Using the theory of planned behaviour to develop an assessment of attitudes and beliefs towards prosthetic use in amputees.

PURPOSE: To develop a questionnaire based on the theory of planned behaviour (TPB) to predict prosthetic use. METHOD: In part one, 31 amputees over 50 years of age with peripheral arterial disease completed attitude items containing 27 bipolar adjectives and open-ended questions on behavioural, normative and control beliefs relating to using the prosthesis. Academic, clinical and patient experts (n = 12) identified bipolar adjectives with best face validity. In part two, 15 amputees completed three behavioural format questions relating to prosthetic use and were asked to indicate the easiest to answer. RESULTS: Following the completion of the attitude items by the amputees and the expert panel review, 5 items remained (Cronbach's alpha = 0.87) with corrected item-total correlations ranging from 0.43 to 0.83. Modal behavioural beliefs concerned mobility (46.5%), independence (25.6%) and participation restrictions (16.3%), normative beliefs concerned family (33.3%), NHS staff (31.7%), friends (19.1%) and other patients (15.9%) and control beliefs concerned stairs (21.1%), slippery/rough surfaces (28.9%), disabled facilities (54.8%) and people helping (22.6%). In relation to part 2, an exact numerical report of hours and days of prosthetic use was found easiest to answer (73%). CONCLUSIONS: Based on this qualitative and quantitative development work, the questionnaire contains five attitude items, six behavioural, eight normative, eight control belief items and two self-report questions of the behaviour.

A randomised trial of rigid stump dressing following trans-tibial amputation for peripheral arterial insufficiency.

BACKGROUND: A multicentre randomised controlled trial to determine the effect of a rigid plaster dressing applied at the time of trans-tibial amputation on the number of days to casting for a prosthesis, and the incidence of post-operative stump infection. METHODS: Patients requiring trans-tibial amputation were randomised to one of 2 groups: In Group 1 (intervention) a rigid above-knee plaster dressing was applied at operation and patients were managed according to a standard protocol. Group 2 (control) had the individual surgeons' usual non-rigid dressing regime. Rehabilitation data were extracted from the national physiotherapy database. On completion of the trial a questionnaire was sent to all participants. RESULTS: 14 surgeons in 7 centres enrolled 154 patients, with 96 ultimately cast for a prosthesis. Patients who received a rigid dressing (n = 78) had reduced days to casting (median 36, confidence interval 30-47) when compared with other dressings (n = 76) (median 42, confidence interval 36-45), these differences did not reach statistical significance. There was no significant difference in post-operative infection rates in the two groups. 64% of surgeons, and all physiotherapists and vascular nurses responding to the post-trial questionnaire felt that the rigid dressing was an improvement on their normal regime and wished to continue with the technique. CONCLUSIONS: Despite a median reduction of 6 days in time to casting in patients treated with a rigid post-operative dressing this failed to reach statistical significance. The majority of participants who replied to the post-trial questionnaire expressed a wish to continue using the rigid dressing technique. To confirm that the trends shown in this trial are statistically valid a larger trial is needed.

A post-discharge quality of life outcome measure for lower limb amputees: test-retest reliability and construct validity.

OBJECTIVE: To adapt the Patient Generated Index (PGI) quality of life measure for use with lower limb amputees and to conduct a test-retest reliability and construct validity study on the adapted measure. DESIGN: Repeat questionnaire interviews with a four-week interval administered by trained peers. SETTING: Participants' homes. SUBJECTS: Forty-two unilateral lower limb transfemoral amputees, 16 years of age or older and fluent in English, fitted with a prosthesis and discharged into the community for at least one year following postoperative rehabilitation therapy. MAIN RESULTS: An intraclass correlation coefficient of 0.48 (p < 0.001) was achieved for the index reliability analyses. Intraclass correlation (ICC) values for the seven most commonly mentioned areas of life affected by the amputation and its treatment ranged from 0.40 to 0.92. Comparing the PGI with the SF-12 Health Survey physical and mental component summaries gave Pearson's correlation coefficients of 0.12 (p < 0.5) and 0.56 (p < 0.001) respectively. Multiple linear regression analysis showed the SF-12 physical and mental component scores explained 31.5% of the variability in PGI scores, however, the mental component scores alone explained 31.2%. CONCLUSIONS: The PGI was adapted and found to be moderately reliable in terms of repeatability during successive follow-up interviews. Testing its construct validity supported a stronger relationship between mental health and quality of life than between physical health and quality of life.

A post-discharge functional outcome measure for lower limb amputees: test-retest reliability with trans-tibial amputees.

There are approximately 700 lower limb amputations performed throughout Scotland each year. A national system of survey and analysis conducted by the Scottish Physiotherapy Amputee Research Group (SPARG) provides information on these patients up until discharge from hospital. However, there has been no method of collecting long-term functional and prosthetic use information following discharge. The Functional Measure for Amputees (FMA) has, therefore, been developed from the Prosthetic Profile of the Amputee (PPA) questionnaire, designed by Gauthier-Gagnon and colleagues in Canada (Grisé et al, 1993). Modifications to the PPA were carried out to make it more appropriate for the Scottish amputee population; these changes were approved by the original authors. The test-retest reliability of the 14-question FMA was assessed using a repeat postal questionnaire study. One hundred and thirty-three (133) from a possible 390 trans-tibial amputees were returned. Comparing sociodemographic and clinical variables between consenters and non-consenters showed no evidence to support sample bias. Continuous data items on the FMA analysed using an intraclass correlation coefficient showed ICC values of 0.74, 0.85, 0.96 and 0.64. Categorical data items analysed using percentage agreements showed reliability of over 70% for seven items, between 40% and 70% for three items and between 20% and 40% for the remaining three items. The FMA questionnaire was found to be reliable on the majority of its questions and moderately reliable on the remaining questions during successive follow-up postal administrations.

An evaluation of the Amputee Mobility Aid (AMA) early walking aid.

The most popular early walking aid (EWA) in the United Kingdom (UK) is the Pneumatic Post-Amputation Mobility aid or PPAM aid. A disadvantage of this device is that it does not allow a trans-tibial amputee to flex or extend the knee during walking. The Amputee Mobility Aid (AMA) was developed to allow knee movement, enabling trans-tibial amputees to practise a more natural gait. The benefits of using EWAs include early walking, reduction in post-operative oedema and improvement in patient morale. This pilot study investigated the pneumatic bag/stump interface pressures of the PPAM aid and the AMA. In addition, the range of motion of the knee on the amputated side and the mechanical knee of the AMA were compared. The AMA was found to have higher interface pressures than the PPAM aid during standing and similar pressures during supported walking. Subjects using the AMA did flex and extend their knee during walking but through a reduced range of motion. There were no significant differences between the angular movements of the AMA's mechanical knee and the patient's knee within it.

Screening for diabetes in lower limb amputees: a pilot study.

The Saint Vincent Declaration includes 5-year targets to improve the outcome of diabetic patients as a central tenet. Meeting these targets requires a comprehensive screening and monitoring programme to establish the current incidence of diabetic complications and show that the major goals of the declaration are being achieved. The Scottish Physiotherapy Amputee Research Group and the Scottish Vascular Audit Group jointly organized a three month prospective screening programme of 146 patients presenting for a lower limb amputation. The results suggest that a significant proportion of patients have undiagnosed diabetes. Further, only around half of the patients eligible for testing actually had a test done, highlighting the difficulties associated with establishing a national screening programme. This programme is now ongoing and particular importance is being given to improving the proportion of patients actually being tested.

Three measures of functional outcome for lower limb amputees: a retrospective review.

Outcome measures are becoming increasingly important in health care. Functional outcome measures are of particular importance for lower limb amputees since much of the rehabilitation process is concerned with increasing mobility and personal independence. The Scottish Physiotherapy Amputee Research Group (SPARG) has used three measures of functional outcome: the Barthel Index, Russek's classification and the Locomotor Index. The review reported here involves 938 patients having a primary amputation at the transtibial or transfemoral level between October 1992 and July 1997. Differences in function due to age and level of amputation are well known clinically and the measures were compared by looking at their ability to detect these differences. The Barthel Index lacked sensitivity because of ceiling effects and should not be considered as a suitable functional outcome measure for amputee patients. Russek's classification does detect significant differences but requires a large number of patients making it unsuitable for single hospital investigations. The Locomotor Index demonstrates significant differences due to age and amputation level despite fewer patients being assessed by this measure during the period covered by this paper. The range of the Locomotor Index can be extended to cover more active amputees by considering its 'advanced activities' subscale separately. The Locomotor Index is a promising measure and should be considered by rehabilitation teams looking for a valid, reliable and sensitive functional outcome measure for use with lower limb amputees.