The Functional Lower-Limb Amputee Gait Assessment (FLAG Assessment): An Observational Gait Analysis Tool for People with Unilateral Lower Limb Amputation

The psychometric properties of a new observational gait analysis (OGA) tool for people with unilateral lower limb amputation (LLA) named the Functional Lower-limb Amputee Gait Assessment (FLAG Assessment) was developed to promote communication and collaboration between physical therapists (PTs) and certified prosthetists (CPs). It includes eleven gait deviations evaluated during OGA.Reliability was examined in a group of PT and CP raters who completed the FLAG Assessment for participants with unilateral LLA. The intra-rater reliability of nine gait deviations in the PTs group and seven in the CPs group was found moderate to substantial, suggesting they are stable over time when assessed by the same rater. Two gait deviations in the PTs and four in the CPs group had fair intra-rater reliability. The inter-rater reliability of four gait deviations in the PT group and six in the CP group was moderate to substantial, suggesting multiple PTs can use four gait deviations and multiple CPs can use six gait deviations to evaluate the gait of people with unilateral LLA. Three gait deviations achieved the acceptable level of agreement in both groups of clinicians (K>.41) and can be used across the two professions to evaluate the gait of people with unilateral LLA. Seven gait deviations in the PTs group and five in the CPs group had slight to fair inter-rater reliability.Criterion validity compared the FLAG Assessment results of four gait deviations with an electronic walkway and inertial measurements units. The criterion validity of prosthetic limb step shorter gait deviation was established for participants.The construct validity of three gait deviations was examined based on the ABC score and walking speed. Construct validity was established for all three gait deviations, with participants present of a deviation having a lower balance confidence and slower walking speed compared to those absent of the deviation. &nbsp;The FLAG Assessment has the potential to be used by both PTs and CPs to evaluate gait deviations of people with unilateral LLA and assess changes in these gait deviations over time.</p

Outdoor dynamic subject-specific evaluation of internal stresses in the residual limb: Hydraulic energy-stored prosthetic foot compared to conventional energy-stored prosthetic feet

The prosthetic foot plays an important role in propelling, breaking, balancing and supporting body loads while the amputee ambulates on different grounds. It is therefore important to quantify the effect of the prosthetic foot mechanism on biomechanical parameters, in order to prevent pressure ulcers and deep tissue injury. Our aim was to monitor the internal stresses in the residuum of transtibial amputation (TTA) prosthetic-users ambulating on different terrains, which the amputees encounter during their daily activities, i.e. paved floor, grass, ascending and descending stairs and slope. We specifically aimed to compare between the internal stresses in the TTA residuum of amputees ambulating with a novel hydraulic prosthetic foot compared to conventional energy storage and return (ESR) prosthetic feet. Monitoring of internal stresses was accomplished using a portable subject-specific real-time internal stress monitor. We found significant decrease (p < 0.01) in peak internal stresses and in the loading rate of the amputated limb, while walking with the hydraulic foot, compared to walking with ESR feet. The loading rate calculated while ambulating with the hydraulic foot was at least three times lower than the loading rate calculated while ambulating with the ESR foot. Although the average decrease in internal stresses was similar to 2-fold larger when replacing single-toe ESR feet with the hydraulic foot than when replacing split-toed ESR feet with the hydraulic foot, the differences were statistically insignificant. Our findings suggest that using a hydraulic prosthetic foot may protect the distal tibial end of the TTA residuum from high stresses, therefore preventing pressure-related injury and pain. (C) 2011 Elsevier B.V. All rights reserved

The development and internal consistency of the comprehensive lower limb amputee socket survey in active lower limb amputees

Prosthetic socket fit is an important element associated with successful ambulation and use of a prosthesis. Prosthetists and rehabilitation clinicians would benefit from an assessment tool that discriminates between and quantifies the multiple determinants that influence the lower limb amputee's performance and satisfaction of a prosthetic socket. To determine the internal consistency of the comprehensive lower limb amputee socket survey, a new self-report measure of prosthetic socket satisfaction that quantifies suspension, stability, comfort, and appearance. Cross-sectional sample of active amputees. Interviews were conducted with prosthetists, physical therapists, and lower limb amputees to identify clinical concerns and common activities influencing socket fit. An expert panel of five clinicians reviewed the items and constructed the original version of the comprehensive lower limb amputee socket survey which was then administered to a convenience sample of 47 active lower limb amputees. Item analysis and Cronbach's alpha were used to determine the final version of the comprehensive lower limb amputee socket survey. Following item raw score-to-total score correlation with Cronbach's alpha for comprehensive lower limb amputee socket survey determinants, internal consistency improved when nine questions were eliminated. The comprehensive lower limb amputee socket survey is a self-report measure of prosthetic socket satisfaction with very good internal consistency. When socket problems occur, the ability to determine the specific cause can reduce modification time, enhance socket fit, and promote patient satisfaction. A standardized multi-dimensional assessment measure of socket satisfaction enables prosthetists to quantify the multiple determinants of socket satisfaction, improve patient communication, and demonstrate the value of socket interventions

Variations in 2-Minute Walk Test outcomes for people with lower limb amputation in the outpatient clinic and research settings

This study determined the differences in 2-Minute Walk Test (2MWT) distances between people with lower limb amputations in clinical and research settings and described variations in test administration in various clinical settings. Retrospective Cross-sectional design. The 2MWT for 290 patients with lower limb amputations were obtained from a medium-sized prosthetic company with locations within the central United States. Data on 12 prosthetists' 2MWT administration decisions were obtained from the results of an administrative questionnaire. Patient 2MWT distances were compared with published distances. Multiple regression was used to examine the impact of test settings on 2MWT outcomes. Descriptive statistics were used to present prosthetists' variations in test administration. Clinical 2MWT distances were significantly less than distances obtained in a research setting. Clinical facilities reported inconsistent path dimensions and potential obstacles in proximity to the test area. Variations in test administration by prosthetists with respect to path length, instructions, turn marker, and overage measurement may contribute to the differences. Prosthetists should be aware that comparisons of patients' 2MWT distance in a clinical environment may differ from published results. Although variations in clinical environments are usually nonmodifiable characteristics of the clinical facility, test administration and scoring could be modified

Inertial sensor-based measures of gait symmetry and repeatability in people with unilateral lower limb amputation

People with lower limb amputation often walk with asymmetrical gait patterns potentially leading to long-term health problems, ultimately affecting their quality of life. The ability to discreetly detect and quantify the movement of bilateral thighs and shanks using wearable sensor technology can provide additional insight into how a person walks with a lower limb prosthesis. This study investigated segmental symmetry and segmental repeatability of people with unilateral lower limb amputation, examining performance of the prosthetic and intact limbs. Gyroscope signals were recorded from four inertial measurement units worn on bilateral lower limb segments of subjects with unilateral lower limb amputation during the 10-m walk test. Raw angular velocity signals were processed using dynamic time warping and application of algorithms resulting in symmetry measures comparing similarity of prosthetic to intact limb strides, and repeatability measures comparing movement of one limb to its consecutive strides. Biomechanical differences in performance of the prosthetic and intact limb segments were detected with the segmental symmetry and segmental repeatability measures in 128 subjects. More asymmetries and less consistent movements of the lower limbs were exhibited by subjects with transfemoral amputation versus transtibial amputation (p < .004, Cohen's d = 0.65-1.1). Sensor-based measures of segmental symmetry and segmental repeatability were found to be reliable in detecting discreet differences in movement of the prosthetic versus intact lower limbs in amputee subjects. These measures provide a convenient tool for enhanced prosthetic gait analysis with the potential to focus rehabilitative and prosthetic interventions

The development and reliability testing of the Functional Lower-Limb Amputee Gait Assessment

Objective The study purpose was three-fold: (a) to describe the development of the Functional Lower-Limb Amputee Gait Assessment, (b) to determine its reliability with two groups of raters, physical therapists, and certified prosthetists, and (c) to determine the agreement on its results between the two groups. Design A reliability study. Setting Institution for higher education. Participants Five physical therapists and five certified prosthetists. Intervention Not applicable. Main measure The gait of people with unilateral lower limb amputation was evaluated using the Functional Lower-Limb Amputee Gait Assessment. Kappa statistic was used to analyze reliability. Results The intra-rater reliability of nine gait deviations in the physical therapists’ group and eight in the certified prosthetists’ group was between moderate and almost perfect agreement (kappa = .41–1). In the physical therapists’ group, the inter-rater reliability of four gait deviations was moderate (kappa = .41–.6). In the certified prosthetists’ group, the inter-rater reliability of six gait deviations was moderate to substantial (kappa = .41–.8). Three gait deviations achieved moderate agreement in both groups of clinicians (kappa = .41–.6). Conclusions Most gait deviations included in the Functional Lower-Limb Amputee Gait Assessment appear stable over time when used by the same clinician. Six gait deviations in the certified prosthetists’ group and four in the physical therapists’ group may be used by multiple clinicians, and three gait deviations may be used across both professions to assist in communication and collaboration on the best course of treatment for a patient with a unilateral lower limb amputation

PERFORMANCE TESTING IN PEOPLE WITH LOWER LIMB AMPUTATION: INTERVIEWS WITH PROSTHETISTS, PHYSICAL THERAPISTS, AND PHYSICIANS

INTRODUCTION A variety of performance-based tests are available to assess mobility in people with lower limb amputation (LLA)1. Selection of a specific test is likely to be guided by the clinical value of tasks patients perform; the space and equipment available to administrator the test; and/or the time required to set up, administer, score, and interpret the test results. The aim of this study was to collect information about the clinical value of performance tests, and the space, equipment, and time available to rehabilitation specialists who provide care to people with LLA (i.e., prosthetists, physical therapists (PTs), and physical medicine and rehabilitation (PM&amp;R) physicians). Abstract PDF&nbsp; Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/32018/24437 How to cite:&nbsp;Balkman G, Morgan S, Gaunaurd I, Kristal A, Amtmann D, Gailey R, Hafner B.J. PERFORMANCE TESTING IN PEOPLE WITH LOWER LIMB AMPUTATION: INTERVIEWS WITH PROSTHETISTS, PHYSICAL THERAPISTS, AND PHYSICIANS. CANADIAN PROSTHETICS &amp; ORTHOTICS JOURNAL, VOLUME 1, ISSUE 2, 2018; ABSTRACT, POSTER PRESENTATION AT THE AOPA’S 101ST NATIONAL ASSEMBLY, SEPT. 26-29, VANCOUVER, CANADA, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.32018 Abstracts were Peer-reviewed by the American Orthotic Prosthetic Association (AOPA) 101st National Assembly Scientific Committee.&nbsp; http://www.aopanet.org

PERFORMANCE TESTING IN PEOPLE WITH LOWER LIMB AMPUTATION: INTERVIEWS WITH PROSTHETISTS, PHYSICAL THERAPISTS, AND PHYSICIANS

INTRODUCTION A variety of performance-based tests are available to assess mobility in people with lower limb amputation (LLA)1. Selection of a specific test is likely to be guided by the clinical value of tasks patients perform; the space and equipment available to administrator the test; and/or the time required to set up, administer, score, and interpret the test results. The aim of this study was to collect information about the clinical value of performance tests, and the space, equipment, and time available to rehabilitation specialists who provide care to people with LLA (i.e., prosthetists, physical therapists (PTs), and physical medicine and rehabilitation (PM&R) physicians). Abstract PDF  Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/32018/24437 How to cite: Balkman G, Morgan S, Gaunaurd I, Kristal A, Amtmann D, Gailey R, Hafner B.J. PERFORMANCE TESTING IN PEOPLE WITH LOWER LIMB AMPUTATION: INTERVIEWS WITH PROSTHETISTS, PHYSICAL THERAPISTS, AND PHYSICIANS. CANADIAN PROSTHETICS & ORTHOTICS JOURNAL, VOLUME 1, ISSUE 2, 2018; ABSTRACT, POSTER PRESENTATION AT THE AOPA’S 101ST NATIONAL ASSEMBLY, SEPT. 26-29, VANCOUVER, CANADA, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.32018 Abstracts were Peer-reviewed by the AOPA 2018 National Assembly Scientific Committee

ANATOMICAL AND SURGICAL RISK FACTORS AFFECTING THE INTERNAL MECHANICAL CONDITIONS IN THE TRANSTIBIAL RESIDUUM

Transtibial amputation (TTA) patients face ongoing morphological changes in their residual limb. The residuum volume changes due to weight gain or loss, diurnal edema, and muscle atrophy. Consequently, the TTA prosthetic-user is fitted with a new prosthetic socket approximately every four years. Despite new innovations in socket and liner materials and design, contemporary prosthetics are not yet equipped to confront these changes. The TTA residual limb is therefore subjected to high superficial and internal stresses which may cause injury. Appending the hazardous condition of natural volume change of the residuum is the initial geometrical state of the truncated bones. The primary surgical considerations in TTA are the tibial length, the bevelment of the distal end of the tibia and the location of the surgical scar. These risk factors may significantly affect the well being of the TTA residuum. Previous studies assumed that the criteria for a well-fitted socket were low interface stresses. However, while interface stress measurements may help prevent superficial skin damage, knowledge of the internal stress distribution can prevent the formation of deep tissue injury (DTI) [1]. While superficial pressure ulcers are visually detected, DTI is concealed under the skin and spreads to its surroundings in the soft tissues of the residuum. If this latent wound is ignored, the skin will rupture to reveal a massive injury to skin, fat and muscle tissues, clinically termed as a type IV pressure ulcer. Our purpose was to evaluate the effect of the following risk factors on the internal mechanical condition of the TTA residuum: shorter tibial lengths (thicker muscle flap tissue), milder tibial end bevelments, different mechanical properties of the muscle flap (simulating both variance between patients or flaccid versus contracted muscle) and superficial scarring in inferior and anterior locations on the skin.</jats:p