Targeted Muscle Reinnervation Improves Pain and Ambulation Outcomes in Highly Comorbid Amputees.

BACKGROUND: Approximately 200,000 people undergo a lower extremity amputation each year. Following amputation, patients suffer from chronic pain, inability to ambulate, and high mortality rates. Targeted muscle reinnervation is a nerve transfer procedure that redirects transected sensory and mixed nerves into motor nerves to treat neuroma and phantom limb pain. This study evaluates outcomes with prophylactic targeted muscle reinnervation at the time of below-knee amputation. METHODS: This is a cohort study comparing 100 patients undergoing below-knee amputation with primary targeted muscle reinnervation and 100 patients undergoing below-knee amputation with standard traction neurectomy and muscle implantation. Outcome metrics included the presence of residual and phantom limb pain, pain severity, opioid use, ambulation ability, and mortality rates. RESULTS: The targeted muscle reinnervation group was on average 60 years old with a body mass index of 29 kg/m2. Eighty-four percent had diabetes, 55 percent had peripheral vascular disease, and 43 percent had end-stage renal disease. Average follow-up was 9.6 months for the targeted muscle reinnervation group and 18.5 months for the nontargeted muscle reinnervation group. Seventy-one percent of targeted muscle reinnervation patients were pain free, compared with 36 percent (p < 0.01). Fourteen percent of targeted muscle reinnervation patients had residual limb pain, compared with 57 percent (p < 0.01). Nineteen percent of targeted muscle reinnervation patients had phantom limb pain, compared with 47 percent (p < 0.01). Six percent of targeted muscle reinnervation patients were on opioids, compared with 26 percent (p < 0.01); and 90.9 percent of targeted muscle reinnervation patients were ambulatory, compared with 70.5 percent (p < 0.01). CONCLUSION: Targeted muscle reinnervation reduces pain and improves ambulation in patients undergoing below-knee amputation, which may be critical in improving morbidity and mortality rates in this comorbid patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Improving Postoperative Outcomes in Lower Extremity Amputees Utilizing a Quality Improvement Approach.

This project focused on adult lower extremity amputees from March 2017 through March 2019. The aim was to improve 30-day surgical site infection (SSI) rates by 10% in two orthopaedic populations. Subaims focused on 30-day readmission rates, length of stay, and 30-day mortality rates. The primary intervention of incisional negative pressure wound vac therapy (iNPWT) device application was instituted. This was supported by World Health Organization recommendations, meta-analyses, and consensus statements advising the utilization of iNPWT devices. Plan-Do-Study-Act cycles were aimed at education, operation efficiency, and patient engagement. By March 2019, goals were met for SSI and 30-day readmission rates in each division. Cost analysis showed a savings of $38,500. Improved clinical significance was noted in SSI rates, 30-day readmission rates, and cost in lower extremity amputees. It is unclear whether the innovation led to improvement in the other subaims; however, this revealed areas for additional areas for improvement.

Circumference Method Estimates Percent Body Fat in Male US Service Members with Lower Limb Loss.

BACKGROUND: The Department of Defense circumference method (CM) is used to estimate percent body fat (%BF) in evaluation of health, physical fitness, appearance, and military readiness; however, the CM has not been validated in individuals with lower limb loss. OBJECTIVE: To evaluate the agreement between CM and dual-energy X-ray absorptiometry (DXA) for measuring %BF in individuals with lower limb loss. DESIGN: This study is part of a larger cross-sectional comparison study, and this analysis was included as a secondary objective. Two methods of measuring %BF included CM and DXA, with DXA as the reference standard for this study. PARTICIPANTS/SETTING: This study was conducted at Walter Reed Army Medical Center. Data were collected from summer 2010 to summer 2011. One hundred individuals, 50 with and 50 without lower limb loss, were screened for this study; three individuals with limb loss and two without limb loss had incomplete data, and one individual (female, without limb loss) lacked a comparison participant. All participants were recruited from a military medical center, and data were collected in a clinic research laboratory. MAIN OUTCOME MEASURES: Measurements of %BF were compared between methods for each group. STATISTICAL ANALYSES PERFORMED: Measurements of %BF were compared using paired t-tests and intraclass correlation coefficient. Agreement and bias were assessed with Bland-Altman analysis. Receiver operating characteristic analysis was used to determine the diagnostic accuracy of the CM to identify participants with %BF levels in the obese category (≥25%). RESULTS: A statistically significant difference was found between %BF methods in the group with limb loss (1.7%; P = 0.001) and the group without limb loss (1.4%; P = 0.005), with DXA consistently higher than CM. However, the intraclass correlation coefficient estimates for the agreement between %BF by CM and DXA were 0.848 (95% confidence interval [CI]: 0.683-0.922; P < 0.001) and 0.828 (CI: 0.679-0.906; P < 0.001), for the groups with and without limb loss, respectively, suggesting that CM has good to near excellent agreement with DXA for estimating %BF in these groups. Receiver operating characteristic analysis indicated that the area under the curve supported predictive ability to detect obesity-based %BF in males with and without limb loss. CONCLUSIONS: Although a statistically significant difference was found between methods for individuals with limb loss, there was also good agreement between the methods, suggesting that CM may be a useful tool for estimating %BF in individuals with lower limb loss. The CM may be a useful and field expedient method for assessing %BF in a clinical setting when DXA is not available.

What happens to our amputees? The Darling Downs experience.

BACKGROUND: Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation. METHODS: All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation. RESULTS: A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years. CONCLUSION: The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Optimizing Peripandemic Care for Veteran Major Non-Traumatic Lower Extremity Amputees: A Proposal Informed by a National Retrospective Descriptive Analysis of COVID-19 Risk Factor Prevalence.

INTRODUCTION: In response to the Coronavirus 2019 (COVID-19) pandemic, vascular surgeons in the Veteran Affairs Health Care System have been undertaking only essential cases, such as advanced critical limb ischemia. Surgical risk assessment in these patients is often complex, considers all factors known to impact short- and long-term outcomes, and the additional risk that COVID-19 infection could convey in this patient population is unknown. The European Centre for Disease Prevention and Control (ECDC) published risk factors (ECDC-RF) implicated in increased COVID-19 hospitalization and case-fatality which have been further evidenced by initial reports from the United States Centers for Disease Control and Prevention. CDC reports additionally indicate that African American (AA) patients have incurred disparate infection outcomes in the United States. We set forth to survey the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database over a nearly 20 year span to inform ongoing risk assessment with an estimation of the prevalence of ECDC-RF in our veteran critical limb ischemia population and investigate whether an increased COVID-19 comorbidity burden exists for AA veterans presenting for major non-traumatic amputation. MATERIALS AND METHODS: The VASQIP database was queried for all above knee amputation (AKA) and below knee amputation (BKA) completed 1999-2018 after IRB approval (MIRB:#02507). Patient race and ECDC-RF including male gender, age > 60 years, smoking status, hypertension, diabetes, chronic obstructive pulmonary disease, cancer, and cardiovascular disease were recorded from preoperative patient history. AKA and BKA cohorts were compared via χ2-test with Yates correction or unpaired t-test and a subgroup analysis was conducted between AA and all other race patients for COVID-19 comorbidities in each cohort. RESULTS: VASQIP query returned 50,083 total entries. Average age was 65.1 ± 10.4 years and 68.2 ± 10.5 years for BKA and AKA cohorts, respectively, (P < .0001) and nearly all patients were male (99%). At least one ECDC-RF comorbidity was present in 25,526 (88.7%) of BKA and 17,558 (82.4%) of AKA patients (P < .0001). AA BKA patients were significantly more likely than non-AA BKA patients to present with at least one ECDC-RF comorbidity (P = .01). CONCLUSIONS: According to a large national Veterans Affairs database, there are high rates of ECDC-RF in veteran amputees. During the present crisis, management of these patients should incorporate telehealth, expedient discharge, and ongoing COVID-19 transmission precautions.

The Effectiveness of the DoD/VA Mobile Device Outcomes-Based Rehabilitation Program for High Functioning Service Members and Veterans with Lower Limb Amputation.

INTRODUCTION: The objective was to determine if the Mobile Device Outcomes-based Rehabilitation Program (MDORP) improved strength, mobility, and gait quality in service members (SMs) and Veterans with lower limb amputation (LLA). METHODS: Seven SMs and 10 Veterans with LLA enrolled and were trained to use a mobile sensor system, called Rehabilitative Lower Limb Orthopedic Analysis Device (ReLOAD). ReLOAD provided participants with real-time assessment of gait deviations, subsequent corrective audio feedback, and exercise prescription for normalizing gait at home and in the community. After baseline testing, prosthetic gait and exercise training, participants took ReLOAD home and completed an 8-week walking and home exercise program. Home visits were conducted every 2 weeks to review gait training and home exercises. RESULTS: Significant improvements in hip extensor strength, basic and high-level mobility, musculoskeletal endurance, and gait quality (P < 0.05) were found at the completion of the 8-week intervention. CONCLUSION: Preliminary MDORP results are promising in its ability to improve basic and high-level mobility, lower limb strength, and gait quality in a group of SMs and Veterans with LLA. In addition, "booster" prosthetic training may be justified in an effort helps maintain an active lifestyle, promotes prosthetic use, and mitigates secondary health effects.

Comparison of the Functional Outcomes of Lower Limb Amputees with or without End-Stage Renal Disease.

BACKGROUND: The potential for full rehabilitation following amputation among end-stage renal disease patients is poor. OBJECTIVES: To evaluate the functional outcomes and survival among amputees treated with hemodialysis at the end of the rehabilitation procedure. METHODS: We recruited 46 patients after lower limb amputation. Of these individuals, 19 (41.3%) were treated with dialysis and 27 (58.7%) were non-dialysis-dependent patients (NDDP). Both groups were divided into three sub-groups according to their independence with regard to activities of daily living (ADL) and their ability to walk with prostheses. RESULTS: The survival of lower limb amputees treated with dialysis was shorter compared to NDDP. Survival after amputation among the NDDP who were fully or partially independent in ADL and with regard to mobility, was longer compared to the non-mobile amputees as with the patients treated with dialysis. CONCLUSIONS: Survival was significantly longer in lower limb amputees NDDP and shorter in patients who did not achieve a certain level of functioning.

Low back pain in persons with lower extremity amputation: a systematic review of the literature.

BACKGROUND CONTEXT: Lower extremity amputation (LEA) is associated with an elevated risk for development and progression of secondary health conditions. Low back pain (LBP) is one such condition adversely affecting function, independence, and quality of life. PURPOSE: The purpose of this study was to systematically review the literature to determine the strength of evidence relating the presence and severity of LBP secondary to LEA, thereby supporting the formulation of empirical evidence statements (EESs) to guide practice and future research. STUDY DESIGN/SETTING: Systematic review of the literature. METHODS: A systematic review of five databases was conducted followed by evaluation of evidence and synthesis of EESs. RESULTS: Seventeen manuscripts were included. From these, eight EESs were synthesized within the following categories: epidemiology, amputation level, function, disability, leg length, posture, spinal kinematics, and osseointegrated prostheses. Only the EES on epidemiology was supported by evidence at the moderate confidence level given support by eight moderate quality studies. The four EESs for amputation level, leg length, posture, and spinal kinematics were supported by evidence at the low confidence level given that each of these statements had some evidence not supporting the statement but ultimately more evidence (and of higher quality) currently supporting the statement. The remaining three EESs that addressed function, disability and osseointegrated prosthetic use were all supported by single studies or had comparable evidence that disagreed with study findings rendering insufficient evidence to support the respective EES. CONCLUSIONS: Based on the state of the current evidence, appropriate preventative and, particularly, treatment strategies to manage LBP in persons with LEA remain a knowledge gap and an area of future study.

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.

Clinical Application of Mathematical Long Bone Ratios to Calculate Appropriate Donor Limb Lengths in Bilateral Upper Limb Transplantation.

Background: Limited methods exist to aid in deciding the appropriate donor limb lengths in bilateral upper limb amputees qualifying for vascularized composite allotransplantation. We hypothesized mathematical equations could be created using long bone length ratios, and applied to radiographs, to approximate the patient's limb length prior to amputation. Methods: A data set of 30 skeletons' unilateral upper limb long bones measured using osteometric board and calipers was used. Anatomic segment ratios were calculated based on humerus length after multivariate linear regression analysis. For clinical application testing, 5 cadavers' upper limbs were radiographed. Radiographic bone lengths were then measured along the long axis of each long bone. These measured radiographic lengths were then compared with the predicted bone lengths, generated from the skeleton data set ratios, for each cadaver. Results: The chi-square goodness-of-fit test showed excellent fit (P < .01) between the predicted and radiographically measured lengths for the 5 cadavers, and interobserver measurements showed no statistical difference. Depending on the cadaver, percent error in total limb length predicted to measure ranged from 0.9% to 2.7%. The variables to multiply an individual humerus length to calculate a given anatomic segment thus proved to be effective. Conclusions: If a bilateral upper limb amputee has 1 intact humerus, ratios to the humerus length can be reliably applied to calculate the preamputation limb length based on the patient's radiographic humerus length. These formulas are indicated for finding the appropriate limb lengths, and smaller anatomic segments, for donor-recipient matching in upper limb transplantation.

Life after conflict-related amputation trauma: a clinical study from the Gaza Strip.

BACKGROUND: More than 17.000 Palestinians were injured during different Israeli military incursions on the Gaza Strip from 2006 to 2014. Many suffered traumatic extremity amputations. We describe the injuries, complications, living conditions and health among a selection of traumatic amputees in the Gaza Strip. METHODS: We included 254 civilian Palestinians who had survived, but lost one or more limb(s) during military incursions from 2006 to 2016. All patients were receiving follow-up treatment at a physical rehabilitation center in Gaza at the time of inclusion. We measured and photographed anatomical location and length of extremity amputations and interviewed the amputees using standard questionnaires on self-reported health, socioeconomic status, mechanism of injury, physical status and medical history. RESULTS: The amputees were young (median age 25,6 years at the time of trauma), well educated (37% above graduate level), males (92%), but also 43 children (17% ≤ 18 years). The greater part suffered major amputations (85% above wrist or ankle). Limb losses were unilateral (35% above-, 29·5% below knee), and bilateral (17%) lower extremity amputations. Pain was the most frequent long-term complaint (in joints; 34%, back; 33% or phantom pain; 40·6%). Sixty-three percent of amputees were their family's sole breadwinner, 75·2% were unemployed and 46% had lost their home. Only one in ten (11·6%) of the destroyed homes had been rebuilt. CONCLUSIONS: The most frequently observed amputees in our study were young, well-educated male breadwinners and almost one in five were children. Conflict-related traumatic amputations have wide-ranging, serious consequences for the amputees and their families.

Knee adduction moment peak and impulse do not change during the first six months of walking with a prosthesis.

BACKGROUND: Individuals with unilateral lower limb loss are at increased risk for developing knee osteoarthritis in their contralateral limb. The mechanisms underlying this phenomenon are unknown, but large or unusual loads on the limb are thought to contribute to osteoarthritis development. Yet, to our knowledge, there have been no longitudinal assessments of knee joint kinetics to assist with identifying the origin or progression of such loads. RESEARCH QUESTION: This study aimed to examine knee joint kinetics of individuals with lower limb loss as a function of time from independent ambulation. METHODS: Eight male Service Members with unilateral lower limb loss (3 transfemoral/5 transtibial) completed gait analyses, walking at self-selected speed and cadence, at 0, 2, and 6 months following initial independent ambulation. RESULTS: Although there was a significant time effect on stride length (p = 0.047), there were no pairwise differences (all p ≥ 0.152). Additionally, there was not a significant effect of time on the peak (p = 0.666), loading rate (p = 0.336), or impulse (p = 0.992) of knee adduction moment (KAM), peak knee flexion moment (KFM) (p = 0.128), or the peak (p = 0.485) or loading rate (p = 0.130) of vertical ground reaction force (VGRF). SIGNIFICANCE: The results of the current study demonstrate that major features of knee joint loading do not change over the first 6 months of independently walking with a prosthesis. The magnitude of these loads are similar to loads observed in individuals with lower limb loss further from injury/initial ambulation, but the present results do not imply that no changes occur after 6 months.

The quality of life analysis of knee prosthesis with complete microprocessor control in trans-femoral amputees.

OBJECTIVE: The aim of this study was to analyze the patient demographics, etiology of limb loss as well as reporting SF-36 scores for microprocessor prosthesis users in Turkish population. METHODS: We reviewed 72 patients (61 male and 11 female; mean age: 37.7 ± 10.7) with uni-lateral, above knee amputation and a history of regular and microprocessor prosthesis use. All patients were called back for a last follow-up and they were asked to fill a self-administered general health status questionnaire (SF-36). RESULTS: According to the SF-36 results; physical component score (PCS) score was 46 ± 7.3 and mental components summary (MCS) score was 46.5 ± 9.1. These scores have statistical similarity with Turkish healthy controls, except SF (social functioning) sub-dimension. PCS score for women microprocessor users were significantly lower than men (43.3 vs. 48.7, p = 0.03), but MCS scores were similar in between genders (46 vs. 48.2, p = 0.13). Conventional prostheses usage time was positively correlated with physical function (PF) scores (r = 0.322, p = 0.010). Microprocessor prosthesis usage time was negatively correlated with role limitations due to emotional problem (RE) scores (r = -0,313, p = 0.009). CONCLUSION: The quality of life surveys were showed that the loss of an extremity have higher physical and psychological impact on women's physical scores. Overall, SF-36 results were similar in microprocessor using amputee's and Turkish normal controls. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Characteristics of US combat veterans (2001-2011) who remain on active duty after upper extremity amputations.

OBJECTIVES: Return to duty following traumatic amputations has been extensively studied in those with lower extremity amputation. As upper extremity amputations occur less frequently, the issue of return to duty for those with upper extremity amputations has received relatively little research. The purpose of this study was to determine the rate at which service members remain on active duty at least one year after having sustained traumatic upper extremity amputations during Operation Iraqi Freedom, Operation Enduring Freedom, and other overseas contingency operations of the Global War on Terrorism. DESIGN: Retrospective. SETTING: Military, Academic Level 1 trauma center. PATIENTS: One hundred eighteen patients who sustained combat-related upper extremity amputations between October 2001 and December 2011. INTERVENTION: Data was obtained from the medical record for these 118 patients. MAIN OUTCOME MEASUREMENTS: Percentage of service member remaining on active duty one year following an upper extremity amputation, and evaluation of demographic and injury related factors associated with retention. RESULTS: The overall rate for the upper extremity amputees studied at one year from injury who remained on active duty was 47%. Officers were more likely to remain on active duty than their enlisted counterparts (P=.021) and patients who sustained burns were also more likely to remain on active duty than patients with similar amputation types without concomitant burn injuries (P=.039). CONCLUSIONS: The rate of service members with traumatic upper extremity amputations who were still on active duty status 1-year postinjury was 47%. The presence of burns and rank were significant factors when examining retention on active duty. Further study on war casualties who sustain upper-extremity traumatic amputations with and without burns is required to optimize outcomes in this population.

The importance of orthoses on activities of daily living in patients with unilateral lower limb amputations.

BACKGROUND: The role of the selected prothesis on activities of daily living (ADL). OBJECTIVE: To evaluate the impact of prothesis on ADL in patients with lower-limb amputations. METHODS: The data of 500 patients with unilateral lower limb amputation were recorded. The activity level was defined based on the Medicare Functional Classification Level. Old and new prescribed prosthesis were recorded. Nottingham Extended Activities of daily living activities Daily Living Scale was used to evaluate ADL. RESULTS: Amputation levels were transfemoral (TF) in 268 (53.6%), transtibial (TT) in 178 (35.6%), knee disarticulation (KD) in 54 (10.8%). In patients with TF and KD amputation active vacuum system, pin modular system, hydraulic system and mechanical modular prosthesis were replaced with the swing stance phase microprocessor-controlled prostheses. In patients with TT amputation pin modular system, hydraulic system and mechanical modular prosthesis were converted to active vacuum system prostheses. Prescribed new prosthesis has caused a statistically significant increase in all amputation levels in ADL of patients (p≤ 0.05). CONCLUSIONS: We observed that there was significant improvement in ADL when conventional prostheses replaced with advanced technology prostheses in unilateral lower extremity amputation patients.

Epidemiologic data of trauma-related lower limb amputees: A single center 10-year experience.

OBJECTIVE: The aim of this study is three fold: 1) to introduce epidemiologic data of patients with trauma-related amputations as a 10-year experience of a rehabitation center; 2) to determine comorbidities and secondary conditions of lower limb loss; 3) to determine the rehospitalization reasons for lower limb amputee patients. MATERIALS AND METHODS: This retrospective study was conducted in a tertiary rehabilitation center in Turkey. Clinical and demographic data of amputees including sex, age, employment status, time since amputation, time after amputation to first hospitalization, length of hospitalization, how many times the patient was hospitalized, reason for hospitalization, stump complications, comorbid conditions, amputation level and K classifacation were documented. RESULTS: Three hundred ninetynine patients with a mean age of 23,48±6,04 (4-74) years were included in this study. Mean duration after amputation was 119,71±68,86months. Patients were 3,43±2,53 times hospitalized. Landmine explosion was the most common etiology of amputation with 370 patients (92.7%). Below knee amputation was the most common amputation level with 230 (50,77%) amputations. 399 patients were hospitalized 1369 times and the most common hospitalization reason were stump complications (356 times, 26,00%). Spur formation (202 times) was the most common stump complications. Pyscologic disorders were the most common comorbidity with 68 patient (37,56%). CONCLUSION: Patients with traumatic limb amputations are likely to experience several complications and comorbidities. Prevention of secondary conditions affecting those living with the loss of a limb is an important part of amputee rehabilitation and may prevent rehospitalization.

A comprehensive musculoskeletal and peripheral nervous system assessment of war-related bilateral upper extremity amputees.

BACKGROUND: Upper limb amputations are one of the unpleasant war injuries that armed forces are exposed to frequently. The present study aimed to assess the musculoskeletal and peripheral nervous systems in Iraq-Iran war veterans with bilateral upper extremity amputation. METHODS: The study consisted of taking a history and clinical examinations including demographic data, presence and location of pain, level of amputation, passive and active ranges of movement of the joints across the upper and lower extremities and spine, manual palpation, neurological examination, blood circulation pulses and issues related to a prosthetic limb. In this study, 103 Iranian bilateral upper extremity amputees (206 amputations) from the Iran-Iraq war were evaluated, and a detailed questionnaire was also administered. RESULTS: The most common level of amputation was the finger or wrist level (108, 52.4 %). Based on clinical examination, we found high frequencies of limited active and passive joint range of movement across the scapula, shoulder, elbow, wrist and metacarpophalangeal, interphalangeal and thumb joints. Based on muscle strength testing, we found varying degrees of weakness across the upper limbs. Musculoskeletal disorders included epicondylitis (65, 31.6 %), rotator cuff injury (24, 11.7 %), bicipital tendonitis (69, 33.5 %), shoulder drop (42, 20.4 %) and muscle atrophy (19, 9.2 %). Peripheral nerve disorders included carpal tunnel syndrome in 13 (6.3 %) and unilateral brachial plexus injury in 1 (1 %). Fifty-three (51.5 %) were diagnosed with facet joint syndrome at the level of the cervical spine (the most frequent site). Using a prosthesis was reported by 65 (63.1 %), both left and right sides. The back was the most common site of pain (71.8 %). CONCLUSION: The high prevalence of neuro-musculoskeletal disorders among bilateral upper extremity amputees indicates that they need regular rehabilitation care.

Embodied prosthetic arm stabilizes body posture, while unembodied one perturbs it.

Senses of ownership (this arm belongs to me) and agency (I am controlling this arm) originate from sensorimotor system. External objects can be integrated into the sensorimotor system following long-term use, and recognized as one's own body. We examined how an (un)embodied prosthetic arm modulates whole-body control, and assessed the components of prosthetic embodiment. Nine unilateral upper-limb amputees participated. Four frequently used their prosthetic arm, while the others rarely did. Their postural sway was measured during quiet standing with or without their prosthesis. The frequent users showed greater sway when they removed the prosthesis, while the rare users showed greater sway when they fitted the prosthesis. Frequent users reported greater everyday feelings of postural stabilization by prosthesis and a larger sense of agency over the prosthesis. We suggest that a prosthetic arm maintains or perturbs postural control, depending on the prosthetic embodiment, which involves sense of agency rather than ownership.

Upper Limb Absence: Predictors of Work Participation and Work Productivity.

OBJECTIVES: To analyze work participation, work productivity, contributing factors, and physical work demands of individuals with upper limb absence (ULA). DESIGN: Cross-sectional study: postal survey (response rate, 45%). SETTING: Twelve rehabilitation centers and orthopedic workshops. PARTICIPANTS: Individuals (n=207) with unilateral transverse upper limb reduction deficiency (RD) or acquired amputation (AA), at or proximal to the carpal level, between the ages of 18 and 65 years, and a convenience sample of control subjects (n=90) matched on age and sex. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Employment status, self-reported work productivity measured with the Quality-Quantity method, and self-reported upper extremity work demands measured with the Upper Extremity Work Demands scale. RESULTS: Seventy-four percent of the individuals with RD and 57% of the individuals with AA were employed (vs 82% of the control group and 66% of the general population). Male sex, younger age, a medium or higher level of education, prosthesis use, and good general health were predictors of work participation. Work productivity was similar to that of the control group. Higher work productivity was inversely related to musculoskeletal complaint-related pain. When having predominantly mentally demanding work, individuals with ULA perceived higher upper extremity work demands compared with controls. CONCLUSIONS: Work participation of individuals with RD was slightly higher compared with that of the general population, whereas employment rates of individuals with AA were slightly lower. Furthermore, work productivity did not differ between individuals with RD, AA, and controls.