Factors related to successful job reintegration of people with a lower limb amputation

Objective: To study demographically, amputation-, and employment-related factors that show a relationship to successful job reintegration of patients after lower limb amputation. Design: Cross-sectional study. Setting: University hospital. Patients: Subjects had an acquired unilateral major amputation of the lower limb at least 2 years before, were aged 18 to 60 years (mean, 46yr), and were living in the Netherlands. All 322 patients were working at the time of amputation and were recruited from orthopedic workshops. Intervention: Questionnaires sent to subjects to self-report (1) demographic and amputation information and (2) job characteristics and readjustment postamputation. Questionnaire sent to rehabilitation specialists to assess physical work load. Main Outcome Measures: Demographically related (age, gender); amputation-related (comorbidity; reason and level; problems with stump, pain, prosthesis use and problems, mobility, rehabilitation); and employment-related (education, physical workload) information about the success of job reintegration. Results: Job reintegration was successful in 79% and unsuccessful in 21% of the amputees. Age at the time of amputation, wearing comfort of the prosthesis, and education level were significant indicators of successful job reintegration. Subjects with physically demanding jobs who changed type of job before and after the amputation more often successfully returned to work than subjects who tried to stay at the same type of job. Conclusions: Older patients with a low education level and problems with the wearing comfort of the prosthesis are a population at risk who require special attention during the rehabilitation process in order to return to work. Lowering the physical workload by changing to another type of work enhances the chance of successful reintegration

The lived experience of persons with an amputation

This paper presents an exploratory study of Maltese persons living with an amputation. Semi-structured interviews were conducted with four participants. Three of the participants had a lower limb amputation, while the fourth had an upper limb amputation. Interpretative phenomenological analysis (IPA) was used in the analysis phase. The three core superordinate themes that emerged from the data revolved around the emotional reactions towards the amputation, the numerous changes it brought to the participants’ lives, and the support which enabled amputees to cope with their situation. The study highlights the range of emotions experienced by the participants on having an amputation and the changes in their lifestyle. Support from family, friends, health professionals and other amputees was identified as a factor that helped participants cope and adapt to their new condition.peer-reviewe

Locomotor adaptability in persons with unilateral transtibial amputation

Background Locomotor adaptation enables walkers to modify strategies when faced with challenging walking conditions. While a variety of neurological injuries can impair locomotor adaptability, the effect of a lower extremity amputation on adaptability is poorly understood. Objective Determine if locomotor adaptability is impaired in persons with unilateral transtibial amputation (TTA). Methods The locomotor adaptability of 10 persons with a TTA and 8 persons without an amputation was tested while walking on a split-belt treadmill with the parallel belts running at the same (tied) or different (split) speeds. In the split condition, participants walked for 15 minutes with the respective belts moving at 0.5 m/s and 1.5 m/s. Temporal spatial symmetry measures were used to evaluate reactive accommodations to the perturbation, and the adaptive/de-adaptive response. Results Persons with TTA and the reference group of persons without amputation both demonstrated highly symmetric walking at baseline. During the split adaptation and tied post-adaptation walking both groups responded with the expected reactive accommodations. Likewise, adaptive and de-adaptive responses were observed. The magnitude and rate of change in the adaptive and de-adaptive responses were similar for persons with TTA and those without an amputation. Furthermore, adaptability was no different based on belt assignment for the prosthetic limb during split adaptation walking. Conclusions Reactive changes and locomotor adaptation in response to a challenging and novel walking condition were similar in persons with TTA to those without an amputation. Results suggest persons with TTA have the capacity to modify locomotor strategies to meet the demands of most walking conditions despite challenges imposed by an amputation and use of a prosthetic limb

Limb amputations in fixed dystonia: a form of body integrity identity disorder?

Fixed dystonia is a disabling disorder mainly affecting young women who develop fixed abnormal limb postures and pain after apparently minor peripheral injury. There is continued debate regarding its pathophysiology and management. We report 5 cases of fixed dystonia in patients who sought amputation of the affected limb. We place these cases in the context of previous reports of patients with healthy limbs and patients with chronic regional pain syndrome who have sought amputation. Our cases, combined with recent data regarding disorders of mental rotation in patients with fixed dystonia, as well as previous data regarding body integrity identity disorder and amputations sought by patients with chronic regional pain syndrome, raise the possibility that patients with fixed dystonia might have a deficit in body schema that predisposes them to developing fixed dystonia and drives some to seek amputation. The outcome of amputation in fixed dystonia is invariably unfavorable

Major Limb Amputations: A Tertiary Hospital Experience in Northwestern Tanzania.

Major limb amputation is reported to be a major but preventable public health problem that is associated with profound economic, social and psychological effects on the patient and family especially in developing countries where the prosthetic services are poor. The purpose of this study was to outline the patterns, indications and short term complications of major limb amputations and to compare our experience with that of other published data. This was a descriptive cross-sectional study that was conducted at Bugando Medical Centre between March 2008 and February 2010. All patients who underwent major limb amputation were, after informed consent for the study, enrolled into the study. Data were collected using a pre-tested, coded questionnaire and analyzed using SPSS version 11.5 computer software. A total of 162 patients were entered into the study. Their ages ranged between 2-78 years (mean 28.30 ± 13.72 days). Males outnumbered females by a ratio of 2:1. The majority of patients (76.5%) had primary or no formal education. One hundred and twelve (69.1%) patients were unemployed. The most common indication for major limb amputation was diabetic foot complications in 41.9%, followed by trauma in 38.4% and vascular disease in 8.6% respectively. Lower limbs were involved in 86.4% of cases and upper limbs in 13.6% of cases giving a lower limb to upper limb ratio of 6.4:1 Below knee amputation was the most common procedure performed in 46.3%. There was no bilateral limb amputation. The most common additional procedures performed were wound debridement, secondary suture and skin grafting in 42.3%, 34.5% and 23.2% respectively. Two-stage operation was required in 45.4% of patients. Revision amputation rate was 29.6%. Post-operative complication rate was 33.3% and surgical site infection was the most common complication accounting for 21.0%. The mean length of hospital stay was 22.4 days and mortality rate was 16.7%. Complications of diabetic foot ulcers and trauma resulting from road traffic crashes were the most common indications for major limb amputation in our environment. The majority of these amputations are preventable by provision of health education, early presentation and appropriate management of the common indications

The Influence of Socioeconomic Factors on Fear of Falling and Mobility Outcomes after Lower Limb Loss: a Preliminary Study

Background and Purpose: Current research has revealed that as much as 52.4% of individuals with lower limb loss report falling at least once in the past year. Previous research has also indicated that rehabilitation, including physical therapy (PT), generally improves patient outcomes after definitive amputation. Socioeconomic status has been shown to be an important factor in accessing healthcare but has yet to be investigated in this population. The purpose of this study was to investigate the effects of socioeconomic status and access to PT, and how limb loss affects mobility and fear of falling perception. We hypothesized: [1] individuals with socioeconomic difficulty would have reduced access to PT after amputation, and [2] individuals with limb loss will have increased fear of falling and decreased mobility performance when compared to non-amputee, age-matched controls. Subjects: 23 participants (7 females,16 males) mean age 51.30 years old (+ 13.17 SD, range 22-70) with lower limb loss ambulating with a definitive prosthesis. Materials/Methods: Participants completed a survey that included the Fear of Falling Avoidance Behavior Questionnaire (FFABQ), questions to determine their socioeconomic status, and whether they received PT after amputation. Mobility outcomes were measured using the standardized Timed Up and Go test (TUG) and the Six Minute Walk Test (6MWT). Results: There was no statistically significant difference in access to PT after amputation between those with and without financial difficulty (p=.354). However, 75% of participants who had no socioeconomic difficulty reported receiving PT, in comparison to only 25% in those who had socioeconomic difficulty. Additionally, 34.8% of our participants reported socioeconomic difficulties. When comparing the participants with amputation to the non-amputee, age-matched controls, there was a significant difference in the TUG (p\u3c.001), 6MWT (p\u3c.001), and FFABQ (p=.008). On average, participants with limb loss were 4.4 seconds slower on the TUG, walked 136.4m less on the 6MWT, and had an increased FFABQ score of 6.6 points out of 56 points. Discussion: Access to physical therapy and socioeconomic status have been overlooked in current literature for individuals after amputation. While the effect of socioeconomic status on PT access did not reach statistical significance in this preliminary study, only 25% of those who reported socioeconomic difficulty received physical therapy after amputation, compared to 75% in those who reported no difficulty. Further research is needed to determine whether low socioeconomic status is predictive of receiving rehabilitation services post-amputation and long-term outcomes. Our findings also showed that when compared to age-matched non-amputees, amputees tend to have impaired mobility and higher degree of fear of falling. These findings agree with current literature. Conclusion: Although not statistically significant, our preliminary findings showed that socioeconomic difficulty may affect access to physical therapy after amputation. Furthermore, our data demonstrated that individuals with lower limb loss exhibit reduced mobility performance and increased fear of falling when compared to the age-matched controls

Can real-time visual feedback during gait retraining reduce metabolic demand for individuals with transtibial amputation?

The metabolic demand of walking generally increases following lower extremity amputation. This study used real-time visual feedback to modify biomechanical factors linked to an elevated metabolic demand of walking in individuals with transtibial amputation. Eight persons with unilateral, traumatic transtibial amputation and 8 uninjured controls participated. Two separate bouts of real-time visual feedback were provided during a single session of gait retraining to reduce 1) center of mass sway and 2) thigh muscle activation magnitudes and duration. Baseline and post-intervention data were collected. Metabolic rate, heart rate, frontal plane center of mass sway, quadriceps and hamstrings muscle activity, and co-contraction indices were evaluated during steady state walking at a standardized speed. Visual feedback successfully decreased center of mass sway 12% (p = 0.006) and quadriceps activity 12% (p = 0.041); however, thigh muscle co-contraction indices were unchanged. Neither condition significantly affected metabolic rate during walking and heart rate increased with center-of-mass feedback. Metabolic rate, center of mass sway, and integrated quadriceps muscle activity were all not significantly different from controls. Attempts to modify gait to decrease metabolic demand may actually adversely increase the physiological effort of walking in individuals with lower extremity amputation who are young, active and approximate metabolic rates of able-bodied adults

Presentations of major peripheral arterial disease and risk of major outcomes in patients with type 2 diabetes: results from the ADVANCE-ON study.

BACKGROUND: Peripheral arterial disease (PAD) is known to be associated with high cardiovascular risk, but the individual impact of PAD presentations on risk of macrovascular and microvascular events has not been reliably compared in patients with type 2 diabetes. We aimed to evaluate the impact of major PAD, and its different presentations, on the 10-year risk of death, major macrovascular events, and major clinical microvascular events in these patients. METHODS: Participants in the action in diabetes and vascular disease: PreterAx and DiamicroN modified-release controlled evaluation (ADVANCE) trial and the ADVANCE-ON post-trial study were followed for a median of 5.0 (in-trial), 5.4 (post-trial), and 9.9 (overall) years. Major PAD at baseline was subdivided into lower-extremity chronic ulceration or amputation secondary to vascular disease and history of peripheral revascularization by angioplasty or surgery. RESULTS: Among 11,140 participants, 516 (4.6 %) had major PAD at baseline: 300 (2.7 %) had lower-extremity ulceration or amputation alone, 190 (1.7 %) had peripheral revascularization alone, and 26 (0.2 %) had both presentations. All-cause mortality, major macrovascular events, and major clinical microvascular events occurred in 2265 (20.3 %), 2166 (19.4 %), and 807 (7.2 %) participants, respectively. Compared to those without PAD, patients with major PAD had increased rates of all-cause mortality (HR 1.35, 95 % CI 1.15-1.60, p = 0.0004), and major macrovascular events (1.47 [1.23-1.75], p < 0.0001), after multiple adjustments for region of origin, cardiovascular risk factors and treatments, peripheral neuropathy markers, and randomized treatments. We have also observed a trend toward an association of baseline PAD with risk of major clinical microvascular events [1.31 (0.96-1.78), p = 0.09]. These associations were comparable for patients with a lower-extremity ulceration or amputation and for those with a history of peripheral revascularization. Furthermore, the risk of retinal photocoagulation or blindness, but not renal events, increased in patients with lower-extremity ulceration or amputation [1.53 (1.01-2.30), p = 0.04]. CONCLUSIONS: Lower-extremity ulceration or amputation, and peripheral revascularization both increased the risks of death and cardiovascular events, but only lower-extremity ulceration or amputation increased the risk of severe retinopathy in patients with type 2 diabetes. Screening for major PAD and its management remain crucial for cardiovascular prevention in patients with type 2 diabetes (ClinicalTrials.gov number, NCT00949286)

Influence of physical capacities of males with transtibial amputation on gait adjustments on sloped surfaces

The aim of the study was to investigate how kinematic and kinetic adjustments between level and slope locomotion of persons with transtibial amputation are related to their individual muscular and functional capacities. A quantified gait analysis was conducted on flat and slope surfaces for seven patients with transtibial amputation and a control group of eight subjects to obtain biomechanical parameters. In addition, maximal isometric muscular strength (knee and hip extensors) and functional scores were measured. The results of this study showed that most of the persons with transtibial amputation could adapt to ramp ascent either by increasing ankle, knee, and hip flexion angles of the residual limb and/or by recruiting their hip extensors to guarantee enough hip extension power during early stance. Besides, 6-minute walk test score was shown to be a good predictor of adaptation capacities to slope ascent. In ramp descent, the increase of knee flexion moment was correlated with knee extensor strength and residual-limb length. However, no correlation was observed with functional parameters. Results show that the walking strategy adopted by persons with transtibial amputation to negotiate ramp locomotion mainly depends on their muscular capacities. Therefore, muscular strengthening should be a priority during rehabilitation.This material was based on work supported by the French National Research Agency (grant ANR-2010-TECS-020)

Factors influencing quality of life following lower limb amputation for peripheral arterial occlusive disease: a systematic review of the literature

Background: The majority of lower limb amputations are undertaken in people with peripheral arterial occlusive disease,\ud and approximately 50% have diabetes. Quality of life is an important outcome in lower limb amputations; little is known\ud about what influences it, and therefore how to improve it.\ud Objectives: The aim of this systematic review was to identify the factors that influence quality of life after lower limb\ud amputation for peripheral arterial occlusive disease.\ud Methods: MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science and Cochrane databases were searched to identify\ud articles that quantitatively measured quality of life in those with a lower limb amputation for peripheral arterial occlusive\ud disease. Articles were quality assessed by two assessors, evidence tables summarised each article and a narrative\ud synthesis was performed.\ud Study design: Systematic review.\ud Results: Twelve articles were included. Study designs and outcome measures used varied. Quality assessment scores\ud ranged from 36% to 92%. The ability to walk successfully with a prosthesis had the greatest positive impact on quality\ud of life. A trans-femoral amputation was negatively associated with quality of life due to increased difficulty in walking\ud with a prosthesis. Other factors such as older age, being male, longer time since amputation, level of social support and\ud presence of diabetes also negatively affected quality of life.\ud Conclusion: Being able to walk with a prosthesis is of primary importance to improve quality of life for people with lower\ud limb amputation due to peripheral arterial occlusive disease. To further understand and improve the quality of life of this\ud population, there is a need for more prospective longitudinal studies, with a standardised outcome measure