Development of the AMPDECIDE Decision Aid to Facilitate Shared Decision Making in Patients Facing Amputation Secondary to Chronic Limb Threatening Ischemia.

INTRODUCTION: We developed a patient decision aid to enhance patient participation in amputation level decision making when there is a choice between a transmetatarsal or transtibial amputation. METHODS: In accordance with International Patient Decision Aid Standards, we developed an amputation level patient decision aid for patients who are being considered for either a transmetatarsal or transtibial amputation, incorporating qualitative literature data, quantitative literature data, qualitative provider and patient interviews, expert panel input and iterative patient feedback. RESULTS: The rapid qualitative literature review and qualitative interviews identified five domains outcome priority domains important to patients facing amputation secondary to chronic limb threatening ischemia: 1) the ability to walk, 2) healing and risk for reamputation, 3) rehabilitation program intensity, 4) ease of prosthetic use, and 5) limb length after amputation. The rapid quantitative review identified only two domains with adequate evidence comparing differences in outcomes between the two amputation levels: mobility and reamputation. Patient, surgeon, rehabilitation and decision aid expert feedback allowed us to integrate critical facets of the decision including addressing the emotional context of loss of limb, fear and anxiety as an obstacle to decision making, shaping the decision in the context of remaining life years, and how to facilitate patient knowledge of value tradeoffs. CONCLUSIONS: Amputation level choice is associated with significant outcome trade-offs. The AMPDECIDE patient decision aid can facilitate acknowledgment of patient fears, enhance knowledge of amputation level outcomes, assist patients in determining their personal outcome priorities, and facilitate shared amputation level decision making.

Prognosticating Prosthetic Ambulation Ability in People With Lower Limb Amputation in Early Post-operative Phase.

OBJECTIVE: To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation. DESIGN: Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques. SETTING: Regional hospital's ambulatory rehabilitation clinic. PARTICIPANTS: Patients with major lower limb amputation (N=329). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP. RESULTS: In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79. CONCLUSION: The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals.

The Effect of Prosthetic Limb Sophistication and Amputation Level on Self-reported Mobility and Satisfaction With Mobility.

OBJECTIVE: To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level. DESIGN: Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes. SETTING: The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls. PARTICIPANTS: 347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020. INTERVENTIONS: Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system. MAIN OUTCOME MEASURE: Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0-10-point Likert scale. RESULTS: Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI), .98-3.3; P=.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1-96.8; P=.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted ß coefficient (aß)=.77, 95% CI, .11-1.4; P=.02). A statistically significant association was only observed in those who underwent a TT amputation (aß=.79, 95% CI, .09-1.5; P=.03). CONCLUSIONS: Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction.

Utilization and Perception of Peer-Support After Lower Limb Loss in the United States: Potential Benefits on Mobility Outcomes.

OBJECTIVE: To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes. DESIGN: Quantitative and qualitative descriptive study with a cross-sectional design. SETTING: National survey (distributed to 169 peer-support groups in 44 states in the US). PARTICIPANTS: The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82). MAIN OUTCOME MEASURES: A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M). RESULTS: Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055). CONCLUSION: Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility.

Care Priorities for Individuals with Lower Extremity Amputations: A Patient Delphi Study.

OBJECTIVE: To gather preliminary evidence on short- and long-term care priorities for people with lower extremity amputations. DESIGN: A three-round modified Delphi study using semi-structured interviews. PARTICIPANTS: A convenience sample of 20 adult participants who had undergone lower extremity amputations at a tertiary public hospital. MAIN MEASURE: Consensus on each care priority was defined a priori as an agreement of more than 50%. Semi-structured interviews were conducted to understand the rationales for endorsing the care priorities. RESULTS: Consensus was reached on 24 short-term care priorities and 12 long-term care priorities in the biomedical, practical and psychological and spiritual domains. The rationales for endorsing each of the care priorities generated three themes: preparedness; mental health, psychological and spiritual well-being; and participating in life, with respect and dignity. CONCLUSIONS: Our results highlight the substantial need to improve patient access to education and planning support prior to undergoing limb amputation, and optimising post-amputation rehabilitation programmes, enabling people with amputations to participate in meaningful life roles that provide them with purpose, dignity, and self-respect. The knowledge of care priorities revealed in this study may promote effective patient-centred care and improve clinical outcomes.

Validation of IMU against optical reference and development of open-source pipeline: proof of concept case report in a participant with transfemoral amputation fitted with a Percutaneous Osseointegrated Implant.

BACKGROUND: Systems that capture motion under laboratory conditions limit validity in real-world environments. Mobile motion capture solutions such as Inertial Measurement Units (IMUs) can progress our understanding of "real" human movement. IMU data must be validated in each application to interpret with clinical applicability; this is particularly true for diverse populations. Our IMU analysis method builds on the OpenSim IMU Inverse Kinematics toolkit integrating the Versatile Quaternion-based Filter and incorporates realistic constraints to the underlying biomechanical model. We validate our processing method against the reference standard optical motion capture in a case report with participants with transfemoral amputation fitted with a Percutaneous Osseointegrated Implant (POI) and without amputation walking over level ground. We hypothesis that by using this novel pipeline, we can validate IMU motion capture data, to a clinically acceptable degree. RESULTS: Average RMSE (across all joints) between the two systems from the participant with a unilateral transfemoral amputation (TFA) on the amputated and the intact sides were 2.35° (IQR = 1.45°) and 3.59° (IQR = 2.00°) respectively. Equivalent results in the non-amputated participant were 2.26° (IQR = 1.08°). Joint level average RMSE between the two systems from the TFA ranged from 1.66° to 3.82° and from 1.21° to 5.46° in the non-amputated participant. In plane average RMSE between the two systems from the TFA ranged from 2.17° (coronal) to 3.91° (sagittal) and from 1.96° (transverse) to 2.32° (sagittal) in the non-amputated participant. Coefficients of Multiple Correlation (CMC) results between the two systems in the TFA ranged from 0.74 to > 0.99 and from 0.72 to > 0.99 in the non-amputated participant and resulted in 'excellent' similarity in each data set average, in every plane and at all joint levels. Normalized RMSE between the two systems from the TFA ranged from 3.40% (knee level) to 54.54% (pelvis level) and from 2.18% to 36.01% in the non-amputated participant. CONCLUSIONS: We offer a modular processing pipeline that enables the addition of extra layers, facilitates changes to the underlying biomechanical model, and can accept raw IMU data from any vendor. We successfully validate the pipeline using data, for the first time, from a TFA participant using a POI and have proved our hypothesis.

[Validated German PROMs for People with Major Amputation of the Lower Extremity - A Narrative Review Based on the Final Report of the LEAD and COMPASS Initiative of the ISPO]. / Validierte deutschsprachige PROMs für Menschen mit Majoramputation der unteren Extremität ­ Ein narrativer Review anhand des Abschlussreports der LEAD- und COMPASS-Initiative der ISPO.

Patient-reported outcome measures (PROMs) play an important role in the rehabilitation of people with major limb amputations. Patient-completed questionnaires help collect specific constructs on this patient population. The COMPASS and LEAD initiatives, carried out by the International Society for Prosthetics and Orthotics (ISPO), underscore the importance of regularly collecting high-quality PROMs. These are essential for the evaluation of rehabilitation needs, progress, and success. In the final report of ISPO's major international initiative, PROMs recommendations of the expert panel are tabulated. In Table 3.2 of the report, ISPO lists n=12 PROMs that were included in the narrow consensus process were considered to be of acceptable quality, and therefore recommended. The aim of this systematic review was to specifically search for these recommended PROMS regarding their availability in a German and validated version in order to identify potential gaps. All PROMs that were available in a German and validated version were then examined further with regard to the quality of the validation study, using the checklist of COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN). Through a systematic literature search, six validated German-language versions were found. Only four of these met the quality standards of the COSMIN checklist sufficiently. Overall, this review shows serious gaps in the availability in the German language of validated versions of PROMs used internationally and recommended as standard by the ISPO. This gap needs to be closed by guideline-oriented translation and subsequent validation studies in order to be able to offer and collect the PROMS recommended by the ISPO also for German-speaking patient populations.

Self-Contained Neuromusculoskeletal Arm Prostheses.

We report the use of a bone-anchored, self-contained robotic arm with both sensory and motor components over 3 to 7 years in four patients after transhumeral amputation. The implant allowed for bidirectional communication between a prosthetic hand and electrodes implanted in the nerves and muscles of the upper arm and was anchored to the humerus through osseointegration, the process in which bone cells attach to an artificial surface without formation of fibrous tissue. Use of the device did not require formal training and depended on the intuitive intent of the user to activate movement and sensory feedback from the prosthesis. Daily use resulted in increasing sensory acuity and effectiveness in work and other activities of daily life. (Funded by the Promobilia Foundation and others.).

Postamputation Cognitive Impairment Is Related to Worse Perceived Physical Function Among Middle-Aged and Older Prosthesis Users.

OBJECTIVE: To compare characteristics between middle-aged and older prosthesis users with and without cognitive impairment and determine whether cognitive impairment contributes to variability in perceived physical function. DESIGN: Cross-sectional, observational study SETTING: General community. PARTICIPANTS: Adults 45 years or older, at least 1-year post lower limb amputation (LLA) who were walking independently with a prosthesis (N=119). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: We identified cognitive impairment using an education-adjusted Telephone Interview for Cognitive Status-modified score. Perceived physical function was measured using the Prosthesis Mobility Questionnaire. RESULTS: Of 119 participants (mean age, 62.6±8.2 years; male: 89.1%; vascular etiology: 82.4%; years since amputation: 4.9±4.7 years), 28 (23.5%) had cognitive impairment. Compared with participants without cognitive impairment, those with cognitive impairment were more likely to use an assistive device (60.7% vs 25.3%, P=.002); were older (66.3±7.3 vs 61.5±8.1 years, P=.006) and had more chronic conditions (7.1±3.4 vs 5.4±2.5, P=.004), more depressive symptoms (6.6±5.1 vs 4.2±3.8, P=.008), and worse perceived physical function (2.0±0.6 vs 2.6±0.7, P<.001). Using backward stepwise linear regression, we found that participants with cognitive impairment had worse perceived physical function (standardized parameter estimate [ß]=-0.15, P=.02), even after adjusting for depressive symptoms (ß=-0.31, P<.001), prosthesis satisfaction (ß=0.34, P<.001), number of chronic conditions (ß=-0.19, P=.006), and assistive device use (ßcane=0.01, P=.93; ßother=-0.20, P=.003). Together, these variables explained 59% of perceived physical function variability. CONCLUSIONS: Cognitive impairment is common and associated with worse perceived physical function post LLA, even after controlling for physical and mental health differences. Tailored rehabilitation interventions may be needed to improve perceived physical function in prosthesis users with cognitive impairment.

The First FDA Approved Early Feasibility Study of a Novel Percutaneous Bone Anchored Prosthesis for Transfemoral Amputees: A Prospective 1-year Follow-up Cohort Study.

OBJECTIVE: Evaluate the safety and efficacy of a novel press-fit bone-anchored prosthesis in an FDA approved study. DESIGN: Single-center, prospective 1-year follow-up cohort study of a percutaneous bone anchored prosthesis. SETTING: Veterans Health Administration Hospital. PARTICIPANTS: Ten male Veterans with unilateral transfemoral amputation that occurred at least 6 months prior to enrollment and was not the result of dysvascular disease (N=10). INTERVENTIONS: All participants received the novel press-fit Percutaneous Osseointegrated Prosthesis (POP) and a minimum of 10 days supervised rehabilitation therapy. OUTCOME MEASURES: Adverse events and radiographs were collected to assess device safety. Temporal assessments of bone density, stomal skin, prosthetic don/doff, functional ambulation, and patient-reported outcome compared our POP to a socket suspension system. RESULTS: Ten male participants mean age 48.8±12.1 years (range, 32-68 y) with mean time since amputation of 9.4± years (range 1-18 y) completed a two-staged implantation protocol and progressed to ambulation with an assistive device by post-operative day 14. Eight of 10 completed all study procedures. One implant loosened at 5 weeks, requiring removal. A second was removed after periprosthetic fracture from a non-device-related fall at 28 weeks. One patient required oral antibiotics for superficial infection. There were significant (P<.05) increases in bone density in the lumbar spine and adjacent to the distal porous coating with no radiographic evidence of bone resorption. Compared to the socket system, the use of POP significantly (P<.05) reduced prosthetic don and doff times and patient-reported prosthetic problem scores. Significant improvements (P<.05) in mean mobility, global health, and walking test scores were also observed. CONCLUSIONS: Improvements in bone density, function, and patient reported outcomes were observed with the POP device when compared to a socket suspension system. This Early Feasibility Study established initial safety and effectiveness of the POP device, supporting expanded investigation as an alternative to socket prostheses.

Rehabilitation of high upper limb amputees after Targeted Muscle Reinnervation.

STUDY DESIGN: This is a Delphi study based on a scoping literature review. INTRODUCTION: Targeted muscle reinnervation (TMR) enables patients with high upper limb amputations to intuitively control a prosthetic arm with up to six independent control signals. Although there is a broad agreement regarding the importance of structured motor learning and prosthetic training after such nerve transfers, to date, no evidence-based protocol for rehabilitation after TMR exists. PURPOSE OF THE STUDY: We aimed at developing a structured rehabilitation protocol after TMR surgery after major upper limb amputation. The purpose of the protocol is to guide clinicians through the full rehabilitation process, from presurgical patient education to functional prosthetic training. METHODS: European clinicians and researchers working in upper limb prosthetic rehabilitation were invited to contribute to a web-based Delphi study. Within the first round, clinical experts were presented a summary of recent literature and were asked to describe the rehabilitation steps based on their own experience and scientific evidence. The second round was used to refine these steps, while the importance of each step was rated within the third round. RESULTS: Experts agreed on a rehabilitation protocol that consists of 16 steps and starts before surgery. It is based on two overarching principles, namely the necessity of multiprofessional teamwork and a careful selection and education of patients within the rehabilitation team. Among the different steps in therapy, experts rated the training with electromyographic biofeedback as the most important one. DISCUSSION: Within this study, a first rehabilitation protocol for TMR patients based on a broad experts' consensus and relevant literature could be developed. The detailed steps for rehabilitation start well before surgery and prosthetic fitting, and include relatively novel interventions as motor imagery and biofeedback. Future studies need to further investigate the clinical outcomes and thereby improve therapists' practice. CONCLUSION: Graded rehabilitation offered by a multiprofessional team is needed to enable individuals with upper limb amputations and TMR to fully benefit from prosthetic reconstruction. LEVEL OF EVIDENCE: Low.

[Functional rehabilitation after transfemoral amputation : Shaft prosthesis or endo-exo prosthesis?] / Funktionelle Rehabilitation nach Oberschenkelamputation : Schaftprothese oder Endo-Exo-Prothese?

BACKGROUND: After transfemoral amputation a prosthesis is required to restore autonomous standing and bipedal locomotion. Attachment of the prosthesis can be achieved either classically via socket suspension with a shaft in the stump or directly via implantation of an intramedullary transcutaneous femoral prosthesis (osseointegrated prosthesis). AIM: A fully instrumented gait analysis should enable objectification of the anticipated advantages of the EEP with respect to the gait pattern and individual mobility. MATERIAL AND METHODS: In two patients with a unilateral transfemoral amputation a comprehensive gait analysis was carried out prior to and 6 months (patient 1) or 11 and 20 months (patient 2) after switching from a socket prosthesis to an EEP. This was carried out in the Gait Realtime Analysis Interactive Lab (GRAIL), a fully instrumented gait laboratory with virtual reality and enables assessment close to the conditions of daily life. RESULTS: In both cases the gait analysis confirmed the advantages associated with an EEP for the transmission of force to the prosthesis and the accompanying improvement in gait symmetry.

Systematic Review of Clinical Practice Guidelines for Individuals With Amputation: Identification of Best Evidence for Rehabilitation to Develop the WHO's Package of Interventions for Rehabilitation.

OBJECTIVES: To report the results of the systematic search performed to identify interventions and related evidence for rehabilitation of individuals with amputation based on the current evidence from clinical practice guidelines (CPG). DATA SOURCES: Pubmed, Pedro, CINAHL, Embase, Google Scholar, and multiple guideline databases (date restriction, 2008-2018). STUDY SELECTION: Exclusion criteria were no CPG, not reporting on rehabilitation, published before 2008, developed for health conditions other than amputation, presence of conflict of interest (financial or nonfinancial), lack of information on the strength of the recommendation, and lack of quality assessed by the "Appraisal of Guidelines for Research and Evaluation." DATA EXTRACTION: Data extraction was done using a standardized form, which comprised information on the recommendation, the strength of recommendation and the quality of the evidence used to inform the recommendation. DATA SYNTHESIS: We included 4 guidelines, providing a total of 217 recommendations (20 on assessments, 131 on interventions, and 66 on service provision). Most recommendations concerned pain management, education, pre- and postoperative management, and residual limb care. The strength of recommendation was generally weak to intermediate. The level of evidence mostly compromised expert opinions, with only 6.9% (15 of 217) being provided by randomized controlled trials, systematic reviews, or meta-analyses. CONCLUSIONS: The field of amputation is well covered for recommended interventions, but the level of evidence is generally low and is based mostly on expert opinion. Some important domains are not covered (eg, vocation and education, sexual and/or intimate relationships, activities of daily living or leisure activities, education concerning socket/liner fitting). There is also a lack of description of the contents of training and rehabilitation programs. This should be taken into account for the development of future guidelines.

PREDICTIVE FACTORS FOR SUCCESSFUL PROSTHETIC REHABILITATION AFTER VASCULAR TRANSTIBIAL AMPUTATION.

Lower extremity amputation is a very common amputation and successful prosthetic rehabilitation is a desirable outcome. The aim of this study was to determine which factors affect the success of prosthetic rehabilitation after transtibial vascular amputation. The study included 61 patients who had undergone transtibial amputation (mean age, 64.2±10.4 years; 50 (82%) males). Patients who were able to walk at least 45 meters without aids or with only one walking stick after rehabilitation program were classified into the group of successful prosthetic users. Age, gender, comorbidities, patency of the popliteal artery, wound healing complications, and presence of the phantom limb pain were used as predictive variables. Multivariate logistic regression analysis was used to identify predictive factors of successful prosthetic rehabilitation. The model included all variables explaining up to 59.8% of variance, however, only age, absence of functional patency of the popliteal artery and compromised wound healing made significant contribution to the model. In conclusion, good general condition of the patient and sustained patency of the popliteal artery reliably led to clinical improvement and realization of full capacity of rehabilitation after below-knee amputation.

Factors influencing quality of life, function, reintegration and participation after musculoskeletal tumour operations.

BACKGROUND: The number of people living with soft-tissue and bone sarcomas is increasing due to improved individual therapy and changes in demographics. At present, there are no recommendations for psychological co-treatment, occupational and social reintegration following the treatment of soft tissue and bone sarcomas. METHODS: Seventy-four patients, 42 males and 32 females, aged between 18 and 80 years (54.58 ± 16.99 yr.) with soft-tissue (62) and bone sarcomas (12) were included to answer five standardized and one personal questionnaire regarding quality of life, function, reintegration and participation after surgical treatment. RESULTS: A number of tumour-specific and patient-specific factors were identified that affected the therapeutic outcome. Patients with sarcoma of the lower extremity described poorer mobility. Patients who underwent amputation reported a higher anxious preoccupation. Patients with a higher range of education were less fatalistic and avoiding. The size of tumours or additive radiation therapy did not affect the post-therapeutic quality of life, coping and function. There was a good correlation between anxiety and depression with occupational reintegration, function, quality of life and coping. CONCLUSION: Patients with sarcomas of the lower limb have a higher demand for postoperative rehabilitation and need more help in the postoperative occupational reintegration. Furthermore patients that underwent limb-preserving operations reported better postoperative function and quality of life. Risk assessment using patient-specific factors and an intensive psychological co-treatment may have a large role in the co-treatment of patients from the beginning of their cancer therapy.

Comparison of Removable Rigid Dressing and Elastic Bandage for Residual Limb Maturation in Transtibial Amputees: A Randomized Controlled Trial.

OBJECTIVE: To determine the effect of a removable rigid dressing (RRD) on the time to residual limb maturation compared with elastic bandage (EB) in transtibial amputees. DESIGN: Experimental single-blinded (assessor-blinded) randomized controlled trial. SETTING: Department of Rehabilitation Medicine, King Chulalongkorn Memorial Hospital. PARTICIPANTS: Transtibial amputees (N=25) with immature residual limb. INTERVENTION: Participants were allocated to use RRD or EB to achieve residual limb maturation, and all participants in both groups were trained with the same preprosthetic program. MAIN OUTCOME MEASURES: The time to residual limb maturation, patient satisfaction, and complications were compared between the 2 groups. RESULTS: Median time to residual limb maturation was significantly lower in the RRD group (median, 28d [interquartile range, 17-51d]) than in the EB group (median, 54d [interquartile range, 30-77d]; P=.020). After accounting for time since amputation, maturation time remained significantly lower in the RRD group (adjusted hazard ratio, 3.32; 95% CI, 1.08-10.20; P=.036). There was no significant difference in complications or patient satisfaction. CONCLUSION: In postoperative management of transtibial amputation, the use of RRD had a significantly shorter period to residual limb maturation when compared with the EB group.

Investigation of the Effects of Dual-Task Balance Training on Gait and Balance in Transfemoral Amputees: A Randomized Controlled Trial.

OBJECTIVES: To investigate the effects of dual-task balance training on static and dynamic balance, functional mobility, cognitive level, and sleep quality in individuals with transfemoral amputation. DESIGN: Randomized controlled clinical trial. PARTICIPANTS: Transfemoral amputees (N=20). INTERVENTIONS: Participants were randomly assigned to the single-task gait and balance training group (n=10) or the dual-task gait and balance training group (n=10). Training was given in sessions of 60 min/d, 3 d/wk for 4 weeks. The single-task training group performed traditional gait and balance exercises, and the dual-task training group practiced cognitive and motor tasks while performing gait and balance exercises. MAIN OUTCOME MEASURES: The 1-leg stance test and the Four Square Step Test were used for balance assessment. The timed Up and Go test and 10-m walk test were used for gait assessment. Three test conditions to evaluate the training effects were single walking, walking while performing a cognitive task (serial subtraction), and walking while performing a motor task (tray carrying). The Montreal Cognitive Assessment scale was used for cognitive assessment and the Pittsburgh Sleep Quality Index for sleep quality assessment. RESULTS: Balance and mobility improved in both groups. Dual-task balance performance, functional mobility, and gait speed improved more in the dual-task training group after training (P<.05). Cognitive status and sleep quality improved significantly in the dual-task group (P<.05). CONCLUSIONS: Dual-task training was more effective than single-task training in the improvement of dual-task performance and cognitive status. The inclusion of dual-task exercises in the rehabilitation program of transfemoral amputees will provide a different perspective because of increased task automation.

The Influence of Tobacco Use, Alcohol Consumption, and Weight Gain on Development of Secondary Musculoskeletal Injury After Lower Limb Amputation.

OBJECTIVES: To evaluate whether tobacco use, alcohol consumption, and weight gain are associated with the diagnosis of overuse musculoskeletal injuries within the first 12 months after lower limb amputation. DESIGN: Retrospective cohort study. SETTING: Military treatment facilities. PARTICIPANTS: Service members (N=681) with a deployment-related lower limb amputation. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Clinical diagnosis codes associated with musculoskeletal overuse injuries of the lower limb, upper limb, and low back regions. RESULTS: In the first three months after amputation, tobacco use and alcohol consumption were reported in 55.7% and 72.0%, respectively, of the retrospective sample. The overall mean weight change was 22.9±23.6 pounds. The prevalence of reporting at least 1 overuse injury within 4 to 12 months after amputation was 57.0% in the sample, with prevalence rates of lower limb, upper limb and low back pain diagnoses at 28.3%, 21.7%, and 21.1%, respectively. Service members reporting tobacco use in the first 3 months after amputation were nearly twice as likely to be diagnosed with a lower limb musculoskeletal injury 4 to 12 months after amputation. Similarly, service members reporting alcohol consumption within the first 3 months after amputation were more than twice as likely to be diagnosed with at least 1 overuse musculoskeletal injury 4 to 12 months after amputation. However, weight change or maximum weight after amputation were not associated with the diagnosis of an overuse musculoskeletal injury. CONCLUSIONS: Development of secondary overuse musculoskeletal injury appears to be related to tobacco use and alcohol consumption, but not to weight gain. These findings warrant focused research efforts toward developing preventive interventions.

The Utility of the 2-Minute Walk Test as a Measure of Mobility in People With Lower Limb Amputation.

OBJECTIVES: To establish reference values for the 2-minute walk test (2-MWT) distance and gait speed in people with a lower limb amputation (LLA) who are prosthetic ambulators. Also, to describe the differences in distance and gait speed between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups. DESIGN: Cross-sectional study. SETTING: National meeting for people with lower limb amputation. PARTICIPANTS: A convenience sample of unilateral people (N=101; 47 men, 54 women; mean age ± SD, 50.9±14.3 y) with an LLA; 48 had a transtibial amputation and 53 had a transfemoral amputation. Participants were classified as either limited community ambulators, community ambulators, or those who exceed basic ambulation skills (K2, n=7; K3, n=70; K4, n=24). INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: 2-MWT performance (ie, distance and gait speed). RESULTS: The mean ± SD 2-MWT distance and gait speed for the entire sample was 143.8±37.5 meters (range, 49-259 m) and 72.1±18.8 meters per minute (range, 25-130 m/min), respectively. Men walked farther (distance: men, 154.2±34.2 m; women, 134.4±38.1 m) and faster (gait speed: men, 77.3±17.1 m/min; women, 67.4±19.1 m/min) than women (P<.05). The mean ± SD 2-MWT distance for K4, K3, and K2 level participants was 177.9±31.1 meters, 138.4±28.5 meters, and 81.7±26.9 meters, respectively. Functional level K4 participants performed better than K3 participants (P<.05), and K3 participants performed better than K2 participants (P<.05). People with transtibial amputation walked farther than those with transfemoral amputation (152.9±43.0 m vs 135.6±43.0 m) (P<.05). The distance and speed ambulated by those participants classified in the very high health risk group was worse than those categorized as being at an increased high health risk group (P<.05) and the no increase health risk group (P<.05). The performance of participants older than 70 years old was inferior to the performance of all younger age groups. CONCLUSIONS: Reference values for the 2-MWT distance and gait speed were established in people with LLA who are prosthetic ambulators. Significant differences in the 2-MWT performance were found between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups.

The effect of a home exercise intervention on persons with lower limb amputations: a randomized controlled trial.

OBJECTIVE: To establish if a home-based exercise and education programme is more effective than usual treatment in improving function, mobility and quality of life in people with lower limb amputation due to peripheral vascular disease. METHOD: A blocked randomized single-blinded controlled trial (RCT) with 154 participants (54 female; mean age 58) compared a home-based exercise and education programme (n = 77) with usual care (control) (n = 77). Participants were measured at baseline, immediately post intervention at three months, and after a further three months without any intervention. The outcome measures were the Barthel Index, Participation Scale, EuroQuol 5D, Modified Locomotor Capability Index and Timed Up and Go Test. Changes over time were established using generalized estimating equations and analysis of covariance, (P < 0.05). RESULTS: The Participation Scale (18.73 ± 14.91 against 26.67 ± 19.14; P = 0.011), the EuroQuol5D visual analogue scale (69.10 ± 20.31 against 55.37 ± 27.67; P = 0.003), EuroQuol5D utility index (0.672 ± 0.300 against 0.532 ± 0.358; P = 0.25) and the Modified Capability Index (21.03 ± 15.79 against 15.91 ± 13.67; P = 0.034) improved in the intervention group compared with the control group at three months. At six months, there was no difference between the groups in any of the measures except for the EuroQuol5D visual analogue scale (74.52 ± 16.14 against 66.34 ± 22.91; P = 0.033). Although there were no differences between the Timed Up and Go test at 3 (35.39 ± 32.48 against 45.08 ± 41.52; P = 0.192) and six months (28.22 ± 20.96 against 36.08 ± 36.19; P = 0.189) between the groups the intervention group was more mobile. CONCLUSION: This intervention improved function, mobility and quality of life in persons following lower limb amputation in the first three months post amputation.