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PubMed2001

A foot care program for diabetic unilateral lower-limb amputees.

OBJECTIVE: To assess the efficacy of a specialist foot care program designed to prevent a second amputation and to assess peripheral vascular disease (PVD) and peripheral neuropathy in diabetic unilateral lower-limb amputees. RESEARCH DESIGN AND METHODS: Investigations were carried out in 143 diabetic lower-limb unilateral amputees referred to a subregional rehabilitation center for prosthetic care from a catchment area of approximately 3 million people. Peripheral vascular and nerve assessment, education, and podiatry were provided for each patient. RESULTS: For the patients referred to the foot care program, there were no baseline differences between the patients who proceeded to a bilateral amputation (n = 22) and those who remained as unilateral amputees (n = 121) in their level of foot care knowledge and mean neuropathy scores. Mean ankle-brachial pressure index was significantly lower for the bilateral amputees (0.75 +/- 0.04) compared with the unilateral amputees (0.90 +/- 0.03, mean +/- SEM, P < 0.05), but there was no difference in the level of oxygen in the skin. However, the level of carbon dioxide was significantly lower in patients with bilateral amputation (24.21 +/- 2.16 vs. 31.20 +/- 0.85 mmHg, P < 0.03). Overall, the establishment of a specialist foot care program made no impact on contralateral limb amputation (22 of 143, 15.4%) compared with matched patients without the program (21 of 148, 14%) over a 2-year outcome period for each patient. CONCLUSIONS: PVD is more closely associated with diabetic bilateral amputation than neuropathy or level of foot care knowledge. Preventative foot care programs for diabetic unilateral amputees should therefore place greater emphasis on peripheral vascular assessment to identify patients at risk and on the development of timely intervention strategies.

Aged↗
PubMed1986

Prosthetic use in adult upper limb amputees: a comparison of the body powered and electrically powered prostheses.

Three hundred and fourteen adult upper limb amputees were reviewed retrospectively at the Ontario Workers' Compensation Board. A questionnaire was used to evaluate the use of body and electrically powered prostheses. Follow-up ranged from 1 to 49 years with a mean of 15 years. Results indicated that complete or useful acceptance of an electrically powered prosthesis was reported by 69 of 83 amputees (83%); 199 of 291 amputees (68%) used the cable operated hook, 57 of 291 (20%) used the cable operated hand and 40 of 83 (48%) used the cosmetic prosthesis. The majority of amputees used more than one prosthesis for their functional needs and should be fitted with more than one type of prosthesis. Acceptance of an upper limb prosthesis by 89% (196/220) of below-elbow, 76% (56/74) of above-elbow and 60% (12/20) of high level amputees indicates that for most upper limb amputees, their prostheses are well used and essential to their personal and employment activities.

Activities of Daily Living↗
PubMed1986

Running patterns of transfemoral amputees: a clinical analysis.

The challenge of rehabilitating young, healthy transfemoral amputees may extend beyond the boundaries of teaching them to adapt to functional activities of daily living. The goal for several of these amputees is to participate and sometimes even compete in recreational activities, including running. These amputee runners require prosthetic adaptations as well as a comprehensive individualized training programme to ensure that their running is as safe and energy efficient as possible. To help amputees achieve this, clinicians must understand normal and prosthetic locomotion. This paper compares the biomechanical differences between walking and running in normal locomotion and analyses the running modes used by transfemoral amputees. The modified running mode achieved with the Terry Fox Running Prosthesis subjectively "looks" more energy efficient to the observer and "feels" more energy efficient to the user. These assumptions have yet to be confirmed or refuted by a rigorous scientific research study. An outline of the proposed physiotherapy protocol includes the familiarization, treatment, and training phases. Physiotherapists involved in amputation rehabilitation may not be commonly confronted with this level of patient expectation. It is their responsibility to give realistic guidance to these amputees so that they can safely and independently pursue their recreational running activities. This need can best be fulfilled by providing sound clinical advice which has been validated by research findings.

Amputation, Surgical↗
PubMed1994

Functional outcome of rehabilitated bilateral lower limb amputees.

The functional outcome of rehabilitated bilateral lower limb amputees was studied. The study included 31 amputees who were admitted during 1980-1990 to a rehabilitation centre in the north of the Netherlands. The clinical notes made during the patients' admission were studied to obtain information about their characteristics, while mobility and prosthetic use were studied at discharge. The patients who were alive and willing to participate in the study were interviewed by a physician at their residence in November 1992, using among other things, the Sickness Impact Profile (SIP) and the Life Satisfaction questionnaire. Some 25 of the 31 patients were amputated for vascular reasons, 1 patient primarily for traumatic reasons and secondarily for vascular reasons, 5 patients for traumatic reasons. Eight patients had a bilateral trans-femoral amputation, 18 patients a bilateral trans-tibial amputation, 2 patients a combination of trans-tibial and knee-disarticulation amputation, 3 patients a trans-femoral/trans-tibial amputation. Mean age at second amputation was 66.3 years. Of the 31 amputees 21 were men and 10 women, 25 amputees were prosthetically rehabilitated during admission, 3 of them died during admission and 5 did not achieve mobility at discharge. In their activities of daily life 22 of the 28 patients alive at discharge were almost independent. At the time of the follow-up evaluation 17 of the 31 patients had died. For several reasons only 8 patients could be included in the follow-up, 6 vascular amputees and 2 traumatic amputees.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed2001

[Illusions of body normality in amputees and paraplegic patients].

Phantom limbs in amputees, or body illusion in hemiplegics, have been the subject of wide ranging descriptions. The detected abnormalities involve morphological, postural and/or kinetic features. The aim of this prospective study carried out in 25 amputees and 10 adult paraplegics was to describe the typology of these perceptions. Data were collected from free and semi-directive investigations before and after caloric vestibular stimulation. Amputees and paraplegics perceived normal, deformed and painful body phantom segments, reffered perceptions and "normal limbs" which took on the request posture considering the general body position (illusion of body normality). This perception corresponds to an image of the body, such as it should be and not such as it is. In amputees, the limb follows the movements of the prothesis. These perceptions conform quite well reality so that the loss of the paralyzed limb is not perceived as a missing limb. This illusion of body normality should be distinguished from the normal phantom limb, characterized by a stronger perception of the lost limb compared with the other. In both amputees and paraplegics, vestibular stimulation can generate or modify phantoms limbs or body illusion and can abolish painful phantom limbs. The neuromatrix, which rebuilds body representations, could get its information from reorganized cortical areas (instantaneous body image), autobiographical engrams (painful phantoms limbs), or innate engrams (identity body schema) that, via congruence mechanisms, could be identified as a somatic reference, particularly for motor programming. This interpretation is compatible with current knowledge and suggests how amputees can easily use a prothesis.

Adult↗
PubMed1986

Improved ankle-foot system for above-knee amputees.

Above-knee amputees were studied while wearing a prosthesis containing either a standard or a modified single axis foot. The modified foot allowed 12-15 degrees of dorsiflexion and reduced stiffness in the area of the metatarsal-phalangeal (MTP) joint. The amputees were allowed to vary the stiffness at the two joints to obtain what "felt best." The amputees agreed that in comparison to the standard single-axis foot, the modified foot: a) offered a more comfortable gait while walking on level ground; b) made walking up inclines easier; c) affected knee stability while walking on declines; and d) made foot placement on stairs and ladders more critical due to potential knee instability. As well as qualitative reactions, changes in the gait cycle were measured quantitatively for different speeds and inclinations of walking on a treadmill. Measurements from normal subjects matched by age and sex were used for control purposes. All participants wore soft-soled shoes. The amputees selected a stiffness that allowed a degree of dorsiflexion which precisely matched on average that of the normal subjects. In contrast, they selected a stiffness at the MTP joint which allowed very little flexion of the toes. Significant changes also occurred in the pattern of hip movements, so that they became much more symmetrical on the two sides, although substantial differences remained between the hip movements of the amputees and the normal subjects. If modifications in the ankle joint can be coupled with improvements in the knee joint to prevent potential instability, a much improved gait should be possible for above-knee amputees.

Adult↗
PubMed1994

Osteoarthritis and elderly amputee gait.

The hypothesis that an increased load on the nonamputated leg of long-term prosthetic users leads to an increased risk of developing osteoarthritis was investigated using physical examinations and gait analysis. Based on the clinical results from an elderly group of experienced trans-tibial amputees and a similar control group of nonamputees, the amputee group experienced a significantly greater incidence of osteoarthritis (p < 0.05) in the knee of their nonamputated leg. The amputee group had consistently larger knee joint reaction forces, joint impulses, net joint moments, and net joint powers. Significantly higher results (p < 0.05) were found for amputee vertical impulse and net joint power during the double support phase of gait. These results support the hypothesis that elderly, trans-tibial amputees have a higher risk of developing osteoarthritis and experience larger forces at the knee of their nonamputated limb than people without lower extremity amputations.

Aged↗
PubMed1989

Performance assessment of the Terry Fox jogging prosthesis for above-knee amputees.

The Terry Fox jogging (TFJ) prosthesis was developed at Chedoke-McMaster Hospital to alleviate the asymmetric jogging pattern experienced by above-knee amputees when attempting to jog with conventional walking prostheses. This prosthesis features a spring-loaded, telescoping shank designed to eliminate any vaulting action and control the trunk motion during stance. The spring is intended to attenuate the impact forces and release its stored energy at push-off to provide momentum transfer to the jogger. This prosthesis was comprehensively assessed in the gait laboratory, by evaluating the kinematics, energy and power flow patterns of an above-knee amputee jogger wearing the TFJ prosthesis. Included in the assessment is the ability of the prosthesis to satisfy a set of relevant design criteria that have been established from non-amputee jogging patterns. An increased swing phase time for the prosthetic limb and the need to have the knee hyperextended throughout the stance phase contributed to an asymmetric jogging style. The telescoping action did lower the amputee's centre of mass, thereby reducing the vaulting effect. However, the spring only imparted a lifting action to the jogger and the ground reaction forces were double those of a non-amputee jogger. These findings clearly indicate a need to redesign the TFJ prosthesis and are being incorporated in the design of a new physiological jogging prosthesis.

Adult↗
PubMed1991

Joint moment and muscle power output characteristics of below knee amputees during running: the influence of energy storing prosthetic feet.

Stance phase joint moments, muscle power outputs and mechanical energy characteristics were determined in five normal and five below knee amputee subjects running at 2.8 m s-1. The amputees were studied sequentially on three different prosthetic feet: the SACH foot (solid ankle cushion heel), and two energy storing feet, Seattle and Flex. While wearing the SACH foot, the amputees exhibited major alterations in the distribution and magnitude of muscle power output and muscle work: (1) the total work done by the lower extremity was reduced; (2) the hip extensors became the main source of energy absorption and generation, while in normal subjects the ankle plantarflexors were the major energy generators and the knee extensors the major energy absorbers; (3) the eccentric and concentric knee extensor power outputs were reduced and an abnormal concentric knee flexor power output was noted immediately after heel contact. In four of the amputees, energy storing feet resulted in improvements in the power output and mechanical work characteristics of the lower extremity: (1) the energy storing prosthetic feet generated 2-3 times greater energy than the SACH foot; (2) with the Flex foot the amputees exhibited a more normal pattern and magnitude of hip and knee extensor muscle work. One of the subjects, however, exhibited increased abnormalities with the energy storing prosthetic feet. The amount of energy restored relative to the amount of energy absorbed by each of the prosthetic feet was greater with the energy storing feet than the SACH foot (Flex 84%, Seattle 52%, SACH 31%).

Amputation Stumps↗
PubMed2005

Phantom pain, residual limb pain, and back pain in amputees: results of a national survey.

OBJECTIVES: To describe the prevalence of amputation-related pain; to ascertain the intensity and affective quality of phantom pain, residual limb pain, back pain, and nonamputated limb pain; and to identify the role that demographics, amputation-related factors, and depressed mood may contribute to the experience of pain in the amputee. DESIGN: Cross-sectional survey. SETTING: A sample of persons who contacted the Amputee Coalition of America from 1998 to 2000 were interviewed by telephone. PARTICIPANTS: A stratified sample by etiology of 914 persons with limb loss. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Prevalence, intensity, and bothersomeness of residual, phantom, and back pain, depressed mood as measured by the Center for Epidemiologic Study Depression Scale, characteristics of the amputation, prosthetic use, and sociodemographic characteristics of the amputee. RESULTS: Nearly all (95%) amputees surveyed reported experiencing 1 or more types of amputation-related pain in the previous 4 weeks. Phantom pain was reported most often (79.9%), with 67.7% reporting residual limb pain and 62.3% back pain. A large proportion of persons with phantom pain and stump pain reported experiencing severe pain (rating 7-10). Across all pain types, a quarter of those with pain reported their pain to be extremely bothersome. Identifiable risk factors for intensity and bothersomeness of amputation-related pain varied greatly by pain site. However, across all pain types, depressive symptoms were found to be a significant predictor of level of pain intensity and bothersomeness. CONCLUSIONS: Chronic pain is highly prevalent among persons with limb loss, regardless of time since amputation. A common predictor of an increased level of intensity and bothersomeness among all pain sites was the presence of depressive symptoms. Further studies are needed to elucidate the relationship between pain and depressive symptoms among amputees.

Age Factors↗
PubMed2005

Relationship between energy cost, gait speed, vertical displacement of centre of body mass and efficiency of pendulum-like mechanism in unilateral amputee gait.

The energy cost of gait (C) is greater in amputee than in normal subjects. Our objective was to assess the influence of lower speed, inefficient pendulum mechanism and disturbed smoothness of centre of body mass (CM(b)) displacement on C in unilateral amputees and to have a better understanding the relationship between these variables. Twelve adult patients (six traumatic transfemoral and six vascular transtibial amputees) participated in the study. Lower limb kinematics, displacement of CM(b), mechanical work done by the muscles to move the CM(b) and the segments due to their movements relative to the CM(b), efficiency of the pendulum mechanism, and C were assessed simultaneously in the 12 amputees walking at their self-selected speed. Our results show that C depended on gait speed, and efficiency of pendulum-like mechanism of walking but did not depend on the smoothness of CM(b). The use of only a single variable to explain the extra cost in amputee gait could sometimes be misleading.

Adult↗
PubMed2003

Physical, mental, and social predictors of functional outcome in unilateral lower-limb amputees.

OBJECTIVE: To study the value of physical, mental, and social characteristics as predictors of functional outcome of elderly amputees. DESIGN: Prospective, inception cohort study; comparisons with reference populations. SETTING: Main hospitals, rehabilitation centers, nursing homes, patients' own residence settings in 1 of the 3 northern provinces in the Netherlands. PARTICIPANTS: Forty-six patients older than 60 years, with unilateral transtibial or transfemoral amputation or knee disarticulation because of vascular disease. INTERVENTIONS: Measurement of physical, mental, and social predictors 2 and 6 weeks postamputation. MAIN OUTCOME MEASURES: The Sickness Impact Profile (SIP-68), Groningen Activity Restriction Scale (GARS), Timed up and go (TUG) test, and prosthetic use. RESULTS: A total of 15% of amputees died within the first year after amputation. Seventy percent lived independently at home 1 year postamputation. The functional level of the patients was low, as shown by high scores on the SIP-68 (mean, 23.6), GARS (mean, 41.2), and TUG test (mean, 23.9s). Functionally effective prosthetic use, as measured with the classification of Narang and Pohjolainen, was reached by 49%. For the SIP-68 scores, age, comorbidity, 1-leg balance, and the 15-word test predicted functional outcome in 69% of amputees. For the GARS score, age, 1-leg balance, and the 15-word test predicted functional outcome in 64%. For the TUG test, age and 1-leg balance predicted functional outcome in 42% of amputees. After correction for age, the only significant predictor for prosthetic use was 1-leg balance. CONCLUSIONS: Elderly patients with a leg amputation had a low functional level 1-year postamputation. An important part of functional outcome could be predicted 2 weeks after amputation by age at amputation, 1-leg balance on the unaffected limb, and cognitive impairment. Severe comorbidity probably also played a role. The results may be used in the general policy concerning leg amputees.

Activities of Daily Living↗
PubMed1996

Mechanical work adaptations of above-knee amputee ambulation.

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.

Adaptation, Physiological↗
PubMed2000

Biomechanical adaptations of transtibial amputee sprinting in athletes using dedicated prostheses.

OBJECTIVE: To determine the biomechanical adaptations of the prosthetic and sound limbs in two of the world's best transtibial amputee athletes whilst sprinting. DESIGN: Case study design, repeated measures. BACKGROUND: Using dedicated sprint prostheses transtibial amputees have run the 100 m in a little over 11 s. Lower-limb biomechanics when using such prostheses have not previously been investigated. METHODS: Moments, muscle powers and the mechanical work done at the joints of the prosthetic and sound limbs were calculated as subjects performed repeated maximal sprint trials using a Sprint Flex or Cheetah prosthesis. RESULTS: An increased hip extension moment on the prosthetic limb, with an accompanying increase in the amount of concentric work done, was the most notable adaptation in Subject 1 using either prosthesis. In Subject 2, an increased extension moment at the residual knee, and an accompanying increase in the amount of total work done, was the most notable adaptation using either prosthesis. This later adaptation was also evident in Subject 1 when using his Sprint Flex prosthesis. CONCLUSIONS: Increased hip work on the prosthetic limb has previously been shown to be the major compensatory mechanism that allow transtibial amputees to run. The increased work found at the residual knee, suggests that the two amputee sprinters used an additional compensatory mechanism. RELEVANCE: These findings provide an insight into the biomechanical adaptations that allow a transtibial amputee to attain the speeds achieved when sprinting.

Adaptation, Physiological↗
PubMed2002

Military lower extremity amputee rehabilitation.

The role of the military has changed over the past eight decades. Although the threat of global warfare still exists, the military of today faces new challenges as a peacekeeper in countries under turmoil. Despite these changes, the fear of bodily injury, such as limb loss and even the possibility of death, are real concerns for our active duty personnel. The military physician must be aware of the appropriate surgical, rehabilitative, and psychosocial needs of the lower extremity traumatic amputee. The physical medicine and rehabilitation specialist is a physician particularly suited to provide direction for and to oversee the overall care of the amputee's condition. An amputee center providing a multidisciplinary team approach has worked well for the military during war and peacetimes. The physical medicine and rehabilitation inpatient service at WRAMC continues the tradition and philosophy of the military amputee centers dating back to WWI. By growing with the fast-paced technologic advances in prosthetic devices, yet keeping true to the fundamentals of prosthetic prescription and design, physical medicine and rehabilitation in the military has remained at the forefront of amputee rehabilitation. Patient satisfaction with the rehabilitation process and his or her new artificial limb remain priorities whether the goal is to return to active duty or to resume an active lifestyle in the civilian world.

Amputation, Surgical↗
PubMed2003

Better practical evaluation for lower limb amputees.

PURPOSE: To avoid wastage of prostheses and unfair selection methods for prosthetic prescription, we aimed to develop a practical assessment tool for amputees with doubtful potential, using refurbished second hand modular prostheses. METHOD: Thirty-seven primary amputees (33 transfemoral, 4 transtibial; 22 males, 15 females; median age 71 years, range 19-91) were considered to have doubtful potential for prosthetic use, due to single or multiple impairments. Amputees were assessed using custom-made socket and refurbished second-hand modular prostheses. Liability issues were fully covered. RESULTS: Two patients died before completing the assessment. Median duration of assessment was 4 weeks (range 1-31 weeks). Among the 35 amputees who completed the trial, 14 (38%) proceeded to final prosthesis successfully and 21 (58%) decided to abandon the prostheses. The main reasons for prostheses rejection identified by the team were: hip flexion deformity (4); frailty (4); bilateral amputations (4); COAD (6), stroke (4), stump pain (3) and contralateral leg problems (2) CONCLUSION: High prosthetic rejection rate was expected and confirmed in this group (58%), but considerable number did proceed to definitive prosthesis. The method is practical and fair for amputees of doubtful potential, with considerable cost saving.

Adult↗
PubMed2004

A picture of amputees and the prosthetic situation in Haiti.

PURPOSE: The purpose of this study is to present the situation of Haitian amputees and to outline some of the major barriers in Haiti that prevent people from receiving prosthetic treatment. METHOD: Interviews were conducted with amputees throughout Haiti using a 42-question questionnaire. Additionally, interviews were conducted with traditional healers, health care workers, and leaders of handicap associations. Each interview was manuscripted and the data were subsequently coded and analysed in the USA. RESULTS: There are three full-time prosthetic shops and two part-time prosthetic shops in Haiti, all of which are severely limited in the scope of services they are able to provide amputees due to insufficient supplies and inadequately trained personnel. Only 25% of the 164 amputees interviewed had ever had a prosthetic limb. Typically prosthetic treatment is inaccessible and unaffordable for amputees, which prevents many from seeking treatment. The most common cause of amputation in Haiti is infection, followed by motor vehicle accidents. CONCLUSION: There must be additional cooperation between Haitian patients, doctors, traditional healers, prosthetists, and government officials in order to provide more adequate prosthetic care. Prosthetic treatment in Haiti can be successful with cooperation of different entities, proper rehabilitation therapy, adequately trained personnel, and development of culturally appropriate limbs.

Adolescent↗
PubMed1992

A comparison of psychosocial functioning and personality in amputee and chronic pain populations.

OBJECTIVE: To compare two populations with disabling conditions, amputation and chronic pain, in terms of psychosocial functioning and personality factors. We hypothesized that the degree of disability of amputees would resemble that of patients with chronic musculoskeletal pain. We also examined the prevalence of personality characteristics stereotypic of chronic pain in the two samples. DESIGN: Survey. SETTING: Outpatients at the pain and amputee clinics of a teaching hospital. PATIENTS: Ninety-four patients (47.7% of the number approached) were selected in consecutive samples taken from records and clinics. MAIN OUTCOME MEASURES: Sickness Impact Profile (SIP) and the Millon Clinical Multiaxial Inventory (MCMI). RESULTS: The two groups did not differ on the SIP total score. Sixteen of 47 amputees reported significant pain, and this group showed higher levels of overall disability than did patients with chronic musculoskeletal pain (n = 47) and significantly greater disability than the 31 amputees reporting low levels of pain. Contrary to common perceptions of chronic pain patients, 25% showed no significant evidence of psychopathology. Only anxiety and dysthymia levels were clinically elevated in more than 50% of chronic pain patients. CONCLUSIONS: Results are discussed in terms of the dual disability of amputees with chronic pain and of the hazards of attributing common characteristics to heterogenous patient groups.

Adult↗