Quantitative methods used to evaluate balance, postural control, and the fear of falling in lower limb prosthesis users: A systematic review.

Problems with balance, postural control, and fear of falling are highly prevalent in lower limb prosthesis users, with much research conducted to understand these issues. The variety of tools used to assess these concepts presents a challenge when interpreting research outcomes. This systematic review aimed to provide a synthesis of quantifiable methods used in the evaluation of balance, postural control, and fear of falling in lower limb prosthesis users with an amputation level at or proximal to the ankle joint. A systematic search was conducted in CINAHL, Medline, AMED, Cochrane, AgeLine, Scopus, Web of Science, Proquest, PsycINFO, PsycArticles, and PubPsych databases followed by additional manual searching via reference lists in the reviewed articles databases. Included articles used quantitative measure of balance or postural control as one of the dependent variables, lower limb prosthesis users as a sample group, and were published in a peer-reviewed journal in English. Relevant assessment questions were created by the investigators to rate the assessment methods used in the individual studies. Descriptive and summary statistics are used to synthesize the results. The search yielded (n = 187) articles assessing balance or postural control (n = 5487 persons in total) and (n = 66) articles assessing fear of falling or balance confidence (n = 7325 persons in total). The most used test to measure balance was the Berg Balance Scale and the most used test to measure fear of falling was the Activities-specific Balance Confidence scale. A large number of studies did not present if the chosen methods were valid and reliable for the lower limb prosthesis users. Among study limitations, small sample size was common.

Clinical guidelines recommending prosthetics and orthotics in Sweden: Agreement between national and regional guidelines.

BACKGROUND: Despite the presence of both national and regional clinical practical guidelines (CPGs) in Sweden, no previous studies have investigated the quality of CPGs or the level of agreement between national and regional CPGs. OBJECTIVES: This study aimed to assess the quality of national CPGs recommending prosthetics and orthotics (P&O) and quantify the agreement between national and regional CPGs in Sweden. STUDY DESIGN: Literature Review. METHODS: National and regional CPGs were identified in public databases and by surveyed local nurse practitioners. Quality of the national guidelines was assessed by using AGREE II. Agreement between recommendations in the national and regional CPGs was quantified on a 4-grade rating scale ("similar," "partially similar," "not similar/not present," and "different"). RESULTS: Of 18 national CPGs, 3 CPGs (CPGs of Diabetes, Musculoskeletal disorders, and Stroke) had 9 recommendations related to P&O. The Musculoskeletal disorders and Stroke CPGs had quality scores .60% in all domains, and the Diabetes CPG had scores .60% in 5 of 6 domains according to AGREE II. Seven regional CPGs for P&O treatment were identified. Three national recommendations (in Diabetes CPGs) showed "similar" content for all regions, and 2 national recommendations (in Diabetes CPGs) showed "not similar" content for all regions. The remaining recommendations (Diabetes, Musculoskeletal disorders, and Stroke CPGs) had varying agreement with regional CPGs. CONCLUSIONS: There is a limited number of national recommendations for treatment within P&O. There was variation in the agreement of P&O-related recommendations in national and regional CPGs, which might lead to unequal care throughout the national healthcare system.

Wheelchair service provision education for healthcare professional students, healthcare personnel and educators across low- to high-resourced settings: a scoping review protocol.

PURPOSE: Appropriate wheelchair provision is necessary for addressing participation barriers experienced by individuals with mobility impairments. Health care professionals involved in the wheelchair service provision process require a specific set of skills and knowledge to enable wheelchair use that meets individual posture, mobility and daily living requirements. However, inconsistencies exist in academic programmes globally about providing comprehensive education and training programmes. The planned scoping review aims to review and synthesize the global literature on wheelchair service provision education for healthcare professional students, healthcare personnel and educators offered by universities, organizations and industries. METHODS: This scoping review will be guided by the Joanna Briggs Institute (JBI) methodological framework. Comprehensive literature searches will be conducted on various global electronic databases on health to seek out how wheelchair service provision education is organized, integrated, implemented and evaluated. Two independent reviewers will perform eligibility decisions and key data extractions. Data from selected studies will be extracted and analysed using conventional content analysis. Information related to wheelchair service provision education including curriculum development, content, teaching methods, evaluation and models of integration will be synthesized. IMPLICATIONS AND DISSEMINATION: The planned scoping review will be the first to examine all aspects of wheelchair service provision education across professionals, settings and countries. We anticipate that results will inform the content of a Wheelchair Educators' Package, and if appropriate, a follow-up systematic review. An article reporting the results of the scoping review will be submitted for publication to a scientific journal.Implications for RehabilitationA comprehensive examination of wheelchair service provision education could help develop strategies to address the unmet need for wheelchair services globally.Findings for this review will facilitate the planning and development of an evidence-based education package that could bridge the existing knowledge gaps related to safe and effective wheelchair service provision among health professionals involved.This review will also inform the potential barriers and enablers for effective integration and implementation of wheelchair service provision education worldwide.

Wheelchair service provision education for healthcare professional students, healthcare personnel and educators across low- to high-resourced settings: a scoping review.

PURPOSE: This review aimed to collate and summarize available research literature about wheelchair service provision education available to healthcare professional students, healthcare personnel and educators across low- to high-resourced settings. METHODS: The Joanna Briggs Institute methodological steps for scoping reviews were followed. Included studies were mainly sourced from Medline, Embase, CINAHL, Scopus, Academic Search Complete and ProQuest. Independent title, abstract and full-text screening with defined inclusion and exclusion criteria was performed. All screening and extraction were performed independently by two authors. A thematic approach was used to synthesize results. Data extracted from included studies were charted according to a template that we created. The study quality was also appraised. RESULTS: A total of 25 articles were included (11, 36% from high-income settings) with 12 (48%) observational studies and 13 (52%) experimental studies. The literature addressed three main topics: (1) assessing wheelchair service provision knowledge, (2) implementing training interventions using in-person, online and/or hybrid learning approaches and (3) describing current wheelchair service provision education globally. The most frequently reported training programs used were the Wheelchair Skills Program and the World Health Organization Wheelchair Service Training Package - Basic Level. CONCLUSION: Limited information has been published about the integration of wheelchair content into the curricula of professional rehabilitation programs. Efforts to build international partnerships, improve the quality and currency of training programs and build resources that can assist educators in the integration of wheelchair-related content into professional rehabilitation programs should be prioritized.Implications for RehabilitationThis is the first review that examined and synthesized the current state of wheelchair service provision education for rehabilitation students and personnel across low- to high-income countries.Findings from this review indicate that there is limited information about the integration of wheelchair-related content into professional rehabilitation programs.Efforts to build international partnerships, standardize wheelchair service provision content and evaluation and integrate training into professional rehabilitation programs worldwide should be prioritized.

Personalized Offloading Treatments for Healing Plantar Diabetic Foot Ulcers.

BACKGROUND: Non-removable knee-high devices are the gold-standard offloading treatments to heal plantar diabetic foot ulcers (DFUs). These devices are underused in practice for a variety of reasons. Recommending these devices for all patients, regardless of their circumstances and preferences influencing their ability to tolerate the devices, does not seem a fruitful approach. PURPOSE: The aim of this article is to explore the potential implications of a more personalized approach to offloading DFUs and suggest avenues for future research and development. METHODS: Non-removable knee-high devices effectively heal plantar DFUs by reducing plantar pressure and shear at the DFU, reducing weight-bearing activity and enforcing high adherence. We propose that future offloading devices should be developed that aim to optimize these mechanisms according to each individual's needs. We suggest three different approaches may be developed to achieve such personalized offloading treatment. First, we suggest modular devices, where different mechanical features (rocker-bottom sole, knee-high cast walls/struts, etc.) can be added or removed from the device to accommodate different patients' needs and the evolving needs of the patient throughout the treatment period. Second, advanced manufacturing techniques and novel materials could be used to personalize the design of their devices, thereby improving common hindrances to their use, such as devices being heavy, bulky, and hot. Third, sensors could be used to provide real-time feedback to patients and clinicians on plantar pressures, shear, weight-bearing activity, and adherence. CONCLUSIONS: By the use of these approaches, we could provide patients with personalized devices to optimize plantar tissue stress, thereby improving clinical outcomes.

Development and validation of a sensitive MEDLINE search strategy to identify literature relevant to limb prostheses.

BACKGROUND: Researchers and clinicians may find it challenging to identify relevant articles about limb prostheses in online databases. Searches may be improved by using standardized strategies, also known as filters or hedges. OBJECTIVES: To develop and validate a highly sensitive MEDLINE (EBSCOHost) search strategy for limb prostheses. STUDY DESIGN: Search strategy development/validation. METHODS: A gold standard (GS) list of peer-reviewed articles on the topic of limb prostheses was created using a relative recall method. This involved identifying and including relevant systematic reviews/meta-analyses and then adding articles that were included in the analysis section of these reviews. Possible terms for the search strategy were identified through brainstorming and exploration of medical subject headings in MEDLINE (MeSH) and standards from the International Organization for Standardization (ISO). Concepts were grouped using relevant Boolean operators (e.g. AND and OR) and database record search fields (i.e. MeSH terms, title, and abstract). Part of the GS was used to refine the search strategy and reduce the number of records retrieved in total. The remaining GS set was used to validate and calculate sensitivity of the search strategy. Performance of the search strategy was compared against searches using only relevant MeSH terms. RESULTS: After screening, the final GS totaled 853 records. The developed search strategy was highly sensitive (99.80%) and performed with higher relative recall than searches with relevant MeSH terms. CONCLUSIONS: This study provides a highly sensitive search strategy that can be used by clinicians and researchers when searching for relevant literature on limb prostheses in MEDLINE (EBSCOHost).

Development of a theoretical model for upright postural control in lower limb prosthesis users.

Methods used to assess quiet standing in unilateral prosthesis users often assume validity of an inverted pendulum model despite this being shown as invalid in some instances. The aim of the current study was to evaluate the validity of a proposed unilaterally-constrained pin-controller model in explaining postural control in unilateral prosthesis users. Prosthesis users were contrasted against the theoretical model as were able-bodied controls that stood on a platform which unilaterally constrained movement of the CoP. All participants completed bouts of quiet standing with eyes open, eyes closed and with feedback on inter-limb weight bearing asymmetry. Correlation coefficients were used to infer inverted pendulum behavior in both the anteroposterior and mediolateral directions and were derived from both kinematic (body attached markers) and kinetic (centre of pressure) experimental data. Larger, negative correlation coefficients reflected better model adherence, whilst low or no correlation reflected poorer model adherence. Inverted pendulum behavior derived from kinematic data, indicated coefficients of high magnitude in both mediolateral (all cases range 0.71-0.78) and anteroposterior (0.88-0.91) directions, irrespective of groups. Inverted pendulum behavior derived from kinetic data in the anteroposterior direction indicated validity of the model with large negative coefficients associated with the unconstrained/intact limbs (prosthesis users: - 0.45 to - 0.65, control group: - 0.43 to - 0.72), small coefficients in constrained/prosthetic limbs (prosthesis users: - 0.02 to 0.07, control group: 0.13-0.26) and large negative coefficients in combined conditions (prosthesis users: - 0.36 to - 0.56, control group: - 0.71 to - 0.82). For the mediolateral direction, coefficients were negligible for individual limbs (0.03-0.17) and moderate to large negative correlations, irrespective of group (- 0.31 to - 0.73). Data suggested both prosthesis users' and able-bodied individuals' postural control conforms well to that predicted by a unilaterally-constrained pin-controller model, which has implications for the fundamental control of posture in transtibial prosthesis users.

Comment on van Netten, et al: Definitions and criteria for diabetic foot disease.

OBJECTIVE: The International Working Group on the Diabetic Foot (IWGDF) recently published updated definitions for the diabetic foot field. However, the suggested definitions of lower limb amputations differ from the definitions of the International Organization of Standardization (ISO), which may create problems when implementing the definitions. This paper compares and discusses the amputation definitions of IWGDF and ISO. RESULTS: Despite many similarities, the IWGDF and ISO systems have some important differences. First, the IWGDF uses the term "minor amputation" which is value-laden, arbitrary and has been defined in several different ways in the literature. Second, the IWGDF system lacks descriptions of amputations distal or through the ankle, which may increase the risk for misclassification. Third, hip disarticulations and transpelvic amputations are not included in the IWGDF system. CONCLUSION: It is suggested that future updates of the IWGDF definitions should be aligned with those of ISO, to meet the goal of global consensus on terminology related to lower limb amputation.

Transitioning to a microprocessor-controlled prosthetic knee: Executive functioning during single and dual-task gait.

BACKGROUND: Walking with a prosthesis requires substantial concentration on behalf of the user and places increased demands on executive functions. Little is known of the effects that prosthetic knee joint prescription may have on executive functioning. OBJECTIVES: Evaluate executive functioning in trans-femoral prosthesis users during single and dual-task walking, before and after they transition to a Microprocessor-controlled prosthetic knee unit. STUDY DESIGN: Multiple case-study design. METHODS: Single and dual task gait was evaluated while recording cortical brain activity. Testing occasion 1 occurred prior to participants receiving their microprocessor-controlled prosthetic knee, while testing occasion 2 was conducted a minimum of 8 months after they had been fitted with an microprocessor-controlled prosthetic knee. RESULTS: During single-task level walking and walking while performing a dual-task key finding test, executive functions, measured as the relative haemodynamic response in the frontal cortex, reduced for most, but not all participants after transitioning to an Microprocessor-controlled prosthetic knee. There did not appear to be any difference when participants performed a trail walk test. CONCLUSIONS: Results suggest Microprocessor-controlled prosthetic knee prosthetic knees may have a positive effect on executive functioning for some individuals who have undergone a lower-limb amputation. A larger, longitudinal study with careful control of extraneous variables (e.g. age, training) is needed to confirm results and determine causality. CLINICAL RELEVANCE: This article provides some evidence to suggest that prosthetic prescription may influence executive functioning and that microprocessor-controlled prosthetic knee mechanisms may reduce cognitive effort when walking.

Effects of knee orthoses on kinesthetic awareness and balance in healthy individuals.

INTRODUCTION: Conflicting evidence exists regarding the effects of knee orthoses on proprioception. One belief is that pressure applied by orthoses heightens kinesthetic awareness and that this affects balance. This study aimed to investigate the effects of two different orthosis designs on kinesthetic awareness and balance in healthy individuals. METHODS: Twenty individuals (13 women) participated in this case series study. Each was tested wearing 1/no orthosis, 2/soft elastic orthosis and 3/non-elastic jointed orthosis. Pressure under orthoses was recorded. Kinesthetic awareness was investigated by testing joint position sense and threshold to detection of passive motion. Balance was tested using a modified sensory organization test. RESULTS: Non-elastic jointed orthoses applied the greatest pressure to the knee. With non-elastic jointed orthoses, threshold to detection of passive motion was significantly poorer for pooled results (p = 0.02) and when the start position of the knee was 70° (mean threshold = 0.6°, 0.6°, 0.7° for no-orthosis, elastic and jointed-orthoses; p = 0.03). No major differences were observed in JPS or balance and correlation between proprioception and balance was poor. CONCLUSIONS: There may be a limit to the amount of pressure that should be applied to the knee joint by an orthosis. Exceeding this limit may compromise kinesthetic awareness.

Adaptations from the prosthetic and intact limb during standing on a sway-referenced support surface for transtibial prosthesis users.

Purpose: To investigate the bilateral postural adaptations as a result of standing on an increasingly unstable sway-referenced support surface with both the intact and prosthetic limb for transtibial prosthesis users (TPUs). Method: TPUs (n = 14) and matched controls (n = 14) stood quietly in multiple foot placement conditions (intact foot, prosthetic foot and both feet) on a sway-referenced support surface which matched surface rotation to the movement of the centre of pressure (CoP). Force and motion data were collected and used to analyse CoP mean position, displacement integral and force components under intact and prosthetic limbs. Results: Significant differences were found between prosthesis users and controls in CoP mean position in anteroposterior (1.5 (95% CI, 1.2-1.8) cm) and mediolateral directions (3.1 (95% CI, 0.5-5.7) cm. CoP displacement integrals were significantly different greater for prosthesis user group in the anteroposterior direction. Force components differences were found in all planes (anteroposterior: 0.6 (95% CI, 0.4-0.8 N); mediolateral: 0.1 (95% CI, 0.0-0.2 N & 0.3 (95% CI, 0.2-0.4) N, inferosuperior: 2.2 (95% CI, 1.4-3.0) N). Conclusions: TPUs have bilateral static and dynamic postural adaptations when standing on a sway-referenced support surface that is different to controls, and between prosthetic and intact sides. Results further support evidence highlighting importance of the intact limb in maintenance of postural control in prosthesis users. Differences indicate clinical treatment should be directed towards improving outcomes on the intact side. Implications for rehabilitation Prosthesis users have bilateral adaptations when standing on a sway referenced support surface These adaptations are different to controls, and between prosthetic and intact sides. The intact limb is the major contributor to maintenance of postural control in prosthesis users. Clinical treatment should account for this when interventions are designed.

Do Predictive Relationships Exist Between Postural Control and Falls Efficacy in Unilateral Transtibial Prosthesis Users?

OBJECTIVE: To assess whether variables from a postural control test relate to and predict falls efficacy in prosthesis users. DESIGN: Twelve-month within- and between-participants repeated measures design. Participants performed the limits of stability (LOS) test protocol at study baseline and at 6-month follow-up. Participants also completed the Falls Efficacy Scale-International (FES-I) questionnaire, reflecting the fear of falling, and reported the number of falls monthly between study baseline and 6-month follow-up, and additionally at 9- and 12-month follow-ups. SETTING: University biomechanics laboratories. PARTICIPANTS: Participants (N=24) included a group of active unilateral transtibial prosthesis users of primarily traumatic etiology (n=12) with at least 1 year of prosthetic experience and age- and sex-matched control participants (n=12). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Postural control variables derived from center of pressure data obtained during the LOS test, which was performed on and reported by the Neurocom Pro Balance Master, namely reaction time, movement velocity (MVL), endpoint excursion (EPE), maximum excursion (MXE), and directional control (DCL). Number of falls and total FES-I scores. RESULTS: During the study period, the prosthesis users group had higher FES-I scores (U=33.5, P=.02), but experienced a similar number of falls, compared to the control group. Increased FES-I scores were associated with decreased EPE (r= -0.73, P=.02), MXE (r= -0.83, P<.01) and MVL (r= -0.7, P=.03) in the prosthesis users group, and DCL (r= -0.82, P<.01) in the control group, all in the backward direction. CONCLUSIONS: Study baseline measures of postural control, in the backward direction only, are related to and potentially predictive of subsequent 6-month FES-I scores in relatively mobile and experienced prosthesis users.

Development of a limits of stability protocol for use in transtibial prosthesis users: Learning effects and reliability of outcome variables.

The aims of this study were to empirically quantify reliability and learning effects of a Limits of Stability protocol for transtibial prosthesis users. Outcome variables from center of pressure and center of mass were tested on: 1) multiple test repetitions within a single test occasion; and 2) between multiple test occasions. Trantibial prosthesis users (n=7) and matched controls (n=7) executed five trials of the Limits of Stability protocol on two occasions per day, on two consecutive days. Inter-trial learning effects and reliability of outcomes extracted via center of mass and center of pressure were evaluated utilizing standard biomechanics laboratory equipment. Reliability was good to excellent except the reaction time variable which was poor (Pooled 95%CI of ICC=0.248-0.484). An inter-trial learning effect was present in directional control for prosthesis users when the first trial was included in analysis (center of mass: 95%CI of r=0.065-0.239; center of pressure: 95%CI of r=0.076-0.249). The use of standard biomechanics lab equipment can produce reliable results for the Limits of Stability protocol. Researchers should be aware of low reliability of reaction time variable in the protocol assessed and should execute at least one practice trial prior to that which is used in subsequent analysis.

The validity of forceplate data as a measure of rapid and targeted volitional movements of the centre of mass in transtibial prosthesis users.

PURPOSE: To validate outcome variables from the limits of stability protocol that are derived from the center of pressure with those same variables derived from the center of mass during rapid, volitional responses in transtibial prosthesis users. METHOD: Prosthesis users (n = 21) and matched controls (n = 21) executed movements while force and motion data were collected. Correlation coefficients were used to investigate relationships between center of pressure and center of mass for: x/y coordinates positions, limits of stability outcome variables and muscular reaction times. RESULTS: Significant differences were seen in correlation between x/y coordinate positions toward the intact limb (mean effect size of differences: r = .38). Limits of stability variables were positively correlated (reaction time and maximum excursion range rs: .585-.846; directional control and mean velocity range rs: .307-.472). Muscular reaction times correlated weakly with those from center of pressure (mean rs prosthesis users: .186 and controls: .101). CONCLUSIONS: Forceplate measures are valid in describing rapid, volitional movements in unilateral transtibial prosthesis users. Limits of stability outcomes extracted from center of pressure and center of mass are highly correlated, but can be sensitive to direction. Muscular reaction time correlates very little with reaction times extracted from the other variables. Implications for rehabilitation Rehabilitation programs utilizing limits of stability are valid measures of postural control in transtibial prosthesis users. Clinicians interpreting the outcomes from limits of stability need to be aware of their varying validity. Muscular reaction times correlate weakly with other measures of reaction time, highlighting the complexity of rapidly coordinating volitional movements in prosthesis users.

Validation of the Inverted Pendulum Model in standing for transtibial prosthesis users.

BACKGROUND: Often in balance assessment variables associated with the center of pressure are used to draw conclusions about an individual's balance. Validity of these conclusions rests upon assumptions that movement of the center of pressure is inter-dependent on movement of the center of mass. This dependency is mechanical and is referred to as the Inverted Pendulum Model. The following study aimed to validate this model both kinematically and kinetically, in transtibial prosthesis users and a control group. METHODS: Prosthesis users (n=6) and matched control participants (n=6) stood quietly while force and motion data were collected under three conditions (eyes-open, eyes-closed, and weight-bearing feedback). Correlation coefficients were used to investigate the relationships between height and excursion of markers and center of masses in mediolateral/anteroposterior-directions, difference between center of pressure and center of mass and the center of mass acceleration in mediolateral/anteroposterior directions, magnitude of mediolateral/anteroposterior-component forces and center of mass acceleration, angular position of ankle and excursion in mediolateral/anteroposterior-directions, and integrated force signals. FINDINGS: Results indicate kinematic validity of similar magnitudes (mean (SD) marker-displacement) between prosthesis users and control group for mediolateral- (r=0.77 (0.17); 0.74 (0.19)) and anteroposterior-directions (r=0.88 (0.18); 0.88 (0.19)). Correlation between difference of center of pressure and center of mass and the center of mass acceleration was negligible on the prosthetic side (r = 0.08 (0.06)) vs. control group (r=-0.51(0.13)). INTERPRETATION: Results indicate kinematic validity of the Inverted Pendulum Model in transtibial prosthesis users but kinetic validity is questionable, particularly on the side with a prosthesis.