assess prosthetic attention is needed to accurately evaluate this relationship.

Disparities in functional recovery after dysvascular lower limb amputation are associated with employment status and self-efficacy.

PURPOSE: Employment status is considered a determinant of health, yet returning to work is frequently a challenge after lower limb amputation. No studies have documented if working after lower limb amputation is associated with functional recovery. The study's purpose was to examine the influence of full-time employment on functioning after lower limb amputation. METHODS: Multisite, cross-sectional study of 49 people with dysvascular lower limb amputation. Outcomes of interest included performance-based measures, the Component Timed-Up-and-Go test, the 2-min walk test, and self-reported measures of prosthetic mobility and activity participation. RESULTS: Average participant age was 62.1 ± 9.7 years, 39% were female and 45% were persons of color. Results indicated that 80% of participants were not employed full-time. Accounting for age, people lacking full-time employment exhibited significantly poorer outcomes of mobility and activity participation. Per regression analyses, primary contributors to better prosthetic mobility were working full-time (R2 ranging from 0.06 to 0.24) and greater self-efficacy (R2 ranging from 0.32 to 0.75). CONCLUSIONS: This study offers novel evidence of associations between employment and performance-based mobility outcomes after dysvascular lower limb amputation. Further research is required to determine cause-effect directionalities. These results provide the foundation for future patient-centered research into how work affects outcomes after lower limb amputation. IMPLICATIONS FOR REHABILITATIONLower limb amputation can pose barriers to employment and activity participation, potentially affecting the quality of life.This study found that the majority of people living with lower limb amputation due to dysvascular causes were not employed full-time and were exhibiting poorer prosthetic outcomes.Healthcare practitioners should consider the modifiable variable of employment when evaluating factors that may affect prosthetic mobility.The modifiable variable of self-efficacy should be assessed by healthcare professionals when evaluating factors that may affect prosthetic mobility.

A survey for characterizing details of fall events experienced by lower limb prosthesis users.

Despite their importance to fall prevention research, little is known about the details of real-world fall events experienced by lower limb prosthesis users. This gap can be attributed to the lack of a structured, population-specific fall survey to document these adverse health events. The objective of this project was to develop a survey capable of characterizing the circumstances and consequences of fall events in lower limb prosthesis users. Best practices in survey development, including focus groups and cognitive interviews with diverse samples of lower limb prosthesis users, were used to solicit input and feedback from target respondents, so survey content would be meaningful, clear, and applicable to lower limb prosthesis users. Focus group data were used to develop fall event definitions and construct a conceptual fall framework that guided the creation of potential survey questions and response options. Survey questions focused on the activity, surroundings, situation, mechanics, and consequences of fall events. Cognitive interviews revealed that with minor revisions, survey definitions, questions, and response options were clear, comprehensive, and applicable to the experiences of lower limb prosthesis users. Administration of the fall survey to a national sample of 235 lower limb prosthesis users in a cross-sectional preliminary validation study, found survey questions to function as intended. Revisions to the survey were made at each stage of development based on analysis of participant feedback and data. The structured, 37-question lower limb prosthesis user fall event survey developed in this study offers clinicians and researchers the means to document, monitor, and compare fall details that are meaningful and relevant to lower limb prosthesis users in a standardized and consistent manner. Data that can be collected with the developed survey are essential to establishing specific goals for fall prevention initiatives in lower limb prosthesis users.

Fall-related events in people who are lower limb prosthesis users: the lived experience.

PURPOSE: To explore lived experiences, and identify common themes as well as vocabulary associated with fall-related events in lower limb prosthesis (LLP) users. MATERIALS AND METHODS: Five focus groups of LLP users from across the United States were conducted remotely via video or tele-conferencing. Focus group transcripts were coded and analyzed using methods adapted from a grounded theory approach to identify themes. RESULTS: Focus group participants (n = 25) described experiences associated with fall-related events that resulted in the identification of six themes: (1) memories of fall-related events are shaped by time and context, (2) location and ground conditions influence whether falls occur, (3) some activities come with more risk, (4) fall-related situations are multi-faceted, and often involve the prosthesis, (5) how LLP users land, but not the way they go down, tends to vary, and (6) not all falls affect LLP users, but some near-falls do. CONCLUSION: Consideration for where LLP users fall, what they are doing when they fall, how they fall, what occurs as a result of a fall, and how well memory of a fall persists may enhance recording and reporting of falls, contribute to development of improved fall risk assessment tools, and inspire the design and function of prosthetic componentry for patient safety.Implications for rehabilitationFalls are a common problem in lower limb prosthesis (LLP) users that can lead to adverse health outcomes.Concerns over near falls, not just falls, may merit greater attention from rehabilitation professionals.Elements of the lived experience that appear unique to LLP users include the role of prosthetic fit, function, and comfort in losing and/or recovering balance; as well as the tendency of LLP users to modify rather than stop or avoid activities associated with falls.

Information access and sharing among prosthetics and orthotics faculty in Ghana and the United States.

BACKGROUND: Information access is essential for quality healthcare provision and education. Despite technological advances, access to prosthetics and orthotics information in low- and middle-income countries is not ubiquitous. The current state of information access, availability, and exchange among prosthetics and orthotics faculty is unknown. OBJECTIVES: Describe information exchange networks and access at two prosthetics and orthotics programs in Ghana and the United States. STUDY DESIGN: Cross-sectional survey, social network analysis. METHODS: An online survey of faculty at two prosthetics and orthotics programs using REDCap. The survey included a social network analysis, demographics, and prosthetics and orthotics information resources and frequency of use. Descriptive statistics were calculated. RESULTS: Twenty-one faculty members completed the survey (84% response). Ghanaian faculty were on average younger (median Ghana: 27 years, United States: 43 years), had less teaching experience, and had less education than US faculty. Textbooks were the most commonly used resource at both programs. The Ghanaian network had more internal connections with few outside sources. The US network had fewer internal connections, relied heavily upon four key players, and had numerous outside contacts. CONCLUSION: Ghana and US faculty have two distinct information exchange networks. These networks identify key players and barriers to dissemination among faculty to promote successful knowledge translation of current scientific literature and technology development. Social network analysis may be a useful method to explore information sharing among prosthetics and orthotics faculty, and identify areas for further study.

Global prevalence of traumatic non-fatal limb amputation.

BACKGROUND: Reliable information on both global need for prosthetic services and the current prosthetist workforce is limited. Global burden of disease estimates can provide valuable insight into amputation prevalence due to traumatic causes and global prosthetists needed to treat traumatic amputations. OBJECTIVES: This study was conducted to quantify and interpret patterns in global distribution and prevalence of traumatic limb amputation by cause, region, and age within the context of prosthetic rehabilitation, prosthetist need, and prosthetist education. STUDY DESIGN: A secondary database descriptive study. METHODS: Amputation prevalence and prevalence rate per 100,000 due to trauma were estimated using the 2017 global burden of disease results. Global burden of disease estimation utilizes a Bayesian metaregression and best available data to estimate the prevalence of diseases and injuries, such as amputation. RESULTS: In 2017, 57.7 million people were living with limb amputation due to traumatic causes worldwide. Leading traumatic causes of limb amputation were falls (36.2%), road injuries (15.7%), other transportation injuries (11.2%), and mechanical forces (10.4%). The highest number of prevalent traumatic amputations was in East Asia and South Asia followed by Western Europe, North Africa, and the Middle East, high-income North America and Eastern Europe. Based on these prevalence estimates, approximately 75,850 prosthetists are needed globally to treat people with traumatic amputations. CONCLUSION: Amputation prevalence estimates and patterns can inform prosthetic service provision, education and planning.

A systematic review in prosthetics and orthotics education research.

BACKGROUND: Formal prosthetic/orthotic education has evolved greatly since its inception in the 1950s. The International Society for Prosthetics and Orthotics has established guidelines and recognition for prosthetic/orthotic programs worldwide. However, the current state-of-the-science in prosthetic/orthotic education is largely unknown. OBJECTIVES: To evaluate and synthesize available prosthetic/orthotic education research. STUDY DESIGN: Systematic review. METHODS: Three bibliographic databases were searched and quality of included articles assessed using criteria from the National Institutes for Health Quality Assessment Tool for Observational Cohort, Cross-Sectional Studies, and the Critical Appraisal Skills Programme Qualitative Research Checklist, and Delphi quality criteria. RESULTS: This review included 25 articles from 23 studies. Included studies explored description, development, implementation, and/or assessment of the teaching/learning methods, curriculum, program, or country/region level. Studies were conducted in 18 countries and published in 14 journals. Methodological quality was rated high in 6 articles, moderate in 6, and low in 13. Content synthesis was not attempted due to the heterogeneous literature. CONCLUSION: This systematic review suggests that prosthetic/orthotic education research is only being conducted at a limited level. There is a strong need for high quality, collaborative education research to be conducted and published in peer-reviewed journals to improve prosthetic/orthotic education and build a global conversation. CLINICAL RELEVANCE: Research in prosthetic/orthotic education is limited. The current body of literature is not sufficient to inform and guide future education of prosthetic/orthotic students. Opportunities to improve prosthetic/orthotic education research include academic collaborations, a dedicated education special issue or journal, and disciplinary support for prosthetic/orthotic education research.

Perceptions of ability among adults with upper limb absence: impacts of learning, identity, and community.

Aims: The purpose of this research was to examine the lived experiences of adults with upper limb absence, specifically the interplay of device use, ability, and quality of life through semi-structured interviews. We sought to draw insight from these experiences to improve the practice and perceptions of adults with upper limb absence, prosthetists, and technology designers.Methods: Semi-structured interviews were conducted and interpreted with phenomenological analysis for fourteen individuals with acquired or congenital limb absence. Through an interpretive phenomenological analysis approach, researchers employed an inductive approach to coding and identification of central themes.Results: Participants shared high perceptions of ability and function, regardless of prosthesis or assistive technology use. Life experiences related to three dimensions strongly influenced perceptions of ability: (1) learning to live with upper limb absence, (2) developing their identity, and (3) connecting with their community. The diversity of experiences across participants highlighted the limitations of identifying "normative" pathways of recovery or device use, emphasizing the need for flexible and adaptable systems that can creatively support personal goals and needs.Conclusions: Integration of novel platforms for professional practice, supportive communities, and technology innovation can support the evolving needs and care of individuals with upper limb absence.Implications for rehabilitationIn this study, perceptions of ability were largely independent of prosthetic use and each individual developed a unique toolkit of devices and strategies to support function in daily life.Clinicians can support perceptions of ability by promoting opportunities for community development and life-long learning.Informal communities, such as online networks, can provide novel device designs, resources for learning, and societal awareness to empower individuals with limb absence.

A conceptual framework for orthotic and prosthetic education.

BACKGROUND: Variables that influence orthotic and prosthetic patient outcomes beyond direct care are poorly conceptualized for orthotic and prosthetic students. Restructuring educational curricula around important clinical reasoning variables (i.e. factors that may influence outcomes) could improve teaching, learning, and clinical practice. OBJECTIVES: To propose an orthotic and prosthetic education framework to enhance the development of orthotic and prosthetic students' clinical reasoning skills. STUDY DESIGN: Scoping review. METHODS: We conducted a scoping review, identified variables of orthotic and prosthetic usability, and performed a qualitative thematic analysis through the lens of orthotic and prosthetic clinical educators to develop a conceptual framework for orthotic and prosthetic education. RESULTS: Sorting of variables identified from the literature resulted in three thematic areas: (1) the state of functioning, disability, and health (International Classification of Functioning, Disability and Health); (2) orthotic and prosthetic technical properties, procedures, and appropriateness; and (3) professional service as part of orthotic and prosthetic interventions. The proposed orthotic and prosthetic education framework includes these three areas situated within the context of patient-centered care. CONCLUSIONS: A conceptual framework was developed from variables identified in peer-reviewed literature. This orthotic and prosthetic education framework provides a structure to explore orthotic and prosthetic clinical reasoning and advance our teaching and assessment of students' clinical reasoning skills. CLINICAL RELEVANCE: The proposed orthotic and prosthetic (O&P) education framework is intended to promote conversation about variables (e.g. health condition, procedures, services, and O&P principles) that influence O&P clinical practice outcomes and further advance our teaching and assessment of students' clinical reasoning skills.

Assessment of low- and high-level task performance in people with transtibial amputation using crossover and energy-storing prosthetic feet: A pilot study.

BACKGROUND:: Crossover feet incorporate features of energy-storing feet and running-specific feet. As such, crossover feet may be suitable for both daily ambulation and participation in physically demanding activities. OBJECTIVES:: To compare crossover feet and energy-storing feet on performance-based tests including a range of low-level (e.g. sit-to-stand) and high-level (e.g. jogging) activities. STUDY DESIGN:: Cross-sectional, repeated measures. METHODS:: Participants with transtibial amputation completed a battery of performance-based outcome measures, including the Five Times Sit-to-Stand, Timed-Up-and-Go, Four Square Step Test, and the Comprehensive High-level Activity Mobility Predictor. Participants wore duplicate prostheses fit with crossover feet and energy-storing feet to perform the tests; the order of foot conditions was randomized. Paired t tests were used to evaluate differences between feet and order of testing. RESULTS:: Data from seven participants showed improvements in all measures while using crossover feet. Improvements in the second foot condition were also observed, indicating a practice effect for all measures. However, differences between feet and order of conditions were not statistically significant ( p > 0.05). CONCLUSION:: Results of this study suggest that crossover feet may improve low- and high-level mobility outcomes. However, intervention effects are small and practice effects were observed in all outcomes. Future research is needed to evaluate the influence of practice effects on performance-based mobility measures. CLINICAL RELEVANCE: Crossover feet may improve transtibial prosthesis users' performance compared to energy-storing feet across a range of activities, but additional research is needed. Practice effects may be an influential factor in the measurement of performance-based mobility outcomes and should be considered when performing a clinical assessment.

Energy expenditure in people with transtibial amputation walking with crossover and energy storing prosthetic feet: A randomized within-subject study.

BACKGROUND: Energy storing feet are unable to reduce the energy required for normal locomotion among people with transtibial amputation. Crossover feet, which incorporate aspects of energy storing and running specific feet, are designed to maximize energy return while providing stability for everyday activities. RESEARCH QUESTION: Do crossover prosthetic feet reduce the energy expenditure of walking across a range of speeds, when compared with energy storing feet among people with transtibial amputation due to non-dysvascular causes? METHODS: A randomized within-subject study was conducted with a volunteer sample of twenty-seven adults with unilateral transtibial amputation due to non-dysvascular causes. Participants were fit with two prostheses. One had an energy storing foot (Össur Variflex) and the other a crossover foot (Össur Cheetah Xplore). Other components, including sockets, suspension, and interface were standardized. Energy expenditure was measured with a portable respirometer (Cosmed K4b2) while participants walked on a treadmill at self-selected slow, comfortable, and fast speeds with each prosthesis. Gross oxygen consumption rates (VO2 ml/min) were compared between foot conditions. Energy storing feet were used as the baseline condition because they are used by most people with a lower limb prosthesis. Analyses were performed to identify people who may benefit from transition to crossover feet. RESULTS: On average, participants had lower oxygen consumption in the crossover foot condition compared to the energy storing foot condition at each self-selected walking speed, but this difference was not statistically significant. Participants with farther six-minute walk test distances, higher daily step counts, and higher Medicare Functional Classification Levels at baseline were more likely to use less energy in the crossover foot. SIGNIFICANCE: Crossover feet may be most beneficial for people with higher activity levels and physical fitness. Further research is needed to examine the effect of crossover feet on energy expenditure during high-level activities.

Laboratory- and community-based health outcomes in people with transtibial amputation using crossover and energy-storing prosthetic feet: A randomized crossover trial.

Contemporary prosthetic feet are generally optimized for either daily or high-level activities. Prosthesis users, therefore, often require multiple prostheses to participate in activities that span a range of mobility. Crossover feet (XF) are designed to increase the range of activities that can be performed with a single prosthesis. However, little evidence exists to guide clinical prescription of XF relative to traditional energy storing feet (ESF). The objective of this study was to assess the effects of XF and ESF on health outcomes in people with transtibial amputation. A randomized crossover study was conducted to assess changes in laboratory-based (endurance, perceived exertion, walking performance) and community-based (step activity and self-reported mobility, fatigue, balance confidence, activity restrictions, and satisfaction) outcomes. Twenty-seven participants were fit with XF and ESF prostheses with standardized sockets, interfaces, and suspensions. Participants were not blinded to the intervention, and wore each prosthesis for one month while their steps were counted with an activity monitor. After each accommodation period, participants returned for data collection. Endurance and perceived exertion were measured with the Six-Minute Walk Test and Borg-CR100, respectively. Walking performance was measured using an electronic walkway. Self-reported mobility, fatigue, balance confidence, activity restrictions, and satisfaction were measured with survey instruments. Participants also reported foot preferences upon conclusion of the study. Differences between feet were assessed with a crossover analysis. While using XF, users experienced improvements in most community-based outcomes, including mobility (p = .001), fatigue (p = .001), balance confidence (p = .005), activity restrictions (p = .002), and functional satisfaction (p < .001). Participants also exhibited longer sound side steps in XF compared to ESF (p < .001). Most participants (89%) reported an overall preference for XF; others (11%) reported no preference. Results indicate that XF may be a promising alternative to ESF for people with transtibial amputation who engage in a range of mobility activities. TRIAL REGISTRATION: ClinicalTrials.gov NCT02440711.