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PubMed2002

Pain in traumatic upper limb amputees in Sierra Leone.

Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10-48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.

Adolescent↗
PubMed2000

The functional demands on the intact limb during walking for active trans-femoral and trans-tibial amputees.

The aim of this study was to investigate the loading demands placed on the intact limb in terms of joint moments and power for active trans-femoral and trans-tibial amputees in comparison to a group of able-bodied subjects. Four (4) trans-tibial, 4 trans-femoral amputees and 10 able-bodied subjects walked at 1.2m.s(-1) along a walkway whilst kinematic data from both the intact and prosthetic limbs, and kinetic data from the intact limb only were collected. A Panasonic VHS video camera was used to film subjects walking in the sagittal plane with simultaneous force data collected from a Kistler force platform. The amputees were found to compensate for the functional loss of one or more joints by increasing net joint moments and power output on their intact limb compared to able-bodied subjects. At the intact limb ankle, the range of motion, peak dorsiflexor moment and power generation at toe-off increased. At the intact limb knee, power generation during stance and extensor moments and power absorption at toe-off increased. At the intact limb hip, extensor moment and power absorption during stance, and hip flexor moment and power generation at toe-off increased. These findings were partly attributed to the prostheses used but mainly to adaptation mechanisms displayed by trans-femoral and trans-tibial amputees. They have implications for the mobility of amputees and the long term health of their joints. It was recommended that prosthesis design, prosthesis fitting and training in the use of the prosthesis were all factors which could be investigated with a view to minimising intact limb loading.

Adult↗
PubMed2000

Lower limb prosthesis utilisation by elderly amputees.

The goal of prosthetic rehabilitation is to compensate for the loss of a limb by amputation by, in the case of a lower limb, encouraging walking, and to achieve the same level of autonomy as prior to the amputation. However, because of difficulties walking, elderly amputees may use their prosthesis to a greater or lesser degree or simply stop using it during the rehabilitation period. The objective of this research was to study factors such as physical and mental health, rehabilitation, physical independence and satisfaction with the prosthesis to understand why amputees use their prosthesis or not. The sample was composed of 65 unilateral vascular amputees 60 years old or over living at home. The information was collected from medical records, by telephone interview and by mail questionnaire. Prosthesis use was measured by a questionnaire on amputee activities developed by Day (1981). Eighty-one per cent (81%) of the subjects wore their prosthesis every day and 89% of this group wore it 6 hours or more per day. Less use of the prosthesis was significantly related to age, female gender, possession of a wheelchair, level of physical disability, cognitive impairment, poorer self-perceived health and the amputee's dissatisfaction. A multiple regression analysis showed that satisfaction, not possessing a wheelchair and cognitive integrity explained 46% of the variance in prosthesis use.

Age Distribution↗
PubMed2003

Is the Rivermead Mobility Index appropriate to measure mobility in lower limb amputees?

PURPOSE: Measurement of lower limb amputee mobility was investigated using the Rivermead Mobility Index (RMI). METHOD: Reliability and reproducibility were assessed in 62 patients. The timed waking test (TWT) was used to investigate concurrent validity. The RMI construct was examined in 200 established amputees. RESULTS: One hundred and forty-four males and 66 females, aged 13-90 were recruited. Intraclass correlation coefficients and kappa statistics showed good reproducibility. Spearman correlation coefficient between the RMI and TWT -0.58 (p<0.000). Psychometric properties of the RMI were tested using item response theory. Hierachical differences in RMI grades were identified in amputees compared with neurologically impaired patients for which the RMI was developed. The RMI construct was not unidimensional, with redundancy of items and local dependency. At the upper end of the scale there were insufficient items measuring high levels of mobility. Finally, differential item functioning showed items behaving differently for patient subgroups. CONCLUSIONS: Although initial impressions suggest the RMI is a useful measure of lower limb amputee mobility, further analysis shows it is not appropriate for all amputees, with a number of limitations of its psychometric properties. Its use is not recommended in this population.

Activities of Daily Living↗
PubMed2007

Turning bias and lateral dominance in a sample of able-bodied and amputee participants.

Turning bias is the tendency to turn towards a given direction. Conflicting results from previous studies suggest that a number of factors may influence turning direction. The aim of this study was to determine if biomechanical asymmetries influence turning bias. A total of 100 able-bodied participants, and 30 trans-tibial amputees who, by definition, possess a functional asymmetry, volunteered to participate in the study. The right hand and right foot were significantly dominant for the able-bodied sample. Able-bodied participants showed a significant turning preference towards the left, which was opposite to the dominant hand and foot. The amputees were significantly right-hand dominant and the side of the amputation influenced foot dominance. The amputee sample showed no preferred turning direction. Turning bias indices in the amputee sample were not significantly associated with handedness, footedness, side of amputation, or dominance prior to amputation. The lack of a preferred direction of turn in the amputee sample suggests that biomechanical asymmetries can influence turning bias.

Adult↗
PubMed1992

Reflex sympathetic dystrophy of the stump in below-knee amputees.

OBJECTIVE: To document the occurrence of reflex sympathetic dystrophy of the stump in two patients with below-knee amputation. DESIGN: A retrospective survey emphasising two clinical case reports. SETTING: Department of orthopaedic rehabilitation at a teaching rehabilitation hospital. PATIENTS: Lower limb amputees (n = 164) were accepted for prosthetic rehabilitation. Twenty-one amputees were regarded as rehabilitation failures; in two below-knee amputees intractable pain was the major problem. RESULTS: Clinical manifestations, radiological, and scintigraphic findings in the two amputees with intractable pain met the criteria for diagnosis of reflex sympathetic dystrophy. CONCLUSIONS: Reflex sympathetic dystrophy of the stump should be suspected in below-knee amputees whenever severe pain persists over a period of 3 to 4 months following amputation.

Amputation Stumps↗
PubMed2006

Effect of physical fitness on prosthetic ambulation in elderly amputees.

OBJECTIVE: To evaluate the physical fitness and prosthetic ambulation ability of high-level (hip disarticulation, transfemoral) lower-limb amputees aged 60 and above, and to investigate the level of fitness required for successful prosthetic ambulation. DESIGN: The test subjects were 49 amputees aged 60 and above. Subjects were permitted to use any necessary ambulatory aids and were asked to walk at their most comfortable walking speed for evaluation of prosthetic ambulation ability. An incremental exercise test was performed to evaluate physical fitness. RESULTS: The average %VO(2max) value for the successful user group was 64.4%, and the average %VO(2max) value for the failed user group was 44.8%, a statistically significant difference (P < 0.01). Of the amputees with %VO(2max) > or =50, 93.7% were in the successful user group. Of the amputees with %VO(2max) <50, only 23.5% were in the successful user group. CONCLUSION: This study showed that the ability to sustain an exercise intensity of > or =50%VO(2max) can be regarded as a guideline value for the level of fitness required for successful prosthetic ambulation in elderly amputees.

Aged↗
PubMed1982

New perspectives on nursing lower limb amputees.

New perspectives on nursing lower limb amputees arise from the author's researches into amputee rehabilitation and a summary of other recent research findings. These are dealt with in the context of basic amputee treatment and the nursing process. There is new material on the psychological and neurological sequelae of amputation, the practical problems of loss of a limb and the prosthetic dimension of treatment. The patients' reactions to lower limb amputation were found to vary from intense grief to intense relief, many noting it to be of minor or moderate consequence. The model of sudden and shocking loss is largely incorrect. Attention is drawn to an unrecognized ordinariness which should become part of amputee nursing. Patients have many practical problems. These are social and economic, personal and domestic. The ward environment is unsuited to these needs but, working closely with therapists, nurses can do much to facilitate amputee rehabilitation. The modern purpose of amputation surgery is prosthetic replacement. Nurses should be working with some urgency towards uniting patient and prosthesis. Pain and discomfort are underestimated and research shows them to be a major characteristic of amputation continually and for many years after surgery. A variety of pain syndromes are involved.

Adaptation, Psychological↗
PubMed1992

Cause of death of lower limb amputees.

A study was carried out on the cause of death of 100 lower limb amputees who had been admitted to the Dundee Limb Fitting Centre, Tayside, Scotland for prosthetic management or wheelchair training. A comprehensive database has been established in the Centre for 25 years and the database is updated regularly. The date of death was collected and recorded. One hundred sequential deaths were investigated to review the cause of their death and compare this with the recorded causes of death for the Tayside population for the year of study. Ninety three per cent had an amputation for vascular related causes, with 73% having a below-knee amputation and 17% above-knee. Heart disease was the most frequent recorded cause of death (51%) of the amputee whereas only 28.1% of the Tayside group died from this pathology (p less than 0.01). Carcinomatosis was reported as a cause of death in 14% of the amputees and 23.5% of the Tayside group. Cerebrovascular disease caused death in 6% of the amputees and in 12.3% of the Tayside group (both p less than 0.01). These findings confirm earlier suggestions that vascular amputees die from heart disease more often than the general population.

Amputation, Surgical↗
PubMed1990

New developments in recreational prostheses and adaptive devices for the amputee.

Regardless of age, conventional prostheses and traditional rehabilitation programs no longer meet the needs and expectations of active amputees. The emphasis on fitness, the availability of stronger and lighter materials, and strong consumer demand have led to plethora of new prosthetic designs by progressive prosthetists and engineers. Prosthetic training techniques now take into account the amputee's recreational and sports needs and desires, using advanced athletic training concepts to achieve superior performance in a wide variety of activities. The surgeon, as a key member of the amputee team, should be aware of these profound changes so that they may contribute his or her skill in surgically crafting an optimally functional residual limb. This will allow the amputee to reach for the maximum in cardiopulmonary fitness while achieving social reintegration after amputation. The combination of skills, concepts, and techniques of the amputation surgeon, prosthetist, and therapist/trainer has led to a unique situation, in which for the first time, amputees are able to successfully compete in sports because of their prostheses, rather than in spite of them.

Amputation, Surgical↗
PubMed1993

Dynamics of below-knee child amputee gait: SACH foot versus Flex foot.

Gait kinematics and dynamics during stance of unilateral, below-knee child amputees were analyzed for self-selected, comfortable (0.9 m s-1) and fast (1.3 m s-1) speeds with the SACH foot and the energy-storing Flex-foot prostheses. The three-dimensional movements of the lower limbs were recorded and synchronized with ground reaction forces for 12 subjects (7 girls and 5 boys, ages 6-16 yr). Each lower limb was modeled as a set of interconnected rigid links (thigh, leg, and foot) with frictionless joints (hip, knee, and ankle) to calculate moment and joint power profiles. Marked asymmetries were noted in ground reaction force, joint moment, and power profiles for the prosthetic versus the natural limb, but with the Flex foot the asymmetries were less pronounced than with the SACH foot. For the amputee wearing the Flex foot, greater moments and power were generated by the natural limb at the comfortable pace as compared to the SACH foot, but during fast walking, the SACH foot required greater output from the natural limb. With both prostheses, for the prosthetic limb the amputees used similar force, moment, and power patterns, but with significantly different amplitudes. At both speeds of walking, the Flex foot returned significantly more energy (66% at comfortable and 70% at fast walking) than the SACH foot (21% at comfortable and 19% at fast walking). Thus, the Flex foot had a greater potential for reducing the energy cost of walking at comfortable and fast speeds for the below-knee child amputee.

Adolescent↗
PubMed2004

Adaptations to mass perturbations in transtibial amputees: kinetic or kinematic invariance?

OBJECTIVE: To establish the adaptation strategy transtibial amputees use after mass perturbation of their prosthetic lower leg. DESIGN: We investigated whether the measured adaptations to mass perturbation of the lower leg in transtibial amputees can better be described as (1) a kinetic invariance strategy in which kinetics (joint torques) remain the same while kinematics (joint angles) change or (2) a kinematic invariance strategy in which kinematics remain the same while kinetics change. SETTING: A gait laboratory. PARTICIPANTS: Ten transtibial amputees. INTERVENTIONS: Five different mass conditions. MAIN OUTCOME MEASURES: Measured joint torques and angles during the swing phase in the different mass conditions. RESULTS: Mass perturbation induced more significant changes and larger effect sizes in joint torques than in joint angles. CONCLUSIONS: Transtibial amputees adapt to mass perturbation primarily by maintaining the same kinematic pattern and adjusting their joint torques, that is, they use a kinematic invariance strategy. This implies that manipulating prosthetic inertial properties does not directly influence gait kinematics and that inertial properties should be evaluated in terms of the energetic cost of the swing phase.

Adaptation, Physiological↗
PubMed2006

The effect of foot and ankle prosthetic components on braking and propulsive impulses during transtibial amputee gait.

OBJECTIVE: To assess the influence of energy storage and return (ESAR) prosthetic feet and multi-axis ankles on ground reaction forces and loading asymmetry between lower limbs in transtibial amputees. DESIGN: Subjects wore 2 different prosthetic feet with and without a multi-axis ankle and were analyzed using a blind repeated-measures multivariate analysis-of-variance design. SETTING: Gait analysis laboratory. PARTICIPANTS: Fifteen healthy unilateral transtibial amputees (>55 y) who had an amputation at least 1 year before testing because of vascular disorders. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The anteroposterior ground reaction force impulse, peak ground reaction forces, and braking and propulsion impulse duration were analyzed as subjects walked at a self-selected speed while wearing each of the 4 foot-ankle prosthesis combinations. Statistical analyses were used to determine if there was a significant foot, ankle, or foot-ankle interaction effect on the outcome measures for each foot (P<.05). RESULTS: Amputees generated a significantly greater propulsive impulse with the residual leg when wearing a multi-axis ankle with the ESAR and non-ESAR foot, which improved the propulsive symmetry between the residual and intact legs. There was no prosthetic foot effect on these measures. There were no significant differences in the peak residual-leg braking or propulsive ground reaction forces or the impulse durations due to the prosthetic foot, ankle, or foot-ankle interactions, although an increase in the propulsive impulse duration approached significance (P=.062) with a multi-axis ankle. CONCLUSIONS: These results suggest that amputee gait may improve with the prescription of multi-axis ankles that allow for greater propulsive impulses by the residual leg, which improve the loading symmetry between legs.

Amputation, Surgical↗
PubMed2004

Residual function in peripheral nerve stumps of amputees: implications for neural control of artificial limbs.

PURPOSE: It is not known whether motor and sensory pathways associated with a missing or denervated limb remain functionally intact over periods of many months or years after amputation or chronic peripheral nerve transection injury. We examined the extent to which activity on chronically severed motor nerve fibers could be controlled by human amputees and whether distally referred tactile and proprioceptive sensations could be induced by stimulation of sensory axons in the nerve stumps. METHODS: Amputees undergoing elective stump procedures were invited to participate in this study. Longitudinal intrafascicular electrodes were threaded percutaneously and implanted in severed nerves of human amputees. The electrodes were interfaced to an amplifier and stimulator system controlled by a laptop computer. Electrophysiologic tests were conducted for 2 consecutive days after recovery from the surgery. RESULTS: It was possible to record volitional motor nerve activity uniquely associated with missing limb movements. Electrical stimulation through the implanted electrodes elicited discrete, unitary, graded sensations of touch, joint movement, and position, referring to the missing limb. CONCLUSIONS: These findings indicate that both central and peripheral motor and somatosensory pathways retain significant residual connectivity and function for many years after limb amputation. This implies that peripheral nerve interfaces could be used to provide amputees with prosthetic limbs that have more natural feel and control than is possible with current myoelectric and body-powered control systems.

Action Potentials↗
PubMed2005

The activation of the cortical hand area by toe tapping in two bilateral upper-extremities amputees with extraordinary foot movement skill.

Functional reorganization of the human brain after an arm amputation has been documented in several investigations, but as far as we know, there has been no report on amputees with skilled foot movement ability. To further assess the power of functional reorganization of the brain after an amputation, we investigated two bilateral upper-extremities amputees who were professional sculptors and painters with their feet. Performance tests showed that they possessed high foot movement ability. Functional MRI data indicated that toe tapping of the amputees not only activated the classical foot primary motor cortex, but also activated the hand area. In the T1-weighted MRI, the central sulci of both amputees kept their characteristic shape. Our study suggests that there is a remarkable power of neural plasticity in the motor cortex, and the maturation of the cortex develops in response to daily practice. The possible mechanisms of the reorganization are tentatively discussed.

Adult↗
PubMed2004

Evaluation of muscle metabolic activity in the lower limb of a transfemoral amputee using a prosthesis by using (18)F-FDG PET imaging--an application of PET imaging to rehabilitation.

This study used FDG PET to evaluate the lower limb muscles metabolic activities of transfemoral amputees during walking with prostheses. As a preliminary study, FDG PET was applied for two normal adult volunteers to evaluate muscle activity in the lower extremities after gait exercise. This same method was applied for two amputee volunteers with prostheses. We found that FDG accumulated more in both gluteus medius muscles after gait exercise compared to other muscles in normal adult volunteers. In the skilled amputee volunteer, FDG uptake increased in the adductor and gluteus medius in the amputated side, while in the unskilled the adductor, gluteus maximus, and gluteus medius showed increased FDG uptake only in the normal side. This result suggests that basic metabolic changes such as an increase in oxidative metabolism and less reliance on glycolytic activity would occur as a result of skeletal muscle training in amputees.

Adult↗
PubMed1997

Physiological comparison of walking among bilateral above-knee amputee and able-bodied subjects, and a model to account for the differences in metabolic cost.

OBJECTIVE: To compare the metabolic cost for prosthetic ambulation among persons with bilateral above-knee amputation with that for able-bodied ambulation, and to test a model that differentiates the metabolic cost of walking into three components. DESIGN: Cross-sectional comparison. SETTING: Community-dwelling subjects studied at an academic medical center. PARTICIPANTS: Five bilateral above-knee amputee subjects with mean (+/-SD) age of 22 +/- 3 years, and five able-bodied control subjects matched for gender, height, weight, and age. INTERVENTION: Subjects performed 6-minute bouts of walking at three paced speeds and their chosen walking speed with oxygen uptake being determined during the last 2 minutes of each bout. MAIN OUTCOME MEASURES: Chosen walking speed and oxygen uptake during each walking condition. RESULTS: The chosen walking speed was 21% slower and induced aerobic demands 49% higher for the amputee subjects. Across specified paced speeds, aerobic demands were 55% to 83% higher for the amputee subjects than for the able-bodied subjects. The described model suggests that the higher metabolic costs for the amputee subjects resulted from greater demands for maintenance of balance and posture and for performing the walking movement. CONCLUSIONS: Prosthetic ambulation by young healthy persons with bilateral above-knee amputation induces significantly greater metabolic demands than walking by able-bodied individuals. Although the chosen walking speed of persons with bilateral above-knee amputation is slower, the reduction in speed is insufficient to equalize their metabolic cost with that of able-bodied individuals walking at their chosen walking speed.

Adult↗
PubMed1999

Altered kinetic strategy for the control of swing limb elevation over obstacles in unilateral below-knee amputee gait.

Our goal was to document the kinetic strategies for obstacle avoidance in below-knee amputees. Kinematic data were collected as unilateral below-knee traumatic amputees stepped over obstacles of various heights in the walking path. Inverse dynamics were employed to calculate power profiles and work during the limb-elevation and limb-lowering phases. Limb elevation was achieved by employing a different strategy of intra-limb interaction for elevation of the prosthetic limb than for the sound limb, which was similar to that seen in healthy adult non-amputees. As obstacle height increased, prosthetic side knee flexion was increased by modulating the work done at the hip, and not the knee, as seen on the sound side. Although the strength of the muscles about the residual knee was preserved, the range of motion of that knee had previously been found to be somewhat limited. Perhaps more importantly, potential instability of the interface between the stump and the prosthetic socket, and associated discomfort at the stump could explain the altered limb-elevation strategy. Interestingly, the limb-lowering strategy seen in the sound limb and in non-amputees already features modulation of rotational and translational work at the hip, so an alternate strategy was not required. Thus, following a major insult to the sensory and neuromuscular system, the CNS is able to update the internal model of the locomotor apparatus as the individual uses the new limb in a variety of movements, and modify control strategies as appropriate.

Adaptation, Physiological↗