Activity, socket fit, comfort and community participation in lower limb prosthesis users: a Cambodian cohort study.

BACKGROUND: After amputation, many people become less active, feel lonely and lose independence. Understanding the factors associated with low physical activity levels and participation could contribute to defining key interventions which can support prosthesis users so they can live a more active and socially included lifestyle. This longitudinal observational study aims to assess relationships between physical activity, community participation, prosthetic fit, comfort and user satisfaction using actimetry, 3D scans and questionnaires in a Cambodian cohort of established lower limb prosthesis users. METHODS: Twenty participants (5F:15M, nine transfemoral, eleven transtibial, 24-60 years old and 3-43 years since amputation) were recruited. They completed a questionnaire which included their demographics, community participation, prosthesis satisfaction and comfort at the start of the study, and between three and six months later. Their prosthetic sockets and residual limbs were 3D scanned at the start and end of the study. Accelerometers were embedded under the cosmesis on the shank of the prosthesis, to collect ten weeks of activity data. RESULTS: Participants averaged 4470 steps/day (743-7315 steps/day), and wore their prosthesis for most waking hours, averaging 13.4 h/day (4.5-17.6 h/day). Self-reported measures of activity and hours of wear correlated with these accelerometer data (Spearman's rho rs = 0.59, and rs = 0.71, respectively). Participants who were more active wore their prosthesis for more hours/day (Pearson r = 0.73) and were more satisfied with socket fit (rs = 0.49). A longer residual limb correlated with better community participation (rs = 0.56) and comfort (rs = 0.56). Self-reported community participation did not correlate with a person's activity level (rs = 0.13), or their prosthesis comfort (rs = 0.19), and there was only weak correlation between how important the activity was to an individual, and how often they participated in it (rs = 0.37). A simple 0-10 scale of overall comfort did not provide enough detail to understand the types and severity of discomfort experienced. CONCLUSION: Associations between perceived and measured activity levels correlated with socket satisfaction in this cohort of people with established lower limb amputations. The small sample size means these correlations should be interpreted with caution, but they indicate variables worthy of further study to understand barriers to community engagement and physical activity for prosthesis users in Cambodia, and potentially in other settings.

Technology for monitoring everyday prosthesis use: a systematic review.

BACKGROUND: Understanding how prostheses are used in everyday life is central to the design, provision and evaluation of prosthetic devices and associated services. This paper reviews the scientific literature on methodologies and technologies that have been used to assess the daily use of both upper- and lower-limb prostheses. It discusses the types of studies that have been undertaken, the technologies used to monitor physical activity, the benefits of monitoring daily living and the barriers to long-term monitoring, with particular focus on low-resource settings. METHODS: A systematic literature search was conducted in PubMed, Web of Science, Scopus, CINAHL and EMBASE of studies that monitored the activity of prosthesis users during daily-living. RESULTS: Sixty lower-limb studies and 9 upper-limb studies were identified for inclusion in the review. The first studies in the lower-limb field date from the 1990s and the number has increased steadily since the early 2000s. In contrast, the studies in the upper-limb field have only begun to emerge over the past few years. The early lower-limb studies focused on the development or validation of actimeters, algorithms and/or scores for activity classification. However, most of the recent lower-limb studies used activity monitoring to compare prosthetic components. The lower-limb studies mainly used step-counts as their only measure of activity, focusing on the amount of activity, not the type and quality of movements. In comparison, the small number of upper-limb studies were fairly evenly spread between development of algorithms, comparison of everyday activity to clinical scores, and comparison of different prosthesis user populations. Most upper-limb papers reported the degree of symmetry in activity levels between the arm with the prosthesis and the intact arm. CONCLUSIONS: Activity monitoring technology used in conjunction with clinical scores and user feedback, offers significant insights into how prostheses are used and whether they meet the user's requirements. However, the cost, limited battery-life and lack of availability in many countries mean that using sensors to understand the daily use of prostheses and the types of activity being performed has not yet become a feasible standard clinical practice. This review provides recommendations for the research and clinical communities to advance this area for the benefit of prosthesis users.

Khmer translation and cultural adaptation of the Locomotor Capabilities Index-5.

BACKGROUND: Mobility is a major goal of prosthetic and orthotic rehabilitation, and use of outcome measures to evaluate mobility is necessary for good clinical practice. To support the use of outcome measures worldwide, work is needed to translate relevant instruments and adapt them for use in multiple cultures. OBJECTIVES: The objective of this research was to use a standardized method to translate the Locomotor Capabilities Index-5 (LCI-5) into Khmer, the national language in Cambodia, and to evaluate its cultural integrity by assessing it with a group of prosthesis and orthosis users. STUDY DESIGN: Instrument translation and cultural validation. METHODS: Two forward translations of the LCI-5 were produced and then reconciled into a single document. The Khmer version was back translated into English, and a group of experts reviewed the back translation. Two rounds of cognitive interviews were conducted with lower-limb prosthetic and orthotic users who provided feedback. RESULTS: During the reconciliation process, minor changes were made to 6 of the 14 items. Changes were most often made to better reflect the conceptual meaning of the original English version. Cognitive interviews resulted in the addition of a new response alternative. CONCLUSIONS: Use of a standardized method to translate the LCI-5 resulted in a linguistically and culturally valid Khmer version of the instrument. Following appropriate psychometric testing, this instrument will facilitate measurement of mobility in prosthetic and orthotic clinical practice in Cambodia as well as support national and multinational research.

Listening to children with lower limb loss: Rationale, design, and protocol for delivery of a novel globally applicable research toolkit-Prosthetic user needs, quality of life, pain, and physical function.

INTRODUCTION: Rehabilitation after childhood lower limb loss is complex and dependent on multiple stakeholders and environmental factors. While research with adults underscores the importance of involving prosthetic limb users and caregivers in discussions to drive innovation, children are often excluded or not effectively engaged. This protocol lays out the development and implementation protocol for an internationally applicable research toolkit which has been designed and evaluated around the essential presence of the child. Research domains span their unique prosthetic needs, quality of life, pain, and mobility. METHODS AND ANALYSIS: Cohorts of children in contrasting environments were identified (Cambodia, Gaza Strip, and the UK) to provide a comprehensive global understanding of the child with lower limb loss. A literature review revealed a lack of appropriate tools for identifying paediatric prosthetic user requirements leading to the development of novel interview guides for each key stakeholder: child, caregiver, and prosthetist. The child's guide centred around enjoyment and engagement using card games and activities. A panel of experts in paediatric limb loss and mental health rigorously reviewed the guides. Guides were integrated with existing validated measures for quality of life, pain, and mobility to form a comprehensive toolkit. The toolkit was successfully piloted with 5 children, their families, and 2 prosthetists. This protocol lays out the toolkit rationale and implementation plan (Jan 2023 to Dec 2025). This work offers the opportunity for this cohort to enjoyably engage with research that seeks to radically improve prospects for all children living with limb loss. The outlined best practices ensure ethical considerations when working with vulnerable cohorts. ETHICS AND DISSEMINATION: This study is approved to cover implementation at all geographical locations as well as the researcher institutions. Results will be disseminated through national and international conferences, as well as through manuscripts in leading peer-reviewed journals.

From outcome measurement to improving health outcomes after lower limb amputation-A narrative review exploring outcome measurement from a clinical practice perspective.

Outcome measurement is essential to understand the impact of clinical interventions and the performance of services. Despite national and professional body encouragement, and successful examples of system level outcome measurement within some health care settings, many barriers still exist preventing outcome measurement from becoming embedded in clinical practice. This paper presents a narrative review which aims to describe the state of the outcome measurement evidence base in prosthetic rehabilitation, as applied in clinical practice, with a view to identifying areas for future work aimed at making outcome measurement in prosthetic rehabilitation a meaningful reality. A literature search of four databases was undertaken, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis principals appropriate to narrative reviews, and using the search terms outcome, measur*, tool, scale, instrument, prosthe*, amput* and limb loss. A total of 1116 papers were identified. Following screening 35 papers, focusing on four main themes, were included in the review. Themes were: 1) What outcome domains should be measured? 2) How can these outcome domains be measured? 3) What are the barriers to outcome measurement? and 4) What can be learnt from examples of ROM in prosthetic rehabilitation? Findings suggest that successful outcome measurement is multifaceted. Understanding and embedding value at every step appears to be key to success. Addressing the questions of 'what' outcome domains to measure and 'how' to measure them, may help establish consensus. Routine outcome measurement practice at the clinical level should ensure data collection is valuable to clinical practice, makes use of information technology solutions and has organisational engagement.

Learning about the changing needs for prosthetics service provision from routinely collected digital centre management data: An exemplar study across three clinics in Cambodia.

Background: Prosthetic service development and delivery rely on data describing population needs. These needs are context-specific, but most existing data come from high-income countries or small geographic areas, which are often not comparable. This study analysed routinely collected digital patient record data at multiple time points to provide insights into characteristics of people accessing Cambodian prosthetic services. Methods: We investigated trends in birth year, sex, year and reason for limb absence, and prosthesis type, over three decades. Then, we observed data from 2005 and 2019 indicating how the population actively accessing prosthetics services has changed. Results: Temporal trends in prosthetics service user demographics corresponded with events in Cambodia's socio-political history. The predominant historical reason for limb absence prior to 2000 was weapon trauma during and following conflict. Since 2000, this was replaced by non-communicable disease and road accidents. Transtibial remained the most prevalent amputation level but transfemoral amputation had higher incidence for people with limb loss from road accidents, and people with limb loss due to disease were older. These observations are important as both transfemoral and older-aged groups experience particular rehabilitation challenges compared to the young, transtibial group. Conclusions: The study shows how standardised, routinely collected data across multiple clinics within a country can be used to characterise prosthetics service user populations and shows significant changes over time. This indicates the need to track client characteristics and provides evidence for adapting services according to population dynamics and changes in patient need.

Functional outcomes and user preferences of individuals with transfemoral amputations using two types of knee joints in under-resourced settings.

BACKGROUND: Information relating to prosthetic performance can inform clinical practice and improve patient outcomes in under-resourced countries. OBJECTIVES: The main goal of this study was to compare functional outcomes and user preferences of individuals with transfemoral amputations using common types of knee joints in an under-resourced country. STUDY DESIGN: Prospective, longitudinal, before and after trial. METHODS: Twenty individuals with unilateral transfemoral amputations from a center in Cambodia transitioned from a commonly used single-axis manually locking knee International Committee of the Red Cross (ICRC) to a more advanced multiaxis knee joint with stance control All-Terrain Knee (ATK). Data were collected for the ICRC knee joint and the ATK immediately after fitting, after acclimation, and as part of a long-term follow-up. A timed walk test assessed walking distance and efficiency. Mobility and user-preferences were evaluated through questionnaires. RESULTS: Distance during the timed walk test was significantly higher for the ATK compared with ICRC (P < 0.001), with functional gains retained at follow-up. No differences were found for gait efficiency and the mobility questionnaires. All participants, except one, preferred the ATK prosthesis. Benefits included greater knee stability and fewer perceived knee collapses; however, some disliked the appearance of the ATK. CONCLUSIONS: The findings suggest positive outcomes with prosthetic services in under-resourced regions and the ICRC system, as well as the potential for improved functional outcomes with more advanced multiaxis knee components.

Education in prosthetic and orthotic training: Looking back 50 years and moving forward.

There is a long history of prosthetic and orthotic services helping to mitigate the impact of physical impairment by restoring function, and enabling and equipping the user. The training of health professionals who design, fit, and maintain prosthetic and orthotic devices has evolved over the centuries, reflecting an increase in knowledge, technology, understanding, and social attitudes in each era. Improvements in pedagogical thinking and biomechanical understanding, as well as the advent of new integrated technologies, have driven the profession over the past 50 years to modernize, evolve training and service delivery models in line with new attitudes toward clients, and search for new ways to improve users' quality of life. In this narrative review, the authors examined the evolution of prosthetic and orthotic education, the impact of changing educational techniques and technologies, and the impact of the International Society for Prosthetics and Orthotics in that process. Through conversations with experts and review of peer-reviewed literature, accreditation documents, and the International Society for Prosthetics and Orthotics records and databases, the authors identified three areas of change in prosthetics and orthotics education over the past 50 years: (1) prosthetic/orthotic curriculum content, (2) pedagogy and course delivery, and (3) internships/residencies. This narrative review is a snapshot of a growing profession and we can only speculate where the next 50 years will lead us as we strive to serve patients, ever placing their needs and aspirations at the center of this professional service.

The challenges of upgrading from ISPO Category II level to Bachelor Degree level by distance education.

The Cambodian School of Prosthetics and Orthotics (CSPO) in collaboration with La Trobe University, Australia, has established an upgrade programme from ISPO Category II level to a Bachelor Degree in Prosthetics and Orthotics. One group of students have completed the course and following a review process, a second group are now enrolled. The upgrade curriculum focuses on clinical reasoning and development of learning skills. A survey aimed to investigate the challenges of the programme using long distance education was prepared and data was gathered by questionnaires delivered to the organizer, host, coordinators, lecturers and students of the programme. Eleven subjects from various backgrounds participated in the questionnaire. The questionnaire showed the programme improves the capacity of the clinicians and future educators in Cambodia and the region. The distance education course delivery method was found to be beneficial for the students and allows them to remain in their home country. In addition, there is a cost reduction compared to full-time study in Australia.