How has body image been evaluated among people with lower limb loss? A scoping review.

PURPOSE: Lower limb loss can result in an altered body image, leading to changes in self-esteem, mental health and quality of life. This scoping review explored how body image has been evaluated among people with lower limb loss. MATERIALS AND METHODS: Five databases (Embase, Medline, PsychINFO, CINHAL, and Nursing and Allied Health Database) were searched from inception until March 19, 2023. Inclusion criteria: 1) people with lower limb loss; 2) evaluated a body image outcome or theme; and 3) a qualitative, quantitative or mixed methods design. RESULTS: Twenty-four quantitative (n = 19 cross-sectional, n = 3 intervention cohort and n = 2 prospective cohort), 2 qualitative and 1 mixed methods design studies were included. The definition of body image varied across studies, with 59% of studies not reporting a conceptual or theoretical definition. People with lower limb loss perceived a more negative body image compared to control groups. In prospective cohort studies, changes in body image over time were inconclusive. CONCLUSION: People with lower limb loss report a negative body image when compared to other populations. Definitions and understanding of body image changed overtime and varied among studies which may impact introducing interventions to promote positive body image during rehabilitation and beyond in this population.

People with lower limb loss experience altered body image following limb amputation, at the initiation, during and after prosthetic rehabilitation, and re-integrating into the community.Clinicians are encouraged to use this study's proposed lower limb loss-specific definition of body image.The proposed definition incorporates common terminology used in past research in the field and amputee-specific situations when referring to altered body image among this patient population.To better support the psychological adjustment of people with lower limb loss in rehabilitation programs and beyond, clinicians and researchers should evaluate body image at multiple time points (e.g., admission and discharge to rehabilitation, follow-up) using an outcome measure that asks about both with and without a prosthesis on the residual limb.

What are relevant predictors of physical activity in older adults with lower limb loss (LLL)? Results of a retrospective analysis.

BACKGROUND: People with lower limb loss (LLL) have reduced physical activity (PA). There is evidence of physical and psychosocial predictors of PA in older adults with limb loss. However, these 2 areas (physical/psychosocial) have not been evaluated in the same analysis. OBJECTIVES: To describe and identify predictors of PA in individuals with LLL. STUDY DESIGN: Cross-sectional study. METHODS: Secondary analysis of data from a multisite Canadian randomized control trial involving community-dwelling prosthetic ambulators with unilateral transtibial or transfemoral amputation (N = 72). The dependent variable was the Physical Activity Scale for the Elderly. Potential predictors were four step square test, 2-minute walk test, Short Physical Performance Battery, Life Space Assessment, walking while talking test, and Activities-specific Balance Confidence scale. RESULTS: Seventy-two community-dwelling lower limb prosthesis users were enrolled. The sample included 62 male participants (86%), and 58 participants (81%) had transtibial amputation. The average age of participants was 65 (8.9) years, and for 49 participants (70%), the amputation was over 24 months ago. The total mean Standard Deviation (SD) Physical Activity Scale for the Elderly score was 153.2 (88.3), with scores of 148.1 (11.4) and 184.5 (24.7) for male and female participants, respectively. Regression analysis identified Life Space Assessment (ß = 1.15, p = 0.007) and Short Physical Performance Battery (ß = 3.51, p = 0.043) as statistically significant predictors accounting for 25% of the variance in PA. CONCLUSIONS: Community mobility and physical performance are the most meaningful predictors of PA. Future research should examine additional factors (e.g., environment, motivation). Understanding the predictors for PA after LLL would improve clinical practice as clinicians would have increased knowledge to modify and improve training.

The effect of exercise interventions on gait outcomes in subacute and chronic rehabilitation from lower-limb amputation: A systematic review and meta-analysis.

Successful walking is a substantial contributor to quality of life in people with lower-limb amputation (PLLA), yet gait difficulties are common. Evidence-based exercise guidelines are necessary for PLLA with different clinical characteristics and at different phases of recovery. To systematically review the literature evaluating effects of exercise interventions on gait outcomes in PLLA at subacute and chronic stages of recovery. Databases MEDLINE, EMBASE, CINAHL, SPORTDiscus, Scopus, and the Cochrane Library were searched (inception to May 10, 2022). Inclusion criteria: randomized controlled trials assessing gait outcomes following exercise intervention; subjects were PLLA ≥18 years of age and used a prosthesis for walking. Meta-analysis using random effects with inverse variance to generate standardized mean differences (SMDs) was completed for primary gait outcomes. Subgroup analysis was conducted for the recovery phase (i.e., subacute and chronic) and level of amputation (e.g., transfemoral and transtibial). Of 16 included articles, 4 studies examined the subacute phase of recovery, whereas 12 examined the chronic phase. Subacute interventions were 30 minutes, 1-7 times/week, for 2-12 weeks. Chronic interventions were 15-60-minutes, 2-3 times/week, for 4-16 weeks. Low-moderate level evidence was shown for a small improvement in the subacute phase (SMD = 0.42, 95% confidence interval [0.06-0.79], I 2 = 46.0%) and a moderate improvement in the chronic phase (SMD = 0.67, 95% confidence interval [0.40-0.94], I 2 = 0.0%) in favor of exercise intervention groups. Multicomponent exercise programs consisting of gait, balance, and strength training are effective at improving gait outcomes in PLLA at subacute and chronic phases of recovery. The optimal duration and frequency of exercise is unclear because of variation between interventions, highlighting an area for future work.

An eight-year analysis of participant characteristics at admission to inpatient prosthetic rehabilitation following a lower limb amputation: a Canadian perspective.

PURPOSE: To describe admission and discharge characteristics of participants admitted to prosthetic rehabilitation following a lower limb amputation and determine changes in participant characteristics including if the population has gotten older over time at admission. METHODS: A retrospective chart audit of consecutive admissions to an amputee rehabilitation program. Study criteria were transtibial level LLA and above and ≥ 18 years old. Admission characteristics included: age, Montreal Cognitive Assessment (MoCA), Functional Comorbidity Index (FCI) and days between amputation surgery and admission. Discharge characteristics included the L -Test of Functional Mobility (L-Test), 2-Minute Walk Test (2MWT), 6-Minute Walk Test (6MWT), and Activities-specific Balance Confidence (ABC) scale. Multivariable linear regression modelling quantified the association between participant characteristics and admission time. RESULTS: A total of 601 participants (62.3 ± 14.1 years) were included, 63 were (84.9 ± 3.7 years) aged 80 and over. FCI scores [ß = 70.34, (95% CI: 20.93, 119.74), p = 0.005] and days between amputation surgery [ß = -0.08, (95% CI: -0.13, -0.02), p = 0.011] were independently associated with admission time. CONCLUSION: People with an LLA are presenting with a higher number of comorbidities at admission over time while being admitted faster from amputation surgery. Future research should investigate the impact of these changing characteristics on rehabilitation outcomes to better assist this population.

It is expected that the rate of inpatient prosthetic rehabilitation admissions due to lower limb amputations will increase amongst those over eighty.An analysis of participant characteristics of people admitted to inpatient prosthetic rehabilitation over time will inform modification and developments to future programs.Future prosthetic rehabilitation programs should consider an increased number of comorbidities when developing prognostic expectations for participants.A shortened interval between amputation surgery and admission should be considered when developing prosthetic rehabilitation programs.

Cortical activation during imagined walking for people with lower limb loss: a pilot study.

Each year in Canada, a substantial number of adults undergo limb amputation, with lower limb amputation (LLA) the most prevalent. Enhancing walking ability is crucial for optimizing rehabilitation outcomes, promoting participation, and facilitating community reintegration. Overcoming challenges during the acute post-amputation phase and sub-acute rehabilitation necessitates alternative approaches, such as motor imagery and mental practice, to maximize rehabilitation success. However, the current evidence on activation patterns using motor imagery in individuals with LLA is limited. The primary objective was to assess the feasibility of observing brain activation during imagined walking in individuals with LLA utilizing 3T functional magnetic resonance imaging (fMRI). Eight individuals with LLA and 11 control subjects participated. Consistent with representations of the lower limbs, both control and amputee groups demonstrated bilateral activation in the medial surface of the primary motor and somatosensory cortices. However, individuals with lower limb amputations exhibited significantly greater activation during imagined walking, particularly in frontal regions and the medial surface of the primary motor and supplementary motor cortices. Furthermore, the volume of activation in the bilateral primary motor cortices was higher for participants with amputations compared to controls. The protocol developed in this study establishes a foundation for evaluating the effects of a gait training program that incorporates mental imagery alongside conventional rehabilitation practices, in contrast to standard care alone. This pilot investigation holds potential to enhance our understanding of brain plasticity in individuals with LLA and pave the way for more effective rehabilitation strategies to optimize functional recovery and community reintegration.

The Effect of Advanced Age on Prosthetic Rehabilitation Functional Outcomes in People With Lower Limb Amputations: A Retrospective Chart Audit of Inpatient Admissions.

OBJECTIVE: To evaluate the effect of age on functional outcomes at discharge from prosthetic rehabilitation. DESIGN: Retrospective chart audit. SETTING: Rehabilitation hospital. PARTICIPANTS: Individuals ≥50 years with a transtibial level lower limb amputation (LLA) and above admitted to the inpatient prosthetic rehabilitation program from 2012 to 2019 (n=504). A secondary analysis included a subset of matched participants (n=156). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The L-Test of Functional Mobility (L-Test), 2-Minute Walk Test (2MWT), 6-Minute Walk Test (6MWT), and Activities-specific Balance Confidence scale. RESULTS: A total of 504 participants (66.7±10.1 years) met the inclusion criteria, 63 participants (84.9±3.7 years) were part of the oldest old group. The sample was stratified into 4 age groups (50-59, 60-69, 70-79, and 80+) for data analysis. The analysis of variances were statistically significant for all outcome measures (P<.001). Post-hoc testing for the L-Test, 2MWT, and 6MWT demonstrated that the oldest old had significantly reduced performance compared with people 50-59 years old (P<.05), but there were no significant differences between the oldest old and the 60-69 [(L-Test, P=.802), (2MWT, P=.570), (6MWT, P=.772)] and 70-79 [(L-Test, P=.148), (2MWT, P=.338), (6MWT, P=.300)] age groups. The oldest old reported significantly lower balance confidence compared with all 3 age groups (P<.05). CONCLUSION: The oldest old achieved similar functional mobility outcomes as people 60-79 years, the most common age group of people with an LLA. Advanced age alone should not disqualify individuals from prosthetic rehabilitation.

Health utility in community-dwelling adults with dysvascular lower limb loss.

PURPOSE: Adults with dysvascular lower extremity amputation (LEA) experience a large number of secondary health conditions yet there is a gap in the literature on health utility scores for this population. A health utility score relates to a person's state of well-being, and is a single metric anchored at 0 (death) and 1 (perfect health). This study aimed to provide a descriptive account of health utility scores in community-dwelling adults with dysvascular LEA. METHODS: Participants were adults with dysvascular LEA who were 3 months post-amputation. Data collected included socio-demographic characteristics, the Special Interest Group in Amputee Medicine (SIGAM) grades, the dysvascular conditions scale (DCS), which is a scale developed for this study, and the Short Form-36 (SF-36). SF-6D health utility scores were derived from the SF-36 using a software algorithm. Participants were grouped into low-impact and high-impact groups based on self-reported severity of symptoms using the DCS. Health utility scores were compared between the low-impact and high-impact groups using independent t-tests. RESULTS: A total of 231 participants were enrolled in the study. The mean SF-6D health utility score was 0.689 (0.127). A significant association was found between health utility score and SIGAM grade (p < 0.001, η2 = .09). Health utility was positively associated with age (r = 0.137, p = 0.037) and months post-amputation (r = 0.141, p = 0.032), and negatively associated with DCS severity (r = -0.526, p < 0.001). Health utility scores were lower for participants in the DCS high-impact groups for conditions such as diabetes mellitus, phantom limb pain, musculoskeletal pain, back pain, psychological distress, depression, vision problems, and other pain. CONCLUSION: Cost-utility analyses rely on health utility estimates and our findings provide data for future economic evaluations that may assist policy makers in evidence informed allocation of healthcare resources for this population.

Association between balance confidence and basic walking abilities in people with unilateral transtibial lower-limb amputations: A cross-sectional study.

INTRODUCTION: Falls are common for people with lower-limb amputations (PLLA). Low balance confidence is also prevalent, is worse in PLLA not reporting walking automaticity, and is known to negatively affect prosthesis use, social engagement, and quality of life. Moreover, walking with a prosthesis requires continuous attention. Low balance confidence may act as a distractor imposing an additional cognitive load on the already cognitively demanding task of walking with a prosthesis. METHODS: Adults with unilateral, transtibial amputations were recruited. The Activities-specific Balance Confidence (ABC) scale quantified balance confidence. The L Test assessed basic walking abilities under single-task (ST) (usual) and dual-task (DT) (walking while counting backwards) conditions. The relative change in gait and secondary task performance between conditions (ie, DT cost) was calculated. Separate multivariable linear regressions examined the association of balance confidence on the L Test. RESULTS: Forty-four PLLA (56.6 ± 12.6 years) participated. An independent association of the ABC to ST ( P < 0.001, R 2 = 0.56) and DT ( P = 0.008, R 2 = 0.43) L Test performance was observed. A 1% ABC increase was related with a 0.24 (95% confidence interval, 0.35-0.14) and 0.23 (95% confidence interval, 0.39-0.06) second reduction with the ST and DT L Test, respectively. No association to DT cost was observed. CONCLUSIONS: Balance confidence influences basic walking abilities yet does not modulate the added cognitive load associated with DT. Interventions that address balance confidence may be beneficial throughout rehabilitation. This research is novel and offers the possibility for alternative avenues for focus in rehabilitation and falls prevention in a population at high risk for falls.

Association between measures of cognitive function on physical function in novice users of a lower limb prosthesis.

BACKGROUND: Cognitive impairment is prevalent in people with lower limb amputations (PLLA) and is associated with adverse outcomes, such as falls and worse rehabilitation outcomes. Physical function tests are essential to examine abilities; however, no research in PLLA has clarified the magnitude of cognitive demands amongst available tests in users novice at walking with a prosthesis. RESEARCH QUESTION: Is there an association between cognitive and physical function for PLLA novice at walking with a prosthesis? METHODS: People from inpatient prosthetic rehabilitation were recruited. Inclusion criteria were: age ≥ 50 years, unilateral transtibial amputation and able to walk independently. Gait velocity and the L Test under single-task (usual) and dual-task (walking while counting backwards) conditions assessed functional mobility. The Four Square Step Test (FSST) examined dynamic balance. The Montreal Cognitive Assessment (MoCA) and the Trail Making Test (TMT-B) assessed global cognitive status and executive function, respectively. Multivariable linear regressions evaluated the association of cognition on physical function. RESULTS: Twenty-two people participated (age: 62.3 ± 8.9 years, male: 68.18%). The mean MoCA score was 26.23 ± 2.90. A 1-point MoCA increase was independently associated with faster gait velocity (cm/s) [single-task: 5.45 (95%CI: 2.35-8.54, AdjR2 =0.46), dual-task: 5.04 (95%CI: 1.33-8.75, AdjR2 =0.20) and a quicker L Test (s) [single-task: - 4.75 (95%CI: 7.22-2.28, AdjR2 =0.45), dual-task: - 5.27 (95%CI: 8.74-1.80, AdjR2 =0.38)]. A 1-second TMT-B increase was also independently associated with worse L Test performance [single-task: 0.21 s (95%CI: 0.03-0.39, AdjR2 =0.20), dual-task: 0.29 s (95%CI: 0.06-0.51, AdjR2 =0.30)]. No association was observed between MoCA or TMT-B on the FSST (p > 0.13). SIGNIFICANCE: Better global cognitive function and executive function were independently associated with faster gait velocity and improved functional mobility, but not dynamic balance. The present study demonstrates a unique relationship between cognition and physical function that warrants further research on the cognitive demands among clinical tests of physical function in PLLA.

The effect of dual-task testing on the balance and gait of people with lower limb amputations: A systematic review.

OBJECTIVE: To systematically review the literature on the effect of dual-task testing on the balance and gait of people with lower limb amputations (PLLA). LITERATURE SURVEY: Databases MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus were searched in duplicate (inception to December 1, 2020). METHODOLOGY: Inclusion criteria: participants were adults with transtibial, knee-disarticulation, transfemoral, or bilateral lower limb amputations; balance or gait was paired with a secondary task; and studies were peer-reviewed and published in English. Two authors independently reviewed articles and consensus was required. A standardized data extraction sheet was used to gather study relevant information in duplicate. Methodological quality of reporting was examined using the Downs and Black Scale. A meta-analysis was unable to be performed owing to substantial participant and protocol heterogeneity among the studies included. SYNTHESIS: Of 3950 articles screened, 22 met inclusion criteria. Four assessed dual-task balance and 18 dual-task gait. During single-task standing, PLLA demonstrated higher sway distance and sway velocity than controls (CN); however, a greater dual-task effect was observed only for sway velocity. Gait pace, rhythm, variability, asymmetry, and postural control were observed to be worse in PLLA relative to CN during single-task. Dual-task gait testing resulted in a disproportionally reduced pace and rhythm and increased asymmetry in PLLA compared to CN. CONCLUSIONS: People with lower limb amputations have impaired balance and gait, which is affected by dual-task to a greater degree compared to healthy adults. An examination of how PLLA-specific factors such as level of amputation, reason for amputation, and experience with a prosthesis affect dual-task performance has not yet been thoroughly explored. Future research should continue to characterize the cognitive-mobility link to better understand the challenges associated with the use of a prosthesis.

The reliability of four standardized concern for falling scales among adults with a major lower extremity amputation.

INTRODUCTION: More than 52.4% of people with a lower extremity amputation (PLEA) will fall at least once each year. Previously established standardized scales that evaluate a concern for falling (CFF) were developed primarily among community-dwelling older adults. The reliability of commonly used scales to evaluate a CFF among PLEA is needed. OBJECTIVE: To evaluate test-retest relative and absolute reliability, and agreement of the Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE), Falls Efficacy Scale - International (FES-I), Consequences of Falling (COF) Scale, Perceived Control Over Falling (PCOF) Scale, and Perceived Ability to Manage Falls (PAMF) Scale among PLEA. DESIGN: Web-based cross-sectional repeated-measures study. SETTING: Rehabilitation hospital. PARTICIPANTS: Adults with a transtibial or transfemoral level amputation, who had completed a prosthetic rehabilitation program, and at minimum of 1 year using a prosthesis for ambulation were recruited after regularly scheduled appointments (N = 22, mean age ± SD, 63.5 ± 12.9 years). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE(S): Initial and re-test scores on the mSAFFE, FES-I, COF, PCOF, and PAMF. RESULTS: Intraclass correlation coefficients (ICCs) demonstrated excellent relative reliability of the mSAFFE (ICC = 0.92, 95% confidence interval [CI]: 0.82-0.97), good relative reliability of the FES-I (ICC = 0.87, 95% CI: 0.70-0.94), and fair relative reliability of the COF (ICC = 0.78, 95% CI: 0.53-0.90) and PAMF (ICC = 0.73, 95% CI: 0.46-0.88) scales. The ICC value of the PCOF scale could not be validly calculated and was not further analyzed. Calculated standard error of measurement values for the mSAFFE, FES-I, COF, and PAMF scales were small in magnitude, and Bland-Altman graphs demonstrated good agreement of initial and re-test scores for all scales. CONCLUSION: This study provides initial evidence on the suitability and reliable use of the mSAFFE, FES-I, COF, and PAMF scales within this population. Further evaluation of the validity of these scales is needed.

A concern for falling impacts quality of life for people with a lower limb amputation.

The purpose of this web-based survey study was to comprehensively evaluate subdomains of concern for falling and its association with quality of life (QoL) among people with lower-limb amputations (PLLA). Forty-eight adults (mean 61.8 ± 11.6 years) with a major (i.e. transtibial or transfemoral) amputation participated. Individuals were currently using a prosthesis for ambulation, completed a prosthetic rehabilitation program, had functional use of English and had access to an internet-connected device (e.g. laptop). Five standardized scales assessed a concern for falling: Modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE), Activities-specific Balance Confidence (ABC) Scale, Prosthetic Limb Users Survey - Mobility (PLUS-M), Consequences of Falling Scale and Perceived Ability to Manage Falls Scale. QoL was evaluated using the WHO QoL-100 questionnaire. Spearman correlation analysis evaluated the relationship between the five concerns for falling scales. Five independent linear regression modeling evaluated the association of each concern for falling measure on QoL. Strong statistically significant correlations were found between mSAFFE and PLUS-M (r s = -0.87; P < 0.05). Three scales were significantly associated with QoL: mSAFFE [-1.16 (95% CI, -2.04 to -0.29)], ABC [0.36 (95% CI, 0.11-0.61)] and PLUS-M [0.50 (95% CI, 0.05-0.95)]. This is the first study to evaluate multiple concerns for falling subdomains among PLLA. Concern for falling should be addressed in prosthetic rehabilitation to improve community re-integration and QoL.

Examination of social disconnectedness and perceived social isolation on health and life satisfaction in community-dwelling adults with dysvascular lower limb loss.

BACKGROUND: People with physical disabilities are at risk for social isolation, which has been shown to negatively influence health and well-being. OBJECTIVES: The purpose of this study was to examine the association of social disconnectedness and perceived social isolation (PSI) on health-related quality of life (HrQoL) and life satisfaction in adults with dysvascular lower extremity amputation (LEA). STUDY DESIGN: Cross-sectional survey. METHODS: Data were collected from community-dwelling adults with dysvascular major LEA (N = 231). The main outcome measures were the Short-Form 36 and the Life Satisfaction-11. Other measures were used to quantify comorbidities/secondary health conditions, PSI, social disconnectedness, self-efficacy, social support, and social engagement. Three hierarchical regression models were conducted to predict (1) physical HrQoL, (2) mental HrQoL, and (3) life satisfaction. RESULTS: Approximately one-third of the sample had high levels of social disconnectedness and PSI. The regression model predicting physical HrQoL accounted for 47% of the variance and only found that higher levels of mobility, lower perceived impact of comorbidities/conditions, and higher levels of social engagement and self-efficacy were associated with better physical HrQoL. A model predicting mental HrQoL accounted for 36% of the variance, with older age, lower PSI, and higher levels of self-efficacy being significant predictors. Finally, the model predicting life satisfaction accounted for 56% of the variance, with older age, lower perceived impact of comorbidities/conditions, and higher self-efficacy remaining as significant predictors. CONCLUSIONS: These findings highlight that one-third of our sample were at risk for being socially isolated and that PSI was influential on mental HrQoL and life satisfaction. There is a need for approaches to address social isolation for people with dysvascular LEA living in the community to optimize their long-term health and well-being.

Pregnancy After Amputation: A Systematic Review of Pregnancy Experiences for Women With Lower Extremity Amputations.

ABSTRACT: Pregnancy could affect the mobility of women with lower extremity limb loss, deficiency, or amputations. The aim of this systematic review was to characterize the pregnancy-related experiences, including prosthesis, gait aid, and mobility outcomes, of women with lower extremity limb loss, deficiency, or amputations. MEDLINE, CINAHL, and Embase databases were searched for all relevant English-language articles describing pregnancy experiences of women with lower extremity limb loss, deficiency, or amputations. Data extracted were age, amputation level and etiology, obstetrical history, prosthesis and/or gait aid use before, during, and after pregnancy, and pregnancy-related complications. Risk of bias was assessed using applicable CLARITY tools. Data were analyzed with descriptive statistics. Among 399 retrieved studies, 24 met inclusion criteria describing 31 pregnancies in 25 women. All were case series/reports with high risk of bias. All women had acquired lower extremity limb loss, deficiency, or amputations. Sixteen women had hemipelvectomy (64%) and 4 had transfemoral amputations (16%). Three women used a prosthesis, 5 did not, and use was not described for 17 (68%). Prosthesis or gait aid use changed in 2 pregnancies, did not change in 6, and was not specified in 23 (74%). Available cases are likely not representative; additional research is required to characterize the impact of pregnancy on women with lower extremity limb loss, deficiency, or amputations.

A qualitative study exploring individuals' experiences living with dysvascular lower limb amputation.

PURPOSE: The majority of lower extremity amputations (LEAs) are the result of diabetes or peripheral vascular disease. There is a paucity of literature on individuals' experiences living with dysvascular LEAs in the community, particularly in Canada. The purpose of this study was to explore the perceptions and experiences of community-dwelling adults living with dysvascular LEA. METHODS: Semi-structured qualitative interviews were conducted with individuals with a dysvascular LEA recruited from three rehabilitation hospitals. Participants were included if they were English-speaking adults at least three months post-amputation and no longer receiving inpatient rehabilitation. Sampling was purposive to ensure variation by gender, level of amputation, and geographic location. Data were analyzed using an inductive content-analysis approach. RESULTS: Thirty-five interviews were completed with individuals with dysvascular LEA. Study participants portrayed LEA as having an impact on many aspects of their lives, resulting in changes in their mobility, social activities and roles, and psychological wellbeing. Three main factors shaped individuals' experiences with dysvascular LEA including social support, accessibility, and socioeconomic factors. CONCLUSION: Our findings highlight the impacts of dysvascular LEA in peoples' lives. Future research is warranted to explore how community-based interventions and strategies can address the ongoing needs of individuals with dysvascular LEA.Implications for rehabilitationOur findings highlight the long-term impacts of dysvascular lower extremity amputations, which resulted in changes in mobility, social activities and roles, and psychological wellbeing.Participants identified issues in access to community services and resources, including rehabilitation.Mechanisms to identify people at risk for social isolation need to be developed and implemented in rehabilitation centers.Access to ongoing rehabilitation services in the community are needed to optimize mobility outcomes and address ongoing psychological needs.

Group-based telerehabilitation intervention using Wii Fit to improve walking in older adults with lower limb amputation (WiiNWalk): A randomized control trial.

OBJECTIVE: Determine efficacy of the novel WiiNWalk intervention on walking-related outcomes in older adults with lower limb amputation. DESIGN: Multi-site, parallel, evaluator-masked randomized controlled trial. SETTING: Home-setting in three Canadian cities. PARTICIPANTS: Community-dwelling lower limb prosthesis users over 50 years of age. INTERVENTIONS: The WiiNWalk group (n = 38) used modified Wii Fit activities for prosthetic rehabilitation. The attention control group (n = 33) used Big Brain Academy: Wii Degree, comprising of cognitive activities. Both groups completed a 4-week supervised phase with three 1-h sessions/week in groups of three overseen by a clinician via videoconferencing and a 4-week unstructured and unsupervised phase. MAIN MEASURES: Primary outcome was walking capacity (2 min walk test); secondary outcomes were balance confidence (activities-specific balance confidence scale), dynamic balance (four-step square test), and lower limb functioning (short physical performance battery). Outcomes were compared across time points with repeated measures analysis of covariance, adjusting for baseline and age. RESULTS: Mean age was 65.0 (8.4) years, with 179.5 (223.5) months post-amputation and 80% transtibial amputation. No group difference in a 2 min walk test with an effect size: 1.53 95% CI [-3.17, 6.23] m. Activities balance confidence was greater in the WiiNWalk group by 5.53 [2.53, 8.52]%. No group difference in the four-step square test -0.16 [-1.25, 0.92] s, nor short physical performance battery 0.48 [-0.65, 1.61]. A post-hoc analysis showed the greatest difference in balance confidence immediately after an unsupervised phase. CONCLUSIONS: The WiiNWalk intervention improved balance confidence, but not walking-related physical function in older adult lower limb prosthesis users. Future rehabilitation games should be specific to the amputation context.Clinical Trial Registration number, NCT01942798.

Walking while talking: validation in older adults with lower-limb amputation.

BACKGROUND: Walking while talking (WWT) is a dual-task (cognitive and motor) performance test that has not yet been validated in older adults with lower-limb amputation (LLA). WWT is composed of two sections: WWT-simple (walking while reciting every letter of the alphabet) and WWT-complex (walking while reciting every other letter of the alphabet). OBJECTIVE: To determine the validity, and provide normative data and a new scoring system for the WWT test in older adults with LLA. STUDY DESIGN: Baseline cross-sectional data were collected from 56 community-living older adults (≥50 years old) with LLA at rehabilitation hospitals in Vancouver, BC, London, ON, and Edmonton, AB, Canada. METHODS: Time and number of recited letters and errors during both sections were recorded. A new score was developed based on all these variables. Correlations of the recorded times with the Activities-specific Balance Confidence (ABC) scale and the 2-Minute Walk Test (2MWT) score were used to evaluate the validity of the WWT test. RESULTS: As hypothesized, the times for both sections of the WWT were negatively correlated with both the ABC and 2MWT scores. Positive correlations were observed between the scores developed for both WWT sections with the 2MWT score. CONCLUSION: Times taken to complete each section of the WWT test were correlated with the 2MWT and the ABC scale scores, providing evidence for the validity of the WWT test. We also provided a scoring method that is more objective and in line with the dual-task nature of the test.

Rehabilitation outcomes after major lower limb amputation in the oldest old: a systematic review.

BACKGROUND: Because the population grows older and the burden of chronic disease increases, many individuals will undergo major lower limb amputation (LLA) at advanced ages. There is a scarcity of literature focusing on the outcomes of rehabilitation for people who acquire LLA at 80 years of age and older. OBJECTIVES: To determine the scope of empirical evidence regarding prosthetic rehabilitation for newly acquired LLA in the oldest old (≥80 years of age). STUDY DESIGN: Systematic Review. METHODS: The databases CINAHL, EMBASE, MEDLINE, and Scopus were searched from inception through June 6, 2020 (PROSPERO: #CRD 42020188623). Two authors independently reviewed all titles and abstracts for inclusion. Inclusion criteria, LLA of any etiology at the transtibial level or above, those who were ≥80 years of age at the time of amputation, and had rehabilitation outcomes reported. RESULTS: Of 11,738 articles identified from databases, 117 underwent full-text review and 10 met inclusion criteria. Multiple rehabilitation outcomes were assessed by the selected studies, including general outcomes, prosthetic-related outcomes, and functional abilities. Individuals ≥80 years of age were able to successfully use a prosthesis, discharged home, and performed activities independently or with support. However, increased age was negatively associated with prosthesis fitting and rehabilitation success was not uniform in some participants. CONCLUSIONS: The oldest old with major LLA can be successful in prosthetic rehabilitation. Age alone should not disqualify individuals from assessment or participation in an amputee rehabilitation program. More research is needed to better understand the rehabilitation outcomes in this population of people with LLA.

Validity of measures for life space mobility and physical activity in older adults with lower-limb amputation.

BACKGROUND: Older adults with lower-limb amputations (LLAs) often experience lack of confidence and poor balance, which limits their mobility. There are few validated measures for assessing these outcomes in the LLA population. OBJECTIVES: To assess the validity of the Life Space Assessment (LSA) and the Physical Activity Scale for the Elderly (PASE) for older adults with LLA. STUDY DESIGN: Secondary analyses of cross-sectional data. METHODS: Sixty-eight older adults with LLA across Canada were recruited to complete the LSA and the PASE. Validity was assessed via correlations with the Activities-specific Balance Confidence (ABC), Four-Square Step Test (FSST), and Two-Minute Walk Test (2-MWT). RESULTS: As hypothesized, the LSA was positively correlated with the ABC (ρ = 0.36, 95% confidence interval [CI] [0.17, 0.62]) and 2-MWT (r = 0.49, 95% CI [0.27, 0.70]) and negatively correlated with FSST (ρ = -0.39, 95% CI [-0.56, -0.10]). The PASE was positively correlated with the ABC (ρ = 0.34, 95% CI [0.10, 0.56]) and 2-MWT (ρ = 0.32, 95% CI [0.05, 0.52]), and negatively correlated with FSST (ρ = -0.36, 95% CI [-0.53, -0.07]). CONCLUSIONS: The LSA has validity in measuring life space mobility. The PASE captures the physical activity with weaker support of validity in older adults with LLA. CLINICAL RELEVANCE: The LSA and PASE are quick low-cost tools for clinicians to assess mobility-related functional health and physical activity, respectively, in older adults with LLA. However, the PASE may contain activities that are not common among older adults with LLA.

Identifying priorities and developing strategies for building capacity in amputation research in Canada.

BACKGROUND: Compared to other patient population groups, the field of amputation research in Canada lacks cohesion largely due to limited funding sources, lack of connection among research scientists, and loose ties among geographically dispersed healthcare centres, research institutes and advocacy groups. As a result, advances in clinical care are hampered and ultimately negatively influence outcomes of persons living with limb loss. OBJECTIVE: To stimulate a national strategy on advancing amputation research in Canada, a consensus-workshop was organized with an expert panel of stakeholders to identify key research priorities and potential strategies to build researcher and funding capacity in the field. METHODS: A modified Delphi approach was used to gain consensus on identifying and selecting an initial set of priorities for building research capacity in the field of amputation. This included an anonymous pre-meeting survey (N = 31 respondents) followed by an in-person consensus-workshop meeting that hosted 38 stakeholders (researchers, physiatrists, surgeons, prosthetists, occupational and physical therapists, community advocates, and people with limb loss). RESULTS: The top three identified research priorities were: (1) developing a national dataset; (2) obtaining health economic data to illustrate the burden of amputation to the healthcare system and to patients; and (3) improving strategies related to outcome measurement in patients with limb loss (e.g. identifying, validating, and/or developing outcome measures). Strategies for moving these priorities into action were also developed. CONCLUSIONS: The consensus-workshop provided an initial roadmap for limb loss research in Canada, and the event served as an important catalyst for stakeholders to initiate collaborations for moving identified priorities into action. Given the increasing number of people undergoing an amputation, there needs to be a stronger Canadian collaborative approach to generate the necessary research to enhance evidence-based clinical care and policy decision-making.IMPLICATIONS FOR REHABILITATIONLimb loss is a growing concern across North America, with lower-extremity amputations occurring due to complications arising from diabetes being a major cause.To advance knowledge about limb loss and to improve clinical care for this population, stronger connections are needed across the continuum of care (acute, rehabilitation, community) and across sectors (clinical, advocacy, industry and research).There are new surgical techniques, technologies, and rehabilitation approaches being explored to improve the health, mobility and community participation of people with limb loss, but further research evidence is needed to demonstrate efficacy and to better integrate them into standard clinical care.