Lower Limb Prosthetic Rehabilitation in Canada: A Survey Study.

Purpose: This study describes prosthetic rehabilitation services provided to individuals who have had a lower limb amputation in Canada. Method: This cross-sectional survey study used an online survey to collect data from facilities that provide lower limb prosthetic rehabilitation; it included questions about approaches and types of service, therapies, focus of service, and health care providers. One representative from each facility was asked to complete the survey. Results: Of the 65 identified eligible facilities, 59 completed the survey (response rate = 90.8%). The majority of facilities (n = 39; 66.1%) indicated that they provided both in-patient and outpatient prosthetic rehabilitation services. All facilities provided balance, coordination, and gait training as well as prosthetic fit education. Most facilities indicated that they had a physical therapist (n = 58; 93.8%), an occupational therapist (n = 52; 88.1%), and a prosthetist (n = 52; 88.1%) on their team. Conclusions: The majority of the facilities surveyed provided both in-patient and outpatient services and had specialized health care provider teams. Future surveys are required to collect more specific information about prosthetic rehabilitation in Canada.

Objectif : décrire les services de réadaptation avec prothèse du Canada pour les personnes amputées des membres inférieurs. Méthodologie : une étude transversale en ligne a permis d'amasser des données auprès d'établissements qui offrent une réadaptation avec prothèse des membres inférieurs. Elle incluait des questions sur les approches et les types de services, les traitements, l'objet des services et les professionnels de la santé. Un représentant de chaque établissement était invité à remplir le sondage. Résultats : des 65 établissements admissibles répertoriés, 59 ont rempli le sondage (taux de réponse = 90,8 %). La majorité des établissements (n = 39, 66,1 %) a indiqué qu'il offrait des services de réadaptation avec prothèse aux patients hospitalisés et ambulatoires. Tous les établissements offraient un entraînement sur l'équilibre, la coordination et la démarche et de l'information sur l'ajustement des prothèses. La plupart des établissements indiquaient qu'ils comptaient un physiothérapeute (n = 58, 93,8 %), un ergothérapeute (n = 52, 88,1 %) et un prothésiste (n = 52, 88,1 %) au sein de leur équipe. Conclusions : la majorité des établissements sondés offraient à la fois des services aux patients hospitalisés et ambulatoires et étaient dotés d'équipes soignantes spécialisées. Il faudra réaliser d'autres sondages pour colliger de l'information plus précise sur la réadaptation avec prothèse au Canada.

Impact of Critical Illness Polyneuromyopathy in Rehabilitation: A Prospective Observational Study.

BACKGROUND: Critical illness polyneuromyopathy (CIPNM) increasingly is recognized as a source of disability in patients requiring intensive care unit (ICU) admission. The prevalence and impact of CIPNM on patients in the rehabilitation setting has not been established. OBJECTIVES: To determine the proportion of at-risk rehabilitation inpatients with evidence of CIPNM and the functional sequelae of this disorder. DESIGN: Prospective observational study. SETTING: Tertiary academic rehabilitation hospital. PATIENTS: Rehabilitation inpatients with a history of ICU admission for at least 72 hours. METHODS: Electrodiagnostic studies were performed to evaluate for axonal neuropathy and/or myopathy in at least one upper and one lower limb. MAIN OUTCOME MEASUREMENTS: The primary outcome was prevalence of CIPNM. Secondary outcomes included Functional Independence Measure (FIM) scores, rehabilitation length of stay (RLOS), and discharge disposition. RESULTS: A total of 33 participants were enrolled; 70% had evidence of CIPNM. Admission FIM score, discharge FIM, FIM gain, and FIM efficiency were 64.1, 89.9, 25.5, and 0.31 in those with CIPNM versus 78.4, 94.6, 16.1, and 0.33 in those without CIPNM, respectively. Average RLOS was 123 days versus 76 days and discharge to home was 57% versus 90% in the CIPNM and non-CIPNM groups, respectively. CONCLUSIONS: CIPNM is very common in rehabilitation inpatients with a history of ICU admission. It was associated with a lower functional status at rehabilitation admission, but functional improvement was at a similar rate to those without CIPNM. Longer RLOS stay may be required to achieve the same functional level. LEVEL OF EVIDENCE: III.

A clinical survey about commercial games in lower limb prosthetic rehabilitation.

BACKGROUND: Despite the popularity of commercial games in lower limb prosthetic rehabilitation, data about their prevalence of use as well as therapists' perspectives about these games are still lacking. OBJECTIVES: To learn about the prevalence of use of commercial games in lower limb prosthetic rehabilitation and therapists' perspectives about these games. STUDY DESIGN: Cross-sectional. METHODS: An online survey was sent to physical and occupational therapists across prosthetic rehabilitation facilities in Canada. The survey had questions about the use of commercial games and therapists' perspectives. RESULTS: Data were collected from 82 therapists. Overall, 46.3% (38/82) reported that they use commercial games; of those, 94.7% (36/38) used the Nintendo Wii Fit. The most reported perceived benefits were the Wii Fit helping to improve weight shifting ( n = 76/82, 92.7%) and balance ( n = 75/82, 91.5%), and being motivating and complementing traditional therapy ( n = 75/82, 91.5%). The most reported perceived barriers/challenges were lack of time and familiarity with the games ( n = 58/82, 70.7%). CONCLUSION: Commercial games, particularly the Wii Fit, are commonly used in lower prosthetic rehabilitation in Canada. Most of the queried therapists view the Wii Fit positively. Knowledge translation activities and developing standard treatment protocols would be helpful in minimizing the barriers identified in this study. Clinical relevance The Wii Fit is prevalent in lower limb prosthetic rehabilitation in Canada and it is viewed positively by therapists as having the potential to improve balance and weight bearing, making rehabilitation more motivating, and complementing traditional therapy. Future studies should investigate the efficacy of the Wii Fit in prosthetic rehabilitation.

Incidence of lower limb amputation in Canada.

OBJECTIVES: To determine the Canadian age-adjusted incidence rates of lower limb amputation (LLA) by province, sex, level, and cause of amputation. METHODS: Data on all hospital discharges associated with LLA from April 1, 2006, to March 31, 2012, were obtained from the Canadian Institute for Health Information's Discharge Abstract Database. National and provincial age-adjusted rates were calculated per 100 000 individuals by sex, level, and cause of LLA using the direct method of standardization. The relative risk of LLA in people with diabetes was calculated. RESULTS: There were a total of 44 430 LLAs performed in Canada over the study years. The number of LLAs increased from 7331 in 2006 to 7708 in 2011. Mean (SD) age was 65.7 (16.6) years, and 68.8% were males. Sixty-five percent of the LLA cases were due to diabetes. The average age-adjusted rate of LLA in Canada was 22.9 per 100 000 individuals. The age-adjusted rates declined over the study years. The relative risk of diabetes-related LLAs was 28.9. CONCLUSION: This study provided the first Canadian national and provincial age-adjusted incidence rates of LLA and a baseline for monitoring and evaluation in the future. Understanding the incidence of LLA is essential to managing preventive and rehabilitation services for this population. Although the age-adjusted LLA incidence rates have decreased, the number of new LLAs has increased. The increase in the number of LLAs has important implications for social and health care costs.

Thoracic Outlet Syndrome Causing Phantom Hand Pain in a Person With a Transradial Amputation: A Case Presentation.

In this case, a 47-year-old commercial truck driver with a remote right transradial amputation presented with pain in the medial aspect of his right phantom hand. He was diagnosed with thoracic outlet syndrome (TOS). This was attributed to the muscular demands associated with using his body-powered prosthesis for many years. TOS remains a controversial diagnosis in the able-bodied population and a unique diagnostic challenge in a patient with a transradial amputation. In this case, consideration of TOS guided the rehabilitation and treatment plan. His pain improved with a conservative stretching program.

A Telehealth Intervention Using Nintendo Wii Fit Balance Boards and iPads to Improve Walking in Older Adults With Lower Limb Amputation (Wii.n.Walk): Study Protocol for a Randomized Controlled Trial.

BACKGROUND: The number of older adults living with lower limb amputation (LLA) who require rehabilitation for improving their walking capacity and mobility is growing. Existing rehabilitation practices frequently fail to meet this demand. Nintendo Wii Fit may be a valuable tool to enable rehabilitation interventions. Based on pilot studies, we have developed "Wii.n.Walk", an in-home telehealth Wii Fit intervention targeted to improve walking capacity in older adults with LLA. OBJECTIVE: The objective of this study is to determine whether the Wii.n.Walk intervention enhances walking capacity compared to an attention control group. METHODS: This project is a multi-site (Vancouver BC, London ON), parallel, evaluator-blind randomized controlled trial. Participants include community-dwelling older adults over the age of 50 years with unilateral transtibial or transfemoral amputation. Participants will be stratified by site and block randomized in triplets to either the Wii.n.Walk intervention or an attention control group employing the Wii Big Brain cognitive software. This trial will include both supervised and unsupervised phases. During the supervised phase, both groups will receive 40-minute sessions of supervised group training three times per week for a duration of 4 weeks. Participants will complete the first week of the intervention in groups of three at their local rehabilitation center with a trainer. The remaining 3 weeks will take place at participants' homes using remote supervision by the trainer using Apple iPad technology. At the end of 4 weeks, the supervised period will end and the unsupervised period will begin. Participants will retain the Wii console and be encouraged to continue using the program for an additional 4 weeks' duration. The primary outcome measure will be the "Two-Minute Walk Test" to measure walking capacity. Outcome measures will be evaluated for all participants at baseline, after the end of both the supervised and unsupervised phases, and after 1-year follow up. RESULTS: Study staff have been hired and trained at both sites and recruitment is currently underway. No participants have been enrolled yet. CONCLUSIONS: Wii.n.Walk is a promising in-home telehealth intervention that may have useful applications for older adults with LLA who are discharged from rehabilitation or live in remote areas having limited or no access to existing rehabilitation programs. TRIAL REGISTRATION: Clinicaltrial.gov NCT01942798; http://clinicaltrials.gov/ct2/show/NCT01942798 (Archived by WebCite at http://www.webcitation.org/6V0w8baKP).

Resident selection for a physical medicine and rehabilitation program: feasibility and reliability of the multiple mini-interview.

The development of a process to select the best residents for training programs is challenging. There is a paucity of literature to support the implementation of an evidence-based approach or even best practice for program directors and selection committees. Although assessment of traditional academic markers such as clerkship grades and licensing examination scores can be helpful, these measures typically fail to capture performance in the noncognitive domains of medicine. In the specialty of physical medicine and rehabilitation, physician competencies such as communication, health advocacy, and managerial and collaborative skills are of particular importance, but these are often difficult to evaluate in admission interviews. Recent research on admission processes for medical schools has demonstrated reliability and validity of the "multiple mini-interview." The objective of our project was to develop and evaluate the multiple mini-interview for a physical medicine and rehabilitation residency training program, with a focus on assessment of the noncognitive physician competencies. We found that the process was feasible, time efficient, and cost-efficient and that there was good interrater reliability. The multiple mini-interview may be applied to other physical medicine and rehabilitation residency programs. Further research is needed to confirm reliability and determine validity.

Botulinum toxin injection for management of thoracic outlet syndrome: a double-blind, randomized, controlled trial.

We studied the effect of botulinum toxin type A (BTX-A) injections to the scalene muscles on pain in subjects with thoracic outlet syndrome (TOS) in this double-blind, randomized, parallel group trial with follow-up at 6 weeks, 3 months, and 6 months. Thirty-eight patients referred to physiatrists for management of TOS with BTX-A injection were included. One subject was lost to follow-up and all other subjects completed the trial. A 75-unit dose of BTX-A reconstituted with 0.75 cc of normal saline was injected to the anterior scalene (37.5 units) and middle scalene (37.5 units) muscles using electromyographic guidance. The primary outcome measure was pain as measured on a horizontal visual analog scale (VAS) 6 weeks-post-injection. Secondary outcomes were paresthesias measured on a VAS and function measured with the Disabilities of the Arm, Shoulder and Hand (DASH) and Short-form 36 (SF-36) questionnaires. For the primary outcome measure of VAS scores for pain at 6 weeks, the difference in the means adjusted for baseline VAS scores between placebo and BTX-A was 5.03 mm in favor of BTX-A (95% confidence interval -15.7 to 5.7, P=.36). Changes in secondary outcome measures were also not statistically significant. We conclude that BTX-A injections to the scalene muscles did not result in clinically or statistically significant improvements in pain, paresthesias, or function in this population of subjects with TOS.