The effect of rehabilitation therapies on quality of life and function in individuals with phantom limb pain after lower-limb amputation: A systematic review.

PURPOSE: To evaluate the existing evidence surrounding the effect of rehabilitation therapies on quality of life (QOL) and function of individuals with a lower-limb amputation and experiencing phantom limb pain (PLP). METHODS: This review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses methodology. Four databases were searched with key terms that covered 4 broad areas: phantom limb, lower-limb amputation, rehabilitation interventions, and randomized controlled trial (no date limits). Outcomes of either function or QOL in people receiving rehabilitation for PLP were included. The RoB2.0 risk-of-bias tool was used to rate quality. RESULTS: Five studies were included, reporting on QOL (n = 5) and function (n = 3), using interventions including mirror therapy, phantom exercises, and muscle relaxation. The evidence was mixed in direction and significance, and this was likely attributed to by the heterogeneity of interventions and types of outcomes as well as incomplete reporting. There was very low certainty in the effect of these rehabilitation interventions to affect QOL or function. CONCLUSION: The overall effect of rehabilitation interventions on QOL and function is inconclusive because of the variable results across the included randomized controlled trials. More research is needed to explore the impact of interventions beyond the outcome of pain and to establish a clearer conclusion. Including measures of QOL and function as well as pain in studies with people with PLP is encouraged.

What are the barriers and enablers that people with a lower limb amputation experience when walking in the community?

Purpose: To explore barriers and enablers to community walking perceived by people with lower limb amputation.Materials and methods: Three focus groups (n = 14 participants), using purposive sampling, were conducted with people with lower limb amputation who used a prosthesis to walk in the community. Three investigators analyzed transcripts using thematic content analysis.Results: Themes aligned with the International Classification of Functioning, Disability and Health domains. Barriers related to body function and structure included prosthetic function, residual limb integrity, phantom limb pain and other medical issues, with optimal prosthetic function and adequate fitness identified as enablers. Personal barriers included challenges adjusting to change, whereas personal enablers included being able to adjust to change, having a positive attitude, goal setting and a purpose for community walking. Environmental barriers included physical (e.g., terrain, crowds, climate) and social (e.g., unwanted attention and finances). Environmental enablers included aids, transport, preparation, social support and finances. Community walking was essential to participation in work, leisure, social activities and family roles.Conclusion: Walking in the community for people with a lower limb amputation presents many barriers, but enablers have also been identified. Targeted assessments and interventions, and appropriate environmental planning may assist in minimizing barriers to community walking.Implications for rehabilitationAlthough rehabilitation for people with lower limb amputation should continue to optimise body function and structure (such as strength, fitness, pain and prosthetic function) to help prepare individuals for walking in the community, personal and environmental factors should also be addressed.Optimising an individual's personal enablers may facilitate community walking; this may include strategies to assist with adjusting to change, setting goals, instilling a positive attitude towards walking, and seeing a purpose for walking in the community.Enhancing environmental (physical and social) enablers and minimising environmental barriers to walking in the community may be possible through environmental planning (e.g. infrastructure such as lifts), social awareness and education.

Are people with lower limb amputation changing? A seven-year analysis of patient characteristics at admission to inpatient rehabilitation and at discharge.

Purpose: What are the characteristics of people with lower limb amputation at admission to, and discharge from, subacute rehabilitation? Have these characteristics changed over time?Methods: A total of 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission characteristics, including aetiology, gender, age, amputation level, cognition (Mini-Mental State Examination (MMSE)), indoor mobility aid, motor function (Functional Independence Measure motor subscale) and number and type of comorbidities, and discharge characteristics, including prosthetic prescription, motor function, discharge mobility aid, and destination were compared by admission date and year.Results: Proportion of people with lower limb amputation with nonvascular aetiology increased over time (2004, 15% to 2011, 24%) (ß = -181.836, p < 0.001). Admission cognition increased over time (ß = 9.296, p < 0.001). Motor function worsened over time; median admission (IQR) Functional Independence Measure motor 70 (59-77) in 2005 to 67 (51.5-73.25) in 2011 (ß = -1.937, p < 0.001) and discharge from 81 in 2005 to 79 in 2011 (ß = -1.267, p < 0.001). Prosthetic prescription rates were highest in 2005 (68%) decreasing to 47% in 2010 (ß = -200.473, p < 0.001).Conclusions: Total numbers of people with lower limb amputation did not change over the seven-year study period. Changes were observed in aetiology, cognition and motor function. Prosthetic prescription rates decreased over time.Implications for rehabilitationRehabilitation should account for the changing characteristics of people with lower limb amputation.Motor function should be addressed as part of rehabilitation to optimise the patient's ability to return home and to the community.Prescription rates for lower limb prostheses reduced across time, indicating more specific selection processes and refined clinical decision making; this decision is best informed by a multi-disciplinary approach.

Gait speed as an indicator of prosthetic walking potential following lower limb amputation.

BACKGROUND:: The relationship between gait speed and prosthetic potential (K-level classifications) and function has not been explored among people transitioning from hospital rehabilitation to the community. OBJECTIVES:: To examine gait speed at discharge from inpatient rehabilitation among people prescribed a prosthetic leg after unilateral lower limb amputation, and associations between gait speed, prosthetic potential and functional ability. STUDY DESIGN:: Cohort. METHODS:: Gait speed (10-m walk test), K-level (Amputee Mobility Predictor) and Functional Independence Measure motor were compared for 110 people (mean (standard deviation) age: 63 (13) years, 77% male, 71% transtibial amputation, 70% dysvascular causes). RESULTS:: Median (interquartile range) gait speed and Functional Independence Measure motor were 0.52 (0.37-0.67) m/s and 84 (81, 85), respectively. Median (IQR) gait speed scores for each K-level were as follows: K1 = 0.17 (0.15-0.19) m/s, K2 = 0.38 (0.25-0.54) m/s, K3 = 0.63 (0.50-0.71) m/s and K4 = 1.06 (0.95-1.18) m/s. Median (IQR) FIM-Motor scores for each K-level were as follows: K1 = 82 (69-84), K2 = 83 (79-84), K3 = 85 (83-87) and K4 = 87 (86-89). Faster gait speed was associated with higher K-level, higher FIM-Motor, being younger, male and having transtibial amputation with nonvascular aetiology. CONCLUSION:: Gait speed was faster among each higher K-level classification. However, gait speeds observed across all K-levels were slower than healthy populations, consistent with values indicating high risk of morbidity and mortality. CLINICAL RELEVANCE: Factors associated with faster gait speed are useful for clinical teams considering walking potential of people with lower limb prostheses and those seeking to refine prosthetic rehabilitation programmes.

Demographics and discharge outcomes of dysvascular and non-vascular lower limb amputees at a subacute rehabilitation unit: a 7-year series.

OBJECTIVE: To examine personal and social demographics, and rehabilitation discharge outcomes of dysvascular and non-vascular lower limb amputees. METHODS: In total, 425 lower limb amputation inpatient rehabilitation admissions (335 individuals) from 2005 to 2011 were examined. Admission and discharge descriptive statistics (frequency, percentages) were calculated and compared by aetiology. RESULTS: Participants were male (74%), aged 65 years (s.d. 14), born in Australia (72%), had predominantly dysvascular aetiology (80%) and a median length of stay 48 days (interquartile range (IQR): 25-76). Following amputation, 56% received prostheses for mobility, 21% (n = 89) changed residence and 28% (n = 116) required community services. Dysvascular amputees were older (mean 67 years, s.d. 12 vs 54 years, s.d. 16; P < 0.001) and recorded lower functional independence measure--motor scores at admission (z = 3.61, P < 0.001) and discharge (z = 4.52, P < 0.001). More non-vascular amputees worked before amputation (43% vs 11%; P < 0.001), were prescribed a prosthesis by discharge (73% vs 52%; P < 0.001) and had a shorter length of stay (7 days, 95% confidence interval: -3 to 17), although this was not statistically significant. CONCLUSIONS: Differences exist in social and demographic outcomes between dysvascular and non-vascular lower limb amputees.

Using near real-time morbidity data to identify heat-related illness prevention strategies in North Carolina.

Timely public health interventions reduce heat-related illnesses (HRIs). HRI emergency department (ED) visit data provide near real-time morbidity information to local and state public health practitioners and may be useful in directing HRI prevention efforts. This study examined statewide HRI ED visits in North Carolina (NC) from 2008-2010 by age group, month, ED disposition, chief complaint, and triage notes. The mean number of HRI ED visits per day was compared to the maximum daily temperature. The percentage of HRI ED visits to all ED visits was highest in June (0.25%). 15-18 year-olds had the highest percentage of HRI visits and were often seen for sports-related heat exposures. Work-related HRI ED visits were more common than other causes in 19-45 year-olds. Individuals ≥65 years were more likely admitted to the hospital than younger individuals. The mean daily number of HRI ED visits increased by 1.4 for each 1°F (degree Fahrenheit) increase from 90°F to 98°F and by 15.8 for each 1°F increase from 98°F to 100°F. Results indicate that HRI prevention efforts in NC should be emphasized in early summer and targeted to adolescents involved in organized sports, young adults with outdoor occupations, and seniors. At a maximum daily temperature of 98°F, there was a substantial increase in the average daily number of HRI ED visits. ED visit data provide timely, sentinel HRI information. Analysis of this near real-time morbidity data may assist local and state public health practitioners in identification of HRI prevention strategies that are especially relevant to their jurisdictions.

Peat bog wildfire smoke exposure in rural North Carolina is associated with cardiopulmonary emergency department visits assessed through syndromic surveillance.

BACKGROUND: In June 2008, burning peat deposits produced haze and air pollution far in excess of National Ambient Air Quality Standards, encroaching on rural communities of eastern North Carolina. Although the association of mortality and morbidity with exposure to urban air pollution is well established, the health effects associated with exposure to wildfire emissions are less well understood. OBJECTIVE: We investigated the effects of exposure on cardiorespiratory outcomes in the population affected by the fire. METHODS: We performed a population-based study using emergency department (ED) visits reported through the syndromic surveillance program NC DETECT (North Carolina Disease Event Tracking and Epidemiologic Collection Tool). We used aerosol optical depth measured by a satellite to determine a high-exposure window and distinguish counties most impacted by the dense smoke plume from surrounding referent counties. Poisson log-linear regression with a 5-day distributed lag was used to estimate changes in the cumulative relative risk (RR). RESULTS: In the exposed counties, significant increases in cumulative RR for asthma [1.65 (95% confidence interval, 1.25-2.1)], chronic obstructive pulmonary disease [1.73 (1.06-2.83)], and pneumonia and acute bronchitis [1.59 (1.07-2.34)] were observed. ED visits associated with cardiopulmonary symptoms [1.23 (1.06-1.43)] and heart failure [1.37 (1.01-1.85)] were also significantly increased. CONCLUSIONS: Satellite data and syndromic surveillance were combined to assess the health impacts of wildfire smoke in rural counties with sparse air-quality monitoring. This is the first study to demonstrate both respiratory and cardiac effects after brief exposure to peat wildfire smoke.

Improving cancer incidence estimates for American Indians in Wisconsin.

OBJECTIVES: The purpose of this study was to improve the measurement of cancer incidence among American Indians in Wisconsin and compare incidence rates with state and national incidence rates. METHODS: The Wisconsin Cancer Reporting System (WCRS) entered into a data linkage project with CDC and the Indian Health Service (IHS) to improve classification of American Indian cancer cases in Wisconsin. WCRS data were linked to IHS patient registration files to identify American Indian cases that were misclassified as a non-Indian race for the years 1998-2002. American Indian age-adjusted rates and rate ratios for major cancer sites were compared before and after the linkage, and with statewide and national rates. RESULTS: The age-adjusted incidence rate for all cancer among American Indians increased from the pre-linkage rate of 386.3 per 100,000 to the post-linkage rate of 471.7 per 100,000, a statistically significant increase. The post-linkage rate was over twice the comparable Surveillance Epidemiology and End Results (SEER) national rate among American Indians at 233.6 per 100,000. Post-linkage American Indian incidence rates for male colorectal and female lung cancers were higher than those for the state average. CONCLUSIONS: In contrast to earlier data, the linkage results show that American Indians had similar cancer incidence compared to the general population in Wisconsin, and over twice as high as national SEER American Indian rates. Post-linkage rates resulted in more accurate site-specific and geographically focused cancer incidence rates to help target the national and state priorities of addressing disparities among American Indians.