Uphill and downhill walking in unilateral lower limb amputees.

OBJECTIVE: To study adjustment strategies in unilateral amputees in uphill and downhill walking. DESIGN: Observational cohort study. SUBJECTS: Seven transfemoral, 12 transtibial unilateral amputees and 10 able-bodied subjects. METHODS: In a motion analysis laboratory the subjects walked over a level surface and an uphill and downhill slope. Gait velocity and lower limb joint angles were measured. RESULTS: In uphill walking hip and knee flexion at initial contact and hip flexion in swing were increased in the prosthetic limb of transtibial amputees. In downhill walking transtibial amputees showed more knee flexion on the prosthetic side in late stance and swing. Transfemoral amputees were not able to increase prosthetic knee flexion in uphill and downhill walking. An important adjustment strategy in both amputee groups was a smaller hip extension in late stance in uphill and downhill walking, probably related with a shorter step length. In addition, amputees increased knee flexion in early stance in the non-affected limb in uphill walking to compensate for the shorter prosthetic limb length. In downhill walking fewer adjustments were necessary, since the shorter prosthetic limb already resulted in lowering of the body. CONCLUSION: Uphill and downhill walking can be trained in rehabilitation, which may improve safety and confidence of amputees. Prosthetic design should focus on better control of prosthetic knee flexion abilities without reducing stability.

Balance control on a moving platform in unilateral lower limb amputees.

OBJECTIVE: To study balance control on a moving platform in lower limb amputees. DESIGN: Observational cohort study. PARTICIPANTS: Unilateral transfemoral and transtibial amputees and able-bodied control subjects. INTERVENTIONS: Balance control on a platform that moved in the anteroposterior direction was tested with eyes open, blindfolded and while performing a dual task. MAIN OUTCOME MEASURES: Weight bearing symmetry, anteroposterior ground reaction force and centre of pressure shift. RESULTS: Compared to able-bodied subjects, in amputees the anteroposterior ground reaction force was larger in the prosthetic and non-affected limb, and the centre of pressure displacement was increased in the non-affected limb and decreased in the prosthetic limb. In amputees body weight was loaded more on the non-affected limb. Blindfolding or adding a dual task did not influence the outcome measures importantly. CONCLUSION: The results of this study indicate that experienced unilateral amputees with a high activity level compensate for the loss of ankle strategy by increasing movements and loading in the non-affected limb. The ability to cope with balance perturbations is limited in the prosthetic limb. To enable amputees to manage all possible balance disturbances in real life in a safe manner, we recommend to improve muscle strength and control in the non-affected limb and to train complex balance tasks in challenging environments during rehabilitation.

Gait termination in lower limb amputees.

OBJECTIVE: To study the limitations in function and adjustment strategies of lower limb amputees in gait termination. DESIGN: Observational cohort study. SETTING: University Medical Centre. PARTICIPANTS: Unilateral transfemoral and transtibial amputees, and able-bodied control subjects. MAIN OUTCOME MEASURES: Leading limb preference, temporal variables, lower limb joint angles, ground reaction forces, and centre of pressure shift. RESULTS: Compared to able-bodied subjects, amputees showed a decreased peak braking ground reaction force in the prosthetic limb, no anterior centre of pressure shift during leading with the prosthetic limb and an increased mediolateral centre of pressure shift. Amputees used several adjustment strategies to compensate for the limitations in function; leading limb preference for the non-affected limb, longer production of braking force in the non-affected limb, decreased gait termination velocity and more weight-bearing on the non-affected limb. CONCLUSION: Limitations in function and adjustment strategies were mainly similar in transfemoral and transtibial amputees. Due to the lack of active ankle function, amputees were not able to increase the braking force and to shift the centre of pressure anteriorly. Leading with the non-affected limb is favourable for adequate deceleration and balance control, but in daily life not always applicable. It is important that amputees are trained in gait termination during rehabilitation and prosthetic design should focus on a more active role of the prosthetic foot and knee.

Gait initiation in lower limb amputees.

OBJECTIVE: To study limitations in function and adjustment strategies in lower limb amputees during gait initiation. DESIGN: Observational cohort study. SETTING: University Medical Center. PARTICIPANTS: Amputees with a unilateral transfemoral or transtibial amputation, and able-bodied subjects. MAIN OUTCOME MEASURES: Leading limb preference, temporal variables, ground reaction forces, and centre of pressure shift. RESULTS: Amputees demonstrated a decrease in peak anterior ground reaction force, a smaller or absent posterior centre of pressure shift, and a lower gait initiation velocity. The main adjustments strategies in amputees were more limb-loading on the non-affected limb, prolonging the period of propulsive force production in the non-affected limb and initiating gait preferably with the prosthetic limb. CONCLUSION: Since an intact ankle joint and musculature is of major importance in gait initiation, functional limitations and adjustment strategies in transfemoral and transtibial amputees were similar. Improving prosthetic ankle properties and initiating gait with the prosthetic limb may facilitate the gait initiation process in amputees.

Obstacle crossing in lower limb amputees.

OBJECTIVE: To study limitations in function and adjustment strategies in lower limb amputees during obstacle crossing. DESIGN: Observational cohort study. SUBJECTS: Transfemoral and transtibial amputees and able-bodied control subjects. METHODS: In a motion analysis laboratory unimpeded and obstacle crossing runs were performed. The subjects stepped over an obstacle of 0.1m height and thickness and 1m width. Outcome measures were gait velocity, hip, knee and ankle joint angles and leading limb preference. RESULTS: Whereas able-bodied and transtibial subjects demonstrated an increase in knee flexion during obstacle crossing compared to unimpeded walking, in transfemoral amputees the opposite was seen, namely a decrease in knee flexion. The lack of knee strategy in transfemoral amputees was compensated by circumduction at the hip on the prosthetic side and plantar flexion of the non-affected ankle. Transtibial amputees preferred to cross the obstacle with the prosthetic limb first, while transfemoral amputees preferred the non-affected limb. CONCLUSION: The different leading limb strategy in transfemoral and transtibial amputees could be explained by the restricted flexion and propulsion properties of the prosthetic knee. Training of obstacle crossing tasks during rehabilitation and improvement of prosthetic design may contribute to safe obstacle crossing.

Vocational reintegration following spinal cord injury: expectations, participation and interventions.

STUDY DESIGN: Survey. OBJECTIVES: To explore the process of reintegration in paid work following a traumatic spinal cord injury (SCI), including the role of early expectations of individual patients regarding return to work, indicators of success of job reintegration and a description of reintegration interventions and barriers. SETTING: Dutch rehabilitation centre with special department for patients with spinal cord injuries. METHODS: Descriptive analysis of data gathered by a mailed questionnaire, which was returned by 57 persons (response 83%) with traumatic SCI, aged 18-60 years, and data of earlier expectations reported by the individual patients during the rehabilitation admission following SCI from 1990 to 1998. RESULTS: Of 49 respondents who were employed at the moment of the SCI, 45% expected to be able to resume work. These positive expectations were associated with a higher educational level. In 67%, return to work was successful. The chance to reintegrate successfully was better if the patient expected to resume work. Logistic regression analysis did not reveal other significant indicators. About one-third of the 49 respondents working preinjury followed vocational retraining, which was successful for most of them so far. In the majority of work situations modifications have been made, such as job adaptations and reduction of working hours. Several unmet needs regarding reintegration interventions were also reported. CONCLUSIONS: Positive expectations regarding resumption of work after a SCI are an important indicator of successful reintegration in work. An active role of the rehabilitation team is recommended in drawing up a vocational reintegration plan to prepare the patient, the employer and professionals involved in the reintegration process.

Vocational reintegration after a lower limb amputation: a qualitative study.

The objectives of this study were to describe the process of job reintegration, to obtain more detailed information about workplace adjustments, and to assess the positive and negative experiences of amputees (in the Netherlands) who returned to paid work after their lower limb amputation. The study had a retrospective design with semi-structured interviews. The authors used a qualitative methodology to obtain detailed information on the reintegration process. Thirty-two (32) subjects participated with a mean age of 42.6 years. The mean time between amputation and return to work was nearly one year (11.5 months). The most common reasons for delay in return to work were stump problems and problems in wound healing. Fifty percent (50%) of the amputees got different work tasks or another job than before amputation, mainly because of physical restrictions caused by the amputation. The most important motives of the amputees for job reintegration were work as a form of day spending (69%) and social contacts at the workplace (66%). Bad support of the implementing body which takes care of job reintegration and employer (34%) were the most mentioned obstacle to job reintegration. Vocational workers should be regular members in the rehabilitation teams for amputees.

Factors related to successful job reintegration of people with a lower limb amputation.

OBJECTIVE: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. DESIGN: Cross-sectional study. SETTING: University hospital. PATIENTS: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. INTERVENTION: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. MAIN OUTCOME MEASURES: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. RESULTS: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. CONCLUSIONS: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration.

Employment status, job characteristics, and work-related health experience of people with a lower limb amputation in The Netherlands.

OBJECTIVES: To describe the occupational situation of people with lower limb amputations in The Netherlands and to compare the health experience of working and nonworking amputee patients with a nonimpaired reference population. DESIGN: Cross-sectional study in which patients completed a questionnaire about their job participation, type of job, workplace adjustments to their limb loss, their position in the company, and a general health questionnaire. SETTING: Orthopedic workshops in The Netherlands with a population of lower limb amputees. PATIENTS: Subjects were recruited from orthopedic workshops in the Netherlands. They ranged in age from 18 to 60 years (mean, 44.5yr) and had a lower limb amputated at least 2 years (mean, 19.6yr) before this study. MAIN OUTCOME MEASURES: A self-report questionnaire, with 1 part concerning patient characteristics and amputation-related factors, and the other concerning job characteristics, vocational handicaps, work adjustments, and working conditions; and a general health questionnaire (RAND-36) to measure health status. RESULTS: Responses were received from 652 of the 687 patients (response rate, 95%) who were sent the questionnaire. Sixty-four percent of the respondents were working at the time of the study (comparable with the employment rate of the general Dutch population), 31% had work experience but were not presently working, and 5% had no work experience. After their amputations, people shifted to less physically demanding work. The mean delay between the amputation and the return to work was 2.3 years. Many people wished their work was better adjusted to the limitations presented by their disability and they mentioned having problems concerning possibilities for promotion. Seventy-eight percent of those who stopped working within 2 years after the amputation said that amputation-related factors played a role in their decision. Thirty-four percent said that they might have worked longer if certain adjustments had been made. The health experience of people who were no longer working was significantly worse than that of the working people with amputations. CONCLUSIONS: Although amputee patients had a relatively good rate of job participation, they reported problems concerning the long delay between amputation and return to work, problems in finding suitable jobs, fewer possibilities for promotion, and problems in obtaining needed workplace modifications. People who had to stop working because of the amputation showed a worse health experience than working people.

The Timed "up and go" test: reliability and validity in persons with unilateral lower limb amputation.

OBJECTIVE: To determine the interrater and intrarater reliability and the validity of the Timed "up and go" test as a measure for physical mobility in elderly patients with an amputation of the lower extremity. DESIGN: To test interrater reliability, the test was performed for two observers at different times of the same day in an alternating order. To test intrarater reliability, the patients performed the test for one observer on two consecutive visits with an interval of 2 weeks. To test validity, the results of the Timed "up and go" test were compared with the results on the Sickness Impact Profile, 68-item version (SIP68), and the Groningen Activity Restriction Scale (GARS). PATIENTS: Thirty-two patients, age 60 yrs or older, with unilateral transtibial or transfemoral amputation because of peripheral vascular disease. RESULTS: The Timed "up and go" test showed good intrarater and interrater reliability (r = .93 and .96, respectively). A moderate relationship exists between the Timed "up and go" test and the GARS, a good relationship exists with the "physical subscales" of the SIP68, and there is no relationship with the "mental subscales" of the SIP68. CONCLUSIONS: The Timed "up and go" test is a reliable instrument with adequate concurrent validity to measure the physical mobility of patients with an amputation of the lower extremity.