Search

Objective: To determine if lower limb prosthesis (LLP) sophistication is associated with patient-reported mobility and/or mobility satisfaction, and if these associations differ by amputation level., Design: Cohort study that identified participants through a large national database and prospectively collected self-reported patient outcomes., Setting: The Veterans Administration (VA) Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls., Participants: 347 Veterans who underwent an incident transtibial (TT) or transfemoral (TF) amputation due to diabetes and/or peripheral artery disease and received a qualifying LLP between March 1, 2018, and November 30, 2020., Interventions: Basic, intermediate, and advanced prosthesis sophistication was measured by the accurate and reliable PROClass system., Main Outcome Measure: Patient-reported mobility using the advanced mobility subscale of the Locomotor Capabilities Index-5; mobility satisfaction using a 0-10-point Likert scale., Results: Lower limb amputees who received intermediate or advanced prostheses were more likely to achieve advanced mobility than those who received basic prostheses, with intermediate nearing statistical significance at nearly twice the odds (adjusted odds ratio (aOR)=1.8, 95% confidence interval (CI), .98-3.3; P=.06). The association was strongest in TF amputees with over 10 times the odds (aOR=10.2, 95% CI, 1.1-96.8; P=.04). The use of an intermediate sophistication prosthesis relative to a basic prosthesis was significantly associated with mobility satisfaction (adjusted β coefficient (aβ)=.77, 95% CI, .11-1.4; P=.02). A statistically significant association was only observed in those who underwent a TT amputation (aβ=.79, 95% CI, .09-1.5; P=.03)., Conclusions: Prosthesis sophistication was not associated with achieving advanced mobility in TT amputees but was associated with greater mobility satisfaction. In contrast, prosthesis sophistication was associated with achieving advanced mobility in TF amputees but was not associated with an increase in mobility satisfaction., (Published by Elsevier Inc.)

Objective: To evaluate whether prosthetic prescription differed by gender and the extent to which differences were mediated by measured factors., Design: Retrospective longitudinal cohort study using data from Veterans Health Administration (VHA) administrative databases., Setting: VHA patients throughout the United States., Participants: The sample included 20,889 men and 324 women who had an incident transtibial or transfemoral amputation between 2005 and 2018., Interventions: Not applicable., Main Outcome Measures: Time to prosthetic prescription (up to 1 year). We used parametric survival analysis (an accelerated failure time model) to assess gender differences. We estimated mediation effects of amputation level, pain comorbidity burden, medical comorbidities, depression, and marital status on time to prescription., Results: In the 1 year after amputation, the proportion of women (54.3%) and men (55.7%) prescribed a prosthesis was similar. However, after we controlled for age, race, ethnicity, enrollment priority, VHA region, and service-connected disability, the time to prosthetic prescription was significantly faster among men compared with women (acceleration factor=0.73; 95% confidence interval, 0.61-0.87). The difference in time to prosthetic prescription between men and women was significantly mediated by amputation level (23%), pain comorbidity burden (-14%), and marital status (5%) but not medical comorbidities or depression., Conclusions: Although the proportion of patients with prosthetic prescription at 1-year postamputation was similar between men and women, women received prosthetic prescriptions more slowly than men, suggesting that more work is needed to understand barriers to timely prosthetic prescriptions among women, and how to intervene to reduce those barriers., (Published by Elsevier Inc.)

Objective: To develop and validate a patient-specific multivariable prediction model that uses variables readily available in the electronic medical record to predict 12-month mobility at the time of initial post-amputation prosthetic prescription. The prediction model is designed for patients who have undergone their initial transtibial (TT) or transfemoral (TF) amputation because of complications of diabetes and/or peripheral artery disease., Design: Multi-methodology cohort study that identified patients retrospectively through a large Veteran's Affairs (VA) dataset then prospectively collected their patient-reported mobility., Setting: The VA Corporate Data Warehouse, the National Prosthetics Patient Database, participant mailings, and phone calls., Participants: Three-hundred fifty-seven veterans who underwent an incident dysvascular TT or TF amputation and received a qualifying lower limb prosthesis between March 1, 2018, and November 30, 2020 (N=357)., Interventions: Not applicable., Main Outcome Measure: The Amputee Single Item Mobility Measure (AMPSIMM) was divided into a 4-category outcome to predict wheelchair mobility (0-2), and household (3), basic community (4), or advanced community ambulation (5-6)., Results: Multinomial logistic lasso regression, a machine learning methodology designed to select variables that most contribute to prediction while controlling for overfitting, led to a final model including 23 predictors of the 4-category AMPSIMM outcome that effectively discriminates household ambulation from basic community ambulation and from advanced community ambulation-levels of key clinical importance when estimating future prosthetic demands. The overall model performance was modest as it did not discriminate wheelchair from household mobility as effectively., Conclusions: The AMPREDICT PROsthetics model can assist providers in estimating individual patients' future mobility at the time of prosthetic prescription, thereby aiding in the formulation of appropriate mobility goals, as well as facilitating the prescription of a prosthetic device that is most appropriate for anticipated functional goals., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To (1) evaluate the effects of a group-based self-management treatment intervention (VETPALS) on physical and psychosocial functioning (primary outcomes) and quality of life (secondary outcome) in individuals with amputation and (2) examine the feasibility and acceptability of the intervention in a large national health care system., Design: Randomized controlled trial with masked outcome assessment., Setting: Five Veterans Affairs medical centers geographically dispersed across the United States., Participants: 147 individuals with amputation during the past 2 years due to chronic limb threatening ischemia (N=147)., Interventions: Participants were randomized into VETPALS (N =71) or education control (N=76). VETPALS consisted of a 4-hour workshop and 4 additional 2-hour sessions addressing self-management skills, health and activity, managing emotions, communication and social support, and maintaining goals and gains. Education control consisted of the provision of amputation-related educational materials and provider follow-up if requested., Main Outcome Measures: Primary outcomes were physical functioning (Short Musculoskeletal Functional Assessment) and psychosocial functioning (Patient Health Questionnaire-9). Secondary outcomes were quality of life (global) and quality of life (satisfaction with health) from the World Health Organization Quality of Life Scale (brief). Assessment was conducted at baseline, 6 weeks (treatment completion), and 6 months (follow-up)., Results: Participants randomized to VETPALS reported significantly improved psychosocial functioning and quality of life (satisfaction with health) relative to controls at 6 months (B=1.84; 95% confidence interval, 0.37,3.31 and B=-0.61; 95% confidence interval, -1.11,-0.12, respectively). There were no differences in physical functioning over time between VETPALS and education control at either time point. Follow-up multiple imputation sensitivity analyses produced an identical pattern of results. Among VETPALS participants, treatment initiation was low (56%), but treatment retention (93% attended 4 of 5 classes) and overall satisfaction (100% reported very helpful or better and would recommend to a friend) were high., Conclusions: Group-based self-management improves psychosocial functioning for individuals with amputation due to chronic limb threatening ischemia. In-person participation is challenging for this population, but individuals who successfully initiate treatment typically persist and are highly satisfied., (Published by Elsevier Inc.)

Objectives: Characterize the course of depressive symptoms during the first year after dysvascular amputation and identify factors that predict symptom trajectories., Design: Prospective cohort study of individuals undergoing lower extremity amputation (LEA), surveyed at 4 time points (perioperative period, 6 weeks, 4 months, and 12 months postamputation). Multilevel modeling was used to describe and predict trajectories., Setting: Four Veterans Affairs medical centers, a university hospital, and a level I trauma center., Participants: Participants (N=141; 74% retention) were a consecutive sample, eligible if they were undergoing their first unilateral LEA secondary to dysvascular disease., Interventions: Not applicable., Main Outcome Measure: Patient Health Questionnaire-9., Results: Approximately 40% of participants endorsed at least moderate depressive symptoms at perioperative baseline. Individuals with greater depressive symptoms in the perioperative period concurrently reported greater pain, poorer self-rated health, and prior mental health treatment. In the first 6 weeks after amputation there was a substantial improvement in depressive symptoms, especially among individuals with greater symptoms at baseline. Depressive symptoms were generally stable after 6 weeks. None of the covariates assessed significantly predicted trajectories of depressive symptom improvement., Conclusions: Watchful waiting may be the most appropriate course of action for many patients in the first 6 weeks after amputation. After 6 weeks, however, symptom levels tend to stabilize, suggesting that active intervention is called for if patients remain depressed at this point. Some patients may benefit from more proactive intervention, such as those with prior mental health treatment histories., (Published by Elsevier Inc.)

Objective: To describe the relationship between caregiver-specific support and conflict, and psychosocial outcomes among individuals experiencing their first dysvascular lower extremity amputation (LEA)., Design: Cross-sectional cohort study using self-report surveys., Setting: Department of Veterans Affairs, academic medical center, and level I trauma center., Participants: Individuals undergoing their first major LEA because of complications of peripheral arterial disease (PAD) or diabetes who have a caregiver and completed measures of caregiver support and conflict (N=137; 94.9% men)., Interventions: Not applicable., Main Outcome Measures: The Patient Health Questionnaire-9 to assess depression and the Satisfaction With Life Scale to assess life satisfaction., Results: In multiple regression analyses, controlling for global levels of perceived support, self-rated health, age, and mobility, caregiver-specific support was found to be associated with higher levels of life satisfaction and caregiver-specific conflict was found to be associated with lower levels of life satisfaction and higher levels of depressive symptoms., Conclusions: The specific relationship between individuals with limb loss and their caregivers may be an important determinant of well-being. Conflict with caregivers, which has received little attention thus far in the limb loss literature, appears to play a particularly important role. Individuals with limb loss may benefit from interventions with their caregivers that both enhance support and reduce conflict., (Published by Elsevier Inc.)

Objective: To examine the estimated prevalence and correlates of suicidal ideation (SI) among individuals 1 year after a first lower extremity amputation (LEA)., Design: Cohort survey., Setting: Four medical centers., Participants: A referred sample of patients (N=239), primarily men, undergoing their first LEA because of complications of diabetes mellitus or peripheral arterial disease, were screened for participation between 2005 and 2008. Of these patients, 136 (57%) met study criteria and 87 (64%) enrolled; 70 (80.5%) of the enrolled patients had complete data regarding SI at 12-month follow-up., Interventions: Not applicable., Main Outcome Measures: SI, demographic/health information, depressive symptoms, mobility, independence in activities of daily living (ADL), satisfaction with mobility and ADL, medical comorbidities, social support, self-efficacy., Results: At 12 months postamputation, 11 subjects (15.71%) reported SI; of these, 3 (27.3%) screened negative for depression. Lower mobility, lower satisfaction with mobility, greater impairment in ADL, lower satisfaction with ADL, lower self-efficacy, and depressive symptoms were all correlated with the presence of SI at a univariate level; of these, only depressive symptoms remained significantly associated with SI in a multivariable model., Conclusions: SI was common among those with recent LEA. Several aspects of an amputee's clinical presentation, such as physical functioning, satisfaction with functioning, and self-efficacy, were associated with SI, although depression severity was the best risk marker. A subset of the sample endorsed SI in the absence of a positive depression screen. Brief screening for depression that includes assessment of SI is recommended., (Copyright © 2015 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe cognition among individuals with new amputations at 3 time points: presurgical, 6 weeks postamputation, and 4 months postamputation., Design: Prospective cohort., Setting: Medical centers., Participants: Referred sample Veterans who were primarily men (N=80) experiencing their first lower extremity amputation as a result of complications of diabetes mellitus or peripheral arterial disease. Patients were screened for the absence of gross cognitive impairment using the Short Portable Mental Status Questionnaire (SPMSQ). Of those 87 individuals who were eligible, 64% enrolled; 29 were enrolled presurgically and have cognitive data for all 3 time points, and 58 were enrolled postamputation. Eighty of the 87 individuals enrolled by 6 weeks remained enrolled at 4 months., Interventions: Not applicable., Main Outcome Measures: Demographic and general health information, general mental status (SPMSQ), and 4 brief, well-established neuropsychological measures., Results: Most mean neuropsychological test scores fell in the low average or average range. For most participants, overall cognitive status improved from pre- to postsurgery and then remained stable between 6 weeks and 4 months. There were significant improvements between pre- and postsurgical test scores in verbal learning and memory, and these remained unchanged between 6 weeks and 4 months. Better 4 month cognitive performance was associated with higher perceived general health., Conclusions: Overall cognitive performance is poorest presurgically. Though there is improvement between pre- and postamputation, cognition appears generally stable between 6 weeks and 4 months., (Copyright © 2014 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To describe changes in ambulation among individuals with lower-extremity amputation secondary to peripheral artery disease and/or diabetes prior to surgery through 12 months after surgery. To compare differences in ambulation by amputation level and to examine risk factors for change in ambulation over time., Design: Prospective cohort study., Setting: Two Veterans Affairs medical centers, 1 university hospital, and a level I trauma center., Participants: Patients with peripheral artery disease or diabetes (N=239) undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 57% (n=136) met study criteria, and of these, 64% (n=87) participated., Interventions: Standard of care at each facility., Main Outcome Measures: Ambulatory function measured using the Locomotor Capability Index-5., Results: Seventy-five of the 87 (86%) subjects enrolled finished their 12-month follow-up interview. Ambulatory mobility declined during the period immediately prior to surgery (premorbid) and remained low at 6 weeks postsurgery. On average, ambulation improved after surgery but did not return to premorbid levels. In the final multivariate model, age and history of lower-extremity arterial reconstruction were significantly associated with a poorer ambulatory trajectory over time, while other factors, such as amputation level, prior alcohol use, and length of disability prior to amputation, were not., Conclusions: The findings highlight the importance of considering premorbid ambulatory function. Informing providers and patients about the trajectory and time course of changes in ambulation can enhance patient education, patient expectations, and treatment planning., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To (1) compare the total volume of rehabilitation therapy for patients ever attending a comprehensive inpatient rehabilitation unit (CIRU) versus never during the 12 months after amputation; (2) determine whether rehabilitation in a CIRU at any time in the first year after amputation results in greater mobility success compared with other types of rehabilitation environments of care; and (3) determine for those patients treated in a CIRU, which specific patient characteristics were associated with improved mobility outcome., Design: Prospective cohort study., Setting: Two Veterans Affairs medical centers., Participants: Patients (N=199) with peripheral vascular disease or diabetes undergoing a first unilateral major amputation were screened for participation between September 2005 and December 2008. Among these, 113 (57%) met study criteria; of these, 72 (64%) participated., Intervention: Ever attending a CIRU versus never attending a CIRU in first 12 months after amputation., Main Outcome Measures: Number of rehabilitation therapy visits, Locomotor Capability Index scores, and mobility success., Results: The mean number of all therapy visits for patients ever attending a CIRU was significantly greater than that for those never attending over a 12-month period (48.6 vs 22.6; P=.001). Mean total time per any rehabilitation visit was .83±.27 hours for those ever attending and .60±.20 hours for those never attending (P<.001). Patients who ever were treated in a CIRU were 17% more likely to achieve mobility success than those who were not, controlling for amputation level, major depressive episode, alcohol use, social support, total number of rehabilitation visits, and hospital site (risk difference=.17; 95% confidence interval, .09-.25; P<.001)., Conclusions: Rehabilitation in a CIRU resulted in improved mobility success for veterans undergoing major lower extremity amputation secondary to peripheral vascular disease or diabetes. Among those admitted to a CIRU, younger patients with greater social support, healthy weight, and without chronic obstructive pulmonary disease had the greatest probability of mobility success., (Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the effect of prosthetic interventions on the functional mobility of lower-extremity amputees., Design: Crossover with repeated measures., Setting: Household and community environment., Participants: Twelve transtibial and 5 transfemoral amputees., Interventions: For transtibial amputees, shock-absorbing versus rigid pylons. For transfemoral amputees, C-Leg versus Mauch SNS knees., Main Outcome Measures: Daily activity level (step count) and duration (minutes of activity)., Results: Pylon type had no effect on the daily activity level or duration of transtibial amputees. Knee type had no effect on the daily activity level or duration of transfemoral amputees. Transtibial amputees were more active on weekdays (3079+/-1515 steps/d) than weekends (2386+/-1225 steps/d) (P=.007). In general, lower-extremity amputees perform numerous short-duration bouts of activity (1-2 min) consisting of fewer than 17 steps/min, but activities of more than 15 minutes in duration were relatively rare (<1 per day)., Conclusions: Intervention had no effect on amputee activity level and duration. Higher weekday activity levels of transtibial amputees suggest their vocational activities are more demanding than recreational activities. The fitting, alignment, and design of prosthetic components should be optimized for 1 to 2 minute bouts of activity consisting of only a few dozen steps.

Objective: To determine whether amputees have an increased risk of knee pain or symptomatic osteoarthritis (OA) compared with nonamputees., Design: Retrospective cohort study., Setting: Veterans Administration Patient Treatment and Outpatient Care files., Participants: All male unilateral (transtibial or transfemoral) traumatic amputee patients and a random sample of male nonamputees. Patients were excluded if they were younger than 40 years, had sustained a significant injury to their knee(s), or had a rheumatic disease., Interventions: Not applicable., Main Outcome Measures: The prevalence of knee pain and symptomatic knee OA., Results: The age and average weight-adjusted prevalence ratio of knee pain among transtibial amputees, compared with nonamputees, was 1.3 (95% confidence interval [CI], 0.7-2.1) for the knee of the intact limb and 0.2 (95% CI, .05-0.7) for the knee of the amputated limb. The standardized prevalence ratio of knee pain in the intact limb and symptomatic OA among transfemoral amputees, compared with nonamputees, was 3.3 (95% CI, 1.5-6.3) and 1.3 (95% CI, 0.2-4.8), respectively., Conclusions: Stresses on the contralateral knee of amputees may contribute to secondary disability. Possible explanations include gait abnormalities, increased physiologic loads on the knee of the intact limb, and the hopping and stumbling behavior common in many younger amputees.

Objective: To evaluate whether amitriptyline is more effective than placebo in improving phantom limb pain or residual limb pain., Design: Randomized controlled trial of amitriptyline for 6 weeks., Setting: University hospital., Participants: Thirty-nine persons with amputation-related pain lasting more than 6 months., Intervention: Six-week trial of amitriptyline (titrated up to 125 mg/d) or an active placebo (benztropine mesylate)., Main Outcome Measures: Analyses were conducted to examine whether there was a medication group effect on the primary outcomes (average pain intensity) and secondary outcome measures (disability, satisfaction with life, handicap)., Results: No significant differences were found between the treatment groups in outcome variables when controlling for initial pain scores., Conclusions: Our findings do not support the use of amitriptyline in the treatment of postamputation pain.

Objective: To evaluate the frequency, duration, intensity, and interference of back pain in a sample of persons with lower limb amputations., Design: Retrospective, cross-sectional survey., Setting: Community-based survey from clinical databases., Participants: Participants who were 6 or more months post lower limb amputation (n = 255)., Intervention: An amputation pain survey that included several standardized pain measures., Main Outcome Measures: Frequency, duration, intensity, and interference of back pain., Results: Of the participants who completed the survey (return rate, 56%), 52% reported experiencing persistent, bothersome back pain. Of these, 43% reported average back pain intensity in the mild range (1-4 on 0-10 rating scale) and 25% reported pain of moderate intensity (5-6 on 0-10 scale). Most respondents with back pain rated the interference of their pain on function as none to minimal. However, nearly 25% of those with back pain described it as frequent, of severe intensity (>or=7 on 0-10 scale), and as severely interfering with daily activities including social, recreational, family, and work activities., Conclusions: Back pain may be surprisingly common in persons with lower limb amputations, and, for some who experience it, may greatly interfere with function.

Objectives: To determine the characteristics of phantom limb sensation, phantom limb pain, and residual limb pain, and to evaluate pain-related disability associated with phantom limb pain., Design: Retrospective, cross-sectional survey. Six or more months after lower limb amputation, participants (n = 255) completed an amputation pain questionnaire that included several standardized pain measures., Setting: Community-based survey from clinical databases., Participants: A community-based sample of persons with lower limb amputations., Main Outcome Measures: Frequency, duration, intensity, and quality of phantom limb and residual limb pain, and pain-related disability as measured by the Chronic Pain Grade., Results: Of the respondents, 79% reported phantom limb sensations, 72% reported phantom limb pain, and 74% reported residual limb pain. Many described their phantom limb and residual limb pain as episodic and not particularly bothersome. Most participants with phantom limb pain were classified into the two low pain-related disability categories: grade I, low disability/low pain intensity (47%) or grade II, low disability/high pain intensity (28%). Many participants reported having pain in other anatomic locations, including the back (52%)., Conclusions: Phantom limb and residual limb pain are common after a lower limb amputation. For most, the pain is episodic and not particularly disabling. However, for a notable subset, the pain may be quite disabling. Pain after amputation should be viewed from a broad perspective that considers other anatomic sites as well as the impact of pain on functioning.

Objective: To quantify the muscular adaptations of above-knee amputee patients' ambulation using an experimental and modeling approach., Design: Nonrandomized controlled study., Setting: A referral center for treatment of veterans with amputation., Subjects: Eight normal ambulators and 8 nondysvascular above-knee amputee subjects wearing the same lightweight prostheses were studied with a gait analysis system, walking at self-selected speeds., Main Outcome Measures: Using an inverse dynamics linked segment model, the mechanical torque, power output, and work done were calculated at the hip, knee, and ankle joints., Results: The mean concentric ankle plantarflexor work done was much greater for the normal subjects compared to the prosthetic limb in pushoff (25.2 +/- 3.7 J vs 4.9 +/- 2.1 J), but greatest for the intact limb of the amputee subjects (34.2 +/- 6.6 J). Also, the concentric hip extensor work done in early stance was greater for the intact limb of the amputee subjects than for normal subjects (9.9 +/- 5.5 J vs 3.6 +/- 2.6 J), presumably compensating for the coincident decreased pushoff of the prosthetic limb. Other compensatory mechanisms are also discussed., Conclusions: Increased joint torques and power outputs of the amputee subjects' intact limb compared to normal ambulation may be viewed as providing additional gait progression and upright stance during parts of the gait cycle when the amputated limb lacks needed active muscle support.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in limb deficiency in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses normal gait, the influence of prosthetic alignment on amputee function, and the effects of prosthetic components on the metabolic costs and the biomechanical function of the amputee. The biomechanics of normal ambulation are presented as a background to enable the practitioner to gain an understanding of the typical gait adaptations that occur in below-knee and above-knee amputees. The effects of newer prosthetic components and socket designs on the biomechanical adaptations are reviewed. The metabolic costs of amputee ambulation are significantly greater than normal. The theoretical mechanisms for this are discussed, and the effects of newer socket designs, ultra-light-weight components, and energy-storing prosthetic components are presented.

The purpose of this study was to compare the effects of posterior and anterior walkers on the gait parameters of five children with spastic diplegic cerebral palsy. Computer-based kinematic analysis was used to investigate differences in gait. Gait laboratory data indicated that use of the posterior walker (1) facilitated more upright posture in these subjects, as seen in decreased trunk and hip flexion during stance phase; (2) decreased double stance time; and (3) increased walking velocity. According to parent report, both the parents and their children preferred the posterior walker. Most parents also reported that when using the posterior walker, their children walked more normally with increased stability and interacted more easily with other children.

Reflex sympathetic dystrophy (RSD) has been described primarily in the upper extremity and is infrequently considered part of the differential diagnosis of postamputation pain. The manifestations of autonomic dysfunction may mimic other potential diagnoses of postoperative stump pain. We report a 47-year-old man who developed RSD of the knee during the mobilization phase after below-knee amputation for atherosclerotic peripheral vascular disease. The diagnosis was made by clinical examination, radiography, and scintigraphy without the need for any invasive studies. The characteristic diagnostic findings for the knee during the acute phase are emphasized and the therapy described.