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Background: People with lower limb loss (LLL) have reduced physical activity (PA). There is evidence of physical and psychosocial predictors of PA in older adults with limb loss. However, these 2 areas (physical/psychosocial) have not been evaluated in the same analysis., Objectives: To describe and identify predictors of PA in individuals with LLL., Study Design: Cross-sectional study., Methods: Secondary analysis of data from a multisite Canadian randomized control trial involving community-dwelling prosthetic ambulators with unilateral transtibial or transfemoral amputation (N = 72). The dependent variable was the Physical Activity Scale for the Elderly. Potential predictors were four step square test, 2-minute walk test, Short Physical Performance Battery, Life Space Assessment, walking while talking test, and Activities-specific Balance Confidence scale., Results: Seventy-two community-dwelling lower limb prosthesis users were enrolled. The sample included 62 male participants (86%), and 58 participants (81%) had transtibial amputation. The average age of participants was 65 (8.9) years, and for 49 participants (70%), the amputation was over 24 months ago. The total mean Standard Deviation (SD) Physical Activity Scale for the Elderly score was 153.2 (88.3), with scores of 148.1 (11.4) and 184.5 (24.7) for male and female participants, respectively. Regression analysis identified Life Space Assessment (β = 1.15, p = 0.007) and Short Physical Performance Battery (β = 3.51, p = 0.043) as statistically significant predictors accounting for 25% of the variance in PA., Conclusions: Community mobility and physical performance are the most meaningful predictors of PA. Future research should examine additional factors (e.g., environment, motivation). Understanding the predictors for PA after LLL would improve clinical practice as clinicians would have increased knowledge to modify and improve training., (Copyright © 2024 International Society for Prosthetics and Orthotics.)

Background: Returning to work is a key outcome of rehabilitation and social re-integration after lower limb amputation. It is important to understand what biopsychosocial factors contribute to returning to work after dysvascular amputation., Objective: Examining relative contributions of functional and contextual predictors of returning to work in participants with lower limb amputation due to diabetes and other dysvascular diseases., Study Design: Cross-sectional., Methods: Return-to-work outcome, biopsychosocial characteristics including physical functioning, self-efficacy & perceived ability, and socioeconomical support data were collected from a purposive sample (n = 57) in a multi-state collaborative research network. Grouped Weighted Quantile Sum model analysis was conducted to evaluate relative contributions of biopsychosocial predictors., Results: Less than 30% of the participants returned to work after their amputation. Physical functioning (odds ratio = 10.19; 95% CI 2.46-72.74) was the most important predictor group. Working before amputation, prosthetic mobility, and access to rehabilitation care were also identified as key factors associated with returning to work., Conclusions: Fewer than 1 in 3 participants with dysvascular amputation returned to work, despite an average age of only 54 years at the time of amputation. Physical functioning was shown to be the most important predictor, while socioeconomic factors such as a lack of access to care also contribute to not returning to work after dysvascular amputation., (Copyright © 2024 The Authors. Published by Wolters Kluwer incorporated on behalf of The International Society for Prosthetics and Orthotics.)

Background: Prosthetic embodiment is the perception of the prosthesis as a part of the body, and it is important for acceptance and adequate and effective use of the prosthesis., Objective: The aim of this study was to investigate the validity and reliability of the Turkish version of the Prosthesis Embodiment Scale for Lower Limb Amputees., Methods: This cross-sectional study included a total of 88 lower limb amputees. Internal consistency was evaluated using Cronbach α coefficient. The test-retest reliability of the scale, which was reapplied after 7-10 d, was evaluated using intraclass correlation coefficient. Principal component analysis with Varimax rotation was used to analyze the factor structure. Spearman correlation coefficient with Trinity Amputation and Prosthesis Experience Scale subscales was calculated for concurrent validity., Results: The mean age of the participants was 45.13 ± 15.05 years, and 76.1% were male. Internal consistency (Cronbach α = 0.905) and test-retest reliability (intraclass correlation coefficient = 0.822) were high. 76.1% of the total variance could be explained by the 3 dimensions. Significant correlation was found with the Trinity Amputation and Prosthesis Experience Scale subscales (r = 0.542 for psychosocial adjustment subscale, r = -0.452 for activity restriction subscale, r = 0.490 for prosthesis satisfaction subscale, p < 0.001)., Conclusions: The results of this study showed that the Turkish version of the Prosthesis Embodiment Scale for Lower Limb Amputees is a valid and reliable tool that can be used to evaluate prosthetic rehabilitation outcomes., (Copyright © 2024 International Society for Prosthetics and Orthotics.)

Purpose: To explore the rehabilitation preferences and experiences of clinicians and patients for education after lower limb loss to facilitate the development of an online self-management program., Methods: A qualitative descriptive approach was used. Thirty-one clinicians (physiotherapists, occupational therapists, and prosthetists), and 26 patients with lower limb loss (transtibial and transfemoral amputation; mean age (SD) of 63.3 (9.1), years) were recruited. We used semi-structured focus groups and one-on-one interviews, and audio recorded the interviews. Data were analyzed using conventional content analysis., Results: Three themes were identified: (1) Needing education in rehabilitation described the education in current practice as one-on-one discussion and booklets and highlighted the limitations of education such as its length, static nature, and inaccessible for patients living in remote areas. (2) Getting back to activities prior to amputation emphasized how goal setting and social support could assist patients and facilitate self-management. (3) Augmenting learning highlighted the need for an accessible complementary source for education and potential solutions to overcome the barriers of online delivery., Conclusions: Our findings underscore the importance of education in the rehabilitation of patients to help them get back to their activities. An online accessible tool may improve education by providing information and peer support.

Purpose: Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease., Methods: Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data., Findings: Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants' imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations., Conclusions: Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.

Background: Although postoperative complications of lower limb amputations and complications related to prosthetics are well known, complications before prosthetic fitting are less often emphasized in literature. There are no Saudi studies documenting the complications before prosthetic fitting where there is high rise in dysvascular amputation, and early prosthetic provision remains a challenge., Objectives: To investigate the complications following major lower limb amputations (MLLAs)., Study Design: Retrospective study., Methods: One hundred thirty-six electronic files for individuals with major lower limb amputations were reviewed. Individuals visiting the primary limb loss clinic for the first time, who have not been fitted with a prosthesis before, were included., Results: Muscle weakness was the most common complication (55.1%), followed by edema (52.9%), while infection was found to be the least frequent (5.1%). Age was significantly associated with etiology ( p value < 0.001), usage of assistive device ( p value = 0.002), and complications ( p value = 0.013). Complications were also significantly associated with time since amputation ( p value = 0.001). In addition, etiology was significantly associated with the usage of assistive device ( p value = 0.012)., Conclusions: Muscle weakness and edema were the most common complications after MLLA in a cohort of patients with median onset of 8.5 ± 6.8 months since amputation. Presence of various complications in MLLAs before prosthetic evaluation reflect gaps of care including delayed prosthetic evaluation. National strategies need to be introduced to promote early rehabilitation interventions, prevent complications, and improve quality of life of individuals with MLLAs., (Copyright © 2024 International Society for Prosthetics and Orthotics.)

Most research on people undergoing lower limb amputations for dysvascular disease summarizes average patient outcome risks and average associations between patient factors and these outcomes. More recently, the importance of predicting patient-specific outcomes based on individual factors (ie, personalized rehabilitation) has become evident. This article reviews the evidence and discusses the importance of the following: (1) predicting outcomes to facilitate amputation-level and prosthesis prescription decisions and (2) how prediction models can be leveraged to develop decision support tools to facilitate provider/patient shared decision-making to ensure decisions considering each individual patient's priorities and preferences. Examples of these tools are discussed and referenced., Competing Interests: Disclosure No authors have any commercial or financial conflicts of interest nor any funding sources to report at the time of this submission., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: The aim of this review is to synthesise the experiences and needs of people who had undergone dysvascular lower extremity amputations. Given the increasing global prevalence of vascular diseases like diabetes mellitus and peripheral arterial disease, the risk of requiring an amputation remains high., Materials and Methods: This systematic review follows the PRISMA and ENTREQ reporting guidelines. Seven databases were searched for qualitative studies from January 2011 to October 2023. In total 6435 studies were obtained, where 1146 were duplicates and 5271 studies failed to meet the eligibility criteria. The remaining 18 studies were synthesised using Sandelowski and Barroso's approach and appraised using the CASP checklist., Results: Four themes emerged from the meta-synthesis: (1) making the decision to amputate, (2) difficulties in the physical adaptation to limb loss, (3) psychosocial consequences of living with an amputation, and (4) regaining control and building hope., Conclusions: Having dysvascular lower extremity amputations is a complicated experience as not only was the pre-amputation pain relieved, but a new set of physical, emotional and social challenges would surface after the amputation. These synthesised findings serve as a platform to explore the factors behind the various experiences faced by these people and how healthcare professionals can help them in their adjustment.

Purpose: Outcome measurement provides clinicians, services and funders with useful information. However, little is known about the experience of participating in outcome measurement during lower limb prosthetic rehabilitation from the patient's perspective., Materials and Methods: Thirty-two participants who underwent lower limb amputation within 5 years, and had experience of taking part in outcome measurement during prosthetic rehabilitation, were recruited from UK limb fitting centers and social media. Data were collected using focus groups and interviews and analysed using reflexive thematic analysis., Results: Four themes were identified. (1) How does participating in outcome measurement make me feel? (2) Do the outcome measures used in routine clinical care capture an accurate picture of my recovery? (3) Who is outcome measurement for? and (4) are prosthetic services measuring what is meaningful? These themes suggest outcome measurement is not a neutral activity for patients following lower limb amputation., Conclusions: Harnessing the positive impacts of measuring outcomes could be used for motivation, to support adjustment and recovery, to improve communication and to support shared decision-making. This could make outcome measurement more meaningful and patient-centered. However, there may be potential for patients to respond negatively to outcome measures and clinicians should consider their impact on psychosocial factors.

Objective: To perform the translation, cross-cultural adaptation and validation the Physical Activity Scale for Individuals with Physical Disabilities (PASIPD) for the Brazilian Portuguese in a sample of people with lower limb amputation., Methods: This is a methodological study with cross-sectional design. Translation and cross-cultural adaptation of the scale were initially carried out in accordance with international guidelines. After its psychometric properties were evaluated, in addition to the presence of floor and ceiling effect, the standard error of measurement and the minimal detectable change., Results: The Brazilian version of PASIPD presented face and content validity and correlated significantly with International Physical Activity Questionnaire ( rs : 0.71/p = 0.001). The degree of inter-examiner agreement ranged from 0.29 to 0.75, and the intra-examiner from 0.13 to 0.72. The inter-examiner was 0.71, and the intra-examiner was 0.78. The internal consistency measure (Cronbach's α) was 0.75. No floor or ceiling effect were observed. The standard error of measurement was 0.36 and the minimal detectable change was 1.66., Conclusions: The Brazilian version of PASIPD is valid, reliable and has internal consistency among its items, and can be used by researchers and health professionals to evaluate the physical activity of Brazilians with lower limb amputation., Competing Interests: Declaration of competing interest The authors report no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objective: To gather preliminary evidence on short- and long-term care priorities for people with lower extremity amputations., Design: A three-round modified Delphi study using semi-structured interviews., Participants: A convenience sample of 20 adult participants who had undergone lower extremity amputations at a tertiary public hospital., Main Measure: Consensus on each care priority was defined a priori as an agreement of more than 50%. Semi-structured interviews were conducted to understand the rationales for endorsing the care priorities., Results: Consensus was reached on 24 short-term care priorities and 12 long-term care priorities in the biomedical, practical and psychological and spiritual domains. The rationales for endorsing each of the care priorities generated three themes: preparedness; mental health, psychological and spiritual well-being; and participating in life, with respect and dignity., Conclusions: Our results highlight the substantial need to improve patient access to education and planning support prior to undergoing limb amputation, and optimising post-amputation rehabilitation programmes, enabling people with amputations to participate in meaningful life roles that provide them with purpose, dignity, and self-respect. The knowledge of care priorities revealed in this study may promote effective patient-centred care and improve clinical outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Purpose: A systematic review and meta-analysis investigating the duration and frequency of lower extremity prosthesis use and what factors were associated with changes in their use., Materials and Methods: A search of PubMed, CINAHL, and Scopus over 20 years revealed 2409 articles. After review, 29 studies remained, representing 4814 participants with lower limb loss. Quality, funding, publication, and quantitative analyses were addressed., Results: The mean prosthesis use was 9.6 (5.3) hours/day and 6.4 (1.9) days/week. Distal amputation sites averaged more hours/day of prostheses use than proximal amputations (13.2 [3.2] vs. 10.8 [5.0], p  < .001). After hemipelvectomy or hip dislocations, average prostheses use was less hours/day (6.0 [4.7]) than after transfemoral (12.9 [4.8]) or transtibial amputations (14.0 [4.5]) ( p  < .05). Pooled effects revealed an association between comorbidities and abandonment (OR 0.35, p  = .03). The data supported six empirical evidence statements concerning age, sex, social support, amputation proximity, balance, skin condition, comorbidities, pain, falls, and fitness in association with changes in prosthesis utilization., Conclusions: The study provided systematic data on lower-extremity prosthesis use, thus helping to inform clinical decision-making and patient education. It also elucidated a path for future studies focused on modifiable factors related to prosthesis use and related outcomes.Implications for rehabilitationLower limb loss can trigger costly and debilitating sequela, which could be mitigated by increased prosthesis use and functionality, but there is no consensus on how often prostheses are being used and what affects changes in their use.When counseling patients on what they can expect after a lower extremity amputation and to set goals, the aggregated means of 9.6 (5.3) hours per day and 6.4 (1.9) days per week can be informative.Individuals who use a lower extremity prosthesis or may have to use one in the future can increase their prosthesis use and mobility by limiting further health deterioration.Rehabilitative care involving the multidisciplinary prioritization of proper socket fit, fitness training, gait training, and social support is associated with increased prosthetic device usage.

Background: In people with lower limb amputation (LLA), the loss of limb structures and peripheral motor and sensory systems result in significant mobility challenges, including impaired postural stability., Objective: The primary objective of this study was to evaluate the dual-task interference (DTI) on postural control and dual-task interference on cognition during static and dynamic balance in people with LLA and compare the same with controls. The secondary objective of this study was to compare the DTI on postural control and DTI on cognition between LLA of different etiology., Design: Cross-sectional observational study METHODOLOGY: Fifteen people with unilateral LLA and 15 age and gender-matched controls participated in this study at a tertiary care hospital. The outcome measures used were anterior-posterior stability index (APSI), medial-lateral stability index, and overall stability index (OSI) using Biodex Balance System and a cognitive task parameter, namely correct response rate in serial seven subtraction test. Quantitative variables were compared using a Wilcoxon rank-sum test. Spearman's correlation test was used to establish the correlation between the DTI on cognition and the DTI on postural control., Results: DTI on postural control during static balance was significantly higher in people with LLA than controls (APSI, OSI). No significant difference was observed in DTI on postural control during dynamic balance. No significant difference was observed in DTI on cognition during static and dynamic balance. A significant negative correlation was observed between DTI on cognition and DTI on postural control (APSI) during static balance people with LLA., Significance: In people with unilateral LLA, the addition of a cognitive task results in significant deterioration of sagittal plane postural control during static balance but not during dynamic balance due to the over-allocation of resources to a cognitive task., Competing Interests: Declaration of Competing Interest The authors declare that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

High-energy expenditure during walking is one of the most important limiting factors for lower limb amputees. Although several physical training methods have been proposed to reduce energy expenditure, little is known about the effects of high-intensity interval training in lower limb amputees. This study aimed to test the effects of a 6-week high-intensity interval training protocol in subjects with lower limb amputation on walking distance, physiological cost of walking, and functional mobility. A quasi-experimental pre and post-study included 13 subjects with lower limb amputation. They performed 12 sessions of a high-intensity interval training protocol with a frequency of 2 days/week for 6 weeks. Walking distance, physiological cost of walking, and functional mobility before and after the training protocol were assessed. Walking distance increased from 204.48 to 229.09 m ( P  = 0.003), physiological cost of walking decreased from 0.66 to 0.31 beats/m ( P  = 0.001), and functional mobility improved from 30.38 to 33.61 points ( P  = 0.001). High-intensity interval training improved walking distance, physiological cost of walking, and functional mobility in subjects with lower limb amputation., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To understand how persons with non-dysvascular lower limb amputation (LLA) use occupations to contextualize their quality of life (QoL)., Methods: A qualitative study using an interpretative description approach was conducted. Analysis of the interviews was guided by an occupational perspective, which considers the day-to-day activities that are important to an individual., Results: Twenty adults with an adult-acquired non-dysvascular amputation (e.g., trauma, cancer or infection) were interviewed. Following thematic analysis, two main themes were developed: (1) sense of self expressed through occupations; and (2) sense of belonging with others influenced by occupations. Participants expressed the way they felt about themselves through their activities and placed high value on whether they could participate in certain occupations. Participants also described how their sense of belonging was changed through the context of their changing occupations., Conclusion: The findings from this work can be leveraged by clinicians and researchers alike to improve care for this population. Rehabilitation programs should consider interventions and programming that help to restore occupations or develop new ones given the importance placed on occupations by persons with non-dysvascular LLA.

Background: Little is known about which outcome domains characterise meaningful recovery following prosthetic rehabilitation and should be measured. Our previous qualitative work developed a conceptual model of outcome domains which are meaningful to patients. This qualitative synthesis aims to develop that model by exploring views and experiences of recovery captured in the limb loss literature, and use these to produce a second iteration of the model describing outcome domains of importance following prosthetic rehabilitation from the patient's perspective., Methods: Systematic searches were conducted using CINAHL, Psychinfo and Web of Science from 2011 to early 2023. Studies with a qualitative design focusing on views and experiences of lower limb prosthetic users were eligible for inclusion. Quality was assessed using the CASP tool. 'Best Fit' framework synthesis was used to synthesise the evidence and develop the conceptual model., Results: 40 studies were included, describing the experiences of 539 participants. Data supported the pre-existing conceptual model and led to development of four of the five domains. The newly named ECLIPSE model describes meaningful outcome domains as 1) Being able to participate in important activities and roles, 2) Participating in the way I want to, 3) My prosthesis works for me, 4) If I am in pain, I can manage it, and 5) I am able to accept my new normal. Studies came from 15 countries showing good coverage of high-income settings. Few participants from low-and-middle-income countries were included, it is unclear if the ECLIPSE model describes outcome domains of importance in these settings., Conclusions: This synthesis provides a rigorous foundation for understanding outcome domains of importance following lower limb prosthetic rehabilitation from the patient's perspective. The ECLIPSE model is an accessible representation of recovery which could direct rehabilitation programmes, as well as inform the evaluation of prosthetic care through the selection of outcome measures., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Ostler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objective: To formulate a prognostication model in the early post-operation phase of lower limb amputation to predict patient's ability to ambulate with a prosthesis post rehabilitation., Design: Retrospective cohort study, using data collected from electronic medical records. Predictive factors and prosthetic ambulation outcomes post rehabilitation were used to develop prognostic models via machine learning techniques., Setting: Regional hospital's ambulatory rehabilitation clinic., Participants: Patients with major lower limb amputation (N=329)., Interventions: Not applicable., Main Outcome Measures: The outcome of prosthetic ambulation ability post rehabilitation collected was categorized in 3 groups: non-ambulant with prosthesis, homebound ambulant with prosthesis (AP), and community AP., Results: In a 2-class model of non-ambulant and AP (homebound and community), the model with highest accuracy of prediction included ethnicity, total Functional Comorbidity Index (FCI), level of amputation, being community ambulant prior to amputation, and age. The f1-score and area under receiver operator curve (AUROC) of the model is 0.78 and 0.82. In a 3-class model consisting of all 3 groups of outcomes, the model with highest accuracy of prediction required 10 factors. The additional factors from the 2-class model include presence of caregiver, history of congestive heart failure, diabetes, visual impairment, and stroke. The 3-class model has a moderate accuracy with a f1-score and AUROC of 0.60 and 0.79., Conclusion: The 2-class prognostication model has a high accuracy which can be used early post-amputation to predict if patient would be ambulant with a prosthesis post rehabilitation. The 3-class prognostication model has moderate accuracy and is able to further differentiate the walking ability to either homebound or community ambulation with a prosthesis, which can assist in prosthetic prescription and setting realistic rehabilitation goals., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Knowledge about the energy expenditure of typical activities of daily living (ADL) in persons with lower limb amputation (LLA) is lacking. This study investigated the following: (1) oxygen consumption per unit distance (V̇O 2 ; mL·kg -1 ·min -1 ), (2) proportion utilization of peak oxygen consumption (%V̇O 2 peak), (3) oxygen cost (energy cost; mL·kg -1 ·m -1 ), and (4) perceived exertion (rating of perceived exertion) of ADL in persons with LLA and able-bodied controls., Methods: Participants (21 with LLA/12 controls) performed 2 household ADL experiments: in-house walking and vacuuming and 3 community ADL experiments: marked shopping, fast walking, and stair negotiation. V̇O 2 peak was assessed with arm crank ergometry, and ambulatory activity was monitored for 7 days with a StepWatch., Results: Participants with LLA performed in-house walking, marked shopping, vacuuming, and stair negotiation at a similar V̇O 2 as controls, while their self-selected walking speed (WS) was significantly lower. Participants with LLA had significantly higher %V̇O 2 peak than controls during in-house walking and reported a significantly higher rating of perceived exertion for vacuuming and marked shopping. The highest possible WS of participants with LLA during fast walking was significantly lower than that of controls, but V̇O 2 was also significantly lower, indicating a limited capacity to walk at higher WS. Participants with LLA had a significantly lower daily step count, significantly lower-proportion high-intensity ambulation, but significantly higher-proportion low-intensity ambulation than controls, indicating that persons with LLA also walked at lower WS in daily life., Conclusions: The results indicate that persons with LLA have increased physical and perceived effort during performance of ADL compared with persons without amputation, which has consequences for community participation, and hence independence and quality of life., (Copyright © 2023 International Society for Prosthetics and Orthotics.)

Background: Lower limb amputations (LLAs) have long been associated with physical, social, and psychological consequences. Individuals with LLAs have challenges with mobility and often become isolated from their social networks. Disability rehabilitation technologies such as prosthetic devices are used to improve the mobility capabilities of lower limb amputees. To improve clinical outcomes, feedback from the prosthetic users is a key element to consider., Objectives: The study sort to explore the experiences of lower-limb prosthetic users after prosthetic rehabilitation in a prosthetic and orthotic rehabilitation center in the Eastern Region of Ghana., Study Design: This study adopted an exploratory descriptive qualitative study design., Methods: A purposive sampling technique and semistructured interview guide was used to interview 17 participants by the first author. The social model of disability underpinned the study. Lower-limb prosthetic users (≥18 years) with unilateral LLA attending outpatient follow-up at a prosthetic and orthotic rehabilitation center were recruited. The interviews were audio recoded, transcribed verbatim, and analyzed using the procedure for thematic content analysis by Braun and Clarke (2013)., Results: Participants reported injuries and tingling in their residual limb. Internal stigma resulting from negative comments and labeling from the public were reported. Prosthetic users experienced empathy and being treated as weaklings by their family/peers. Participants avoided relationships because of recurrent rejection, embarrassment, fear of sexual abuse, and exploitation. As a coping method, some participants chose to isolate themselves to avoid humiliation and public disgrace. Other coping mechanisms included watching television, listening to music, conversing with others, ignoring criticism, and having faith in God., Conclusion: Participants' narrative in this study gave insight into the varied lived experiences on the individual level, family/peer level, and the coping mechanisms used. Challenges relating to discomfort from the prosthesis, internal stigma, relationship avoidance, and altered sexual life should be given much attention and used in implementing initiatives to improve clinical outcomes., (Copyright © 2023 International Society for Prosthetics and Orthotics.)

Objective: To answer the following questions: (1) Do physical activity (PA) and exercise improve fitness, mobility, and functional capacity among adults with lower limb amputation (LLA) and (2) What is the type and minimum dose of PA (frequency, intensity and duration) needed?, Design: Systematic review., Setting: Outpatient intervention, outside of the prosthetic rehabilitation phase., Participants: Adults with lower limb amputation living in the community., Intervention: Any physical activity or exercise intervention., Outcomes and Measures: Any fitness, mobility, or functional capacity indicators and measurements., Results: Twenty-three studies were included, totaling 408 adults with LLA. Studies evaluated the effect of structured PA sessions on fitness, mobility, and functional capacity. The highest evidence is for mixed exercise programs, that is, programs combining aerobic exercise with strengthening or balance exercise. There is moderate confidence that 1-3 sessions of 20-60 minutes of exercise per week improves balance, walking speed, walking endurance, and transfer ability in adults with LLA above the ankle. As for flexibility, cardiorespiratory health, lower-limb muscles strength, and functional capacity, there was low confidence that exercise improves these fitness components because of the lack of studies., Conclusion: Exercise 1-3 times per week may improve balance, walking speed, walking endurance, and transfer ability in adults with LLA, especially when combining aerobic exercises with lower limb strengthening or balance exercises. There is a need for most robust studies focusing on the effect of PA on cardiorespiratory health, muscles strength, flexibility, and functional status., (Copyright © 2023 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

The aim of this study is to gain insight in the cardiorespiratory fitness of persons with lower limb amputation (LLA) during rehabilitation, and in potential factors influencing their cardiorespiratory fitness. We performed a retrospective cohort study using data from cardiopulmonary exercise tests. Included participants were adults with LLA. Main outcome was cardiorespiratory fitness expressed as O 2 peak (ml/min/kg) and was directly determined using breath-by-breath gas analysis. O 2 peak was compared to reference values for able-bodied controls. Multivariate regression analysis was performed to investigate potential factors related to O 2 peak in persons with LLA. Potential factors were age, BMI adjusted, gender, level of amputation, aetiology of amputation, unilateral/bilateral, type of ergometry and use of beta blockers. Data of 74 participants with LLA are presented; 84% male (n = 62), mean age 58.9 (SD 11.6), mean BMI 26.7 (SD 5.6), 44 participants have a LLA above the knee, 30 below the knee. Overall O 2 peak was lower in persons with LLA compared to reference values for able-bodied controls, with mean O 2 peak for the total LLA group of 14.6 ± 4.1 ml/kg/min. In the multivariate regression analysis, only age was a significant predictor for lower O 2 peak (regression coefficient: -0.15, 95% CI [0.23-0.069], r 2  = 0.166). These results indicate that the cardiorespiratory fitness in persons with LLA is low, while they actually need more energy to walk and perform other daily activities. Cardiorespiratory fitness is not closely associated with the analysed demographic or clinical factors and will have to be determined on an individual basis for use in daily practice., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Aim: Early mobilization of patients with a major lower extremity amputation (LEA) is often a challenge because of lack of compliance. Therefore, we investigated factors limiting independent mobility and physiotherapy on the first day with physiotherapy (PTDay1) and the following 2 days after LEA., Methods: A total of 60 consecutive patients, mean age 73.7 years (SD 12.1 years), undergoing LEA were included over a period of 7 months. The Basic Amputee Mobility Score was used to assess basic mobility. Predefined limitations for not achieving independent mobility or not completing physiotherapy were residual limb pain, pain elsewhere, fear of being mobilized, fatigue, nausea/vomiting, acute cognitive dysfunction or "other" factors reported on PTDay1 and the following 2 days after LEA., Results: Fatigue and fear of being mobilized were the most frequent limitations for not achieving independent mobility on PTDay1 and the following 2 days after LEA. Patients (n = 55) who were not independent in the Basic Amputee Mobility Score activity transferring from bed to chair on PTDay1 were limited by fatigue (44%) and fear of being mobilized (33%). A total of 21 patients did not complete planned physiotherapy on PTDay1, and were limited by fatigue (38%), residual limb pain (24%) and "other" factors (24%)., Conclusion: Fatigue and fear of being mobilized were the most frequent factors that limited independent mobility early after LEA. Fatigue, residual limb pain and "other" factors limited completion of physiotherapy. Geriatr Gerontol Int 2024; 24: 470-476., (© 2024 The Authors. Geriatrics & Gerontology International published by John Wiley & Sons Australia, Ltd on behalf of Japan Geriatrics Society.)

Purpose: As United States healthcare transitions from traditional fee-for-service models to value-based care, there is increased need to demonstrate quality care through clinical outcomes. Therefore, the purpose of this study was to create equations to calculate an expected mobility score for lower limb prosthesis users specific to their age, etiology, and amputation level to provide benchmarks to qualify good outcomes., Materials and Methods: A retrospective cross-sectional analysis of outcomes collected during clinical care was performed. Individuals were grouped based on amputation level (unilateral above-knee (AKA) or below-knee (BKA)) and etiology (trauma or diabetes/dysvascular (DV)). The mean mobility score (PLUS-M® T-score) for each year of age was calculated. AKAs were further stratified into having a microprocessor knee (MPK) or non-microprocessor (nMPK) for secondary analysis., Results: As expected, average prosthetic mobility declined with age. Overall, BKAs had higher PLUS-M T-scores compared to AKAs and trauma etiologies had higher scores compared to DV. For AKAs, those with a MPK had higher T-scores compared to those with a nMPK., Conclusions: Results from this study provide average mobility for adult patients across every year of life. This can be leveraged to create a mobility adjustment factor to qualify good outcomes in lower limb prosthetic care.

Objective: To examine participants' experiences with peer-support after lower limb loss (LLL) and the associations between the peer-support experience (perceived benefits and barriers) and mobility outcomes., Design: Quantitative and qualitative descriptive study with a cross-sectional design., Setting: National survey (distributed to 169 peer-support groups in 44 states in the US)., Participants: The survey was completed by 82 individuals with a major lower limb amputation (53% female, 54% over 55 years of age; N=82)., Main Outcome Measures: A 32-item survey to examine respondents' experiences in peer-support activities. Prosthetic mobility was measured using the Prosthetic Limb Users Survey of Mobility (PLUS-M)., Results: Two out of 3 respondents received some forms of peer-support after amputation. Among them 75% reported peer-support having a positive effect on their outlook on life, and 78% reported that information gained from peer-support was helpful. Companionship, altruistic acts, and gaining information on how to cope with amputation were the top themes of why respondents enjoyed the peer-support experience. Nearly all (94%) respondents would recommend peer-support to other people with LLL. Individuals who received peer-support exhibited a trend of greater mobility (55th vs 36th percentile on PLUS-M; P=.055)., Conclusion: Individuals with LLL reported generally positive experiences regarding their engagement in peer-support activities. Peer-support groups are viewed as a helpful source for both information and emotional support, potentially benefiting functional and psychological recovery after amputation. Individuals who have received peer-support also exhibited greater mobility., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Significance: The intent of this work was to summarize the existing evidence of, and highlight knowledge gaps specific to, prosthetic devices/componentry and training regimes, particularly in the context of the human-device interaction and deleterious musculoskeletal conditions secondary to lower limb loss. Recent Advances: With the recent and evolving technological advancements in prostheses, there are numerous devices available to individuals with lower limb loss. Current literature demonstrates the importance of expanding the knowledge of all prosthetic device-specific factors and the significance of proper prescription, fit, and alignment, along with adequate device-/activity-specific training, to enhance human-device interaction, reduce gait abnormalities and compensatory motions, and as a result, mitigate risk for secondary musculoskeletal conditions. Critical Issues: Inadequate device prescription, fit, alignment, and training are evident owing to the lack of knowledge or awareness of the many device-specific properties and factors, leading to suboptimal use, as well as, biomechanical compensations, which collectively and adversely affect the function, activity level, and overall health of the prosthesis user. Future Directions: To maximize optimal outcomes after lower limb loss, it is essential to better appreciate the factors that affect both prosthesis use and satisfaction, particularly any modifiable factors that might be targeted in rehabilitation interventions such as device prescription, fit/alignment, and training regimes. A better understanding of such device-specific factors will help enhance the human-device interaction and resulting functional performance, thereby reducing secondary musculoskeletal conditions, allowing for the readiness of the fighting force (return-to-duty/redeployment) and/or improved reintegration into civilian society/work, and overall enhancing quality of life after lower limb loss.

Abstract: There are over 185,000 amputations annually in the United States, and most of these patients will receive a short inpatient rehabilitation hospital stay as part of their recovery. Complications in care after amputation can negatively impact rehabilitation and subsequent disposition and community reintegration after discharge. The purpose of this article is to discuss the literature, significance, and practice recommendations for three specific challenges-skin integrity, postamputation pain, and falls. The focus population is rehabilitation patients who have undergone nontraumatic, lower limb amputation. Information about the incidence and risks of these complications give nurses necessary knowledge to improve care delivery, reduce suffering, and improve patient safety for postamputation patients during inpatient rehabilitation., (Copyright © 2020 Association of Rehabilitation Nurses.)

Fall-risk classification is a challenging but necessary task to enable the recommendation of preventative programs for individuals identified at risk for falling. Existing research has primarily focused on older adults, with no predictive fall-risk models for lower limb amputees, despite their greater likelihood of fall-risk than older adults. In this study, 89 amputees with varying degrees of lower limb amputation were asked if they had fallen in the past 6 months. Those who reported at least one fall were considered a fall risk. Each participant performed a 6 minute walk test (6MWT) with an Android smartphone placed in a holder located on the back of the pelvis. A fall-risk classification method was developed using data from sensors within the smartphone. The Ottawa Hospital Rehabilitation Center Walk Test app captured accelerometer and gyroscope data during the 6MWT. From this data, foot strikes were identified, and 248 features were extracted from the collection of steps. Steps were segmented into turn and straight walking, and four different data sets were created: turn steps, straightaway steps, straightaway and turn steps, and all steps. From these, three feature selection techniques (correlation-based feature selection, relief F, and extra trees classifier ensemble) were used to eliminate redundant or ineffective features. Each feature subset was tested with a random forest classifier and optimized for the best number of trees. The best model used turn data, with three features selected by Correlation-based feature selection (CFS), and used 500 trees in a random forest classifier. The resulting metrics were 81.3% accuracy, 57.2% sensitivity, 94.9% specificity, a Matthews correlation coefficient of 0.587, and an F1 score of 0.83. Since the outcomes are comparable to metrics achieved by existing clinical tests, the classifier may be viable for use in clinical practice., Competing Interests: The authors have declared that no competing interests exist.

Objective: The study was aimed to determine the survivorship and functional outcomes of modular endoprosthetic reconstruction in the management of primary and metastatic bone tumors of the lower limbs and to investigate the rate and causes of implant failure., Methods: A total of 84 limbs of 82 patients (49 male, 33 female; mean age=48 years, age range=13-78 years) with a minimum follow-up of 12 months in whom resection and modular endoprosthetic reconstructions were performed for primary or metastatic bone tumors of the lower extremity were retrospectively reviewed and included in the study. The mean follow-up was 43 (range=13-119) months. Functional status was assessed using the Musculoskeletal Tumor Society (MSTS) scoring system at the final follow-up. Implant survival was defined as the time from implantation until partial or complete exchange of the prosthesis secondary to mechanical or nonmechanical causes or amputation. The effects of the anatomical site on functional scores and implant survival were statistically analyzed. Additionally, the effects of diagnosis and adjuvant treatments on functional scores, implant survival, and failure rates were investigated., Results: At the time of the study, 55 patients were still alive with a mean follow-up of 48 (range=15-119) months. The mean MSTS scores resulting from the final follow-up of all patients and of those surviving were 87.9% (range=16%-100%) and 86.8% (range=16%-100%), respectively. Overall implant survival was 95.2%, 89.2%, 87%, and 87% at 1, 2, 3, and 4 years, respectively. Statistically, both functional scores and implant survival analysis in different anatomical sites were found similar. In 15 of the patients (17.8%), endoprosthetic reconstructions had failed. The causes of failure were soft tissue failure (dislocation) in 5 patients, infection in 5, structural/mechanical failure in 2, local recurrence in two, and aseptic loosening in one. The diagnosis and receiving preoperative and/or postoperative adjuvant treatment did not affect functional scores, implant survival or failure rates., Conclusion: The results of this study have shown that modular endoprosthetic replacement can provide satisfactory functional results and a durable mid-term limb salvage option in the management of patients with primary and metastatic bone tumors of the lower limbs., Level of Evidence: Level IV, Therapeutic Study.

Abstract: Lower limb amputation (LLA) is still a health issue requiring rehabilitation and long-term care even in industrial societies. Several studies on subjects with LLA have been focused on the efficacy of rehabilitation and factors influencing the use of prosthesis. However, literature data on the recovery of ability to walk outdoors, and thus to participate in social life in this population is limited.To investigate potential correlations between socio-demographic and clinical factors, and the use of the prosthesis for indoor and/or outdoor walking referred to as community ambulation (CA) in subjects with LLA.An observational cohort study on 687 LLA subjects was conducted. Socio-demographic and clinical characteristics of 302 subjects who received similar rehabilitative treatment with respect to the standard protocol were collected by a telephone survey with a structured questionnaire. The CA recovery, in terms of patient's autonomy and participation, assessed by Walking Handicap Scale, was considered as the main outcome.The univariate analysis demonstrated statistical significant positive correlation between CA and gender (χ2 = 3.901, P = .048); amputation level (χ2 = 24.657, P < .001); pre-LLA (χ2 = 6.338, P = .012) and current work activity (χ2 = 25.192, P < .001); prosthesis use (χ2 = 187.037, P < .01); and time from LLA (r = 0.183, P < .001); increasing age was negatively correlated with the outcome (r = -0.329, P < .001), while pain intensity was not significant. Being male (75.4%); trans-tibial (TT) amputation level (9.79%); working before (3.81%) and after LLA (7.68%); and the prosthesis use (24.63%) increased the probability of CA recovery. Multivariate binary logistic regression analysis confirmed that the prosthesis use (P < .001) and TT amputation level (P = .042) are predictors of a positive outcome (Walking Handicap Scale 4-6).These findings highlight the importance of the use of prosthesis in people with LLA for the restoration of a good capacity of participation (CA), especially in subjects with TT amputation level. The identification of predictive factors may help tailor-made rehabilitation approaches addressing an earlier reintegration to social life., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Functional recovery for people with lower limb amputations is quantified using objective or subjective measures of performance. In this brief report, the prospective relationship between objective and subjective mobility after rehabilitation was evaluated in people with lower limb amputations. Adults undergoing inpatient prosthetic rehabilitation for a first unilateral transtibial or transfemoral level lower limb amputation were recruited. Assessment times: discharge and 4-mo follow-up. Gait velocity and the L Test under single- and dual-task conditions measured objective mobility. The Prosthetic Evaluation Questionnaire (section 4 and question 5b) measured subjective mobility. Paired t tests and Pearson correlation analysis evaluated change over time and the association between mobility types, respectively. Twenty-one people with lower limb amputations (61.6 ± 8.2 yrs) participated. Gait velocity significantly improved (single- and dual-task: P < 0.001). L Test significantly improved for single-task (P = 0.002) but not dual-task conditions. No statistically significant Prosthetic Evaluation Questionnaire changes were observed. One subjective mobility question (sidewalk walking) correlated with objective mobility at follow-up (L Test single- and dual-task: r = -0.77; P < 0.001). Objective mobility improved after discharge; however, subjective reporting had no change. Lack of association may represent a mismatch between quantitative outcomes and subjective self-assessment. Both subjective and objective measures of mobility should be collected to provide a holistic picture of clinical and patient-relevant outcomes in people with lower limb amputations.

Objective: To evaluate the clinical characteristics and rehabilitation management of patients who undergo amputation for COVID-19-associated coagulopathy., Methods: Clinical and laboratory data for 3 patients were analysed and their rehabilitative management discussed., Results: The medical records of 3 patients who had undergone amputation due to acute lower extremity ischaemia and who were provided with rehabilitation in our COVID-19 unit were reviewed., Conclusion: Coagulation changes related to SARS-CoV-2 may complicate recovery from this devastating disease. The rehabilitation management of amputated patients for COVID-19 acute lower extremity ischaemia is based on a multilevel approach for clinical, functional, nutritional and neuropsychological needs. Based on this limited experience, a dedicated programme for this specific group of patients seems advantageous to warrant the best functional outcome and quality of life.

Introduction: This study sought to evaluate the natural history of patients undergoing below-knee amputation (BKA) and compare their evolution over 2 decades, as well as survival predictors, prosthetic fitting, and contralateral amputation., Methods: Retrospective study of 209 consecutive patients (mean age 72.9 years; 68% males) who underwent BKA in 2 periods: 1996-2005 and 2006-2015. The fitting of prostheses, risk of contralateral amputation and survival, as well as their predictive factors, were assessed by survival analysis., Results: 133 BKA were performed from 1996-2005 and 106 from 2006-2015. The etiology that motivated the BKA was acute ischemia (4.3%), chronic ischemia (34.0%), infection (9.1%) or mixed (chronic+infection, 52.6%), with no differences found between periods. Survival: mortality within one month=9.2%, one year=31.9%, 2 years=43.8% and 5 years=63.9%, with no significant differences between the 2 periods. Prosthetic: the fitting rate was 44.5% throughout the follow-up, with no significant differences between the two periods. 41.1% patients managed to walk. Contralateral amputation: 20.1% of the patients later required a major contralateral amputation, with no significant differences between the two periods., Conclusions: In the last decade, fewer BKA have been performed probably, due to higher previous interventional revascularization. Despite this, the results of fitting, contralateral amputation or survival were not modified. In any case, the number of patients who are able to achieve ambulation is modest, so it emphasizes the need for an optimal selection of patients with BKA with the goal of prosthetic fitting., (Copyright © 2019 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Objectives: To establish reference values for the 2-minute walk test (2-MWT) distance and gait speed in people with a lower limb amputation (LLA) who are prosthetic ambulators. Also, to describe the differences in distance and gait speed between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups., Design: Cross-sectional study., Setting: National meeting for people with lower limb amputation., Participants: A convenience sample of unilateral people (N=101; 47 men, 54 women; mean age ± SD, 50.9±14.3 y) with an LLA; 48 had a transtibial amputation and 53 had a transfemoral amputation. Participants were classified as either limited community ambulators, community ambulators, or those who exceed basic ambulation skills (K2, n=7; K3, n=70; K4, n=24)., Intervention: Not applicable., Main Outcome Measure: 2-MWT performance (ie, distance and gait speed)., Results: The mean ± SD 2-MWT distance and gait speed for the entire sample was 143.8±37.5 meters (range, 49-259 m) and 72.1±18.8 meters per minute (range, 25-130 m/min), respectively. Men walked farther (distance: men, 154.2±34.2 m; women, 134.4±38.1 m) and faster (gait speed: men, 77.3±17.1 m/min; women, 67.4±19.1 m/min) than women (P<.05). The mean ± SD 2-MWT distance for K4, K3, and K2 level participants was 177.9±31.1 meters, 138.4±28.5 meters, and 81.7±26.9 meters, respectively. Functional level K4 participants performed better than K3 participants (P<.05), and K3 participants performed better than K2 participants (P<.05). People with transtibial amputation walked farther than those with transfemoral amputation (152.9±43.0 m vs 135.6±43.0 m) (P<.05). The distance and speed ambulated by those participants classified in the very high health risk group was worse than those categorized as being at an increased high health risk group (P<.05) and the no increase health risk group (P<.05). The performance of participants older than 70 years old was inferior to the performance of all younger age groups., Conclusions: Reference values for the 2-MWT distance and gait speed were established in people with LLA who are prosthetic ambulators. Significant differences in the 2-MWT performance were found between sexes, causes of amputation, levels of amputation, health risk classification, functional levels, and age groups., (Published by Elsevier Inc.)

Objective: We aimed to describe the causes, types, and consequences of lower limb amputation and the demographics of subjects with such amputation who attended a tertiary rehabilitation center in Bangladesh, Centre for the Rehabilitation of the Paralysed. Methods: Cross-sectional data were collected from subjects with lower limb amputation who attended a specialized rehabilitation center between January 2014 and August 2016. Telephone interviews were conducted using a structured questionnaire. Descriptive analysis, paired t -test, and Fisher's exact test were conducted as well as a regression analysis was performed. Results: A total of 332 respondents, aged 5 to 76 years (mean 37.5± SD 13.8), with lower limb amputation participated in the study. Of the respondents, the majority were male (87.7%) and lived in rural areas (64.8%). Road traffic accidents were the leading cause (58.7%) of amputation followed by peripheral vascular diseases (7.5%) and hit by sharp objects (7.2%). Age (odds ratio: 0.9) and driving as occupation (odds ratio: 7.3) were found to be statistically significant covariates for amputation from road traffic accidents. The mean duration between having an amputation and receiving the first prosthetic fitting was 6.4 years (±8.9). Among the study participants, 30.7% lost their jobs after amputation and their mean monthly income reduced significantly ( p  < 0.01) from US$119.9 (±421.5) to US$45.8 (±63.1). Conclusion: Majority of the lower limb amputations resulted from traumatic road traffic accidents. Younger males and drivers were found to be more prone to amputation from road traffic accidents. Lower limb amputation creates great health and economic disparity in the amputee's lives.Implications for rehabilitationMajority of the lower limb amputation cases in Bangladesh were attributable to road traffic accidents-a largely preventable cause.The mean time between amputation and prosthetic fitting was more than 6 years which implies lack of awareness and inaccessibility of prosthetic management.Policymakers, regulators, law enforcement, and traffic safety advocates should take urgent actions to prevent road traffic accidents and raise awareness about and improve availability of prosthetic rehabilitation in Bangladesh.

Purpose: To assess the test-retest reliability of the Special Interest Group on Amputation Medicine Mobility Scale/Dutch Working Group on Amputations and Prosthetics, better known as SIGAM/WAP mobility scale, in persons with a lower-limb amputation. Method: Longitudinal study at the outpatient departments of a rehabilitation center and a university medical center. Persons with a lower-limb amputation, wearing a prosthesis, were assessed at the end of their multidisciplinary rehabilitation treatment twice, with a 3-week interval, by the same practitioner. Test-retest reliability was quantified using the intraclass correlation coefficient for agreement. Results: Eighty persons participated (mean age ± SD, 61 ± 15 years; 61% men; 76% vascular cause of amputation; 70% able to walk >50m). Fifty-one of them rated themselves to be stable with respect to their mobility and their intraclass correlation coefficient was 0.90 (95% confidence intervals 0.84-0.94). Conclusions: The Special Interest Group on Amputation Medicine Mobility Scale/Dutch Working Group on Amputations and Prosthetics had, at the outpatient departments of a rehabilitation center and a university medical center, excellent test-retest reliability in persons wearing a prosthesis after a lower-limb amputation.Implications for rehabilitationThe Special Interest Group on Amputation Medicine/Dutch Working Group on Amputations and Prosthetics Mobility Scale was developed to classify mobility after a lower-limb amputation and wearing a prosthesis.The Dutch translation of this mobility scale has excellent test-retest reliability.

Background: In people living with limb loss, addressing the resulting functional deficit with prostheses increases the risk for secondary conditions such as pressure sores, impaired blood perfusion, and injuries from accidental falls. Any of those occurrences can render the prosthesis temporarily useless, making it challenging for users to engage in many activities of daily life, including work, exercise, and social participation. Many of the described issues originate at the interface between residual limb and prosthetic socket, where the objectives of sufficient weight distribution and suspension are conflicting with the necessity to facilitate heat exchange and limit contact pressure and friction. Recently, prosthesis liners that contain phase-change material have become commercially available, holding the promise that the micro climate at the interface between the residual limb skin and the prosthetic socket can be regulated to reduce the users' tendency to sweat. Preliminary studies on these liners indicate that the socket temperatures inside the socket stayed lower and rose slower than in conventional liners. However, the clinical relevance of those findings remains unclear. The purpose of this study is to investigate whether longer (6+ months) periods of use of phase-change material based temperature-control liners have clinically meaningful effects., Methods: The protocol is a double-blind longitudinal cross-over research design. A sample of trans-tibial prosthesis users are wearing their regular gel or silicone liners for six months and phase-change material liners for another six months in a randomized sequence. Their prostheses is equipped with activity monitors to detect days when they could not wear their prosthesis. In six-week intervals, individuals' activity, physical performance, and overall prosthesis assessment is recorded using standardized methods., Discussion: Expected results will inform prescription and reimbursement practice of phase-change material-based prosthesis liners and will help improve and economize prosthetic fitting for people with limb loss. The design and duration of the protocol, including randomization, blinding, and within-subject comparison, will generate scientific evidence of a comparably high level. Inclusion of a comparably large sample and different climates, e.g. across all four seasons, will make findings applicable to a large number of prosthesis users., Trial Registration: Clinicaltrials.gov, NCT03428815. Registered on 12 February 2018.

Objective: To report the rates of persons returning home within one year following dysvascular major amputation of the lower limb in the Netherlands, and to identify factors associated with returning home directly after hospital admission and after discharge to care facilities., Design: Retrospective cohort study., Patients: Dysvascular major amputation of the lower limb, n = 382, mean age 71.9 years (standard deviation (SD) 12.5 years), 65% male., Methods: Medical records of all persons undergoing major amputation of the lower limb in 2012-2013 in 12 hospitals in Northern Netherlands were reviewed. Odds ratios (OR) were calculated using multivariate logistic regression., Results: Among persons admitted from home and surviving the hospital admission, 21% returned home, with higher odds of returning home being associated with living with a partner (OR = 2.8, p = 0.006) and younger age (< 65 years). Among those discharged to care and surviving the first year, 77% returned home within one year after amputation, with higher odds being associated with younger age (<75 years) and admission to inpatient rehabilitation (OR = 10.6, p = 0.004) or geriatric rehabilitation in skilled nursing facilities (OR = 3.5, p = 0.030)., Conclusion: Four out of 5 persons surviving dysvascular major amputation of the lower limb return home within one year, although a majority requires care in either inpatient rehabilitation or a skilled nursing facilities setting.

Objective: To establish if a home-based exercise and education programme is more effective than usual treatment in improving function, mobility and quality of life in people with lower limb amputation due to peripheral vascular disease., Method: A blocked randomized single-blinded controlled trial (RCT) with 154 participants (54 female; mean age 58) compared a home-based exercise and education programme (n = 77) with usual care (control) (n = 77). Participants were measured at baseline, immediately post intervention at three months, and after a further three months without any intervention. The outcome measures were the Barthel Index, Participation Scale, EuroQuol 5D, Modified Locomotor Capability Index and Timed Up and Go Test. Changes over time were established using generalized estimating equations and analysis of covariance, ( P  < 0.05)., Results: The Participation Scale (18.73 ± 14.91 against 26.67 ± 19.14; P  = 0.011), the EuroQuol5D visual analogue scale (69.10 ± 20.31 against 55.37 ± 27.67; P  = 0.003), EuroQuol5D utility index (0.672 ± 0.300 against 0.532 ± 0.358; P  = 0.25) and the Modified Capability Index (21.03 ± 15.79 against 15.91 ± 13.67; P  = 0.034) improved in the intervention group compared with the control group at three months. At six months, there was no difference between the groups in any of the measures except for the EuroQuol5D visual analogue scale (74.52 ± 16.14 against 66.34 ± 22.91; P  = 0.033). Although there were no differences between the Timed Up and Go test at 3 (35.39 ± 32.48 against 45.08 ± 41.52; P  = 0.192) and six months (28.22 ± 20.96 against 36.08 ± 36.19; P  = 0.189) between the groups the intervention group was more mobile., Conclusion: This intervention improved function, mobility and quality of life in persons following lower limb amputation in the first three months post amputation.

Background: During the rehabilitation phase, physical exercise is a key element that requires an assessment of the best alternatives for application since the pre-prosthetic phase (PPF) for an accurate prescription. Therefore, the assessment of fitness for health (FFH) shall be included in the initial rehabilitation process., Objective: To develop a FFH evaluation battery (Evam1) for pre-prosthetic unilateral lower-limb amputees (PPULLA)., Method: A descriptive study of the theoretical construction and validation of a FFH evaluation battery based on a review of international literature for tests that measure amputee physical capability., Results: During the scientific literature review, no batteries designed with this goal were found. We therefore designed a battery that was assembled of five tests for anthropometry, aerobic capacity, strength and flexibility. Combined leg and arm cycloergometrics, isokinetic dynamometry, and flexi test are the most reliable tests for the corresponding assessment of each component., Conclusions: PPF is of great importance, since the basic physical capabilities are altered due to long immobilization and hospitalization periods, inadequate postures, alteration of basic daily activities, and decrease in participation in sports, recreational, and work activities. This is a fundamental proposal, given that the procedures for FFH assessment of PPULLA have been rarely addressed, thus limiting the information on assessment methods, processes and/or tests established for these procedures.

Purpose: To gather ideas from lower-limb prosthesis users and certified prosthetists regarding possible residual limb monitoring system features and data presentation. We also gathered information on the type of residual limb problems typically encountered, how they currently manage those problems, and their ideas for methods to better manage them. Materials and methods: Two focus groups were held; one with certified prosthetists and another with lower-limb prosthesis users. Open-ended questions were used in a moderated discussion that was audio recorded, transcribed, and assessed using applied thematic analysis. Results and conclusions: Seven individuals participated in each focus group. Prosthetists came from a mix of practice settings, while prosthesis users were diverse in level of amputation, aetiology, and years of experience using lower-limb prostheses. Residual limb problems reported by participants were consistent with those in the literature. Participants suggested better managing residual limb problems through improved education, better detection of residual limb problems, and using sensor-based information to improve prosthetic technology. Participants favoured short-term use of a possible residual limb monitoring systems to troubleshoot residual limb problems, with temperature and pressure the most frequently mentioned measurements. Participants described that an ideal residual limb monitoring system would be lightweight, not interfere with prosthesis function, and result in benefits with regard to prosthetic care and socket function that outweighed inconveniences or concerns regarding system use. A potential positive of system use included having objective data for reimbursement justification, although it was pointed out that the residual limb monitoring system itself also needed to be reimbursable.Implications for RehabilitationStakeholders suggested better managing residual limb problems through improved education, better detection of residual limb problems, and using sensor-based information to improve prosthetic technology.Stakeholders favored short-term use of a possible system to troubleshoot residual limb problems, with temperature and pressure the most frequently mentioned measurements.Stakeholders described that an ideal residual limb monitoring system would be lightweight, not interfere with prosthesis function, and result in benefits with regard to prosthetic care and socket function that outweighs any inconveniences or concerns regarding system use.Stakeholders indicated that a potential positive of system use included having objective data for reimbursement justification, although it was pointed out that the residual limb monitoring system itself also needed to be reimbursable.

Background: Low balance confidence is a prevalent yet overlooked issue among people who use lower limb prostheses (LLP) that can diminish community integration and quality of life. There is a critical need to develop rehabilitation programs that specifically target balance confidence in people who use LLP. Previous research has shown that multicomponent interventions including cognitive-behavioral therapy (CBT) techniques and exercise are feasible and effective for improving balance confidence in older adults. Therefore, a cognitive behavioral-physical therapy (CBPT) intervention was developed to target balance confidence and increase community integration in people who use LLP., Methods/design: This randomized control trial will recruit 60 people who use LLP with low balance confidence. Participants will be randomized to the CBPT intervention condition or control condition., Discussion: The trial is designed to test the effects of the CBPT intervention on balance confidence and functional mobility in lower limb prosthesis users by examining self-reported and objective measures of community integration and quality of life. The trial will also examine the relationship between changes in balance confidence and changes in community integration following participation in CBPT intervention. Additionally, through participant feedback, researchers will identify opportunities to improve intervention efficacy., Trial Registration: ClinicalTrials.gov, NCT03411148. Registration date: January 26, 2018.

Aim: This study investigates the effect of time and age on health-related quality of life, general self-efficacy, and functional level 12 months following dysvascular major lower limb amputation (LLA). Methods: A prospective cohort study design with assessments at baseline and follow-up 3, 6, and 12 months post-amputation. Data were collected via in-person interviews using Short Form 36, the General Self-efficacy scale and Barthel Index 100. Out of a consecutive sample of 103 patients having dysvascular major LLA (tibia, knee, or femoral), 38 patients completed the study. Outcome at follow-up was compared with baseline and analyzed in age groups. Results: All SF36 subscale scores were below population norms at baseline. At 12 months, two out of eight scores-physical function and role-physical-had not improved. Different patterns of change over the 12 months were detected among the subscales, and psychosocial problems persisted and fluctuated throughout the 12 months in all age groups. Large differences were identified between age groups in physical function with the loss of physical function almost solely evident among the oldest (aged 75+ years) patients. Conclusions: Special attention should be given to the oldest patients need for rehabilitation so that they gain higher quality of life.Implications for rehabilitationPsychosocial problems persist and fluctuate throughout the first 12 months after major LLAs in all age groups and rehabilitation services should include psychosocial support throughout the first year to all patients independent of age.Waiting for an unnecessarily long period of time for a prosthesis can negatively impact both physical and psychosocial aspects of health-related QOL, and interventions to reduce waiting time are warranted.Differences between age groups in functional level after 12 months exist, with the loss of function almost solely evident among the oldest patients (aged 75+ years). A special focus should be given to the oldest patients' need of everyday rehabilitation to regain basic physical functions.

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.

Objectives: To assess (1) the effect of task (single and dual task), time (discharge and 4mo), and their interaction for mobility; (2) task prioritization during dual-task testing; and (3) the association between cognition on change in mobility between discharge from rehabilitation and 4 months' follow-up., Design: Prospective cohort study., Setting: Rehabilitation hospital., Participants: People with lower extremity amputations (N=22) were consecutively recruited at discharge from an inpatient prosthetic rehabilitation program., Interventions: Not applicable., Main Outcome Measures: Gait velocity and the L Test of Functional Mobility, single and dual task (serial subtractions by 3), were the primary outcomes. Montreal Cognitive Assessment and Trail Making Test quantified cognition as secondary outcomes. Repeated measures analysis of variance evaluated the effects of task (single task and dual task) and time (at discharge and 4 months' follow-up) and their interaction on each outcome. A performance-resource operating characteristic graph evaluated gait and cognitive task prioritization. Multivariable linear regression evaluated the association between cognition and change in mobility over time., Results: No significant interactions between task and time were found (all P>.121) for L Test and gait velocity. The L Test single task (P=.001) and dual task (P=.004) improved over time. Gait velocity improved over time for both single task and dual task (P<.001). Dual-task performance was slower than single-task performances at each time point. The Trail Making Test B was independently associated with the change in dual-task L Test (P=.012), and single-task (P=.003) and dual-task (P=.006) gait velocity at follow-up., Conclusions: Gait velocity and L Test single and dual task improved over time. No significant interactions indicated that cognitive task did not differentially affect performance over time. Lower executive function scores at discharge were independently associated with lower gains in all gait velocity and dual-task L Test outcomes at follow-up., (Copyright © 2019 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: To develop a valid preoperative scoring tool that predicts the probability of walking with a prosthetic limb after major lower limb amputation. Methods: A retrospective review of 338 patients who had undergone lower limb amputation was conducted to identify characteristics that affected the success of rehabilitation with a prosthetic limb. These data were used to devise an assessment tool (the BLARt score), which was then tested and validated in 199 patients planned to undergo lower limb amputation in two UK regional centers. Functional rehabilitation outcomes were recorded at 12 months after surgery using the SIGAM mobility grading. Results: No patient with a BLARt score ≥13 achieved good functional outcome (defined as independent mobility, SIGAM grade E or F) and only 6 patients with a BLARt score ≥17 achieved any functional outcome (defined as any ability to walk unaided, SIGAM grade C or greater). Conclusions: In the patient cohorts studied, the BLARt assessment tool was a strong predictor of whether or not patients would be able to walk with a prosthetic limb after surgery. It is simple to administer and could be useful in clinical practice to inform expectations for patients and clinicians. Implications for rehabilitation Patients undergoing lower limb amputation face major physical and psychological challenges after surgery that have a considerable impact on rehabilitation and their ability to walk independently. Many amputees are unable to walk with a prosthetic limb, but there are no validated tools to predict this before surgery. The BLARt is a potentially valuable measure that can predict the likelihood of being unable to walk after amputation. It is simple to use and could be useful to inform patients' and clinicians' expectations before surgery.

The aim of this study was to examine the metric properties of the Prosthetic Mobility Questionnaire, an outcome measure of mobility following lower-limb amputation, in Slovene outpatients undergoing rehabilitation. The 12-item Prosthetic Mobility Questionnaire was administered to 148 Slovene adults (74% men) with unilateral lower-limb amputation since >12 months and regularly wearing a prosthesis. The psychometric analysis included classical test theory methods and Rasch models. Rasch analysis disclosed two pairs of locally dependent items (same task but in opposite directions: walk up/down stairs; walk up/down a hill). Thus, we devised a new version (PMQ 2.0) assessing all 12 Prosthetic Mobility Questionnaire items but calculating the global score on only 10, i.e. considering-for each pair of locally dependent items-just the item with worst performance. The PMQ 2.0 demonstrated correct functioning of rating scale categories, construct validity (item fit, hierarchy of item difficulties), convergent validity, high-reliability indices and unidimensionality. In conclusion, the new 10-item PMQ 2.0 shows good reliability and validity, and an excellent overall metric quality for measuring perceived mobility capabilities in people with lower-limb amputation.

Purpose: The objective of this study was to estimate fall incidence and describe associated risk factors among people with a lower limb amputation (LLA) during various stages of recovery: the surgical ward, in-patient rehabilitation and return to community life. Materials and methods: A systematic search of relevant English language articles was performed using PubMed and EMBASE. Out of 310 initial "hits," six retrospective cohort studies, one prospective cohort study and eleven cross-sectional studies from which fall incidence and risk factors could be extracted, were selected for critical review. Fall incidence and associated risk factors were extracted and analyzed in the context of various clinical stages of recovery after amputation. The studies were evaluated for quality using the "Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies." Results: Results showed that during all stages of recovery, people with a LLA are at increased risk of falling compared with able-bodied individuals, as well as other clinical populations. Each stage of recovery is associated with different fall risk factors. The current review is limited mainly by the paucity of studies on the topic. Conclusions: Specialised care focusing on the most relevant risk factors for each stage of recovery may enhance fall prevention during post-fall recovery. Implications for rehabilitation •  People with a lower limb amputation are at a high risk of falling in all stages of their clinical course.      •  Health professionals should be aware that people with a lower limb amputation in the first 4 years ofamputation or with four or more health-related problems are at an increased risk.      •  Health professionals should also be aware that increased gait variability, excess confidence in balance andwalking abilities and less cautious stair walking, impose an elevated risk of falling and should focus theirefforts in reducing these factors.

Background: Preferred walking speed (PWS) is an indicator of walking ability, prosthetic walking potential, and function following a lower-limb amputation (LLA). There is a link between lower-limb muscle performance and PWS in individuals with LLA. However, the ability of select hip muscle performance parameters to determine PWS in these individuals still needs to be thoroughly investigated., Research Question: Which hip muscle and joint torque parameters best determine PWS in persons with LLA?, Methods: Seventeen patients with LLA (6 transfemoral, 4 knee disarticulation, and 7 transtibial; 16 men, 1 woman; mean age ± standard deviation, 56 ± 15yr) participated in this cross-sectional study. Maximal joint torque and power were evaluated unilaterally, for both amputated and intact limbs, in isometric and isokinetic conditions during hip flexion/extension (60°/s and 180°/s) and abduction/adduction (30°/s and 90°/s). PWS was measured at habitual walking speed over a 10-m distance. Pearson's correlation coefficient was used to verify the degree of association between each torque parameter and PWS and multiple regression analysis was performed to identify the best predictors of PWS. The level of significance was p < 0.05., Results: Correlations between hip muscle performance parameters and PWS were found in most cases (r = 0.51-0.82; p ≤ 0.036-0.0005). The multiple regression model revealed that the best independent predictors of PWS were hip extension power at 180°/s on the amputated side (r² = 0.672; p < 0.0005) and the asymmetry of hip abduction power at 30°/s (r² = -0.147; p < 0.008), accounting together for 82% of the variance in PWS., Significance: Lesser hip extension power on the amputated side and greater hip abduction power asymmetry between limbs are detrimental to PWS in persons with LLA. These muscle groups and performance parameters should be considered during gait rehabilitation to assist individuals with LLA in achieving functional waking speed., (Copyright © 2019 Elsevier B.V. All rights reserved.)