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.

Returning to work after dysvascular lower limb amputation-A novel multivariate approach to examine relative contributions of biopsychosocial predictors.

BACKGROUND: Returning to work is a key outcome of rehabilitation and social re-integration after lower limb amputation. It is important to understand what biopsychosocial factors contribute to returning to work after dysvascular amputation. OBJECTIVE: Examining relative contributions of functional and contextual predictors of returning to work in participants with lower limb amputation due to diabetes and other dysvascular diseases. STUDY DESIGN: Cross-sectional. METHODS: Return-to-work outcome, biopsychosocial characteristics including physical functioning, self-efficacy & perceived ability, and socioeconomical support data were collected from a purposive sample (n = 57) in a multi-state collaborative research network. Grouped Weighted Quantile Sum model analysis was conducted to evaluate relative contributions of biopsychosocial predictors. RESULTS: Less than 30% of the participants returned to work after their amputation. Physical functioning (odds ratio = 10.19; 95% CI 2.46-72.74) was the most important predictor group. Working before amputation, prosthetic mobility, and access to rehabilitation care were also identified as key factors associated with returning to work. CONCLUSIONS: Fewer than 1 in 3 participants with dysvascular amputation returned to work, despite an average age of only 54 years at the time of amputation. Physical functioning was shown to be the most important predictor, while socioeconomic factors such as a lack of access to care also contribute to not returning to work after dysvascular amputation.

Association of Race, Ethnicity, and Gender to Disparities in Functional Recovery and Social Health After Major Lower Limb Amputation: A Cross-sectional Pilot Study.

OBJECTIVE: To assess if evidence of disparities exists in functional recovery and social health post-lower limb amputation. DESIGN: Race-ethnicity, gender, and income-based group comparisons of functioning and social health in a convenience sample of lower limb prosthetic users. SETTING: Prosthetic clinics in 4 states. PARTICIPANTS: A geographically diverse cohort of 56 English and Spanish speaking community-dwelling individuals with dysvascular lower limb amputation, between 18-80 years old. INTERVENTIONS: None. MAIN OUTCOMES MEASURES: Primary outcomes included 2 physical performance measures, the Timed Up and Go test and 2-minute walk test, and thirdly, the Prosthetic Limb Users Survey of Mobility. The PROMIS Ability to Participate in Social Roles and Activities survey measured social health. RESULTS: Of the study participants, 45% identified as persons of color, and 39% were women (mean ± SD age, 61.6 (9.8) years). People identifying as non-Hispanic White men exhibited better physical performance than men of color, White women, and women of color by -7.86 (95% CI, -16.26 to 0.53, P=.07), -10.34 (95% CI, -19.23 to -1.45, P=.02), and -11.63 (95% CI, -21.61 to -1.66, P=.02) seconds, respectively, on the TUG, and by 22.6 (95% CI, -2.31 to 47.50, P=.09), 38.92 (95% CI, 12.53 to 65.30, P<.01), 47.53 (95% CI, 17.93 to 77.13, P<.01) meters, respectively, on the 2-minute walk test. Income level explained 14% and 11% of the variance in perceived mobility and social health measures, respectively. CONCLUSIONS: Study results suggest that sociodemographic factors of race-ethnicity, gender, and income level are associated with functioning and social health post-lower limb amputation. The clinical effect of this new knowledge lies in what it offers to health care practitioners who treat this patient population, in recognizing potential barriers to optimal recovery and quality of life. More work is required to assess lived experiences after amputation and provide better understanding of amputation-related health disparities.

Description, reliability and utility of a ground-reaction-force triggered protocol for precise delivery of unilateral trip-like perturbations during gait.

Tripping is a common cause of falls and a focus of many biomechanical investigations. Concerns regarding the precision of delivery of simulated-fall protocols reside in the current biomechanical methodology literature. This study aimed to develop a treadmill-based protocol that generated unanticipated trip-like perturbations during walking with high timing precision. The protocol utilized a side-by-side split-belt instrumented treadmill. Programmed treadmill belt acceleration profiles (two levels of perturbation magnitude) were triggered unilaterally at the instant the tripped leg bore 20% of the body weight. Test-retest reliability of fall responses was examined in 10 participants. Utility was examined as to whether the protocol could differentiate the fall recovery responses and likelihood of falls, estimated using peak trunk flexion angle after perturbation, between young and middle-aged adults (n = 10 per group). Results showed that the perturbations could be precisely and consistently delivered during early stance phases (10-45 milliseconds after initial contact). The protocol elicited excellent reliability of responses in both perturbation magnitudes (ICC = 0.944 and 0.911). Middle-aged adults exhibited significantly greater peak trunk flexion than young adults (p = 0.035), indicating that the current protocol can be utilized in differentiating individuals with different levels of fall risks. The main limitation of the protocol is that perturbations are delivered in stance rather swing phase. This protocol addressed some issues discussed in previous "simulated fall" protocols and may be useful for future fall research and subsequent clinical interventions.

Comparison of clinical and biomechanical characteristics between individuals with lower limb amputation with and without lower back pain: A systematic review and meta-analysis.

BACKGROUND: Lower back pain is a debilitating condition common to individuals with lower limb amputation. It is unclear what risk factors contribute to the development of back pain. This study systematically reviewed and analyzed the available evidence regarding the clinical and biomechanical differences between individuals with amputation, with and without lower back pain. METHODS: A literature search was conducted in PubMed, Web of Science, Scopus, and CINAHL databases in November 2020 and repeated in June 2021 and June 2022. Studies were included if they reported comparisons of demographic, anthropometric, biomechanical, and other clinical variables between participants with and without LBP. Study quality and potential for reporting bias were assessed. Meta-analyses were conducted to compare the two groups. FINDINGS: Thirteen studies were included, with aggregated data from 436 participants (239 with LBP; 197 pain free). The median reporting quality score was 37.5%. The included studies enrolled participants who were predominantly male (mean = 91.4%, range = 77.8-100%) and with trauma-related amputation. Meta-analyses showed that individuals with LBP exhibited moderate (3.4 out of 10) but significantly greater pain than those without LBP. We found no between-group differences in age, height, weight, BMI, and time since amputation (p = 0.121-0.682). No significant differences in trunk/pelvic kinematics during gait were detected (p = 0.07-0.446) between the groups. INTERPRETATION: Demographic, anthropometric, biomechanical, and simple clinical outcome variables may be insufficient for differentiating the risk of developing back pain after amputation. Investigators should be aware of the existing gender bias in sampling and methodological limitations, as well as to consider incorporating psychosocial measures when studying LBP in this clinical population.

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.

Patient Experience and Perceived Benefits of Physical Therapy after Lower Limb Amputation in Middle-Aged and Older Adults.

The current study aimed to investigate the long-term effects of receiving post-amputation physical therapy (PT) on individuals' self-reported functional outcomes and quality of life in middle-aged to older adults with lower limb amputation (LLA). Further, we qualitatively explored the patients' perception and experience of PT post-amputation. We assessed participants' functional outcomes using Short-Form Health Survey, Prosthetic Evaluation Questionnaire-Physical Mobility portion, and Fear of Falling Avoidance Behavior Questionnaire. Furthermore, participants' experience and perception to PT were assessed through in-person interviews guided by the custom Amputation Patient Perception Survey. Functional outcome scores were compared between participants who have (Yes-PT) and have not (No-PT) received PT following their amputations, controlling for age. Perception to PT was qualitatively analyzed. Out of the 70 participants, 56 had received PT (80%) following amputation. Functional outcome scores were not significantly different between Yes-PT and No-PT groups. Among participants in the Yes-PT group, 84% expressed overall positive perception toward their post-amputation PT care. Main positive and negative perceptions were related to outcome/benefits and unfulfilled needs/lack of benefits, respectively. Participants with LLA generally expressed a positive perception of PT. However, no significant long-term benefits were found. We recommend goal-directed intervention with patient engagement to improve care experience.

Acute Handgrip Fatigue and Forearm Girth in Recreational Sport Rock Climbers.

Indoor sport rock climbing has been increasing in popularity both recreationally and competitively. Despite this increase in popularity, the physiological responses to sport climbing as an exercise to specific muscle groups are not well defined. The purpose of this study was to quantify the change in handgrip strength over a 30-minute bout of continuous climbing, specifically in intermediate-level sport climbers. Ten intermediate rock climbers (age = 27 ± 2 years; climbing experience: 7.3 ± 1.5 years) completed baseline handgrip strength and forearm girth measurements. Each participant ascended one of two 5.9 difficulty routes as many times as possible in 30 minutes. After each ascent, heart rate was obtained, and handgrip strength and forearm girth were measured. Data were analyzed using repeated-measures ANOVA with significance set at α < 0.05. Dominant arm handgrip strength decreased by 22%, and non-dominant handgrip strength reduced by 23%. Dominant and non-dominant forearm girth increased by 4.5% and 4.4%, respectively. Weak but significant negative correlations were observed between handgrip strength and forearm girth in dominant (r = -0.311, p = 0.001) and non-dominant limbs (r = -.491, p = 0.001). These results indicate a relationship between increased forearm girth and decreases in muscular strength. Since handgrip strength decreases substantially during a 30-min climb in intermediate rock climbers, this population would be advised to carefully monitor recovery time between bouts.

Direction of attentional focus in prosthetic training: Current practice and potential for improving motor learning in individuals with lower limb loss.

OBJECTIVE: Adopting an external focus of attention has been shown to benefit motor performance and learning. However, the potential of optimizing attentional focus for improving prosthetic motor skills in lower limb prosthesis (LLP) users has not been examined. In this study, we investigated the frequency and direction of attentional focus embedded in the verbal instructions in a clinical prosthetic training setting. METHODS: Twenty-one adult LLP users (8 female, 13 male; 85% at K3 level; mean age = 50.5) were recruited from prosthetic clinics in the Southern Nevada region. Verbal interactions between LLP users and their prosthetists (mean experience = 10 years, range = 4-21 years) during prosthetic training were recorded. Recordings were analyzed to categorize the direction of attentional focus embedded in the instructional and feedback statements as internal, external, mixed, or unfocused. We also explored whether LLP users' age, time since amputation, and perceived mobility were associated with the proportion of attentional focus statements they received. RESULTS: We recorded a total of 20 training sessions, yielding 904 statements of instruction from 338 minutes of training. Overall, one verbal interaction occurred every 22.1 seconds. Among the statements, 64% were internal, 9% external, 3% mixed, and 25% unfocused. Regression analysis revealed that female, older, and higher functioning LLP users were significantly more likely to receive internally-focused instructions (p = 0.006, 0.035, and 0.024, respectively). CONCLUSIONS: Our results demonstrated that verbal instructions and feedback are frequently provided to LLP users during prosthetic training. Most verbal interactions are focused internally on the LLP users' body movements and not externally on the movement effects. IMPACT STATEMENT: While more research is needed to explore how motor learning principles may be applied to improve LLP user outcomes, clinicians should consider adopting the best available scientific evidence during treatment. Overreliance on internally-focused instructions as observed in the current study may hinder prosthetic skill learning.

Patient engagement in cosmetic designing of prostheses: current practice and potential outcome benefits.

BACKGROUND: Making a prosthesis for an individual with limb loss is a highly personalized process. A currently unexplored area is whether there are tangible benefits in greater patient engagement during the cosmetic designing of their prostheses. We examined the current clinical practice of engaging patients in prosthetic cosmetic designing and identified factors associated with patient outcomes. METHODS: One hundred and four prosthetists and 28 prosthesis users were surveyed in this cross-sectional study. The questionnaires covered aspects of prosthetic prescription and fabrication, users' perceived level of engagement, and self-reported outcomes. Regression analyses were used to examine the associations between patients' perceived levels of engagement during the design process, satisfaction, and other outcomes. RESULTS: Seventy-five percent of the prosthesis users reported being offered at least one cosmetic option during the making of their prostheses, which corroborated with 82.7% of the prosthetists reporting that they typically engage their patients in this aspect of their practices. Patients who were offered at least one cosmetic design option reported significantly greater satisfaction ( P = 0.027) than those who were not offered such an option. Patients' level of satisfaction regarding the look of their prostheses was significantly correlated with their perception that their prostheses empower them in daily activities (r = 0.415, P = 0.028). CONCLUSION: Engaging patients in the cosmetic designing of their prostheses is a widely accepted practice. Patients who are more satisfied with the look of their prostheses perceived higher levels of empowerment. Prosthetic practitioners should consider the potential outcome benefits of higher level engagement for users of prosthetic devices.

Do people with low back pain walk differently? A systematic review and meta-analysis.

BACKGROUND: The biomechanics of the trunk and lower limbs during walking and running gait are frequently assessed in individuals with low back pain (LBP). Despite substantial research, it is still unclear whether consistent and generalizable changes in walking or running gait occur in association with LBP. The purpose of this systematic review was to identify whether there are differences in biomechanics during walking and running gait in individuals with acute and persistent LBP compared with back-healthy controls. METHODS: A search was conducted in PubMed, CINAHL, SPORTDiscus, and PsycINFO in June 2019 and was repeated in December 2020. Studies were included if they reported biomechanical characteristics of individuals with and without LBP during steady-state or perturbed walking and running. Biomechanical data included spatiotemporal, kinematic, kinetic, and electromyography variables. The reporting quality and potential for bias of each study was assessed. Data were pooled where possible to compare the standardized mean differences (SMD) between back pain and back-healthy control groups. RESULTS: Ninety-seven studies were included and reviewed. Two studies investigated acute pain and the rest investigated persistent pain. Nine studies investigated running gait. Of the studies, 20% had high reporting quality/low risk of bias. In comparison with back-healthy controls, individuals with persistent LBP walked slower (SMD = -0.59, 95% confidence interval (95%CI): -0.77 to -0.42)) and with shorter stride length (SMD = -0.38, 95%CI: -0.60 to -0.16). There were no differences in the amplitude of motion in the thoracic or lumbar spine, pelvis, or hips in individuals with LBP. During walking, coordination of motion between the thorax and the lumbar spine/pelvis was significantly more in-phase in the persistent LBP groups (SMD = -0.60, 95%CI: -0.90 to -0.30), and individuals with persistent LBP exhibited greater amplitude of activation in the paraspinal muscles (SMD = 0.52, 95%CI: 0.23-0.80). There were no consistent differences in running biomechanics between groups. CONCLUSION: There is moderate-to-strong evidence that individuals with persistent LBP demonstrate differences in walking gait compared to back-healthy controls.

Fear of falling avoidance behavior affects the inter-relationship between vision impairment and diminished mobility in community-dwelling older adults.

BACKGROUND: Age-related decline in vision may contribute to the development of fear of falling (FOF) behavior and reduced mobility, which are related to increased fall risk in older adults. PURPOSE: To investigate the inter-relationship between vision impairment, physical mobility performance, and FOF behavior in community-dwelling older adults. METHODS: A total of 400 participants from community centers (267 females; age = 74.8 (6.4), range = 65-97 years) participated in this cross-sectional study. Presence of age-related eye diseases (e.g. macular degeneration, cataracts, glaucoma, and retinopathy) and visual acuity (VA) was assessed. Physical mobility and FOF avoidance behavior were assessed using the Timed Up-and-Go (TUG) test and the Fear of Falling Avoidance Behavior Questionnaire (FFABQ). The inter-relationships between parameters were analyzed using mediation model analysis. RESULTS: Significant decreases in mobility performance were observed in those with eye disease (eye disease = 9.56 [5.2] sec, no eye disease = 8.54 [2.75] sec; p = .037) and FOF avoidance behavior (avoiders = 12.87 [6.04] sec, non-avoiders = 8.51 [3.56] sec; p < .001). Furthermore, FOF behavior was found to significantly influence the inter-relationship between presence of eye disease and TUG performance (p = .004). VA alone had no significant effect on mobility (p = .69). CONCLUSION: The presence of eye disease and the associated FOF behavior was related to decreased mobility and potentially increased fall risk. We recommend clinicians to inquire about the presence of eye disease and FOF behavior to identify risk factors related to falls in older adults.

Post-acute physical therapy for a patient with critical illness associated with COVID-19: A case report.

BACKGROUND: The COVID-19 pandemic is expected to bring a surge of survivors in need of post-acute rehabilitation. Preliminary research and clinical guidelines suggest patients recovering from critical illness associated with COVID-19 will present compromised function similar to acute respiratory distress syndrome (ARDS) and ICU-acquired weakness (ICUAW). However, information regarding physical therapy and progressions of physiological and functional outcomes is currently limited. This case report describes the course of recovery of a patient without significant preexisting medical conditions. CASE DESCRIPTION: The patient RW (male, age 56) tested positive for COVID-19, and was admitted to ICU for 29 days. After weaning off mechanical ventilation after 2 months of hospitalization, he was transferred to our post-acute rehabilitation facility to recover from the residual effects. Physical therapy evaluation showed that while the patient was cognitively alert, he exhibited impaired general strength and activity intolerance due to severe exertional dyspnea. The patient received physical therapy aimed at improving his functional capacity. During his 16-day stay, the patient was able to significantly improve his capacities (i.e. 600% increase in 30-second chair stand test, 69.5% improvement in walking distance in 6-minute walk test, and 132.4% longer time to exhaustion during level ground ambulation). Dyspnea remained the main factor that limited his activities. DISCUSSION: This case demonstrated that post-acute physical therapy appeared to be effective and safe in improving function after critical illness due to COVID-19 for this patient. Physical therapists are encouraged to closely monitor respiratory parameters such as heart rate, oxygen saturation, and levels of dyspnea during treatment for patient response and decisions regarding activity progression.

Maximal force production requires OPTIMAL conditions.

The OPTIMAL theory of motor learning identifies several motivational and attentional factors that draw out latent motor performance capabilities. One implication of the OPTIMAL theory of motor learning (Wulf & Lewthwaite, 2016) is that standardized motor performance assessments likely do not reflect maximal capabilities unless they are "optimized" with appropriate testing conditions. The present study examined the effects of three key motivational (enhanced expectancies, EE, and autonomy support, AS) and attentional (external focus, EF) variables in the OPTIMAL theory on maximum force production. In Experiment 1, a handgrip strength task was used. EE, AS, and EF were implemented, in a counterbalanced order, on consecutive trial blocks in an optimized group. A control group performed all blocks under neutral conditions. While there were no group differences on Block 1 (baseline), the optimized group outperformed the control group on all other blocks. In Experiment 2, participants performed two one-repetition maximum (1-RM) squat lift tests, separated by one week. Two groups, an optimized group and control group, had similar 1-RM values on the first test performed under neutral conditions. However, on the second test, a group performing under optimized conditions (EE, AS, EF) showed an increase in 1-RM, while there was no change from the first to the second test for a control group. We argue that standard test conditions may not produce true maximal performance. The findings corroborate the importance of key factors in the OPTIMAL theory and should be applied to ensure accurate strength performance assessment.

Step Count Reliability and Validity of Five Wearable Technology Devices While Walking and Jogging in both a Free Motion Setting and on a Treadmill.

Wearable technology devices are used by millions of people who use daily step counts to promote healthy lifestyles. However, the accuracy of many of these devices has not been determined. The purpose was to determine reliability and validity of the Samsung Gear 2, FitBit Surge, Polar A360, Garmin Vivosmart HR+, and the Leaf Health Tracker when walking and jogging in free motion and treadmill conditions. Forty volunteers completed walking and jogging free motion and treadmill protocols of 5-minute intervals. The devices were worn simultaneously in randomized configurations. The mean of two manual steps counters was used as the criterion measure. Test-retest reliability was determined via Intraclass Correlation Coefficient (ICC). Validity was determined via a combination of Pearson's Correlation Coefficient, mean absolute percent error (MAPE: free motion ≤ 10.0%, treadmill ≤ 5.00%), and Bland-Altman analysis (device bias and limits of agreement). Significance was set at p < 0.05. The Samsung Gear 2 was deemed to be both reliable and valid for the jogging conditions, but not walking. The Fitbit Surge was reliable and valid for all conditions except for treadmill walking (deemed reliable, ICC = 0.76; but not valid). The Polar A360 was found to be reliable for one condition (treadmill jog ICC = 0.78), but not valid for any condition. The Garmin Vivosmart HR+ and Leaf Health Tracker were found to be both reliable and valid for all situations. While each device returned some level of consistency and accuracy during either free motion or treadmill exercises, the Garmin Vivosmart HR+ and the Leaf Health Tracker were deemed to be reliable and valid for all conditions tested.

Financial difficulty in community-dwelling persons with lower limb loss is associated with reduced self-perceived health and wellbeing.

BACKGROUND: Socioeconomic status has been shown to be an important factor in the disparate prevalence and selected treatment of limb loss, but how personal financial difficulty affects patients' health outcomes is currently unclear. OBJECTIVE: Examining how presence and experience of personal financial difficulty affects perceived health and wellbeing in individuals with lower limb loss. STUDY DESIGN: Cross-sectional study. METHODS: A total of 90 participants (68 males, mean age 58.7 ± 16.7 years) were recruited from local physical therapy and prosthetic and orthotic clinics, rehabilitation hospitals, and a regional amputee patient support group. All participants were community-dwelling, non-military adults with amputation involving at least one major lower limb joint. Participants were interviewed, and each completed a survey that included basic demographic/medical information, self-reported health and wellbeing (Short-Form Health Survey, SF-36v2), and a question to determine their financial situation after limb loss. Multiple regression analyses were used to examine the effect of financial difficulty on the eight subscales of SF-36v2 while accounting for age, gender, and amputation level. RESULTS: Experiencing financial difficulty significantly and negatively affected Role-Physical and Role-Emotional subscale scores (p < 0.01 and p = 0.02, respectively). Individuals with financial difficulty scored approximately 60% lower in these two specific subscales. CONCLUSION: Experiencing financial difficulty is a significant predictor for diminished work or daily activity participation due to physical and emotional stresses. Clinicians and health policy makers need to understand how socioeconomic factors may prevent individuals with lower limb loss from achieving higher levels of functional recovery and community re-integration after amputation. CLINICAL RELEVANCE: Our findings showed that presence or experience of financial difficulty was significantly associated with diminished community re-integration in community-dwelling, non-military adults with lower limb loss. It affects both physical and emotional aspects of wellbeing. Clinicians should be aware how socioeconomic factors may affect social re-integration after amputation.

Current and Emerging Trends in the Management of Fall Risk in People with Lower Limb Amputation.

PURPOSE OF REVIEW: People living with lower limb amputation are at an increased risk of falling compared with the healthy geriatric population. Factors of increased age and increased number of comorbidities could compound the already increased risk. The purpose of this article is to highlight recent research associated with fall risk in amputees and provide the reader with evidence to help guide clinical interventions. RECENT FINDINGS: Though research on the topic of falls in people with amputation is becoming more common, there is still a dearth of evidence regarding what contributes to increased fall risk and how to address it in this population. There are recent studies that have examined therapy and prosthetic interventions that could mitigate fall risk in people with amputation, yet there is not enough evidence to develop a consensus on the topic. More research is required to determine what contributes to increased fall rates in people with amputation, and what detriments to an amputee's function or psyche may result after incurring a fall. SUMMARY: Borrowing from what is known about geriatric fall risk and combining the information with novel and existing approaches to fall mitigation in amputees can offer clinicians the opportunity to develop evidence-based programs to address fall risk in their patients with lower limb amputation.

Individuals With Recurrent Low Back Pain Exhibit Significant Changes in Paraspinal Muscle Strength After Intramuscular Fine Wire Electrode Insertion.

OBJECTIVE: To examine how insertion and presence of intramuscular fine-wire electromyography electrodes (IFWEs) in lumbar multifidus affect paraspinal muscle strength, endurance, and activation in persons with and without recurrent lower back pain (RLBP) during activities that require high levels of muscle contraction. DESIGN: Case-control with randomization of conditions. SETTING: Clinical research laboratory. PARTICIPANTS: Forty participants age 18 to 40 years were recruited (18 female; mean age = 25.5 years); 20 with a history of RLBP were compared to a matching control group of 20 without RLBP. INTERVENTIONS: Each participant was tested under three conditions over three sessions. On Session 1, the baseline condition, we assessed muscle performance without IFWE insertion. On Sessions 2 and 3, participants were randomly alternated between two experimental conditions: (1) wire-in, in which the IFWE was inserted and remained within the muscle during testing; and (2) wire-out, in which the IFWE was inserted and immediately removed. MAIN OUTCOME MEASUREMENTS: Lumbar spinal extensor peak strength, endurance, and normalized electromyography (EMG) amplitude during the endurance test. RESULTS: Individuals with RLBP showed a significant decrease in peak strength during conditions that involved IFWE insertion and tend to experience more pain during muscle testing. Both groups exhibited similar levels of performance and muscle activation during the endurance test. CONCLUSION: Our findings indicate that individuals with RLBP exhibited reduced lumbar extensor strength in response to IFWE insertion to the deep paraspinal muscles. This behavior is different from those without RLBP. Researchers should carefully consider the use of IFWE in individuals with RLBP during high exertion activities.

Patellar tendon morphology in trans-tibial amputees utilizing a prosthesis with a patellar-tendon-bearing feature.

A patellar-tendon-bearing (PTB) bar is a common design feature used in the socket of trans-tibial prostheses to place load on the pressure-tolerant tissue. As the patellar tendon in the residual limb is subjected to the perpendicular compressive force not commonly experienced in normal tendons, it is possible for tendon degeneration to occur over time. The purpose of this study was to compare patellar tendon morphology and neovascularity between the residual and intact limbs in trans-tibial amputees and healthy controls. Fifteen unilateral trans-tibial amputees who utilized a prosthesis with a PTB feature and 15 age- and sex- matched controls participated. Sonography was performed at the proximal, mid-, and distal portions of each patellar tendon. One-way ANOVAs were conducted to compare thickness and collagen fiber organization and a chi-square analysis was used to compare the presence of neovascularity between the three tendon groups. Compared to healthy controls, both tendons in the amputees exhibited increased thickness at the mid- and distal portions and a higher degree of collagen fiber disorganization. Furthermore, neovascularity was more common in the tendon of the residual limb. Our results suggest that the use of a prosthesis with a PTB feature contributes to morphological changes in bilateral patellar tendons.

Heel-Raised Foot Posture Does Not Affect Trunk and Lower Extremity Biomechanics During a Barbell Back Squat in Recreational Weight lifters.

Lee, S-P, Gillis, CB, Ibarra, JJ, Oldroyd, DF, and Zane, RS. Heel-raised foot posture does not affect trunk and lower extremity biomechanics during a barbell back squat in recreational weight lifters. J Strength Cond Res 33(3): 606-614, 2019-It is claimed that weightlifting shoes with a raised heel may lead to a more upright trunk posture, and thus reduce the risk of back injuries during a barbell back squat. These proclaimed biomechanical effects have not been thoroughly investigated. The purpose of this study was to compare trunk and lower extremity biomechanics during barbell back squats in three foot postures. Fourteen recreational weight lifters (7 men and 7 women) between the ages of 18 and 50 years performed barbell back squats in three conditions (barefoot on a flat surface, barefoot on a heel-raised platform, and wearing heel-raised weightlifting shoes) at 80% of their 1 repetition maximum. Surface electromyography was used to assess the activation of the knee extensors and paraspinal muscles at L3 and T12 spinal levels. A 3D motion capture system and an electrogoniometer recorded the kinematics of the thoracic spine, lumbar spine, and knee during the back squat to a depth where the hip was at least at the same level to the knee. Results indicated that none of the heel-raised foot postures significantly affected trunk and lower extremity muscle activation (thoracolumbar paraspinal [p = 0.52], lumbar paraspinal [p = 0.179], knee extensor [p = 0.507]) or the trunk angles (thoracolumbar spine [p = 0.348], lumbar spine [p = 0.283]) during the squat. Our results demonstrated that during barbell back squats, heel-raised foot postures do not significantly affect spinal and knee extensor muscle activations, and trunk and knee kinematics. Heel-raised weightlifting shoes are unlikely to provide significant protection against back injuries for recreational weight lifters during the barbell back squat.